maternal anxiety in pregnancy and fetal homeostasis

principles and practice

Maternal Anxiety in Pregnancy and Fetal Homeostasis BARBARA H . ASCHER, C N M , M S

Although it is recognized that pregnant women may be extremely anxious and that anxiety i s accompanied by sympathetic nervous system hyperactivtty, little clinical consideration has been given to the potenttal harm to the fetus. A reutew of the literature, including research on both animal and human pregnancies, reveals what Is known about this subject. A section on implications for muterntty care follows, including a summary of the possible efects of anxiety dudng pregnancy, identification of women most at rtsk from anxiety, and intervention measures.

It has long been recognized that pregnancy may be a source of anxiety. Alterations in body image, an- ticipated changes in life style, con- cern over having a normal baby, and family and financial stresses may all be anxiety-provoking, For some women, the physical aspects of childbearing itself may evoke fears of pain, illness, mutilation, or death.

Many of the services we perform as providers of care to childbearing families are intended, at least in part, to reduce anxiety levels. The most common rationales behind this care include a) to make pregnancy and childbirth a more positive experience for the mother and family, b) to im- prove the patient's cooperation in her care, c) to reduce the need for analgesic medications in labor, and d) to prevent the prolongation of labor which may result when a woman is too tense and anxious. The physical effects of anxiety have been con- sidered only in regard to labor; for the antepartum patient, the primary rationale for reducing anxiety re- mains the woman's emotional comfort. All too frequently in the antepartum clinic setting, measures to assess and alleviate anxiety are bur- ied under heavy patient caseloads.

Yet we must all be aware that emotions, although perceived and interpreted by the cerebral cortex,

always have physiological effects elsewhere in the body. In the case of anxiety these include motor tension, restlessness, tachycardia, sweating, and flushing. These are mediated by the sympathetic nervous system through the release of catecholamines and through changes in circulating levels of adrenocortical and other hormones. In view of this, why has there been so little clinical consideration of the possible effects of anxiety on the fetus during pregnancy? If we do not routinely evaluate anxiety in the antepartum patient and intervene to reduce anxiety when necessary, are we jeopardizing the safety of the fetus as well as the emotional comfort of the mother?

Review of Literature One category of related research

involves animal experiments to determine the effects of maternal anxiety and/or catecholamine administration on the fetus. Ewes,'-a guinea pigs,4 rabbit^,^^^ and monkeys"^' have been used by various researchers. For the most part the experiments involved catheterization of a maternal artery for blood sampling and hood prgssure recording, catheriza- tion of a maternal vein for drug administration, insertion of a pressure transducer into the uterus, and use of a flow probe to determine uterine

blood flow. Several studies also involved measurement of the fetal heart rate, blood pressure, andblood gases. ~ A A '

The results of these experiments were quite similar. Intravenous administration of epinephrine and norepinephrine resulted, in every case, in an increased maternal blood pressure and a markedly decreased uterine blood flow. This decrease (reported in one study to be 33%) was sustained, lasting long after the maternal blood pressure had returned to pre-infusion levels. One study4 dem- onstrated that catecholamines in the mother's circulation caused a greater decrease in uterine blood flow and more fetal stress than strong uterine contractions induced by oxytocin. Greiss and Gobblea found that, with conscious ewes, fear associated with strange conditions, loud noises, and other startling stimuli reduced uterine blood flow by 25 to 33%.

