Rethinking Bed Rest In Pregnancy

Your pregnancy gets labeled “high risk,” and suddenly the default advice can feel like a single blunt command: stop moving. That can be crushing if exercise is how you regulate stress, manage pain, and feel at home in your body. We go straight at the uncomfortable question many active moms are asking quietly: is activity restriction actually helping, or are we sometimes making outcomes worse by prescribing fear and deconditioning?

I’m Christina Previtt, pelvic floor physical therapist and pregnancy researcher, and I walk through what we know and what we still do not know about pregnancy complications and exercise. We unpack why bed rest and strict “no exercise” rules became common, why the Society for Maternal-Fetal Medicine has moved away from routine activity restriction for certain preterm birth risks, and why so many providers still reach for restrictions as a knee-jerk response. We also talk about the real-world costs of sedentary behavior during pregnancy, from mental health to loss of strength and capacity that you need for birth, postpartum recovery, and motherhood.

Then we get specific about the studies that are shifting the conversation: the AWARE study on short cervix and step count, the AMBL study on PPROM patients walking on the hospital ward, and research on pelvic rest with placenta previa. The theme is nuance. Movement is not the same as high-intensity training, and “strain” is relative to your fitness, your symptoms, and what your day demands.

If you’re pregnant, navigating cervical insufficiency, a short cervix, PPROM, placenta previa, or other complications, I share practical prompts to bring to your OB or maternal-fetal medicine visit so you can find the safest middle ground. Subscribe for more evidence-based pregnancy fitness conversations, share this with a friend who was told to stop moving, and leave a review so more moms can find it.

