Next Article in Journal
The Relationship between Hypertension and Periodontitis: A Cross-Sectional Study
Previous Article in Journal
A Comprehensive Review on Neuroendocrine Neoplasms: Presentation, Pathophysiology and Management
 
 
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Systematic Review

Influence of Physical Activity during Pregnancy on Type and Duration of Delivery, and Epidural Use: Systematic Review and Meta-Analysis

by
Dingfeng Zhang
1,
Stephanie-May Ruchat
2,
Cristina Silva-Jose
1,
Javier Gil-Ares
1,*,
Rubén Barakat
1 and
Miguel Sánchez-Polán
1
1
AFIPE Research Group, Faculty of Physical Activity and Sport Sciences-INEF, Universidad Politécnica de Madrid, 28040 Madrid, Spain
2
Department of Human Kinetics, Université du Québec à Trois, Trois-Rivières, QC G8T 0A1, Canada
*
Author to whom correspondence should be addressed.
J. Clin. Med. 2023, 12(15), 5139; https://doi.org/10.3390/jcm12155139
Submission received: 14 July 2023 / Revised: 1 August 2023 / Accepted: 3 August 2023 / Published: 5 August 2023
(This article belongs to the Section Obstetrics & Gynecology)

Abstract

:
Cesarean delivery may increase the need for anesthesia administration, thereby causing potential risks to both maternal and fetal health. This article aimed to investigate the effect of physical activity during pregnancy on the type of delivery, the duration of labor, and the use of epidurals (registration No.: CRD42022370646). Furthermore, 57 RCTs (n = 15301) were included showing that physical activity could decrease the risk of cesarean section (z = 3.22, p = 0.001; RR = 0.87, 95% CI = 0.79, 0.95, I2 = 37%, Pheterogeneity = 0.004), and 32 RCTs (n = 9468) showed significant decreases in instrumental delivery through performing physical activity (z = 3.48, p < 0.001; RR = 0.84, 95% CI = 0.76, 0.93, I2 = 0%, Pheterogeneity = 0.63). A significant decrease in the 15 RCTs’ (n = 4797) duration of first stage labor was found in physically active pregnant women (z = 2.09, p = 0.04; MD = −62.26, 95% CI = −120.66, −3.85, I2 = 93%, Pheterogeneity < 0.001) compared to those not active. Prenatal physical activity could decrease the risk of cesarean section and instrumental delivery and the duration of first stage labor.

1. Introduction

Childbirth is a complex process that can have significant implications for the health of both mother and infant. Spontaneous delivery without the need for intervention such as instrumental delivery or cesarean section is recommended [1,2]. However, the World Health Organization (WHO) has stated that the global caesarean section rate has risen from around 7% in 1990 to 21% today. By 2030, it is projected that the caesarean section rate will reach 63% in East Asia, followed by Latin America and the Caribbean (54%), Western Asia (50%), North Africa (48%), Southern Europe (47%), and Australia and New Zealand (45%) [3]. Compared to vaginal delivery, cesarean delivery increases the risk of adverse outcomes for both mother and infant, delays recovery duration, and thus incurs higher medical costs [4]. However, vaginal delivery may also lead to an increase in acute and chronic maternal morbidity [5].
The most common indication for cesarean section is slow progress of labor leading to delayed delivery and maternal fatigue. Prolonged labor can lead to various deleterious consequences for the well-being and health of both the mother and the fetus. For the mother, these include fatigue and physical exhaustion, increased risk of infection, vaginal or perineal injury, and psychological stress. For the fetus, there may be risks of oxygen deprivation, distress, and injury, which can affect the functioning of the brain and other organs [6]. Then, limiting prolonged duration of labor is important. The second stage of labor holds great significance due to its connection with higher rates of maternal and perinatal health issues and even death.
An important breakthrough in delivery management is relieving labor pain. About 80% to 90% of women request and receive epidural anesthesia to alleviate labor pain in United Kingdom hospitals [7]. However, some evidence suggests that while relieving maternal pain, epidural anesthesia also prolongs the second stage of labor, increases the risk of operative delivery [8]. Moreover, this type of anesthesia could directly reduce uterine contraction ability, pelvic floor muscle tension, and reflexive maternal pushing response, all of which are necessary conditions for normal internal rotation of the fetal head [9] and thus for the delivery progress.
It is worth acknowledging that meta-analyses were previously published, showing that engaging in physical activity during pregnancy decreases the odds of cesarean section and instrumental delivery [4,10,11]. Physical activity during pregnancy did not influence the duration of the first stage labor and the use of epidural [12,13]. However, some of the meta-analyses were published five years ago (or even more) and more literature on the topic has been published since. Meta-analyses were published recently (three years ago) with few studies (less than 15 articles); in fact, some important studies have not been included in the analysis. Certainty of previous evidence was not high. Moreover, there were few meta-analyses published about physical activity during pregnancy and duration of labor and use of epidural. Therefore, providing an update of the literature would be important to better understand the impact of prenatal exercise on these outcomes. The objective of this systematic review was to assess the effect of physical activity during pregnancy on the type of delivery, duration of labor, and on the use of epidural anesthesia.

2. Materials and Methods

A systematic review was carried out based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [14]. The protocol was registered in the International Prospective Registry of Systematic Reviews (PROSPERO, registration No. CRD42022370646).

2.1. Eligibility Criteria

The eligibility criteria for this systematic review were guided by the PICOS framework: participants, interventions, comparisons, outcomes, and study design [14].

2.2. Population

The population of interest was pregnant women without contraindication to exercise (according to the most recent international clinical guidelines about physical activity during pregnancy) [15,16]. Absolute contraindications were defined as: ruptured membranes, premature labor, unexplained persistent vaginal bleeding, placenta previa after 28 weeks’ gestation, pre-eclampsia, incompetent cervix, intrauterine growth restriction, high-order multiple pregnancy (e.g., triplets), uncontrolled type I diabetes, uncontrolled hypertension or uncontrolled thyroid disease, and other serious cardiovascular, respiratory or systemic disorders. Relative contraindications were defined as: recurrent pregnancy loss, history of spontaneous preterm birth, gestational hypertension, symptomatic anemia, malnutrition, eating disorder, twin pregnancy after the 28th week, mild/moderate cardiovascular or respiratory disease, and other significant medical conditions [15,16].

2.3. Intervention

Physical activity interventions during pregnancy were searched for. Studies were selected if they reported any type of quantifiable physical activity: frequency, intensity, type and duration of physical activity, duration of the intervention, adherence to the intervention, and mode of delivery of the intervention (supervised or unsupervised physical activity).

2.4. Comparison

The comparator was no physical activity (i.e., the control group). Women receiving standard care (i.e., regular obstetrical follow-ups with health care providers) were considered as controls.

2.5. Outcome

The primary outcome of interest was the type of delivery (cesarean, instrumental delivery). Secondary outcome was the duration of labor (first, second, and third stage), and the use of epidural anesthesia.

2.6. Data Sources

An exhaustive and comprehensive search was carried out using the Universidad Politécnica de Madrid software in the following databases: Academic Search Premier, ERIC, MEDLINE, SPORTDiscus, OpenDissertations, Clinicaltrials.gov, Web of Science, Scopus, and Cochrane Database of Systematic Reviews. To ensure equality in the selection process, the same article selection criteria were used for all databases, considering differences in controlled vocabulary and rules of selection syntax. As articles published in English and Spanish were considered for the search, the search terms used were:
  • English: physical activity OR exercise OR training OR physical exercise OR fitness OR strength training OR physical intervention OR Pilates OR Yoga OR strengthening OR aerobic OR resistance training OR pelvic floor muscle training AND pregnancy OR maternal OR antenatal OR pregnant AND type of delivery OR mode of delivery OR duration of labor OR epidural OR anesthetic AND randomized clinical trial OR randomized controlled trial OR RCT OR Quasi experimental clinical trial.
  • Spanish: actividad física O ejercicio O entrenamiento O ejercicio físico O fitness O entrenamiento de fuerza O intervención de actividad física O Pilates O Yoga O fortalecimiento O aeróbico O entrenamiento de resistencia O fortalecimiento del suelo pélvico Y embarazo O materno O antenatal O embarazada Y tipo de parto O modo de parto O duración del parto O epidural O anestesia Y ensayo clínico aleatorizado O ensayo controlado aleatorizado O ECA O cuasiexperimental.

