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Antepartum Bedrest: Helpful or Harmful?

Each year approximately 750,000 women in the United States are prescribed antepartum bed rest (ABR) for a portion of their pregnancy due to (but not limited to) preterm labor contractions, incompetent cervix, placental issues, multiple gestation, vaginal bleeding, hypertension/pre-eclampsia, gestational diabetes, impaired fetal growth or oligoamnios. The amount of time spent on bed rest can be anywhere from a few days to several months and women are typically confined to bed with activity restricted (AR) to bathroom privileges only. While the indications for ABR vary, the unifying rationale for prescribing ABR and its perceived benefits remain the same—to prevent preterm labor and the delivery of a premature infant. Preterm birth is the leading cause of perinatal infant morbidity and mortality in developed countries. In 2005, 68.5% of all infant deaths <1 year old in the U.S. were in preterm infants.  The rate of preterm birth in 2005 was 12.7% in the US (and continues to climb) compared to 5-7% in European countries. (Go here and here for additional information on these statistics.)

To date, there is no data to support the efficacy of ABR in the prevention of preterm labor and premature birth. Much of the research done on antepartum bed rest actually shows that it does more harm than good (1-5).  Additionally, in-patient ABR has been shown to have worse effects on maternal and infant morbidity and mortality than ABR at home. To further investigate these findings, Judith Maloni, PhD, RN, FAAN performed an integrative literature review on the research to date. Her findings were published in the article, “Antepartum Bed Rest for Pregnancy Complications: Efficacy and Safety for Preventing Preterm Birth” (Biological Research for Nursing, October 2010,Volume 12 (2) 102-124). Although ABR has been a mainstay of clinical obstetrical practice for the past 30 years in the United States, Maloni found no evidence for its effectiveness. On the contrary, she found that there is increasing evidence that ABR leads to several negative physical and psychological effects to both mothers and babies yet these findings have not lead to a change in clinical practice. Here she presents the evidence for the practice of prescribing ABR and its associated physiologic, psychological, and experiential side effects. She also presents recommendations for additional research on ABR including the evidence that supports prescribing home care with support as a safe, efficacious and cost effective model.

Methods
Maloni chose to organize her work following the Human Response Model and its concept of physiologic, behavioral and experiential adaptation. 69 publications made up the sample for this study: 26 articles discussed the physiologic, behavioral and experiential side effects of bed rest; 17 articles compared ABR at home vs. the hospital setting; 5 meta-analyses of RCTs assessed the effectiveness of ABR; and 4 articles analyzed physician use of bed rest. Articles ranged in date from 1990 when major interest in the study of bed rest began, to the present time. The articles come from research in nursing, medicine, psychology, social, biological and aerospace sciences. Maloni searched MEDLINE, CINAHL, PubMed/Medline, and the Cochrane Database of Systematic Reviews.

Results
Several conclusions emerged following the literature review, but none of them supported the idea that ABR with activity restriction (AR) is beneficial in preventing preterm labor. What quickly became apparent is that ABR/AR has some very deleterious effects on mothers and babies. Aerospace research showed that prolonged inactivity in the supine position leads to redistribution of body fluids towards the head, causing functional changes in the cardiovascular/cardiopulmonary systems, fluid and electrolytes balances, hormone balances, hematologic systems, neurosensory and vestibular systems. Additionally, the body weight distribution is shifted and the result is muscle atrophy and bone demineralization. These changes persist far into the postpartum period and may have long standing consequences. They also necessitate a longer than usual postpartum recovery due to deconditioning. Women also reported fatigue, back aches, muscle soreness, sleep changes, round ligament pain, nasal congestion, reflux and indigestion which also persisted well beyond 6 weeks postpartum.

Non-pregnant women on bed rest (astronauts) tend to lose weight due to fluid and bone loss, and occasional loss of appetite. Carbohydrate and fat metabolism are also altered during bed rest. Similar to findings with female astronauts, (pregnant) women on bed rest have been noted to either maintain or to lose weight which is dangerous for fetal growth. Three of the studies, including one which focused on multiple gestations showed that women on ABR—both in the hospital and at home—did not gain the anticipated one pound per week as recommended by the Institute of Medicine for adequate (fetal) growth.

