This prospective cohort study was conducted in university hospital. Overall, 151 primiparous women who are at 36 weeks of gestational age, coming to Obstetry and Gynecology Department for their antenatal care, were asked to participate in a trial which investigates the effect of exercise on maternal and neonatal outcome. The study was approved by the local Ethics Committee and complied with the Helsinki Declaration including current revisions and Good Clinical Practice guidelines. Eligible patients were informed about the study protocol and signed informed consent was obtained from all patients before starting study.
Inclusion criteria were women between 18 and 35 years, primiparous with a 37–41 weeks of gestation and were singleton pregnant with babies of cephalic presentation and normal birthweight, expected to have normal spontaneous vaginal delivery. Women who had any of the followings were excluded; maternal hypertensive disorders, heart diseases, chronic renal diseases, current use of corticosteroids, cervical incompetence, previous treatments with tocolytic agents between the beginning of pregnancy and the date of interview, any kind of bleeding during pregnancy, postdates, multiple pregnancies, desired caesarian, receiving analgesic or antipsychotic medications, mothers with hearing difficulties, inability to understand visual annolog scale or EPDS, fetal death in utero, known fetal anomaly.
Women were asked by personal interview how many times per week on average during their pregnancy they exercised for 30 minutes or more above their usual activities. For analysis, exercise status was defined as exercise group (one or more times per week) versus control group (no exercise ). Data for age, height, first maternal weight, step count and step lenght were recorded on a data sheet. Exercise capasity of women was assessed with 6 minutes walking test with using step counter (A digital Omron HJ-112 pedometer) for each participitant at 36 week of gestation. Patient normal step lenght was measured. Patient worn the pedometer on the belt and kept on during the walking time, it recorded how many steps the wearer has walked during the 6 minutes.
Postpartum maternal health was measured using responses to four self-reported measures: visual analog scale (VAS) for anxiety (VAS-A), the VAS for satisfaction (VAS-S) and the Edingburg Postpartum Depression Scale (EPDS) for postpartum depression. Data for depression were also collected before the procedure to compare baseline antenatal depression rates between groups.
Anxiety ratings; The first outcome measure was anxiety level during the 0–24 hours of postpartum period. Anxiety level was assessed using a 0–10 cm horizontal visual analog scala; 0 = having no anxiety or the least possible anxiety, 10 = having severe anxiety or the worst possible anxiety. Patients were asked by a blinded member of the medical staff to marked their anxiety to eliminate possible hesitancy to report anxiety scores. All patients were asked to score their anxiety at 4 real-time points (2-8-12 and 24. hour). Anxiety level was compared between the groups.
Satisfaction rate: The third outcome measure was satisfaction with childbirth. Satisfaction rates were assessed also using a 0–10 cm VAS. All patients were educated about the VAS before starting the study and were asked to marked for their satisfaction level (0 = totally unsatisfied, 10 = totally satisfied) at 2, 8, 12 and 24 h postpartum.
Postpartum depression rate; The EPDS is one of the most widely used self-report instruments to screen for depression in the postnatal and antenatal periods. The 10-item EPDS was created to identify postpartum women who had depression symptoms. [10] The scale is easy to use and doesn't require expert knowledge to score. Minimum and maximum total scores ranged from 0 to 30. The scale concentrates on the cognitive and emotional characteristics of depression and has been validated for use both postnatally and during pregnancy. Scores of Z10 and Z13 on the scale indicate moderate depressive symptoms and likely significant depression, respectively, while the scale cannot by itself confirm a diagnosis of depression. At three different intervals, depression rates were evaluated: 36 weeks gestation, day one postpartum before being released, and day eight postpartum while utilizing EPDS.
When patient applied for labor, last maternal weight, gestational weight gain, gestational week, first cervical dilatation, cervical efasman, maternal hemodynamic parameters including systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR), and pregnancy complications were recorded. Maternal pulse was palpated and counted for sixty seconds and blood pressure was measured in the right arm at heart level using a sphygmomanometer. First stage of labor was defined as the duration from diagnosis of labor (regular contractions, progressive dilation of the cervix) to full dilation of the cervix (duration of latent phase from reguler contractions to cervical dilatation was 6 cm; duration of active phase of labour when the cervical dilatation was within 6–10 cm). Second stage of labor was from full dilation to delivery. Third stage of labor was from delivery to complet placental separation. Duration of labor stages, neonatal and labor outcome were recorded and compared between the groups.
Statistical Analysis
Power analysis of the study showed that 45 patients were needed in each group to gain 80% power when alpha error was set at 0.05, beta error at 0.20 and effect size at 0.60. Twenty patients were also added to each group to replace possible missing data for all potential causes.
Continuous variables were first inspected for normality of statistical distribution graphically and by Shapiro-Wilk test. None of the variables were parametric. Median (minimum-maximum) was used for continuous variables, numbers and percentages were used for categorical variables. Baseline characteristics and outcome measures of the two groups were analyzed with Mann–Whitney test for continuous data and chi-square test for the comparison of categorical variables. Spearmans rank coralation was used to detect releationsheep between walking parameters and prenatal - neonatal outcomes. All the comparisons were two-tailed. P values ≤ 0.05 were considered statistically significant. Statistical analysis was performed with SPSS version 16.0 software (SPSS Inc., Chicago, IL).