2.7. Study Selection and Data Extraction

Only randomized controlled trials (RCTs) were selected. Articles published between 2010 and 2023, written in English and Spanish were considered for the search. Reference lists of selected studies, as well as of systematic reviews previously published on the same topic, were retrieved to ensure studies of interest were not missed by the electronic keyword search.
To ensure compliance with the inclusion criteria, two reviewers conducted an independent screening of the titles and abstracts. The abstracts that met the initial screening were then retained for full text revision. The full texts were also revised by two independent reviewers to identify outcomes of interest for data extraction. For studies where one reviewer recommended exclusion and the other inclusion, both reviewers tried to reach a consensus to make a final decision for exclusion or inclusion. In situations of absolute discrepancy, a third reviewer provided their expert opinion on whether the study should be included or excluded.
In cases where a study had multiple publications, the most recent or comprehensive publications was chosen as the primary source. However, relevant data from all the publications were extracted to ensure that no valuable information was overlooked.
Data extraction tables were created in an Excel sheet. One researcher extracted the data and then, data extraction was independently verified by a content expert to facilitate further analysis.
Extracted data were study characteristics (i.e., author last name, year, and country), total sample size and sample size per study group, intervention (type of quantifiable physical activity: frequency, intensity, type and duration of physical activity, duration of the intervention, adherence to the intervention, and supervised or unsupervised physical activity), and primary and secondary outcomes.

2.8. Quality of Evidence and Risk of Bias Assessments

To evaluate the certainty of evidence for each study design and outcome, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework was used. This framework provides a standardized and comprehensive approach to assess the certainty of the evidence across multiple studies [17].
To evaluate the risk of bias of RCTs, the Cochrane Handbook was utilized. The potential sources of bias evaluated are: selection bias (inadequate randomization procedures), performances bias (compliance with the intervention), detection bias (flawed outcome measurement), attrition bias (incomplete follow-up and high loss to follow-up), and reporting bias (selective or incomplete outcome reporting) [18].

2.9. Statistical Analysis

Statistical analyses were performed with Review Manager software (RevMan, version 5.4). Dichotomous outcomes (i.e., cesarean delivery, instrumental delivery, and the use of epidural anesthesia) were expressed as categorical variable (Yes/No). The number of events in the intervention and control group were recorded and relative risks (RR) and odds ratio (OR) were calculated [19]. For continuous outcomes (duration of first, second, and third stage of labor), mean differences (MD) were calculated [20].
To establish the compensated average in both dichotomous and continuous analyses, a weight system was used that considered the sample size per groups and generally, contributed by each study. A random effects model was used for all analysis. Meta-analyses were performed separately by study design and significance was set at p-value < 0.05. To assess the variation in study results between studies (i.e., the degree of heterogeneity), the I2 statistic was calculated. The I2 statistic was interpreted using established thresholds: low heterogeneity—<25%, moderate heterogeneity—25% to 75%, and high heterogeneity—>75%. In the cases of high heterogeneity, post hoc subgroup analyses were conducted to further explore heterogeneity. In this study we found high heterogeneity with duration of first, second, and third stage labor; therefore, we divided the articles of mentioned analyses into different subgroups according to the age of participants (age ≥ 30 years, 25–30 years, and <25 years).

3. Results

A total of 60 RCT studies met the inclusion criteria, involving 15,968 pregnant women across 20 countries after the search process that is shown in Figure 1.
Among all of the interventions, 33 included only supervised physical activity, 12 included a combination of supervised and unsupervised physical activity, and 15 included only unsupervised physical activity. Studies varied in frequency of exercise from 1 to 7 days per week, exercise intensity was low to moderate, and the duration of exercise sessions varied between 10 and 75 min. These interventions were carried out during the first, second, or third trimesters, and lasted from 3 to 30 weeks. The type of exercise included walking, stationary cycling, water aerobics, swimming, resistance training, stretching, Pilates, yoga, pelvic floor muscle training, or a combination of various exercise types (Table 1).

3.1. Certainty of Evidence and Risk of Bias

Collectively, the certainty of evidence was high. In some situations, blinding of participants to the group (intervention or control group) was not feasible, and it is typically impossible to achieve due to the intervention characteristics (physical activity intervention), resulting in unclear or high risk of bias (performance bias) depending on how it was recorded. Other sources of bias found in some cases were the impossibility to find the article protocol published (to compare the planned and measured outcomes), but also not reporting (or being uncertainly defined) the randomization process. Overall, the majority of the studies presented low risk of bias within the five types of bias assessed. Risk of bias analysis is reported in Figure 2.

3.2. Effect of Prenatal Physical Activity on Cesarean Delivery

Overall, there was high certainty of evidence from 57 RCTs (n = 15,301) [9,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,41,42,43,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79] regarding the effect of prenatal physical activity on cesarean section. A significant decrease in the risk of cesarean deliveries was found with prenatal physical activity compared to no physical activity (z = 3.22, p = 0.001; RR = 0.87, 95% CI = 0.79, 0.95, I2 = 37%, Pheterogeneity = 0.004) as shown in Figure 3.

3.3. Effect of Prenatal Physical Activity on Instrumental Delivery

In this meta-analysis, 32 RCTs (n = 9468) [9,23,25,26,27,28,29,30,31,35,36,37,38,39,44,47,48,49,50,51,54,56,57,58,59,67,69,70,71,72,75,77] reviewing the effect of prenatal physical activity on instrumental section were analyzed. A significant decrease in the risk of instrumental deliveries was found with prenatal physical activity compared to no physical activity (z = 3.48, p < 0.001; RR = 0.84, 95% CI = 0.76, 0.93, I2 = 0%, Pheterogeneity = 0.63). Figure 4 details the current analysis.

3.4. Effect of Physical Activity during Pregnancy on Duration of the First Stage of Labor

Fifteen RCTs were analyzed (n = 4797) [29,36,38,44,46,50,52,57,58,65,67,69,71,73,78]. Overall, prenatal physical activity was associated with a reduction in the duration of the first stage of labor (in minutes) compared with no physical activity (z = 2.09, p = 0.04; MD = −62.26, 95% CI = −120.66, −3.85, I2 = 93%, Pheterogeneity < 0.001). Due to the high heterogeneity obtained, subgroup analyses were performed to split the studies into three groups depending on the age of participants as is shown in Figure 5. The first subgroup (age > 30 years) shows non-statistical differences between the groups (z = 1.54, p = 0.12; MD = −40.54, 95% CI = −92.30, 11.22, I2 = 70%, Pheterogeneity = 0.02), also not having differences in the second subgroup (age between 25 to 30 years) (z = 1.02, p = 0.31; MD = −29.29, 95% CI = −85.33, 26.75, I2 = 59%, Pheterogeneity = 0.02) and in the third (age < 25 years) group (z = 1.56, p = 0.12; MD = −104.99, 95% CI = −236.90, 26.92, I2 = 97%, Pheterogeneity < 0.001).

3.5. Effect of Physical Activity during Pregnancy on Duration of the Second Stage of Labor

Overall, there was high certainty of evidence from 26 RCTs (n = 7800) [9,29,35,36,38,39,42,44,45,46,47,48,49,50,51,52,54,57,58,61,65,66,67,69,71,73,78] regarding the effect of prenatal physical activity on the second stage of labor. There was no significant decrease in the risk of duration of second stage labor found with prenatal physical activity compared to the non-physical activity group (z = 1.21, p = 0.23; MD = −2.04, 95% CI = −5.34, 1.26, I2 = 75%, Pheterogeneity < 0.001). Subgroup analyses were realized to split the studies into two groups due to high heterogeneity depending on age of participants as is shown in Figure 6. The first subgroup (age ≥ 30 years) shows non-statistical differences between the physical activity group and control group in duration of second stage labor (z = 0.22, p = 0.83; MD = −0.41, 95% CI = −4.08, 3.26, I2 = 69%, Pheterogeneity < 0.001). Similarly, in the second subgroup (age < 30 years) there were no differences between groups in duration of second stage labor (z = 1.27, p = 0.20; MD = −3.70, 95% CI = −9.40, 1.99, I2 = 75%, Pheterogeneity < 0.001).

