Prenatal exposure to alcohol can lead to a range of physical, mental, behavioral, learning, and developmental disabilities, with possible lifelong effects for the child exposed in utero. This range is commonly known as fetal alcohol spectrum disorder or FASD. FASDs are 100% preventable when a baby is not  exposed to alcohol during pregnancy.

Healthcare professionals may tell women that it’s OK to drink alcohol on occasion or even in moderation, when they are pregnant. However, evidence shows that there is no known safe type, safe amount, or safe time to consume alcohol while pregnant.

Additionally, it’s important for healthcare professionals to broach the subject of alcohol consumption, not only with their pregnant patients, but with all women of reproductive age. Women who are sexually active and not using effective contraception may be at an increased risk for alcohol exposed pregnancies, as nearly half of all pregnancies within the United States are unplanned.

It is critical that healthcare professionals educate all women of reproductive age about alcohol use and pregnancy. Alcohol screening and brief intervention (alcohol SBI) is one evidence-based approach to assessing patients for at-risk alcohol use. Screening includes use of a validated tool, such as the Alcohol Use Disorders Identification Test (AUDIT). The AUDIT is a clinically reliable and valid instrument (Bohn, Babor & Kranzler, 1995). The AUDIT has been consistently found to screen and detect alcohol use across a spectrum of low, moderate, and high risk consumption (Reinert & Allen, 2007).  The AUDIT has been found to be valid and reliable with diverse populations and in a variety of settings.

When a patient screens positive for at-risk use, a non-judgmental discussion, called a “brief intervention” occurs with the use of motivational interviewing techniques. For example, the patient is provided with the score on the AUDIT during the health care visit. If a patient scores between an 8 and 15, this score is discussed in relation to their current health condition and presented objectively to the patient as moderate alcohol consumption. If the AUDIT score is between 16 and 19, then brief counseling and continued monitoring are suggested. With a score of 20+ a referral for further assessment is indicated (Babor & Higgins-Biddle, 2001). The main goals of the brief intervention are to increase a patient’s awareness of their alcohol consumption patterns, understand the associated risks and options for reducing or eliminating those risks, and to increase their motivation to make healthy choices.

As nurses, it is our obligation to ensure that women are provided with the knowledge needed to make informed choices regarding their health. For example, giving the patient objective feedback about their score on the AUIDT and then asking them “What are your thoughts about this score?” is a way to elicit their thoughts and feelings about their alcohol consumption in relation to their health and wellness. Further, exploring the pros and cons of the patients current level of alcohol consumption is an excellent technique to elicit the patients thoughts and provides an opportunity for the health professional to provide feedback and health education.  Patients have high trust in confiding to their healthcare provider and in particular nurses.

Additional Resources

• AWHONN’s FASD Resources
• AUDIT Website

Dr. Ann M. Mitchell is professor of nursing and psychiatry at the University of Pittsburgh School of Nursing. She is principal investigator on a CDC-funded project for the implementation of alcohol screening and brief intervention with the ultimate goal of preventing FASDs.

Dr. Holly Hagle is Director of Education for the Institute for Research, Education and Training in Addiction (IRETA) and a partner in the CDC-funded FASD project.

Brayden Kameg is a graduate student in the psychiatric-mental health nurse practitioner DNP program at the University Of Pittsburgh School Of Nursing. She is actively participating in grant-related activities on Dr. Mitchell’s projects.

For Nurses Week, we are promoting the “year of the healthy nurse.” We are encouraging nurses, like you, to focus on having a healthy mind, body, and spirit, to support your overall wellbeing. For me, I love exercise and have become more committed to it than ever. I find that the simple activity of exercising helps to clear my head and prepares me for my day. If your body and the mind are healthy, the care you can give your patients will be improved.

Exercising has so many benefits for the body: weight management, endorphins that elevate your mood and the energy it delivers to you. Here are my personal five tips for exercising that I believe will help improve your mind, body and spirit.

