Why Bed Rest
It’s almost here. “What?” You ask? The Mamas on Bedrest E-Book Series! I have spent all month preparing and it will be ready for launch next week.The e-book series has the same organic origins that Bedrest Fitness and Mamas on Bedrest & Beyond. I’ve been looking for a comprehensive reference for Mamas on Bedrest and I just can’t seem to find what I am looking for. So necessity being the mother of invention, I’ve created it. Initially I had the idea to make a regular book, but my impatient nature got the best of me. When I am surfing the web late at night and I find a reference that meets my needs, I hate that I often have to wait for it to come in the mail (or pay double the cost of the reference in shipping!). An e-book solves that problem. Whenever mama finds what she needs, she can simply pay and access it immediately. (Ah, the power of Technology!!!)
I have a couple of edits to complete and the first book, Mamas on Bedrest-The Basics will be available next week. It will kick off our annual spring promotion in honor of Mother’s Day. Look for a big announcement in our next e-newsletter. What? Not on our newsletter list??? Look in the upper right hand corner of this webpage and get yourself signed up! You won’t want to miss this announcement!
Babies are cheeky little creatures. One minute, they are all gunho to get out, the next minute, it’s as if they want to stay inside forever! And why wouldn’t they? They live inside a warm, comfortable environment, get lots of good food, are rocked to and fro with the movements of their mamas, are soothed by mama’s heartbeat and generally are in the one of the most secure places they’ll ever be in their entire lives. This month as many mamas from our Facebook Community prepare to birth their babies, I am struck by how many of them have gone really pretty far into their pregnancies, several are at term, when yet just a few months ago they were gripped with fear as they fought to keep their babies inside. What changed?
The entire process of labor and delivery is orchestrated by an interaction between the mama’s brain, the baby brain and the placenta. When baby is preparing to “exit” its brain begins sending out neurochemicals so that mama’s body begins preparing not only to deliver the baby, but also to receive her baby with love and adoration. This is primarily carried out by increased levels of oxytocin put out by the fetal brain as well as the placenta in an effort to prepare the uterus for contractions and expulsion of the fetus. Mama’s brain also begins secreting increasing amounts of opioids, corticotropin releasing hormone (CRH) and catecholamines which aid in pain management and management of inflammation during labor and delivery. Mama’s brain also begins releasing prolactin as it prepares mama’s body for lactation.
All of these systems work in concert to bring baby into this world safely. Unfortunately, sometimes “the signals get crossed” and neurochemicals begin releasing and sending signals for labor and delivery when it isn’t time. This is an overly simplified explanation of preterm labor, which is in reality a fairly complex neurochemical process.
At this time, most clinicians and researchers aren’t entirely sure why some women experience preterm labor. To date most people agree that when a mama is stressed, her body will produce and secrete increased levels of adrenal hormones, the flight or fight hormones, and these catecholamines do play a role in labor and delivery. But they are not fully responsible for preterm labor. In many women, elevated levels of Corticotropin Releasing Hormone (CRH), a hormone secreted by the hypothalamic pituitary axis in the brain is and elevated. Since CRH also secreted by the placenta (at term, levels rise in preparation for labor and delivery) its clear that the signal to secrete CRH has malfunctioned in mother, placenta or both in the case of preterm labor. Oxytocin levels are also elevated in preterm labor, further signaling an abnormal activation of this hormone that acts to relax maternal muscles and soft tissue for delivery, to increase uterine contractility and to enhance mama/baby bonding. Several other hormones and neurochemicals are activated (?inappropriately/prematurely) and add to the cascade that becomes preterm labor.
So what, if anything, does bed rest do to halt the production and release of these hormones and neurochemicals? To date, the research is not able to attribute any efficacy to bedrest for the slowing of this cascade and the halting of preterm labor. But perhaps if we look at the stress reaction, we may be able to gleen a bit of insight into how bed rest may help prevent preterm laobr. Keep in mind, this is all theory, supposition. Physicians and researchers still have not been able to produce concrete evidence that bed rest prevents preterm labor.