3.6. Effect of Physical Activity during Pregnancy on Duration of the Third Stage of Labor

Eight RCTs were retrieved and analyzed in this analysis (n = 3443) [29,36,38,57,58,65,69,71]. No statistical differences (Figure 7) were observed overall between groups regarding duration of the third stage of labor (z = 1.07, p = 0.29; MD = −0.38, 95% CI = −1.09, 0.32, I2 = 75%, Pheterogeneity < 0.001). It was necessary to split the studies into subgroups due to high heterogeneity present in the general analysis. In the first subgroup no statistical differences were found between study groups (z = 0.71, p = 0.48; MD = 0.16, 95% CI = −0.27, 0.58, I2 = 47%, Pheterogeneity = 0.13). Similarly, in the second subgroup no significant relationships were observable in both groups (z = 1.80, p = 0.07; MD = −2.15, 95% CI = −4.50, 0.20, I2 = 70%, Pheterogeneity = 0.02).

3.7. Effect of Physical Activity during Pregnancy on Epidural Use

Thirteen RCT articles were analyzed (n = 4119) [21,29,35,40,42,48,49,51,55,62,64,66,79] regarding the effect of prenatal physical activity on the use of epidurals. No significant differences were observed in the use of epidural anesthesia between the intervention and control groups (z = 1.98, p = 0.05; OR = 0.73, 95% CI = 0.53, 1.00, I2 = 64%, Pheterogeneity = 0.001) as shown in Figure 8.

4. Discussion

In this systematic review, 60 RCTs were included, and there was high certainty of evidence showing that prenatal physical activity could decrease the risk of cesarean delivery by 13% and the risk of instrumental delivery by 16%. We also found that prenatal physical activity was associated with 62.26 min of reduction in the duration of first stage labor.
A review developed by Domenjoz et al. [11] with 16 articles found that women performing exercise during pregnancy had a significant lower risk of cesarean delivery compared to those who did not, and another article published by Wang et al. [12] with 13 RCTs showed that women who exercise during pregnancy had a significantly higher incidence of vaginal delivery than non-physically active women. Furthermore, Davenport et al. [10], in their review published in 2019 with 20 articles analyzed, found that engaging in a prenatal exercise program was associated with a 24% reduction in the likelihood of instrumental delivery. Our systematic review and meta-analysis examined the relationship between physical activity during pregnancy and type of delivery, showing the same conclusions as previously published articles.
Physical activity has been shown to reduce the risk of several pregnancy complications that are often associated with a higher likelihood of cesarean section and instrumental delivery, for example, physical activity during pregnancy has been linked to a lower risk of gestational diabetes mellitus, excessive gestational weight gain, and macrosomia [80,81]. Elsewhere, labor duration is another factor that may contribute to the association between physical activity and decreased risk of cesarean section and instrumental delivery. Regular physical activity during pregnancy has been shown to improve overall fitness, cardiovascular health, and muscle strength [82], which could potentially enhance the efficiency and progress of labor. Shorter labor duration is generally associated with a reduced need for medical intervention, including cesarean section and instrumental delivery. The majority of studies suggest that engaging in regular physical activity during pregnancy can be beneficial for reducing cesarean sections and instrumental deliveries. Consequently, it is necessary that pregnant individuals maintain an active lifestyle throughout their pregnancy.
Our results showed a significant decrease in the duration of first stage labor in the physical activity group compared with the control group. We did not find an association between physical activity during pregnancy and duration of second and third stage labor. Despite the high heterogeneity obtained and after dividing the articles in these three analyses into different subgroups, high heterogeneity was still reported in the first stage of labor meta-analysis (I2 = 97%). However, due to the low number of articles and the impossibility to split the articles into other subgroups based on other factors, the research team opted to report the current analysis.
A previously published review [12] found that exercise during pregnancy had no significant influence on first and second stages of labor. Interestingly, a recent review [13] showed that exercise significantly reduced the duration of the second stage of labor, but it did not reduce the first stage of labor, which is contrary to the conclusion drawn from our study. This discrepancy in results between our study and this previous meta-analysis may be attributed to several factors such as differences in study design, inclusion criteria, sample size, or specific characteristics of the populations studied. Regarding the potential link between physical activity and the duration of labor, it is important to note that the first stage of labor is often associated with increased interventions and potential complications. The second stage of labor, although shorter in duration, is crucial for the actual delivery of the baby. The third stage of labor involves the delivery of placenta and is typically shorter compared to the previous stages [83]. Therefore, further research in needed to better understand the potential relationship between physical activity during pregnancy and the different stages of labor.
Our study did not find that prenatal physical activity significantly reducing the need for epidural use during labor. However, it is important to consider the potential advantage of reducing epidural use, such as minimizing medical interventions, promoting a more active and engaged birthing experience, and potentially reducing associated risks or side effects. Further research is essential to better understand the underlying mechanisms and causative factors contributing to this association. Factors such as improved pain tolerance, increased endurance, or enhanced overall fitness may play a role in reducing the need for epidurals among physically activity pregnant women. More researches are needed to better understand the potential importance of incorporating physical activity as part of prenatal care to optimize outcomes and potentially reduce the reliance on epidurals during childbirth.

Limitations and Strengths

Strengths of this article include the selection and review of both English and Spanish articles expanding the scope of our search in comparison to previous reviews that were restricting to one language, and the inclusion specifically of randomized controlled trials allowing for assessment of the features of physical activity interventions that may not be captured through observational studies (e.g., frequency and type of activity) and are deemed to provide more high certainty of evidence. However, these results should be interpreted with caution in lieu of the inclusion of studies deemed of low quality as well as heterogeneity in the contents of the included interventions. Limitations of this review were the difficulty of obtaining data due to the discrepancies at the moment of reporting data from these studies. This limitation precluded the chance of performing a meta-analysis of the total duration of gestation but also to assess epidural use through a quantitative measure. Other limitations were the high heterogeneity reported in some analyses and the shortage of published articles regarding outcomes of interest as duration of the second stage of delivery. In fact, analyzed articles did not clearly report definitions of stages, possibly increasing variability of analyzed articles per analysis. Division of articles was necessary in three meta-analyses, but due to some retrieved scientific literature not reporting all participant sociodemographic characteristics, it was opted to split articles according to maternal age. Future research should aim to further extrapolate findings based on intensity of the intervention, and types of physical activity.

5. Conclusions

This review identified that prenatal physical activity could reduce the risk for cesarean section, instrumental delivery, and decrease the duration of the first stage of labor.

