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Exercise during pregnancy: A practical approach

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 Exercise During Pregnancy:
A Practical Approach
Theodore S. Paisley, MD*, Elizabeth A. Joy, MD, and Richard J. Price, Jr., MD
Address
*Department of Family and Preventive Medicine, University of Utah,
Madsen Family Health Clinic, 555 Foothill Drive, Suite 301, Salt Lake
City, UT 84112, USA.
E-mail: tsp@alum.dartmouth.org
Current Sports Medicine Reports 2003, 2:325–330
Current Science Inc. ISSN 1537-890x
Copyright © 2003 by Current Science Inc.
Attitudes toward exercise during pregnancy have changed
dramatically over the past 20 years. Recent studies show
that, in most cases, exercise is safe for both the mother
and fetus during pregnancy, and support the recommenda-
tion to initiate or continue exercise in most pregnancies.
This report discusses the rationale behind the changes,
and offers educational tools that may be employed to ini-
tiate behavioral change. We also propose exercise pre-
scriptions for pregnant women who are sedentary,
physically active, and competitive athletes. Armed with
this information, the practitioner will be better equipped
to counsel patients and incorporate a discussion on physi-
cal activity into prenatal visits.
Introduction
Practitioner recommendations and guidance concerning
exercise during pregnancy have evolved throughout the
years. This evolution reflects the growing acceptance of
exercise without new evidence of danger to the mother or
fetus. Early standards of care allowed pregnant women to
walk 1 mile a day [1,2]. In 1985, the American College of
Obstetrics and Gynecology (ACOG) approved aerobic
exercise routines for pregnant women, but restricted dura-
tion to 15 minutes and heart rate to 140 beats/min [3]. The
next expansion occurred in 1994 when ACOG stated, “dur-
ing pregnancy, women can continue to exercise and derive
the health benefits even from mild to moderate exercise
routines. Regular exercise (three times per week) is prefera-
ble to intermittent activity” [4].
Although the 1994 proclamation was seen as a cau-
tious approval to engage in exercise, the first formal recom-
mendation to include exercise during pregnancy came in a
2002 ACOG position statement. It states, “in the absence
of either medical or obstetric complications, 30 minutes or
more of moderate exercise a day on most, if not at all, days
of the week is recommended for pregnant women” [5•].
The 2002 ACOG statement takes into account much of
the information found in the August 1996 issue of Semi-
nars in Perinatology. The entire issue is devoted to exercise
during pregnancy and discusses all aspects of exercise dur-
ing pregnancy from study methods of animal and human
models to exercise at altitude and scuba diving. The works
presented clarified the scientific basis of exercise during
pregnancy, and dispelled many myths about risk of pre-
term delivery and negative effects of exercise on the fetus. A
few high-risk activities were identified, but no adverse out-
comes for mother or fetus were seen secondary to regular
exercise [6–14].
Gestational diabetes was also introduced in the 2002
ACOG committee opinion in support of exercise during
pregnancy. More recent reports indicate that gestational
diabetes is a diabetogenic state, both hormonally and
physically, and that exercise can prevent the onset of non–
insulin-dependent diabetes mellitus [8,17]. Gestational
diabetes is an increasing cause of morbidity and mortality
to pregnant women and their offspring, causing increased
rates of infection, pre-eclampsia, hydramnios, and postpar-
tum hemorrhage. Gestational diabetes complicates
between 1.4% and 12.3% of pregnancies [8,15–17]. Exer-
cise, however, is helpful in improving glycemic control in
patients with gestational diabetes, and may play a role for
primary prevention of developing gestational diabetes in
morbidly obese patients (body mass index > 33) [8,15–
17]. Although the impact of exercise on gestational diabe-
tes is important, the impetus for the 2002 statement seems
to have primarily been to allow women “to derive the same
associated health benefits during their pregnancies as they
did prior to pregnancy” [5•].
