This is an addendum to my previous post, “Mamas on Bedrest: Don’t Get out of Bed!”, a response to an article on bed rest published in the January 30th Chicago Tribune.
I have been watching the chatter back and forth on The Chicago Tribune website, on twitter and on facebook. While I am smiling at all this recognition of bed rest, I am a bit surprised at some of the venom coming out in the comments. Ladies, (I’ve not seen any responses from men/dads) I think we all need to step back, take a deep breath and then consider what needs to happen next.
What I am most concerned about is how tightly we are holding onto bed rest. I don’t know if it’s because bed rest is connected to child bearing, something so visceral and intimate for a woman but I want to remind us all that bed rest is simply a treatment, a tool, to help us during pregnancy. Some of the responses I’ve read have elevated bed rest to a spiritual endeavor. Its as if women are wearing their bed rest experiences like badges of honor. Many women are stating, “Bed rest saved my baby.” To that comment I wince. We have no scientific evidence that bed rest cures or treats anything. As Judith Maloni Ph.D aptly put in her publication,
“It is possible that antepartum bed rest might decrease preterm birth but evidence has not yet been found to support that conclusion. Such evidence may be masked by the complex multi-causal and interrelated factors that contribute to preterm birth.”
It is likely that a combination of bed rest, medical treatment, support (and support is critical!) and factors that we don’t yet understand contribute to high risk pregnant women successfully giving birth to healthy babies. But what about the women who go on bed rest and don’t deliver healthy babies or even live babies? What then?
I want to put this out there for everyone’s consideration. Back in the middle ages, physicians used leeches to “bleed out” infection/poison from sick people. If you were ill today and went to your doctor and he/she recommended bleeding with leeches as your treatment, you’d consider them crazy as you sprinted out of their office. We don’t do that anymore because somewhere along the way a physician or researcher either realized the practice didn’t work or, more likely, found something that was more effective.
Likewise, from the 1940′s to the early 1970′s Diethylstilbestrol (DES), a synthetic estrogen, was given to women of child bearing age with the mistaken belief that it would prevent pregnancy complications and miscarriage. We now know that DES not only does not prevent pregnancy complications and miscarriage, but it also damages the reproductive organs of the babies in utero. I have friends whose moms took DES. One has no uterus. One had a bicornate uterus (a skinny uterus with two separate sides, not able to hold a pregnancy). I have a male friend who is infertile (makes no sperm) and the origin was traced back to his DES exposure in utero. DES was a product approved by the US Food and Drug Administration in the 1940′s and was finally ordered off the market in 1975. As new evidence became available, we had to change our thinking and our treatment methods.
Wouldn’t it be nice if the same could be said of high risk pregnancy? The Sidelines Support Network was founded in 1991. Better Bedrest was established in 1995. The work that these organizations have done for high risk pregnant women is nothing less than phenomenal, supporting thousands of high risk pregnant women in 20 years. But it is also a sin and a shame that we can’t say that much else has changed in the care of high risk pregnant women in the 20 years since these organizations were established. In what other medical discipline has there been such slow progress? Not heart surgery. Many bypasses are now being done via incisions in a person’s left side and using arteries from breast and upper arm muscles as opposed to the bone cracking open chest surgeries formerly performed as standard. Breast cancer no longer requires the mandatory, disfiguring radical mastectomy but is often treated with lumpectomy, (much less disfiguring and tissue sparing surgery) chemotherapy and precisely focused radiation. Prostate surgeries today are more frequently performed via minimally invasive DaVinci Robotic surgery than open abdominal surgery. And what about Diabetes? Today many patients receive insulin via minipumps which provide pulses of the medication enabling more evenly sustained blood sugar levels as opposed to half a dozen or sometimes more individual shots daily. Even birth control pills have been radically redesigned and the dosages and release of hormones manipulated such that some only need be taken quarterly or once a year. I could go on with the advances in arthroscopic orthopedic surgeries and Automatic Implanted Cardiac Defibrillators (AICD’s) (which are now so small and compact they fit virtually unnoticed in the small depression below one’s collar bone) and other medical advances but you get the picture. Despite all these amazing medical and technological advances in other medical disciplines, high risk pregnant women are still being treated with bed rest, with no new treatment options proposed or offered in more than twenty years, no improvements in outcomes and no reduction in maternal and infant morbidity and mortality. Isn’t it time for a change?