1. Establish routine. As nurses, our schedules can be pretty hectic and unpredictable, which is why it’s important to establish a regular exercise routine. This is key because when you neglect to establish a routine, it’s easier to make excuses or find reasons not to workout. For me, I go to the gym at 5 AM because that works for me. Take a step back and see what time works best for you. Exercise has to be established as a priority and built into your schedule for a day or for the week.
2. Stand up regularly at work. As nurses, we stand up most of the day which is a wonderful way to stay active during the day. I find that getting up every once in a while is important to do at work because it keeps the blood flowing. It’s as simple as taking a brisk walk around the block, the facility or the grounds that can make all the difference. If you have the opportunity to have a standing desk, use it. I love mine. It makes it easier to walk around the office, and simple tasks that require you to go to a different part of the office are no longer hard to do.
3. Use a medicine ball as your chair. If I am going to sit at work, I always sit on my medicine ball chair. This keeps my body still exercising even when I am sitting because it keeps my leg muscles moving and works out my core.
4. Switch it up. When it comes to exercise, many of us are creatures of habit. We tend to gravitate towards doing the same routine on the elliptical, treadmill, or muscle work out. Regular workout is great but to maximize the time spent at the gym it’s important to include variety in your exercises to keep your muscles challenged. This helps overcome a weight loss plateau, builds new muscles, and prevents boredom from doing the same routine.
5. Meditate for five minutes a day. Spend five minutes a day doing either spiritual meditation or just focus your mind in a direction of positive thinking. As nurses, we have stressful days. Meditation helps relieve some of the stress you face in your day-to-day life.

I have found that when I take care of my body and my mind my overall spirit is better. Nurses have hard days and multiple stress points at work. Whether its meditation, yoga, or exercise, all of these methods help improve the work-life balance we all reach to achieve.

Lynn Erdman, MN, RN, FAAN,
Chief Executive Officer, AWHONN

Lynn joined AWHONN in 2014 with more than 30 years of experience in the healthcare and nonprofit sectors.  She is a highly skilled national leader in the field of nursing and previously held key national leadership positions with three global health organizations: the American Cancer Society, the American College of Surgeons, and the Susan G. Komen Global Headquarters.  Lynn has also served in top leadership positions with several hospitals and healthcare systems.

“The history of man for the nine months preceding his birth would probably be far more interesting and contain events of greater moment than for all the three score and ten years that follow it.”

~Samuel Taylor Coleridge

Decreasing the amount of stress that we encounter daily is beneficial to our health.   Stress initiates the body’s ‘emergency response system’ which activates the adrenal glands to secrete cortisol and adrenaline.  Cortisol is important for energy (glucose metabolism), blood pressure regulation, immune function and inflammatory response, but is secreted in higher levels during increased stress.  Heart disease, diabetes, autoimmune disorders, chronic inflammatory disorders, mental health issues, obesity can all in some way be linked to how the chemicals of stress wreak havoc on our bodies.   Statistics paint a grim picture:

• Preterm birth in the U.S. is higher than in other developed countries (Kaiser Family Foundation, 2015).
• Stress is associated with an increased chance of preterm birth (PLos One, 2012)
• High rates of anxiety and depression, according to WHO, the U.S. has one of the highest rate of mental disorders of any other developed country. (U.S. News, 2016)
• High rates of obesity – females affected more than males (World Obesity, 2017)
• Immune and allergy disorders, chronic diseases have increased drastically in the last few decades (overwhelming majority affecting women)(Molecular Metabolism, 2016)

One concern is how these chemicals affect a woman and her growing fetus during pregnancy.  Many pregnant women  are exposed to chronic stress;  examples are the stress of jobs, finances, family responsibilities, the expectation and drive for success, high fat and low nutrient diets, lack of time for physical activity,  lack  of community and family support, intimate partner violence, effects of racism and social marginalization.  Stress chemicals can pass to the developing baby through the placenta.

Watering the Seeds of Peace:

But pregnant women can seek to balance and reduce their stress in order to pass on positive neurological chemicals to their babies.  In particular, mindfulness practices such as yoga and meditation have profound impacts on the human brain and, when practiced in the prenatal period, can also influence the growing brain of the fetus. (PLos One, 2012)These types of practices produce changes in the neural pathways and hormonal centers that support parasympathetic response and as these neural connections are strengthened, sympathetic hypersensitivity is decreased. Mindfulness has the potential to reduce the effect of stress chemicals in the body (Journal of Obstetric, Gynecologic and Neonatal Nursing, 2009) since these chemicals are being sent directly to the fetus, through the placenta.

Mindfulness may also reduce the effects of stress chemicals in the baby.  Research shows increases in gray matter concentration in the left hippocampus, which affects learning, memory, and emotional control.  Infants  born of mothers who practice meditation have been shown to have better self-regulation and more emotional control. (Infant Behavior and Development, 2014)

Practicing mindfulness on a regular basis can also “create change in the brain that support feelings of peace, contentment, self-confidence and joy.  As these connections in the brain are strengthened, states of anxiety, worry and anger are decreased. Consequently, incidence and severity of stress related conditions are decreased and may, at the very least, become easier to manage.  Mindfulness practice has been shown to decrease anxiety, depression, insomnia, hyperactivity, substance abuse and chemical dependency.  It can also increase bonding and connection to others.

