Archive | July 2012

Things to do while on bedrest in pregnancy

Bedrest in Pregnancy

Before taking a look at things to do while on bedrest in pregnancy, let’s get a little deeper understanding of bedrest first.

Sometimes there are risk factors in pregnancy for which pregnancy bedrest may be recommended. They include :

–  Preterm labor
–  Multiple babies
–  Low amniotic fluid
–  Unexplained bleeding
–  Hypertension (high blood pressure)
–  Preeclampsia
–  Incompetent cervix (when the cervix opens prematurely)
–  Gestational diabetes
–  Premature rupture of the membranes
–  Placenta previa (placenta covering the cervix)

With my clients, I always get them to think about things critically. I explain the difference between evidence-based practice in medicine and non-evidence based practice. While most people would assume that ALL medical practice is evidence-based, in reality this is not practical. It is impossible for everything to be evidence based simply because new evidence is being generated on a daily basis. Sometimes research can be contradictory, or new evidence can refute old practices that have been the standard practice for decades. It is difficult for medical professionals to be always changing the way they practice to keep up with all the new research. Also, what works for some people with certain conditions may not work with other people who have variations of the condition, or compounding factors. The reason I have taken the time to explain all this is because the research on bedrest may surprise you.

The assumption is that while bedrest may be uncomfortable, inconvenient, cause muscle atrophy and make moms-to-be bored out of their minds, it is all worth it as along as it helps prevent preterm labour and reduce health problems for the baby. Any pregnant mom would be willing to do whatever it takes to have better health for her baby. I was pretty shocked, to say the least, when I examined the evidence around pregnancy bedrest, that the research doesn’t quite support the common assumption.

Surprisingly, not very much research has been done on the risks vs benefits of bedrest in pregnancy. Of the studies done, they showed that bedrest either did not improve outcomes, or it caused worse outcomes.

Research on Bedrest in Pregnancy

A New York Times article questions the routine recommendation of  bedrest for pregnancy complications :

”Some benefits may be there, but they haven’t been documented,” said Dr. Judith A. Maloni of the Bolton School of Nursing at Case Western Reserve University, who just completed a $1.7 million study of bed rest supported by the National Institutes of Health. In fact, as Dr. Maloni’s study showed, there is good evidence that bed rest in pregnancy can cause harm, resulting in more than a dozen consequences, including babies who are smaller than normal and mothers who are too weak and tired to care for them. Their babies also tended to weigh less than normal, perhaps because there were fewer blood cells to carry oxygen and nutrients to the womb.

Dr. Robert L. Goldenberg, an expert in maternal-fetal medicine at the University of Alabama at Birmingham, said in an interview: ”Most obstetricians believe bed rest will reduce the risk of preterm births and other pregnancy complications like preeclampsia, incompetent cervix and intrauterine growth retardation. But the data are mostly nonexistent.

Dr. Goldenberg noted, for example, that in two of four clinical trials of preventive bed rest in twin pregnancies, the women randomly assigned to hospital bed rest experienced a greater rate of preterm births than those who weren’t. The other two studies showed no difference.

So why do doctors persist in prescribing bed rest, not only when prematurity threatens but often preventatively, especially in pregnancies involving two or more babies? In Dr. Goldenberg’s view, ”physicians don’t have any real tools to prevent preterm birth, but they want to do something so they choose one they think is innocuous.”

After giving birth, many of the women found themselves so out of shape that they had trouble getting out of a car or using their legs to stand up, and they were so fatigued that their ability to care for their newborns was compromised.

Dr. Maloni suggested that after childbirth, women who have been on bed rest should undergo cardiovascular and physical assessments and receive a rehabilitation program.

Physical problems aside, women who have endured enforced bed rest describe themselves as bored, frustrated, depressed, irritable, guilty and scared. Many mention increased family and spousal tensions and angry young children at home. Fathers, meanwhile, have to take over all the household responsibilities while continuing to work and wait on their wives or visit them.

The economic burdens can be great, as well, especially if the women have jobs that they can’t perform in bed and young children who need care. One study estimated the cost of bed rest per woman at $1,400.So why do so many women follow prescriptions of bed rest? Mostly because they are afraid not to. As Kris explained: ”I was told that there were no concrete studies. But fear plays a big part. You’ve got to play it conservatively. After all, it’s not just about you. It’s about one or more other beings. You have to rely a lot on the experience of your providers who believe that if a woman is put on bed rest, the pregnancy will last a little longer.”

