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Changing guidelines: Does bed rest help or hurt a pregnancy?

September 22, 2014


ST. LOUIS, Mo. ó When Lindsey Lafferty was 22 weeks pregnant with triplets, her body showed signs that it was preparing for delivery, so her doctor prescribed one of the most common interventions used to prevent preterm birth: bed rest.

For most of the past eight weeks, seven of which have been in the hospital, Lafferty has lain in bed, only getting up to use the bathroom, shower or go on a short wheelchair ride. She eventually got to sit upright in a chair for 30 minutes a day, and recently got the OK to walk down the hallway of the antepartum unit at Mercy Hospital St. Louis.

"It was exhausting," said Lafferty, 31, of OíFallon, Mo.

She is worried about being strong enough to take care of three newborns. She misses being home with her husband and 3-year-old son. But sheís thankful sheís made it past 30 weeks, she said. "I think if I was not on bed rest, the babies wouldíve already been here."

The scientific evidence, however, paints a different picture. Mounting research shows the century-old prescription of bed rest does not improve outcomes and, worse, is causing more harm than good.

Recently the nationís society of high-risk obstetricians issued a new guideline recommending against the routine use of bed rest in pregnancy. The Society of Maternal-Fetal Medicine guideline said bed rest has not been proven to benefit any pregnancy condition.

"We have to stop," said Dr. Anthony Sciscione, the director of the Christiana Care Health System in Delaware and co-author of the guideline.

Bed rest is often recommended for potential complications, such as preterm contractions, dilated cervix from preterm labor, a short cervix, premature rupture of the amniotic sac, elevated blood pressure, pre-eclampsia, inadequate growth of the baby, placenta complications, risk of miscarriage and pregnancies of multiples.

Also referred to as "modified bed rest" or "activity restriction," bed rest varies in definition, and how and when it is used among practitioners. It can range from resting for a few hours a day to not even being allowed to stand up to shower.

Researchers started to question the use of bed rest in the 1980s, and researchers concluded as early as 1994 that doctors should sharply reduce ordering bed rest. Ten years later, nursing professor Judith Maloni called for the use of bed rest to be discontinued until evidence supported its use. More than a half dozen comprehensive reviews of studies have been done, each concluding that bed rest has not been shown to achieve its goals.

Despite the research, the use of bed rest has changed little over the years. About one in five women are placed on bed rest during their pregnancy ó or about 1 million women a year. Surveys show nearly all obstetricians report prescribing it, while at the same time, they admit expecting little benefit from the intervention.

"Itís like obstetric heroin," Sciscione said, "We donít want to tell anyone we use it, but we all do."

Sciscione said he suspects thatís because medicine lacks good interventions for preterm birth, the leading cause of infant morality and morbidity, and doctors have a hard time doing nothing.

"Itís like the Linus and his blanket. They just canít rid of it," he said. "Patients want it, and we want to give it to them, but this is just a bad thing to give them."

The new guideline, researchers hope, will accomplish what study after study hasnít ó send a clear, unified message that bed rest is out.

"We feel like we so really needed to put out a statement to put practitioners up to speed, but also itís important to educate the public as well," said Dr. Alison Cahill, chief of the maternal-fetal division at Washington University School of Medicine. "Itís hard to believe itís true that something weíve been doing for a long time is not good, but that really is the case with bed rest."

Most large hospitals have had antepartum units, caring for high-risk pregnant women like Lafferty, for decades. The director of maternal-fetal medicine at Mercy Hospital St. Louis, Dr. James Bartelsmeyer, said his staff discussed the new guideline at their weekly meeting. He said they agreed the key word in the guideline was "routine," and it should be reserved for rare cases.

"We donít believe that routine use of bed rest is appropriate, but patient care needs to be individualized," Bartelsmeyer said. "In some cases, it is appropriate to use activity restriction."

While bed rest has not been proved to benefit any condition, more stringent studies could prove otherwise, he said. "I think we all would like more data in these areas, but it is lacking."

Cahill, who cares for patients at Barnes-Jewish Hospital, said the antepartum unit is no longer used to make sure women are adhering to bed rest. Patients in the unit have conditions that require close monitoring and frequent tests or need immediate access to intensive care for their babies. Except in extremely rare cases of severe heart disease, patients are encouraged to stay as active as possible, she said. "Bed rest is not something we prescribe any more," she said. "It simply doesnít work."

While bed rest might have been first used under the assumption that it didnít hurt to try, studies show several harmful side effects.

After just a few days of immobility, muscle and bone loss begins. Blood volume decreases, and every major organ system is affected. Blood pressure tends to rise. Women are at an increased risk of weight loss because of these changes and are more likely to have low birth weight babies.

Recovery from birth is also more difficult. In one of Maloniís studies, she found that 71 percent of women struggled going up and down stairs, 71 percent needed assistance sitting, and 14 percent needed help walking. Researchers fear this could lead to a downward spiral of inactivity across a womanís lifetime.

Bed rest may increase the risk of developing blood clots in the legs. The clots can move to the lungs, a leading cause of maternal death, and increase the risk of gestational diabetes.

Some studies even show that active women have a significantly lower risk of preterm birth, Maloni reported in her 2011 review. Regular leisure physical activity also appeared to protect against low birthweight babies, gestational diabetes and pre-eclampsia ó perhaps because exercise improves blood flow and reduces oxidative stress and inflammation.

Women on bed rest are at increased risk of anxiety and depression, which is also associated with poor birth outcomes, studies show. Patients report feeling isolated, scared and out of control. Other family members are stressed, and a majority faced financial difficulties because of loss of income.

While hospital antepartum units offer counseling and have activities such as crafts and pedicures, bed rest is most commonly prescribed to women at home.

After having gone through bed rest herself, Elizabeth Lowder started Sage Tree Therapy a few years ago to help women struggling emotionally from being on bed rest. She commonly sees women confined at home because of a thinning cervix, high blood pressure or placenta problems.

"Thereís a lot of guilt and shame," Lowder said, "that they didnít do something right, that they canít play with their kids, keep up with cleaning the house, or check emails related to work."

Bed rest, however, is so prevalent that many pregnant women come to expect it or even self-prescribe it, Sciscione said, especially when pregnant with twins. Mothers send him letters calling him crazy, he said, because they believe bed rest saved their babies.

Because the practice is so ingrained, Sciscione is not hopeful the new guideline will have much impact.

"Until there is a large study that looks at this," he said, "they are not going to stop."

Sciscione is applying for a federal grant to study 1,700 women at high risk of preterm birth. Half would go on bed rest, while the other half would continue normal activities. All would be outfitted with a device that accurately measures their movement.

"What I think we are going to find," he said, "is that it doesnít do anything except cause problems for moms, and thatís it."

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