DOI: 10.1097/JPN.

0b013e31823f565b

J Perinat Neonat Nurs r Volume 26 Number 4, 296–306 r Copyright 

C 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Relaxation During Pregnancy

What Are the Benefits for Mother, Fetus, and the Newborn?
A Systematic Review of the Literature
Nadine S. Fink, PhD; Corinne Urech, PhD; Marialuisa Cavelti, MSc; Judith Alder, PhD

ABSTRACT interpreted as improved result. (4) Higher-birth-weight and

Previous studies have reported associations between ma- improved performance on the Neonatal Behavioral Assess-
ternal stress during pregnancy and obstetric outcomes as ment Scale was related to relaxation. (5) Relaxation training
well as fetal development and neonatal adaptation. These was associated with reductions in maternal physiological
findings highlight the importance of identifying pregnant and endocrine measures. Relaxation during pregnancy is
women who experience severe stress and the need for associated with salutogenic effects that include regulation
interventions that commence early in pregnancy. The aim of emotional states and physiology. Relaxation is also as-
of this study was to review studies that investigated the sociated with positive effects both on fetal behavior and
effects of relaxation techniques during pregnancy, includ- on obstetric and neonatal outcomes. Identifying pregnant
ing maternal, fetal, and neonatal outcomes. In addition, women at risk and instituting treatment early in pregnancy
studies examining maternal endocrine and physiological al- could improve obstetric and developmental outcomes for
terations were reviewed. PubMed was searched using the both the mother and her fetus.
following key words: maternal well-being, maternal stress, Key Words: fetal heart rate, fetal neurobehavior, maternal
relaxation techniques, pregnancy, fetal neurobehavior, fetal stress, maternal well-being, neonatal adaptation and
heart rate, neonatal adaptation, and neonatal behavior. (1) neonatal behavior, pregnancy, relaxation techniques,
Relaxation had a positive impact on women’s emotional
state. (2) Pregnancy outcomes improved with fewer admis- aternal psychosocial well-being positively
sions to the hospital, fewer obstetric complications, longer
gestation, reduction of caesarean sections, and fewer post-
partum complications. (3) Fetal heart rate and fetal motor
M influences pregnancy outcomes, fetal de-
velopment, and neonatal adaptation.1 A
wealth of evidence indicates that prenatal stress2−5 and,
activity were reduced as a result of relaxation and therefore more specifically, pregnancy-related stress6 can directly
influence fetal growth and length of gestation. A hand-
Author Affiliations: Department of Newborn Medicine, Harvard ful of cross-sectional studies have measured fetal heart
Medical School, Brigham and Women’s Hospital, Boston,
Massachusetts (Dr Fink); Department of Personality and
rate (FHR) and/or FHR variation reactivity in associ-
Developmental Psychology, University of Basel (Dr Fink); and ation with women’s chronically experienced stress or
Departments of Obstetrics and Gynecology (Drs Urech and Alder) and anxiety and found that the fetuses of these women
Psychiatric Policlinic (Ms Cavelti), University Hospital Basel, Basel,
Switzerland.
showed different FHR and/or FHR variation reactivity
compared with fetuses of mothers who did not experi-
Supplemental digital content is available for this article. Direct URL cita- ence high levels of stress or anxiety.7−11 Similarly, Fink
tions appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.jpnnjournal.com) et al12 showed that fetuses responded to maternal lab-
Disclosure: The authors have disclosed that they have no significant oratory stress with changes in FHR variation. Findings
relationships with, or financial interest in, any commercial companies from the latter study lend support to previous studies re-
pertaining to this article. porting associations between mother’s emotional state
Corresponding Author: Nadine S. Fink, PhD, Department of Newborn and fetal neurobehavioral development.
Medicine, Harvard Medical School, Brigham and Women’s Hospital, 75
Francis St, Boston, MA 02115 ([email protected]). The mechanisms by which chronic maternal stress
Submitted for publication: January 5, 2011; accepted for publication: contributes to adverse pregnancy-related outcomes are
October 28, 2011. not well understood. However, it is likely that chronic

