Postpartum Depression Safe to Getting Pregnant Again

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Number 804 (Replaces Commission Opinion Number 650, December 2015)

Committee on Obstetric Practice

This Committee Opinion was developed by the Committee on Obstetric Do with the assistance of committee members Meredith L. Birsner, MD; and Cynthia Gyamfi-Bannerman, Physician, MSc.

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Abstruse: Exercise, defined equally physical activity consisting of planned, structured, and repetitive bodily movements done to improve one or more components of physical fettle, is an essential chemical element of a good for you lifestyle, and obstetrician–gynecologists and other obstetric care providers should encourage their patients to continue or to commence exercise as an important component of optimal health. Women who habitually engaged in vigorous-intensity aerobic activity or who were physically active earlier pregnancy can continue these activities during pregnancy and the postpartum period. Observational studies of women who exercise during pregnancy have shown benefits such as decreased gestational diabetes mellitus, cesarean birth and operative vaginal delivery, and postpartum recovery time. Physical action also tin exist an essential factor in the prevention of depressive disorders of women in the postpartum menstruation. Physical activity and exercise in pregnancy are associated with minimal risks and have been shown to benefit most women, although some modification to do routines may be necessary because of normal anatomic and physiologic changes and fetal requirements. In the absence of obstetric or medical complications or contraindications, concrete activity in pregnancy is safety and desirable, and pregnant women should exist encouraged to proceed or to initiate safe physical activities. This certificate has been revised to incorporate contempo evidence regarding the benefits and risks of physical activity and do during pregnancy and the postpartum menstruation.

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Recommendations

Regular concrete activeness in all phases of life, including pregnancy, promotes wellness benefits. Pregnancy is an ideal time for maintaining or adopting a healthy lifestyle and the American College of Obstetricians and Gynecologists makes the post-obit recommendations:

• Physical activity and exercise in pregnancy are associated with minimal risks and have been shown to benefit almost women, although some modification to do routines may be necessary considering of normal anatomic and physiologic changes and fetal requirements.

• A thorough clinical evaluation should be conducted earlier recommending an exercise program to ensure that a patient does not accept a medical reason to avoid practice.

• Women with uncomplicated pregnancies should be encouraged to engage in aerobic and strength-conditioning exercises before, during, and after pregnancy.

• Obstetrician–gynecologists and other obstetric intendance providers should evaluate women with medical or obstetric complications carefully before making recommendations on physical activeness participation during pregnancy. Activity restriction should non be prescribed routinely as a treatment to reduce preterm birth.

• Additional research is needed to study the effects of practice on pregnancy-specific conditions and outcomes and to clarify farther effective behavioral counseling methods and the optimal type, frequency, and intensity of exercise. Similar research is needed to create an improved evidence base concerning the effects of occupational concrete activity on maternal–fetal health.

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Introduction

This document has been revised to contain contempo evidence regarding the benefits and risks of concrete activity and exercise during pregnancy and the postpartum period. Physical activity , defined as any actual movement produced by the wrinkle of skeletal muscles ane in all stages of life, maintains and improves cardiorespiratory fettle, reduces the risk of obesity and associated comorbidities, and results in greater longevity. Women who begin their pregnancy with a healthy lifestyle (eg, practice, skilful nutrition, nonsmoking) should be encouraged to maintain those healthy habits. Women who exercise not have salubrious lifestyles should be encouraged to view the prepregnancy menstruation and pregnancy as opportunities to embrace healthier routines. Do , defined as physical action consisting of planned, structured, and repetitive bodily movements done to improve one or more components of physical fettle 1, is an essential element of a healthy lifestyle, and obstetrician–gynecologists and other obstetric intendance providers should encourage their patients to proceed or to embark exercise as an important component of optimal wellness.

The World Health Organization and the American College of Sports Medicine accept issued bear witness-based recommendations indicating that the benign effects of practise in almost adults are indisputable and that the benefits far outweigh the risks 2 3.