Although not cited in the ACOG report, the general
acceptance of exercise in pregnancy has grown in the past
decade, and exercise studies continued to support the
notion that exercise during pregnancy was safe to the
mother and the fetus [18–21]. A 1998 study by Krandel
and Kase [20] is noteworthy because the subjects were very
physically fit and performed at high intensities. Three of
the subjects in the study were among the five best women
athletes in the world in their respective events (biathlon,
bicycling, and marathon). The athletes participated in
high- or medium-intensity exercise programs throughout
their pregnancies. The conditioning programs consisted of
muscle strength training, interval training, and endurance
training. The medium-intensity group exercised an average
326 Special Populations
of 6.2 hours per week, and the high-intensity group an
average of 8.6 hours per week. Maternal heart rate was
monitored during the interval and endurance training pro-
grams, with averages during the interval training session
measured between 170 and 180 beats/min. Most women
in the study continued to exercise during the week prior to
their delivery, and the outcome of the study showed no
decrease in birth weight of the fetuses, as had been shown
in previous studies [22–27].
Physician Counseling
The effect of exercise on pregnancy has been the subject
of extensive research. It is generally agreed that healthy
women with uncomplicated pregnancies can and should
participate in regular physical activity throughout preg-
nancy, in order to derive the health benefits associated
with such activity [1,5•,28•,29,30••,31,32]. ACOG rec-
ommends that in the absence of obstetric or medical con-
traindications, pregnant women should be encouraged to
engage in regular, moderate-intensity physical activity
during pregnancy [5•]. This strong message from ACOG
is not directed toward pregnant women, but to their
obstetric care providers. The process of encouragement
involves educating women about the risks and benefits of
exercise during pregnancy, in addition to developing and
writing an individualized exercise prescription for each
woman. Several articles advocate the FITT principle (F—
Frequency of the activity, I—Intensity of the activity, T—
Type of activity, T—Time or duration of the activity) to
the provider composing an exercise prescription for a
pregnant patient [5•,28•,30••,33,34]. However, none of
these sources actually address how the obstetric care pro-
vider should educate his or her patient about exercise
during pregnancy over the course of a 10-minute, fre-
quently double-booked, prenatal appointment.
Several reports in the literature address the effectiveness
of physician counseling for increasing physical activity and
fitness in the adult population at large [35–37]. Petrella
and Lattanzio [35] conducted a systematic literature review
and found that interventions that incorporated behavior
change strategies and written materials for the patient and
provided training to the physicians regarding such counsel-
ing, were effective at increasing levels of physical activity.
None of the 13 articles they reviewed addressed exercise
counseling during pregnancy, but the result would likely
be the same for pregnant women and their providers.
Obstetricians, midwives, and family physicians need edu-
cation about exercise during pregnancy, as well as tools to
incorporate this information into the course of 10 to 14
prenatal appointments throughout a woman’s pregnancy.
Additionally, these providers need to assess a woman’s
readiness for change should she be adding exercise to her
lifestyle for the first time. Luckily, many women see preg-
nancy as an opportunity to improve their lifestyle to posi-
tively impact pregnancy outcome. Using this as a primary
motivating tool may be very helpful in encouraging them
to adopt a more active lifestyle. Finally, pregnant women
will need written educational materials that cover a wide
range of topics such as warning signs to terminate exercise
during pregnancy, contraindicated activities, nutrition, and
the exercise prescription itself.
In 1996, the Canadian Society for Exercise Physiology
created the Physical Activity Readiness Medical Examina-
tion (PARmed-X) for Pregnancy [33]. The PARmed-X is a
guideline for health screening prior to participation in a
prenatal exercise program. Both the patient and her obstet-
ric care provider fill out the form during the course of rou-
tine prenatal care. The PARmed-X consists of a pre-exercise
health checklist including general health status, status of
current pregnancy, regular fitness/recreational activities
during the past month, and physical activity intentions
that the patient completes. The obstetric care provider
completes a section on contraindications to exercise, and
gives the woman a prescription for both aerobic activity
and muscular conditioning. This three-page form is quite
suitable for the time constraints of a routine prenatal
appointment, and includes all of the relevant information
for a healthy woman having an uncomplicated pregnancy.