296 www.jpnnjournal.com October/December 2012

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
maternal stress contributes to adverse pregnancy- criteria. The review included 12 studies on relaxation
related outcomes via neuroendocrine and autonomic techniques, 4 on massage therapy, and 5 on yoga.
nervous system pathways, as in the generalized stress
response,13,14 but with additional physiological dysreg-
ulation in maternal-placental-fetal feedback.11,15 RESULTS
The associations between chronic stress, fetal de- Supplemental Digital Content Table 1 (available at
velopment, and obstetric outcomes highlight the need http://links.lww.com/JPNN/A0) displays the main re-
for intervention programs starting early in pregnancy.16 sults of the reviewed studies. An overview of stud-
Clinical experience shows that many pregnant women ies investigating the associations of relaxation exercise
are reluctant to take psychopharmaceuticals during and maternal outcomes, including maternal psychology,
pregnancy because of potential risks to health and de- physiology, and obstetric outcomes, is given. Following
velopment of fetus. This trend suggests a need for be- this overview, studies looking at the effect of maternal
havioral interventions aimed at both improving subjec- relaxation on fetal and on neonatal behavior are sum-
tive well-being and monitoring associated physiological marized.
changes. With subjective and objective data, it would be
possible to develop evidence-based intervention guide- Relaxation and well-being of pregnant women
lines based on novel understanding of the psychophys- Heart rate and blood pressure changes
iological mechanism of relaxation and its health effects. Relaxation interventions such as PMR, guided imagina-
The purpose of this article was to review studies tion, yoga, and massage have been found to reduce
on the effects of relaxation during pregnancy, includ- maternal heart rate (HR) and blood pressure (BP).17,18
ing maternal well-being, pregnancy outcomes, and fe- Seven studies investigated cardiovascular changes to re-
tal and neonatal outcomes. The evidence from this re- laxation during pregnancy.19−25
view would be helpful for nurses, midwives, and other In a British study, 58 pregnant women between 28
healthcare professionals who treat pregnant women and 32 weeks of gestation were randomly assigned to
who experience severe stress. Healthcare professionals an active hypnotherapeutic condition (n = 29), which
can also benefit from the overview of useful relaxation uses self-generated imagination at appropriate points of
techniques that can be adapted for clinical manage- a narrative, with the aim of inducing feelings of com-
ment of stress in pregnancy. An additional aim was fort or a passive relaxation condition (n = 29), involving
to review studies that examined maternal endocrine quiet sitting for 45 minutes. Maternal HR decreased after
and physiological alterations after relaxation in order both types of relaxation (active: P < .0001; passive: P =
to clarify the state-of-knowledge regarding biological .002), but the effect was significantly more pronounced
mechanisms that underpin the maternal to fetal effects in the active relaxation group (reduction of 11 beats per
of relaxation. minute [bpm] vs 6 bpm).24 In a similar randomized con-
trol study by Urech et al,25 39 pregnant women between
32 and 34 weeks of gestation were randomly assigned
LITERATURE AND SEARCH STRATEGY to two 10-minute active (PMR: n = 13; guided im-
A PubMed search was conducted for articles between agery [GI], n = 13) and a quiet sitting control condition
1980 and 2011 using the following key words: well- (n = 13). Compared with the first study, HR levels were
being, maternal stress, relaxation techniques, preg- significantly lower after active relaxation than after the
nancy, fetal neurobehavior, fetal heart rate, and neona- passive control condition (P = .027).25
tal behavior. Fifty-one articles were retrieved with key In a semicontrol study of 99 women at 32 weeks of
words “relaxation techniques,” “pregnancy,” “maternal gestation by DiPietro et al,19 maternal HR declined sig-
stress,” and “well-being.” Seven additional articles were nificantly from a 18-minute baseline measure (mean) of
identified after adding key words “fetal neurobehavior,” 86.4 to 82.6 bpm (P <.0001) after an 18-minute pro-
“fetal heart rate,” and “neonatal behavior.” gressive relaxation intervention. The study used a pre-
Studies were retained for review if, (a) the study baseline group (41%) to control for temporal effects
subjects were pregnant women, (b) the journal article on maternal or fetal responses related to maternal re-
was published in a peer-reviewed journal, (c) the inter- cumbence or postural change. No differences were ob-
vention was progressive muscle relaxation (PMR), yoga, served in participants who were randomly assigned to
an imagination technique, or massage therapy, and (d) the prebaseline group; however, because of the lack of
the study used one of the following outcome measures: a “real” control group, it remains unclear whether these
physiological or endocrine reactivity, maternal stress, findings are the result of relaxation or whether they are
anxiety or depression, fetal, obstetric, birth, or neona- due to the recumbent position for 36 minutes (18 +
tal outcome. In total, 21 studies fulfilled the eligibility 18) and 45 minutes (18 + 18 + 18) respectively.19

