Little scientific information is available to guide physicians in advising patients and employers about physical exertion during pregnancy. This issue of Clinical Discussions examines the published literature regarding exercise tolerance, physical activity and pregnancy complications.

Traditionally, standard maternity considerations have involved a combination of recommendations limiting physical activity and creating a "maternity leave" to allow for preparation for and recovery from delivery. Recent literature 8,9 has suggested a link between certain forms of job stress and adverse pregnancy outcomes (spontaneous abortion, premature delivery, low birth weight delivery). The consistent recommendations made from studies of working women include:

1. Limitation of long work days/weeks
2. No prolonged periods of standing
3. Limitations to heavy lifting and physical activity

Based on these reports, practical recommendations for employers should include:

1. No work days of longer than 8 hours
2. No work weeks of longer than 40 hours
3. Provision of chairs/stools for employees whose job requires prolonged periods of standing
4. No lifting of objects heavier than 25 pounds (10-12 kilos)
5. Provision of leave for delivery based on estimated date of delivery (EDC)

The most common complications reported in association with strenuous or prolonged work during pregnancy are spontaneous abortion and low birth weight 1,8,9,10. However, no generalization can be made about job stresses, long working hours, and other "ergonomic stressors". Literature regarding pregnancies in resident physicians 14 and other female physicians 18 suggests no increased rate of spontaneous abortion or low-birth weight delivery. However, female physicians do have an increased risk of threatened premature labor when compared to the general population.

Recent accusations that work with video display terminals (VDT's) increases the risk of spontaneous abortion 19,20 have been refuted by subsequent studies 21-24. There is no reason based on current literature to support the restriction of work with VDT's during pregnancy.

Maternity Leave

No literature has examined the relationship between maternal health and the duration of maternity leave. Much of obstetric advice regarding maternity leave has been "borrowed" from practices of post-operative surgical leave. As post-operative recovery times have shortened, there has been no corresponding effort to shorten maternity leave for patients with uncomplicated vaginal deliveries. The Family and Personal Leave Act of 1993 provides job security to patients who wish to take maternity leave from work and return to their employment. This law applies to large employers and specifies that 12 weeks of unpaid leave must be granted a new mother or father following delivery or adoption. This trend attempts to emphasize the importance of family bonding following delivery and allows for a prolonged recovery time should the patient request it.

Standard recommendations for maternity leave have included:

First Trimester Abortion	1-2 weeks
Second Trimester Abortion	2-4 weeks
Vaginal Delivery/Forceps	4-6 weeks
Cesarean Section		6 weeks
Cesarean Hysterectomy		6-8 weeks

Patients should be encouraged to inquire about maternity leave allowances from their employer, once the information about their pregnancy is common knowledge. A patient should be granted the maximum allowable personal leave from work for maternity recovery. Declarations of "temporary disability" from pregnancy should be limited to patients with legitimate pregnancy complications who are anticipated to miss more than 30 days of work prior to delivery. Because Georgia is an "at will" state for employment, small employers may dismiss a pregnant employee without cause. Because of work time missed for prenatal visits, tests, and delivery, proving unfair dismissal from work solely from pregnancy discrimination is very difficult to prove. The physician should be cognizant of the risk that the employee takes by requesting liberal maternity leave or temporary disability. Dismissal from work may follow, from which the patient employed by a small company has little recourse to appeal.

Exercise in Pregnancy

Exercise programs during pregnancy have been controversial due to physiologic concerns regarding issues of hyperthermia, glucose regulation and acidosis in the fetus. Research from infertility centers has documented several endocrine "adaptations" to chronic exercise that are potentially deleterious in pregnancy including hyperprolactinemia, anovulation and shortened luteal phase 27.

Studies suggest that pregnant women who exercise during pregnancy may be at particular risk for hypoglycemia 29,30. Adjusting the patient's diet (carbohydrate loading) is the best strategy for patients wishing to continue exercise programs during their pregnancy 28. Although birth weights may be slightly lower in patients who follow a program of exercise in pregnancy, other potential benefits from exercise include improved glucose tolerance.

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