Stress in Pregnancy

I’ve mentioned before that I’m a huge fan of the Headspace meditation app.  I find it to be very well-designed, and makes it much easier and fun for me to meditate on a daily basis.  They have sessions on various topics such as stress, sleep, relationships, even creativity.  I was very excited that they recently introduced a new session on pregnancy- worked out perfectly for me, timewise.  The sessions evolve during the course of 30 days, and involve visualizations for yourself as well as focusing on the baby.

Per the narrations, the basis of the sessions is that it’s beneficial for you and the baby to have a more calm, positive mindset and that stress is bad for you and the baby.  While I don’t disagree with that, it did get me wondering- how much do we really know about how bad stress is for the pregnancy?

Like most things in pregnancy, I figure it’s hard to study.  You can’t exactly split a group of pregnant women, subject half to significant stress and half not and see what happens.  I’m not one to go searching through all the evidence, so I went to two of my go-to sources.  One is UpToDate, a website many of us clinicians subscribe to that gives us current evidence and recommendations from experts.  It’s generally reliable, and most of us use it as a higher-level Google.  The other resource is ACOG, the organization that oversees us OB/Gyn docs in the US and gives us practice guidelines (how to manage patients based on the current evidence).

According to UpToDate, there is evidence that stress is associated with preterm birth.  They say that major maternal physical and psychological stressors, including anxiety and depression, can activate the HPA axis (involved in the stress response), and it’s been associated with a slightly higher rate of preterm birth.  One study showed that women who had depression early in pregnancy had a higher rate of preterm birth, and there was a “dose-response” effect, meaning that the worse the depression, the more it was correlated with preterm birth.  They talk about the various mechanisms thought to be related to this, and even have the graphic below.

UpToDate

Pathogenesis of preterm birth

Image
HPA: hypothalamus-pituitary-adrenal; ACTH: Adrenocorticotropic hormone 16-OH; DHEA: 16-hydroxydehydroepiandrosterone; E1 – E3: estrogen, estradiol, estrone; CRH: Corticotropin releasing hormone; Cox-2: Cyclooxygenase 2; PG: Prostaglandin; MLCK: Myosin light chain kinase; PROM: Premature rupture of membranes; PGDH: Hydroxyprostaglandin dehydrogenase

Don’t ask me to explain it in detail, as I’m certainly no expert in it.  Bottom line is, stress apparently causes certain factors to be released, which are then thought to cause physiologic changes that lead to preterm labor and preterm birth.

ACOG doesn’t specifically have any articles on stress and pregnancy that I found.  When I looked at their practice bulletin on preterm birth, they didn’t mention stress as a risk factor.  Unfortunately, there is a lot that we still don’t know about preterm birth, or we’d be better at preventing it.  The biggest risk factor is if one has had a prior preterm birth.  There are other things, like underlying infection that have been correlated with preterm birth, but then again treatment hasn’t been shown to prevent preterm births.  Some cervical procedures, like conization of the cervix which is performed to remove cervical dysplasia (advanced precancerous changes), were traditionally thought to increase risks of preterm birth, but they also wonder if there are other factors that contributed to the dysplasia in the first place that also put one at risk for preterm birth.  There are some behavioral factors like smoking and substance abuse that increase risks.

So how do I approach the topic in real life?  July was a brutal month work-wise, working nearly 60 hours a week consistently the whole month.  I can’t say my mindset was exactly Zen as I’d be finishing yet another long work day.  But am I worried that this is going to significantly affect my pregnancy?  No.

My patients often worry about the stress in their lives affecting their pregnancies, and I think it’s generally unnecessary.  While I wouldn’t advise volunteering for combat and voluntarily going to a war zone, most of us experience normal life stressors throughout the pregnancy, and that’s fine.  That’s life.  I can’t imagine that from the caveman days to now, that women have ever been able to get through 9 months of pregnancy without normal life stressors.  And sometimes my patients have more significant stressors- some of them have lost family members during their pregnancy.  Do they all go into preterm labor?  Nope, their babies do just fine.

As a doctor, my goal is to make sure that my patients don’t need a higher level of care for what’s going on.  If they are significantly depressed or anxious, then they may need to see a therapist or psychiatrist.  I certainly wouldn’t want their underlying condition to affect their behaviors, such as eating or substance use, which would then affect the pregnancy.