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Narendran et al21 investigated the effects of an inte- changes in heart rate variability. These findings speak to
grated approach to yoga therapy (IAYT) on gestational the effectiveness of relaxation techniques during preg-
hypertension between the 18th and 20th weeks of ges- nancy. Nurses and midwives could, therefore, actively
tation. Yoga therapy included physical postures, breath- provide relaxation techniques (eg, by applying relax-
ing techniques, and meditation and was practiced daily ation themselves) or giving relaxation compact disks
for 1 hour until delivery. In this study, subjects were (CDs) to the women who could profit from relaxation.
matched and assigned either to a yoga therapy (n = Sometimes, there are hospital psychologists who spe-
169) or to a control condition (walking half an hour cialize in relaxation techniques.
twice a day) (n = 166). The incidence of gestational Direct methodological comparisons between these
hypertension was lower in the yoga therapy condition, studies are difficult to make, given the diversity of tech-
but this difference was not statistically significant. In a niques used and differences in duration and frequency
similar study, Satyapriya et al23 focused on heart rate of application. Findings by Nickel et al22 implicate dura-
variability in 90 pregnant women at 36 weeks of gesta- tion and frequency, as well as continuous guided train-
tion. These participants were randomly assigned either ing sessions and instructions for home practice, as im-
to an IAYT (n = 45) or a control condition (n = 45) in- portant factors.
volving standard prenatal exercises.23 A comparison of
pre-/postsessions showed a decrease in low-frequency
bands (indicator for sympathetic activity) in the IAYT Changes in stress hormone levels
group (P < .001) and an increase in high-frequency Pregnancy involves a complex interaction between dif-
bands (indicator for parasympathetic activity) in both ferent hormonal systems, including a peripheral hor-
conditions (P < .001). monal system in the placenta. Hyper- or hypoactiv-
Nickel et al.22 investigated whether a 30-minute PMR ity of the maternal hypothalamic-pituitary-adrenal axis
training session (3 times per week, for a period of as well as of the sympathetic-adrenal-medullary26 sys-
8 weeks) would induce cardiovascular alterations in tem is associated with acute or chronic stress and with
pregnant women (pregnancy week not significant) with negative obstetric and neonatal outcomes, modulated
bronchial asthma. Participants were asked to practice by maternal-placental-fetal communication.1,4 Similar
twice a day for 15 minutes. Compared with the control to nonpregnant clinical populations,27,28 relaxation in-
intervention (moving extremities 3 times a week for 30 terventions during pregnancy can affect maternal en-
minutes), PMR was significantly more effective in re- docrine response and have beneficial effects on the
ducing HR (PMR group: pre = 76.7 bpm, post = 66.5 mentioned outcome parameters. So far, only 7 stud-
bpm vs control group: pre = 75.0 bpm, post = 73.4 ies investigated the effects of relaxation on hormonal
bpm) and systolic BP (PMR group: pre = 136.3 mm reactivity (pre-/postintervention).19,24,25,29−32
Hg, post = 120.3 mm Hg vs control group: pre = 133.9 The randomized study by Teixeira et al24 found re-
mm Hg, post = 132.2 mm Hg) (Ps < .001). This study duced cortisol levels in maternal plasma after (i) a sin-
was the only one to report higher efficacy of PMR than gle active or (ii) a single passive exercise (delta pre-/
that in the control condition. Moreover, its intervention post–cortisol levels for active relaxation: 80.8 nmol/L;
elicited the largest changes in HR and systolic BP. P = .002, delta pre-/post–cortisol levels for passive re-
Finally, Little et al20 investigated the effectiveness of laxation: 133 nmol/L; P < .0001).24 These results are
relaxation in 60 pregnant women (pregnancy week not comparable with the results of the randomized control
significant) with high BP (ε = 135/85 mm Hg) at 2 suc- study by Urech et al.25 These authors applied 2 active
cessive clinic visits) in 2 intervention groups. Groups A (PMR and GI) and 1 passive relaxation (quiet rest, con-
and B attended 6 weekly relaxation sessions and were trol group) exercises. Levels of cortisol as well as of
asked to follow guided relaxation audiotapes once a the adrenocorticotropin hormone and norepinephrine
day. Group B also received skin conductance audio (NE) significantly changed after the relaxation interven-
feedback (reflecting sweat gland activity), and a control tion (Ps < .001). There were no differences observed
group (group C) received standard prenatal care. Sys- between active and passive relaxation.25 Similar, DiPi-
tolic BP was significantly lower in the relaxation-only etro et al19 applied a single 18-minute progressive relax-
treatment group (group A) than in the GC (group C) ation exercise and found a significant reduction in cor-
(P < .001). tisol levels (log scores) from baseline to postrelaxation
In summary, these studies addressing the influence (P < .001). Moreover, a stress reduction (SR) instruction
of relaxation (PMR, yoga, guided relaxation, inducing a (“Eliminate things that are stressful and/or participate in
comfortable feeling, sitting quietly) on maternal cardio- things that increase your level of relaxation.”) resulted
vascular parameters found a reduction of HR and/or BP in decreased levels of morning cortisol (log scores)
and a lower incidence of gestational hypertension and (P = 0.01) in a group of 41 low-income Latina women