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Transcript

Welcome And Podcast Scope

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Hello everyone and welcome to the Farmer Mamas Podcast. My name is Christina Farman. I'm a public force, but researcher, and exercise, and I can be in a mom of the two who has completed a constantly or we would be pregnant post-part or a post-famous podcast. We want to talk about the realities of being a mom who loves to exercise. Whether you're a recreational exerciser or an athlete, we want to talk about all of the things that we go through as females going into this motherhood journey. We're going to talk about fertility, pregnancy, and post-partism topics that are relevant to the active individual. While I am a public floor physical therapist, I am not your public floor physical therapist, and know that this podcast does not substitute medical advice. Alright, come along for this journey with us while we navigate motherhood together. And I can't wait to get to it. Hello, everybody, and welcome to the Barbell Mamas podcast. Christina Previtt here. And today I want to be talking about pregnancy-related complications. Now, this is a very big topic and where exercise fits in. When it comes to pregnancy, it is such a protected time in a woman's life. And now instead of protecting one life from a health perspective, you are protecting two. It is a complicated process. It puts a lot of stress on mom. It puts a lot of stress on her body, on her, all of her organ systems, her heart, et cetera. And because it's such a complicated process, things can go wrong. There are complications from high blood pressure, gestational diabetes, issues with your liver, all of these things, right? Cervical insufficiency, short cervix, risk for free-term labor, intereter and growth restriction. You start going through some of these complications. You start learning about pregnancy, the pregnancy process, and what can go awry. And it's kind of terrifying, right? Where sometimes you're navigating all these things, you're so uncertain. And then you're trying to figure out what you can do. One of the things that I have learned, having gone through four pregnancies, two that did not end well, being a pregnancy researcher, treating moms all the time in the clinic, is that one of the hardest things to recognize, or one of the hardest things to have to sit with, is that sometimes there is nothing that we can do but wait. When you get that advice though, you can sometimes feel like you are failing or the system is failing, or you just want your doctor to give you a recommendation of something that you can do. And the truth is that there is nothing that we can do sometimes. When we are thinking about complications, when the risk gets elevated, oftentimes it is a knee-jerk reaction of the provider. Usually now you're in the obstetrical to maternal fetal medicine high-risk OB provider. One of the knee-jerk reactions can be to restrict exercise, restrict movement in general. Everywhere, like the restriction kind of goes across a spectrum from complete bed rest, complete bed rest on the ward with monitoring, all the way to no exercise, no orgasms, because that can disrupt the cervix, to, you know, you can do everything except for exercise. Like there's kind of this light to moderate to severe to complete bed rest kind of spectrum of activity restriction. There has been a big shift in this space with respect to our recommendations, where, you know, 10 years ago, bed rest was more commonly recommended in the presence of complication when something was going awry. And oftentimes this was like cervical insufficiency, premature rupture of membranes, preterm delivery, those types of complications. And newer data has shown that bed rest, one, there is a higher risk of worse obstetrical outcomes, higher need for cesarean delivery, et cetera. And there has been a challenge that we need to not only think about trying to reduce movement to help the pregnancy, because that's not panning out, but also to balance that with the very real cost of sedentary behavior on mental health of mom, on physical capacity on mom, on ability to fulfill her other roles financially via work, parenting, caregiving, um, other members of her household, et cetera. And that has to be balanced to say, is this net benefit worth it? And now that we're not seeing a net benefit, it's time for us to move away from some more of those more intense restrictions. Despite the fact that the Society for Maternal Fetal Medicine, the consult series, has decided that activity restriction of any kind is not recommended in the presence of risk for preterm delivery and cervical or short cervix. Still, up to 80 to 95% of obstetrical providers can recommend activity restriction in the presence of certain complications. Now, over the last three years, we have seen several studies that have come out that are really starting to challenge this narrative. And I'm hoping that it is going to pick up steam. Where I would like to see your evidence goes. And I want to acknowledge what we do know versus what we don't. My biggest pet peeve around activity restrictions in pregnancy complication is the knee-jerk reaction in medicine that exercise is going to make something worse. The reason why this is such a huge pet peeve for me is that in no area of medicine have we said your aerobic fitness makes your outcomes worse. Your muscular strength and your fitness makes your outcomes worse. In all of our literature, across almost every comorbidity, fitness, aerobic, and strength capacity are all protective factors on the development of different chronic diseases. And once the complication or chronic disease has been established, maintaining fitness, reducing deconditioning, or increasing fitness is going to prevent the disease process from getting worse. Those who are more sedentary and less active have higher chronic disease burden, higher healthcare utilization, worse longevity outcomes, increases in all-cause mortality. And in my space, as a person with a PhD in geriatric rehab, it is mind-boggling to me that in pregnancy, our assumption is that in the presence of complications, that exercise may make things worse. We just do not have that data anywhere else. Many of these activity restrictions