Both the Canadian Academy of Sports Medicine and the
Society of Obstetricians and Gynaecologists of Canada
have endorsed the PARmed-X [38]. Although PARmed-X
has not been endorsed by any of the sports medicine or
obstetric societies in the United States, it does not diminish
its value to obstetric care providers. A copy of the PARmed-
X can be found at http://www.csep.ca/forms.asp.
Clearly, there is a gap in the medical literature concern-
ing the best way to counsel women on exercise during
pregnancy. By extrapolating data from research done on
the adult populations, and the work of our Canadian col-
leagues, we can begin to create an educational model. The
future should include prospective research in this area, as it
has the potential to benefit not one, but two lives.
Known Entities
It is crucial for physicians to understand both the benefits and
risks of exercise during pregnancy. This understanding will
enable the provider to engage in discussion, answer questions,
adapt exercise programs to fit individuals, and protect at risk
patients. Ideally, each patient is already following the 1995
guidelines from the Centers for Disease Control and Preven-
tion and the American College of Sports Medicine (CDC-
ACSM), which recommends the accumulation of 30 minutes
or more of moderate-intensity physical activity on most, prefer-
ably all, days of the week for all adults [39]. Without contrain-
dications, pregnant women should be held to the same
standards to promote overall health and fitness. The literature
shows no harmful effects of exercise on the mother or fetus
[23], and that women are able to maintain, or even improve,
their fitness during pregnancy [40,41]. Therefore, both the sed-
entary and active woman should be encouraged to exercise.
 Exercise During Pregnancy: A Practical Approach • Paisley et al.
Table 1. Physiologic changes during pregnancy
Cardiovascular
Cardiac output increases up to 50%
Resting heart rate increases 15 beats/min
Blood volume increases 45%
Respiratory
Minute ventilation increases 50%
Tidal volume increases
Resting oxygen requirements increase
Work of breathing increases
Endocrine/metabolic
Required energy intake increases 300 kcal/d
Carbohydrates are preferential fuel
Plasma glucose significantly reduced with 45 min
of exercise
Musculoskeletal
Joint laxity increases
Weight gain of 20–40 lbs
Lumbar lordosis increases
Physiologic adaptations of pregnancy related to exer-
c i s e h a v e b e e n we l l d e s c r i b e d by o t h e r a u t h o r s
[1,7,9,10,14]. Physicians prescribing exercise during preg-
nancy should be aware of these changes, and a brief sum-
mary can be found in Table 1. The clear maternal benefits
appear to be both physical and psychologic in nature.
Many common complaints of pregnancy, including
fatigue, varicosities, and swelling of the extremities, are
reduced in women who exercise [24,42]. Additionally,
when compared with sedentary counterparts, active
women experience less insomnia, stress, anxiety, and
depression [43]. There is some evidence that weight-bear-
ing exercise throughout pregnancy can reduce length of
labor and decrease delivery complications. In 1990, Clapp
[44] compared labors of women performing vigorous
weight-bearing exercise throughout pregnancy with “physi-
cally active” controls who discontinued their regular exer-
cise regimen before the end of the first trimester. Labor for
the active women was shorter than for controls, and there
was a decrease in need for forceps or cesarean section deliv-
ery, need for oxytocin, maternal exhaustion, and the need
to intervene secondary to fetal heart rate abnormalities.
Perhaps the strongest argument for exercise during
pregnancy falls in the realm of public health. Women
who incorporate exercise into their routine during preg-
nancy are more likely to continue exercising postpartum
than women who did not [45]. Clapp [46] also showed
that more than 90% of women who exercise during preg-
nancy continue exercising after delivery, and 70% reach
or exceed prepregnancy fitness levels. Women are more
aware of their personal health, as well as the potential
impact of their actions on their unborn child, during
pregnancy. Thus, it is the perfect time for the provider to
highlight physical activity and its protective effect on cor-
onary heart disease, hypertension, osteoporosis, diabe-
tes, and depression.
