Open Journal of Obstetrics and Gynecology, 2012, 2, 250-254 OJOG
http://dx.doi.org/10.4236/ojog.2012.23052 Published Online September 2012 (http://www.SciRP.org/journal/ojog/)
Feasibility of i nc or po ra ti ng a bed-rest exercise program
during a twin pregnancy: Case reports*
Chantale R. Brun1#, Jo-Anne Hammond2,3,4, Michelle F. Mottola2,5,6
1School of Kinesiology and Recreation, Université de Moncton, Moncton, Canada
2Samuel McLaughlin Foundation—Exercise & Pregn ancy Laborator y, London, Canada
3Department of Family Medicine, Schulich School of Medicine & Dentistry, University of West ern Ontario, London, Canada
4St. Joseph’s Health Care, London, Canada
5School of Kinesiology, Faculty of Health Sciences, University of Western Ontario, London, Canada
6Department of A natomy & Cell Biology, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Canada
Received 7 May 2012; revised 10 June 2012; accepted 22 June 2012
Considering the maternal risk for both short- and
long-term disability imposed by activity restriction, it
is of great concern that the antepartum symptoms of
bed rest are still evident in the postpartum period.
The benefits of bed-rest-exercise may alleviate or
even prevent physiological distresses or decondition-
ing associated with activity restriction, thus, elimi-
nating or stabilizing, factors that may augment exist-
ing complications. This is the first study to investigate
the feasibility of incorporating a bed-rest exercise
program in a specific hospitalized twin pregnancy
case. The maternal physiological responses of heart
rate, blood pressure and uterine contractions to a
four week bed-rest resistance program were meas-
ured in a woman hospitalized due to complications
during her twin pregnancy. A second participant
(same diagnoses) was included as a control. The bed-
rest-exercise reduced the degree of swelling in the
lower extremities, promoted more energy during the
day and a better night’s sleep. There were no signifi-
cant differences in uterine contractions pre vs post
protocol and all babies were born healthy.
Keywords: Exercise; Bed Rest; Pregnancy; Antepartum;
Muscle Conditioning ; Training
Bed-rest has been extensively researched, in the non-
pregnant population, especially by the National Aeronau-
tics and Space Administration (NASA) and other aero-
space scientists who are interested in the effects of mi-
crogravity on human physiology. Bed rest is also one of
the oldest treatments in health care and therefore not an
uncommon treatment for patients with chronic disease or
injury as well as to treat women with complications of
Prolonged bed-rest has been associated with decreases
in cardiovascular and muscular performance with re-
duced physical work capacity [1-7]. An active individual
who is suddenly restricted from daily activities may,
therefore, experience several physiological side-effects
related to bed-rest (or activity restriction). Patients with
chronic disease or injury are prescribed bed-rest rou-
tinely to improve the disease state or to help with the
healing process. Thus, the side effects of activity restric-
tion should be distinguished from the disease process for
which the individual was bed-rested and the resulting
side effects of activity restriction.
Despite non-existent scientific evidence to show effi-
cacy, bed-rest is also prescribed as the primary mode of
care for high-risk pregnant women [8,9]. Limited re-
search evidence would suggest that pregnant women are
also affected by the physiological effects of activity re-
striction. Important antepartum side effects range from
loss of muscle strength and muscle atrophy, weight loss,
dizziness, headaches and indigestion to possible life-
thr eatening thromboembolic events [10-15]. Bed rest may
therefore be responsible for complicating the antepartum
period, regardless of the disease process for which bed
rest was originally prescribed.
When considering th e maternal risk for both shor t- and
long-term disability imposed by bed rest as well as the
lack of attention given to recovery (or rehabilitation), it
is concerning that the antepartum symptoms of bed rest
are still evident in the postpartum period. For instance,
during the first week postpartum, women on complete
and partial bed-rest complained of muscle soreness to the
lower back, upper and lower leg, arms and heels [11,12].
They also reported mobility problems such as difficulty
*Supported by Child He a l th Research Institute, London, C anada.
