Judith A. Maloni

Antepartum bed rest for pregnancy complications: efficacy and safety for preventing preterm birth.

Preterm birth is the major maternal—child health issue across developed nations and the leading cause of perinatal mortality and morbidity. Of all deaths of infants <1year of age in the United States in 2005, 68.6% occurred in infants born prior to term. Although the preterm birth rate in European countries is 5-7%, the U.S. preterm birth rate is 12.7%, representing an increase of 9% since 2000. Antepartum bed rest/activity restriction (ABR/AR) has been a mainstay of treatment to prevent preterm birth for the past 30 years prescribed for nearly 1 million women in the United States annually, despite a lack of evidence for its effectiveness. In fact, there is increasing evidence that ABR causes several adverse physiologic and psychological side effects among women and their infants. Unfortunately, these findings have had little impact on clinical practice. This integrative review of literature provides a comprehensive analysis of the evidence for the practice of prescribing ABR and its physiologic, behavioral, and experiential side effects. It also presents a model to guide continuing research about the effects of maternal bed rest as well as evidence supporting the use of home care with bed rest, a different, safe, and feasible model of prenatal care for treating women with pregnancy complications used particularly in other countries. Finally, suggestions to improve the health of high-risk pregnant and postpartum women and their infants are provided.

Postpartum Symptoms After Antepartum Bed Rest

OBJECTIVE To determine the type and frequency of postpartum symptoms during recovery from antepartum bed rest treatment across 6 weeks postpartum. DESIGN Longitudinal repeated measures study. SETTING Three perinatal tertiary care hospitals in two cities in the Midwest. PARTICIPANTS One hundred six postpartum women who had a singleton high-risk pregnancy and were treated with antepartum bed rest. MAIN OUTCOME MEASURES A Postpartum Symptom Checklist assessed physiologic and psychological symptoms. RESULTS Women reported 12.5 symptoms at 2 days postpartum, but symptoms rapidly declined at 1 week. Ninety-three percent reported a mean of 6.6 symptoms at 6 weeks postpartum. Symptoms that continued to be reported at 6 weeks by at least 40% of women were fatigue, mood changes, tenseness, difficulty concentrating, back muscle soreness, dry skin, and headache. Women who had a cesarean delivery reported significantly more symptoms than those who had a vaginal delivery (p = .006). Length of maternal bed rest was significantly correlated with the number of symptoms at postpartum weeks 1, 2, 4, 5, and 6. CONCLUSION Postpartum symptoms decreased across time but reveal an underlying morbidity that is not resolved by 6 weeks postpartum.

Web Recruitment and Internet Use and Preferences Reported by Women With Postpartum Depression After Pregnancy Complications

Nearly one million women each year have pregnancy complications that cause antepartum and postpartum anxiety and depression. This exploratory study determined 1) feasibility of using social media to recruit women with depressive symptoms following high risk pregnancy, 2) womens barriers to treatment, 3) use of online resources for assistance with PPD, and 4) preferences for internet treatment. Among a national sample of 53 women, nearly 70% had major depression. Common barriers were lack of time and stigma. Over 90% of women would use the internet to learn coping strategies for PPD. Women expressed interest in web-based PPD treatment and identified desired characteristics of an intervention.

Multiple Gestation: Side Effects of Antepartum Bed Rest

The birth rate for higher order multiples has dramatically increased in recent decades. Multiple gestation pregnancies are considered to be at high obstetric risk. Antepartum bed rest is often prescribed to offset complications despite the lack of evidence for its effectiveness in preventing complications. This longitudinal repeated-measures study identified side effects of antepartum bed rest treatment for 31 hospitalized women with twin or triplet gestation. Maternal weight gain and infant birth weight were recorded. Antepartum stressors were measured by the Antepartum Stressors Hospital Inventory, and depressive symptoms were measured by the Center for Epidemiologic Studies Depression Scale (CES-D). Antepartum and post-partum side effects of bed rest were also assessed by the Antepartum and Postpartum Symptom Checklists. The weekly rate of maternal weight gain during hospitalization was significantly less than recent recommendations for multiple gestation weight gain (t =– 2.14,p = .04). Infant birth weights were appropriate for gestational age. There were fewer than expected small-for-gestational-age infants. Concerns regarding family status and separation from family were the major antepartum stressors. Women reported a high number of symptoms during bed rest (M=22), which did not significantly change across 2 weeks. CES-D scores for depressive symptoms were high on antepartum hospital admission. Postpartum symptoms were initially high but had significantly declined by 6 weeks: F(1, 27)=15.68, p =.00. These findings suggest that interventions are needed to reduce antepartum maternal weight loss, stress, physiologic and psychosocial symptoms, and depressive symptoms, as well as reduce postpartum symptoms of maternal morbidity.