327
Neonatal and childhood benefits of exercise during
pregnancy are still being explored. Evidence to date has
suggested that fetuses of exercising women may tolerate
labor better than of nonexercising women. Interestingly,
Clapp [44] found that clinical evidence of stress, as exhib-
ited by meconium, Apgar scores, and fetal heart rate pat-
tern was less frequent in women who exercised at 50% of
their preconceptional level throughout pregnancy com-
pared with well-conditioned athletes who discontinued
exercise before the end of their first trimester. Additionally,
differences in morphometric and neurodevelopmental
outcome have been observed. Offspring of women who
exercised (running, aerobics, or cross country skiing) three
or more times each week, for more than 30 minutes a ses-
sion, were compared with those of women who regularly
exercised prior to pregnancy, but stopped all sustained
exercise except walking during pregnancy. At birth, head
circumference and length were similar, but the offspring of
the exercising women weighed less and had less fat. At age
5, the head circumference and height were similar, but the
children of exercising women weighed less and had a lower
sum of five-site skin folds. Neurodevelopmentally, motor,
integrative, and academic readiness skills were similar.
Exercise offspring did perform significantly better on the
Wechsler scales and tests of oral language skills [47]. There
is no clear explanation why exercise offspring showed
improved performance, but reassuringly for women choos-
ing to exercise during pregnancy, no deficits were noted.
At this time, there are relatively few absolute and rela-
tive contraindications to aerobic exercise in pregnancy
reported in the literature [5•]. These are screened for dur-
ing routine prenatal evaluation (Table 2). Relative con-
traindications should be evaluated on an individual basis,
and the benefits of exercise for the individual need to
clearly outweigh the risks prior to initiation of an exercise
program. Patients should also be made aware of warning
signs to stop exercise and seek medical evaluation.
Exercise Prescription
In the absence of contraindications, the development of an
exercise prescription requires individual adaptation.
Assessment of fitness status, current athletic/exercise activi-
ties, and individual goals of exercise should be considered.
The provider should identify if the patient’s exercise rou-
tine is performed primarily for stress relief and general fit-
ness, not undertaken at the time of evaluation, or done at a
high performance level. These classifications into seden-
tary, recreational athlete, and competitive athlete will help
guide the choice and intensity of activity.
Proposed guidelines for exercise during pregnancy
tend to follow the CDC-ASCM guideline for adults, which
suggests moderate intensity exercise (3–4 mets, or any
activity that is equivalent in difficulty to brisk walking)
[39], but controlled studies have yet to be performed. Per-
ceived exertion scales can be used as an alternative to
328 Special Populations
Table 2. Absolute and relative contraindications to
aerobic exercise in pregnancy
Absolute contraindications to exercise during pregnancy
Hemodynamically significant heart disease
Restrictive lung disease
Incompetent cervix/cerclage
Multiple gestation at risk for premature labor
Persistent 2nd or 3rd trimester bleeding
Placenta previa after 26 weeks gestation
Premature labor during the current pregnancy
Ruptured membranes
Pre-eclampsia/pregnancy-induced hypertension
Relative contraindications to exercise during pregnancy
Severe anemia
Unevaluated maternal cardiac arrhythmia
Chronic bronchitis
Poorly controlled type 1 diabetes
Extreme morbid obesity
Extreme underweight (body mass index < 12)
History of extremely sedentary lifestyle
Intrauterine growth restriction in current pregnancy
Poorly controlled hypertension
Orthopedic limitations
Poorly controlled seizure disorder
Poorly controlled hyperthyroidism
Heavy smoking
Warning signs to stop exercise and seek medical evaluation
Vaginal bleeding
Dyspnea prior to exertion
Dizziness
Headache
Chest pain
Muscle weakness
Calf pain or swelling
Preterm labor
Decreased fetal movement
Amniotic fluid leakage
(Adapted from the American College of Obstetricians and
Gynecologists [5•].)
heart rate monitoring [48], and a perceived exertion of
“somewhat hard” is a 12 to 14 on the 6 to 20 scale used in
PARmed-X, or a 3 to 5 on the Borg 1 to 10 scale. Develop-
ing and maintaining fitness, however, requires higher
activity, and the ACSM recommends 60% to 90% of max-
imal heart rate. Artal and O’ Toole [28•] advocated 60%
to 70% of maximal heart rate for women who were seden-
tary prior to pregnancy, and the upper range of the 60%
to 90% maximal heart rate for women wishing to main-
tain fitness during pregnancy. This correlates well with a
meta-analysis that found no significant adverse affects
with exercise intensities of 81% maximum heart rate [49].
