J. Perinat. Med.

2020; 48(6): 519–525

Review

Ioannis Tsakiridis, Dimitra Rafailia Bakaloudi, Artemis Christina Oikonomidou

Themistoklis Dagklis and Michail Chourdakis*

Exercise during pregnancy: a comparative review

of guidelines
https://doi.org/10.1515/jpm-2019-0419 Keywords: counselling; exercise; guidelines; physical
Received November 13, 2019; accepted April 27, 2020; activities; pregnancy.
published online July 3, 2020

Abstract: Exercise during pregnancy may be beneficial

provided that there are no contraindications. The aim of
Introduction
this study was to summarize and compare recommenda-
The adoption of a healthy lifestyle that includes appropriate
tions regarding exercise in pregnancy. Thus, a comparative
physical activity has been reported as beneficial in every
descriptive review was conducted and included guidelines
period of life, including pregnancy [1–3]. Regular exercise
by the American College of Obstetricians and Gynecolo-
during pregnancy for women without contraindications
gists, the Society of Obstetricians and Gynaecologists of
may have positive effects for both the pregnant woman and
Canada and the Royal Australian and New Zealand College
the fetus [2, 4–6]. These include, among others, prevention
of Obstetricians and Gynaecologists. All compared guide-
of musculoskeletal low back pain, reduction of excessive
lines recommend that pregnant women without contrain-
maternal weight-gain [7], lower incidence of gestational
dications should undertake physical activities regularly,
diabetes mellitus (GDM) [8], better glycemic control in cases
however, the type of workout performed should be
of pregestational diabetes [9], reduced rates of deep vein
adjusted based on the previous exercise experience and the
thrombosis and preeclampsia [10]. Moreover, physical ac-
physical condition of each pregnant woman. A variation
tivity has a positive effect on the psychological health of
among the reviewed guidelines was identified on appro-
pregnant women while they are facing the physical changes
priate and inappropriate activities and on indications to
which occur during pregnancy [11].
interrupt exercise. To summarize, the adoption of an in-
However, there are conditions in which pregnant
ternational up-to-date consensus regarding appropriate
women should not exercise to prevent the risk of fetal
exercise during pregnancy may be beneficial in ensuring
trauma or other complications of pregnancy. For that
the safety of the pregnant women while promoting their
reason, various pre-exercise screening tools have been
physical and mental health.
developed, which can help physicians to assess whether a
specific pregnant woman may exercise with safety [11]. As
Ioannis Tsakiridis and Dimitra Rafailia Bakaloudi share first
authorship.
every pregnancy is unique, personalized counseling and
monitoring on physical activity is necessary [2, 3, 6, 11, 12].
*Corresponding author: Michail Chourdakis, School of Medicine, The aim of this study was to summarize and compare the
Facutly of Health Sciences, Aristotle University, University Campus, guidelines on exercise during pregnancy from three major
54124, Thessaloniki, Greece, Phone: +30 2310 999035; Fax: +30 2312 national medical societies with international influence.
205270, E-mail: mhourd@gapps.auth.gr
Ioannis Tsakiridis and Themistoklis Dagklis: Third Department of
Obstetrics and Gynaecology, Department of Medicine, School of
Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Evidence acquisition
Greece, E-mail: igtsakir@auth.gr (I. Tsakiridis), dagklis@auth.gr
(T. Dagklis) Two national guidelines and a Committee Opinion pub-
Dimitra Rafailia Bakaloudi and Artemis Christina Oikonomidou: lished by the American College of Obstetricians and Gy-
Laboratory of Hygiene, Social & Preventive Medicine and Medical
necologists (ACOG 2015) [3], the Royal Australian and New
Statistics, School of Medicine, Facutly of Health Sciences, Aristotle
University of Thessaloniki, Thessaloniki, Greece,
Zealand College of Obstetricians and Gynaecologists
E-mail: dmpakalo@auth.gr (D.R. Bakaloudi), (RANZCOG 2016) [2] and the Society of Obstetricians and
artemis.oikonomidou@gmail.com (A.C. Oikonomidou) Gynaecologists of Canada (SOGC 2018) [11] which refer to
520 Tsakiridis et al.: Exercise in pregnancy: guidelines comparison

Table : Summary of recommendations for exercise during pregnancy.