Author Contributions

Conceptualization, S.-M.R., R.B. and M.S.-P.; methodology, C.S.-J., R.B. and M.S.-P.; software, J.G.-A.; validation, D.Z., S.-M.R. and C.S.-J.; formal analysis, D.Z., S.-M.R., C.S.-J., R.B. and M.S.-P.; investigation, D.Z., S.-M.R. and M.S.-P.; resources, R.B.; data curation, J.G.-A.; writing—original draft preparation, D.Z., S.-M.R. and M.S.-P.; writing—review and editing, D.Z., S.-M.R. and M.S.-P.; visualization, J.G.-A.; supervision, M.S.-P.; project administration, R.B. and M.S.-P.; funding acquisition, R.B. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by the Instituto de las Mujeres. Ministerio de Igualdad. Spain, grant number “UPM-C2311580017”.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Burcher, P.; Gabriel, J.L.; Campo-Engelstein, L.; Kiley, K.C. The case against cesarean delivery on maternal request in labor. Obstet. Gynecol. 2013, 122, 684–687. [Google Scholar] [CrossRef]
  2. Halpern, S. SOGC Joint Policy Statement on Normal Childbirth. J. Obstet. Gynaecol. Can. 2009, 31, 602. [Google Scholar] [CrossRef]
  3. Betran, A.P.; Ye, J.; Moller, A.-B.; Souza, J.P.; Zhang, J. Trends and projections of caesarean section rates: Global and regional estimates. BMJ Global. Health 2021, 6, e005671. [Google Scholar] [CrossRef]
  4. Poyatos-León, R.; García-Hermoso, A.; Sanabria-Martínez, G.; Álvarez-Bueno, C.; Sánchez-López, M.; Martínez-Vizcaíno, V. Effects of exercise during pregnancy on mode of delivery: A meta-analysis. Acta Obstet. Gyn. Scan. 2015, 94, 1039–1047. [Google Scholar] [CrossRef] [PubMed]
  5. MacLennan, A.H.; Taylor, A.W.; Wilson, D.H.; Wilson, D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG Int. J. Obstet. Gynaecol. 2000, 107, 1460–1470. [Google Scholar] [CrossRef] [PubMed]
  6. Sheiner, E.; Levy, A.; Feinstein, U.; Hallak, M.; Mazor, M. Risk factors and outcome of failure to progress during the first stage of labor: A population-based study. Acta Obstet. Gyn. Scan. 2002, 81, 222–226. [Google Scholar] [CrossRef]
  7. Khor, L.; Jeskins, G.; Cooper, G.; Paterson-Brown, S. National obstetric anaesthetic practice in the UK 1997/1998. Anesth 2000, 55, 1168–1172. [Google Scholar] [CrossRef]
  8. Anim-Somuah, M.; Smyth, R.; Howell, C. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst. Rev. 2018, 5, CD000331. [Google Scholar] [PubMed]
  9. Awad, E.; Mobark, A.; Hamada, H.A.; Yousef, A.M.; El Nahas, E.M. Effect of antenatal exercises on bearing down in primiparous under epidural anesthesia during labor: A randomized controlled trial. Eur. Asian J. Biosci. 2020, 14, 1079–1085. [Google Scholar]
  10. Davenport, M.H.; Ruchat, S.-M.; Sobierajski, F.; Poitras, V.J.; Gray, C.E.; Yoo, C.; Skow, R.J.; Garcia, A.J.; Barrowman, N.; Meah, V.L.; et al. Impact of prenatal exercise on maternal harms, labour and delivery outcomes: A systematic review and meta-analysis. Br. J. Sports Med. 2019, 53, 99–107. [Google Scholar] [CrossRef]
  11. Domenjoz, I.; Kayser, B.; Boulvain, M. Effect of physical activity during pregnancy on mode of delivery. Am. J. Obstet. Gynecol. 2014, 211, e401–e411. [Google Scholar] [CrossRef] [PubMed]
  12. Wang, Y.; Wu, L.; Wu, X.; Zhou, C. The Association between Physical Exercise during Pregnancy and Maternal and Neonatal Health Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Comput. Math Methods Med. 2022, 2022, 3462392. [Google Scholar] [CrossRef] [PubMed]
  13. Masoud, A.T.; AbdelGawad, M.M.; Elshamy, N.H.; Mohamed, O.M.; Hashem, Z.Y.; Abd Eltawab, A.K.; Samy, A.; Abbas, A.M. The effect of antenatal exercise on delivery outcomes: A systematic review and meta-analysis of randomized controlled trials. J. Gynecol. Obstet. Hum. 2020, 49, 101736. [Google Scholar] [CrossRef] [PubMed]
  14. Moher, D.; Shamseer, L.; Clarke, M.; Ghersi, D.; Liberati, A.; Petticrew, M.; Shekelle, P.; Stewart, L.A.; Group, P.-P. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst. Rev. 2015, 4, 1. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  15. ACOG Committee on Obstetric Practice. “ACOG Committee Opinion. Number 267, January 2002.” Exercise during pregnancy and the postpartum period. Obstet. Gynecol. 2002, 99, 171–173. [Google Scholar]
  16. ACOG Committee on Obstetric Practice. “ACOG Committee Opinion. Number 650, December 2015.” Physical Activity and Exercise During Pregnancy and the Postpartum Period. Obstet. Gynecol. 2015, 126, e135–e142. [Google Scholar]
  17. Granholm, A.; Alhazzani, W.; Møller, M.H. Use of the GRADE approach in systematic reviews and guidelines. Br. J. Anaesth. 2019, 123, 554–559. [Google Scholar] [CrossRef]
  18. Higgins, J.P.; Savović, J.; Page, M.J.; Elbers, R.G.; Sterne, J.A. Assessing risk of bias in a randomized trial. In Cochrane Handbook for Systematic Reviews of Interventions; Wiley: Hoboken, NJ, USA, 2019; pp. 205–228. [Google Scholar]
  19. Higgins, J.P.; Thompson, S.G. Quantifying heterogeneity in a meta-analysis. Stat. Med. 2002, 21, 1539–1558. [Google Scholar] [CrossRef]
  20. Hedges, L.V.; Tipton, E.; Johnson, M.C. Robust variance estimation in meta-regression with dependent effect size estimates. Res. Synth. Methods 2010, 1, 39–65. [Google Scholar] [CrossRef]
  21. Abd El fttah Ali, H. Effects of prenatal perineal massage and Kegel exercise on the episiotomy rate. IOSR-JNHS 2015, 4, 61–70. [Google Scholar]
  22. Aktan, B.; Kayikcioglu, F.; Akbayrak, T. The comparison of the effects of clinical Pilates exercises with and without childbirth training on pregnancy and birth results. Int. J. Clin. Pract. 2021, 75, e14516. [Google Scholar] [CrossRef]
  23. Babbar, S.; Hill, J.B.; Williams, K.B.; Pinon, M.; Chauhan, S.P.; Maulik, D. Acute feTal behavioral Response to prenatal Yoga: A single, blinded, randomized controlled trial (TRY yoga). Am. J. Obstet. Gynecol. 2016, 214, 399.e1–399.e8. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  24. Backhausen, M.G.; Tabor, A.; Albert, H.; Rosthoj, S.; Damm, P.; Hegaard, H.K. The effects of an unsupervised water exercise program on low back pain and sick leave among healthy pregnant women—A randomised controlled trial. PLoS ONE 2017, 12, e0182114. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  25. Barakat, R.; Cordero, Y.; Coteron, J.; Luaces, M.; Montejo, R. Exercise during pregnancy improves maternal glucose screen at 24-28 weeks: A randomised controlled trial. Br. J. Sports Med. 2012, 46, 656–661. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  26. Barakat, R.; Pelaez, M.; Lopez, C.; Montejo, R.; Coteron, J. Exercise during pregnancy reduces the rate of cesarean and instrumental deliveries: Results of a randomized controlled trial. J. Matern.-Fetal Neonatal Med. 2012, 25, 2372–2376. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  27. Barakat, R.; Perales, M.; Bacchi, M.; Coteron, J.; Refoyo, I. A program of exercise throughout pregnancy. Is it safe to mother and newborn? Am. J. Health Promot. 2014, 29, 2–8. [Google Scholar] [CrossRef]
  28. Barakat, R.; Pelaez, M.; Cordero, Y.; Perales, M.; Lopez, C.; Coteron, J.; Mottola, M.F. Exercise during pregnancy protects against hypertension and macrosomia: Randomized clinical trial. Am. J. Obstet. Gynecol. 2016, 214, 649.e1–649.e8. [Google Scholar] [CrossRef]
