Bed Rest in Pregnancy Part I: What’s the Evidence?

This may shock you, but there is no evidence that bed rest does anything to prevent preterm birth or help with any other health condition of pregnancy, including placenta previa, pre-eclampsia, preterm premature rupture of membranes (pPROM), or shortened cervix.

Really, truly.  No evidence that bed rest helps.  And this has been known for a long time.

Preventing Preterm Birth

 (image from Babble)

The American Congress of Obstetricians and Gynecologists (ACOG) published the following recommendation in 2003, which was reaffirmed in 2012:

Bed rest and hydration have not been shown to be effective for the prevention of preterm birth and should not be routinely recommended.*

Got that?  Not effective.  Should not be routinely recommended.

In fact, a study of women with shortened cervix by Grobman et al showed that bed rest increased risk for preterm birth.

The Cochrane Collaboration, which sets international standards for evidence based medicine by reviewing randomized control trials (considered the “gold standard” in medical research), says of bed rest for preterm labor,

Due to the potential adverse effects that bed rest could have on women and their families, and the increased costs for the healthcare system, systematic advice of bed rest for preventing preterm birth should not be given to pregnant women.

The World Health Organization reports on the largest known randomized control trial of bed rest for preventing preterm labor:

For the purpose of comparing the effects of bed rest to no bed rest, 432 women allocated to bed rest at home were compared with a control group …422 had received no intervention. Incidence of preterm birth prior to 37 weeks was similar in both groups.

Here are the conclusions on the efficacy of bed rest from a series of articles posted on Medline:

Bed rest is used extensively to treat a wide variety of pregnancy conditions, at substantial cost but with little proof of effectiveness (Goldenberg, et al).

We should not assume any efficacy for bed rest. (Glaziou and Del Mar)

Mitigating Medical Conditions in Pregnancy

There is no evidence base for bed rest for conditions other than preterm birth risk either.  Here is what ACOG guidelines say about bed rest for hypertension/pre-eclampsia (high blood pressure in pregnancy):

There is little evidence of the efficacy of nonpharmacologic management of hypertension in pregnancy.  Whether bed rest is efficacious requires more research, including larger trials, and the risks of immobilization for long periods of time (e.g. thromboembolic events [blood clots, etc]) must also be addressed.

Update: I have a full post on preeclampsia here.

On placenta previa, for which hospital bed rest is often prescribed, Cochrane says,

[T]here are only trials of cervical cerclage (‘tying’ the cervix), and the effects of hospitalisation. The review found that cervical cerclage may reduce very premature births, although the evidence was not strong. There is little evidence of advantages or disadvantages to hospitalisation.

Regarding threatened miscarriage, and multiple gestations (e.g. twins or triplets), and preeclampsia, in addition to preterm labor, Drs. Bigelow and Stone of Mount Sinai School of Medicine in New York write,

Although the use of bed rest is pervasive, there is a paucity of data to support its use. Additionally, many well-documented adverse physical, psychological, familial, societal, and financial effects have been discussed in the literature. There have been no complications of pregnancy for which the literature consistently demonstrates a benefit to antepartum bed rest.

The evidence is unwavering.  There is no known benefit of bed rest in pregnancy.  Even if bed rest has no associated harms, if it has no benefit, why bother?  When we have two options with equal outcomes, one involving living life normally, and one involving a major life alteration that is inconvenient, expensive, and boring, why would anyone choose the latter?

But, in fact, bed rest does have harms–lots of them.  Read Part II and Part III .

*All emphasis in quotes throughout the post is mine

Update: WebMD has a new piece on bed rest for preventing preterm birth that actually provides evidence based information here.

Cesareans Are Us: Mississippi

I am a big fan of Jill Arnold’s cesareanrates.com, and I encourage you to visit.  Here is Jill’s report on Mississippi cesarean rates.

River Oaks Hospital, which is just outside of Jackson, has the highest cesarean rate in the state of Mississippi:  57.2%.  Just for reference, the national rate is 32.8%,  the average for Mississippi is 38.3%, and the World Heath Organization says that 15% is a “threshold not to be exceeded” because maternal and infant health do not improve when rates rise higher.  To be fair, River Oaks handles many high risk cases from around the state, but the WHO threshold is supposed to cover even high risk populations.  A rate nearly four times the maximum threshold seems excessive.

According to March of Dimes Peristats, the VBAC rate in Hinds County (where River Oaks is located) was 4.3% in 2010, meaning that among women who have already had at least one cesarean, only 4.3% who had another baby in 2010 birthed vaginally.  According to the Jackson chapter of the International Cesarean Awareness Network, River Oaks does “allow” VBAC, though there were fewer than 200 VBACs in the entire state in 2010.

So let’s look at what happens at River Oaks.  The homepage for their Labor and Delivery Center features three links: planning a pregnancy, healthful pregnancy and cesarean.  Hmm….  Here is their list of possible reasons a woman would need a cesarean at their hospital (followed by my commentary):

There are several conditions which may make a cesarean delivery more likely. These include, but are not limited to:

• Abnormal fetal heart rate. The fetal heart rate during labor is a good sign of how well the fetus is handling the contractions of labor. The heart rate is monitored during labor…If the fetal heart rate shows there may be a problem, immediate action can be taken… A cesarean delivery may be necessary.