Bed rest has been shown to have some fairly major negative consequences and yet no one can definitively say that it is helpful. I believe that the truth about bed rest in pregnancy is yet to be elucidated. Until then, I humbly request everyone who is on bed rest, who supports women on bed rest, or who endured bed rest for one or many children:
- Let’s at least be open to the fact that bed rest may not be what we think that it is; it may be better than we believe, it may be more harmful than any of us could have ever expected.
- Let’s be open to the fact that there are likely treatments out there-some sitting idly on a shelf or currently being developed-that may be much better than what we are using now to manage high risk pregnant women.
- Let’s not hold so tightly to our own experiences and to our own work (those of us who support high risk pregnant women) that we resist changes and advances.
Finally, 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 children, if she does have complications, we have something more to offer her than the same inconclusive bed rest prescription that was offered to her mother 28 years earlier.
Sometimes you just know when the s–t is going to hit the fan! Such was the case with this bed rest article published in the Sunday, January 30, 2011 Chicago Tribune, “Value of bed rest for pregnant women questioned.”
I actually thought that I’d be raked over the coals first. I wrote a similar article for Science and Sensibility, the blog for Lamaze International. The article was an editorial review of “Antepartum Bedrest for Pregnancy Complications: Efficacy and Safety for Preventing Preterm Birth” by Judith Maloni, Ph.D. Dr. Maloni is one of the leading researchers in the field of bed rest and this article was a literature review. It covered 69+ research articles on bed rest and found that there is no medical or scientific evidence that bed rest is effective in preventing preterm births. As you can imagine, those of us who work in the field of bed rest support are aghast.
Support for women on bed rest first began in 1991 with Sidelines, founded by Candace Hurley. Hurley herself had been on bed rest with her pregnancies and knew first hand how difficult a task bed rest can be. She started the Sidelines support network to assist other women who ended up in her situation. To date, Sidelines has supported over 100,000 women through the bed rest experience with their one on one phone support and online resources.
In 1995, Joanie Reisfeld founded Better Bedrest . You remember Better Bedrest, don’t you? Mamas on Bedrest & Beyond sponsored a fundraiser for Better Bedrest just last fall. Better Bedrest provides peer support to pregnant women on prescribed bed rest but may be is best known for the microgrants that it provides mamas in need. It’s an awesome organization as well.
One of my favorite support resources is KeepEmCookin’. Founded by Angela Davids, KeepEmCookin’ is an online forum where women on prescribed bed rest can come and share their stories and get support from one another and from Angela. Angela was on bed rest with both her pregnancies and started KeepEmCookin’ after the birth of her son. She has been running the forum for about 3 years.
But a colleague recently reminded me,
“It’s important to heal (from your own experience) and focus on the work”
(Dr. Mimi Poinsett, @yayayarndiva, Thanks for keeping me focused!)
As much as we may all be shocked at what researchers are saying, it is important for us to all take a deep breath, step back and look at the data critically. Read the articles for yourself, look at what the data is saying. Much to all of our dismay, bed rest may not be the panacea it is touted to be. Despite many of the experiences of the founders of the aforementioned organizations and for millions of other women, bed rest may not have had anything to do with their pregnancy outcomes.
Currently there is not strong enough evidence that putting a woman on bed rest with activity restriction prolongs a pregnancy. The research to date states that in acute, emergent situations, women should be put on hospital bed rest and the situation stabilized. However, once a woman is stable and the complication has been “adequately managed” then women should be discharged home and supported there, but should not be placed on full bed rest. (Goldenberg, 2002, 2005). Further, researchers advocate considering alternative models as used in other countries which prescribe activity restriction in home and also provides home care programs (housekeeping, childcare, errands/shopping and medical monitoring).
One thing is very clear, the practice of bed rest needs to come under review. It may be time for clinicians, especially those in the United States, which has some of the highest rates of complications, bed rest, maternal and infant morbidity and mortality in the world (WHO, Amnesty International) to rethink how to manage high risk pregnant women.