The authors of this report advocate the PARmed-X
because of its comprehensive approach, and it appears to
correlate well with the suggestions of the ACSM and Artal
and O’ Toole [28•]. We propose an informal guide that
includes elements of all three, and takes competitive ath-
letes into account (Table 3). As a guide, however, it must
be emphasized that these suggestions are not absolutes,
Table 3. Exercise prescription
Sedentary
Frequency: minimum of 3 times per week
Intensity: perceived exertion = moderately hard, heart rate
65%–75% maximum
Type: low-impact (eg, walking, bicycling, swimming,
aerobics, water aerobics)
Time/duration: 30 minutes
Recreational athlete
Frequency: 3–5 times per week
Intensity: perceived exertion = moderately hard to hard,
heart rate 65%–80% maximum
Type: same as above plus prior activities such as running/
jogging, tennis, cross country skiing
Time/duration: 30–60 minutes
Elite athlete
Frequency: minimum of 4–6 times per week
Intensity: perceived exertion = hard, heart rate 75%–80%
maximum
Type: same as above plus some competitive activites,
depending on gestational age
Time/duration: 60–90 minutes
(Adapted from Joy EA: Exercise and pregnancy. In Family Practice
Obstetrics, edn 2. Edited by Ratcliffe SD. Philadelphia: Hanley &
Befus; 2001:81–88.)
no “safe” upper limit of exercise has been determined,
and pregnancy is not the optimal time to increase one’s
level of fitness. Additionally, all pregnant athletes must be
made aware of proper hydration, the additional nutri-
tional requirements of pregnancy and exercise, and the
dangers of heat stress. Routine obstetric evaluation must
be strongly recommended. Additional evaluation to
assess for fetal growth and well being may be appropriate
if clinically indicated.
Conclusions
Exercise during pregnancy should be encouraged for all
women who do not have known contraindications. Known
benefits of exercise apply during pregnancy, and there are
few absolute and relative contraindications. New areas of
benefit, such as gestational diabetes, are being explored,
and further research is needed to refine our current under-
standing and application of exercise during pregnancy in
varying populations. Tools are now available, such as the
PARmed-X, to facilitate the obstetric provider’s approach to
develop exercise programs for patients. Regular obstetric
visits should be used to monitor progress, and a common-
sense approach to exercise, avoiding dehydration and over-
exertion while monitoring thermoregulation and caloric
intake, and adapting exercise regimens based on changes
during pregnancy is needed. If more women develop sus-
tainable exercise habits during pregnancy, we may see
long-term individual and societal health benefits.
 Exercise During Pregnancy: A Practical Approach • Paisley et al.
References and Recommended Reading
Papers of particular interest, published recently, have been
highlighted as:
• Of importance
•• Of major importance
1. Artal R, Sherman C. Exercise during pregnancy: safe and bene-
ficial for most. Phys Sportsmed 1999, 27:51–52;54;57–58.
2. Artal R, Gardin K: Historical perspectives. In Exercise in Preg-
nancy. Edited by Artal R, Wiswell RA. Baltimore: Williams &
Wilkins; 1986:1–6.
3. American College of Obstetricians and Gynecologists: Exercise
during pregnancy and the postnatal period. In ACOG Home
Exercise Programs. Washington, DC: American College of Obste-
tricians and Gynecologists; 1985:1–5.
4. American College of Obstetricians and Gynecologists: Exercise
during pregnancy and the postpartum period. American Col-
lege of Obstetricians and Gynecologists Technical Bulletin
No. 189. Int J Gynecol Obstet 1994, 45:65–70.