I do agree that there is potential benefit in working on handling stress levels, such as meditating and exercising.  But rather than doing that, many of my patients worry that their stressful work situation is going to affect their pregnancy, and then they come to me asking for notes for work.  While work modifications are reasonable for patients who have physical pains and limitations, I do think some women are misguided when they think they need to modify because of “stress.”  One extreme example is a patient who works as a school bus driver, driving 2 hours in the morning, and 2 hours in the afternoon.  She felt like this was too much, and asked to reduce her hours.  This is the kind of behavior that will make your doctor roll her eyes and complain about you behind closed doors.

My thoughts are to do what you can to handle your normal life stresses while you’re pregnant.  Meditation is a good use of your time if you are so inclined, but it’s not for everyone.  If there are significant issues going on, they need to be taken care of.  But worrying about how much your normal life stressors are affecting your pregnancy is unnecessary and just increasing your stress.  You have enough to worry about in pregnancy; make this one less thing.

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2 thoughts on “Stress in Pregnancy

  1. Jamie Bee August 11, 2015 / 9:14 am

    Hi!

    I was thinking about the paleo lifestyle this morning as it relates to pregnancy (and recovery therefrom), and was wondering if, in light of your impending arrival, you had any thoughts to share on gravity-assisted birthing positions. You hear stories about African bush women who give birth in the fields while squatting and then walk miles back to their village immediately afterwards, seemingly no worse for the wear. Perhaps those tales are a tad hyperbolic, but it does seem to make sense to use the effects of gravity to hasten and minimize the difficulties of labor from a physiological perspective (see, for example, the squatty potty). Modern medicine, with its need to “get all up in there”, surely prefers a woman to lie meekly on her back (or at least semi-reclined / crookline) but I wonder if the former (squatting, even if not in a field) isn’t a more natural and less intrusive way to give birth?

    I recognize that this may be too personal a topic for you to address publicly on your blog, but I wondered if it’s something you’ve given any thought to more generally as an OB – if you suggest it to your patients, etc – and if there are any drawbacks you’re aware of. I used a modified all-fours position when I gave birth a few weeks ago, and it worked great. The delivery bed was set in an “L” shape and I gracelessly draped my upper body and elbows over the head of it, with my knees on the bed and bottomside flapping in the breeze. I thought the position really enabled me to push effectively when the time came, and kept tears and other “down there” problems to a minimum. Obviously with any complications, such a position would not have been possible, but in the circumstances it led to a very fast and easy delivery. I didn’t have an epidural, in part so that the gravity positions would be available to me (I’d heard that you can lose leg function with an epidural and I knew if I was squatting or kneeling I’d need my legs), and I recognize that may be a huge drawback for some women.

    Thanks for your thoughts. Also, please feel free to NOT approve this comment, as I know it isn’t really relevant to this particular blog post. It’s just that I didn’t see an e-mail address for you elsewhere on the site and didn’t know how else to contact you.

    All best,
    Jamie

    Like

    • Paleo OB August 12, 2015 / 7:54 pm

      Hi Jamie! Thanks for your comment. I’m not very techie, so I’m not sure if there is another way to send me messages rather than commenting on my posts. In any case, I don’t mind.

      To be honest, I don’t know much about positions in labor and haven’t looked into it. In modern medical training, at least from my personal experience, we are all generally taught in hospitals so our patients are delivering lying on their backs in the hospital beds, granted sitting up a bit. The majority of patients get epidurals, so yes they don’t have much leg function and don’t have a lot of other options for positioning. We mostly show up for the delivery itself, so it’s usually the nurses or midwives who are spending more time with the patients as they are laboring and pushing.

      At my particular hospital, and at many hospitals that I’ve worked at, we now have midwives taking care of normal, uncomplicated patients. I think the midwives are more knowledgeable about the different positions. I have heard of some of the different positions like squatting or all fours, but I have never actually delivered any patients that way. I’ve occasionally had them push in different positions, then got them back to the traditional hospital bed position to deliver.

      So I’m just not that knowledgeable about it, but I do appreciate you bringing it up. I’m hoping as I start my maternity leave and have more time, that I can start looking into various things like the above that I’m less knowledgeable about, and blog about my findings.

      Like

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