ACOG RANZCOG SOGC

Country United States Austalia Canada

Issued   
Title Physical Activity and Exercise During Exercise during pregnancy Exercise in Pregnancy and the
Pregnancy and the Postpartum Period Postpartum Period
Page   
References   
Aerobic and strength- Recommended Recommended Recommended
conditioning type of
exercise
Intensity of exercise Talk test Talk test Talk test
Borg’s rating of perceived exertion Check heart rate Check heart rate
Borg’s rating of perceived exertion Borg’s rating of perceived exertion
Individualized exercise Recommended Recommended Not mentioned
Sedentary and obese Start exercise with low-intensity and Start exercise with low-intensity Start exercise with low-intensity
pregnant women gradual increase as able and gradual increase as able and gradual increase as able
Place to exercise Avoid extremely high temperatures and Avoid extremely high temperatures Not mentioned
humidity and humidity
Exercise in the post- Can be resumed after birth Not mentioned Can be resumed after birth
partum period
Breastfeeding and ex- Recommended Not mentioned Recommended
ercise

ACOG, The American College of Obstetricians and Gynecologists; RANZCOG, The Royal Australian and New Zealand College of Obstetricians and
Gynaecologists; SOGC, The Society of Obstetricians and Gynaecologists of Canada.

exercise during pregnancy were compared and a summary
of these recommendations is presented in Table 1.
Appropriate/inappropriate physical
pregnancy. Regarding duration of exercise, the ACOG
recommends 150 min of exercise per week (20–30 min/
day) as a satisfactory time for a pregnant woman, while
the RAZCOG suggests that 150-300 min of regular exercise
per week or 70–150 min of vigorous exercise per week (no

activities – contraindications to
exercise during pregnancy
It is important that pregnant women endorse physical ac-
tivities that do not increase the risk of fetal trauma. There is a
variety of activities that are considered safe during preg-
nancy. All activities recommended as safe in the guidelines
are summarized and presented in Table 2. Although exercise
during pregnancy may be beneficial, there are some activ-
ities which should not be offered to pregnant women. The
main differences among the guidelines are presented in
Table 2. Finally, the contraindications for exercise during
pregnancy are presented in Table 3.
Frequency and duration of exercise
All the guidelines agree that women without contraindi-
cations should be encouraged to take part in regular
aerobic and strength-conditioning exercise during
more than 60 min per session) is also acceptable. The
SOGC makes no official recommendation regarding
duration of exercise. As already mentioned, exercise in
pregnancy may have a positive aspect for the health of
both the mother and the fetus, while physical inactivity is
regarded as one of the most severe risk factors for
maternal mortality [13]. In addition, regular exercise
during pregnancy has not been correlated with any
adverse perinatal outcome [14, 15].
Intensity of exercise
Regarding exercise intensity, most pregnant women will
voluntarily reduce it as pregnancy progresses [3]. Athletes
will also reduce their activity levels during pregnancy [3]. In
addition, all the guidelines recommend the assessment of
perceived exertion (using Borg’s rating) and “talk test”, while
the SOGC and the RANZCOG also suggest that the conven-
tional heart rate target zone may be effective. The “talk test”
implies that the woman is able to maintain the level of
 Tsakiridis et al.: Exercise in pregnancy: guidelines comparison 521

Table : Summary of “safe”, “unsafe-dangerous” activities and “warning signs during exercise” during pregnancy.

ACOG RANZCOG SOGC

Safe activities during Walking Brisk walking Brisk walking

pregnancy Stationary cycling Stationary cycling Stationary cycling
Running or jogging Running Running or jogging
Swimming Swimming or water-based exercises Swimming or Aquafit aerobic
Strength training Strengthening exercises exercises
Yoga Cross-country skiing
Pilates Exercises at altitudes above
Racquet sports  m
Unsafe-dangerous Contact sports (e. g. Ice hockey, Activities involving jumping or Scuba dive
activities during boxing soccer and basketball) bouncing Horseback riding
pregnancy Activities with high risk of falling Activities involving frequent Downhill skiing
(e. g., downhill snow skiing, water direction changes (court sports) Ice hockey
skiing, surfing, off-road cycling, Learning to ski Gymnastics
gymnastics and horseback riding) Team sport games Cycling
Scuba diving
Sky diving
“Hot yoga” or “Hot pilates”
Warning signs during Vaginal bleeding Vaginal bleeding Vaginal bleeding
exercise during Painful urinary contractions Painful urinary, pelvic, abdomen Painful urinary contractions
pregnancy Amniotic fluid leakage contractions Amniotic fluid leakage
Chest pain Amniotic fluid leakage Chest pain
Dyspnea Chest pain Dyspnea
Dizziness Dyspnea Presyncope
Headache Dizziness
Muscle weakness which affect Headache
balance Muscle weakness
Calf pain or swelling Calf pain or swelling
Feeling faint
Swelling
Redness
Sudden swelling of the ankles/
hands/face
Decreased fetal movement