Antepartum Bed Rest: Maternal Weight Change and Infant Birth Weight

Despite lack of evidence for effectiveness, obstetricians in the United States prescribe antepartum bed rest for more than 700,000 women per year. However, in nonpregnant samples, bed rest treatment produces weight loss. This study assessed maternal weight change (gain) during antepartum hospitalization for bed rest treatment; compared appropriateness of infant birth weights for gestational age, race, and gender; and determined whether maternal weight change predicted infant birth weight. The convenience sample for this longitudinal study consisted of 141 women with high-risk pregnancies who were treated with hospital bed rest. Weekly rate of pregnancy weight change by body mass index was compared with Institute of Medicine recommendations for rate of pregnancy weight gain. Infant birth weight was compared with current US infant birth weights for matching gestational age, gender, and race. Weekly antepartum weight change was significantly lower than Institute of Medicine recommendations (P < 0.001). Infant birth weights were also significantly lower than the national mean when matched for each infant’s gestational age, race, and gender ( P < 0.001). Maternal weight change predicted infant birth weight ( P = 0.05). Bed rest treatment is ineffective for improving pregnancy weight gain. Lower infant birth weights across all gestational ages suggest that maternal weight loss during bed rest may be associated with an increased risk of fetal growth restriction. A randomized trial comparing women with high-risk pregnancies who are ambulatory with those on bed rest is needed to determine whether bed rest treatment, underlying maternal-fetal disease, or both influence inadequate maternal weight gain and poor intrauterine growth.

Effect of Postpartum Practices of Doing the Month on Chinese Women’s Physical and Psychological Health

The purpose of the study was to describe Chinese women’s postpartum physiological and psychological health and adherence to “doing-the-month” practices. A descriptive repeated measures design was used, with data collected at 3 days and 6 weeks postpartum. The convenience sample consisted of 198 healthy childbearing women with a term birth. Maternal physical health was measured by the Six-Minute Walk (endurance), Chair Stand test (muscle strength), severity of physical symptoms, and physical health subscales of SF36v2. Maternal psychological health was measured by the Edinburgh Postnatal Depression scale. Adherence was measured by the Adherence to Doing-the-Month Practices questionnaire. Aerobic endurance and lower-body muscle strength improved significantly across time (p < .001) but remained suboptimal for maternal age. Women who delivered by Cesarean section had significantly poorer physical health than those who had a vaginal delivery. Physical functioning significantly increased, but general health and role limitations due to physical health significantly decreased over time. Postpartum physical symptoms decreased in number and severity. Depression increased over time (p < .001). Adherence to doing the month was negatively correlated with aerobic endurance and positively correlated with depression at 6 weeks (p < .05). These findings challenge the assumption that practices of doing the month are healthy for Chinese women’s recovery after childbirth. Research-based evidence needs to be integrated into doing-the-month practices. Education of Chinese women and families, whether living at home or abroad, is needed about the adverse health effects of doing the month. Routine screening for postpartum depression is also advised.

