The physical and psychological problems of hospitalized high-risk pregnant women in partial bed rest

Objective

The pregnant women who have high risk are prescribed partial/complete bed rest in hospital/home by health professionals. Hospitalized pregnant could have different physical and psychological problems which are related to bed rest. This descriptive study was conducted to determine the problems. 

Methods

The sample group consisted of high-risk pregnant who had completed 16th gestational week, had partial bed rest in hospital for at least 5 days and were accepted to participate in the study (n=52). An information form, "Antepartum Symptom Report" and "Antepartum Hospital Stressors Inventory" (AHSI) were used for collection of the data. The data were evaluated with the tests of Cronbach (a) consistency coefficients, percentage, mean and correlation distribution. 

Results

The pregnant women have lived mild mood changes, moderate tenseness and severe reflux in bed rest period. The pregnant have mostly experimented these stressors according to AHSI: "Thinking about my baby’s health" and "Wondering how long I’ll be in hospital". The psychological symptoms are related to physical symptoms, obstetric story and age.

Conclusion

Hospitalized high-risk pregnant women have some problems. The pregnant, who have planned pregnancies, have experi enced more severe nightmares and sensitiveness than the pregnant who have unplanned pregnancies (p<0.001). Level of tenseness and sensitiveness are associated with number of children (p<0.05). The nurses, who work in the perinatology services, have to know the problems related to bed rest in order to prevent mother’s and baby’s health.

Keywords

High-risk pregnancy, bed rest, nursing.

Introduction

High-risk pregnancy is defined as “a physiologic and psyhcosocial state endangering the life and health of the mother, fetus or neonate, and increasing the risk of morbidity and mortality”.(1,2) Complications that make a pregnant included in the "high-risk pregnancy” group are several: Anomalies of placenta, incompetent cervix, preeclampsia, preterm labor threat, systemic diseases (diabetes, anemia, infection etc.), Rh incompatibility, intrauterine growth retardation, cervical insufficiency and multiparity.(1-5)
In majority of high-risk pregnancies, pregnant woman is firstly recommended to take a bed rest at home or hospital. Bed rest is frequently recommended for risky pregnancies between 20-36 weeks’ gestation. In the U.S., each year nearly 700,000 pregnant women with high risk are sent to bed.(1,3,6,7) Benefits of bed rest for high-risk pregnancies are that resting regulates uterus perfusion and fetal circulation; it reduces the pressure on cervix and provides an opportunity to take a rest to the pregnant.(1,3,8,9)
Despite such benefits, pregnant women who are at bed rest also experience some physiologic and psychosocial side effects. Degree of side effects varies according to the type and duration of the bed rest. The most common physiologic complications of bed rest are as follows: fluid and electrolyte imbalance, reduction in the stroke volume, slow pulse, muscle atrophy, loss of calcium, glucose intolerance, weight loss, increased coagulation factors, reflux, constipation, headache and delayed postpartum rehabilitation.(1,3,9) And, psychosocial problems related with bed rest are listed as follows: anxiety, low self-esteem, self-blaming, frustration, conflict, sentimentality, crisis, uncertainity, loss of control, boredom and concerns about fetus.(1,3,4,10-12)
Main causes of psychosocial problems observed in pregnant women with risk include separation from family due to hospitalization, being uncomfortable with hospital atmosphere and other patients, and economic concerns. Any increase in the degree and duration of bed rest would increase the level of problems experienced.(1,3,4,10,16)
Information about the type and duration of bed rest recommended for high-risk pregnancies is unclear.(1,16) A national study carried out in the U.S. by Maloni et al. showed that types and duration of bed rest advised by obstetricians in risky conditions vary greatly.(7)
There are three types of bed rest: Type 1: Light bed rest (light housework, part-time working, short-distance walking, two-hours resting within day), Type 2: Moderate bed rest (leaving job, need for assistance for housework, restricted exercise including walking, resting at most part of the day), Type 3: Complete bed rest (staying at bed all day long, eating at bed, only bathroom privileges). Types of bed rest ordered in Turkish hospitals are Type 2 (also known as partial bed rest) and Type 3 (also known as strict bed rest).1,3 Bed rests recommended by Sachar et. al. for high-risk pregnancies are also classified as “Light”, “Moderate” and “Heavy”. In this study, the investigators scored the activities during the rest and identified the bed rest range for a high-risk pregnant woman.(17)
In any woman who has a pregnancy-related risk, her own health and child’s health are under threat. As already demonstrated by many studies, the psychosocial status of physically high-risk pregnant women is also at risk, and increased anxiety causes development of various complications related with pregnancy and labor (pregnancy related vomitting, pregnancy toxemia, recurrent miscarriage, dystocia, preterm labor etc.).(2,4,513,14)
Nurses taking care of high-risk pregnants at bed rest should be acknowledged about the physical and psychological problems that women can experience related with the bed rest at pregnancy and apply nursing practices that will prevent or at least minimize such problems. Based on this, we planned to identify and define the physiologic and physical problems that high-risk pregnant women at partial bed rest may experience.