 

A study from the National Institute for Biotechnology Information reported that 

Research indicates, that bed-rest treatment is ineffective for preventing preterm birth and fetal growth restriction, and for increasing gestational age at birth and infant birthweight. Studies of women treated with pregnancy bed-rest identify numerous side effects, including muscle atrophy, bone loss, weight loss, decreased infant birthweight in singleton gestations and gestational age at birth, and psychosocial problems. Antepartum bed-rest treatment should be discontinued until evidence of effectiveness is found.

They went on to cite evidence that exercise actually improved outcomes 

Sedentary pregnant women were compared with those who participated in more than one type of leisure sports activity [22]. Active women had a significantly reduced risk of preterm birth. Women who engaged in light physical activity (walking) has a 24% reduced risk of preterm delivery and women who engaged in moderate to heavy activity (sports such as tennis, swimming or weekly running, to competitive sports several times a week) had a 66% reduced risk. The greater the intensity of the activity, the greater the reduced risk of preterm birth.

Every major organ system is rapidly affected by reduced hydrostatic gradients, and reduced loading and disuse of weight-bearing tissues during bed rest.

An Article in Babycenter.com states that

The American College of Obstetricians and Gynecologists has concluded that bedrest does “not appear to improve the rate of preterm birth and should not be routinely recommended.”

The bottom line is that more good scientific studies are desperately needed. In the meantime, caregivers disagree on when and how to prescribe bedrest. Some say that until there’s good evidence to the contrary, bedrest is worth a try. Others argue that bedrest itself can have a variety of negative effects and that women should not be subjected to it until we know that it does more good than harm.

These caregivers tend to believe that the use of complete bedrest should be curtailed, and that some women would be better off just taking it easy. That means restricting their activity level, cutting back on work, avoiding heavy lifting and prolonged standing, and resting for a few hours each day, for example.

If you’re going to be on prolonged bedrest, you may want to line up additional professional support. Ask your practitioner for a referral to a physical or occupational therapist, who can teach you simple exercises to do in bed to improve your circulation and maintain some muscle tone. The therapist may be able to suggest ways to reposition yourself in bed so that you’re more comfortable.

You may also benefit from counseling, since you’re likely to feel torn between your obligation to your unborn child and to your family or job. Counseling can be helpful for your partner as well if your bedrest is putting a strain on your relationship.

 

Why is bedrest still being recommended?

Why is bed rest still recommended despite the recent evidence that it does not prevent preterm labour? Bed rest for pregnancy problems has been a common recommendation since the early 1900’s, so it has been around a long time. If there are risks that are associated with preterm birth, most expecting mothers would expect their doctor to do be able to do something about it, and they expect bedrest to be one of those things. If a doctor went against the norm and didn’t recommend bedrest, the mom-to-be would likely find him/her to be negligent of proper care.

Furthermore, it makes logical sense that bedrest would decrease the stress put on the cervix and uterus or other systems in the body and so reduce the chance of preterm birth. It could be possible that some amount of rest, destressing and lying down could be very beneficial to high risk pregnancies.

 

Making sense of the situation

While it seems logical that rest and lying down may have some benefits, extreme amount of inactivity seems to be related to more problems than solutions. It is also logical that if mom’s circulation is severely compromised by long periods of inactivity, this will lead to poor circulation to baby. Also, because mom’s muscles atrophy with long periods of inactivity, she is less likely to be able to look after her newborn normally, and is less likely to have the stamina to do the hard work of labour. 

In some situations where mom is doing a lot of strenuous or stressful activity in her job or daily life, having the recommendation for bedrest can be a relief. In those situations bedrest may be fantastic.

Despite the current evidence, if I were a mom who was at risk for preterm birth, I may still feel the need to avoid too much activity or be upright for long periods in the day, but at the same time, make sure I did appropriate exercises to maintain muscle strength and circulation.

This is just general information. Every mom needs to discuss her unique concerns and situation with her doctor or midwife in order to come up with a plan that she can feel comfortable with. 

