A C TA Obstetricia et Gynecologica

AOGS M A I N R E SE A RC H A R TI C LE

Does regular exercise in pregnancy influence duration of

labor? A secondary analysis of a randomized controlled
trial
KJELL 
A. SALVESEN1,2, SIGNE N. STAFNE3,4, TORBJØRN M. EGGEBØ5 & SIV MØRKVED3,4
1
Clinical Sciences, Obstetrics and Gynecology, Lund University, Lund, Sweden, 2National Center for Fetal Medicine,
Department of Obstetrics and Gynecology, St. Olavs Hospital, Trondheim University Hospital, 3Clinical Services, St. Olavs
Hospital, Trondheim University Hospital, 4Faculty of Medicine, Department of Public Health and General Practice,
Norwegian University of Science and Technology, Trondheim, and 5Department of Obstetrics and Gynecology, Stavanger
University Hospital, Stavanger, Norway

Key words Abstract

Exercise, labor, pregnancy, randomized
controlled trial
Correspondence
Kjell 
A. Salvesen, Clinical Sciences, Obstetrics
and Gynecology, Lund University,
Klinikgatan12, SE-221 85 Lund, Sweden.
E-mail: kjell.salvesen@med.lu.se
Conflict of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Please cite this article as: Salvesen K
A, Stafne
SN, Eggebø TM, 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.
Received: 29 May 2013
Accepted: 6 September 2013
Objectives. To study effects of regular physical exercise in pregnancy on dura-
tion of the active phase of labor and the proportions of women with prolonged
active second stage. Design. A two-armed, two-center randomized controlled
trial. Setting. St. Olavs Hospital, Trondheim University Hospital and Stavanger
University Hospital. Population. A total of 855 women were randomized to
intervention or control groups. Methods. The intervention was a 12-week exer-
cise program, including aerobic and strengthening exercises, conducted
between the 20th and 36th week of gestation. One weekly group session was
led by physiotherapists and home exercises were encouraged twice a week.
Controls received standard antenatal care. Main outcome measures. The dura-
tion of active phase of labor and number of prolonged second stage deliveries
(active pushing > 60 min). We also studied labor outcomes. Supplementary
analyses were done in a subgroup of nulliparous women with a singleton
cephalic fetus and spontaneous start of term delivery. Results. Duration of
labor was similar in the two groups, and there were no differences in labor
outcomes. In a subgroup analysis the duration of active second stage labor was
shorter in the control group (p = 0.01). Conclusions. Regular physical exercise
during pregnancy did not influence duration of the active phase of labor or
the proportion of women with prolonged active second stage.

DOI: 10.1111/aogs.12260 Abbreviations: BMI, body mass index.

of the pelvic floor muscles may produce strong and well

controlled muscles that will facilitate labor, and one ran-
Introduction
domized controlled trial has demonstrated that intensive
Exercise is defined as regular, leisure-time physical activi- pelvic floor muscle training in pregnancy prevented a
ties to improve physical condition, ability or health. Pre- prolonged second stage of labor in about one in eight
vious studies indicate that women with uncomplicated
pregnancies are fit for exercise with few restrictions, with-
out any risk of harm to the mother or fetus (1). A myth
prevails that athletes, gymnasts and horsewomen may Key Message
experience difficult labors due to strong pelvic floor mus-
Regular exercise during pregnancy does not influence
cles, and these questions are frequently discussed on chat-
duration of the active phase of labor.
ting websites for pregnant women (2). However, training