Methods

The field of our study included high-risk pregnant women hospitalized at the Department of Obstetrics and Gynecology of a Social Insurance Institution (SII) hospital in İstanbul between December 2003 and April 2004, and our sampling consisted of 52 pregnant women with high-risk who had completed their 16 weeks’ gestation, and hospitalized for partial bed rest at least for a period of five days and accepted to participate in the study. The clinic, location of the study, admits mean 15-20 high-risk pregnancies per month. We’ve reached to all of the pregnant women who had been admitted to the clinic during our study period and who were complying with our criteria.
For data collection, “Patient Information Form”, “Antepartum Symptom Control List” and “Antepartum Hospital Stressors Inventory (AHSI)” were used. Patient Information Form consists of 16 questions to collect data about the demographic, obstetric and gynecologic status of the pregnant women. Antepartum Symptom Control List is a Likert-type form (grading scale), comprising 46 items used for identifying the physical and psychological symptoms of pregnants at bed rest, which was developed by Maloni in 1993. The Cronbach’s alpha coefficient was a0.79 (35 cases) in the Maloni study; it was found 0.94 (60 cases) in the study by Oskay who translated the form into Turkish and realized its validitation; and it was found 0.88 (52 cases) in our study. Antepartum Hospital Stressors Inventory is also a Likert-type scale (grading scale), which was first developed by White &Richie in 1981, and then improved by Maloni in order to evaluate the sources of stress for hospitalized high-risk pregnant women. The stressors were gathered in 7 sub-groups in the scale such as “Separation", "Environment", “Health status", "Communicaton with Health Providers", "Self-image", "Emotional status" and "Family Status". The stress resulting from those stressors were classified as "No stress=0", "Slightly stressed =1", "Stressed =2", "Very stressed=3" and "Extremely stressed=4" depending on their severity. If the stressor is not related, the patient selects “Not applicable for me”. The Cronbach’s coefficient was found at an interval of 0.61 – 0.93 by White &Richie, of _0.63 –0.93 by Maloni et. al., and of 0.65- 0.83 by Oskay who translated the scale into Turkish and performed its validation. The alpha range was found between 0.62 to 0.87 in our study. For the assessment of data, Cronbach alpha coefficient calculation, calculations of percentage (%), mean (x), standard deviation (±SD) and correlation were used.

Results

An analysis of demographic and obstetric characteristics of the pregnant women hospitalized due to partial bed rest showed that 30.79% were aged between 19 and 23 years; 92.30% were not working; 69.24% were graduated from elementary school; 71.6% were willingly conceived; and 71.15% had no other child yet (Table 1).
It was shown that during the hospitalization period, the pregnant women received best support from their husbands (80.76%), they mostly communicated with their roommates (86.53%), and they mostly chatted with their roommates during their leisure time (92.30%) (Table 2).
At the end of the study, it was found out that 53.84% of pregnant women would have preferred to take their bed rest at home (Table 3).
The most commonly experienced psycological findings associated with hospitalization for pregnant women were mild attitude change (38.46%), moderate tension-nervousness (46.15%), severe boredom (23.08%), moderate nightmare (%28.84) and moderate emotionality (23.08%) (Table 4).
And the most commonly experienced physical findings associated with hospitalization for pregnant women were severe reflux (38.46%), mild pubic pain (48.08%), moderate back pain (38.46%), mild leg pain (44.23%), moderate dry lips (38.46%), mild skin tenderness (46.15%), mild pelvic/pubic pain/ache (53.85%), mild cramp at legs (46.15%), moderate headache (46.15%), moderate sleeplessness after waking up (38.46%), mild involuntary drowsiness at day time (55.76%) and mild dizziness (59.61%) (Table 5).
According to the Antepartum Hospital Stressors Inventory, the most common stressors for pregnant women were as follows: “anxious about the baby’s well-being” (3.61 points over 4), “anxious about hospitalization period” (3.30 points), “separation from my family” (3.27 points), “concerns about the care of children at home” (3.25 points), “lack of information about my status” (3.18 points), “concerns about labor” (3.16 points), “feeling sad” (3.06 points) and “feeling bored” (3.03 points) (Table 6).
It was also found out that as age advanced and parity increased, concentration was reduced in the high-risk pregnant women participated in our study; again, tension-nervousness was increased as age advanced; women who willingly conceived were more tense, more emitonal and had nightmares compared to those who were unwillingly conceived; and tension and emotionality were increased as the number of living children increased (Table 7).
It was also found out that findings for tension-nervousness and being more emotional of “Separation” sub-group in the Antepartum Hospital Stressors Inventory scale, findings for sensorial changes and having nightmares of “Environment” subgroup, findings for tension-nervousness of “Health” subgroup, findings for boredom of “Communication with Health Providers” subgroup and “Self-image” subgroup, findings for attitude change and being more emotional of “Emotional status” subgroup and findings for tension-nervousness of “Family status” subgroup were all related. Significant relations were found between the physical findings and psychological findings experienced by the high-risk pregnant women participated in our study. Reflux was significantly related with tension and boredom; nausea with lack of concentration; pubic pain with tension and being more emotional; pelvic pain/ache with being more emotional; earache, headache and sight problems with lack of cencentration; sleeplessness after waking up with attitude change and having nightmares; waking up unrefreshed and dizziness with tension; drowsiness at daytime with tension; tiredness with lack of concentration and sensorial changes, and finally stuffiness with tension (Table 9).