While one study' reported no change in fetal heart rate or blood pressure, others reported profound effects on the fetus after maternal administration of catecholamines or exposure to psychological stress. In Dornhurst and Young's study4 the fetal heart rate dropped from an av- erage of 300 to 150-170 beats/min within 60 seconds after beginning the infusion. Adamsons and co- workerse reported that administration of catecholamines to the mother resulted in fetal hypoxia and acidosis, followed by changes in the fetal heart rate (FHR), blood pressure (BP), and electrocardiogram (ECG). In both studies the fetus proved to be relatively insensitive to direct, i.e., fetal, infusion of epinephrine and norepinephrine. Both studies concluded that the fetal response was due to decreased uterine blood flow and consequent fetal asphyxia. Myers? after exposing pregnant

18 May/June 1978 JOCN Nursing 0060-0511/78/~~-0018$0100

monkeys to contrived episodes of psychological stress, noted marked fetal bradycardia, hypoxia, and acidosis. Four of the offspring died shortly after delivery and showed evidence of asphyxia1 brain damage. (The researcher noted that the fetuses were already somewhat com- promised by the surgery performed on the mothers and that the extreme effects of maternal stress on the fetuses may have been due to this.) Shabanah and associates,6 after ad- ministering phenylephrine to pregnant rabbits, concluded that va- soconstriction resulting from sympathetic hyperactivity may con- tribute to perinatal wastage, premature labor, placental changes, and fetal anomalies. Other animal studies using rats have shown that greater levels of conditioned stress in pregnancy are associated with more emo- tionality, lower birth weights, and death in the offspring.8-10 One in- vestigator has stated, “There is good evidence that severe emotional stress and strong sensory stimuli cause em- bryonic resorption and stillbirth in some mammals.””

Other researchers have studied the effects of maternal emotional stress on the human fetus, but since they have used different terminology (“anxiety in pregnancy,’,’ “psychological tension,” “life stresses”) and since the dependent variables differ from study to study, it is not possible to state with certainty that these in- vestigators have proven anything. The points that are raised, however, are too serious to be ignored.

In these studies, women have been evaluated for anxiety or psychological stress by a variety of methods, including standardized psychological tests like the Taylor Manifest Anx- iety Scale and Thematic Appercep- tion Test, interviews by clinical psy- chologists, and tools designed by the researchers. They have investigated

the relationship between maternal emotional stress and several dependent variables.

1. Fetallneonatal abnormalities. In prospective investiga- tors have found a significantly higher incidence of fetal asphyxia, con- genital anomalies, stillbirths, and neonatal deaths among infants of women rated as having high levels of anxiety or stress during pregnancy as compared to control groups. In a retrospective study, Morgan and associates” reported significantly greater prenatal stress in mothers who delivered premature infants with hyaline membrane disease than in a control group who delivered normal, full- term infants.

2. Infant birthweight. While one researcher found no relationship,18 another reported a significant nega- tive correlation between maternal anxiety during pregnancy and infant birthweight.

3. Maternal obstetric complica- tions. Women who later experienced some intrapartum complication were reported to be under greater emotional stress during pregnancy than control groups in several studies.=-16 Unfortunately, “obstetric complica- tions” were not well defined and are therefore difficult to evaluate, although three authors specifically discussed prolonged labors. 12*14.30

4. Parity. Pkimiparas have been found to be significantly more anxious during pregnancy than multi- paras.16*a1 For most women, anxiety levels decrease after delivery.”JS

In an interesting retrospective study, Stott2’ interviewed the parents and examined the medical records of 102 retarded children and 450 normal control children. He found that illness during pregnancy or severe emotional distress were reported in 66% of the mothers of the retarded group and 30% of the controls. Juve- nile ill-health, defined as failure to

gain weight, poor eating habits, and frequent ,respiratory infections were reported in 55% of the retarded children and 18% of the controls. Both these differences were statistically significant. When all premature, un- derweight, and other abnormal births were excluded, there was still a significant association between emotional distress during pregnancy and juvenile ill-health, even within the group of 450 controls. Stott concluded that various mental and physical handicaps facilitated by a disturbed pregnancy are a part of a “continuum of reproductive casualty” resulting from borderline insult to the fetus, who is able to tolerate less stress both during and after birth.