ª 2013 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 73–79 73
Exercise in pregnancy and labor
women (3). Improved aerobic capacity and general mus-
cular strength may also be beneficial and facilitate labor,
but this has been sparsely studied in randomized con-
trolled trials (4).
The present study was designed to evaluate effects of
regular exercise in pregnancy. The primary outcome was
gestational diabetes, and results have been published else-
where (5). This report deals with two of five pre-specified
secondary outcomes of the trial. The aim of this report
was to study the influence of exercise on duration of the
active phase of labor and the proportion of women with
prolonged active second stage.
Material and methods
This was a two-armed, two-center randomized controlled
trial of a 12-week exercise program vs. standard antenatal
care. Pregnant women booking for second trimester ultra-
sound at St. Olavs Hospital, Trondheim University Hos-
pital and Stavanger University Hospital in 2007–2009
were invited to participate. During the inclusion period
from April 2007 to June 2009 in Trondheim and October
2007 to January 2009 in Stavanger approximately 12 000
pregnant women had ultrasound at the two hospitals,
and 875 women consented to participate in the trial.
Inclusion criteria were (1) age ≥18 years and (2) a single-
Assessed for eligibility (n = 875)
Randomized (n = 855)
Allocated to intervention group (n = 429)
Missing data from labor and delivery (n = 2)
Included in analysis (n = 427)
Figure 1. Flow-chart of the study participants.
74 ª 2013 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 73–79
K.
A. Salvesen et al.
ton live fetus. Exclusion criteria were high-risk pregnan-
cies and/or diseases that could interfere with
participation. For practical reasons we also excluded
women who lived too far from the hospitals to attend
weekly training groups. The study population was pre-
dominantly white European and representative of preg-
nant Norwegian women with respect to body mass index
(BMI) and physical activity (5,6).
Randomization in blocks of 30 was performed at the
Unit for Applied Clinical Research, Norwegian University
of Technology and Science, by a web-based computerized
procedure. The staff involved with training or outcome
assessments had no influence on the randomization pro-
cedure. Because of the nature of the study it was not
blinded. However, labor outcomes were analyzed blind
for group allocation.
The allocation of the study population is shown in
Figure 1. One group of women (n = 429) was randomly
allocated to a standardized exercise program. This con-
sisted of 30–35 min low impact aerobics, 20–25 min
strength exercises, including pelvic floor muscle training,
and 5–10 min light stretching and body awareness.
Women trained in groups with a physiotherapist once a
week over a period of 12 weeks between the 20th and the
36th week of pregnancy. In addition, they were encour-
aged to follow a written 45-min home exercise program
Excluded (n = 20)
♦ Twin pregnancies (n = 2)
♦ Miscarried (n = 5)
♦ Not meeting inclusion criteria (n = 13)
Allocated to control group (n = 426)
Missing data from labor and delivery (n = 0)
Included in analysis (n = 426)
K.
A. Salvesen et al.
at least twice a week (30 min aerobic activity and 15 min
strength and balance exercises). Performing the exercise
program was recorded in the women’s personal training
diary and through reports from the physiotherapists. In
addition, physical activity was recorded in a question-
naire. Women in the control group (n = 426) received
standard antenatal care and the customary information
given by their midwife or general practitioner.
The primary outcome of this trial was gestational dia-
betes. Based on a prevalence estimate of gestational diabe-
tes of 9% and a reduction to 4% in the intervention
group, a study population of 381 women in each group
was needed, and 855 women were included (5). Five
other hypotheses regarding secondary outcomes were pre-
specified in the study protocol; urinary incontinence, anal
incontinence, lumbopelvic pain, duration of labor and
number of prolonged second stage deliveries. The results
regarding urinary and anal incontinence and lumbopelvic
pain have been published elsewhere (7,8). For the second-
ary outcomes presented in this report we did a power cal-
culation based on the fixed sample size determined by the
primary outcome of the trial. We assumed that 45% of
all women in the trial (n = 855) would be nulliparous
with term cephalic deliveries (n = 385). In a previous
trial of nulliparous women we found that 21% in the
intervention group and 34% in the control group had
prolonged second stage labor (3). Assuming the same dif-
ference, a sample size calculation with a = 0.05 and a
power of 80% showed that 185 women in each group
would be sufficient. Thus, we planned a subgroup analysis
of nulliparous women with a singleton fetus in cephalic
position and spontaneous start of labor after the
37th week of gestation.
Data from labor and delivery were recorded in parto-
grams by birth attendants. Birth attendants were blinded
to the randomization. The start of the active phase of
labor was defined when the cervix was dilated 4 cm and
the woman had regular contractions. The start of the sec-
ond stage was defined when the cervix was fully dilated,
and the active phase of the second stage was defined as
the time of active pushing. Prolonged active second stage
was defined when the woman had pushed actively more
than 60 min. Labor outcomes were recorded by one
research assistant after the delivery from hospital records.
She was not involved in training of the women and was
blinded to group allocation while recording and plotting
the data.
Gestational length was calculated based on a mid-tri-
mester ultrasound scan. Preterm delivery was defined as
delivery before pregnancy week 37 + 0. Small-for-gesta-
tional age was defined as birthweight below 2 SD ( 22%)
for gestational age according to Marsal et al. (9).
ª 2013 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 73–79
Exercise in pregnancy and labor
The statistical analyses were done according to the
intention-to-treat principle. We analyzed categorical vari-
ables using the chi-squared test and normally distributed
continuous variables using the t-test. We used Kaplan–
Meier curves to analyze duration of labor and compared
groups using the log rank Mantel–Haenschel test. Cesar-
ean sections and cases with duration of labor >12 h were
censored investigating duration of active phase of labor,
and operative deliveries and active second stage >60 min
were censored investigating duration of second stage. We
also performed a Cox regression analysis investigating
duration of active second stage with possible confounding
variables, such as maternal age, BMI, birthweight, aug-
mentation of labor and epidural analgesia. Data were ana-
lyzed using the statistical software package PASW
statistics version 18.0 (Chicago, IL, USA).
The study was in accordance with ethical standards of
research and the Helsinki declaration. The women
received written information and signed informed consent
forms. Participants were not compensated financially. The
study was approved by the Regional Committee for Med-
ical and Health Research Ethics (REK 4.2007.81) and reg-
istered with Clinical trial gov (NCT 00476567) www.
clinicaltrials.gov.
Results
In all, 875 women consented to participate in the trial.
Twenty women were excluded or withdrew before the
first examination: five miscarried, two had twin pregnan-
cies and 13 did not meet the inclusion criteria. A total of
855 women were randomly allocated to an intervention
group or a control group (Figure 1). Two intervention
group women had missing data on delivery outcomes.
Data from 427 intervention group women and 426 con-
trol group women were included in a complete case
analysis.
The groups had similar baseline characteristics
(Table 1). There were 247 (58%) nulliparous women in
the intervention group and 239 (56%) in the control
group, and 92% of all parous women had previous vagi-
nal deliveries.
We found no significant differences in the prevalence
of gestational diabetes or levels of insulin resistance
between the intervention group and control group (the
primary outcome of the trial; results have been reported
elsewhere) (5). There was no difference between groups
in weight gain, weight or BMI at a follow-up at 36 weeks’
gestation (data not shown). Adherence to protocol (exer-
cising three days per week or more at moderate to high
intensity) in the intervention group was 55% at follow-up
at 36 weeks’ gestation. Only 10% of women in the
75
Exercise in pregnancy and labor K.
A. Salvesen et al.