are also not based on evidence that exercise exacerbates or makes that complication worse in the first place, right? Many of our red lights, traffic lights for um when it comes to exercise and pregnancy are often because of medical complexity and not because we have evidence that exercise exacerbates these conditions. And that's an important distinction, right? Because you've heard me say on the podcast that if we don't know, the answer is often no. Now, when you are dealing with complications, I think what has happened is we have put an absolute label on a relative recommendation that requires a more nuanced conversation. What do I mean by that? When we think about exercise, people have locked down exercise entirely in the presence of premature rupture membranes, cervical insufficiency, et cetera. Do I think that we should be removing all restrictions and have a person do a one-rep max deadlift with what we know right now? No, because most people are not bracing appropriately. They may put extra strain down on their bodies that their body isn't ready for just yet. But a one-rep max deadlift versus deadlifting at 50 to 60% in a moderate intensity range, those are very different strains on that pregnant person's body. And there is where nuance and context happen. In the aerobic fitness domain, maybe I'm not going to be recommending big high intensity exercise or max out, do a marathon, right? When you're kind of going through an evaluation process for a different complication, whatever that complication is. But going on a bike or an elliptical at moderate intensity, I cannot see how that would be bad for moms in the throes of a very stressful area where they are just waiting to make sure a baby is okay and they need that stress coping mechanism. Where we have gone, though, is instead of sitting with those nuanced conversations, we have just shut exercise down entirely. Where we say no exercise at all, you're on pelvic rest, nothing in the vagina, no exercise. We don't have evidence even to say that those high intensity exercises are bad. But where we are at right now is we're going to start maybe with the first step, which is removing the restriction altogether, and instead remove or keep the restriction on high intensity exercise until our evidence has substantiated a relative risk and we understand what that risk profile looks like depending on intensity of exercise. Where we are at now is that we have been looking almost exclusively at step count as a marker of the amount of activity restriction a person is doing without any intensity markers or any exercise questionnaires that give us a clearer picture of what type of activity mom is engaging in. And so I'm gonna go through a couple of studies that have looked at this. And this is going to show you how we are starting to poke holes in this argument around activity restriction in the presence of complication. So, number one, if you were looking at my Instagram account, I just published a reel about the aware study. So the aware study just got published in the Green Journal, and it was looking at individuals with shortened cervix and their um the amount of walking or steps that a person does per day, what their activity restriction was, what that activity restriction did for individuals' quality of life, and their obstetrical outcomes. With that, they looked at a cutoff score of 3,500 steps. Under 3,500 steps was considered sedentary, and over 3,500 steps was considered um non-sedentary. What they found was that those who took more than 3,500 steps per day were pregnant for over two and a half weeks longer. 34.9 weeks in the sedentary group versus 37.7 weeks. Individuals then obviously had a higher risk of preterm delivery in the sedentary group than in the non-sedentary group. Babies in the sedentary group were more likely to be admitted to the NICU if they were in the sedentary group versus the non-sedentary group. What this is showing is that your activity restriction may be making your outcomes worse. And so that is a lot of reflection, right, in our obstetrical space around is there harm in our restrictions? And I have had conversations with other pelvic providers who have said to me, Christina, like, why risk it? Right? Why risk it? Just this is not my time to be active. Like that's fine. No, because somebody had to tell you the risk was there when it wasn't, right? That's what gets me mad. Like somebody said there is a risk here without any substantiated evidence that that was true. And so when we create fear as a medical staff, there are very real consequences to the sense of safety that women feel within their bodies. And that has very real consequences in their pregnancy, how they feel within their pregnancy, because the amount of fitness that they have and the mitigation of deconditioning in pregnancy has huge implications in how much pain people have in pregnancy. Postpartum is super hard on the body. And so you want to have as much fitness as possible. And this idea around kinesophobia is a new area and one where my research is showing that kinesophobia in general, so fear of movement in pregnancy can be a very real variable and barrier to movement. And then on the pelvic side, this fear of core and pelvic floor dysfunction from our rehab providers is also very real. And so the why risk it is because our obstetrical team has said that there is a risk in the first place. And all of our new evidence is saying that that's not true. And so this relative confidence and saying, yes, it's important that you activity restrict is it's just not evidence-based care. So the aware study is number one. The second one was the AMBL study. And this one I find very, very interesting because it is even in a higher escalation of relative risk, because this study was done in individuals who were on ward because of leaking of amniotic fluid. So a premature rupture of membranes, they were on the maternity ward being monitored. They were trying to stay pregnant for as long as they could to try and increase chance of baby being okay and having a good obstetrical outcome. Group one, Fitbit, 2,000 steps per day. Go around the ward. Group two, control group, bathroom privileges. So not trying to do walking around the ward, you're trying to stay in bed for as much as you can, going to the