“Doing the month”: Postpartum practices in Chinese women

This review describes the traditional ancient Chinese postpartum practice of “doing the month” or “zuoyuezi”, the evidence for specific practices, maternal adherence to practices, and their effect upon the maternal postpartum physical and psychological health. A comprehensive search yielded 38 English or Chinese publications about common practices, adherence to practices, and their effects upon Chinese womens physical and psychological health. Doing the month involves a series of practices related to the maternal role, physical activity, maintenance of body warmth, and food consumption that are believed to restore maternal postpartum health and prevent future disease. Strengths of these practices include acknowledgment of the womans societal and familial contribution to childbearing and the provision of consistent family support. There is concern for the effect of some practices upon both maternal physical and psychological health, particularly for postpartum depression. Current evidence about the effects of doing-the-month practices upon maternal health needs to be integrated into the traditional practices of doing the month to improve maternal health.

Implementing Evidence-Based Practice: Reducing Risk for Low Birth Weight Through Pregnancy Smoking Cessation

In 1989, the Association of Womens Health, Obstetric and Neonatal Nurses (AWHONN) developed a research utilization program to integrate evidence into practice areas where there were large discrepancies between research evidence and clinical practice. The current program, renamed Research-Based Practice (RBP), uses translational research methods to build from evidence such as that in the Cochrane database and to create protocols for integration of research directly into clinical practice. This article describes the development of the sixth project (RBP6), in which an evidence-based protocol to address smoking in pregnancy was integrated into clinical practice. The protocol includes screening women using descriptive statements and integrates the 5 As (ask, advise, assess, assist, arrange) into prenatal and postpartum care at every visit. By integrating smoking cessation counseling into care, nurses may reduce the risk of low birth weight among pregnant women in both the United States and Canada.

Pain measurement during labor: comparing the visual analog scale with dermatome assessment

OBJECTIVE The purpose of this article is to examine the agreement between two measures of pain in laboring women who receive epidural analgesia for relief to support validity and reliability of the Visual Analog Scale (VAS) in this population. BACKGROUND There are several different approaches to measuring pain in laboring women. However, the psychometric properties of pain relief measures in this population are not well established. This investigation examines agreement (i.e., concordance) between the visual analog scale for pain sensation and sensation measured by dermatome level assessment. METHOD Fifty pregnant women in labor who underwent epidural placement recorded their sensation of pain on the VAS simultaneously with the certified nurse anesthetist recording sensation by using a standard dermatome chart after administration of epidural analgesia. RESULTS There was moderate, significant correlation between the two measures. However, agreement between the two measures did not meet preset standards with Bland-Altman analysis, suggesting that one measure cannot be substituted for the other. Overall, the average dermatome levels alone underestimated pain in laboring women as recorded by the VAS, although both under-and overestimation of pain relief occurred during the series of observations.

Bone Status in Activity-Restricted Pregnant Women Assessed Using Calcaneal Quantitative Ultrasound

Objective: Pregnancy-induced bone loss may be further exacerbated by activity restriction (AR). The authors compared the bone status of AR hospitalized (≥7 days) pregnant women in the third trimester to ambulatory (AM) women at the same gestational age, using a prospective cross-sectional design. Method: AR was quantified in AR women by daily step counts using a pedometer for 7 consecutive days. Bone status was evaluated in the left and right calcaneus bones of both AR (n = 13) and AM (n = 20) women using quantitative ultrasound (QUS). Results: AR women took an average of 1,504 ± 1,377 steps/day. Speed of sound scores (1,543.05 ± 41.97 m/s vs. 1,569.60 ± 46.12 m/s) and broadband ultrasound attenuation (BUA) scores (107.93 ± 9.59 dB/MHz vs. 114.69 ± 17.06 dB/MHz) were not different between the AR and AM groups, respectively (p > .05). However, bone stiffness index (SI) scores (84.0 ± 16.2 vs. 95.8 ± 22.1, respectively, p < .05) were different between groups, indicating a greater relative risk of future fracture in the AR women. Conclusion: Increased fracture risk appears to be a negative side effect incurred through an average of 16 days of hospitalized AR in late pregnancy. Further investigations using a larger sample size are necessary to evaluate the effect of antepartum AR on bone status in the postpartum period to determine if bone status is further attenuated by breastfeeding or if recovery occurs with resumption of ambulation and return of menses and to assess future risk in these women as they age. Prenatal care providers should be made aware of these risks.