C. R. Brun et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 250-254 251
with descending and ascending stairs, knees buckling,
needing support to walk or sit . Symptoms such as
fatigue, headache, mood changes, tenseness, difficulty
concentrating, back muscle soreness, and dry skin were
still present at six weeks postpartum . The presence
of such symptoms is proof for the physio logical decondi-
tioning caused by the antenatal bed rest prescription as
well as for the prolonged recovery in the postpartum pe-
riod. Yet they seem to go unnoticed . Interven tions should
exist at both levels (antepartum and postpartum) espe-
cially when healthy postpartum women show a high
prevalence of morbidity [17-19]. Recovery symptoms
such as exhaustion/extreme tiredness and backache are
still apparent six months after childbirth (81% of women
reported health problems) . Bed rest may therefore
be responsible for not only complicating the antepartum
period but also the postpartum period, regardless of the
disease process for which bed rest was originally pre-
scribed, and the quality of life of both mother and family.
The benefits of bed-rest-exercise may alleviate or even
prevent physiological distresses or deconditioning asso-
ciated with activity restriction, thus, eliminating or stabi-
lizing, factors that may augment existing complications.
One must consider the benefits of exercise, the benefits
of exercise during pregnancy, the possible detrimental
effects of activity restriction, and the feasibility of exer-
cising in a hospital setting before incorporating a bed-
rest-exercise intervention program for activity restricted
antenatal women. The benefits of incorporating a bed-
rest-exercise program have yet to be fully investigated in
the antepartum hospitalized population, but are well do-
cumented in the non pregnant population [20-24]. The
first study was condu cted in 1992, by Mayberry and col-
leges, in order to assess the short-term effects of con-
trolled bed-rested exercise on uterine activity of women
diagnosed with preterm labour . Preliminary findings
suggested that women diagnosed with preterm labour
may be able to participate safely in an exercise program
with minimal risk for in creased uterine activ ity after bed-
rest exercise. Twenty years after this first study, our lab
has investigated the effects of a bed-rest-exercise session
on hospitalized antenatal women. Results showed that
women respond well to one bout of a bed-rest session of
resistance training when examining heart rate, blood
pressure and uterine contractions . In the current
study, the primary objective was to implement and
monitor a four week bed-rest resistance training program
(while listening to music) in a patient ho spitalized due to
complications during her twin pregnancy. A second pa-
tient (twin pregnancy) was also included in the study as a
control. She listened to same music but did not exercise.
To our knowledge this is the first pilot study investigat-
ing the effects of a bed-rest-exercise program in specific
hospitalized twin preg nancy cases.
2. CASE REPORTS
Two hospitalised pregnant women, age and diagnosis-
matched, were randomly recruited from a larger study
investigating the effects of acute bed-rest-exercise .
Both women had twin pregnancies, were non-smokers
and bed-rested for at least 6 weeks. Study participants
gave written informed consent, as approved by the hu-
man research board for Health Sciences at The Univer-
sity of Western Ontario. Both participants also received
medical clearance from their health care provider in or-
der to participate in the study. They were then inter-
viewed for previou s h istory of activity (prior to bed rest),
amount of current activity restriction, medications, age,
lifestyle status (e.g., smoking), and gestational age.
Characteristics of the two particip ants are presented in
Table 1. Both were sedentary prior to bed-rest, with
similar biological and gestational ages and the amount of
time they were bed-rested prior to the study.
2.1. Case 1
The first case (experimental) consisted of an antepartum
woman thirty years of age, hospitalized at 27 weeks ges-
tational age (GA), due to a shortened cervix during her
twin pregnancy. Her bed-rest prescription was to remain
in the hospital bed at all times with the exception of
bathroom privileges. Other than work around the house,
she was not physically active. This was her third preg-
nancy, with two childr en (2 and 4 years of ag e) at home.
Height and weight were 1.6 m and 109.2 kg, respec-
The bed-rest resistance program was implemented at
33 weeks gestational age, 2 - 3 sessions a week for four
weeks. The protocol has been described previously .