Table 1. Baseline characteristics of the study population. group and 11% (38/358) in the control group (p = 0.65).
Data on labor and delivery are presented for nulliparous
Intervention group Control group
(n = 429) (n = 426) women in Table 2 and parous women in Table 3. As can
be seen, nulliparous but not parous women in the inter-
n % n % vention group had a significantly longer active second
Age, yearsa 30.5  4.4 30.4  4.3 stage of labor as compared with the control group.
Nulliparous 247 58 239 56 There were no differences between groups in mean gesta-
Booking BMI, 24.7  3.0 25.0  3.4 tional age at birth (280 vs. 281 days, p = 0.22) or mean
kg/m2a birthweight (3515 vs. 3523 g, p = 0.82), and no differences
Booking weight, 70.4  9.8 70.8  10.3 in the numbers of preterm births (20 vs. 19, p = 0.88) or
kga
small for gestational age babies (8 vs. 7, p = 0.80).
Exercise regularly 228 53 216 51
Exercise regularly 60 14 50 12
One subgroup analysis of a secondary outcome was
≥3 times per week pre-specified in the study protocol, and a power calcula-
at high intensity tion had been done. In this subgroup analysis of nullipa-
rous women (n = 387) with a fetus in cephalic position
a
Mean  SD.
and spontaneous start of labor at term, women in the
BMI, body mass index.
control group had a significantly shorter duration of the
active second stage labor (p = 0.01) (Figure 3). In Cox
control group exercised at this level (p < 0.001) at regression analyses the unadjusted hazard ratio analyzing
36 weeks’ gestation. the duration of second stage was 1.37 (95% CI 1.05–1.80;
The mean duration of labor in the intervention group p = 0.02), and the difference remained statistically signifi-
was 289 min vs. 281 min in the control group. In a sur- cant when possible confounders were entered in the
vival analysis the duration of labor was similar (p = 0.13, model [hazard ratio 1.34 (95% CI 1.02–1.77; p = 0.04].
log rank test) (Figure 2). The mean duration of active
second stage was 32 min in the intervention group vs. Table 2. Labor and delivery for nulliparous women in intervention
29 min in the control group (p = 0.12, log rank test). and control groups.
The frequencies of prolonged second stage in women
Intervention Control
with a vaginal birth was 12% (43/368) in the intervention group group
(n = 245) (n = 239)