Preparation for Birth

In addition to all the above mentioned benefits, mindfulness has the added benefit of decreasing sensation of chronic and acute pain and possible subsequent psychological distress caused by pain.  This effect has been correlated to altered function and structure in somatosensory areas and an increased ability to disengage regions in the brain associated with the cognitive appraisal of pain, basically ‘reframing’ the sensation.  Most childbirth methods are based on meditative techniques (Lamaze and Bradley breathing, Hypnobirthing, etc.)  Mindfulness practices also enhance immune function – extremely important in pregnancy where it is already suppressed.  If there is a complication that is present (obesity, immune disorder, mental illness) or one that is diagnosed during the pregnancy (gestational diabetes, hypertension, multiples) or that happens during birth (prolonged labor, surgical intervention), regular meditative practices can help prime the immune system so that the effects of these events may be milder.

It’s as simple as ‘ABC’

One of the great things about mindfulness is that it can be practiced literally anytime, anywhere.

A is for Awareness:  Simply pause or stop and become AWARE of the present moment. An easy way to do this is just notice the body in space… the arrangement of the legs or arms, the overall tone in the body… the sensations in the body. Use the senses to drive your awareness:  the feel of the coffee cup in your hand, the sound of a bird chirping or the rain on the roof, the warmth of the sun on your skin.

B is for Breathing:  Bring your awareness to your breath.  The breath is always present.  Notice the inhalation and the exhalation.  Just by noticing the breath without changing it in any way, nervous system shifts to parasympathetic activity. You can enhance this shift by guiding the breath to be longer and deeper. Regulating the breath in this way also decreases blood pressure and heart rate.  Imagine your breath bringing oxygen to your growing baby. Imagine your baby listening to your deep rhythmic breaths and the slowing of your heart beat.  Calm, serene.

C is for Consciousness:   Or ‘thinking’. Now you have the space in the nervous system to examine your thoughts. Notice that they come and go like clouds on a windy day.  If there is a particular thought or sensation that is troubling you or seems uncomfortable, you have the ability to CHOOSE your reaction instead of unconsciously reacting with habitual patterns of response.

When we practice in this way, even for a few minutes a day, our nervous system slowly begins to rewire and connections of peace and joy are strengthened.  In the pregnant mom, this benefit is wiring the baby’s brain from the very beginning of development.

Helpful Resources and Links

• Antenatal mindfulness intervention to reduce depression, anxiety and stress
• Fit Pregnancy: 5 Prenatal Meditation Techniques
• Impact of stress and stress physiology during pregnancy on child metabolic function and obesity risk
• Incidence and prevalence of chronic disease
• Mindful Birthing
• Prenatal meditation influences infant behaviors
• Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization
• The Association for Prenatal and Perinatal Psychology and Health
• The effects of mindfulness-based yoga during pregnancy on maternal psychological and physical distress.
  

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  Holly Lammer is an Obstetric Nurse, Clinical Educator and Childbirth Instructor for St. Luke’s Health System based in Boise, ID.  In addition to teaching credentialed courses through AWHONN and AHA,  she develops and teaches curriculum for prenatal and perinatal specialty courses offered in the St. Luke’s system.  Holly is also registered with the Yoga Alliance as a 500-hr Yoga Instructor and on faculty as a Prenatal Yoga Teacher Training Instructor. She is certified in Inpatient Obstetrics and Electronic Fetal Monitoring through NCC and is in process of obtaining her Pre and Perinatal Psychology Educator through the Association for Pre and Perinatal Psychology and Health.

  Holly has blended her experience in high volume high risk inpatient setting with her training and research in mind-body therapies to form unique educational programs for pregnant women and the providers that care for them, including Intuitive Birth – the area’s only Mindfulness-Based Childbirth Education series. A driving force for patient centered, evidence-based practice, her passion is apparent in her program content and her ability to drive changes at the policy level to improve outcomes for women and babies.

  Holly has spoken regularly at multidisciplinary local and regional conferences on the subjects of physiologic birth, prenatal psychology and health, and mindfulness-based strategies to improve health.  In addition, she provides regular educational opportunities for the public and for inpatients and care providers in her community.