Though widely prescribed to cut risk of premature delivery, bed rest is not proven to help, and may even hurt, writes KATHLEEN PHALEN.
WHEN Jessica Cannon started spotting – having a vaginal discharge of a small amount of blood that is sometimes a sign of early labour – late in her second trimester, her obstetrician recommended bed rest to help keep the pregnancy from ending prematurely. Unlike many women who receive this prescription, Cannon – herself an obstetrician in – knows that there’s little scientific support for following the advice.
Still, she plans to stay away from her office and off her feet for as long as three months. “Every week I can stay pregnant is better” for her unborn second child, she says.
So ingrained is the belief that bed rest is effective and safe that each year nearly 1 million pregnant women in the United States spend at least one week in bed. Some put themselves there with no symptoms. But most do so after their doctors detect such things as preterm labour, pregnancy-related hypertension, slow foetal growth, a multiple pregnancy or preeclampsia – conditions that help account for the 11% of US pregnancies that end in preterm deliveries.
For many women with such risks to their pregnancies, there is little evidence that bed rest will keep them pregnant even one day longer or make the likelihood of delivering a healthy baby any greater. “The traditional approach (to preterm labour) has always been to recommend bed rest,” says Charles Lockwood, chairman of the Department of Obstetrics and Gynaecology at the Yale University School of Medicine in New Haven, Connecticut. “Really, there is scanty evidence ? but people do it.’’
In the November issue of the journal Obstetrics & Gynecology, Robert L. Goldenberg, a professor of obstetrics at the University of Alabama at Birmingham, reports that no randomised studies have evaluated bed rest for the prevention of preterm labour in singleton pregnancies. And of the four randomised trials for twin pregnancies that he assessed, two found that bed rest and hospitalisation produced no benefit and two showed that these steps actually increased the chance of preterm birth.
Reducing physical activity may benefit some women at risk of preterm birth, Goldenberg acknowledges, but there’s no evidence to support its widespread use.
The argument against bed rest includes its side effects: muscle deconditioning, depression, isolation, pulmonary embolism and blood clots.
“This is an old-fashioned management,” says Laura E. Riley, an obstetrician and chair of the OB Practice Committee for the American College of Obstetricians and Gynecologists. “There is no proven benefit and there are lots of downsides. In the last 10 years, there’s been a huge effort on the part of the college to make us do things based on evidence. And we are trying to say, ‘Don’t do it.’”
Preterm birth – a delivery that occurs less than 37 weeks into a pregnancy – is the leading cause of neonatal death and can cause cerebral palsy, mental retardation, respiratory distress syndrome, sepsis and haemorrhage. For Cannon, the risks that bed rest poses for her are nothing compared with the hazards her unborn child might face from early delivery.
“I’ve worked with extreme preemies, and they’ve got a rough road,” Cannon says. “I might lose some income; I may get deconditioned, stressed or depressed. Those are reversible risks. But what if I deliver a baby at 27 weeks with cerebral palsy?”
Bed rest may stop contractions, but it will not delay labour, says Terry Hoffman, a Baltimore obstetrician. “If someone is spotting early, some say, ‘Stay off your feet’. But that doesn’t keep you pregnant longer,” she says. “Whether you stay off your feet or keep working, if you’re going to miscarry, you’re going to miscarry.”
If a woman is really in labour – experiencing contractions that change the shape of the cervix – the most physicians can do is postpone delivery for 24 to 48 hours by using tocolytic drugs. During this window steroids are given to help the baby’s lungs mature. In 48 to 72 hours, the steroids can advance the lung maturity up to the equivalent of a 34-week baby in some cases.
About 40 years ago, aerospace scientists used bed rest as a model for understanding the effect of weightlessness on astronauts. NASA researchers and their counterparts in the Soviet Union found widespread detrimental effects, including muscle weakness and atrophy, loss of bone density, psychological problems, sensory deprivation, fainting, dizziness and weight loss.
Prompted in part by these studies, doctors started getting surgical and cardiac patients out of bed faster than before. But decades later, researcher Judith A. Maloni wondered why pregnant women were still frequently placed on bed rest. So in 1989 she began examining the side effects of bed rest in pregnancy.
Maloni, an associate professor at the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, discovered that women experience muscle loss, weight loss, indigestion, dizziness, shortness of breath on exertion, depression, sleep changes, fatigue, boredom, physical deconditioning and increased family stress. Postpartum, the side effects were also troubling: muscle weakness, backache, deep muscle soreness, feeling overwhelmed, swollen feet, feelings of loss, fatigue, loneliness.
“I want to change clinical practice,” says Maloni, to make bed rest less common. “If we discover that bed rest is effective, we have to know it has side effects and develop interventions, such as planned rehabilitation and a system at home to help deal with tasks.”
“We can’t rule out that there is some self-selection going on,” said Kelly Evenson, research assistant professor of epidemiology at UNC’s School of Public Health and the study’s lead author. “Women who are feeling better during pregnancy may choose to engage in regular physical activities, while those who do not feel well may choose to be less active.” – LAT-WP
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