Discussion

Major part of our demographic data is parallel to the demographic data of the study carried out by Oskay1 on 60 pregnant women at partial and complete bed rest. According to our data, the pregnant women were mostly supported by their partners (80.76%) and parents (65.38%) during the hospitalization period. Similarly, in the study by Oskay 1 most of the support was provided by partners (91.7%), close relatives (61.7%) and parents (55.0%). The results of an interview carried out by Gupton, Heaman and Aschroft 11 ’with 24 high-risk pregnant women at bed rest showed that parents and friends are most common support providers. In a study by Maloni, Brezinski-Tomasi and Johnson12 on 89 high-risk hospitalized pregnant women, the pregnant women and their partners were evaluated together, and it was found out that most common sources of support were parents and close relatives. In a study carried out by Schroeder15 on 12 high-risk pregnant women, it was also shown that pregnant women are mostly supported by their parents and close relatives during the hospitalization period. Our data is also in compliance with the literature.
Our participants mostly communicated with their roommates during the hospitalization period (86.53%). It was also reported by Oskay 1 that pregnant women communicated with their roommates at most (83.3%). Our participants spent most of their leisure time by chatting (92.3%); rate for reading was very low (15.38%). It is also the case in the Oskay1 study that pregnant women spent most of their time by chatting (85%), but rate for reading was pretty high (75.0%). Lower reading rates in our study may result from the fact that majority of our participants were graduated from elementary school.
Of all pregnant women participated in our study, 53.84% indicated that they would have preferred to take bed rest at home whereas in the Oskay study1, 53.3% of pregnant women expressed that they would prefer to stay at hospital for bed rest. In our study, the pregnant women, who indicated that they would have preferred to take bed rest at home, explained that they would prefer it in order to be able take care of their children, take a bath and not to feel bored and irritated.
Presence and severity of bed-rest-associated physical (reflux, pelvi/back/leg pain, dry lip, skin tenderness, headache, stuffiness, sleep disorders, etc.) and psychological (attitude change, tension-nervousness, boredom, etc.) symptoms in the pregnant women participated in our study are parallel with the study carried out by Oskay and Şahin3. Nine out of 10 high-risk pregnant women participated in this study indicated that they mostly experienced “boredom” among psychological symptoms, and eight out of 10 pregnant women indicated that they mostly experienced “sleep disorder” among all physical symptoms. McGain and Deatrick10 studying the hospitalization-associated- psychological problems experienced by 21 high-risk pregnant women showed that the pregnant women remarkably experienced “anxiety”, “attitude change” and “boredom”. Psychological problems identified by Gupton, Heaman and Aschroft11 in risky pregnancies are as follows: Boredom, sense of loss of control and being a prisoner, uncertainity, being tired of waiting and concerns regarding fetus’s well being. In Schroeder’s15 study, it was reported that pregnant women who were at bed rest in the hospital underwent serious physical and psychological changes. The results of our study are supportive to the literature in that respect.
The most common stressors for the high-risk pregnant women participated in our study were “anxious about my baby’s well-being", "concerns about hospitalization period", "Being away from my family", "Concerns about the care of children at home", "Lack of information about my status", "Concern about labor" and "Feeling sad". Findings of “Being away from my family”, “Lack of information about my status” and “Feeling sad” were similar to the study carried out by Oskay.1 The hospital stressors identified by Gupton, Heaman and Aschroft11 in high-risk pregnant women were "Feeling irritated", "Anxious about my baby’s well-being", "Concerns about care of children at home" and "Being away from my family". The results of a study by Heaman and Gupton13 on 24 hospitalized risk pregnancies have shown that the most important stressors were "Being away from by family", "Lack of privacy" and "Uncomfortable hospital conditions". The major stressor identified by Martin-Arafeh et al.14 and Maloni16 is also "Being away from my family". Our results are in parallel to the literature.
Depending on our data, as age advanced, difficulty in concentrating and tension-nervousness increased in the pregnant women at bed rest (p<0.05). There was a significant relation between planned pregnancies and tension-nervousness (p<0.05). Again, a significant relation was found between planned pregnancies and nightmares (p<0.01) and being more emotional (p<0.0001). As parity increased, concentration problems increased (p<0.05). As number of living children increased, tension-nervousness and being more emotinal became more intense (p<0.05). Those results were supported by the fact that pregnant women with one or more children preferred to take bed rest at home rather than at hospital. Pregnant women with children are concerned about their children at home as well as the risks of their current pregnancy and they experience psychological problems.
We have found a significant relation between the stressors and the psychological symptoms the pregnant women experienced. The most strong relationships were found  between the stress caused by leaving home and being more emotional (p<0.001), and stress caused by health status and tension-nervousness (p<0.001). Emergence of psychological problems due to being away from home and fetus’s health being under threat during pregnancy is a comprehensible situation.
From physical symptoms experienced by pregnant women, nausea was very significantly related with concentration problem (p<0.001). Pelvic pain and tension-nervousness were significantly related (p<0.01). Such physical and psychological problems are considered to be associated with pregnant woman’s fear of fetus loss. We have found that psychological problems experienced by high-risk pregnant women participated in our study were related with age, obstetric characteristics and physical problems experienced. Pregnant women experience some physical and psychological problems due to the bed rest at hospital, and physical problems are significantly related with psychological problems. Age and obstetric histories of the pregnant women have an impact on the structure and level of the psychological problems. Studies have shown that efficient nursing care significantly reduced the physical problems of high-risk pregnant women at bed rest. Oskay1 emphasized that professional support is required to eliminate the psychological problems. However, our data showed that there was a significant relation between physical problems and psychological problems, which amplifies the significance of nursing care that would be given for elimination of physical problems.