 

Resources for bedrest

Here are some websites and exercise videos I have found useful:

1. From the website Exercises To Do When Pregnant and on Bedrest :

Isometric Exercises

Isometric exercises focus on tightening and relaxing a muscle group, and prove helpful as a way to prepare for relaxation during labor. To carry out this type of exercise, a woman can focus on each and every muscle group beginning at her feet. Perform this exercise by clenching muscles for a brief period, such as a count of three, and then releasing them. She can squeeze a stress ball to help with hand and arm stiffness. The American Pregnancy Association also suggests simply pressing the hands and feet against the bed as a way to engage multiple muscle groups.

Core Exercises

Tightening the abdominal muscles and releasing them can help maintain some of the woman’s core strength. While sit ups and crunches may not be recommended or allowed by a doctor, a static exercise may prove sufficient. Any abdominal muscle engagement should only be done with the permission of a doctor. The health care provider may even recommend carrying these exercises out only with supervision. Static means the body remains in a position, such as reaching out from the chest at a 45 degree angle while lifting the back off the bed. Just a slight bit of resistance can help improve the abdominal strength. Squeezing and releasing the buttock muscles can help build and remain muscle tone in the core areas as well. 

Back Rest

Back aches occur frequently during pregnancy. To take some of the pressure off the back, a simple arch and relax exercise can prove helpful. To do this, the woman must lie flat and slightly arch her back for a count of three. She can then rest out flat for a count of three before repeating. Lying flat for more than a few seconds is not recommended, as it can cut off the blood circulation during pregnancy. While resting or sleeping, reduce back pain by using pillows to take the weight off the muscles.

 

2. Read more at Bedrest Guide at Storknet about :

– Kegels

– Pelivc Tilts

– Back and Abdominal Strengthening

 

3.  You Tube videos for bedrest exercises

Yoga for Bedrest

 

Upper Body Resistance Bands

 

4. Here’s a video for Bedrest Exercises at a website called Educated Pregnancy with Dr Cathy. She’s got tons of other pregnancy videos on there as well.

 

5. And lastly, Mamas On Bedrest is a website that offers a DVD that is specific to bedrest in pregnancy. Here’s some of what the website says :

Until now there was no readily available, effective exercise program a woman could do while on bedrest. Bedrest Fitness, an exercise DVD, gives women the skills and guidance they need to safely exercise while on bedrest. Without regular exercise, a pregnant woman on bedrest is at increased risk for:

  • Blood clots in her legs that can lead to strokes, heart attacks or pulmonary embolisms.
  • “Failure to progress” during labor resulting in cesarean section delivery.
  • She is less able to care for herself and her new baby post partum and requires additional time to recover from her pregnancy and birth experience.

The Bedrest Fitness exercise program is designed and performed by Darline Turner-Lee, a nationally certified physician assistant, an American College of Sports Medicine Exercise Specialist® and certified perinatal fitness instructor. The exercise DVD takes women through a series of gentle yet effective movements and also offers a brief lecture on bedrest. Women who regularly perform the exercises while on bedrest can expect the following health benefits:

  • Maintenance of muscle tone and physical strength
  • Improved circulation
  • Reduction in the risk of leg clots leading to strokes, heart attacks and pulmonary embolisms
  • Increased endurance during labor
  • More effective pushes during delivery
  • Decreased recovery time post partum
  • The emotional assurance that she is doing something great for herself and her baby

The exercise program adheres to the guidelines set forth by the American College of Obstetricians and Gynecologists for exercise during pregnancy and uses pillows for support and rubber exercise bands for resistance. A rubber resistance band comes with the exercise DVD.

So I hope you have found this information useful. I hope you realise that you don’t have to feel like the situation is out of your control if bedrest has been recommended. Complete bedrest for weeks at a time is not as useful as was previously thought, so a balanced approach seems to be more beneficial. You still have a lot of choices that you can make, and figure out how to balance resting and destressing with strategic activities for muscle strength and circulation, and still live life as normally as possible. 

Have fun, and let me know about your experience in the comments below!

 

Kaurina Danu teaches Prenatal Classes in Surrey / Langley, BC, Canada. She also provides Birth Doula Support to moms in pregnancy, birth and post-partum in the Lower Mainland area. To contact her, email kaurina @ prenataljourney.ca or call 604-809 3288.

 

Working on writing book about Birth

Anyone who knows me, knows that I’ve been working on writing a book about birth for a couple of years now. Anyone who’s ever written a book, knows that writing a book is a tricky process.