5.• American College of Obstetricians and Gynecologists: Exercise
during pregnancy and the postpartum period. American Col-
lege of Obstetricians and Gynecologists Committee Opinion
No. 267. Obstet Gynecol 2002, 99:171–173.
This is the most recent guideline on exercise during pregnancy and
the postpartum from ACOG. It is much more liberal in its approach
than previous statements from ACOG.
6. Camporesi EM: Diving and pregnancy. Semin Perinatol
1996, 20:292–302.
7. Pivarnik JM: Cardiovascular responses to aerobic exercise
during pregnancy and postpartum. Semin Perinatol
1996, 20:242–249.
8. Bung P, Artal R: Gestational diabetes and exercise: a survey.
Semin Perinatol 1996, 20:328–333.
9. Veille JC: Maternal and fetal cardiovascular response to exer-
cise during pregnancy. Semin Perinatol 1996, 20:250–262.
10. Jaque-Fortunato SV, Wiswell RA, Khodiguian N, Artal R: A com-
parison of the ventilatory responses to exercise in pregnant,
postpartum, and nonpregnant women. Semin Perinatol
1996, 20:263–276.
11. Hale RW, Milne L: The elite athlete and exercise in pregnancy.
Semin Perinatol 1996, 20:277–284.
12. Katz VL: Water exercise in pregnancy. Semin Perinatol
1996, 20:285–291.
13. Huch R: Physical activity at altitude in pregnancy. Semin Perin-
atol 1996, 20:303–314.
14. Soultanakis HN, Artal R, Wiswell RA: Prolonged exercise in
pregnancy: glucose homeostasis, ventilatory and cardiovas-
cular responses. Semin Perinatol 1996, 20:315–327.
15. Dye TD, Knox KL, Artal R, et al.: Physical activity, obesity, and
diabetes in pregnancy. Am J Epidemiol 1997, 146:961–965.
16. Jovanovic-Peterson L, Peterson CM: Exercise and the nutri-
tional management of diabetes during pregnancy. Obstet
Gynecol Clinic North Am 1996, 23:75–86.
17. Bung P, Artal R, Khodiguian N, et al.: Exercise in gestational
diabetes: an optional therapeutic approach? Diabetes
1991, 40:182–185.
18. Clapp JF III, Capeless EL: Neonatal morphometrics after
endurance exercise during pregnancy. Am J Obstet Gynecol
1990, 163:1805–1811.
19. Bailey DM Davies B Budgett R et al.: Endurance training dur-
ing a twin pregnancy in a marathon runner. Lancet
1998, 351:1182.
20. Krandel KR, Kase T: Training in pregnancy women: effects on
fetal development and birth. Am J Obstet Gynecol
1998, 178:280–286.
21. Hatch MC, Shu XO, McLean DE, et al.: Maternal exercise dur-
ing pregnancy, physical fitness, and fetal growth. Am J Epide-
miol 1993, 137:1105–1114.
22. Clapp JR III, Capeless EL: Neonatal morphometrics after
endurance exercise during pregnancy. Am J Obstet Gynecol
1990, 163:1805–1811.
329
23. Sternfeld B, Quesenberry CP, Eskenazi B, Newman LA: Exercise
during pregnancy and pregnancy outcome. Med Sci Sports
Exerc 1995, 27:634–640.
24. Clapp JF III Little KD: Effects of recreational exercise on preg-
nancy weight gain and subcutaneous fat deposition. Med Sci
Sports Exerc 1995, 27:170–177.
25. Klebanoff MA, Shiona PH, Rhoads GG: Outcomes of preg-
nancy in a national sample of resident physicians. N Engl J
Med 1990, 323:1040–1045.
26. Clapp JF III Dickstein S: Endurance exercise and pregnancy
outcome. Med Sci Sports Exerc 1984, 16:556–562.
27. Abrams BF, Laros RK: Pregnancy weight, weight gain, and
birth weight. Am J Obstet Gynecol 1986, 154:503–509.