The 2022 update to the U.Southward. Department of Health and Human Services Concrete Activeness Guidelines for Americans reinforces prior recommendations of at to the lowest degree 150 minutes of moderate intensity aerobic action per calendar week during pregnancy and the postpartum period 4. This action should be spread throughout the week. The guidelines propose that women who habitually engaged in vigorous-intensity aerobic activity or who were physically active before pregnancy can continue these activities during pregnancy and the postpartum period. Additionally, women who are pregnant should be nether the care of an obstetrician-gynecologist or other obstetric care provider who can monitor the progress of the pregnancy. Women who are pregnant tin consult their obstetrician–gynecologist or other obstetric care provider about whether or how to adapt their physical activeness during pregnancy and postpartum four.

Physical inactivity is the fourth-leading risk factor for early mortality worldwide two. In pregnancy, physical inactivity and excessive weight gain have been recognized as independent risk factors for maternal obesity and related pregnancy complications, including gestational diabetes mellitus (GDM) 5 6 7. Concerns that regular physical activity during pregnancy may cause miscarriage, poor fetal growth, musculoskeletal injury, or premature delivery take not been substantiated for women with uncomplicated pregnancies viii 9 10 11 12. In the absence of obstetric or medical complications or contraindications, physical activeness in pregnancy is prophylactic and desirable, and significant women should be encouraged to continue or to initiate safe physical activities Box 1 , Box 2.

Examples of Exercises That Have Been Extensively Studied in Pregnancy and Found to Be Rubber and Beneficial

• Walking

• Stationary cycling

• Aerobic exercises

• Dancing

• Resistance exercises (eg, using weights, elastic bands)

• Stretching exercises

• Hydrotherapy, water aerobics

Modified from Berghella V, Saccone Thousand. Do in pregnancy! Am J Obstet Gynecol 2017;216:335–7.

Benefits of Exercise in Pregnancy

Higher incidence of:

• Vaginal delivery

Lower incidence of:

• Excessive gestational weight gain

• Gestational diabetes mellitus

• Gestational hypertensive disorders^*

• Preterm nativity

• Cesarean nativity

• Lower birth weight

*Defined as gestational hypertension or preeclampsia

Modified from Berghella Five, Saccone G. Do in pregnancy! Am J Obstet Gynecol 2017;216:335–7.

Virtually meaning patients tin exercise. There are few maternal medical weather condition in which aerobic exercise is absolutely contraindicated. When questions exist regarding rubber of aerobic exercise in pregnancy, consultation with relevant specialists and subspecialists (eg, obstetrics and gynecology, maternal–fetal medicine, cardiology, pulmonology), when indicated, is brash. In women who accept obstetric or medical comorbidities, exercise regimens should be individualized. Obstetrician–gynecologists and other obstetric intendance providers should evaluate women with medical or obstetric complications carefully before making recommendations on concrete activity participation during pregnancy.

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Anatomic and Physiologic Aspects of Exercise in Pregnancy

Pregnancy results in anatomic and physiologic changes that should be considered when prescribing practice. The most distinct changes during pregnancy are weight gain and a shift in the point of gravity that results in progressive lordosis. These changes pb to an increase in the forces across joints and the spine during weight-begetting exercise. As a consequence, more than than lx% of all pregnant women experience low back pain 13. Strengthening abdominal and back muscles could minimize this take chances. Blood volume, middle rate, stroke book, and cardiac output normally increase during pregnancy, and systemic vascular resistance decreases Table i. These hemodynamic changes establish the circulatory reserve necessary to sustain the pregnant adult female and fetus at rest and during practice. Maintaining a supine position during exercise after twenty weeks of gestation may result in decreased venous return due to aortocaval compression from the gravid uterus, leading to hypotension, and this hemodynamic alter should be considered when prescribing exercise modifications in pregnancy xiv fifteen 16.

In pregnancy, there also are profound respiratory changes. Infinitesimal ventilation increases upwardly to fifty%, primarily as a result of the increased tidal book. Because of a physiologic decrease in pulmonary reserve, the power to practice anaerobically is impaired, and oxygen availability for aerobic exercise and increased work load consistently lags. The physiologic respiratory alkalosis of pregnancy may not exist sufficient to compensate for the developing metabolic acidosis of strenuous exercise. Decreases in subjective work load and maximum exercise performance in pregnant women, specially in those who are overweight or obese, limit their ability to engage in more strenuous physical activities 17. Aerobic preparation in pregnancy has been shown to increment aerobic capacity in normal weight and overweight meaning women xviii 19 20.