  29. Barakat, R.; Franco, E.; Perales, M.; Lopez, C.; Mottola, M.F. Exercise during pregnancy is associated with a shorter duration of labor. A randomized clinical trial. Eur. J. Obstet. Gynecol. Reprod. Biol. 2018, 224, 33–40. [Google Scholar] [CrossRef]
  30. Barakat, R.; Vargas, M.; Brik, M.; Fernandez, I.; Gil, J.; Coteron, J.; Santacruz, B. Does Exercise During Pregnancy Affect Placental Weight?: A Randomized Clinical Trial. Eval. Health Prof. 2018, 41, 400–414. [Google Scholar] [CrossRef]
  31. Barakat, R.; Refoyo, I.; Coteron, J.; Franco, E. Exercise during pregnancy has a preventative effect on excessive maternal weight gain and gestational diabetes. A randomized controlled trial. Braz. J. Phys. Ther. 2018, 23, 148–155. [Google Scholar] [CrossRef]
  32. Bhartia, N.; Jain, S.; Shankar, N.; Rajaram, S.; Gupta, M. Effects of antenatal yoga on maternal stress and clinical outcomes in north indian women: A randomised controlled trial. J. Indian Acad. Clin. Med. 2019, 20, 11. [Google Scholar]
  33. Bjontegaard, K.A.; Stafne, S.N.; Morkved, S.; Salvesen, K.A.; Evensen, K.A.I. Body mass index and physical activity in seven-year-old children whose mothers exercised during pregnancy: Follow-up of a multicentre randomised controlled trial. BMC Pediatr. 2021, 21, 496. [Google Scholar] [CrossRef] [PubMed]
  34. Bolanthakodi, C.; Raghunandan, C.; Saili, A.; Mondal, S.; Saxena, P. Prenatal Yoga: Effects on Alleviation of Labor Pain and Birth Outcomes. J. Altern. Complement. Med. 2018, 24, 1181–1188. [Google Scholar] [CrossRef] [PubMed]
  35. Carpenter, R.E.; Emery, S.J.; Uzun, O.; D’Silva, L.A.; Lewis, M.J. Influence of antenatal physical exercise on haemodynamics in pregnant women: A flexible randomisation approach. BMC Pregnancy Childbirth 2015, 15, 186. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  36. Carrascosa, M.D.C.; Navas, A.; Artigues, C.; Ortas, S.; Portells, E.; Soler, A.; Bennasar-Veny, M.; Leiva, A.; Aquanatal, T. Effect of aerobic water exercise during pregnancy on epidural use and pain: A multi-centre, randomised, controlled trial. Midwifery 2021, 103, 103105. [Google Scholar] [CrossRef]
  37. Cordero, Y.; Mottola, M.F.; Vargas, J.; Blanco, M.; Barakat, R. Exercise Is Associated with a Reduction in Gestational Diabetes Mellitus. Med. Sci. Sports Exerc. 2015, 47, 1328–1333. [Google Scholar] [CrossRef] [Green Version]
  38. Daly, N.; Farren, M.; McKeating, A.; O’Kelly, R.; Stapleton, M.; Turner, M.J. A Medically Supervised Pregnancy Exercise Intervention in Obese Women: A Randomized Controlled Trial. Obstet. Gynecol. 2017, 130, 1001–1010. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  39. Dias, L.A.; Driusso, P.; Aita, D.L.; Quintana, S.M.; Bø, K.; Ferreira, C.H. Effect of pelvic floor muscle training on labour and newborn outcomes: A randomized controlled trial. Braz. J. Phys. Ther. 2011, 15, 487–493. [Google Scholar] [CrossRef] [Green Version]
  40. Dieb, A.S.; Shoab, A.Y.; Nabil, H.; Gabr, A.; Abdallah, A.A.; Shaban, M.M.; Attia, A.H. Perineal massage and training reduce perineal trauma in pregnant women older than 35 years: A randomized controlled trial. Int. Urogynecol. J. 2020, 31, 613–619. [Google Scholar] [CrossRef]
  41. Ellingsen, M.S.; Pettersen, A.; Stafne, S.N.; Morkved, S.; Salvesen, K.A.; Evensen, K. Neurodevelopmental outcome in 7-year-old children is not affected by exercise during pregnancy: Follow up of a multicentre randomised controlled trial. BJOG 2020, 127, 508–517. [Google Scholar] [CrossRef] [Green Version]
  42. Ferreira, C.L.M.; Guerra, C.M.L.; Silva, A.I.T.J.; Rosário, H.R.V.d.; de Oliveira Pereira, M.B.F.L. Exercise in pregnancy: The impact of an intervention program in the duration of labor and mode of delivery. Rev. Bras. Ginecol. Obstet. 2019, 41, 68–75. [Google Scholar] [CrossRef]
  43. Fritel, X.; De Tayrac, R.; Bader, G.; Savary, D.; Gueye, A.; Deffieux, X.; Fernandez, H.; Richet, C.; Guilhot, J.; Fauconnier, A. Preventing urinary incontinence with supervised prenatal pelvic floor exercises: A randomized controlled trial. Obstet. Gynecol. 2015, 126, 370–377. [Google Scholar] [CrossRef]
  44. Gau, M.-L.; Chang, C.-Y.; Tian, S.-H.; Lin, K.-C. Effects of birth ball exercise on pain and self-efficacy during childbirth: A randomised controlled trial in Taiwan. Midwifery 2011, 27, e293–e300. [Google Scholar] [CrossRef] [PubMed]
  45. Ghandali, N.Y.; Iravani, M.; Habibi, A.; Cheraghian, B. The effectiveness of a Pilates exercise program during pregnancy on childbirth outcomes: A randomised controlled clinical trial. BMC Pregnancy Childbirth 2021, 21, 480. [Google Scholar] [CrossRef] [PubMed]
  46. Ghodsi, Z.; Asltoghiri, M. Effects of aerobic exercise training on maternal and neonatal outcome: A randomized controlled trial on pregnant women in Iran. J. Pak. Med. Assoc. 2014, 64, 1053–1056. [Google Scholar] [PubMed]
  47. Guelfi, K.J.; Ong, M.J.; Crisp, N.A.; Fournier, P.A.; Wallman, K.E.; Grove, J.R.; Doherty, D.A.; Newnham, J.P. Regular Exercise to Prevent the Recurrence of Gestational Diabetes Mellitus: A Randomized Controlled Trial. Obstet. Gynecol. 2016, 128, 819–827. [Google Scholar] [CrossRef] [PubMed]
  48. Haakstad, L.A.; Bø, K. The marathon of labour—Does regular exercise training influence course of labour and mode of delivery? Secondary analysis from a randomized controlled trial. Eur. J. Obstet. Gynecol. Reprod. Biol. 2020, 251, 8–13. [Google Scholar] [CrossRef]
  49. Johannessen, H.H.; Froshaug, B.E.; Lysaker, P.J.G.; Salvesen, K.A.; Lukasse, M.; Morkved, S.; Stafne, S.N. Regular antenatal exercise including pelvic floor muscle training reduces urinary incontinence 3 months postpartum-Follow up of a randomized controlled trial. Acta Obstet. Gynecol. Scand. 2021, 100, 294–301. [Google Scholar] [CrossRef]
  50. Karthiga, K.; Pal, G.K.; Dasari, P.; Nanda, N.; Velkumary, S.; Chinnakali, P.; Renugasundari, M.; Harichandrakumar, K.T. Effects of yoga on cardiometabolic risks and fetomaternal outcomes are associated with serum nitric oxide in gestational hypertension: A randomized control trial. Sci. Rep. 2022, 12, 11732. [Google Scholar] [CrossRef]
  51. Leon-Larios, F.; Corrales-Gutierrez, I.; Casado-Mejia, R.; Suarez-Serrano, C. Influence of a pelvic floor training programme to prevent perineal trauma: A quasi-randomised controlled trial. Midwifery 2017, 50, 72–77. [Google Scholar] [CrossRef]
  52. Miquelutti, M.A.; Cecatti, G.J.; Makuch, M.Y. Evaluation of a birth preparation program on lumbopelvic pain, urinary incontinence, anxiety and exercise: A randomized controlled trial. BMC Pregnancy Childbirth 2013, 13, 154. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  53. Nascimento, S.L.; Surita, F.G.; Parpinelli, M.A.; Siani, S.; Pinto e Silva, J.L. The effect of an antenatal physical exercise programme on maternal/perinatal outcomes and quality of life in overweight and obese pregnant women: A randomised clinical trial. BJOG 2011, 118, 1455–1463. [Google Scholar] [CrossRef] [PubMed]
  54. Okido, M.M.; Valeri, F.L.; Martins, W.P.; Ferreira, C.H.; Duarte, G.; Cavalli, R.C. Assessment of foetal wellbeing in pregnant women subjected to pelvic floor muscle training: A controlled randomised study. Int. Urogynecol. J. 2015, 26, 1475–1481. [Google Scholar] [CrossRef]