Exercise sessions in weeks 2 and 3 were cancelled due to
unexpected visitors coming in or simply feeling too tired
on that particular day. She was induced at the end of
Table 1. Characterist ic s of the two study subjects.
Maternal Age (y ears) Gestational Age ( wks) Bed-Rest (wks) Physical Activity (befo re bed-rest)
Case 1 30 33 6 House work no structured exercise
Case 2 34 28 8 Walking not on regular basis
ase 1: bed-rest-exe r cise (with music) program; Case 2: bed-rest-control ( music o nl y).
Copyright © 2012 SciRes. OPEN ACCESS
C. R. Brun et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 250-254
week 4 of the program and therefore only one exercise
session was conducted during this particular week. Both
babies were born healthy (B aby A: 2765 g, APGAR 10 at
5 minutes; Baby B: 3265 g, APGAR 10 at 5 minutes).
All exercise sessions were instructed and monitored as
well as conducted at about the same time everyday (be-
tween 8:00 am and 9:45 am). The bed-rest muscle condi-
tioning program consisted of upper and lower body exer-
cises (biceps, triceps, rhomboids, calf and quadriceps
muscle groups) using a dynaband (red resistance for up-
per body; green resistance for calf muscles). Quadriceps
exercises were conducted without the dynaband. Since
this type of exercise was completely new to the partici-
pant, fewer exercises were performed in the 30 minute
sessions. The first week was therefore comprised of only
upper body exercises and then gradually with time the
lower body e xercises were in t ro duc ed.
Both HR and BP were somewhat high and inconsistent
at rest (HR: ranges from 93 to 110 bpm; BP: ranges from
138/72 to 124/80 mmHg). HR during exercise ranged
from 120 - 134 beats per minut e, and by T = 50 heart rate
was lowered slightly but still higher than resting HR. In
general, at twenty minutes post-exercise (T = 70 min),
BP and HR returned to resting values. In a few instances
BP was lower 20 minutes post-exercise (130/80 vs 122/
80; 138/72 vs 130/72; 130/84 vs 124/80). There was only
one uterine contraction monitored post bed-rest-exercise.
She reported having felt a uterine contraction the day
before starting the bed-rest-exercise program. No other
uterine contractions were measured or reported before or
after the bed-rest-exercise sessions for the remainder of
After only one week on the exercise program, she re-
ported having more energy during the day and sleeping
better at night. She also noticed that the swelling in the
lower extremities had diminished. The participant did
keep a journal of her daily activities. Her daily activity
ranged from sitting in bed, walking to the bathroom, do-
ing her laundry and going down to the cafeteria (most
times using a wheelchair).
2.2. Case Report 2
The second antepartum woman received no intervention
and therefore acted as the control case. She was 34 years
of age and was hospitalized due to a shortened cervix at
20 weeks GA during her twin pregnancy. This was her
first pregnancy. Her bed-rest prescription was to stay in
bed with bathroom privileges. She did engage in some
exercise (mild walking) during her leisure time before
and during her first trimester of pregnancy, but not al-
ways on a regular basis (approximately 2x/week for 30
minutes). C-1 was 1.63 m in height and weighed 64 kg at
The bed-rest control intervention was implemented at
28 weeks GA, three sessions a week for four weeks. Her
4 weeks data set is complete. She was able to particip ate
in the study until delivery therefore her total time on the
program was 6 weeks. However, for the purpose of this
paper only the first 4 weeks have been reported. She
went into labour at 33 weeks GA, had a vaginal delivery
and two healthy babies (Baby A: 189 0 g, APGAR 9 at 5
minutes; Baby B: 1825 g, APGAR 9 at 5 minutes).
She listened to music for 30 minutes instead of con-
ducting bed-rest-exercise. All sessions were supervised
and monitored in the same manner as the bed-rest-exer-
cise and conducted at about the same time of day (be-
tween 9:00 am and 9:45 am). The complete protocol has
been described previously . During most music ses-
sions, she would fall asleep and had to be awakened in
order to conduct post-intervention measures. She re-
ported feeling relaxed at the end of each session. Two
weeks into the program, she started to complain of
swelling in her lower extremities, feeling very tired all
the time, difficulty sleeping, no appetite and shortn ess of
breath on exertion.
Resting maternal HR, BP and UC (pre-intervention)
were monitored and recorded. All recorded parameters
did not change dramatically from resting values during
and after listening to music. In some instances HR was
reduced slightly during or after the intervention (123 vs
111 bpm; 110 vs 108 bpm; 118 vs 109 bpm; 117 vs 104
bpm; respectively). However, by week 4, resting HR
increased to 122 bpm from study entry (115 bpm). Blood
pressure was also a little higher at week 4 than at week 1
(108/62 vs 118/72 mmHg; respectively). There were no
uterine contraction s pre vs. post intervention.
She also kept a journal of her daily activities. Her
daily activities ranged from reading, playing cards,
weekly trips in wheelchair for ultrasounds, to occasional
2 minute walks to the kitchenette. She was very dedi-
cated to following he r bed-rest prescripti o n.
Having conducted an acute bed-rest-exercise study pre-
viously in our lab , the primary goal of this study
was to determine the feasibility and the implications of
implementing a bed-rest-exercise program over several
weeks in a woman hospitaliz ed with a twin pregnancy. A
bed-rest-exercise program was therefore applied to one
patient on the antepartum hospital ward. Her results were
then compared to a control wo man with a similar activit y
history, gestational age and pregnancy. The key findings
were no change in maternal BP or in the number of UC
with the exercise intervention compared to the control
case. These are case reports and their findings unfortu-
nately cannot be generalized, however, they warrant
Copyright © 2012 SciRes. OPEN ACCESS
C. R. Brun et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 250-254 253
analysis and discussion.
Treatment with activity restriction is based on the as-
sumption that it is effective in preventing adverse preg-
nancy outcomes and that it is safe for both the woman
and her fetus . The physiological side-effects of bed-
rest on hospitalized antenatal women have been docu-
mented and have shown to be similar than those found
for the non-pregnant population [11-14,28]. According to
Bloomfield , the most important practical implications
when working with bed-rested individuals, should be
avoidance of prolonged immobility. When non-pregnant
subjects were given an exercise bed-rest intervention
program, they maintained heart and lung capacity as well
as muscular integrity . Therefore, if antena tal bed-rest
complicates the postpartum period, bed-rest-exercise
may help to alleviate or even prevent physiological dis-
tresses associated with activity restriction.
Both women were sedentary prior to and during their
pregnancy and were both prescribed bed-rest with bath-
room privileges. However, the women seemed to be a bit
more active than what was prescribed. Case 1 made fre-
quent visits in the hallway, laundry, cafeteria, and gift
shop, sometimes in a wheel chair, sometimes not. When
in bed these women were usually in a semi-recumbent
position, however, sometimes they would simply sit up
in bed or sit in a rocking chair. It would seem that acti-
vity is restricted but, they are not lying down in bed all
day. Activity restriction may therefore better define the
situation of these women than bed-rest.
Both women had uncomplicated vaginal deliveries
with healthy babies. Case 1 was actually induced at 37
week and Case 2 (control) went into labor at 33 weeks
GA. As shown by Maloni and colleagues, pregnancy
outcomes differ depending on the degree of activity re-
striction . For instance, women on complete bed rest
had different pregnancy outcomes than those on partial
bed rest. Thus, the occurrence of vaginal delivery of
women on complete bed rest was lower than women on
partial bed rest and with no bed rest and furthermore
65% of newborns were born prior to term  .
Despite feeling more relaxed after the music interven-
tion, Case 2 complained of swelling in the ankles and
feet and also reported feeling tired, difficulty sleeping, no
appetite and shortness of breath on exertion. Symptoms
that are similar to th ose previously reported in the litera-
ture [11,12]. On the other hand, Case 1 reported less
swelling in the lower extremities, more energy during the
day and a better night’s sleep. In addition, there were no
significant changes in the frequency of uterine contrac-
tions due to exercise, which has also been reported pre-
viously [25,26]. Thus, a bed-rest-exercise program may
be able to alleviate some of the side-effects of prolonged
activity restriction in antenatal women with minimal risk.
Since the goal of the study was to determine feasibility
of the bed-rest-exercise program, physiological measures
such as weight, muscle atrophy or bone status were not
measured but should be considered in future studies in
order to better evaluate the side-effects of activity re-
striction and the possible counter effects of a bed-rest-
The clinical setting can be a challenging area for this
type of res earch . Res earch ers ha ve to be prep ared for la st
minute cancellations due to routine hospital care, un-
expected visitors, or simply that patients are tired or
simply preoccup ied with other and certainly more impor-
tant things on occasional days. Patients can also be
released from hospital at any time depending on their
condition and gestational age. Considering the impor-
tance of exercise in eliciting physiological responses, the
effects of bed-rest-exercise needs further investigation.
Pending these results, the chronic effects of a bed-rest-
exercise program over long term to minimize physio-
logical and psychosocial side-effects of prolonged bed-
rest in this population must also be assessed in larger
randomized controlled studies.
 Bloomfield, S.A. (1997) Changes in musculoskeletal
structure and function with prolonged bed rest. Medicine
& Science in Sports & Exercise, 29, 197-206.
 Convertino, V. and Hoffler, G.W. (1992) Cardiovascular
physiology. Effects of microgravity. Journal of Florida
Medical Associa tion, 79, 517-524.
 Convertino, V.A. (1992) Effects of exercise and inactivity
on intravascular volume and cardiovascular control me-
chanisms. Acta Ast ronau tica, 27, 123-129.
 Convertino, V.A. (1997) Cardiovascular consequences of
bed rest: Effect on maximal oxygen uptake. Medicine &
Science in Sports & Exercise, 29, 191-196.
 Kasper, C.E, Talbot, L.A. and Gaines, J.M. (2002) Ske-
letal muscle damage and recovery. Advanced Practice in
Acute & Critical Care, 13, 237-247.
 Levine, B.D., Zuckerman, J.H. and Pawelczyk, J.A.
(1997) Cardiac atrophy after bed-rest deconditioning: A
nonneural mechanism for orthostatic intolerance. Circula-
tion, 96, 517-525. doi:10.1161/01.CIR.96.2.517
 Vernikos, J., Ludwig, D.A., Ertl, A.C., Wade, C.E., Keil,
L. and O’Hara, D. (1996) Effect of standing or walking
on physiological changes induced by head down bed rest:
Implications for spaceflight. Aviation, Space, and Envi-
ronmental Medicine, 67, 1069-1079.
 Josten, L.E., Savik, K., Mullett, S.E., Campbell, R. and
Vincent, P. (1995) Bedrest compliance for women with
pregnancy problems. Birth, 22, 1-12.
 Saunders, M.C., Dick, J.S., Brown, I.M., McPherson, K.
Copyright © 2012 SciRes. OPEN ACCESS
C. R. Brun et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 250-254
Copyright © 2012 SciRes.
and Chalmers, I. (1985) The effects of hospital admission
for bed rest on the duration of twin pregnancy: A ran-
domised trial. Lancet, 2, 793-795.
 Kovacevich, G.J., Gaich, S.A., Lavin, J.P., Hopkins, M.P.,
Crane, S.S., Stewart, J., et al. (2000) 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. Ame-
rican Journal of Obstetrics & Gynecology, 182, 1089-
 Maloni, J.A., Chance, B., Zhang, C., Cohen, A.W., Betts,
D. and Gange, S.J. (1993) Physical and psychosocial side
effects of antepartum hospital bed rest. Nursing Research,
 Maloni, J.A. and Schneider, B.S. (2002) Inactivity:
Symptoms associated with gastrocnemius muscle disuse
during pregnancy. Advanced Practice in Acute & Critical
Care, 13, 248-262.
 Maloni, J.A., Alexander, G.R., Schluchter, M.D., Shah,
D.M. and Park, S. (2004) Antepartum bed rest: Maternal
weight change and infant birth weight. Biological Re-
search for Nursing, 5, 177-186.
 Maloni, J.A., Margevicius, S.P. and Damato, E.G. (2006)
Multiple gestation: Side effects of antepartum bed rest.
Biological Research for Nursing, 8, 115-128.
 Maloni, J.A. (2010) Antepartum bed rest for pregnancy
complications: Efficacy and safety for preventing preterm
birth. Biological Research for Nursing, 12, 106-124.
 Maloni, J.A. and Park, S. (2005) Postpartum symptoms
after antepartum bed rest. Journal of Obstetric, Gynecolo-
gic & Neonatal Nursing, 34, 163-171.
 Glazener, C.M., Abdalla, M., Stroud, P., Naji, S., Tem-
pleton, A. and Russell, I.T. (1995) Postnatal maternal
mo rbidity: Extent, causes, prevention and treatmen t . BJOG:
An International Journal of Obstetrics & Gynaecology,
102, 282-287. d oi: 10. 1111/j .14 71- 0528.1995.tb09132.x
 Thompson, J.F., Roberts, C.L., Currie, M. and Ellwood,
D.A. (2002) Prevalence and persistence of health pro-
blems after childbirth: Associations with parity and me-
thod of birth. Birth, 29, 83-94.
 Lenz, E.R., Pugh, L.C., Milligan, R.A., Gift, A. and
Suppe, F. (1997) The middle-range theory of unpleasant
symptoms: An update. ANS Advances in Nursing Science,
 Convertino, V.A., Bloomfield, S.A. and Greenleaf, J.E.
(1997) An overview of the issues: physiological effects of
bed rest and restricted physical activity. Medicine &
Science in Sports & Exercise, 29, 187-190.
 Greenleaf, J.E. (1997) Intensive exercise training during
bed rest attenuates deconditioning. Medicin e & Science in
Sports & Exercise, 29, 207-215.
 Ellis, S., Kirby, L.C. and Greenleaf, J.E. (1993) Lower
extremity muscle thickness during 30-day 6 degrees head-
down bed rest with isotonic and isokinetic exerci se trainin g.
Aviation, Space, and Environtal Medicine, 64, 1011-1015.
 Akima, H., Kubo, K., Imai, M., Kanehisa, H., Suzuki, Y.,
Gunji, A., et al. (2001) Inactivity and muscle: Effect of
resistance training during bed rest on muscle size in the
lower limb. Acta Physiologica Scandinavica, 172, 269-
 Kawakami, Y., Akima, H., Kubo, K., Muraoka, Y.,
Hasegawa, H., Kouzaki, M., et al. (2001) Changes in
muscle size, architecture, and neural activation after 20
days of bed rest with and without resistance exercise.
European Journal of Applied Physiology, 84, 7-12.
 Mayberry, L.J., Smith, M. and Gill, P. (1992) Effect of
exercise on uterine activity in the patient in preterm labor.
Journal of Perinatology, 12, 354-358.
 Brun, C.R., Shoemaker, J.K., Bocking, A., Hammond,
J.A., Poole, M. and Mottola, M.F. (2011) Bed-rest exer-
cise, activity restriction, and high-risk pregnancies: A
feasibility study. Applied Physiology, Nutrition, and Me-
tabolism, 36, 577-582. doi:10.1139/h11-036
 Maloni, J.A., Cohen, A.W. and Kane, J.H. (1998) Pre-
scription of activity restriction to treat high-risk preg-
nancies. Journal of Women’s Health, 7, 351-358.
 Maloni, J.A., Kane, J.H., Suen, L.J. and Wang, K.K.
(2002) Dysphoria among high-risk pregnant hospitalized
women on bed rest: A longitudinal study. Nursing Re-
search, 51, 92-99.
 Maloni, J.A. (1993) Bed rest during pregnancy: Implica-
tions for nursing. Journal of Obstetric, Gynecology, Neo-
natal Nursing, 22, 422-426.
d oi: 10. 1111/j .15 52- 6909.1993.tb01825.x