Recommendations of activity restriction in  high-risk pregnancy scenarios: a Danish national survey

Jane Bendix; Hanne Kristine Hegaard; Thomas Bergholt; Jens Langhoff-Roos

doi:10.1515/jpm-2013-0347

Article

Recommendations of activity restriction in high-risk pregnancy scenarios: a Danish national survey

Jane Bendix , Hanne Kristine Hegaard , Thomas Bergholt and Jens Langhoff-Roos

Published/Copyright: April 1, 2014

Published by

Become an author with De Gruyter Brill

Submit Manuscript Author Information Explore this Subject

From the journal Journal of Perinatal Medicine Volume 43 Issue 4

Abstract

Aims: To describe specific recommendations of activity restriction, place of care, expected beneficial and adverse effects, and recommended antithrombotic prophylaxis in nine clinical scenarios.

Methods: A national survey. All members of the Danish Society of Obstetrics and Gynaecology and the Danish Association of Midwives were asked to complete a tested, structured questionnaire.

Results: We sent 1815 invitations; the overall response rate was 54%. A majority of clinicians recommended some form of activity restriction in the nine scenarios. The midwives recommended strict or moderate activity restriction more often than obstetricians in five of the nine scenarios, in women with preterm premature rupture of membranes, preterm labour, cervical ripening, total placenta praevia, and intrauterine growth restriction, whereas no differences were found in the remaining scenarios. Compared to the obstetricians, the midwives also reported that they expected the recommendation to be more effective. Most midwives and obstetricians reported that they thought strict activity restriction was associated with severe or moderate adverse effect, and recommended antithrombotic prophylaxis.

Conclusions: Danish obstetricians and midwives prescribe activity restriction in most high-risk pregnancies. The degree of activity restriction and the presumed effect vary between clinicians. This may reflect different attitudes and lack of guidelines based on clinical studies of a possible benefit of activity restriction.

Keywords: Activity restriction; high-risk pregnancies; midwives; national survey; obstetricians; recommendations

Corresponding author: Jane Bendix, RM, Master of Health Science, PhD student, Department of Gynecology and Obstetrics, Nordsjaellands Hospital, Hillerod, University of Copenhagen, Dyrehavevej 29, DK 3400 Hillerod, Denmark, Tel.: +45 48296054, E-mail: Jane.Bendix@regionh.dk

Funding source: Funding: The study was supported by grants from the Nordsjaellands Hospital, Hillerod, University of Copenhagen, Denmark; TrygFonden; and the Danish Association of Midwives.

Acknowledgements

The authors thank the respondents who took time to participate in this survey. The authors are also very grateful to Louise Biggar for her linguistic revision of the origional manuscript.

Appendix

Clinical scenarios

Threatening preterm delivery

Preterm premature rupture of membranes (PPROM)

The patient is a 30-year-old woman with pregnancy no. 3 and one previous delivery. This pregnancy is the result of fertility treatment with intracytoplasmic sperm injection (ICSI); gestational age (GA) is 28+4. Previous pregnancy and labour were normal.

The patient presents with PPROM an hour earlier. An ample amount of clear amniotic fluid is observed, and there are no clinical signs of infection. Foetal heart rate (FHR) is normal, and there are light uterine contractions every 4–6 min. The cervical length is 21 mm as measured by transvaginal ultrasound scanning (TVUSS).

Antibiotics and steroids are administered, and a course of tocolytics is completed within 36 h. Clear amniotic fluid continues to seep, and there are no further uterine contractions. This is the status quo for the next 48 h.

Preterm labour

The patient is a 24-year-old woman with pregnancy no. 1; GA is 26+4.

The patient presents with increasing painful uterine contractions for the last couple of hours, which are now regular contractions every 3–5 min. No clinical signs of infection are noted. Vaginal examination shows cervical effacement, with 3-cm dilation and pressure on the lower uterine segment and light vaginal bleeding; breech presentation with intact membranes and normal FHR is noted. A 24-h course of steroids and tocolytics is completed. No further uterine contractions are observed for the next 48 h. Vaginal examination shows less dilation of the cervix (1–2 cm). No ongoing pressure at the lower uterine segment is noted.

Cervical ripening

The patient is a 34-year-old woman with pregnancy no. 3 and one previous delivery; GA is 30+0.

The patient presents with frequent Braxton Hicks contractions, a feeling of pelvic/vaginal heaviness and a strong backache. She has noted increasing vaginal discharge over the last couple of days. The woman had given birth prematurely at gestational age 31+0 in her previous pregnancy, which was complicated by PPROM.

Vaginal examination shows cervical effacement, 2-cm dilation, and vertex presentation. The cervical length is 14 mm as measured by TVUSS. Membranes are intact, and there is no vaginal bleeding. FHR is normal.