Implications for Maternity Care Although the complex interaction

between mind and body is not fully understood, animal experiments have shown that maternal administration of catecholamines may result in a marked decrease in uterine blood flow, with consequent fetal hypoxia and acidosis. That any re- duction in uterine blood flow may jeopardize the fetus should be self- evident; in fact, it forms the theoreti- cal basis for the oxytocin challenge test. At least one study has shown that catecholamines in the mother‘s circulation cause a more profound decrease in uterine blood flow than oxytocin-induced contractions.’ Therefore, if a fetus in a high-risk pregnancy may not be able to tolerate the stress of uterine contractions, how much less may it tolerate the physiological effects of maternal anxiety?

Anxiety may also be implicated in prematurity. One author has stated that “the whole pattern by which excitation of the adrenergic nervous system effects uterine blood flow and myometrial excitability is one that is

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conducive to premature birth , . .”.28

In our society, prematurity occurs most frequently in those portions of our population subject to theamost physical and psychological stress: the nonwhite and the poor. The empha- sis in prevention is on diet and scheduled antepartum exams; the emotional component is largely ignored. But can all cases of prematurity in which the cause is not known be attributed to diet, or drug use, or inadequate care? Why does one woman give birth prematurely, while another with similar diet and prenatal care delivers at term? For now, these questions must remain unanswered, but it is possible that severe emotional stress may be involved in the cause of at least some cases of prematurity.

Abruptio placenta is another con- dition in which anxiety may be implicated. This is known to occur in patients with vascular disease or hypertension due to other causes. It is also possible that, in some patients “the spiral arteries are so reactive to catecholamines that they undergo spasms that produce necrosis in the terminal portions of these vessels . . .” leading to partial separation of the placenta.*J’

Identification What can we, as providers of ma-

ternity care, do about maternal anxiety in pregnancy? An increased awareness of the possible consequences of extreme anxiety or emotional stress would be a good start. This should lead to more needed research on its effects on the mother and the fetus.

The next step would be to identify those women who are most at risk from anxiety. One such group would be women with high-risk pregnancies: women with diabetes, pre- eclampsia, hypertension, heart disease, Rh sensitization, or poor obstetric histories. The fetuses of these women are those least able to tolerate any decrease in uterine blood flow or any other kind of stress. They may form part of Stott’s “continuum of reproductive casualty” resulting, from borderline insult to the fetus, superimposed on already exist- ing problems. In addition, the knowledge that they have been idon-

tified as high-risk patients probably contributes to higher anxiety levels in these women. It has been pointed out that women who are diagnosed as high-risk are subject to a gre$ deal of uncertainty, guilt, and an& iety because of their high-risk a tat us.^'

Women under a great deal of emotional stress for other reasons comprise another group at risk from anxiety. Unwanted pregnancy, mari- tal problems, threat of eviction, illness or death in the family, all may result in extreme anxiety. We must recognize that anxiety is quite sub- jective and individual. An occur- rence which may not appear to be anxiety-provoking may in some people cause extreme emotional stress. We must also recognize that poverty and racism cause long-term stress regardless of specific life events. Careful investigation of the patient’s social history, frequently overlooked, is important in identi- fying stressful situations. Those involved in providing maternity care should be aware of the physical man- ifestations of anxiety. Since these may be missed or misinterpreted, it would be helpful to have a screening device for anxiety in pregnancy. We already routinely screen patients for many conditions-tuberculosis, diabetes, veneral disease, sickle cell disease, rubella, etc. Perhaps it is time we gave similar attention to psychological problems and screening for them (taking care to use a pretested screening device and adequate patient privacy safeguards).

Intervention There are many ways in which we

can intervene to reduce anxiety. Sen- sitivity to the individual’s emotional needs is of paramount importance. By being aware of a woman’s facial expression, tone of voice, and man- nerisms, as well as her words, we may pick up indications of anxiety. An attempt to elicit from her the cause of her distress by gentle ques- tioning should follow. In some cases, the woman may have fears about her pregnancy which can be dealt with by reassurance and explanations. In other cases, there may be life stresses for which social service can offer sup- port. Even if nothing can be done to

remove or alleviate the cause, being able to talk with a concerned, sensi- tive listener may help reduce a woman’s anxiety. It is obvious that this kind of sensitivity cannot func- tion in a rushed or hurried atmo- sphere. It is important that each individual be given the time she needs at each antepartum visit.