As previously stated, the catecholamines responsible for the flight or fight response, are increased during stress. They are also increased in women experiencing preterm labor. But what isn’t clear is if the hormones are increased as a result of preterm labor or if mother’s stress increased their secretion and caused preterm labor. What we do know is that if mama’s stress is reduced, these hormones decrease. The stress reaction also causes the release of cytokines which help soften the cervix and “ripen” it in preparation for delivery. In addition to being a stress response, cytokines also are an indication of inflammation. Again, if mama’s stress levels are reduced, cytokine secretion decreases.
So while there is no evidence that bed rest actually “halts” preterm labor, if a mama has been under stress placing her in a state of relaxation (bed rest) may in fact help her preterm labor. Interestingly, many mamas say that being on bed rest is more stressful than not because they worry about what might happen and feel powerless, as if they are not doing enough. So is bed rest helping?
The only thing that I can say is that if the number of healthy babies being born to our mamas in our Facebook Community is any indication, then bed rest has some benefit. Of late we are having a run of healthy term or nearly term (36 weeks or so) deliveries. The next task is to look at the medical interventions as well as the role support, actual and virtual, is having on mamas and their babies. For now we don’t know the actual benefit of bed rest, but we will continue to support Mamas on Bedrest in every way we can to do our part to help mamas deliver healthy term babies.
Felice Petragliam, MD, Alberto Imperatore, MD and John R. G. Challis “Neuroendocrine Mechanisms in Pregnancy and Parturition” Endocrine Reviews December 1, 2010 vol. 31 no. 6 783-816
Roger Smith, M.B., B.S., Ph.D. “Parturition” New England Journal of Medicine 2007; 356:271-283 January 18, 2007 DOI: 10.1056/NEJMra061360
Hormones In Labour & Birth – How Your Body Helps You by Dr. Sarah J. Buckley.
I was speaking with my mom the other day and we were chit chatting away about my work. My mom is really interested in “this bed rest stuff” as it was not really common when she was having us in the late 50′s and early 60′s. My mom asked me, “Is bed rest really that common?”
Bed rest is certainly more common now than when my mom was having kids and there are a myriad of reasons. Just to bring folks up to speed, according to the CDC the numbers are still holding at some 750,000 women going on bed rest annually in the United States. But my mom’s question is one that hounds me. Why are so many women going on bed rest? I tried to find a specific answer and while the literature is not specific, here is what I have been able to gleen.
1. Bed rest is more common right now because we have more diagnostic tools to diagnose conditions for which bed rest is recommended. When my mom was having my sisters and I, many of the ultrasound machines and fetal monitors that are used today to evaluate a mama and her unborn child simply didn’t exist. If a woman had a short cervix, she simply had a short cervix. Now I can hear the collective cyber gasp at that statement. But at the same time it makes you wonder, “How many women over the centuries had a shortened cervix during pregnancy and had a completely healthy baby?” One could give the opposing view, “Well how many women lost babies due to shortened cervix?” We don’t know the answers to these questions, but it does make for interesting mental gymnastics.
I am currently researching the life and career of my great grandmother, a “granny midwife” in the south from the late 1910′s to the early 1950′s. I hear tell that she had an uncanny way of knowing which women were going to have problems and which women were going to be “good breeders”. I also am learning that she had phenomenal clinical skills. I wonder if she was able to examine a woman and note if her cervix was shortened? Or if she would have preterm labor? I do know that she saw a lot of women through their pregnancies and advised them when to stop working (most were farm women) and to rest. It’s an interesting historical perspective and as I learn more, I will certainly share with you all.
2. Bed rest is more common because we have more women having children later in life. I don’t know if I completely agree with this. My grandmother gave birth to my dad at age 43 and he was her 15th child, 13th pregnancy (2 sets of twins, yikes!!) Now one could argue that her body was accustomed to having kids (one about every 18 months!). But one could also argue that her body was “worn out”. As far as I know, she had no problems during pregnancy, no bed rest and no still births. She did lose the twin boys to infant illnesses.