The woman has a busy full-time job. She is a contemporary single parent, as her husband is abroad on business. She has neither domestic help nor help in caring for the child when daycare is closed during the evenings and weekends.

Short cervix

Short cervix and strong social support

The patient is a 29-year-old woman with pregnancy no. 1 and a history of two in vitro fertilisation (IVF) treatments; GA is 29+1.

She presents with a feeling of pelvic/vaginal heaviness. No contractions are reported, and intact membranes are noted along with engaged vertex presentation. The cervical length is 12 mm as measured by TVUSS. FHR is normal.

The woman has a busy everyday life with a full-time job. She is moving into a new home in a few weeks time. She has strong resources and a good social network.

Short cervix and poor social support

The patient is a 29-year-old woman with pregnancy no. 1 and a history of two IVF treatments; GA is 29+1.

The woman is long-term unemployed; she had to give up an unskilled job in a big canteen due to a whiplash injury after a traffic accident 4 years ago. She had recently been abandoned by the father of the unborn child in favour of another woman. The patient was raised in a socially deprived family and has hardly any social network.

Twin pregnancy with a short cervix

The patient is a 33-year-old woman with pregnancy no. 1; she is spontaneously pregnant with dizygotic twins; GA is 30+6.

She presents with a feeling of pelvic/vaginal heaviness. No contractions are noted.

Vaginal examination shows cervical effacement with no dilation; however, moderate pressure is noted on the lower uterine segment. The leading foetus is in vertex presentation. Membranes are intact, and there is no vaginal bleeding. The cervical length is 10 mm as measured by TVUSS. Foetal weight estimations are –5% and –15%. FHRs in both foetuses are normal.

Other complications

False labour

The patient is a 34-year-old woman with pregnancy no. 1; GA is 30+0.

The patient presents with frequent Braxton Hicks contractions and a feeling of pelvic/vaginal heaviness and strong backache, especially during the evening. Vaginal examination shows no cervical effacement and no dilation. Deeply engaged vertex presentation is noted along with intact membranes and no vaginal bleeding. The cervical length is 24 mm as measured by TVUSS. FHR is normal.

The woman has a busy full-time job and is planning a business trip in a week to the Milan fashion fair. The woman asks for your advice whether she should travel.

Total placenta praevia

The patient is a 38-year-old woman with pregnancy no. 3 and two previous deliveries; GA is 26+2.

The patient presents owing to a heavy vaginal bleeding episode at home. She has been diagnosed previously with placenta praevia owing to a similar bleeding episode at GA 22. At arrival, the patient is conscious and blood pressure and pulse are normal. The vaginal bleeding has decreased, and membranes are intact. There is no pain or irritability of the uterus. FHR is normal. The mother has felt foetal movements since arrival at the hospital. A few hours later, the bleeding has ceased. The woman assists her spouse at a medium-sized farm. There are two children of 3 and 6 years of age in the family.

Intrauterine growth restriction

The patient is a 29-year-old woman with pregnancy no. 4 and two previous deliveries; GA is 32+0.

IUGR has recently been diagnosed. Her previous two deliveries were at term with normal birth weights. Foetal weight estimation is 1270 g (-28%). Normal flow was noted in the umbilical artery. FHR is normal.

Maternal blood pressure and urine test result are both normal. The patient is a non-smoker and has a sedentary job at a busy workplace.

References

[1] Abou El Senoun G, Dowswell T, Mousa HA. Planned home versus hospital care for preterm prelabour rupture of the membranes (PPROM) prior to 37 weeks’ gestation. Cochrane Database Syst Rev. 2010;4:CD008053.10.1002/14651858.CD008053.pub2Search in Google Scholar PubMed PubMed Central

[2] Aleman A, Althabe F, Belizán J, Bergel E. Bed rest during pregnancy for preventing miscarriage. Cochrane Database Syst Rev. 2005;2:CD003576.10.1002/14651858.CD003576.pub2Search in Google Scholar PubMed PubMed Central

[3] Bendix J, Kjaergaard H, Zoffmann V. Pregnant women’s management of activity restriction during hospitalisation – A question of yielding and not feeling deprived of a sense of control. J Neonat Nurs. 2014;20:24–30.10.1016/j.jnn.2013.04.011Search in Google Scholar

[4] Bigelow C, Stone J. Bed rest in pregnancy. Mt Sinai J Med. 2011;78:291–302.10.1002/msj.20243Search in Google Scholar PubMed

[5] Biggio JR Jr. Bed rest in pregnancy: time to put the issue to rest. Obstet Gynecol. 2013;121:1158–60.10.1097/AOG.0b013e318294480dSearch in Google Scholar PubMed