One very good thing that is coming from all this flurry of interviews, articles and e-mails is that bed rest and high risk pregnancy are front and center in people’s minds-at least for the moment. When I mention that I support high risk pregnant women on bed rest, so many people are not even aware that women with pregnancy complications are even put on bed rest. Then, they see bed rest as some sort of life of luxury. Nothing could be further from the truth! Bed rest is hard on a mama’s body, it poses risks to the baby (primarily that of being born at low birth weight) it strains mama’s family and can cause significant financial and professional hardship. With these negatives and than an article stating that bed rest is not beneficial, Bed rest Advocates are concerned that women will read the article and simply ignore their bed rest prescriptions.
So let’s just get some things straight. We are not sure if bed rest is efficacious. We know that it causes some harm to a mama’s body, her emotions, disruption to her life and potential harm to the baby. Until there is evidence supporting other treatments, the position of Mamas on Bedrest & Beyond is to continue with the bed rest presciption as your clinician has recommended. Talk candidly with your clinician about your concerns and ask when appropriate: what things can be changed, when your activities can be increased, etc… Finally, utilize all of the support services available-Sidelines, Better Bed Rest, KeepEmCookin’ and of course, Mamas on Bedrest & Beyond.
Maloni, J. “Antepartum Bedrest for Pregnancy Complications: Efficacy and Safety for Preventing Preterm Birth.” Biologicial Research for Nursing, 2010 October. 12, (2) 106-124
Goldenberg, R.L. “The management of preterm labor.” Obstetrics and Gynecology, 2002. volume 100, 1020-1037.
Goldenberg, R.L. “Arrested preterm labor. Do the data support home or hospital care?” Obstetrics and Gynecology, 2005. volume 106, 3-5.
Goldenberg, R.L., Cliver, S.P., Bronstein, J., Cutter, G.R., Andrews, W.W., Mennemmeyer, S.T. “Bed rest in pregnancy.” Obstetrics and Gynecology, 1994. volume 84, 131-136.
Goulet, C., Gevry, H., Gauthier, R.J., Lepage, L., Fraser, W., Afia,M. “A controlled clinical trial of home care management versus hospital care for preterm labor.” International Journal of Nursing Studies, 2001. Volume 38, 259-269.
Goulet, C., Gevry, H., Gauthier, R.J., Lepage, L., Fraser, W., Polomeno, V. “Arandomized clinical trial of care for women with preterm labour: Home management versus hospital management.” Canadian Medical Association Journal, 2001. Volume 164, 985-991.
Helewa, M., Heaman, Dewar, D. Community based antenatal home care programme for the management of preterm premature rupture of membranes.” Journal of the Society of Obstetricians and Gynecologists of Canada, 2000. volume 27, 928-935.
Helewa, M., Heaman, M., Robinson, M.S., Thompson, L. “Community based antenatal home care programme for the management of pre-eclampsia: An Alternative.” Canadian Medical Association Journal, 1993. volume 149, 829-834.
Monincx WM, Birnie E, Zondervan HA, Bleker OP, Bonsel GJ. “Maternal health, antenatal and at 8 weeks after delivery, in home versus in-hospital fetal monitoring in high-risk pregnancies.” European Journal of Obstetrics, Gynecology and Reproductive Biology, 2001. volume 94, 197-204.
Stainton, M.C., Lohan, M., Woodhart, L. “Women’s experiences of being in high risk antenatal care day stay and hospital admission”. Australian Midwifery, 2005. volume 18, 16-20.
The next 2 blog posts will contain excellent information compiled by Chidlbirth Connection . I am presenting the information here, as it is on their website because it is the most comprehensive information that I have seen. I could not do a more thorough review nor add anything pertinent to what has been written. For more information on Childbirth Connection, visit their website.
Unfortunately, research provides very few simple answers about induction of labor. For many of the reasons women undergo induced labor, we simply lack the research to say for sure whether the benefits outweigh the harms. For other common reasons for induction, research actually suggests that waiting for labor is safer.
The safety and effectiveness of labor induction depends on the health of the woman and her baby, whether the woman has given birth before, the timing of the induction, the method used, the characteristics of the birth facility, and many other factors. When studies combine many women with different circumstances – as most studies and all systematic reviews do – it becomes impossible to say for sure what the risks and benefits of induction for an individual woman might be.