Temperature regulation is highly dependent on hydration and environmental weather. During practise, pregnant women should stay well hydrated, wear loose-fitting habiliment, and avert high rut and humidity to protect against heat stress, particularly during the kickoff trimester one. Although exposure to oestrus from sources such as hot tubs, saunas, or fever has been associated with an increased chance of neural tube defects 21, exercise would not be expected to increase core body temperature into the range of business organisation. At least ane study found no association between exercise and neural tube defects 22.

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Fetal Response to Maternal Practise

Well-nigh of the studies addressing fetal response to maternal do have focused on fetal centre rate changes and birth weight. Studies have demonstrated minimum to moderate increases in fetal heart rate by ten–30 beats per minute over the baseline during or after exercise 23 24 25 26. Three meta-analyses concluded that the differences in nascence weight were minimal to none in women who exercised during pregnancy compared with controls 27 28 29. However, women who continued to practice vigorously during the third trimester were more likely to deliver infants weighing 200–400 g less than comparable controls, although in that location was non an increased risk of fetal growth restriction 27 28 29. A cohort study that assessed umbilical artery claret period, fetal heart rates, and biophysical profiles before and after strenuous practise in the second trimester demonstrated that xxx minutes of strenuous exercise was well tolerated past women and fetuses in agile and inactive meaning women 26. More data are needed from athletes who may exert across the accustomed "vigorous" definition of up to 85% of capacity, and it is possible that there is an absolute level of intensity (or elapsing, or both) that exists, and if exceeded, could place the fetus at gamble. Individualized practise prescriptions may be warranted in pregnant athletes to ascertain whether there is a threshold beyond which fetal well-being may be compromised thirty.

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Benefits of Do During Pregnancy

The benefits of exercise during pregnancy are numerous Box 2 31. Regular aerobic exercise during pregnancy has been shown to improve or maintain physical fitness 8 9 27. Observational studies of women who exercise during pregnancy have shown benefits such as decreased GDM (Odds Ratio [OR] 0.103; 95% CI, 0.013–0.803) half-dozen 32 33 34, cesarean nascence (Relative Chance 0.69, 95% CI, 0.42, 0.82) 35 and operative vaginal delivery nine 35 36, and postpartum recovery fourth dimension 9. Physical activity also tin can be an essential gene in the prevention of depressive disorders of women in the postpartum period 37 38. In pregnancy, greater self-reported overall physical fitness and cardiorespiratory fitness are associated with less actual pain, lumbar and sciatic pain, and reduced pain disability 39. Studies are needed to explore whether improving physical fitness before and during pregnancy could decrease pain during the peripartum period.

A 2022 randomized controlled trial that included 300 overweight or obese women with unproblematic, singleton gestations at less than 13 weeks of gestation found that cycling exercises initiated in the outset trimester and performed at least 30 minutes, 3 times per week until 37 weeks of gestation, significantly reduced the incidence of GDM, significantly reduced gestational weight gain at less than 25 weeks of gestation, and lowered neonatal birth weight 40. Although these investigators found no significant differences between the exercise and command groups in the incidence of other outcomes, such as preterm birth, gestational hypertension, cesarean birth, and macrosomia, all these outcomes were less frequent in the practise grouping.