n/N % n/N % p-value

Duration of labor, min a

373  266 377  373 0.90
Duration of active 44  27 38  24 0.03
second stage labor, mina
Prolonged active 41/208 20 34/201 17 0.47
second stage
Spontaneous 176/245 72 167/239 70 0.64
start of labor
Breech presentation 7/234 3 8/228 4 0.75
Epidural analgesia 87/239 36 88/233 38 0.76
Oxytocin augmentation 122/240 51 115/232 50 0.78
Cesarean section: slow 6/31 20 2/31 7 0.13
progress/total number
Operative vaginal 23/46 50 16/37 43 0.54
delivery: slow
progress/total numberb
Episiotomy 64/207 31 48/201 24 0.11
Perineal laceration 12/206 6 12/207 6 0.99
grade 3 + 4
Postpartum 404  277 406  244 0.94
hemorrhage, mLa

a
Mean  SD.
b
Figure 2. Kaplan–Meier plot of the active phase of labor differentiated Unknown indication for seven deliveries in the intervention group
between intervention group (----) and control group (- - -). Cases with and five in the control group.
caesarean sections and duration of labor >12 h were censored. n/N, number/total number in group with available data.

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K.
A. Salvesen et al. Exercise in pregnancy and labor

Table 3. Labor and delivery for parous women in intervention and However, the frequencies of women with prolonged sec-
control groups. ond stage was 22% (37/171) in the intervention group vs.
Intervention Control 17% (27/164) in the control group (p = 0.23), and there
group group were no differences in the duration of active phase (total
(n = 182) (n = 187) length) of labor (p = 0.36). Other labor outcomes are
presented in Table 4 for nulliparous women, and in
n/N % n/N % p-value
Table 5 for parous women.
Duration of labor, mina 182  158 161  170 0.25 Since only 55% of the intervention group women fol-
Duration of active 16  14 16  14 0.72 lowed the recommended exercise protocol, we performed a
second stage labor, mina post-hoc per protocol analysis (not pre-specified in the
Prolonged 2/160 1 4/157 3 0.40
study protocol) comparing 217 women in the intervention
active second stage
Spontaneous 147/182 81 147/187 79 0.61
group exercising ≥ three times per week with 426 women
start of labor in the control group. The duration of the active phase of
Breech presentation 3/178 2 3/181 2 0.98 labor was similar between groups (p = 0.37), and the fre-
Epidural analgesia 34/177 19 23/183 13 0.08 quency of women with prolonged second stage was also
Oxytocin augmentation 32/179 18 27/184 15 0.41 similar (p = 0.39). However, the duration of active second
Cesarean section: slow 2/14 14 2/18 11 0.79 stage tended to be shorter in the control group (p = 0.05).
progress/total number
Operative vaginal 0/6 0 6/8 75 0.005
delivery: slow Discussion
progress/total numberb
Episiotomy 17/165 10 10/164 6 0.17 No differences were found in the duration of labor
Perineal 2/164 1 4/164 2 0.41 between the intervention and control groups, the propor-
laceration grade 3 + 4
Postpartum 303  137 336  187 0.06
Table 4. Maternal characteristics and labor in intervention and
hemorrhage, mLa
control groups restricted to nulliparous women with a singleton
a
Mean  SD. cephalic fetus and spontaneous start of labor after 37 weeks.
b
Unknown indication for three deliveries in the intervention group.
Intervention
n/N, number/total number in group with available data.
group Control group
Maternal (n = 201) (n = 186)
characteristics
and labor outcomes n/N % n/N % p-value