Despite these limitations, studies provide some consistent findings. These findings come from studies of elective induction of labor – that is, induction without a medical reason (King and colleagues 2010, a systematic review). Looking at the outcomes of elective induction lets us evaluate the outcomes of induction itself, rather than the outcomes of complications that led to the induction.
- Elective induction before 41 weeks increases the chance of having a c-section if the cervix is “unripe,” especially in first-time mothers.
- Using medications or procedures to “ripen” the cervix does not decrease the chance of a c-section.
- Women in induced labor are more likely to request an epidural for pain relief than women in spontaneous labor. Epidurals introduce their own set of risks, including increased chance of instrumental vaginal delivery and fever in labor, which is often treated with antibiotics and may result in unnecessary tests and treatments for the baby and separation of the mother and baby after birth. (These and other risks are discussed in greater detail in our Labor Pain section.)
Induction methods also have a predictable effect on the type of care and monitoring you will need in labor. Induction of labor nearly always involves having at least one intravenous (IV) line, continuous electronic fetal monitoring, and medications after birth to reduce the risk of hemorrhage (excessive bleeding). The IV and fetal monitoring lines make it harder to move around in labor, which can increase pain. Many hospitals have policies that restrict what women can eat and drink when undergoing induction of labor.
In recent years, evidence has been mounting that elective delivery before 39 completed weeks clearly increases risks for babies. For optimal outcomes, women may also wish to avoid elective delivery at 40 or 41 weeks and to make informed decisions about this practice after 41 weeks.
In what circumstances does induction of labor improve health outcomes for the mother, baby, or both?
Although decisions about whether and when to induce labor must be individualized, a 2009 systematic review of the research on induction of labor (Mozurkewich and colleagues 2009) found only two conditions for which induction of labor seems to reliably improve health outcomes, and a later study identified a third (Koopmans and colleagues 2009). In all three cases, differences in important health outcomes were small and the studies left some important questions unanswered.
- Pregnancy lasting beyond 41 weeks: Various studies have compared induction of labor at or after 41 weeks with expectant management, which involved repeated tests of fetal well-being between 41 and 42 weeks. Taken together, the studies suggest that for every 369 women induced during the week between 41 and 42 weeks, one stillbirth or neonatal death may be prevented. The risk of meconium aspiration syndrome (a serious illness that causes respiratory distress) may also be reduced, although studies have come to different conclusions on this outcome. The risk of c-section does not seem to be increased with induction between 41 and 42 weeks, and some studies have shown a decrease.
- Prelabor rupture of membranes (PROM) at term (37-42 weeks): A large randomized controlled trial compared immediate induction with waiting up to three days for labor and only inducing before then if a complication developed. The study found that inducing right away was associated with a lower chance that the mother would develop an infection or the baby would go to the neonatal intensive care unit. Immediate induction did not affect the likelihood of c-section, newborn infection, or other important outcomes. These results suggest that early induction is the best approach. Several systematic reviews that relied on data from this large RCT came to the same conclusion. However, most women in the trial had vaginal exams before labor began, and those who carried Group B Strep (GBS, a bacteria that may be present in a woman’s vagina and raises the risk of infection for the baby) were not given antibiotics to prevent infection. Many caregivers and researchers believe that many infections reported in the trial might have been prevented by awaiting labor before performing a vaginal exam and providing antibiotics to women with GBS. These are standard practice in U.S. maternity care settings today.