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between 6 and 32 weeks of gestation.32 Notably, this terations could provide important insights about the
was a 10-day study with non-SR and SR conditions, in positive middle- and long-term effects of relaxation on
which women were instructed to collect saliva sam- obstetric, fetal, and neonatal outcomes and help mo-
ples and complete stress and mood measures over a tivate more widespread use of relaxation and other
10-day period. Only in the evening of the ninth day SR techniques in long-term clinical care for pregnant
were participants instructed to both begin planning for women.
the SR behaviors and continue engaging in SR behav-
iors the following day until collection was completed.32
Compared with the other studies, there were no in- The Placenta and Blood Flow
structions provided for inducing physical or mental Stress hormones have an impact on blood flow by
relaxation. their vasoconstrictive effect.33,34 A relaxation-induced
Field et al31 revealed controversial findings. In a decrease of NE levels could impact uterine-placental
study examining 26 healthy women between 14 and circulation, which, in turn, acts as an important pre-
30 weeks of gestation, the intervention methods (i) dictor of obstetric and fetal outcomes.35 There are
massage therapy and (ii) PMR had no effect on cor- only 2 studies that measured blood flow in the uter-
tisol levels31 whereas urine dopamine levels increased ine and umbilical vessels after 2 single relaxation
by 25% in the massage therapy group (both interven- exercises.19,24
tions: 20-minute sessions twice a week for 5 weeks). Teixeira et al24 found a slight increase (mean = 0.04)
A more recent study by the same authors included a in the resistance index (RI) of the uterine artery blood
clinical sample of 84 depressed pregnant women be- flow (pre = 0.044, post = 0.047) after a single passive
tween 18 and 24 weeks of gestation. Women were ran- relaxation exercise (quiet sitting) (P = .002) but not af-
domly assigned to a massage therapy group, a PMR ter active relaxation (P = .22). The authors concluded
group, or a standard prenatal care group. The massage that this may well be a spurious result and, in any case,
group received two 20-minute therapy sessions by their the degree of the increase would not be clinically mean-
partners for 16 weeks. The PMR group conducted 20- ingful.
minute PMR sessions twice a week for 16 weeks. A In general, the nonfinding in the active relaxation
decrease in cortisol (328.5 ng/mL first day, 252.2 ng/mL group could possibly be explained through the single
last day) and NE levels and an increase in dopamine relaxation session. The participants in the active relax-
and serotonin levels were seen in the massage group ation condition met for the first time with a stress man-
(Ps < .05) but not in the PMR.29 A 16-week massage agement expert and were instructed to use their own
intervention by the partner could have resulted in a imagination at appropriate points of a narrative, with
social support boost and possibly explain these group the aim of inducing feelings of comfort. It is likely that
effects. participants were highly concentrated and tried to fol-
In summary, these studies have examined the im- low the instructions carefully. This explanation would
pact of relaxation on endocrine responses. Comparison speak against single relaxation interventions or to ex-
is difficult, considering the use of different relaxation planation/training (eg, a week) before the actual relax-
interventions and that not all studies reported absolute ation intervention.
cortisol values in either μg/dL or nmol/L. In addition, 2 In the relaxation study by DiPietro et al,19 the au-
studies listed log scores, which do not provide a clear thors report that resistance in the umbilical artery de-
picture of reduction, and 2 studies failed to provide clined over time (P < .01), however, the effect size
the units of measure.24,31 In all but one study,31 relax- was small (η2 p = 0.077). Comparable with the find-
ation interventions, including massage therapy, were ings of Teixeira et al24 regarding their active relaxation
associated with a decrease in cortisol/NE levels and group, no changes were seen in resistance of the right
an increase in serotonin/dopamine levels after short- and left uterine arteries after a single 18-minute guided
and long-term interventions. Interestingly, 2 studies re- imagery relaxation [19]. It is possible that the same ex-
ported declines in endocrine levels after the quiet sit- planations (see earlier) could account for this similar
ting condition.24,25 For healthcare workers and patients, finding. It could be argued that umbilical artery resis-
these objective results are likely to be useful in explain- tance decline was the result of simple rest. Nonetheless,
ing positive effects of relaxation on different levels (eg, in the study by DiPietro et al19 fetal heart rate vari-
maternal physiology, well-being, and stress hormones). ability increased from prebaseline to recovery and was
For future studies, it would be important to assess associated with uterine arterial resistance and umbili-
hormonal parameters over the entire course of preg- cal resistance within individuals (higher fetal heart rate
nancy and to relate endocrine findings to obstetric variability was associated with lower resistance index
parameters. Longitudinal studies of endocrine-level al- in the umbilical artery).

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Maternal psychology: Well-being stress, anxiety, than in the control group with respect to the 3 scales
and depression STAI State Anger (P < .01), Trait Anger (P < .01),
The impact of relaxation on pregnant women’s and Anger Out (direct anger outward) (P < .01).39
mental well-being has been investigated in 9 In addition, increases in quality of life (8 summary
studies.22,24,25,29,31,32,36−38 Although anxiety was assessed scales) were found after treatment.22 Furthermore, an
in most of these studies using the Spielberger State Anx- improvement of mood was observed after massage ses-
iety Inventory,39 few studies measured perceived stress sions in healthy pregnant women (P < .005 and P
or affective state. < .001, respectively).31,37 and less symptoms of de-
Without exception, anxiety levels decreased after pression were reported by depressed pregnant women
relaxation.24,25,29,31,36,38 Relaxation interventions included (P < .05).29
(a) active and passive relaxation exercises described In summary, relaxation interventions during preg-
previously,24,25 (b) applied relaxation sessions for 7 nancy, ranging from single relaxation exercises to PMR,
weeks,36,40 (c) a weekly (2 hours) mindfulness-based massage, and IAYT training over several weeks, have
intervention for 8 weeks,38 (d) PMR, and (e) massage consistently demonstrated benefits to maternal psycho-
therapy for 5 and 16 weeks, respectively.29,31 logical well-being. Relaxation techniques should, there-
Perceived stress levels and negative affect decreased fore, be included into the routine methods for treating
after short- and long-term relaxation.32,36 Bastani et al36 pregnant women experiencing stress, anxiety, or de-
conducted a randomized control trial with a prospec- pression. There is also the possibility of giving the pa-
tive pre-/posttest experimental design. One hundred tients information and a relaxation CD if there are no
ten women between pregnancy weeks 14 and 28 par- opportunities for one-on-one relaxation sessions. In-
ticipated in a 7-week applied relaxation training40 At structions and other technical information can be ac-
posttest, scores on all 3 scales (1) State Anxiety, (2) cessed from the Internet or from bookstores.
Trait Anxiety, and (3) Perceived Stress showed signifi- In future studies, researchers might look for differ-
cant decreases in the experimental group (n = 55) com- ential effects in women with higher to lower levels of
pared with the control group (n = 55) (P = .001). In distress. Except for one study,29 samples consisted of
another study, perceived stress was measured with a vi- healthy pregnant women. Studying the effects of relax-
sual analog scale.25 A clear superiority of the 10-minute ation in women who differ on their level of distress
GI exercise was shown compared with PMR and the would provide information on the beneficial outcome
control condition (P = .007).25 of relaxation interventions across the spectrum of stress,
The SR instruction “Eliminate things that are stress- depression, and anxiety disorders.
ful and/or participate in things that increase your level
of relaxation” lead to significant decreases in morning Positive obstetric and pediatric changes
and evening stress ratings (P = .001), symptoms of de- Ten studies investigated the benefit of relaxation dur-
pression (Center for Epidemiological Studies Depres- ing pregnancy on obstetric outcomes such as labor, de-
sion Scale, P = .002), and negative affect (Positive and livery type, gestational age, weight at birth, low-birth-
Negative Affect Schedule, P < .01).32 weight (LBW), prematurity, or physical condition of the
In a randomized study, 99 women were either newborn.20,21,29,31,40−45
allocated to a yoga group (IAYT) or to a control First, findings regarding birth weight, prematurity,
group (standard prenatal exercises).23 Satyapriya et al23 and preterm are reported. In a randomized control trial
showed that IAYT was effective in reducing perceived by Bastani et al,40 the effects of applied relaxation on
stress levels and negative affect in Indian women (from pregnancy and birth outcomes were studied. The dif-
18 to 36 weeks of gestation) (P = .001).23 In the first ference of the mean-birth-weight was significant in the
month of training, women received 2-hour sessions 3 experimental group (3168 g, SD = 420, n = 52) com-
days per week from trained instructors. After the first pared with the control group (2883 g, SD = 640, n =
month, they were instructed to do 1-hour sessions daily 52) (P = .009). Rates of LBW (<2500 g) were lower in
at home using a prerecorded instruction cassette. The the EG than in the control group (P = .003); the num-
control group did standard prenatal exercises. Both bers of LBW were 3 and 14, respectively. The results
groups attended a 1-hour refresher class during each for preterm birth were at the level of trend (P = .102),
visit for prenatal checkup. Compliance for completing with 1 preterm birth in EG and 5 in the control group.40
the 60-minute practice session was ensured by tele- Similarly, yoga (IAYT) was associated with a decrease in
phone calls and an activity diary.23 preterm deliveries at the level of trend (P = .10) but not
In the previously described study by Nickel et al,22 with differences in mean gestational age at delivery.21
an 8-week PMR intervention was associated with The analysis of a subsample showed higher mean-
significantly greater rate of change in the PMR group birth-weights in newborns of mothers with Doppler

