Interesting New York Times article:
March 22, 2007
How Exercise and Bed Rest in Pregnancy Can Co-Exist
By GRETCHEN REYNOLDS
JEAN IRION was 37 when she found out, 12 years ago, that she was carrying triplets. She and her husband already had two children, then 7 and 9. They had carefully spaced this third pregnancy so that, Dr. Irion said ruefully, “We wouldn’t have three children in college at one time.”
At 21 weeks, Dr. Irion, a professor of physical therapy at the University of South Alabama in Mobile, began having contractions. Immediately, her obstetrician put her on restricted activity, or what Dr. Irion calls “house arrest,” meaning no work and plenty of sitting. Then came two months of almost total bed rest, during which she could rise only to use the bathroom.
“It was awful,” said Dr. Irion, who had been an avid walker. Her once vigorous body began to deteriorate, the muscles wasting and tightening, her heart and lungs losing condition.
Then she gave birth. In the weeks after, her atrophied frame gave way under the weight of the mewling, wriggling newborns and their paraphernalia. She wound up with tendinitis in her shoulders and tennis elbow in an arm. “I was a mess,” she said. “No one had given me any hint of how incapacitating my bed rest would be.”
That experience began Dr. Irion’s crusade. Today she teaches physical therapists nationwide how to create safe exercise programs for pregnant women on bed rest.
Each year, about 700,000 pregnant women in the United States are put on bed rest, according to the best available estimates. This includes virtually all mothers-to-be of twins and multiples, whose numbers have sharply increased in the last 20 years.
It is standard medical advice to assign these women to bed rest, said Dr. Raul Artal, the chairman of the department of obstetrics and gynecology at St. Louis University School of Medicine, even though the evidence that bed rest actually prevents preterm births in women with multiple fetuses is, he said, “flimsy, at best.” (One study out of Sweden found that twins were more likely to reach full term if their mothers were up and about than if they were bedridden.)
The American College of Obstetricians and Gynecologists no longer advises bed rest to prevent preterm births, because no large-scale double-blind studies have shown that it works.
Still women are routinely put on bed rest if they’re having contractions before 37 weeks, bloody spotting, high blood pressure or a history of preterm labor; or if the fetus isn’t growing as expected.
Most pregnant women, receiving any of these diagnoses, will willingly follow doctor’s orders, taking to their beds, sometimes not getting up to shower or use the toilet, for weeks.
A majority rest at home; others are hospitalized. Few complain. As Nancy Pace, a 33-year-old mother-to-be in her 10th week of bed rest in Philadelphia, said, “Who cares, really, what happens to my body, if my baby is born healthy and full-term?”
But there’s growing evidence that the complete immobility of bed rest is more physically devastating to an expectant mom than she or her obstetrician may expect. Studies by scientists at NASA, who used bed rest to simulate weightlessness in space, found that as a result of long periods of bed rest, a person’s entire musculoskeletal and cardiovascular system becomes deconditioned. This degeneration begins in less than 48 hours.
It’s only after birth that many bedridden mothers realize the extent of their deconditioning. For some, even an easy stroll can be a doozy, said Judith Maloni, a professor of nursing at Case Western Reserve University and one of the country’s most prolific researchers on the topic of bed rest during pregnancy. “They have to sit on the sidewalk, wheezing and trying to catch their breath. Obviously even a low-risk pregnancy can be hard on anyone’s body, but that’s ridiculous.”
Until recently, however, few if any obstetricians or the bedridden mothers themselves were concerned about counteracting the physical declines caused by bed rest. “People have been worried, and rightly so, about doing anything that might precipitate preterm labor,” Dr. Irion said.
But those fears are probably exaggerated, according to obstetricians who specialize in high-risk pregnancies. “We don’t know what precipitates labor,” said Dr. William Grobman, an assistant professor of maternal-fetal medicine at Northwestern University. “But low-level activity isn’t it.”
Dr. Artal agreed: “It requires a lot of activity to generate a sufficient rise in hormones to cause contractions.” More important, he added, “Having contractions does not mean a woman actually is in labor, which, by definition, is when the cervix begins dilating.”
Dr. Artal, along with Dr. Grobman and two other high-risk pregnancy specialists interviewed for this article, recommend that women on bed rest see a physical therapist and, if appropriate, begin a light exercise program. (They also should seek additional opinions as to whether they need to be on bed rest at all). Presently, few bedridden pregnant women get exercise consultations, Dr. Irion said. “The majority of general ob-gyns never think to suggest it,” she said.
They are not being neglectful. “They honestly believe that bed rest is benign,” Dr. Irion said. “It’s just ‘rest’ so they don’t worry about the woman’s condition, only the fetus’s. I don’t think they’d feel that way if they’d ever been on bed rest.”
Safety and caution are the chief considerations of any exercise program for a mother-to-be in bed. “There are things you definitely don’t want to do,” said Cheryl Appel, a physical therapist who specializes in high-risk pregnancy at Meriter Hospital in Madison, Wis.
Working the core muscles is not advised because it can stimulate the uterus; so, no abdominal crunches (not something any woman in the final trimester would dream of attempting, anyway). But lifting light weights — a soup can or a two-pound hand weight — can help a bedridden woman maintain “some strength, flexibility, range of motion” in her upper body, Ms. Appel said.
Or a thick rubber band can be attached to the bed to provide resistance for shoulder and arm exercises.
Women confined to bed “need some upper-extremity exercise desperately to help them care for their child or children after delivery,” said Dr. Irion, who will publish one of the first academic textbooks to address bed-rest exercise later this year.
Lower body exercises may be even more vital. The development of blood clots in the legs is a real concern, Dr. Irion said. All bedridden pregnant women with their doctor’s approval should do frequent circular motions with their ankles, she said. They can also bend their knees and pull the ankles toward the body.
Ms. Appel also often suggests what she calls “windshield wipers” — a slow swiping from the 10 o’clock to 2 o’clock position using both legs — along with “snow angels.” Both require back support from a therapist, so the woman won’t inadvertently engage her abdominals.
The exercises will not condition the heart much. But, Ms. Appel said, that’s O.K. “I’ve had bedridden moms who were very active before their pregnancies ask me about aerobic exercise,” she said, “and I’ll tell them that they’ll be amazed at how, after a few days on bed rest, the simplest thing will raise their heart rate.” The goal of regular exercise for a bedridden mother isn’t to ready her for a marathon, anyway. It is, Dr. Irion said, to minimize the loss of muscle and conditioning, and prepare her for the demands of hefting, holding and carrying her newborn.
Ms. Pace, the bedridden mother in Philadelphia, said no one ever mentioned exercise to her. “My husband and I were so paranoid about losing the baby at first, that I’m not sure I would have done any exercises if someone had said to,” she admitted.
After two months of enforced inactivity, Ms. Pace was reconsidering. “I know my body is going to be in pathetic shape by the time I’m done,” she said.
But before she called the physical therapist for an exercise prescription, her daughter was born this week. “Maybe if someone had told me that there are things I could do safely” to stay strong, she said, “I would have tried it.”