  55. Pais, M.; Pai, M.V.; Kamath, A.; Bhat, R.; Bhat, P.; Joisa, G.H. A Randomized Controlled Trial on the Efficacy of Integrated Yoga on Pregnancy Outcome. Holist. Nurs. Pract. 2021, 35, 273–280. [Google Scholar] [CrossRef] [PubMed]
  56. Pelaez, M.; Gonzalez-Cerron, S.; Montejo, R.; Barakat, R. Protective effect of exercise in pregnant women including those who exceed weight gain recommendations: A randomized controlled trial. Mayo Clin. Proc. 2019, 94, 1951–1959. [Google Scholar] [CrossRef] [PubMed]
  57. Perales, M.; Calabria, I.; Lopez, C.; Franco, E.; Coteron, J.; Barakat, R. Regular Exercise Throughout Pregnancy Is Associated With a Shorter First Stage of Labor. Am. J. Health Promot. 2016, 30, 149–154. [Google Scholar] [CrossRef] [PubMed]
  58. Perales, M.; Valenzuela, P.L.; Barakat, R.; Cordero, Y.; Pelaez, M.; Lopez, C.; Ruilope, L.M.; Santos-Lozano, A.; Lucia, A. Gestational Exercise and Maternal and Child Health: Effects until Delivery and at Post-Natal Follow-up. J. Clin. Med. 2020, 9, 379. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  59. Pereira, I.B.; Silva, R.; Ayres-de-Campos, D.; Clode, N. Physical exercise at term for enhancing the spontaneous onset of labor: A randomized clinical trial. J. Matern. Fetal. Neonatal. Med. 2022, 35, 775–779. [Google Scholar] [CrossRef]
  60. Pinzón, D.C.; Zamora, K.; Martínez, J.H.; Floréz-López, M.E.; Aguilar de Plata, A.C.; Mosquera, M.; Ramírez-Vélez, R. Type of delivery and gestational age is not affected by pregnant Latin-American women engaging in vigorous exercise. A secondary analysis of data from a controlled randomized trial. Rev. Salud Pública 2012, 14, 731–743. [Google Scholar]
  61. Price, B.B.; Amini, S.B.; Kappeler, K. Exercise in pregnancy: Effect on fitness and obstetric outcomes-a randomized trial. Med. Sci. Sports Exerc. 2012, 44, 2263–2269. [Google Scholar] [CrossRef] [Green Version]
  62. Rodriguez-Blanque, R.; Sanchez-Garcia, J.C.; Sanchez-Lopez, A.M.; Exposito-Ruiz, M.; Aguilar-Cordero, M.J. Randomized Clinical Trial of an Aquatic Physical Exercise Program During Pregnancy. J. Obstet. Gynecol. Neonatal. Nurs. 2019, 48, 321–331. [Google Scholar] [CrossRef] [PubMed]
  63. Rodriguez-Blanque, R.; Aguilar-Cordero, M.J.; Marin-Jimenez, A.E.; Nunez-Negrillo, A.M.; Sanchez-Lopez, A.M.; Sanchez-Garcia, J.C. Influence of a Water-Based Exercise Program in the Rate of Spontaneous Birth: A Randomized Clinical Trial. Int. J. Environ. Res. Public Health 2020, 17, 795. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  64. Rodríguez-Díaz, L.; Ruiz-Frutos, C.; Vázquez-Lara, J.M.; Ramírez-Rodrigo, J.; Villaverde-Gutiérrez, C.; Torres-Luque, G. Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour. Enferm. Clin. 2017, 27, 271–277. [Google Scholar] [CrossRef] [Green Version]
  65. Ruiz, J.R.; Perales, M.; Pelaez, M.; Lopez, C.; Lucia, A.; Barakat, R. Supervised exercise–based intervention to prevent excessive gestational weight gain: A randomized controlled trial. Mayo Clin. Proc. 2013, 88, 1388–1397. [Google Scholar] [CrossRef] [PubMed]
  66. Salvesen, K.Å.; Stafne, S.N.; Eggebø, T.M.; Mørkved, S. Does regular exercise in pregnancy influence duration of labor? A secondary analysis of a randomized controlled trial. Acta Obstet. Gynecol. Scand. 2014, 93, 73–79. [Google Scholar] [CrossRef]
  67. Sanda, B.; Vistad, I.; Sagedal, L.R.; Haakstad, L.A.H.; Lohne-Seiler, H.; Torstveit, M.K. What is the effect of physical activity on duration and mode of delivery? Secondary analysis from the Norwegian Fit for Delivery trial. Acta Obstet. Gyn. Scan. 2018, 97, 861–871. [Google Scholar] [CrossRef]
  68. Seneviratne, S.N.; Jiang, Y.; Derraik, J.; McCowan, L.; Parry, G.K.; Biggs, J.B.; Craigie, S.; Gusso, S.; Peres, G.; Rodrigues, R.O.; et al. Effects of antenatal exercise in overweight and obese pregnant women on maternal and perinatal outcomes: A randomised controlled trial. BJOG 2016, 123, 588–597. [Google Scholar] [CrossRef] [Green Version]
  69. Shojaei, B.; Loripoor, M.; Sheikhfathollahi, M.; Aminzadeh, F. The effect of walking during late pregnancy on the outcomes of labor and delivery: A randomized clinical trial. J. Educ. Health Promt. 2021, 10, 277. [Google Scholar]
  70. Silva-Jose, C.; Sánchez-Polán, M.; Barakat, R.; Díaz-Blanco, Á.; Mottola, M.F.; Refoyo, I. A Virtual Exercise Program throughout Pregnancy during the COVID-19 Pandemic Modifies Maternal Weight Gain, Smoking Habits and Birth Weight—Randomized Clinical Trial. J. Clin. Med. 2022, 11, 4045. [Google Scholar] [CrossRef]
  71. Sobhgol, S.S.; Smith, C.A.; Thomson, R.; Dahlen, H.G. The effect of antenatal pelvic floor muscle exercise on sexual function and labour and birth outcomes: A randomised controlled trial. Women Birth 2022, 35, e607–e614. [Google Scholar] [CrossRef]
  72. Stafne, S.N.; Salvesen, K.A.; Romundstad, P.R.; Eggebo, T.M.; Carlsen, S.M.; Morkved, S. Regular exercise during pregnancy to prevent gestational diabetes: A randomized controlled trial. Obstet. Gynecol. 2012, 119, 29–36. [Google Scholar] [CrossRef]
  73. Taniguchi, C.; Sato, C. Home-based walking during pregnancy affects mood and birth outcomes among sedentary women: A randomized controlled trial. Int. J. Nurs. Pract. 2016, 22, 420–426. [Google Scholar] [CrossRef] [PubMed]
  74. Tomic, V.; Sporis, G.; Tomic, J.; Milanovic, Z.; Zigmundovac-Klaic, D.; Pantelic, S. The effect of maternal exercise during pregnancy on abnormal fetal growth. Croat. Med. J. 2013, 54, 362–368. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  75. Uria-Minguito, A.; Silva-Jose, C.; Sanchez-Polan, M.; Diaz-Blanco, A.; Garcia-Benasach, F.; Carrero Martinez, V.; Alzola, I.; Barakat, R. The Effect of Online Supervised Exercise throughout Pregnancy on the Prevention of Gestational Diabetes in Healthy Pregnant Women during COVID-19 Pandemic: A Randomized Clinical Trial. Int. J. Environ. Res. Public Health 2022, 19, 14104. [Google Scholar] [CrossRef] [PubMed]
  76. Ussher, M.; Lewis, S.; Aveyard, P.; Manyonda, I.; West, R.; Lewis, B.; Marcus, B.; Riaz, M.; Taylor, A.H.; Barton, P.; et al. The London Exercise And Pregnant smokers (LEAP) trial: A randomised controlled trial of physical activity for smoking cessation in pregnancy with an economic evaluation. Health Technol. Assess. 2015, 19, vii–xxiv. [Google Scholar] [CrossRef]
  77. Wang, C.; Wei, Y.; Zhang, X.; Zhang, Y.; Xu, Q.; Sun, Y.; Su, S.; Zhang, L.; Liu, C.; Feng, Y.; et al. A randomized clinical trial of exercise during pregnancy to prevent gestational diabetes mellitus and improve pregnancy outcome in overweight and obese pregnant women. Am. J. Obstet. Gynecol. 2017, 216, 340–351. [Google Scholar] [CrossRef] [Green Version]
  78. Wang, X.; Xu, X.; Luo, J.; Chen, Z.; Feng, S. Effect of app-based audio guidance pelvic floor muscle training on treatment of stress urinary incontinence in primiparas: A randomized controlled trial. Int. J. Nurs. Stud. 2020, 104, 103527. [Google Scholar] [CrossRef]
  79. Yekefallah, L.; Namdar, P.; Dehghankar, L.; Golestaneh, F.; Taheri, S.; Mohammadkhaniha, F. The effect of yoga on the delivery and neonatal outcomes in nulliparous pregnant women in Iran: A clinical trial study. BMC Pregnancy Childbirth 2021, 21, 351. [Google Scholar] [CrossRef]