A 2022 systematic review and meta-assay 41 showed a significantly reduced risk of gestational hypertensive disorders, gestational hypertension, and cesarean birth in women who performed aerobic exercise thirty–60 minutes 2–seven times per week, as compared with women who were more sedentary 41. Studies take shown that practice during pregnancy tin can lower glucose levels in women with GDM 42 43 or assistance preclude preeclampsia 44. Exercise has shown only a modest decrease in overall weight proceeds (1–two kg) in normal weight, overweight, and obese women 45 46. Another 2022 systematic review and meta-analysis 47 showed that, for overweight and obese women with a singleton pregnancy, compared with women who were more sedentary, aerobic practice for well-nigh 30–60 minutes 3–7 times per week during pregnancy is associated with a reduction in the incidence of preterm birth (RR 0.62, 95% CI, 0.41–0.95) 47. Aerobic exercise in overweight and obese pregnant women too is associated with a significantly lower incidence of GDM and, therefore, should be encouraged 47. A 2022 systematic review and meta-analysis in normal-weight pregnant women with a singleton unproblematic gestation showed that aerobic exercise for 35–90 minutes 3–iv times per week is non associated with an increased risk of preterm birth or with a reduction in hateful gestational age at delivery. Practise was associated with a significantly higher incidence of vaginal delivery and a significantly lower incidence of cesarean birth, with a significantly lower incidence of GDM and hypertensive disorders 48. Finally, a 2022 systematic review and meta-analysis 49 found that in mothers with pregestational medical conditions (chronic hypertension, type 1 diabetes and blazon 2 diabetes), prenatal exercise reduced the odds of cesarean birth by 55% and did non increase the risk of agin maternal and neonatal outcomes (OR 0.45; 95% CI, 0.22–0.95) although findings are based on limited evidence, suggesting a demand for high-quality investigations on exercise in this population of women.

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Recommending an Exercise Program

Motivational Counseling

Pregnancy is an ideal fourth dimension for beliefs modification and adoption of a good for you lifestyle because of increased motivation and frequent access to medical supervision. Patients are more likely to control weight, increase concrete activity, and ameliorate their diet if their physician recommends that they do so l. Motivational counseling tools such equally the Five A's (Inquire, Advise, Assess, Aid, and Arrange), originally adult for smoking cessation, have been used successfully for diet and exercise counseling 51 52. Obstetrician–gynecologists and other obstetric care providers tin can consider adopting the Five A's approach for women with uncomplicated pregnancies who have no contraindications to exercise.

Prescribing an Individualized Exercise Program

The principles of exercise prescription for meaning women do not differ from those for the general population 4. A thorough clinical evaluation should be conducted earlier recommending an practice program to ensure that a patient does non have a medical reason to avoid exercise. An exercise programme that leads to an eventual goal of moderate-intensity practice for at to the lowest degree 20–thirty minutes per mean solar day on nigh or all days of the week should be developed with the patient and adjusted as medically indicated.

Because blunted and normal center-rate responses to exercise take been reported in significant women, the utilize of ratings of perceived exertion may exist a more constructive means to monitor exercise intensity during pregnancy than heart-rate parameters 53. For moderate-intensity practice, ratings of perceived exertion should exist 13–14 (somewhat hard) on the Borg ratings of perceived exertion scale Tabular array two. Using the "talk test" is another fashion to measure out exertion: as long as a woman tin carry on a conversation while exercising, she likely is not overexerting herself 54. Women should be brash to remain well hydrated, avoid long periods of lying flat on their backs, and terminate exercising if they have any of the warning signs listed in Box 3 .

Warning Signs to Discontinue Exercise While Pregnant

• Vaginal bleeding

• Intestinal pain

• Regular painful contractions

• Amniotic fluid leakage

• Dyspnea before exertion

• Dizziness

• Headache

• Chest pain

• Muscle weakness affecting balance

• Calf pain or swelling

Meaning women who were sedentary earlier pregnancy should follow a more gradual progression of practise. Although an upper level of prophylactic exercise intensity has not been established, women who were regular exercisers before pregnancy and who have uncomplicated, salubrious pregnancies should be able to engage in high-intensity exercise programs, such as jogging and aerobics, with no adverse effects. High-intensity or prolonged do in backlog of 45 minutes can pb to hypoglycemia; therefore, acceptable caloric intake before practise, or limiting the intensity or length of the practise session, is essential to minimize this take a chance 55.

Prolonged exercise should exist performed in a thermoneutral environment or in controlled environmental weather (facilities with air-conditioning) and pregnant women should avoid prolonged exposure to oestrus 56 and pay close attention to proper hydration and caloric intake. In studies of pregnant women who exercised in which physical activity was self-paced in a temperature-controlled environment, core body temperatures rose less than ane.5°C over 30 minutes and stayed within safe limits 31. Table three lists suggestions for an exercise plan in pregnancy 31. Finally, although physical action and dehydration in pregnancy have been associated with a small-scale increase in uterine contractions 57, a 2022 systematic review and meta-analysis in normal-weight significant women with singleton unproblematic gestations demonstrated that exercise for 35–90 minutes 3–4 times per week is not associated with an increased risk of preterm birth or with a reduction in mean gestational age at delivery 48.