[6] Crowther CA, Han S. Hospitalisation and bed rest for multiple pregnancy. Cochrane Database Syst Rev. 2010;7:CD000110.10.1002/14651858.CD000110.pub2Search in Google Scholar PubMed PubMed Central

[7] Elliott JP, Miller HS, Coleman S, Rhea D, Abril D, Hallbauer K, et al. A randomized multicenter study to determine the efficacy of activity restriction for preterm labor management in patients testing negative for fetal fibronectin. J Perinatol. 2005;25: 626–30.10.1038/sj.jp.7211359Search in Google Scholar PubMed

[8] Fox NS, Gelber SE, Kalish RB, Chasen ST. The recommendation for bed rest in the setting of arrested preterm labor and premature rupture of membranes. Am J Obstet Gynecol. 2009;200:165.e1–6.10.1016/j.ajog.2008.08.007Search in Google Scholar PubMed

[9] Goldenberg RL, Cliver SP, Bronstein J, Cutter GR, Andrews WW, Mennemeyer ST. Bed rest in pregnancy. Obstet Gynecol. 1994;84:131–6.Search in Google Scholar

[10] Kovacevich GJ, Gaich SA, Lavin JP, Hopkins MP, Crane SS, Stewart J, et al. The prevalence of thromboembolic events among women with extended bed rest prescribed as part of the treatment for premature labor or preterm premature rupture of membranes. Am J Obstet Gynecol. 2000;182: 1089–92.10.1067/mob.2000.105405Search in Google Scholar PubMed

[11] Maloni JA. Antepartum bed rest for pregnancy complications: efficacy and safety for preventing preterm birth. Biol Res Nurs. 2010;12:106–24.10.1177/1099800410375978Search in Google Scholar PubMed

[12] Maloni JA. Lack of evidence for prescription of antepartum bed rest. Expert Rev Obstet Gynecol. 2011;6:385–93.10.1586/eog.11.28Search in Google Scholar PubMed PubMed Central

[13] Maloni JA, Brezinski-Tomasi JE, Johnson LA. Antepartum bed rest: effect upon the family. J Obstet Gynecol Neonatal Nurs. 2001;30:165–73.10.1111/j.1552-6909.2001.tb01532.xSearch in Google Scholar PubMed

[14] Maloni JA, Kane JH, Suen LJ, Wang KK. Dysphoria among high-risk pregnant hospitalized women on bed rest: a longitudinal study. Nurs Res. 2002;51:92–9.10.1097/00006199-200203000-00005Search in Google Scholar PubMed

[15] Maloni JA, Park S, Anthony MK, Musil CM. Measurement of antepartum depressive symptoms during high-risk pregnancy. Res Nurs Health. 2005;28:16–26.10.1002/nur.20051Search in Google Scholar PubMed

[16] Maloni JA, Schneider BS. Inactivity: symptoms associated with gastrocnemius muscle disuse during pregnancy. AACN Clin Issues. 2002;13:248–62.10.1097/00044067-200205000-00010Search in Google Scholar PubMed

[17] McCall CA, Grimes DA, Lyerly Drapkin A. “Therapeutic” bed rest in pregnancy unethical and unsupported by data. Obstet Gynecol. 2013;121:1305–8.10.1097/AOG.0b013e318293f12fSearch in Google Scholar PubMed

[18] Mortensen LH, Diderichsen F, Arntzen A, Gissler M, Cnattingius S, Schnor O, et al. Social inequality in fetal growth: a comparative study of Denmark, Finland, Norway and Sweden in the period 1981–2000. J Epidemiol Community Health. 2008;62:325–31.10.1136/jech.2007.061473Search in Google Scholar PubMed

[19] Neilson JP. Interventions for suspected placenta praevia. Cochrane Database Syst Rev. 2003;2:CD001998.10.1002/14651858.CD001998Search in Google Scholar PubMed

[20] Petersen CB, Mortensen LH, Morgen CS, Madsen M, Schnor O, Arntzen A, et al. Socio-economic inequality in preterm birth: a comparative study of the Nordic countries from 1981 to 2000. Paediatr Perinat Epidemiol. 2009;23:66–75.10.1111/j.1365-3016.2008.00977.xSearch in Google Scholar PubMed

[21] Promislow JH, Hertz-Picciotto I, Schramm M, Watt-Morse M, Anderson JJ. Bed rest and other determinants of bone loss during pregnancy. Am J Obstet Gynecol. 2004;191:1077–83.10.1016/j.ajog.2004.05.058Search in Google Scholar PubMed