  80. Laredo-Aguilera, J.A.; Gallardo-Bravo, M.; Rabanales-Sotos, J.A.; Cobo-Cuenca, A.I.; Carmona-Torres, J.M. Physical activity programs during pregnancy are effective for the control of gestational diabetes mellitus. Int. J. Environ. Res. Public Health 2020, 17, 6151. [Google Scholar] [CrossRef]
  81. Hamann, V.; Deruelle, P.; Enaux, C.; Deguen, S.; Kihal-Talantikite, W. Physical activity and gestational weight gain: A systematic review of observational studies. BMC Public Health 2022, 22, 1951. [Google Scholar] [CrossRef]
  82. Gregg, V.H.; Ferguson, J.E., 2nd. Exercise in Pregnancy. Clin. Sports Med. 2017, 36, 741–752. [Google Scholar] [CrossRef] [PubMed]
  83. Hutchison, J.M.; Heba, M.; Hutchinson, J. Stages of Labor; StatPearls: Tampa, FL, USA, 2023. [Google Scholar]
Figure 1. Flow diagram of the selection process.
Figure 1. Flow diagram of the selection process.
Jcm 12 05139 g001
Figure 2. Risk of bias of the included studies [9,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79].
Figure 2. Risk of bias of the included studies [9,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79].
Jcm 12 05139 g002
Figure 3. Effect of prenatal physical activity on cesarean delivery [9,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,41,42,43,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79].
Figure 3. Effect of prenatal physical activity on cesarean delivery [9,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,41,42,43,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79].
Jcm 12 05139 g003
Figure 4. Effect of prenatal physical activity on instrumental delivery [9,23,25,26,27,28,29,30,31,35,36,37,38,39,44,47,48,49,50,51,54,56,57,58,59,67,69,70,71,72,75,77].
Figure 4. Effect of prenatal physical activity on instrumental delivery [9,23,25,26,27,28,29,30,31,35,36,37,38,39,44,47,48,49,50,51,54,56,57,58,59,67,69,70,71,72,75,77].
Jcm 12 05139 g004
Figure 5. Effect of prenatal physical activity on duration of the first stage of labor [29,36,38,44,46,50,52,57,58,65,67,69,71,73,78].
Figure 5. Effect of prenatal physical activity on duration of the first stage of labor [29,36,38,44,46,50,52,57,58,65,67,69,71,73,78].
Jcm 12 05139 g005
Figure 6. Effect of prenatal physical activity on duration of the second stage of labor [9,29,35,36,38,39,42,44,45,46,47,48,49,50,51,52,54,57,58,61,65,66,67,69,71,73,78].
Figure 6. Effect of prenatal physical activity on duration of the second stage of labor [9,29,35,36,38,39,42,44,45,46,47,48,49,50,51,52,54,57,58,61,65,66,67,69,71,73,78].
Jcm 12 05139 g006
Figure 7. Effect of prenatal physical activity on duration of the third stage of labor [29,36,38,57,58,65,69,71].
Figure 7. Effect of prenatal physical activity on duration of the third stage of labor [29,36,38,57,58,65,69,71].
Jcm 12 05139 g007
Figure 8. Effect of prenatal physical activity on epidural use [21,29,35,40,42,48,49,51,55,62,64,66,79].
Figure 8. Effect of prenatal physical activity on epidural use [21,29,35,40,42,48,49,51,55,62,64,66,79].
Jcm 12 05139 g008
Table 1. Characteristics of analyzed articles.
Table 1. Characteristics of analyzed articles.
RefCountryNIGCGPhysical Activity InterventionMain VariablesSecondary Variables
FreqIntensDuratTypeSupervTimeAdh
Abd et al., 2015 [21]Egypt180110707Low10–15Perineal massageNo4 w-Episiotomy
Perineal tear
Type of delivery
5Pelvic floor muscle training
Aktan et al., 2021 [22]Turkey4321222Mod60Clinical Pilates exerciseYes8 w-General anxiety, gestational weight gainType of delivery, birth weight
Awad et al., 2020 [9]Egypt5025253Mod60Aerobic, pelvic floor exercisesYes22 w-Duration of the second stage laborType of delivery and Apgar scores
335No
Babbar et al., 2016 [23]USA4623233Mod60YogaYes8 w80%Umbilical artery, type of delivery, birth weightGestational weight gain
Backhausen et al., 2017 [24]Denmark5162582582Low70Water exercisesNo12 w76%Low back pain, birth weightType of delivery
Barakat et al., 2012 [25]Spain2901381523Mod40–45Aerobic exerciseYes28 w-Type of deliveryGestational weight gain birth weight
Barakat et al., 2012 [26]Spain8340433Low-Mod35–45Land aerobic and aquatic activityYes28 w-Gestational weight gain and gestational diabetesGestational age, type of delivery, birth weight and Apgar score
Barakat et al., 2014 [27]Spain200107933Low-Mod55–60Aerobic exercise, pelvic floor muscle trainingYes28 w80%Gestational age, gestational weight gain, type of delivery, gestational diabetesBirth weight, head circumference
Barakat et al., 2016 [28]Spain7653823833Mod50–55Aerobic, strength, and flexibility exerciseYes28 w80%HypertensionType of delivery, gestational weight gain, birth weight
Barakat et al., 2018 [29]Spain4292272023Mod55–60Aerobic exerciseYes28 w80%Duration of laborType of delivery, use of epidural, birth weight
Barakat et al., 2018 [30]Spain6533323Mod55–60Aerobic, pelvic floor strength, and flexibility exercisesYes28 w85%Placenta weightGestational age, type of delivery, birth weight
Barakat et al., 2018 [31]Spain4562342223Mod50–55Aerobic exerciseYes28 w-Gestational weight gainGestational age, type of delivery, birth weight
Bhartia et al., 2019 [32]India7838401Mod50YogaYes12 w-Maternal Stress, type of delivery, birth weight-
2No
Bjøntegaard et al., 2021 [33]Norway2811641171Mod-High60Aerobic, strength training and balance exercisesYes12 w-Type of delivery, birth weightPhysical activity of children at age of seven
245No
Bolanthakodi et al., 2018 [34]India15075753Mod30YogaNo9 w-Pain intensity, type of delivery, duration of deliveryLow birth weight, Preterm birth
Carpenter et al., 2015 [35]UK5016341Low-Mod40Stationary cycling, pelvic floor exercises and water exercisesYes18 w-Hemodynamic functionType of delivery, birth weight
Carrascosa et al., 2021 [36]Spain2861451413Mod45Aquatic aerobic exerciseYes20 w-Use of epidural analgesia during laborType of delivery, time of active labor, episiotomy
Cordero et al., 2015 [37]Spain2571011561–2Low50–60Aerobics in gym hall and aquatic activityYes26 w80%Gestational DiabetesGestational weight gain, type of delivery, birth weight
Daly et al., 2017 [38]Ireland8844443Mod50–60Aerobic, pelvic floor exercisesYes26 w-Maternal fasting plasma glucoseType of delivery, duration of labor, birth weight
Dias et al., 2011 [39]Norway4221211Low30Pelvic floor muscle trainingYes16 w75%Type of delivery, duration of labor, birth weightPelvic floor muscle strength
6No
Dieb et al., 2019 [40]Egypt4002002003Low5Pelvic floor muscle trainingNo4 w-Episiotomy, perineal tear, type of deliveryDuration of labor, fetal distress, episiotomy, birth weight
310
Ellingsen et al., 2020 [41]Norway2791641151Mod60Aerobic and strength exercisesYes12 w-Neurodevelopmental in 7-year-old childrenGestational age, birth weight, type of delivery
245No
Ferreira et al., 2019 [42]Portugal255991563Mod45–60Aerobic, strength, coordination and flexibility exercisesYes24 w-Duration of labor, type of deliveryEpisiotomy, perineal tear
Fritel et al., 2015 [43]France2821401421Low20–30Pelvic floor trainingYes8 w-Urinary incontinenceType of delivery, birth weight
Gau et al., 2011 [44]China8748393Low20Ball exerciseNo8 w-Childbirth painDuration of labor