ACOG, The American College of Obstetricians and Gynecologists; RANZCOG, The Royal Australian and New Zealand College of Obstetricians and
Gynaecologists; SOGC, The Society of Obstetricians and Gynaecologists of Canada.

physical activity since she is able to participate in a conver- Individualized exercise

sation [16]. As for the evaluation of the heart rate, it has been
shown that there is an increase of 10–15 beats/minute in
pregnancy, but there is also a blunted heart rate response in
extreme levels of exercise [17]. According to the Physical
Activity Readiness Medical Examination for Pregnancy [18]
the target heart rate zones for aerobic exercise in pregnancy
are: for pregnant women <20 years old 140–155 bpm, 20–29
years old 135–150 bpm and 30–39 years old 130–145 bpm
respectively. The 6–20 Borg’s scale of perceived exertion is a
way to evaluate the intensity of exercise during pregnancy
[19]. High-intensity exercise is associated with hypoglycemia
in pregnancy [20]. As for strengthening exercises, pregnant
women should avoid heavy-lifting, since heavy loads may
lead to preterm birth [21].
Given that every pregnancy is unique, the ACOG and the
RANZCOG recommend that the exercise program should
be individualized to the needs of each pregnant woman.
Recommendations concerning the type, frequency,
duration and intensity of exercise should be given ac-
cording to the pregnant woman’s medical and physical
condition. According to all guidelines, previously highly-
active women may continue their activities, after appro-
priate counselling on adjustment of their vigorous exer-
cise. In fact, there is still a gap in the current literature
regarding the upper limit of strenuous exercise during
pregnancy and its correlation with favorable perinatal
outcomes [20].
522 Tsakiridis et al.: Exercise in pregnancy: guidelines comparison

Table : Summary of contraindications to exercise during pregnancy.

ACOG RANZCOG SOGC

General Cardiovascular disease

contraindications Poorly controlled asthma
Poorly controlled diabetes
Bone/joint problems
Lack of time
Physical discomfort
Fatigue
Uncertainty about exercise
guidelines and how to exercise
properly
Persistent bleeding
Placenta previa
Preeclampsia
Pregnancy-induced
hypertension
Indicators of increased
risk of
premature labor (multiple
pregnancy,
ruptured membranes,
premature
contractions, shortened
cervical length)
Fetal growth restriction
Poorly controlled thyroid
disease
Anemia
Absolute Hemodynamically significant Systemic disorder
contraindications heart Ruptured membranes
disease Preterm labour
Restrictive lung disease Hypertensive disorders of
Incompetent cervix or cerclage pregnancy
Multiple gestation at risk of Incompetent cervix
premature labor Growth restricted fetus
Persistent second- or High order multiple gestation
third- trimester bleeding Placenta previa after th week
Placenta previa after  weeks of Persistent nd or rd trimester
gestation bleeding
Premature labor during the Uncontrolled type I diabetes,
current pregnancy thyroid disease, or other serious
Ruptured membranes cardiovascular,
Preeclampsia respiratory, or systemic
Severe anemia disorder

Relative Anemia Previous spontaneous abortion

contraindications Unevaluated maternal cardiac Previous preterm birth
arrhythmia Mild/moderate cardiovascular
Chronic bronchitis disorder
Poorly controlled type  dia- Mild/moderate respiratory
betes disorder
Extreme morbid obesity Anemia (Hb < g/L)
Extreme underweight (BMI <) Malnutrition or eating disorder
History of extremely sedentary Twin pregnancy after th week
lifestyle Other significant medical
Intrauterine growth restriction conditions
 Tsakiridis et al.: Exercise in pregnancy: guidelines comparison 523

Table : (continued)

ACOG RANZCOG SOGC

in
current pregnancy
Poorly controlled hypertension
Orthopedic limitations
Poorly controlled seizure
disorder
Poorly controlled
hyperthyroidism
Heavy smoker

ACOG, The American College of Obstetricians and Gynecologists; RANZCOG, The Royal Australian and New Zealand College of Obstetricians and
Gynaecologists; SOGC, The Society of Obstetricians and Gynaecologists of Canada.