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
abnormalities who used IAYT.21 Moreover, massage neonatal physical condition (indicated by Apgar scores
therapy was associated with reduced rates of prematu- and head circumference).20,41
rity and LBW in healthy as well as in depressed women In summary, the studies reviewed used a wide range
(Ps < .05).29,31 Furthermore, 2 studies investigated of techniques to induce relaxation, such as applied re-
different relaxation exercises in women experiencing laxation, yoga, massage therapy, hypnosis, combina-
preterm labor. In the first study, women between 26 tions of breathing techniques and head-to-toe release,
and 34 weeks of gestation received either daily hypnotic biofeedback, relaxation, and a combination of GI and
relaxation in addition to pharmacological treatment (n relaxation exercises. The research data show that cer-
= 39) or medication alone (n = 74).45 The experimental tain forms of relaxation techniques are effective re-
group had an average rate of pregnancy prolongation of garding birth weight, prematurity, preterm labor versus
74.2% compared with 55.4% in the control group (P < pregnancy prolongation, and length of gestation.
.002). On average, newborns of mothers in the experi- These results provide healthcare workers with a
mental group weighed 200 g more (P < .005), although good impression of potential benefits of different re-
birth weights of 200 g are not of clinical relevance.45 The laxation techniques. To help mothers at risk for prema-
second study, a randomized control trial by Janke,42 turity massage therapy, hypnotic relaxation and breath-
assigned 84 women with documented early contrac- ing/tension release seemed to be superior to applied
tions and cervical changes either to a relaxation condi- relaxation and yoga. However, the latter 2 relaxation
tion (diaphragmatic breathing and head-to-toe release) types are successful with respect to the type of delivery
(n = 44) or to a control condition (n = 40) without in- and duration of labor.
tervention. In addition, there was a nonadherent group
(n = 23). The experimental group had significantly Benefits for the fetus
longer gestations than the control and the nonadher- Four studies investigated the effect of relaxation on fetal
ent groups (P = .001). Birth weight was also greater in motor (FM) activity, FHR, FHR variability, or intrauterine
the experimental group than in the other groups (P = growth retardation.19,21,29,46 Fink et al46 studied active
.001). In addition, the rate of pregnancy prolongation relaxation (PMR and GI) and passive relaxation (quiet
was highest in the experimental group (P = .001).42 rest) and their effects on fetal behavior using a car-
Second, the controversial findings with regard to the diotocogram device.
type of delivery are summarized. No association was Thirty-nine pregnant women were randomly as-
found for the IAYT study,21 whereas normal vaginal de- signed either to the intervention group (PMR, GI) or
liveries (P = .001), fewer cesarean deliveries (P = .001), to the control group (quiet rest). They made a single
and lower rates of instrumental delivery (P = .001) 2-hour visit to the hospital. There was an accommoda-
were observed in the study by Bastani et al.40 Saisto et tion phase to the laboratory procedure of 30 minutes.
al44 conducted weekly group sessions for 5 weeks with Participants of the intervention group listened to the
102 women in their second trimester. Sessions included standardized relaxation intervention (either PMR or GI)
discussion, GI, and relaxation exercises. These women on CD using headphones (duration = 10 minutes). Par-
had fear of vaginal delivery and requested a caesarean ticipants in the control group were asked to sit quietly
delivery.44 Eighty-five women (control group, not ran- during these 10 minutes.
domly assigned) discussed their fears with an obste- Results indicated that long-term FHR variation dif-
trician. Participation in group sessions was associated fered between the intervention group and the con-
with a reduction in elective caesarean deliveries (P = trol group (P = .039), with fetuses of the intervention
.05) and an increase in successful vaginal deliveries (P groups having higher long-term variation during (9.0
= .02) but not with the duration of delivery.44 ± 4.7 vs 5.6 ± 5.1) and after relaxation (8.4 ± 5.0 vs
Third, results regarding duration of labor were stud- 5.6 ± 6.6) than the control group (quiet rest). How-
ied. No beneficial effect on the duration of labor was ever, there were no differences between the 2 active
found when combining relaxation and biofeedback.20 intervention groups’ PMR and GI observed. However,
In contrast, Chuntharapat et al41 observed lower du- fetuses of participants in the GI group showed more fe-
ration of labor (P < .05), higher maternal comfort tal body movements after relaxation than PMR fetuses
(P < .05), and lower-levels of pain during labor (P < (39 ± 3.2 vs 28 ± 3.5, P = .027). Interestingly, mater-
.05) after six 60-minute yoga sessions between the 26th nal postural changes have been found to stimulate the
and the 37th week of gestation, than routine prenatal fetus.47
care.41 In a single 18-minute GI exercise by DiPietro et al,19
As a final point, 2 of the previously described fetuses showed alterations in fetal neurobehavior such
studies found no association between the use of as suppression of FM activity (P < .0001), decreased
relaxation and yoga therapy during pregnancy and FHR (P ≤ .05) (changes within reference range: from