We know from my past post on Florida that fetal monitoring is not recommended for a normal labor, and that the evidence suggests that fetal monitoring does not lead to better outcomes for infants but does lead to higher cesarean rates.  In normal labors, the best evidence suggests that the baby’s heart rate be monitored by intermittent oscillation (using a hand-held Doppler at regular intervals).

• Abnormal position of the fetus during birth. The normal position for the fetus during birth is head-down, facing the mother’s back. However, sometimes a fetus is not in the right position, making delivery more difficult through the birth canal.

It is true that head down facing back is the most common position and that other positions tend to make births more difficult.  However, according to ACOG committee opinion, a skilled practitioner can deliver some breech babies vaginally (a sideways baby who won’t turn has to be delivered by cesarean).  Unfortunately, many practitioners do not have the skills for safe vaginal breech delivery.   A posterior (“sunny side up”) baby can  be delivered vaginally and does not require unique obstetrical skill.  Breech and posterior babies can often be turned, and posterior babies especially often turn themselves late in pregnancy or during labor, making a planned cesarean  unnecessary.

• Labor that fails to progress or does not progress normally

“Normal labor” has changed.  Many doctors rely on the outdated Friedman’s curve, developed in 1954.  It  does not fit with the  labor progression of contemporary women, who labor under different conditions (e.g. not heavily sedated).  “Active labor” used to be diagnosed at 3 cm of cervical dilation; current thought is a woman should reach 6 cm before being considered in “active labor.” However, many hospitals and many individual physicians still cling to the outdated norms. As women now labor more slowly, this leads to many cesareans for “failure to progress.”

• Baby is too large to be delivered vaginally

The medical term for a large baby is “macrosomia,”  but the condition is often called simply “big baby,” which always sounds to me like the character in Toy Story 3:

Hopefully, most macrosomic babies don’t look like that.  In any case, practice guidelines

do not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb)

Yes, you read that right.  ELEVEN POUNDS.  Rebecca Dekker at Evidence Based Birth has some great information on macrosomia.

• Placental complications (such as placenta previa, in which the placenta blocks the cervix and presents the risk of becoming detached from the uterus too soon). Premature detachment from the fetus is known as abruption.

Placenta previa is a situation in which cesarean is life saving for women and babies.  Please, if you have have placenta previa, follow your doctor’s advice regarding cesarean (but do not go on bed rest).  Abruption may or may not require cesarean, but it is absolutely reasonable that it be considered.  The placenta, however, separates from the uterine wall, not the fetus.  These people scare me.

• Certain maternal medical conditions (such as diabetes, high blood pressure, or human immunodeficiency virus [HIV] infection)

Sometimes conditions like high blood pressure can mean that the baby needs to be delivered early to preserve the life and health of either the baby or the pregnant woman.  In these cases, an induction can often be tried first.  The choice of induction vs. cesarean for a maternal or fetal medical condition should always be made with the full informed consent of the woman.  I have no idea if that’s the case at River Oaks, but given their cesarean rate, I doubt it.

• Active herpes lesions in the mother’s vagina or cervix

Yes, if the infection is active, cesarean is a good choice.  The chance of herpes transmission to the infant during vaginal delivery is up to 50%.  However, if the woman has been receiving prenatal care, the herpes infection can be treated in advance, which should allow for vaginal delivery in most cases.

• Twins or other multiples

I have posted on vaginal birth vs. cesarean for twin delivery.  A new, high-quality study shows that planned cesarean does not improve outcomes for twins as long as Twin A is head down.  In response, the chief of obstetrics as Mass General wrote an opinion piece saying that doctors should plan cesareans for twins anyway.  That appears to be the River Oaks philosophy.

• Previous cesarean delivery

According to ACOG’s practice bulletin on VBAC, the vast majority of women with one prior cesarean are appropriate candidates for VBAC, as are some women with two prior cesareans.  Probability of successful VBAC ranges from 60-80%.  ACOG says that risks and benefits should be discussed, counseling on VBAC should be documented in the medical record, and the ultimate decision should lie with the woman.  According to the River Oaks website,

A woman may or may not be able to have a vaginal birth with a future pregnancy, called a vaginal birth after cesarean (VBAC). Depending on the type of uterine incision used for the cesarean birth, the scar may not be strong enough to hold together during labor contractions.

Who knows what kind of uterine incisions the docs there are using, because apparently the only way to get a VBAC is to come in pushing and have the baby before they can cut you.

• There may be other reasons for your doctor to recommend a cesarean delivery.

Perhaps it is 4:30 on Friday.

There is more non-evidence-based care featured on their website, including this video featuring babies who bottlefeed and do not room-in with their mothers (fine if that’s what the woman wants, but not a message that promotes best practices).

River Oaks does not appear to be the place to have a baby if you want a vaginal birth and evidence based care.  But you can go make them some money if you want.

Note: this is my second piece on a hospital with the highest cesarean rate within a state.  You can read the post on Florida here.