For me, the trickiest bit has been deciding on the angle to write it from. I know what specific topics I’m passionate about. I’m just trying to figure out how all the theses I have evolved over the years can fit together like nice a big puzzle. And how it’s going to have the most impact on improving the culture of birth in the world.

So far I have come up with an outline I’m pretty proud of. Here goes :

 

 

The Epistemology of Woman-Centred Maternity Care :

Bridging The Gap Between Natural and Medical Models of Birth

 

 

In the book I would like to offer solutions to a problem as I see it. While so many advancements have been made in the field of maternity care, and we now know more than ever before, the outline of the problem is this :

1.The statistical rates of mortality, morbidity and complications are still higher than they need to be in much of the world, as evidenced by considerably lower rates in a few places in the world. While poverty is a factor that contributes to much of those statistics, and is a factor that is beyond the scope of this book to address, there are other easier to address factors besides poverty that can be reduced, and I shall highlight some of them. The natural process of birth and medical management of birth exists in a delicate balance. Many experts point to evidence that overuse of medical intervention in birth has tipped the scales of safety towards less safe outcomes. While benefiting those who need it, it has been suggested that its over reliance and use on those who don’t need it has in fact, CAUSED some complications and poor outcomes for mothers and babies.

2.Beyond the statistics, are many women and children who are physically and emotionally damaged in small and large ways by the management of their births.

3. In an effort to avoid this overuse of medical techniques in birth, a small but growing percentage of the population of North America has turned instead to avoiding the hospital altogether as they do not feel safe giving birth there. There is also an alternative philosophy to the medical management model, which is woman-centred care. The field of midwifery is generally responsible for the knowledge produced on woman-centred maternity care, although many individual doctors practice this way, and not all midwives practice woman-centred care. Woman-centred care is the topic I would like to delve more deeply into in this book so that everyone can get a clearer picture of what that means, what it entails in real life practice and how it can make significant differences in outcomes as well as people’s real lives.
So while there is a body of knowledge that comes out of the experience of midwives and the experience of homebirth, there is a tremendous gap between that body of knowledge and mainstream medical maternity care.

4. Furthermore, the body of knowledge that is still missing from both these perspectives of midwives and medical professionals is the epistemology that can come from the experience of the women doing the birthing themselves. I would like to suggest that by piecing together the knowledge from individual women’s experiences and formulating a collective position, it would be possible to bring maternity care a a whole new standard, as well as bridge the gap between the medical and natural birth worlds.

Everything in our world is always improving and evolving. There is no reason why the culture of human birth should not. I strongly believe, however, that the improvements will not come from more technology, but from a deeper understanding into the human psyche of labouring women themselves. It is the inner mental and emotional experience of labour that can offer the clues to understanding the delicate hormonal balance that controls the normal process of birth. While medical advancements have made it safer than ever before to use medical interventions such as epidurals and cesareans in birth, they will probably always be less safe than the non-man-made process of birth. Just as infant formula can be made as close as possible to breastmilk, it will always remain a far cry because it is impossible to create the living enzymes, antibodies and ever changing micronutrients in breastmilk. The long term effects of medical interventions into the process of birth is far greater than anyone can comprehend. I would like to suggest, despite all our advancements and 100,000 years of human history, shockingly little is understood about the normal, uninterrupted process by which human beings come into the world. I would like to bring more understanding of this into mainstream knowing. It is my hope that by fitting the missing pieces together, we can have a future world where human beings start off their lives with less trauma and more love because it is this that makes us human.

 

I’m putting it out there for anyone reading this : If you would like to add your contribution to the book, please let me know. You can email me at kaurina at prenataljourney.ca or call 1 – 604 809 3288.

I am looking for : childbirth experts – midwives, doctors, nurses and doulas, as well as, moms who would like to add their own experiences.

I know your time is valuable, so I would make it as easier as possible for you to add your input. If you prefer to writing, you can write me an email on the aspect you would like to contribute. If you would like to do an interview instead, I can set up a convenient time for you to do an interview.

 

I appreciate your time and wisdom.

Great article called “What is the evidence for doulas?”

Ok, this is probably the most comprehensive explanation of why someone might want to hire a doula I have ever read, and it comes complete with a concept diagram of the whole thing!