- Increased blood pressure near the end of pregnancy: High blood pressure that develops in pregnancy may occur without other symptoms or signs (known as gestational hypertension) or with protein in the urine (a more dangerous condition known as preeclampsia). High blood pressure can affect the flow of oxygen to the baby, increase the chance of complications during labor, and is a risk factor for rare but very serious outcomes like stroke and seizures.Researchers studied outcomes of women at or beyond 36 weeks of pregnancy who developed gestational hypertension (diastolic blood pressure – generally, the second number in a blood pressure reading – between 95 and 110) or mild preeclampsia (diastolic blood pressure between 90 and 110 and protein in the urine). The study found that inducing labor right away improved maternal outcomes. However, they defined “poor maternal outcome” to include any cases where women developed severe high blood pressure. Very few of these women experienced serious health problems as a result of the blood pressure increase. There were no significant differences in the number of serious problems like seizure, need for intensive care, or postpartum hemorrhage, although the study was too small to show whether there were differences in these uncommon outcomes. There were also no significant differences in newborn outcomes, although a later study showed that neonatal intensive care admission, need for artificial ventilation (a machine to help the baby breathe), low birth-weight, and jaundice were more common the earlier a woman with mild gestational hypertension was induced, with best outcomes in the group induced after 38 weeks (Koopmans and colleagues 2009; Barton and colleagues 2011).In the randomized controlled trial, women with mild preeclampsia (versus gestational hypertension), women having their first baby, and those with the least amount of cervical dilation were the most likely to benefit from a policy of early induction. This is most likely because preeclampsia is a more serious condition than gestational hypertension and first-time mothers and those who haven’t begun dilating would have remained pregnant longer, providing more opportunity for their condition to worsen.
For a surprising number of conditions, the effectiveness of induction has not been proven (Mozurkewich and colleagues 2009, a systematic review). Yet many women have induced labor with the understanding that they or their babies will benefit. More or larger studies are needed to confirm the benefits and harms of induction in these situations. These include:
- Preterm prelabor rupture of the membranes (PPROM): A systematic review of 4 randomized controlled trials involving a total of 389 women with ruptured membranes between 30 and 36 weeks found no difference in important health outcomes between those who were induced right away and those who awaited labor. A new, larger study is currently underway.
- Twin pregnancy: A single, small randomized controlled trial compared routine induction at 37 weeks with expectant management and found no differences in important health outcomes. More research is needed.
- Gestational diabetes requiring insulin: One randomized controlled trial looked at the outcomes of 200 women randomized to be induced at 38 weeks or await labor. Those who awaited labor were more likely to have large babies. There were no differences in health outcomes for the mothers or babies, however. The trial may have been too small to detect these differences.
- Intrauterine growth restriction (IUGR) at term: Two trials involving a combined 683 women found no benefit or harm to induction of labor for suspected IUGR at term. More and larger trials are needed.
- Oligohydramnios (too little amniotic fluid): A single, small randomized controlled trial compared induction of labor with expectant management (watching fetal wellbeing closely until 42 weeks) for women with oligohydramnios at 41 weeks. The women were healthy and did not have other risk factors or complications. The study found no difference in maternal or newborn outcomes, but was too small to detect some important differences that may exist. No trials of induction for isolated oligohydramnios at other gestational ages were found.
For other conditions, the available evidence suggests induction is ineffective, harmful, or both (Mozurkewich and colleagues 2009, a systematic review). Despite the research, many caregivers continue to recommend induction of labor for these reasons. These reasons include:
- Suspected macrosomia (too big baby): According to a systematic review of several studies involving over 3700 women, inducing labor when the caregiver believes the baby is large does not improve neonatal outcomes and appears to increase the chance that the woman will have a c-section.
- Intrauterine growth restriction before term: A large, multi-center randomized controlled trial of over 1000 women with growth-restricted fetuses between 24 and 36 weeks and abnormal Doppler artery blood flow studies showed that induction increased the likelihood of c-section. In addition, babies born before 31 weeks in the induction group were more likely to have severe disabilities at 2 years of age than babies born before 31 weeks in the await labor group.
Barton JR, Barton LA, Istwan NB, et al. Elective delivery at 34(0/7) to 36(6/7) weeks’ gestation and its impact on neonatal outcomes in women with stable mild gestational hypertension. Am J Obstet Gynecol. 2011;204(1):44.e1-44.e5..
Boers KE, Vijgen SM, Bijlenga D, et al. Induction versus expectant monitoring for intrauterine growth restriction at term: Randomised equivalence trial (DIGITAT). BMJ. 2010;341:c7087
Koopmans CM, Bijlenga D, Groen H, et al. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks’ gestation (HYPITAT): A multicentre, open-label randomised controlled trial. Lancet. 2009;374(9694):979-988.
Mozurkewich E, Chilimigras J, Koepke E, Keeton K, King VJ. Indications for induction of labour: A best-evidence review. BJOG. 2009;116(5):626-636.