The literature also demonstrates that behavioral changes ensue as a result of prolonged bed rest. Women reported feeling imprisoned with a sense of sensory deprivation. They worried  about their lives and their families and felt powerlessness to fix anything. This stress led to altered mood and often pre- and postpartum depression. These symptoms were most pronounced in women on hospital bed rest and remained well beyond 6 weeks postpartum. Family members were stressed as well, most notably partners who assumed the role of caring for the family in addition to their partners on bed rest. It was also noted that infants born to mothers on ABR had higher incidences of allergies, motion sickness and the need to be rocked to sleep than those infants born to mothers who were never on ABR.

Alternative Models For Antepartum High Risk Care
While ABR in the hospital is currently the standard of care in the United States, it has not been shown to reduce perinatal morbidity or mortality. The literature has shown that women on hospital ABR often had the most pronounced adverse effects, both physical and psychological. Despite these findings, ABR (in-patient ABR, in particular) continues to be prescribed.

Physicians in other countries often prescribe ABR but have patients remain at home, providing maternal and fetal monitoring as well as light housekeeping, child care, nutritional counseling, education and psychological counseling. In contrast, very limited home care assistance is available in the United States.  Home care in the U.S. consists mostly of uterine and fetal monitoring and infusions of Magnesium Sulfate or Terbutaline—medication thought to (but not proven to) inhibit contractions. Maloni’s study showed that women who underwent ABR at home with support (assistance with familial responsibilities and emotional support) actually fared better than women who completed their ABR in the hospital. Additionally, infants born to mothers who experienced ABR at home had fewer or shorter NICU admissions. All researchers concluded that, when truly warranted, home care of high risk pregnant women with ABR is as effective, safe and feasible as hospital care.

Discussion
Because of the significant burden ABR puts on a pregnant woman, her fetus, her family and the U.S. health care system, and given the fact that there has been no recent evidence to support its efficacy, experts agree that bed rest should no longer be a standard component of treatment for the prevention of preterm birth. In fact, these same experts agree that the practice should be eliminated (1,,3, 5,6,7). While there may be a need for an emergent period of intense hospitalization following a crisis, experts concur that once a pregnant woman and her baby have been stabilized, they should be discharged home and managed with modified/restricted activity and supportive home care visits that not only monitor maternal and fetal well-being, but also support a women and her family psychosocially.

While some experts argue that neonatal mortality has gone down over the last 20 years, this has been primarily due to improved neonatal care in NICU’s and increased access to such care. The incidence of preterm birth has essentially remained unchanged (6,7,10).  As such, researchers are increasingly skeptical that the current U.S. model of prenatal care, in terms of prescribing bed rest for threatened pre-term birth, can prevent prematurity. While some researchers advocate the addition of steroids, sedation, psychosocial support and nutrition, other researchers note that these methods have yet to prove effective in reducing the incidence of preterm birth (6,7,11). Maloni, in agreement with their research findings, believes that there really needs to be a complete overhaul of the management of prenatal care. Maloni and others  advocate a re-evaluation and reconceptualization of prenatal care as part of a broader approach to optimize all of women’s health.

References

  1. Crowther, C. (2009) “Hospitalization and bed rest for multiple pregnancy.” Cochrane Database of Systematic Reviews, (2), CD000110. Accession number: 00075320-100000000-00712
  2. Elliott, JP, et al (2005) “A randomized multicenter study to determine the efficacy of activity restriction for preterm labor management in patients testing negative for fetal fibronectin.” Journal of Perinatology, 25, 626-630.
  3. Meher,S., Abalos, E., & Carroli, G. (2005) Bedrest with or without hospitalization for hypertension during pregnancy. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD003514. DOI: 10.1002/14651858.CD003514.pub2. Last update January 18, 2010.
  4. Say, L., Gulmezoglu, A.M., & Hofmeyer, G.J. (2009) Bed rest in hospital for suspected impaired fetal growth. Cochrane Database of Systematic Reviews, (3), CD000034. Accession number: 00075320-100000000-01075.
  5. Sosa, C., Althabe, F., Belizan, J., & Bergel, E. (2009) “Bed rest in singleton pregnancies for preventing preterm birth.” Cochrane Database of Systematic Reviews, (2), CD003581. Accession Number: 00075320-100000000-02667.
  6. Goldenberg, R.L. (2002) “The management of preterm labor.” Obstetrics and Gynecology, 100. 1020-1037.
  7. Lu, M. C., et al (2003) “Preventing low birth weight: Is prenatal care the answer?” Journal of Maternal-Fetal & Neonatal Medicine, 13, 362-380.
  8. Heaman, M., Sprague, A.E., & Stewart, P.J.A. (2001) Reducing the preterm birth rate: A population health strategy.” Birth (30) 20-29.
  9. Hodnett, E.D., Fredericks, S. (2009) “Support during pregnancy for women at increased risk of low birthweight babies.” Cochrane Database of Systematic Reviews , (2) CD 000198. Accession number: 00075320-100000000-00157.