Rebecca Dekker starts out by saying,

When I was pregnant with my first child, I briefly considered hiring a doula. I saw the doula flyers at Baby Moon, where I did prenatal yoga, and I thought it sounded kind of cool. But when I talked to my husband about it, he felt a little squeamish about the idea. We are both pretty private people (although you wouldn’t think it now that I blog about birth), and he didn’t want anybody else there. He just wanted it to be him and me. And he felt like he would do a good job of supporting me. At the time, it made sense. But hindsight, as they say, is 20-20.

Now all I can say is what were we thinking? How could it possibly be just him and me at the birth, anyways? We were planning to birth in a hospital! A teaching hospital, no less! Where there would be strange residents and students coming and going, and where we had no control over who we got as a labor and delivery nurse. And this was my first birth! It is so important to avoid a C-section in your first birth, because that sets the tone and risk level for all of the rest of your births (and we wanted to have at least 4 children, too). I knew on some mental level that doulas lower the risk of C-section, but I guess I just didn’t realize how important doulas are. Well, I do now. So today, I am going to talk to you about the evidence for having a doula present at your birth.

So true! I can relate because during my first pregnancy, I couldn’t imagine what I would need a doula for too. All that changed once I was in labour. To read my story you can go to Birth Stories.

Rebecca goes on to explain the randomized controlled trials that prove how effective doulas can be for improving labour and baby outcomes. To read the rest of the article, click read the article here.

The absolute craziest thing is how after so much research, the medical profession isn’t like totally promoting doulas to every pregnant woman. The fact is, if doulas were a drug, it would be unethical not to recommend them. But they’re not a drug. They’re people. And so, right now, only the people who already get it, are choosing to have a doula. I hope by the time my daughter is having kids, every pregnant woman is informed about doulas and exactly how they can help, so she can make an informed choice, instead of of what I usually hear, which is, “I wish I had known about doulas BEFORE I gave birth!”

Don’t fall into the trap of “The Big Baby Fear”!

When I had my second kid, who was 9 pounds at birth, I thought that was pretty big. In fact, most of the doctors and nurses at the hospital were also surprised at his size. But then I started meeting tons of women who said to me, “9 pounds! That’s nothing my baby was 10 and a half.” One woman even said, “I had my 11 pound baby naturally no problem.” My midwife told me about a 5 foot woman she had as a client who had a 12 pound baby at home with no tears on her perineum.” Recently I read about the woman who gave birth naturally to a 13 pound baby. I started to think that 9 pounds wasn’t so big after all.

After talking to hundreds of pregnant women, however, I can safely say that most expecting moms, and their doctors have a paranoid fear of “The Big Baby. They are afraid the baby will be too big to come out get stuck.  I’ve even heard some women and one doctor say that they are afraid a large baby will make contractions more painful. This makes no logical sense whatsoever. But what about the worry that the baby might be too large to fit through the pelvis? Is this fear justified? It may be, in certain situations, but I would like to point out how there are other factors that are even more important than simply the baby’s size. In this video I explain how the baby’s position, or the way it is facing is more important than it’s size.

The position the baby is in is greatly influenced by the position the mom is in during labour. So moms can help baby to get into a good position by being upright, forward leaning or lying on their left, instead of lying back. This can be a challenge if mom has an epidural or morphine. This is why avoiding epidurals or narcotic analgesia as much as possible during labour, can help speed up labour and avoid cesareans.

Some other factors that affect the baby’s ability to easily fit through the pelvis have to do with the pelvis itself. If a mom has a big pelvis, there may be no problem. If she doesn’t have a large pelvis, or if the baby is not in an optimal position, then again, mom can get into upright positions that open the pelvis more to expand the pelvic outlet and help baby pass through.

You know how you start to feel your joints getting looser and falling apart in pregnancy? That’s due to the hormone relaxin. Relaxin softens the ligaments holding joints together, so that the pelvis can move and expand a little bit during labour. For example, squatting can expand the pelvic outlet by 33%. So squatting or other pelvic opening positions can be excellent in labour of baby is coming very slowly. Please not that if things are going really fast, do not get into a squatting position, cos then things are going to go too fast.

Hope this information help! If you would like to get more useful info or to take prenatal classes in Surrey, Langley or the Lower Mainland, email info@prenataljourney.ca or call 604 809 3288.