Types of Exercises

Box one lists examples of safe exercises in pregnancy. Women with uncomplicated pregnancies should be encouraged to engage in aerobic and forcefulness-conditioning exercises before, during, and subsequently pregnancy. Contact activities with high risk of abdominal trauma or imbalance should be avoided. Scuba diving should exist avoided in pregnancy because of the inability of the fetal pulmonary circulation to filter bubble formation 58. Women living at body of water level were able to tolerate physical action up to altitudes of 6,000 anxiety, suggesting this distance is safe in pregnancy 59, although more than research is needed. Women who reside at higher altitudes may exist able to practise safely at altitudes college than 6,000 feet.

In those instances in which women experience low-back hurting, exercise in water is an alternative sixty. A study of the apparent weight reduction during h2o immersion in a 3rd-trimester pregnant woman measured a mean of 82.9% of torso weight, a reduction that lowers the maternal osteoarticular load due to buoyancy 61. There may be additional benefits of aquatic exercise likewise. A randomized controlled trial of an aquatic physical exercise program during pregnancy consisting of three 60-minute exercises demonstrated a greater rate of intact perineum after childbirth (OR thirteen.54, 95% CI, 2.75–66.56) 62.

Special Populations

Meaning Women With Obesity

Pregnant women with obesity should exist encouraged to appoint in a healthy lifestyle modification in pregnancy that includes physical activities and judicious diets 5. Women should start with depression-intensity, short periods of exercise and gradually increase the flow or intensity of exercise equally they are able. In contempo studies examining the furnishings of exercise among meaning women with obesity, women assigned to exercise demonstrated modest reductions in weight gain and no agin outcomes 45 63.

Athletes

Vigorous-intensity exercise completed into the third trimester appears to be safe for most good for you pregnancies. Further enquiry is needed on the furnishings of vigorous-intensity exercise in the first and second trimesters and of exercise intensity exceeding 90% of maximum heart rate 64. Competitive athletes require frequent and shut supervision because they tend to maintain a more strenuous grooming schedule throughout pregnancy and resume high-intensity grooming postpartum sooner than other women. Such athletes should pay detail attention to avoiding hyperthermia, maintaining proper hydration, and sustaining adequate caloric intake to prevent weight loss, which may adversely affect fetal growth.

An aristocracy athlete tin can exist defined generally as an athlete with several years of experience in a particular sport or sports who has competed successfully against other high level performers and trains twelvemonth-round at a high level; an elite athlete generally trains at to the lowest degree 5 days per week, averaging close to 2 hours per day throughout the yr thirty. In add-on to aerobic training, elite athletes in most sports as well participate in resistance grooming to increment muscular strength and endurance; still, this grooming was not considered a safety activeness in early on guidelines for exercise during pregnancy because of potential injury and possible fetal heart decelerations resulting from Valsalva maneuvers. Consequently, there is thin literature on this topic xxx. Information technology is prudent for elite athletes who wish to keep strenuous activeness during pregnancy to have a clear understanding of the risks, to obtain approval from their health care providers, and to consider decreasing resistance load compared with prepregnant conditions. High-bear upon activities with increased adventure of blunt trauma should be avoided, and it also is important that the significant elite athlete avert overheating when performing their sport or participating in intense training thirty.

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Activity Restriction

Several reviews accept adamant that there is no credible bear witness to prescribe bed residual in pregnancy for the prevention of preterm labor, and it should not exist routinely recommended 65 66. Patients prescribed prolonged bed residual or restricted physical action are at risk of venous thromboembolism, bone demineralization, and deconditioning. There are no studies documenting an comeback in outcomes in women at risk for preterm birth who are placed on activeness brake, including bed rest, and in that location are multiple studies documenting untoward effects of routine activity brake on the mother and family, including negative psychosocial effects. Activity restriction should not be prescribed routinely as a handling to reduce preterm nascency 67. Additionally, there is no testify that bed rest reduces preeclampsia risk, and it should non be routinely recommended for the primary prevention of preeclampsia and its complications 68.

