placenta previa

Resources to Help Mamas on Bedrest & Beyond Quit Smoking

November 18th, 2010

Today, November 18, 2010, marks the 35th anniversary of the American Cancer Society’s Great American Smokeout. It is a well known fact that smoking is the number one preventable/modifiable risk factor to heart disease and stroke as well as to many cancers. However, smoking is also very detrimental to pregnant women and their babies. The National Partnership to Help Pregnant Smokers Quit estimates that between 12 and 20% of pregnant women continue to smoke during their pregnancies.

According to the March of Dimes, Smoking during pregnancy can have the following consequences:

  1. Ectopic (tubal) pregnancy
  2. Vaginal Bleeding
  3. Placental Abruption (separation from the uterine wall)
  4. Placental Previa (The Placenta covering the entrance to the birth canal)
  5. Still Birth
  6. Premature Rupture of Membranes
  7. Preterm labor

The US Centers for Disease Control and Prevention report that 5-7% of infant deaths and 23-34% of infant deaths due to SIDS could have been prevented if the mother had not smoked during her pregnancy.

Babies born to mothers who smoke are at increased risk of:

  1. Birth Defects
  2. Low Birth Weight
  3. Prematurity
  4. Intrauterine Growth Retardation

Premature infants and low birth weight infants are at increased risk of having life long health problems such as asthma, colic and obesity. They also face numerous developmental problems such as  Cerebral Palsy, metal retardation and learning disabilities. In a study published in the July 2010 edition of the American Journal of Preventive Medicine, researchers reported that if all women quit smoking during pregnancy, health care costs in the United States could be reduced by about $232 million a year and there would be improved overall health for mothers and babies.

People often ask, “With all the information available about the dangers of smoking, why would any woman smoke-especially while she is pregnant?” While this is a fair question, many people including many pregnant smokers don’t understand that smoking is a very serious addiction and addictions are very hard to break. What is interesting about smoking and addictions in general is that not everyone who smokes is addicted. We’ve all heard stories about people who one day decided to quit smoking and simply never picked up another cigarette. However, this is the exception rather than the norm. Most smokers have quite a bit of difficulty and need assistance to quit smoking.

Smoking cessation is even more difficult during pregnancy. Many people who decide to try to quite smoking will use nicotine replacements such as patches and gum. The efficacy and safety of these products is not established in the pregnant woman, so in order to avoid harm to the developing baby, they are not recommended for use during pregnancy. The same holds true for the various prescription medications used to help smokers quit. In the November 2010 issue of Obstetrics and Gynecology, a special review committee issued Opinion 471: Smoking Cessation During Pregnancy (Obstetrics & Gynecology: November 2010 – Volume 116 – Issue 5 – ppg 1241-1244), the review panel noted that medications such a buproprion, a common antidepressant and Varenicline, a drug that acts on brain nicotine receptors, are commonly prescribed for smoking cessation in non-pregnant patients. However, while neither medication has been shown to increase fetal anomalies or other adverse pregnancy side effects, they both have been linked to increased psychotic behaviors including suicide, so neither are recommended for use in the pregnant population.  The panel found little or no evidence that meditation, hypnosis and acupuncture as effective strategies for smoking cessation, and although these techniques are often used successfully by smokers who wish to quit, no one has been able to that they are effective and safe in the pregnant population.

So what’s left? What is a pregnant smoker to do if she wishes to quit smoking? We already know that quitting greatly benefits mother and baby and that according to the ACOG review panel, the greatest benefits occur if a pregnant woman is able to quit smoking prior to the 15th week of pregnancy. But if a pregnant woman can’t use nicotine aids nor the available prescription medications, and if alternative therapies are supposedly ineffective, what is a pregnant mama to do?