Maternal age, years a

29.1  3.9 28.9  4.2 0.64
BMI at 18 24.6  3.2 24.8  3.5 0.64
weeks, kg/m2a
Duration of 390  277 377  338 0.69
labor, mina
Duration of active 47  28 38  23 <0.01
second
stage labor, mina
Prolonged 37/171 22 27/164 17 0.23
second stage
Epidural analgesia 65/197 33 68/182 37 0.37
Oxytocin 98/198 50 89/181 49 0.95
augmentation
Operative vaginal 40/201 20 30/186 16 0.34
delivery
Cesarean section 24/201 12 17/186 9 0.37
Episiotomy 54/172 31 40/163 25 0.16
Perineal laceration 10/170 6 9/168 5 0.83
grade 3 + 4
Postpartum 410  291 403  237 0.80
Figure 3. Kaplan–Meier plot of the duration of active second stage hemorrhage, mLa
labor among nulliparous women with a fetus in cephalic position and
spontaneous start of labor at term differentiated in intervention group a
Mean  sd.
(-----) and control group women (- - -). Cases with operative deliveries BMI, body mass index.
and duration of active second stage >60 min were censored. n/N, number/total number in group with available data.

ª 2013 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 73–79 77
Exercise in pregnancy and labor K.
A. Salvesen et al.

