Mamas on Bedrest: A Model of the Incompetent Cervix

May 1st, 2013

The incompetent cervix is far and away the most common reason that the mamas in our community are on bed rest. Some come with shortened cervices. Others come with funneling. Many mamas have both cervical conditions. In this video blog, I try to give a little insight into just what is going on with your cervix-demonstrating with clay models. I’m no Michelangelo, but I think you’ll get the point. Be sure to check back for our follow up post on the effect of inflammation on the cervix.

 

What Exercises Can I Do With an Incompetent Cervix?

July 1st, 2010

I recently received an-e-mail from a mama who had just gone on bedrest with an incompetent cervix at 30 weeks.”What exercises, if any, can I do with an incompetent cervix,” she asked?

An incompetet cervix is one of the more common reasons pregnant mamas are prescribed bed rest. While the rates of incompetent cervix are thought to be low, no one is exactly sure how many women are affected by incompetent cervices during pregnancy. An incompetent cervix can manifest in one of three ways:

  • Opening of the cervical os more than 2.5 cm during the second trimester
  • Thinning and shortening of the cervix (effacing)  in the second trimester or early third trimester
  • Thinning or opening (funneling) of the cervical opening closest to the baby

The treatment for incompetent cervix is cerclage (surgically placing a stitch through the cerix to hold it closed), bed rest, or a combination of the two.

Being prescribed bed rest puts a mama at risk for blood clots in the legs, muscle atophy and overall loss of strength and cardiovascular conditioning. Most women who are prescribed bed rest should also be prescribed-or at least advised about-exercises that they can do to maintain muscle strentgth and tone as well as to reduce the physical effects if prolonged inactivity. However, it has been my experience that many women prescribed bed rest receive little or no instruction on what they can do to exercise their bodies while on bed rest. This is due in part because many obstetricians don’t know what types of exercises are safe for women on prescribed bed rest. A lucky few mamas will have a consultation or two with physical therapists. But the vast majority of mamas who go on prescribed bed rest will receive no exercise instruction. For this reason I produced Bedrest Fitness when I was pregnant during my second pregnancy.Bedrest Fitness is a set of modified prenatal exercises designed specifically for pregnant women on prescribed bed rest.

A mama with an incompetent cervix should avoid any movements or exercises that put pressure on the cervix and many women will be instructed to remain recumbant in bed or on the sofa. But if you think about it, that leaves your arms and legs free to move. Mamas on bed rest with an incompetent cervix should perform a variety of arm and leg exercises daily to maintain steady bloodflow and adequate circulation back to the heart-especially from the legs. Leg exercises should include:

  • Leg Ab/Adduction exercises
  • Passive double knee raises (provided Mama can do them using an exercise band or towel to draw her knees up and not engage her abdominal muscles. If mama feels any pressure in her lower abdomen, these should be avoided!)
  • Point/flex of toes to exercise the calf muscles
  • Ankle circles

Upper body exercises should include (using a towel or exercise band):

  • Modified flies
  • Shoulder extensions with arms extended forward and to the sides
  • Upright rows
  • Bicep curls
  • Triceps extensions (if allowed to sit up)

On Bedrest Fitness I included Cat/Cow stretches. Women with incompetent cervices can actually do these stretches, but in my experience they often are unable to gauge how much pressure they are putting on their cervices. So unless a physical therapist or fitness professional is present, I don’t recommend that mamas with incompetent cervices perform these exercises.The same is true of the modified crunches.

Bed rest can have a profoundly negative (albeit temporary) effect on a mama’s overall physical condition. Depending on how long she was on bed rest prior to delivery and the restrictions she’d been given, a new mama can find herself unable to hold herself upright or to even hold her newborn. But if she engages in a few very simple but targeted exercises while on bed rest, mama will find that she will be less deconditioned after delivery and recover more quickly.

If you or someone you know has been prescribed bed rest during pregnancy, order a copy of Bedrest Fitness. Even if Mama can’t do all of the exercises, she will preserve muscle strength and tone in the areas she does exercise. Mama can also download a free set of lower body exercises, stretches and Kegels when she signs up for the Mamas on Bedrest e-mail list.

Incompetent Cervix, Now What?

October 5th, 2009

One of the most common indications for the bed rest prescription is incompetent cervix. What is an incompetent cervix and what does it mean for the pregnancy if a woman has this diagnosis?

Simply put, an incompetent pregnancy is one that is unable to remain closed for a full term pregnancy. Abnormally weak, an incompetent cervix will gradually widen (dilate) and shrink (efface) typically during the second trimester of pregnancy as the uterus enlarges and becomes heavier. Undiagnosed, incompetent cervix often leads premature labor and/or miscarriage.

There are several causes for incompetent cervix. These include:

  • Congenital abnormalities
  • Hormonal changes such as occur during pregnancy
  • prior cervical surgery (such as conization)
  • Trauma during another procedure (such as during dilation for D&C) or a prior traumatic delivery
  • In Utero Exposure to DES (Diethylstilbestrol)
  • No obvious reason

Unfortunately for many women, the first indication that they have an incompetent cervix is when preterm labor or a miscarriage occurs. With subsequent pregnancies these ladies may opt to have a cerclage, a surgical procedure during which the cervix is stitched closed, performed between about 14-16 weeks gestation. Depending on the woman’s situation, she may then be prescribed bed rest for the remainder of her pregnancy.

For some women, the incompetent cervix is not initially detected, but becomes suspect if a women has 3 consecutive pregnancy losses in the second trimester.  Pregnancy loss due to incompetent cervix occurs in about 20-25% of all second trimester pregnancy losses. An incompetent cervix can be detected via manual examination or by ultrasound.

Once an incompetent cervix is diagnosed, what then? For those ladies in whom there is no anatomic abnormality, the cerclage will typically suffice. If the cervix is too dilated (more then 4 cm) or if there are complications with the fetus (intrauterine fetal demise, premature rupture of membranes (rupture of the amniotic sac) then a cerclage cannot be performed and the pregnancy will be lost. But of the cervix is less than 3 cm dilated and the fetus is not in any danger, then the cerclage can be placed and the mother closely monitored for the rest of her pregnancy. The success rate for cerclage is quite good, especially if done early in the pregnancy. Roughly 80-90% of pregnant women with incompetent cervices will deliver healthy babies.

The decision to put a woman with an incompetent cervix on prescribed bed rest is controversial and the decision is typically made on a case by case basis. Because some women experience significant contractions in addition to the incompetent cervix, bed rest is used in conjunction with the cerclage and medication to stop the contractions and to prolong pregnancy. For other women, the need for bed rest is not so clear. Many obstetricians fearing pregnancy loss will put women with an incompetent cervix, even if they have a cerclage, on bed rest. Medical Research does not support that this is always necessary.

A test has been developed that is able to predict whether or not a woman is going into preterm labor within the subsequent 2weeks. The fetal fibronectin test checks for the presence of fetal fibronectin, a pregnancy protein found in the cervical plug, in the vagina. If fetal fibronectin is found in the vagina, it means that the cervical plug has somehow been disturbed and a woman may in fact be at risk for preterm labor. If no fetal fibronectin is found, there is a 99% or greater chance that the pregnancy is proceeding and there is no current risk for preterm labor.

The fetal fibronectin test has significant indications for high risk obstetrics. Women at risk of preterm labor may now be tested using the fetal fibronectin test and may avoid prescribed bed rest. Some women may in fact still need to be on modified bed rest, but with the fetal fibronectin test, the current number of 700,000 American women who are prescribed bed rest annually may be reduced.

In my next post I’ll look more closely at the fetal fibronectin test.