The ACOG review panel recommends that obstetricians develop and carry out specific protocols in which they ask at each prenatal visit if a woman smokes or if she is exposed to second and/or third hand smoke. They find that OB intervention has a strong bearing on whether or not a pregnant woman quits smoking.The initial screen should be at the first prenatal appointment and the OB should have information readily available about the dangers of smoking during pregnancy and resources and referral sources for quitting (If the OB is unable to provide effective guidance and support for smoking cessation within his or her office). One of the best resources is The National Partnership to Help Pregnant Smokers Quit. The ACOG review panel also recommends that clinicians adopt The 5A’s, an office based smoking intervention designed to be used by trained practitioners. The 5A’s include:

The 5A’s of smoking cessation are as follows:

  1. ASK the patient about smoking status at the first prenatal visit, and continue to ask at subsequent visits. If the patient stopped smoking before or after she learned she was pregnant, the clinician should reinforce her decision to quit, congratulate her on success in quitting, and encourage her to stay smoke-free. If she is still smoking, the clinician should document this in her medical record and proceed with the remaining A’s.
  2. ADVISE the patient who smokes to stop, while offering information about the risks of continued smoking to the woman and her baby.
  3. ASSESS the patient’s motivation to attempt smoking cessation. At subsequent prenatal care visits, the clinician should offer quitting advice, evaluation, and motivational assistance.
  4. ASSIST the patient who wants to quit by offering pregnancy-specific, self-help smoking cessation materials, including a direct referral to the smoker’s quit line (1-800-QUIT NOW).
  5. ARRANGE follow-up visits to monitor the progress of the patient’s attempt to quit smoking.

Smoking is a very difficult habit to break. Pregnant women who smoke are faced with additional challenges because many smoking cessation aids should not be used during pregnancy. If you are a mama on bed rest and want help quitting smoking, talk to your obstetrician. Also, try the resources listed in this blog and in the resource section of our website. If you still need help, contact us directly at

Image courtesy of  The Ultimate Quite Smoking Guide-Smoking During pregnancy.

Indications for Bed Rest

September 22nd, 2009

Each year some 700,000 (about one in five) pregnant women will be prescribed bed rest, either modified activity or complete inactivity and confinement to bed. While bed rest has been a part of obstetrics for years, there is still controversy as to whether or not bed rest actually helps or is effective against any of the conditions for which it is prescribed.

Bed rest is commonly prescribed for women who:

  • Have a multiple gestation; twins, triplets or higher order multiples
  • Have an “incompetent cervix”; a cervix that begins to open prior to 37 weeks pregnancy endangering the life of the fetus and/or mother
  • Preterm labor or a history of preterm labor; labor that begins before 37 weeks gestation
  • History of prior miscarriage, still birth (death in utero) or premature birth (prior to 37 weeks gestation)
  • intrauterine growth restriction/retardation (impaired growth)
  • Placenta Previa; The placenta presenting first at the cervical opening
  • Gestational Hypertension; with or without Pre-Eclampsia(toxemia)
  • Gestational Diabetes
  • Vaginal bleeding
  • Too little amniotic fluid (oligoamnios)

While all of these conditions certainly put mama and baby at risk, to date there is no solid evidence that prescribed bed rest is effective at stopping or improving any of these conditions. In fact, studies to date show that prolonged bed rest and inactivity actually cause a worse overall physical condition to pregnant women-even those considered “high risk”. Women on prescribed bed rest may develop muscle weakness, cardiovascular deconditioning, blood clots, fatigue, drops in blood pressure when standing up, backache, bone loss, changes in metabolism, muscle aches, joint pain, difficulty walking (particularly stairs), difficulty concentrating, dizziness, shortness of breath, insomnia, and weight loss.

What has always struck me is the lack of attention to the emotional and psychological effects that prescribed bed rest has on pregnant women. When I have raised this concern to obstetricians their response typically is many of the psychosocial stressors can be dealt with once mother and baby are physically safe.  However, studies have shown that maternal stress and anxiety prenatally can result in significant depression (perhaps leading to post partum depression) as well as mood changes a sense of confinement and loss of control. These psychological stressors can have significant impact on the course of the pregnancy and the health of both mother and baby. Additionally prescribed bed rest affects a pregnant woman’s entire family an can lead to child care problems, strained relationships and financial difficulties.

The next several blog posts will examine the common conditions for which bed rest is prescribed and the “proposed” benefit of bed rest on the condition. We’ll also look at what some research is revealing about bed rest in these situations and how many clinicians are rethinking how and when they prescribe bed rest for their patients.