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144 to 141.5 bpm), increased FHR variability (P < .01), was assessed using the Brazelton Neonatal Behavioral
and increased FM-FHR coupling (P = .001).19 The pri- Assessment Scale (NBAS).29,50 Neonates of depressed
mary changes were observed from baseline (means) to mothers in the massage group showed best perfor-
relaxation periods (means) and therefore the changes mances on the NBAS (Habituation, Range of State, Au-
in fetal cardiac responses were concluded to be due tonomic Stability, Withdrawal, and Depression scales;
to maternal recumbence. Although there was a slight Ps < .05) compared with neonates of mothers in the
rebound in FHR levels to not return to baseline, which PMR, the standard prenatal care, and the nondepressed
could be the result of a persistent effect of maternal rest control group. In addition, newborns of women in the
on this parameter. A potential prolonged consequence massage and PMR groups performed better on the Mo-
of maternal rest was seen in FHR variability, which, in tor Maturity scale.29 In the second study,50 64 neonates
contrast to all other measures, showed a linear increase (mean age = 6.8 days) were compared according to
for the prebaseline condition through recovery. The lit- their performance on the Brazelton NBAS. Participants’
erature describes that fetuses under stress have elevated partners applied 20-minute pressure massages twice a
FHR and lower FHR variability.48,49 Findings from Fink week over a period of 16 weeks. There were 2 mas-
et al46 and DiPietro et al19 suggest a close link between sage groups: moderate pressure massage versus light
fetal neurobehavior and maternal rest as well as likely pressure massage. Newborns of the moderate pressure
benefits of relaxation techniques for both the mother massage group showed more vocalizing behaviors (P
and her fetus. < .05) and achieved better scores on the Orientation (P
In comparison in the massage study by Field et al,29 < .05), Motor (P < 05), and Excitability (P < .01) scales
fetal activity of depressed and nondepressed mothers and on the depression cluster of the NBAS (P < .05) in
was assessed by Doppler ultrasonography. After the their first week of life.50
16-week intervention, a reduction in fetal movement In the first study by Field et al,29 higher gestational
was seen in all groups—most pronounced in the mas- age and birth weight could have played an important
sage group compared with the PMR group (P < .05). role. Specifically, neonates of massaged women had
Although it could also be argued that toward the end higher gestational age and birth weight, which is known
of the third trimester, there is not much space left in to be associated with neurobehavior of newborns, and
the womb for fetal movement. Narendran et al21 inves- hence these factors could have been an important me-
tigated the effect of IAYT on fetal growth and found a diator for better performance on the NBAS.29 In this
lower incidence of idiopathic intrauterine growth retar- respect, the findings regarding massage therapy and
dation (<10th percentile) (P = .003).21 neonatal performance also have to be interpreted care-
Both, single relaxation19,46 and a 16-week fully, although the second study50 did not seem to have
intervention,29 could potentially be associated with the bias of gestational age and birth weight. It is very
changes in fetal behavior. However, methodologically, likely that if the mother benefits from massage ther-
it is not clear whether maternal recumbence or limited apy (obstetric and psychological outcomes), then fetal
space in the womb toward the end of pregnancy development is also influenced positively and hence
might have explained some of the significant findings neonatal adaptation.
of 2 studies.19,29 Therefore, the observed associations
in the study by DiPietro et al19 were concluded to
be due to maternal autonomic changes. The other DISCUSSION
studies associated maternal endocrine alterations29 or Chronic stress, anxiety, and depression during preg-
a connection with lower gestational hypertension.21 nancy can adversely affect obstetric, fetal, and neonatal
However, Fink et al46 found no associations between outcomes.1 The perinatal period is one of the most sen-
maternal HR, systolic/diastolic BP, and fetal behavior. sitive developmental phases in an individual’s life (as
Similarly, the stress hormones NE and cortisol were not a fetus and as a parent). There is a lack of evidence
correlated with fetal behavior. of interventions during this period. Treatment options
The findings indicate an effect of relaxation (PMR and evidence-based interventions for affected mothers
and GI), massage, and yoga therapy on the fetus; yet, should be readily available. Thus, identifying pregnant
data are still very sparse and these effects have to be women at risk and instituting treatment early in preg-
considered as preliminary. nancy could improve obstetric and developmental out-
comes for both the mother and her fetus. Suggestions
Relaxation and newborn behavior for clinical practice are provided in Table 1.
So far only Field and colleagues29,50 evaluated the as- Case-control studies have evaluated the benefits and
sociations between relaxation during pregnancy and risks of psychotropic medication.51 In contrast, in-depth
newborn behavior. In both studies, neonatal behavior evaluation of the effectiveness of specific psychological