Table 5. Maternal characteristics and labor in intervention and the generalizability of the results should be interpreted
control groups restricted to parous women with a singleton cephalic with caution in other pregnant populations with higher
fetus and spontaneous start of labor after 37 weeks.
BMI, less physically active women and in ethnically
Intervention Control diverse populations.
group group The present trial is in line with previous randomized
(n = 158) (n = 156) trials reporting on labor, delivery and neonatal outcomes.
Maternal characteristics
A Cochrane review from 2010 included 14 trials involving
and labor outcomes n/N % n/N % p-value
1014 women (4). Eleven trials reported on pregnancy
Maternal age, yearsa 32  4 32  4 0.91 outcomes, and no statistically significant associations were
BMI at 18 weeks, kg/m2a 25  3 25  3 0.11 found. This review concluded that available data were
Duration of labor, mina 182  153 154  138 0.11
insufficient to infer important risks or benefits for the
Duration of active 16  15 16  13 0.89
second stage labor, mina
mother or infant (4). The present trial is larger than all
Prolonged second stage 2/138 1 3/132 2 0.62 previous trials grouped together in the Cochrane review.
Epidural analgesia 31/154 20 21/153 14 0.14 Thus, it is reassuring that no significant associations were
Oxytocin augmentation 25/156 16 23/154 15 0.79 found. In addition, two recent trials from 2012 show sim-
Operative vaginal delivery 8/158 5 5/156 3 0.41 ilar results (10,11). Price et al. (10) included 91 women
Cesarean section 13/158 8 16/156 10 0.54 in a randomized controlled trial and found significantly
Episiotomy 14/144 10 9/138 7 0.33
fewer Cesarean sections in the intervention group, but no
Perineal laceration 2/141 1 3/138 2 0.63
grade 3 + 4
other significant differences. Barakat et al. (11) included
Post partum 298  137 339  194 0.03 290 women in a randomized controlled trial and found
hemorrhage, mLa reduced proportions of instrumental deliveries and Cesar-
ean sections in the intervention group, but other preg-
a
Mean SD.
nancy and newborn outcomes were unaffected. In our
BMI, body mass index; n/N, number/total number in group with avail-
trial, there were no differences in numbers of operative
able data.
deliveries or cesarean sections (overall or for prolonged
labor).
tion of women with prolonged active second stage or The finding of a shorter active second stage labor
labor outcomes. In a subgroup analysis of nulliparous among nulliparous women in the control group con-
women, the active second stage labor was shorter in the trasts with findings from a previous trial demonstrating
control group. that intensive pelvic floor muscle training during preg-
A strength of this study was that it was an adequately nancy prevented a prolonged second stage labor in
sized, randomized controlled trial with blinded analyses about one in eight nulliparous women (3). In that
of outcomes. One limitation is that this report is a sec- study the neonates were slightly smaller, there was less
ondary analysis of the trial, and the only significant find- need to perform episiotomy, and there were signifi-
ing was found in a subgroup. However, this subgroup cantly fewer breech presentations in the intervention
analysis was pre-specified in the study protocol, and the group (3). This could not be verified in the present
study was adequately powered for this analysis. Still, the trial, where we found similar birthweights, breech pre-
results from the subgroup analysis should be viewed with sentations and rates of episiotomy. One explanation of
caution. the contradictory results may be differences in the
Another limitation is that only 875 (7%) of 12 000 training program of the two trials. The training pro-
women receiving a study invitation letter with their scan gram of one trial focused specifically on pelvic floor
appointment, participated in the trial. The exact number muscle training to prevent and treat urinary inconti-
of eligible women is unknown because we only included nence. In the other trial the focus was aerobic physical
singleton low-risk pregnancies in the trial, and women training and general strength exercises. Pelvic floor mus-
living too far from the hospital to attend weekly training cle training was part of the training program but was
groups were not eligible. A low inclusion rate may influ- not highlighted to the same extent. Another explanation
ence the external validity (generalizability) but the may be that there is no true effect of physical exercise
internal validity (comparison between groups) of a ran- on labor and delivery and the contradictory results may
domized controlled trial is not affected by a low inclusion be due to chance. One trial found a shorter second
rate. The present trial included women who had a BMI stage and the other a longer second stage of labor after
within the normal range (24.8  3.2), and 32% of the exercise in pregnancy. These findings were of borderline
women exercised regularly prior to pregnancy at moder- statistical significance (p = 0.01–0.06 in various analyses
ate to high intensity three times per week or more. Thus, in both trials).

78 ª 2013 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 73–79
K.
A. Salvesen et al.
Fifty-five percent of the intervention group women fol-
lowed the recommended exercise protocol of training at
moderate intensity of 45–60 min for three days per week.
This was somewhat disappointing as this is the official
recommendation for all pregnant women (1). An explor-
ative analysis of protocol-adherent women compared with
control women demonstrated no differences in labor out-
comes or duration of labor except for a tendency towards
a prolonged active second stage in the intervention group.
This supports our interpretation that there were no major
effects of physical exercise on labor and delivery.
In conclusion, we have found that regular physical
exercise during pregnancy did not influence the duration
of the active phase of labor or the proportion of women
with prolonged active second stage.
Funding
The trial was supported by the Norwegian Fund for Post-
graduate Training in Physiotherapy, and the Liaison
Committee for Central Norway Regional Health Author-
ity (RHA) and the Norwegian University of Science and
Technology. The sponsors of the study had no role in the
study design, data collection, data analysis and interpreta-
tion, writing of the manuscript or decision to submit for
publication.
Acknowledgments
The authors thank all physiotherapists and medical secre-
taries at the two hospitals for their efforts during this study.
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