[22] Public Health Agency of Canada [Internet]. What Mothers Say: The Canadian Maternity Experiences Survey. Ottawa, 2009.Available from http://www.phac-aspc.gc.ca/rhs-ssg/pdf/survey-eng.pdf(29 January 2014).Search in Google Scholar

[23] Ramsey PS, Nuthalapaty FS, Lu G, Ramin S, Nuthalapaty ES, Ramin KD. Contemporary management of preterm premature rupture of membranes (PPROM): a survey of maternal-fetal medicine providers. Am J Obstet Gynecol. 2004;191:1497–502.10.1016/j.ajog.2004.08.005Search in Google Scholar

[24] Royal College of Obstetricians and Gynaecologists. Reducing the risk of thrombosis and embolism during pregnancy and the puerperium. Green-top Guideline No. 37. 2009:1–35.Search in Google Scholar

[25] Rubin M. The physiology of bed rest. Am J Nurs. 1988;88:50–6.10.1097/00000446-198801000-00019Search in Google Scholar

[26] Say L, Gülmezoglu AM, Hofmeyr GJ. Bed rest in hospital for suspected impaired fetal growth. Cochrane Database Syst Rev. 1996;1:CD000034.10.1002/14651858.CD000034Search in Google Scholar

[27] Sciscione AC. Maternal activity restriction and the prevention of preterm birth. Am J Obstet Gynecol. 2010;202:232.e1–5.10.1016/j.ajog.2009.07.005Search in Google Scholar

[28] Smith V, Devane D, Higgins S. Practices for predicting and preventing preterm birth in Ireland: a national survey. Ir J Med Sci. 2011;180:63–7.10.1007/s11845-010-0604-1Search in Google Scholar

[29] Sosa C, Althabe F, Belizán JM, Bergel E. 2004. Bed rest in singleton pregnancies for preventing preterm birth. Cochrane Database Syst Rev. 2004;1:CD003581.10.1002/14651858.CD003581.pub2Search in Google Scholar

[30] Sprague AE. The evolution of bed rest as a clinical intervention. J Obstet Gynecol Neonatal Nurs. 2004;33:542–9.10.1177/0884217504268523Search in Google Scholar

[31] Sprague AE, O’Brien B, Newburn-Cook C, Heaman M, Nimrod C. Bed rest and activity restriction for women at risk for preterm birth: a survey of Canadian prenatal care providers. J Obstet Gynaecol Can. 2008;30:317–26.10.1016/S1701-2163(16)32800-6Search in Google Scholar

[32] Sundhedsstyrelsen. The Danish Health and Medicines Authority [Internet]. Brot C, Poulsen A. Anbefalinger for svangreomsorgen. 2. edition, 1. issue. Sundhedsstyrelsen, 2013. Available from http://sundhedsstyrelsen.dk/publ/Publ2013/10okt/Svangreomsorg2013.pdf(24 January 2014).Search in Google Scholar

[33] The American College of Obstetricians and Gynecologists. Practice bulletin. Management of preterm labor. Obstet Gynecol. 2012;119:1308–17.10.1097/AOG.0b013e31825af2f0Search in Google Scholar PubMed

[34] The American Congress of Obstetricians and Gynecologists [Internet]. About ACOG: Levesque RP. Depression, anxiety rates high among hospitalized pregnant women on bed rest; 2013. Available from http://www.acog.org/About_ACOG/News_Room/News_Releases/2013/Depression_Anxiety_Rates_High_Among_Hospitalized_Pregnant_Women_on_Bed_Rest(accessed 2 August 2013).Search in Google Scholar

[35] Tooher R, Gates S, Dowswell T, Davis LJ. Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period. Cochrane Database Syst Rev. 2010;5:CD001689.10.1002/14651858.CD001689.pub2Search in Google Scholar PubMed PubMed Central

[36] Tsoi E, Akmal S, Rane S, Otigbah C, Nicolaides KH. Ultrasound assessment of cervical length in threatened preterm labor. Ultrasound Obstet Gynecol. 2003;21:552–5.10.1002/uog.131Search in Google Scholar PubMed

[37] Webster J, Linnane JW, Dibley LM, Hinson JK, Starrenburg SE, Roberts JA. Measuring social support in pregnancy: can it be simple and meaningful? Birth 2000;27:97–101.10.1046/j.1523-536x.2000.00097.xSearch in Google Scholar PubMed

The authors stated that there are no conflicts of interest regarding the publication of this article.

Received: 2013-12-23

Accepted: 2014-3-6

Published Online: 2014-4-1

Published in Print: 2015-7-1

You are currently not able to access this content.

Articles in the same Issue

https://doi.org/10.1515/jpm-2013-0347

Keywords for this article

Activity restriction; high-risk pregnancies; midwives; national survey; obstetricians; recommendations