Posted By: Darline Turner-Lee, MHS, PA-C

Bed Rest, Do No Harm, Practice Guidelines, Pregnancy Complications, Research, Science & Sensibility, Systematic Review , , , , , , , , , , , , , ,

  1. avatar
    Maya
    January 20th, 2011 at 19:48 | #1

    Thanks for posting this! The idea that ABR could lead to fluid loss and to fluids moving toward the head makes me wonder about cases of moms on ABR ending up with cesareans for low amniotic fluid. Perhaps the bed rest was actually a cause of the low fluid levels rather than a help that prevented things from getting worse.

  2. January 21st, 2011 at 20:44 | #2

    Maya,
    I have not read anything that suggests that oligoamnios could be attributed to bed rest. I’ve only read that women are put on bed rest for oligoamnios in the hopes that a suspected puncture/tear in the amniotic sac will close naturally and the pregnancy can continue to term.

    The fluid re-distribution discussed in the article was more related to circulatory changes and intestinal changes. While I suppose anything is possible, I don’t have any research articles or data to support or refute oligoamnios being affected by bed rest.

    Thanks for your comment.

  3. January 22nd, 2011 at 13:48 | #3

    There should be great caution about putting women on bedrest who have a family history of blood clotting disorders, since they are at increased risk for developing a deep vein thrombosis. An otherwise healthy California woman with this history suffered a fatal pulmonary embolism after 5 weeks of bedrest. Matt Logelin’s blog can (see the long comment list here). http://www.mattlogelin.com/archives/2008/04/13/what-happened/

    The fact that Matt went public with his grief has given this complication some needed publicity. Women need to know that bedrest itself has some risks.

  4. January 24th, 2011 at 13:36 | #4

    Amen, Ina! That is what these researchers are trying to convey. Yet despite all that is written, there has been no change in practice. I believe that change is going to have to occur at the grass roots level. I’d say with the women themselves, but few women who are put on bed rest know the research and the potential risks of bed rest. Those of us who are aware are going to have to keep pressing for change. Thanks for your comment.

  5. avatar
    Emalee Danforth, CNM
    January 27th, 2011 at 18:30 | #5

    The concept of “community standard of care” is, in my opinion, the biggest roadblock to changing bed rest practices. Though I am very open with patients that there is not evidence that bedrest will actually help prolong a pregnancy, it is the recommendation that virtually all providers would make in multiple clinical situations. Also, there is a sense that if a patient is working or active and delivers preterm when she had a significant identified risk factor (say, a 2 cm length cervix at 28 wks) that “everything” was not done to prevent this outcome and there is a sense of blame on both the provider and the patient herself.

    I would be happy to stop putting people on bedrest if everyone else stopped the practice as well! In the meantime, I feel obligated to adopt the community standard…

  6. avatar
    Laura
    January 29th, 2011 at 22:31 | #6

    I can sympathize, Emalee. It’s true that everyone prescribes it, even unlicensed homebirth midwives. I think until there’s a better alternative that makes it so caregivers and parents feel they are “doing” something about it, bedrest will stay as the standard of care.

  7. January 30th, 2011 at 22:21 | #7

    Emmalee and Laura,
    You have both nailed the heart of the issue on the head. Yes, many of us agree that bed rest is not efficacious. Yet, no one has taken that next step and figured out what the best treatment(s) are for high risk pregnant women. I can imagine that it’s frustrating to do all that you can and stay within “standard of care” only to be blasted that what you are doing is not evidenced based.

    There is a huge discussion going on right now on the Chicago Tribune Website (http://www.chicagotribune.com/health/ct-met-bed-rest-20110129,0,1979845,full.story)over an article that a reporter there did on bed rest. She interviewed me, other organization heads and researchers far more learned on the subject. But she got into trouble with many of the support organizations and what I call Bedrest Veterans (former mamas on bedrest) because she did not present alternatives to bed rest. Many felt that she was telling women to ignore their OB’s/Midwives’ recommendations, and not talking about ways that women could actually make bed rest work. As you’ll see by the comments, this subject is not going away anytime soon.