28.• Artal R, O’Toole M: Guidelines of the American College
of Obstetricians and Gynecologists for exercise during
pregnancy and the postpartum period. Br J Sports Med
2003, 37:6–12.
This article is a good review of the literature and summary of the 2002
Committee Opinion on Exercise During Pregnancy and the Postpar-
tum from ACOG.
29. Kramer MS: Aerobic exercise for women during pregnancy.
Cochrane Database Syst Rev 2002:CD000180.
30.•• Stevenson L, Alleyne J, Mottola MF, et al.: Position Statement:
Exercise and Pregnancy. http://www.casm-acsm.org.
This is a very practical guideline for exercise during pregnancy. It
endorses the PARmed-X, the participation readiness evaluation tool
developed by some of the authors of this paper.
31. Artal R: Exercise: an alternative therapy for gestational diabe-
tes. Phys Sportsmed 1996, 24:54–61.
32. Wang TW, Apgar BS: Exercise during pregnancy. Am Fam Phys
1998, 57:1846–1852.
33. Wolfe LA, Mottola MF: PARmed-X for Pregnancy: Physical Activity
Readiness Medical Examination. Ottawa, Ontario: Can Soc Exerc
Physiol; 1996.
34. Nordahal K, Kerr S, Petersen C: Fit to Deliver. Canada: Fit to
Deliver; 2000.
35. Petrella RJ, Lattanzio CN: Does counseling help patients get
active? Systematic review of the literature. Can Fam Phys
2002, 48:72–80.
36. Norris SL, Grothaus LC, Buchner DM, Pratt M: Effectiveness of
physican-based assessment and counseling for exercise in a
staff model HMO. Prevent Med 2000, 30:513–523.
37. Duffy FD, Schnirring L: How to counsel patients about
exercise: an office-friendly approach. Phys Sportsmed 2000,
28:53–58.
38. Davies G, Wolfe LA, Mottola MF: Joint SOGC/CSEP Clinical
Practice Guideline: exercise in pregnancy and the postpartum
period. Can J Apply Physiol 2003, 28:329–341.
39. Pate RR, Pratt M, Blair SN, et al.: A recommendation from the
Centers for Disease Control and Prevention and the Ameri-
can College of Sports Medicine. JAMA 1995, 273:402–407.
40. Clapp JF III, Capeless E: The V02 max of recreational athletes
before and after pregnancy. Med Sci Sports Exerc 1991,
23:1128–1133.
41. Kulpa PJ, White BM, Visscher R: Aerobic exercise in pregnancy.
Am J Obstet Gynecol 1987, 156:1395–1403.
42. Horns PN, Ratcliffe LP, Leggett JC, Swanson MS: Pregnancy
outcomes among active and sedentary primiparous women. J
Obstet Gynecol Neonatal Nurs 1996, 25:49–54.
43. Goodwin A, Astbury J, McMeeken J: Body image and
psychological well-being in pregnancy. A comparison of
exercisers and non-exercisers. Aust N Z J Obstet Gynaecol
2000, 40:442–447.
44. Clapp JF III: The course of labor after endurance exercise
during pregnancy. Am J Obstet Gynecol 1990, 163(6 Pt
1):1799–1805.
45. Devine CM, Bove CF, Olson CM: Continuity and change in
women's weight orientations and lifestyle practices through
pregnancy and the postpartum period: the influence of life
course trajectories and transitional events. Soc Sci Med
2000, 50:567–582.
 330 Special Populations

46. Clapp JF III: Exercise during pregnancy. A clinical update. Clin 48. Pivarnik JM: Maternal exercise during pregnancy. Sports Med
Sports Med 2000, 19:273–286. 1994, 18:215–217.
47. Clapp JF III: Morphometric and neurodevelopmental out- 49. American College of Sports Medicine: Guidelines for Exercise
come at age five years of the offspring of women who contin- Testing and Prescription, edn 6. Philadelphia: Lippincott Will-
ued to exercise regularly throughout pregnancy. J Pediatr iams & Wilkins; 2000.
1996, 129:856–863.

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