On the other hand, according to all guidelines, Indications to stop exercise

sedentary women before pregnancy should be advised
to start exercise with low-intensity and gradually in-
crease the intensity according to their ability. An
example proposed by SOGC is to start exercise three
times a week with a duration of 15 min and after some
time, the frequency and the duration are gradually
increased four times a week of 30 min continuous ex-
ercise. Similarly, obese pregnant women should start
with low-intensity and short-duration physical activ-
ities; moderate exercise should be recommended for
those women with safety [22].
Due to the lack of evidence regarding the effect of
exercise for women at high risk for fetal growth
restriction, it seems prudent for those women to reduce
their level of exercise in the second and third trimesters
[3].
Exercise setting
The ACOG and the RANZCOG describe that conditions
under which a pregnant woman should exercise, while
the SOGC makes no relevant recommendation. They state
that pregnant women should be appropriately hydrated
and wear loose and comfortable clothes. Moreover, it is
necessary for women to avoid an environment with
extremely high temperatures and humidity in order to
protect themselves from heat stress. Exposure to heat
from sources like saunas is correlated to neural tubal
defects of the fetus, and therefore these places should be
avoided during pregnancy [23]. Evidence from a sys-
tematic review found that the highest mean end-trial
temperature was 38.3 °C for land-based exercise, 37.5 °C
for water immersion exercise, 36.9 °C for hot water
bathing and 37.6 °C for sauna exposure [24].
All the guidelines agree that there are some warning signs
that if noted by pregnant women during exercise they
should interrupt their activity and seek advice by their
physician. These warnings signs are summarized and
presented in Table 2.
Exercise during the postpartum
period and breastfeeding
The ACOG and the SOGC make specific recommendations
regarding exercise in the postpartum period, while the
RANZCOG makes no recommendation. Moreover, the
ACOG and the SOGC highlight the importance of pelvic
floor exercise. Appropriate pelvic floor muscle training is
beneficial and can prevent pelvic floor trauma and future
incontinence [25, 26]. In addition, they state that exercise
routines may be resumed after birth, depending on the
mode of delivery and associated discomfort. Evidence has
shown that exercise is associated with reduced rates of
postpartum depression and stress [27, 28].
The ACOG and the SOGC state that exercise during the
breastfeeding period does not affect negatively the milk
production. However, normal intensity exercise is recom-
mended because vigorous exercise increases lactic acid
[19, 29]. Furthermore, exercise improves the cardiovascular
fitness of the lactating mother without negatively affecting
the child’s growth [30].
Conclusions
Exercise during pregnancy may be beneficial for the preg-
nant woman and the fetus but can also have detrimental
524 Tsakiridis et al.: Exercise in pregnancy: guidelines comparison
effects if medical or obstetric contraindications exist.
Healthcare providers should be well trained and prepared
to manage pregnant women who exercise. Similar recom-
mendations were identified regarding the frequency,
duration and intensity of exercise during pregnancy. On the
contrary, a variation among the reviewed guidelines exists
on important issues, including appropriate and inappro-
priate activities and indications to interrupt exercise.
The major strength of this study is the comparison of
major national guidelines on exercise during pregnancy.
The main limitations of the study are that first, the search
was restricted to guidelines published in English and that
although recent, not all guidelines were published in the
same year.
In summary, exercise during pregnancy is generally
encouraged; however healthcare providers should be
aware that there are specific contraindications and warn-
ing signs to stop exercise. With appropriate guidance
regarding their physical activities, pregnant women will
have the opportunity to benefit from the positive effects of
exercise without jeopardizing the health of themselves or
their fetuses.
Practical implications
• Exercise is generally not contraindicated during preg-
nancy and may be beneficial for the pregnant woman
and the fetus.
• Adequate information and training among healthcare
providers can result in a better management of manage
pregnant women who exercise.
• Similarities in recommendations from different bodies
were identified regarding the frequency, duration and
intensity of exercise during pregnancy.
• On the contrary, a variation among the reviewed
guidelines exists on important issues, including
appropriate and inappropriate activities and in-
dications to interrupt exercise.
Research funding: None declared.
Author contributions: Ioannis Tsakiridis developed the
original idea for the study and participated in the
manuscript writing. Dimitra Rafailia Bakaloudi and
Artemis Christina Oikonomidou evaluated the data and
participated in the manuscript writing. Themistoklis
Dagklis supervised the manuscript development. Michail
Chourdakis supervised the manuscript development,
participated in the revision and submitted the article. All
the authors have accepted responsibility for the entire
content of this submitted manuscript and approved
submission.
Competing interests: Authors state no conflict of interest.
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