    I hope that all this brewing discussion will finally spur some action in clinical research. There is a lot out there-Cervical measuring, fFN, new urine tests for pre-eclampsia, research on communalism-it’s time that we begin integrating (or at least trying to) these research findings into clinical practice. Until we see that, there will continue to be the divide between the “theorists” (researchers), the clinicians and support services.

    Thanks to you both for sharing the “clinician” perspective.

  8. February 1st, 2011 at 18:03 | #8

    I’d just like to clarify that we ran a sidebar which listed four organizations that support pregnant women on bedrest (that was all we had space for.) It wasn’t initially available on line but is there now, and it’s on my blog too. We weren’t telling people to ignore their doctors. We were asking why bed rest is so commonly used when there seems to be very little data showing it’s effective and it comes with signficant side effects. That’s a discussion to have with a doctor.

  9. February 2nd, 2011 at 09:36 | #9

    There has been so much chatter about bed rest as a result of the article that appeared in the January 30th Chicago Tribune. I wrote 2 comments on my own blog in response, http://www.mamasonbedrest.com/2011/01/.

    While it is awesome that we are even having the discussion about bed rest, I am troubled at how tightly people are holding to the treatment. In keeping with evidenced based medicine, IT IS NOT a treatment method that has been proven efficacious. I am aware of why it is prescribed and that it may have some benefit. But to date, the evidence against it is stronger than the evidence for the practice. Perhaps we’ve not done the proper studies. Perhaps there are hidden benefits of which we are unaware. But I am concerned that women themselves, much more so than researchers, are holding so tightly to the practice.

    In the addendum to my original blog comment, I have asked people to consider the history of Medicine. How many treatments have we had over the years that seemed like the latest and greatest only to be found ineffective, toxic or deadly? I gave the examples of how we used to use leeches to treat infections and poisonings in the middle ages and more recently, DES to “prevent pregnancy complications and miscarriage.” We all know that both practices were found ineffective and dangerous and have been discontinued.

    While I believe that there is a place for bed rest in obstetrics, I don’t believe that its current method of employment-a blanket prescription for most any pregnancy complication-is wise. I continue to hope that we will come up with a more comprehensive and effective algorithm for managing high risk pregnant women.

    I will end here as I ended my last blog post.

    “I hope that we can find alternatives to bed rest and that we can vastly improve the way we manage high risk pregnant women. I say this selfishly because I have a beautiful 8 year old daughter and I am concerned about how much of my physiology is in her (i.e.will she experience the same or similar problems I had trying to have children). I certainly hope that in 20 or so years if/when she is having a baby, if she does have complications, we have something more to offer her than the same bed rest prescription that was offered to her mother 28 years earlier.”

  10. avatar
    Frances
    May 17th, 2011 at 12:06 | #10

    @Ina May Gaskin
    Thank you for this information. I started bleeding @ 22 weeks (this is my third baby) and went to the hospital for 24 hrs. Baby and I were monitored and everything looked fine: vitals, blood work/ clotting factors, baby’s HR, closed cervix, no ruptured membranes etc. I was sent home and advised bed rest. The bleeding subsided over the next week but has come back sporadically over the last few days with some clots. I am now 24 1/2 weeks.
    How would you or other midwives advise me to proceed? Is bed rest effective? As I see from the article, it can be dangerous- blood clots and loosing strength are big concerns! Being on bed rest has been a big stress for our family. I am willing to do what our baby needs, but if bed rest doesn’t make a difference, I’d rather get back to my life and taking care of my older children. I’d be so grateful for any help or advice.
    isolafrances@gmail.com

  11. May 17th, 2011 at 19:47 | #11

    Dear isolafrances,
    Have you been re-evaluated by your OB/Midwife? That must be your first step. Without being examined, one cannot rule out any sort of tear or injury. A pelvic examination and /or ultrasound may help to rule out any sort of uterine/amniotic sac injury. The most important thing at this point is to figure out why you are spotting and passing clots. Until that is established and managed, you and your baby are still at risk. At this juncture bed rest is an option, but not a truly definitive treatment as it is not giving you any information as to why you are having these symptoms. You need answers. Once you are evaluated and the cause or source of your spotting and clotting is elucidated, then you can discuss with your health care provider whether or not you need to be on bed rest, modified activity or need some other treatment altogether.

  1. January 25th, 2011 at 06:28 | #1