Parent education classes are also important in reducing anxiety levels. As well as providing realistic infor- mation about pregnancy and childbirth, these classes teach women the concept that they may have some measure of control over what hap- pens to them. Unfortunately, these classes are primarily available to the economically well-off and better edu- cated portions of our population. The economically and educationally disadvantaged, who are most in need of this kind of program, are often left out. In many areas, there are no classes available at all. Groups involved in supporting prepared childbirth and parent education must press for more programs to reach all segments of the population. It would also be helpful if classes were offered earlier in pregnancy. There is no rea- son for people to wait unti1 the third trimester to find out what has been happening to them throughout pregnancy.

Parent education helps to reduce the individual’s anxiety about pregnancy and childbirth. But what about society’s attitudes toward cllildbearing? Adamsons states that, “In the U.S., unlike Great Britain and other countries in Europe, the news media often project pregnancy as an event with many hazards that are overcome only through careful supervision by highly skilled profes- sionals. In other cultures, pregnancy is treated in a more matter-of-fact way . , .”23 “Dedramatizing” pregnancy and birth could result in the elimination of much anxiety. People ought to be aware long before con- ception occurs that pregnancy is a normal physiological event. They should know that antepartum care is necessary because of the problems that can occur, but they should also know that in the majority of cases there are no serious problems. It is our responsibility to spread this knowledge and awareness in our

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contacts with patients and others, as well as by means of the media and the education system.

The environment surrounding the delivery process also needs to be dedramatized. If it is not feasible at this time to provide safe home deliv- eries for most normal childbearing families, as many European nations do, we must consider alternatives. A more homelike environment within the hospital is one alternative. Birth- ing rooms providing a comfortable, more familiar environment and al- lowing women in early labor to move around freely and socialize with others will help to minimize problems created by anxiety during labor. Ma- ternity homes may prove to be an even more attractive alternative for those whose pregnancies are normal and who desire out-of-hospital deliv- eries. Taking childbearing out of the environment of illness, whether in or out of the hospital, will go a long way toward changing attitudes about pregnancy and childbirth. This at- titudinal change is necessary to reduce the amount of anxiety provoked by pregnancy for the individual and for our society.

Conclusion Pregnancy itself, or stressful life

events occurring during a pregnancy, may cause high anxiety levels in many women. Although the relationship between maternal anxiety and fetal or maternal childbirth com- plications has not been clearly estab- lished in human pregnancies, there are implications that are too serious to be ignored any longer. Providers of health care to childbearing families must increase their awareness of maternal anxiety and its possible consequences. Screening for emotional stress, including identification of those individuals most at risk from anxiety, ought to be an integral part of antepartum care. Intervention measures to reduce anxiety, including childbirth education, must be made available to all who need them. To do less is to provide less than optimum care.

References

1. Adams, F. N., N. Assali, M. Cush- man, et al: “Flow-Pressure Re- sponses to Vasoactive Drugs in Sheep.” Pediatrics 27:627, 1961

2. Greiss, F. G. : “The Uterine Vascular Bed: Effects of Adrenergic Stimula- tion.” Obstet Cynecol21:295, 1963

3. Greiss, F. G., and F. L. Gobble: “Ef- fect of Sympathetic Nerve Stimula- tion on the Uterine Vascular Bed.” Am J Obstet Gynecol97:962, 1967

4. Dornhurst, A. C., and I. M. Young: “The Action of Adrenaline and Noradrenaline on the Placental and Foetal Circulations in the Rabbit and Guinea Pig.” J Physfoll18:282, 1952