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Table 1. Suggestions for clinical practice

Method
Provide relaxation training (eg, with audio CD, individual training or group sessions)
Guided imagery
Mindfulness exercises
Provide accurate information, psychoeducation, and specific self-help literature (eg, stress management during
pregnancy)
Support activities that bring joy, relaxation, a balanced day structure, and distraction
Cognitive behavioral therapy (∼10-20 sessions)
Group sessions to foster maternal-fetal attachment and future bonding (eg, childbirth classes)
Patient support groups for pregnant women experiencing stress/anxiety during pregnancy
Provide professional Web sites for pregnant women
Social support system: Who can support the pregnant woman? Find out in conversation, how the patient is supported
and whether additional support is needed. Elaborate with the patient where to find this additional support

Abbreviations: CD, compact disk.

interventions such as relaxation techniques or cogni- techniques and head-to-toe release, biofeedback and
tive behavioral therapy during pregnancy does not exist relaxation, and finally, the combination of GI and re-
at all.16,25 Nevertheless, research in this particular field laxation exercises. These techniques were successful in
would be crucial for assessing how some interventions changing obstetric outcomes. Applied relaxation led to
might be contraindicated during pregnancy because of less LBW and to a trend for less prematurity.40 Compara-
potential harmful effects on pregnancy outcome and bly, yoga also changed rates of prematurity at the level
hence on the fetus. For example, PMR has been found of trend.21 Massage therapy seems to perform slightly
to elicit uterine activity/contractions in one study.46 better; it was clearly associated with reduced rates of
While the evidence for the effectiveness of differ- prematurity and LBW in both healthy and depressed
ent relaxation techniques in nonpregnant populations mothers.29,31 This summary provides healthcare work-
is well established, systematic research on relaxation ers a well-rounded impression about potential benefits
effects during pregnancy is very limited. Therefore, the of different relaxation techniques. To help mothers at
present review aimed at investigating the impact of re- risk for premature delivery, massage therapy, hypnotic
laxation techniques on maternal well-being, pregnancy, relaxation, and breathing/tension release seemed to be
fetal, and neonatal outcomes. superior to applied relaxation and yoga.
The reviewed studies documented various signifi- Third, fetal outcome studies indicated that relaxation
cant effects: First, antenatal relaxation had a positive reduced FHR and increased FHR variability,19,46 reduced
impact on pregnant women’s emotional state, re- FM activity,29 and intrauterine growth retardation.43
flected by a reduction in depressive symptoms,29,32,52 Both single relaxation19,46 and a 16-week intervention29
anxiety,24,25,29,31,36,38,52 worries,31 and experienced could potentially be associated with changes in fetal
stress,25,32,36,43 as well as an increase in perceived social behavior. However, methodologically, it is not clear
support.31 Relaxation techniques should therefore be whether maternal recumbence or limited space in the
included into routine care for treating pregnant women womb toward the end of pregnancy might have ex-
experiencing distress. In future studies, researchers plained some of the significant findings of 2 studies.19,29
could look for differential effects in women with high However, Fink et al46 found no associations between
and low levels of distress. Studying these effects could maternal physiological/endocrine measures and fetal
provide information on potential beneficial outcomes behavior.
of relaxation in women experiencing stress, anxiety, Fourth, higher-birth-weight21,40,42,45 and better per-
depression, and anxiety disorders. formance on the NBAS29,50 were related to relaxation
Second, pregnancy outcomes improved after re- as well. In an NBAS study by Field et al,29 higher
laxation, with less admission to the hospital,20 fewer gestational age and birth weight could have played
obstetric complications,29,31 longer gestations,42,43 less an important role: neonates of massaged women
pain during labor,41 a reduction in caesarean delivery had higher gestational age and birth weight, which
and instrumental extractions,40,44 and fewer postpar- are known to be associated with neurobehavior of
tum complications.31 These studies used different re- newborns, and hence these factors could have been
laxation techniques, such as applied relaxation, yoga, an important mediator for better performance on the
massage therapy, hypnosis, combinations of breathing NBAS.29 Therefore, the findings regarding massage