bathroom is fine. With that group, again, mom was pregnant for 11 days longer. So mom that was walking on ward was pregnant for 11 days longer. When you are thinking about a premi baby, every day that you stay pregnant matters. And so again, this is another area where our activity restriction, and now this is not asking for a lot of activity, but even in probably our one of our most restricted groups, just doesn't seem to pan out completely. And so again, it makes us question why are we restricting, especially walking? Our third study is in, this was a retrospective study. So it was kind of looking at outcomes based on variability and obstetrical provider recommendations, looking at pelvic rest for individuals with placenta previa. In placenta previa and low-lying placenta, there is a chance when the placenta embeds that it can cover, get close to or cover some of or cover all of the cervix, which can cause increased risk for preterm delivery. And often as baby grows and the uterus stretches, there is a unmasking or a moving away from the cervix that happens with the placenta. But after 28 weeks, if there still is that coverage, um, risk can increase. Because of that risk, pelvic rest is sometimes recommended. That recommendation should not start at minimum until 28 weeks. And our study that was looking at pelvic rest versus not showed no difference in any obstetrical outcome, small for gestational AIDS, gestational age of delivery, um, risk for NICU admittance, et cetera. There was no statistically significant differences between outcomes in the activity restricted group versus the non-activity restricted group. What I'm hoping that this is starting to really showcase is that there is a consistent trend in the data. A very consistent trend that activity restriction is leading to negative health outcomes. And so it should not be recommended. What we do not have now, and as I mentioned, is any type of intensity mark. And so we still have a lot of work to do in the research field around what is acceptable exercise and what is not. If I can make a hypothesis, and I think this is true in a lot of areas of healthcare, I am very strongly against any blanket recommendation is that we have to consider relative recommendations versus absolute contraindications. When we are thinking about the goal of activity restriction, we are trying to reduce strain on a sensitive mom baby. Strain, however, is not an absolute measure. It is a relative measure. And it is relative to a person's fitness. She could do that all day and not worry about it. Truly not worry about it. When we are thinking about a mom who has a 30-pound deadlift in a 30-pound toddler, picking up that toddler puts her at a hundred percent relative effort. And so that is a highly strenuous task on the entire body, right? Aerobic capacity, potentially muscoskeletal capacity, and then potentially that bear-down, which is oftentimes what we're trying to avoid when avoiding highly strenuous tasks in the presence of complication. What that means is that we really want to be preserving fitness as much as we can so that strain on the body goes down with activities of daily living and with exercise. And so maybe we're restricting top-end effort, but allowing them to have wiggle room in low to moderate intensity. That's what I would love to see in the presence of complication right now, until we know more at the high intensity side of the spectrum. Unfortunately, what happens with exercise, and this is true with our miscarriage discussion, this is true when any type of complication comes up, there is a very high likelihood that exercise is going to have a saliency effect, which means that if you are a person who exercises four to six times per week, there is a very high likelihood that you will attribute your complication to being around a time that you worked out. Just because it is something that you do often and have that exposure often enough that it's very easy for that connection to be made. And that's where a lot of this fear focused language can occur. And so I am gonna keep up to date with. All of the research that's coming into activity restriction. I'm gonna continue to be talking with my obstetrical colleagues about really balancing the risks of putting restrictions on people, not just from uh our evidence doesn't support this perspective, because that that is new and growing, but also from you know mental health, physiological health, deterioration of muscle mass, like all of these things that I think are often not taken into account as often in that conversation because we're dealing with individuals who kind of do have muscle skeletal reserve. Um however, motherhood is such a high demand task and it does require a lot of fitness that it is something that we want to consider and something that we want to continue having conversations about. All right, I got a little fancy and um a little bit more complicated in today's discussion. I think if you are in this place where you are unsure, I get questions all the time. What is our evidence on this? Like, my doctor is restricting this. What, like, I don't feel like I need to restrict everything. Please have an open and honest conversation with your doctor, right? Like, we are on the same team. This is not to say anything negative about any of my obstetrical colleagues because they are all amazing and they are taking on the burden of risk. This evidence is new. And my world is in exercise physiology and in the impact of exercise on the body. That is not my obstetrical team's world, right? And so it is important for us to lock shields, and it is important for us, if you are a person who is pregnant, to be able to have conversations. Hey, I heard this podcast that said that activity restriction doesn't necessarily have to be an all or nothing. What do you think about getting on a bike versus stopping my orange theory class or my higher intensity exercise? Would you be okay if I swam laps instead of did my 10K running? Like have those conversations. And oftentimes, um, your provider will help pull you in between the buoys so that you can kind of come to this consensus that's gonna make both of you feel. All right, that is all I got for today. If you have any other questions, please let me know. Otherwise, I will see you all next week.