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Occupational Physical Activity

The show regarding a possible association betwixt fetal–maternal wellness outcomes and occupational physical activity is mixed and express. A meta-analysis based on 62 reports assessed the evidence relating preterm delivery, low birth weight, modest for gestational age, preeclampsia, and gestational hypertension to five occupational exposures (work hours, shift work, lifting, standing, and physical work load) 69. Although the analysis was limited by the heterogeneity of exposure definitions, especially for lifting and heavy piece of work load, most of the estimates of run a risk pointed to small or null effects. In contrast, a cohort study of more than 62,000 Danish women reported a dose–response relationship between total daily brunt lifted and preterm nascency with loads more than 1,000 kg per twenty-four hour period 70. In this written report, lifting heavy loads (greater than 20 kg) more 10 times per day was associated with an increased risk of preterm nascency.

The National Institute for Occupational Safety and Health uses an equation that determines the maximum recommended weight limit for lifting that would be acceptable to 90% of healthy women 71. This equation has been used to ascertain recommended weight limits for a broad range of lifting patterns for pregnant women, besides as lifting weather condition that pose a higher take a chance of musculoskeletal injury 72 Effigy 1. Obstetrician–gynecologists and other obstetric care providers tin use their all-time clinical judgment to decide a recommended program for the patient. This plan may include a formal request for an occupational health professional person to perform an analysis to determine maximum weight limits based on actual lifting condition or assistance with writing appropriate letters to employers to aid obtain accommodations 73.

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Exercise in the Postpartum Menstruation

Several reports indicate that women's level of participation in practise programs diminishes after childbirth, oft leading to overweight and obesity 74 75. The postpartum menses is an opportune time for obstetrician–gynecologists and other obstetric care providers to recommend and reinforce a healthy lifestyle. Resuming exercise or incorporating new practise routines after commitment is important in supporting lifelong salubrious habits. Practise routines may be resumed gradually after pregnancy every bit soon every bit medically condom, depending on the style of commitment (vaginal or cesarean birth) and the presence or absenteeism of medical or surgical complications. Some women are capable of resuming physical activities within days of delivery. Pelvic floor exercises can be initiated in the firsthand postpartum menstruation. Intestinal strengthening exercises, including abdominal crunch exercises and the drawing-in do, a maneuver that increases abdominal pressure past pulling in the abdominal wall muscles, have been shown to decrease the incidence of diastasis recti abdominus and decrease the inter-rectus distance in women who gave birth vaginally or by cesarean birth 76 77.

Regular aerobic exercise in lactating women has been shown to improve maternal cardiovascular fettle without affecting milk production, composition, or baby growth 78. Women who are lactating should consider feeding their infants or expressing milk before exercising to avoid discomfort of engorged breasts. They also should ensure adequate hydration before commencing concrete activity.

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Conclusion

Physical activity and exercise in pregnancy are associated with minimal risks and take been shown to benefit most women, although some modification to exercise routines may exist necessary because of normal anatomic and physiologic changes and fetal requirements. In the absence of obstetric or medical complications or contraindications, physical action in pregnancy is condom and desirable, and meaning women should be encouraged to continue or to initiate safe physical activities. Obstetrician–gynecologists and other obstetric care providers should evaluate women with medical or obstetric complications carefully before making recommendations on physical activity participation during pregnancy. Although the evidence is express, do results in benefits to pregnancy outcomes, and at that place is no evidence of harm when practise is not contraindicated. Physical activity and exercise during pregnancy promote concrete fettle and may preclude excessive gestational weight gain. Exercise may reduce the risk of gestational diabetes, preeclampsia, and cesarean birth. Additional research is needed to study the effects of practise on pregnancy-specific conditions and outcomes and to clarify further effective behavioral counseling methods and the optimal type, frequency, and intensity of exercise. Like research is needed to create an improved bear witness base concerning the effects of occupational physical activeness on maternal–fetal wellness.

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Source: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/04/physical-activity-and-exercise-during-pregnancy-and-the-postpartum-period

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