One thing that my reproductive endocrinologist told me when I was in the “height of my childbearing years” is that ovarian age can be uncertain. By that he meant that some women may be 20 yet have the ovarian age of a 40 year old, and some 40 year old women will have more youthful ovarian tissue and function than their much younger counterparts. There is no way to predict which women will have “youthful” ovarian function and which women will not. Likewise, there is no way to predict when a woman will cease to have ovarian function. When we speak of advanced maternal age, we know that in general, as a woman ages, her ovarian function decreases as well as the quality of her eggs. However, we all know of older women who have had completely healthy, unassisted pregnancies, labors and deliveries, and young 30 somethings who have struggled. The best that we can say for now is, relatively speaking, as a woman ages, her chances of having difficulty conceiving and having complications during her pregnancy are increased and continue to increase as she ages.
3. Assisted Reproductive Technologies (ART). Today there are thousands of women who become pregnant as a result of assisted reproductive technologies (IVF, GIFT, ZIFT, IUI, ICI, Surrogacy/gestational carrier). The use of ARTs is a relative risk factor for a woman being prescribed bed rest because women who use ART are often older and often have pre-existing reproductive issues that would predispose them to complications any way. Additionally, women who conceive via ART are at greater risk for having a multiple pregnancy which increases the risk of going on bed rest.
3. Stress. I have written extensively in previous blogs about the role that stress plays on a woman’s ability not only to become pregnant but to maintain that pregnancy. Today more than ever women are balancing the demands of a career, a family that they have created, caring for family members from family of origin (parents or even grand parents) or have other pressing responsibilities not common to women 30 or more years ago. The work of Kathleen Kendall-Tackett PhD and others shows that the stress response has a direct effect on the cervix and preterm labor. Women who are under stress are releasing neurochemicals that soften the cervix and “ripen” it in preparation for labor and delivery-even if it isn’t time. Stress also increases a mama’s blood pressure and may cause her not to eat or take optimum care of herself so her baby may experience Intrauterine growth retardation (IUGR). It is critical that pregnant women avoid stress as much as possible not only for their own health but also for the health of their unborn babies.
4. Litigation. I hate bringing this topic into the argument, but in our current culture, litigation is probably closer to the top as opposed to the bottom of the list of reasons some OB’s put patients on bed rest. Currently, there is not scientific or medical evidence that bed rest is beneficial in preventing preterm labor or preterm birth. In a review article published just over a year ago, I reviewed the current medical literature regarding the efficacy of bed rest and again found no solid medical or scientific evidence for the use of bed rest as a treatment to prevent preterm birth. But as a former clinician, I also understand why OB’s prescribe bedrest. If on the off chance an OB discovered an anomaly with the pregnancy, yet did not prescribe bed rest and the pregnancy had an unhappy ending, that OB can count on being sued and would likely lose his or her ability to practice as an obstetrician. At the current time, medicine in the United States (or globally) has not discovered any other, more effective ways to deal with the complications of pregnancy that often result in the bed rest prescription. Until that occurs, bed rest, effective or not, will remain a “standard of care” in the management of pregnancy complications.
Now whether or not a woman should be put on bed rest is still a heated debate. Given that there is no scientific or medical evidence that bed rest is effective in the treatment of preterm labor, one could argue that we are potentially creating more problems for mamas and babies than solving. But to mamas who have been on bed rest and now have healthy babies, there is no other route to go and no talking her out of the fact that bedrest saved her baby’s life.
I pass no judgement because I know that when I was having my kids, if my OB had told me to spin on my head and shoot marbles out of my nose, I would have done it. I think that high risk pregnancy is an emerging field and one in which there is still much to learn. I am very excited to watch what is emerging in the medicine and science, and I am very excited to be a part of the public health solution of supporting mamas on bed rest.