Ghandali et al., 2021 [45]Iran10351522Low-Mod35Pilates exerciseYes8-Type of delivery, episiotomy, duration of laborMaternal satisfaction with childbirth process
Ghodsi et al., 2014 [46]Iran8040403Low15Stationary cyclingNo15 w-Gestational weight gain, type of delivery, perineal tearPregnancy length, first and second stage of labor, Apgar score
Guelfi et al., 2016 [47]Australia17285873Mod20–60Stationary cycling programYes14 w-Gestational diabetesType of delivery, birth weight
Haakstad et al., 2020 [48]Norway10552532Mod60Aerobic dance and strength trainingYes12 w80%Birth weightGestational age, type of delivery
130No
Johannessen et al., 2021 [49]Norway7223833391Mod55–70Aerobic, strength and pelvic floor exercisesYes12 w-Urinary incontinence at 3 months postpartumType of delivery, episiotomy, epidural, duration of labor, birth weight
245No
Karthiga et al., 2022 [50]India2341211137Mod60YogaNo20 w-Gestational hypertension, preeclampsia, premature deliveryType of delivery, duration of labor, birth weight
León-Larios et al., 2017 [51]Spain4662542125Low18–23Perineal massage and pelvic floor exercisesNo6 w-Perineal tear and episiotomyType of delivery, duration of labor, birth weight and epidural
Miquelutti et al., 2013 [52]Brazil14978717Low10–30Aerobic and pelvic floor muscle exercisesNo14 w-Urinary incontinence, lumbopelvic pain and anxietyType of delivery, duration of labor
Nascimento et al., 2011 [53]Brazil8039411Low-Mod40Aerobic exercise and walkingYes17 w62.5%Scoring women on meeting the intervention goalsGestational weight gain, birth weight, macrosomia, and low birth weight
5No
Okido et al., 2015 [54]Brazil5926337Low20Pelvic floor muscle trainingNo16 w-PI of the uterine artery, type of delivery, duration of delivery, birth weightEpisiotomy, urinary incontinence
Pais et al., 2021 [55]India12461637Low45YogaNo20 w-Preeclampsia and gestational diabetesGestational age, duration of labor, type of delivery, birth weight
Pelaez et al., 2019 [56]Spain3452301153Low-Mod60–65Aerobic and resistance trainingYes24 w80%Gestational weight gainGestational diabetes, macrosomia, type of delivery
Perales et al., 2016 [57]Spain16683833Low-Mod55–60Aerobic, strength exercises, pelvic floor muscle trainingYes28 w-Duration of labor, gestational age, gestational weight gain, type of delivery, birth weighBirth size, head circumference, Apgar score
Perales et al., 2020 [58]Spain13486686603Low-Mod50–55Aerobic and pelvic floor exercisesYes3095%Gestational weight gain, hypertension and diabetesType of delivery, birth weight, gestational age
Pereira et al., 2022 [59]Portugal12663633Low-Mod30WalkingYes3 w-Rate of labor inductionType of delivery, birth weight
Pinzón et al., 2012 [60]Colombia6431333Low-Mod60Aerobic and stretching exercisesYes12 w-Gestational age, gestational weight gain, type of deliveryBirth weight, birth size, head circumference, Apgar score
Price et al., 2012 [61]USA6231313Mod45–60Aerobic exercise and walk brisklyYes23 w-Gestational weight gain. duration of labor, birth weight, postpartum recoveryLength of first and second stage of labor, type of delivery, gestational diabetes
130–60No
Rodríguez-Blanque et al., 2019 [62]Spain12965643Mod60Aquatic physical exerciseYes17 w-Laceration and episiotomy ratesType of delivery, birth weight and anesthesia
Rodríguez-Blanque et al., 2020 [63]Spain12965643Mod60Aquatic physical exerciseYes17 w-Gestational weight gain, type of deliveryBirth weight, Apgar score
Rodríguez-Diaz et al., 2017 [64]Spain10050502Mod40–45PilatesYes8 w90%Gestational weight gain, blood pressure, strength, flexibility, and spinal curvatureType of delivery, episiotomy analgesia and birth weight
Ruiz et al., 2013 [65]Spain9624814813Low-Mod50–55Aerobic and resistance exercisesYes28 w97%Gestational weight gainBirth weight, duration of labor
Salvesen et al., 2014 [66]Sweden8554274261Low-Mod55–70Aerobic, strength and pelvic floor exerciseYes12 w-Gestational diabetesUrinary and anal incontinence, lumbopelvic pain, and duration of labor
245No
Sanda et al., 2018 [67]Norway5892952943Mod60Aerobic exercisesYes22 w-Gestational age, duration of labor, type of delivery-
230No
Seneviratne et al., 2015 [68]New Zealand7538373–5Mod15–30Stationary cycling programNo16 w33%Birth weight, type of deliveryGestational weight gain, gestational age
Shojaei et al., 2021 [69]Iran10049514Mod40WalkingNo4 w-Duration of labor-
Silva-Jose et al., 2022 [70]Spain15778793Mod55–60Aerobic, strength and pelvic floor exercisesYes28 w80%Gestational weight gainType of delivery, birth weight
Sobhgol et al., 2022 [71]Australia2001001001–2Low10Pelvic floor muscle exercisesNo16 w50%Female Sexual FunctionType of delivery, perineal tear, episiotomy, duration of labor, birth weight
Stafne et al., 2012 [72]Norway7613963651Mod-High60Aerobic, strength, and pelvic floor exercisesYes12 w-Gestational diabetes, insulin resistanceBirth weight, gestational age, Apgar scores
345No
Taniguchi et al., 2016 [73]Japan11860583Mod30Walk brisklyYes6 w80%Duration of labor; type of delivery, birth weight-
Tomic et al., 2013 [74]Croatia3341661683Low-Mod50Aerobic exerciseYes28 w80%Macrosomia birth weight, gestational weight gainPreeclampsia, gestational diabetes, type of delivery
Uria-Minguito et al., 2022 [75]Spain2031021013Mod50–60Aerobic, strength, and pelvic floor exercisesYes28 w-Gestational diabetesGestational weight gain, type of delivery, birth weight
Ussher et al., 2015 [76]UK7893943953–4Low20Exercise on a treadmillYes6 w-Continuous smoking abstinenceGestational age, preterm birth, type of delivery, birth weight
Wang et al., 2017 [77]China2261121143Mod45–60Stationary cycling programYes24 w75%Gestational diabetesGestational weight gain, birth weight, macrosomia
Wang et.al., 2020 [78]China10854547Low30Pelvic floor muscle trainingNo12 w-Stress urinary incontinence, episiotomyDuration of labor and type of delivery
Yekefallah et al., 2021 [79]Iran7035352Low -Mod75YogaYes11 w-Episiotomy, perineal tear, type of deliveryBirth weight, gestational age, duration of labor
IG, intervention group; CG, control group; Freq, weekly frequency; Intens, intensity; Mod, moderate; Durat, minutes of session duration; Time, weeks of intervention; Sup, supervised sessions.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Zhang, D.; Ruchat, S.-M.; Silva-Jose, C.; Gil-Ares, J.; Barakat, R.; Sánchez-Polán, M. Influence of Physical Activity during Pregnancy on Type and Duration of Delivery, and Epidural Use: Systematic Review and Meta-Analysis. J. Clin. Med. 2023, 12, 5139. https://doi.org/10.3390/jcm12155139

AMA Style

Zhang D, Ruchat S-M, Silva-Jose C, Gil-Ares J, Barakat R, Sánchez-Polán M. Influence of Physical Activity during Pregnancy on Type and Duration of Delivery, and Epidural Use: Systematic Review and Meta-Analysis. Journal of Clinical Medicine. 2023; 12(15):5139. https://doi.org/10.3390/jcm12155139

Chicago/Turabian Style

Zhang, Dingfeng, Stephanie-May Ruchat, Cristina Silva-Jose, Javier Gil-Ares, Rubén Barakat, and Miguel Sánchez-Polán. 2023. "Influence of Physical Activity during Pregnancy on Type and Duration of Delivery, and Epidural Use: Systematic Review and Meta-Analysis" Journal of Clinical Medicine 12, no. 15: 5139. https://doi.org/10.3390/jcm12155139

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop