Relaxation during pregnancy: what are the benefits for mother, fetus, and the newborn? A systematic review of the literature.

Previous studies have reported associations between maternal stress during pregnancy and obstetric outcomes as well as fetal development and neonatal adaptation. These findings highlight the importance of identifying pregnant women who experience severe stress and the need for interventions that commence early in pregnancy. The aim of this study was to review studies that investigated the effects of relaxation techniques during pregnancy, including maternal, fetal, and neonatal outcomes. In addition, studies examining maternal endocrine and physiological alterations were reviewed. PubMed was searched using the following key words: maternal well-being, maternal stress, relaxation techniques, pregnancy, fetal neurobehavior, fetal heart rate, neonatal adaptation, and neonatal behavior. (1) Relaxation had a positive impact on women's emotional state. (2) Pregnancy outcomes improved with fewer admissions to the hospital, fewer obstetric complications, longer gestation, reduction of caesarean sections, and fewer postpartum complications. (3) Fetal heart rate and fetal motor activity were reduced as a result of relaxation and therefore interpreted as improved result. (4) Higher-birth-weight and improved performance on the Neonatal Behavioral Assessment Scale was related to relaxation. (5) Relaxation training was associated with reductions in maternal physiological and endocrine measures. Relaxation during pregnancy is associated with salutogenic effects that include regulation of emotional states and physiology. Relaxation is also associated with positive effects both on fetal behavior and on obstetric and neonatal outcomes. Identifying pregnant women at risk and instituting treatment early in pregnancy could improve obstetric and developmental outcomes for both the mother and her fetus.

Healthy newborns' neurobehavior: norms and relations to medical and demographic factors.

OBJECTIVE: To generate neurobehavioral norms for an unselected random sample of clinically healthy newborns by examining the newborns with use of the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS). STUDY DESIGN: We recruited 344 healthy mothers and newborns from a well-child nursery. The NNNS, a 128-item assessment of infant neurobehavior, was used to examine newborn performance. Associations between 11 NNNS summary scales and the stress/abstinence scale, as well as medical and demographic variables, were evaluated. Mean, SD, and 5th and 95th percentile values for the summary scores of the NNNS are presented. RESULTS: NNNS scores from the 10th to the 90th percentile represent a range of normative performance. Performance on different neurobehavioral domains was related to marital status, ethnicity, prenatal, intrapartum and neonatal risk factors, complications during labor/delivery, cesarean delivery, gestational age, the age of the newborn at testing, and infant sex. CONCLUSION: These data provide clinicians and researchers with normative data for evaluation of newborn neurobehavior. Even in a low-risk sample, medical and demographic factors below clinical cut-offs were related to newborn performance. Infants with scores outside the ranges for the 11 NNNS summary scores and the stress/abstinence scale may need further observation and, if necessary, early intervention.

Maternal self-efficacy reduces the impact of prenatal stress on infant's crying behavior.

OBJECTIVE: To determine whether prenatal stress is associated with behavioral and emotional regulation problems (crying/fussing) in infants, after controlling for confounding factors. Furthermore, the study investigated the stress-buffering effect of maternal self-efficacy. STUDY DESIGN: Data were collected in 120 pregnant women (29 ± 3.2 weeks gestation) and their infants at 6 weeks of age. Expecting mothers completed a structured interview and self-report questionnaires on prenatal stress and self-efficacy. Crying/fussing data were obtained with a validated parental diary. RESULTS: After controlling for confounding variables, multiple regression analyses show that prenatal stress and self-efficacy accounted for 20% of the variance of infant's fussing and crying behavior. Results suggest a mediating role of self-efficacy. Babies of mothers reporting high levels of prenatal stress cried less when their mother had high levels of self-efficacy compared with mothers with low self-efficacy. In addition, mothers of infants with excessive crying reported more symptoms of stress, depression, and anxiety in pregnancy. CONCLUSION: To foster the development of well-adapted parent-infant relationships and potentially to reduce infant crying in the early postpartum phase, health care professionals need special education about the effects of prenatal stress and interventions that promote self-efficacy.

Identification of antenatal depression in obstetric care.

PURPOSE: Detection rates of depression in obstetric care are generally low, and many women remain undiagnosed and do not receive adequate support. In many obstetric settings, screening tools for depression are not applied routinely and there is a great need to sensitize health care professionals for the patient at risk for enhanced levels of depression. The present study aimed at identifying commonly assessed patient characteristics that are associated with antenatal depression. METHODS: One hundred and thirty seven women were screened using the Edinburgh Postnatal Depression Scale (EPDS) at the beginning of the second trimester at the outpatient department of a Tertiary University Hospital. Women were identified as at high risk for depression if scores were above a cut-off score of twelve. Obstetric history and outcome were extracted from patient files after delivery. RESULTS: Twenty one percent of the sample screened as depression positive. Logistic regression with backwards elimination showed that the triad of nausea during pregnancy, reports of (premature) contractions and consumption of analgesics during pregnancy significantly predicted high depression scores with a positive predictive value of 84.3%. The relative risk for a depressed pregnant woman to regularly take analgesics during pregnancy was fourfold higher than for non-depressed women. CONCLUSIONS: If depression screening is not part of routine prenatal care, systematic assessment of depression should be targeted for patients presenting with the markers identified in this study.

Response to induced relaxation during pregnancy: comparison of women with high versus low levels of anxiety.

Relaxation exercises have become a standard intervention for individuals with anxiety disorders but little is known about their potential for anxiety relief during pregnancy. The purpose of this study was to examine psychoendocrine (i) baseline differences and (ii) changes after a standardized relaxation period in pregnant women with high versus low levels of anxiety. Thirty-nine third-trimester high and low anxious pregnant women performed active or passive relaxation while levels of anxiety, hypothalamic-pituitary-adrenal (HPA) axis and sympathetic-adrenal-medullary (SAM) system activity were assessed before and after the relaxation period. In women with high levels of trait anxiety, state anxiety (F(1,36) = 8.3, p = .007) and negative affect (F(1,36) = 7.99, p = .008) as well as ACTH (F(1,35) = 9.24, p = .002) remained elevated over the entire course of the experimental procedure, the last indicating increased HPA axis activity. In addition, norepinephrine showed a constricted decrease of relaxation reflecting lower response of the SAM-system (F(1,37) = 4.41, p = .043). Although relaxation exercises have become a standard intervention for individuals with anxiety, pregnant women with high levels of trait anxiety benefited less than women with low levels from a single standardized relaxation period.

Fetal response to abbreviated relaxation techniques. A randomized controlled study.

BACKGROUND: stress during pregnancy can have adverse effects on the course of pregnancy and on fetal development. There are few studies investigating the outcome of stress reduction interventions on maternal well-being and obstetric outcome. AIMS: this study aims (1) to obtain fetal behavioral states (quiet/active sleep, quiet/active wakefulness), (2) to investigate the effects of maternal relaxation on fetal behavior as well as on uterine activity, and (3) to investigate maternal physiological and endocrine parameters as potential underlying mechanisms for maternal-fetal relaxation-transferral. STUDY DESIGN: the behavior of 33 fetuses was analyzed during laboratory relaxation/quiet rest (control group, CG) and controlled for baseline fetal behavior. Potential associations between relaxation/quiet rest and fetal behavior (fetal heart rate (FHR), FHR variation, FHR acceleration, and body movements) and uterine activity were studied, using a computerized cardiotocogram (CTG) system. Maternal heart rate, blood pressure, cortisol, and norepinephrine were measured. RESULTS: intervention (progressive muscle relaxation, PMR, and guided imagery, GI) showed changes in fetal behavior. The intervention groups had higher long-term variation during and after relaxation compared to the CG (p=.039). CG fetuses had more FHR acceleration, especially during and after quiet rest (p=.027). Women in the PMR group had significantly more uterine activity than women in the GI group (p=.011) and than CG women. Maternal heart rate, blood pressure, and stress hormones were not associated with fetal behavior. CONCLUSIONS: this study indicates that the fetus might participate in maternal relaxation and suggests that GI is superior to PMR. This could especially be true for women who tend to direct their attention to body sensations such as abdominal activity.

Effects of relaxation on psychobiological wellbeing during pregnancy: a randomized controlled trial.

Prenatal maternal stress is associated with adverse birth outcomes and may be reduced by relaxation exercises. The aim of the present study was to compare the immediate effects of two active and one passive 10-min relaxation technique on perceived and physiological indicators of relaxation. 39 healthy pregnant women recruited at the outpatient department of the University Women's Hospital Basel participated in a randomized controlled trial with an experimental repeated measure design. Participants were assigned to one of two active relaxation techniques, progressive muscle relaxation (PMR) or guided imagery (GI), or a passive relaxation control condition. Self-reported relaxation on a visual analogue scale (VAS) and state anxiety (STAI-S), endocrine parameters indicating hypothalamic-pituitary-adrenal (HPA) axis (cortisol and ACTH) and sympathetic-adrenal-medullary (SAM) system activity (norepinephrine and epinephrine), as well as cardiovascular responses (heart rate, systolic and diastolic blood pressure) were measured at four time points before and after the relaxation exercise. Between group differences showed, that compared to the PMR and control conditions, GI was significantly more effective in enhancing levels of relaxation and together with PMR, GI was associated with a significant decrease in heart rate. Within the groups, passive as well as active relaxation procedures were associated with a decline in endocrine measures except epinephrine. Taken together, these data indicate that different types of relaxation had differential effects on various psychological and biological stress systems. GI was especially effective in inducing self-reported relaxation in pregnant women while at the same time reducing cardiovascular activity.

Maternal laboratory stress influences fetal neurobehavior: cortisol does not provide all answers.

OBJECTIVE: Maternal stress can have an impact on pregnancy. However, effects on fetal neurobehavior are not well understood. In this study, the effect of laboratory stress on maternal psychoneuroendocrinological response and on fetal neurobehavior was studied. Serum cortisol as a potential underlying mechanism was measured. METHODS: Twenty-seven women made a single 1.5-h visit in their third trimester. The laboratory stressor involved an arithmetic task. Associations between maternal laboratory stress response and fetal neurobehavior were analyzed by studying 19 maternal-fetal dyads with high signal quality cardiotocograms. RESULTS: Stress exposure changed participants stress perception (p < 0.0001). However, only half of the participants (responders) had an HPA-axis response. Fetuses responded to the stress exposure depending on their mothers' stress response: (i) there was a fetal heart rate (FHR) group effect at the level of trend (p = 0.06). Fetuses of responders had higher HR levels 20 min after the exposure (p = 0.043), (ii) there were interaction (p = 0.026) and group effects at the level of trend (p = 0.078) found for FHR short-term variation (STV). Fetuses of responders had lower FHR STV 20 min after stress exposure (p = 0.007). Cortisol as a potential underlying mechanism only seemed to be associated with short- and long-term variation of FHR. CONCLUSIONS: An activation of the maternal stress-system could result in a child being born having a history of responding to maternal stress.

Sexual dysfunction after premenopausal stage I and II breast cancer: do androgens play a role?

INTRODUCTION: Sexual dysfunction after breast cancer has been attributed to a variety of treatment associated and psychological factors. Data on the role of a treatment-induced decrease of testosterone for the development of sexual problems in breast cancer survivors have remained inconclusive. However, androgen metabolites constitute a more reliable measure for total androgen activity. AIM: To measure levels of total androgen activity in breast cancer patients and to investigate relevant predictors of sexual dysfunction after breast cancer. METHODS: Twenty-nine patients with a premenopausal diagnosis of Stage I or II breast cancer and terminated adjuvant treatment, completed questionnaires on sexuality, quality of relationship, body image, and depression. In addition, blood samples were taken for the analysis of sex steroids. MAIN OUTCOME MEASURES: Female Sexual Function Index (FSFI), Relationship (PFB), Beck Depression Inventory, and European Organization for Research and Treatment of Cancer quality of life questionnaire. Analysis of dihydroepiandrosterone, dihydroepiandrosterone-sulfate, androstenedione, 17beta-diol, testosterone, dihydrotestosterone, androsterone, and ADT-G, 3-alpha-diol-3G, 3-alpha-diol-17G. RESULTS: Low levels of sex steroids reflected the medication-induced postmenopausal status independent of the type of chemotherapy treatment. Sexual dysfunction was present in 68% of the study group. Women with a history of chemotherapy were more affected in all of the FSFI-domains. The only predictor for desire was quality of relationship, while chemotherapy was predictive for problems with arousal, lubrication, orgasm, and sexual pain. Sexual satisfaction and higher FSFI sum scores were predicted by better quality of relationship and no history of chemotherapy, together explaining 54.2% and 49.7% of the variance. CONCLUSIONS: Sexual dysfunction after breast cancer is common and women should be informed properly at an early stage of treatment. Specific interventions have to be offered considering person-related preexisting factors and couples at risk should be supported in the transition to sexual life after breast cancer.

As testemunhas e o ensino da história: uma abordagem didática / Witnesses and the teaching of history: an educational approach

O objetivo deste artigo é examinar intenções, práticas e aportes da utilização do testemunho oral no ensino da História. Em primeiro lugar, mostraremos as principais preocupações e potencialidades implicadas no recurso à memória das testemunhas, no ensino da História. Depois, estudaremos as motivações inerentes a esse recurso e às diferentes maneiras de contemplá-lo. Proporemos, então, um retrato das práticas escolares em matéria de testemunho oral como sendo uma entrada na História pela empatia e/ou como alavanca cognitiva, favorecendo o desenvolvimento do pensamento histórico dos alunos. Destacaremos o interesse e os limites, a eficácia e os obstáculos que essas práticas induzem.

This article seeks to examine the intentions, practices, and contributions of the use of oral witnesses in the teaching of history. Initially, we will deal with the main concerns and potentials involved in the use of witnesses' memories in the teaching of history. Next, we will study the motivations inherent to this resource and the many different ways of approaching them. We will propose a view of the educational practices concerning oral witnesses as an incursion into history through empathy and/or as a cognitive lever to stimulate the development of the students' thinking about history. We will highlight the interest and the limits, the efficacy and the obstacles resulting from these practices.

The effect of migration background on obstetric performance in Switzerland.

OBJECTIVES: Population-based analysis to compare perinatal outcome between immigrant women and women from the Western industrialized world (WIW). METHODS: Singleton pregnancies of a cohort that was followed from the first trimester to delivery at the University Women's Hospital Basel, Switzerland, were retrospectively analysed. Data were extracted from 203 patient records. Multiple logistic and linear regression analyses were used to determine the impact of origin on perinatal outcome. RESULTS: Immigrants and women from WIW countries were comparable regarding number of pregnancy control visits. Immigrant women were younger, had more children, higher pre-pregnancy body mass index and were more often taking medication of any kind during pregnancy. Migration was only predictive for shorter gestations (p < 0.01). A trend for a lower frequency of gestational hypertension and labour inductions, and a higher frequency of spontaneous delivery and lower birth weights were observed. CONCLUSIONS: Migration background was associated with shorter gestations and lower birth weight. This was not due to differences in antenatal care since both study groups were followed at the same clinic with the same guidelines and had the same number of consultations during pregnancy. Higher stress levels due to migration and lower socioeconomic living standards, nutrition, and genetic factors are possible contributors to these findings.

Depression and anxiety during pregnancy: a risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature.

OBJECTIVE: Research from the past two decades has suggested a link between prenatal maternal psychological distress and adverse obstetric, fetal and neonatal outcome. Comparability of study results, however, is complicated by a diversity of definitions and measurements of prenatal maternal stress and different time points of assessment. Our aim was to critically review studies assessing maternal anxiety and depression during pregnancy and their impact on obstetric, fetal and neonatal outcome. METHODS: We carried out a computerized literature search of PubMed, PsycLIT and EMBASE (1990-2005) and a manual search of bibliographies of pertinent articles. In total 35 studies were identified that fulfilled the inclusion criteria. RESULTS: Elevated levels of depression and anxiety were found to be associated with obstetric outcome (obstetric complications, pregnancy symptoms, preterm labor and pain relief under labor), and had implications for fetal and neonatal well-being and behavior. However, prediction of the impact of mood and anxiety disorders during pregnancy is very limited due to methodological problems. Most notably, the majority of the studies included pregnant women with elevated symptoms of depressed mood and anxiety and did diagnose mood and anxiety disorders. Also, potentially confounding and protecting factors as well as biological mechanisms with a possible role in adverse outcome in pregnant women with depression and anxiety disorders have received little attention. CONCLUSIONS: Enhanced levels of depression and anxiety symptoms during pregnancy contribute independently of other biomedical risk factors to adverse obstetric, fetal and neonatal outcome. However, conclusions for women with mood or anxiety disorders are limited.

[Persistent somatoform pain disorder in migrants from Turkey]. / Anhaltende somatoforme Schmerzstörung bei Migranten und Migrantinnen aus der Türkei. Betreute Selbsthilfegruppen: Therapie-Erfolg langfristig sichern, soziokulturelle Integration nachhaltig fördern.

Migrants from Turkey face several barriers to a successful integration in Switzerland including equal access to the health care system; most important are language problems, cultural and economic barriers. According to the scientific report of the Federal Bureau of Health "Migration and Health " current forms of therapy do not fulfil the needs of this patient population. Ambulatory and in-hospital services are devoted to the acute phase of a pain disorder; they are not imbedded into the circumstances of daily living. Re-Adjusting to daily life however, is crucial for patients' attempt to return to normality. Therefore therapeutic offers are needed to close the gap between high intensity treatment in hospitals and almost no treatment in the ambulatory setting. We developed an integrative post acute model of patient care, consisting of assisted self-help groups that is presented in the current paper.