5. Shabanah, E. H., V. Tricomi, and J. R. Suarez: “Fetal Environment and Its Influence on Fetal Develop- ment.” Surg Cynecol Obstet 129:556, 1969

6. Adamson, K., E. Mueller-Heubach, and R. Myers: “Production of Fetal

$ Asphyxia in the Rhesus Monkey by Administration of Catecholamines to the Mother.” Am J Obstet Cynecol 109:248, 1971

7. Myers, R. E.: “Maternal Psychologi- cal Stress and Fetal Asphyxia: A Study in the Monkey.” Am J Obstet Cynecol 122:47, 1975

8. Morra, M.: “Level of Maternal Stress During Two Pregnancy Peri- ods on Rat Offspring.” Psychosom Sci 3:7, 1965

9. Shabanah, E. H., V, Tricomi, and J. R. Suarez: “Stress and Its Influ- ence on Gestation.” Obstet Gynecol 37:574, 1971

10. Thompson, W. R. : “The Influence of Prenatal Maternal Anxiety on Emo- tionality in Young Rats.” Science 125:698, 1957

11. James, W. H.: “The Effect of Mater- nal Psychological Stress on the Foetus.” Br J Psychiatry 115:811, 1969

12. Davids, A., and S. DeVault: “Mater- nal Anxiety During Pregnancy and Childbirth Abnormalities.” Psycho- som Med 24:464, 1962

13. Davids, A., S. Devault, and M. Tal- madge: “Anxiety, Pregnancy and Childbirth Abnormalities.” J Cun- sult Clin Psycho1 25:74, 1961

14. Engstrom, L., G. Geijerstrom, N. G. Holmberg, et al: “A Prospective Study of the Relationship Between

Psychosocial Factors and the Course of Pregnancy and Delivery.” J Psy- chosom Res 8:151, 1964

15. Gorsuch, R. L., and M. K. Key: “Ab- normalities of Pregnancy as a Func- tion of Anxiety and Life Stress.” Psy- chosom Med 36:352, 1974

16. Grimm, E. : “Psychological Tension in Pregnancy.” Psychosom Med 23:520, 1961

17. Morgan, S. A,, D. Buchanan, and H. S. Abram: “Psychosocial Aspects of Ijyaline Membrane _. Disease.” Psychosomtics 17:147, 1976

18. Burstein, I., R. A. Kinch, and L. Stern: “Anxiety, Pregnancy, Labor and the Neonate.” Am J Obstet Gynecol 118:195, 1974

19. Shaw, J. A., P. Wheeler, and W. Morgan: “ Mother-Infant Relation- ship and Weight Gain in the First Month of Life.” J Am Acad Child Psychiatry 9:428, 1970

20. Ferreira, A. J.: “Emotional Factors in Prenatal Environment.” J N e w Ment Dls 141:108, 1965

21. Light, H. K., and C. Fenster: “Ma- ternal Concerns During Preg- nancy.’’ Am J Obstet Cynecol 118:46, 1974

22. Stott, D. H.: “Physical and Mental Handicaps Following a Disturbed Pregnancy.” Lancet 1:1006, 1957

23. Adamsons, K: “Maternal Sympa- thetic Nervous System and Fetal Homeostasis.” Contemp Obstet Cynecol5:40, 1974

24. Galloway, K.: “The Uncertainty and Stress of High Risk Pregnancy.” MCN 1:294, 1976

Address reprint requests to Barbara H. Ascher, CNM, 35-50 85th Street, Jackson Heights, NY 11372.

Barbara H. Ascher currently works part- time in Maternity-Infant Care Family Planning projects. She received her BSN from the State University of New York at Bufalo and her M S in Maternity Nurs- ing, Nurse-Midwifery, from Columbia University. In 1975-1977 she was a clinical instructor in Columbia’s Graduate Program in Maternity Nursing, Nurse- Midwifery. She is a member of ACNM and Sigma Theta Tau.

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maternal anxiety in pregnancy and fetal homeostasis

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