Conclusion

In our study aiming to identify the bed rest associated physical and psychological problems of the high-risk pregnant women at partial bed rest, it has been found out that physical symptoms of the pregnant women were at mild and moderate levels, and they mostly experienced reflux, pelvic/back/leg pains, headache, dry lip and sleep disorders.   Psychological problems were usually at moderate levels, and they mostly experienced boredom, tension-nervousness, nightmares and being more emotional. The most common stressors of pregnancy were "Anxious about my baby’s well-being", "Concerns about hospitalization period" and "Being away from my family". It was also shown that psychological symptoms are related with age, obstetric characteristics and physical symptoms.
All nurses working at perinatology services should be informed about the bed rest associated physical and psychological problems that we identified and they should be alarmed about the precursor indications. It is very important to support their knowledge about risky pregnancies and side effects of the bed rest by continous training programmes. Evidence-based information and practices are changing and developing day by day. Nursing approaches including various options are needed.
Monitoring high-risk pregnant women at home is vital in achieving healthy pregnancy outcomes as major part of bed rests is also held at home. Efficiency of perinatology nurses at home-care functions, and giving training and consultation to the pregnant women would be of great help. Based on this, preparation of monitoring procedures about pregnancy home care, instructing the pregnant and her family, organizing programmes addressing the patient follow-up methods by phone, and early planning and application of measures to be taken have become essential for executing a contemporary nursing care to provide the pregnant women, who takes bed rest at home, with a safe delivery and a healthy neonate. 
 

References

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3. Oskay ÜY, Şahin NH. Hastanede yatak istirahatindeki yüksek riskli gebelerde ortaya çıkan stresörler. Hemşirelik Forumu Dergisi 2003; 6: 33-9.
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	File/Dsecription
	Table 1. Demographic and obstetric characteristics of the participants.
	Table 2. Features related with bed rest of participants.
	Table 3. Distribution of the responses to the question “Would you prefer taking bed rest at home?”
	Table 4. Distribution of bed rest associated psychological symptoms experienced by pregnant women.
	Table 5. Distribution of bed rest associated physical symptoms experienced by pregnant women.
	Table 5. (continued) Distribution of bed rest associated physical symptoms experienced by pregnant women.
	Tablae 6. Distribution of stress scores for pregnant women at bed rest.
	Table 6 (continued) Distribution of stress scores for pregnant women at bed rest.
	Table 7. Correlation between the age and obstetric characteristics of pregnant women and the psychological smptoms experienced.
	Table 8 Correlation between the mean stress scores of pregnant women and the psychological symptoms experienced.
	Table 9. Correlation between the physical and psychological symptoms of pregnant women.