The Journal of Perinatal & Neonatal Nursing www.jpnnjournal.com 303

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
therapy and neonatal performance also have to be of relaxation, therefore, remains unspecific. Increas-
interpreted carefully. It is very likely that if the mother ing frequency of regular relaxation trainings over
benefits from massage therapy (obstetric and psy- a longer period is likely to enhance the positive
chological outcomes), then fetal development is also psychobiological findings described in the reviewed
influenced positively and hence neonatal adaptation. studies.21,22,29,31,36,37,41,42
Review of studies examining maternal endocrine Measurement of dependent variables was obtained
and physiological reactivity to relaxation was a further through self-reported questionnaires and physiological
aim of this article. In summary, relaxation training determinants, whereas only few studies investigated
was associated with lower maternal HR and BP, lower the effect of relaxation on fetal well-being and/or on
incidence of gestational hypertension, changes in heart neonatal behavior.19,46,53,54 A further limitation of the
rate variability,19,20,22−24 and with decreases in cortisol reviewed studies was the lack of differential analyses
levels.19,24,29,32 Only 3 studies have investigated other concerning response to treatment. For example, while
endocrine parameters and observed a decrease in NE some women are sensitive to GI, others do not re-
and adrenocorticotropin hormone levels (active, pas- spond to this relaxation intervention; the identification
sive relaxation) and an increase in serotonin/dopamine and analyses of nonresponders is important to spec-
levels after massage therapy.24,25,29 For healthcare ify adequate relaxation techniques during pregnancy
workers, these preliminary results can be useful in for both responders and nonresponders. Most studies
explaining positive effects of relaxation on different failed to consider potential mediators such as mental
levels (eg, effects on maternal physiology, well-being, health, ability to relax, quality of partnership, and social
and stress hormones). There are many patients who support.19−21,40,42−45,50,55 These factors have to be con-
appreciate objective background information regarding sidered more systematically in order to provide tailored
interventions during pregnancy. Severe stress, anxiety, treatment options for pregnant women. Consequently,
and depression have been associated with changes the direct comparison of different relaxation techniques
in the endocrine and physiological systems. These should be a further aim for subsequent research.
stress-related alterations could potentially be coun- Except for the studies by Field et al,29,52 samples con-
terbalanced by conducting relaxation methods on a sisted of relatively healthy pregnant women and differ-
regular basis. Notably, none of the reviewed studies ential effects in women with enhanced levels of distress
related relaxation-induced endocrine alterations to were not studied. Although the review cautiously points
maternal cardiovascular and psychological parameters to the general psychophysiological benefits of relax-
or to fetal and neonatal outcomes. The underlying ation during pregnancy, the question remains whether
mechanisms by which relaxation techniques develop relaxation training can be considered as an adequate
their beneficial effect thus still need to be elucidated. and effective intervention for pregnant women with
mental health problems. Thus, future studies should
examine the benefit and risks of relaxation interven-
LIMITATIONS tion during pregnancy in women with a clinical relevant
Despite the reported benefits of relaxation techniques mental health disorder. There is a great need to define
during pregnancy, a direct comparison of the reviewed evidence-based interventions designed for the perinatal
studies remains difficult because of differences in re- period for women presenting with chronic stress, anxi-
laxation paradigms and procedures as well as different ety, and/or depression. It is important to keep in mind
outcome measures. In addition, several methodological potential contraindications (eg, physiological changes
shortcomings limit the validity of the results. Study de- affecting obstetric outcome, such as contractions, due to
signs were partially suboptimal with inadequate or no potential overwhelming interventions) when develop-
control groups; yet, 10 studies22,25,29,36,38,40,42,44−46 had ran- ing and tailoring therapy interventions for the perinatal
domized controlled trials. Of note, sample sizes were period.
often small and a sample bias cannot be excluded. Pre-
sumably, pregnant women at risk were highly encour-
aged to participate and/or highly motivated. In addition, SUMMARY
interventions were carried out in samples at varying ges- The majority of the findings in this review speak to
tational weeks, which might have had an influence on the effectiveness of relaxation techniques during preg-
biological as well as on psychological parameters. Some nancy. Healthcare workers could therefore actively pro-
studies insufficiently specified the applied relaxation vide relaxation techniques as part of a well-being and
procedure.19,21,23,38,43−45 In addition, data collection in SR program. Nurses and midwives see pregnant women
reviewed studies was limited to a single19,24,25,32,46 or a in their first, second, and third trimesters. They could
few45 assessment points. Significance of the influence provide multiple relaxation sessions, follow-up on

304 www.jpnnjournal.com October/December 2012

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
practicing, and, if needed, provide psychoeducation. 11. Mulder EJ, Robles de Medina PG, Huizink AC, Van den Bergh
Table 1 provides a compilation of practical suggestions BR, Buitelaar JK, Visser GH. Prenatal maternal stress: ef-
fects on pregnancy and the (unborn) child. Early Hum Dev.
for clinical practice. 2002;70:3–14.
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neglected the specificity of the perinatal period, where influences fetal neurobehavior: cortisol does not provide all
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