Maternal anxiety and feelings of control during labour: a study of Chinese first-time pregnant women

Association between anxiety and pain in the latent phase of labour upon admission to the maternity hospital: a prospective, descriptive study

This study investigated the association between anxiety experienced by the mother, a request for analgesia, and the level of pain at maternity hospital admission in early labour. Anxiety levels were measured by the State-Trait Anxiety Inventory and pain was assessed using a Visual Analogue Scale. Anxiety and Visual Analogue Scale scores were compared using a linear regression model and indicated a statistically significant association between the anxiety state and degree of pain (p < 0.016; Y = 0.895 x score + 32.656). There was no significant association between anxiety and a request for epidural analgesia. During labour, an evaluation of anxiety should be associated with an assessment of the perceived degree of pain.

Antenatal education and the birthing experience of Brazilian women: a qualitative study

Background

Information is still scarce on the birthing experience of women who participate in antenatal systematic education programs. The objective of the study was to report the experience of labor as described by nulliparous women who participated and who did not in a systematic Birth Preparation Program (BPP).

Method

A qualitative study was conducted with eleven women who participated in a BPP and ten women attending routine prenatal care selected through purposeful sampling. The BPP consisted of systematized antenatal group meetings structured to provide physical exercise and information on pain prevention during pregnancy, the role of the pelvic floor muscles, the physiology of labor, and pain relief techniques. A single, semi-structured interview was conducted with each participant. All interviews were recorded, transcribed verbatim and thematic analyses performed. The relevant themes were organized in the following categories of analysis: control of labor, positions adopted during labor, and satisfaction with labor.

Results

Women who participated in the systematic educational activities of the BPP reported they maintained self-control during labor and used breathing exercises, exercises on the ball, massage, baths and vertical positions to control pain. Also they reported satisfaction with their birthing experience. Women who did not participate in systematic educational activities referred to difficulties in maintaining control during labor and almost half of them reported lack of control. Also they were more likely to report dissatisfaction with labor.

Conclusions

Women who participated in the BPP reported self-control during labor and used non-pharmacological techniques to control pain and facilitate labor and expressed satisfaction with the birthing experience.

The effectiveness of a Chinese midwives' antenatal clinic service on childbirth outcomes for primipare: a randomised controlled trial

BACKGROUND

Antenatal care is an important component of maternity care. In many parts of the world, midwives are the primary caregivers for childbearing women, providing a high level of continuity of care during a normal pregnancy. While in China, obstetricians are the primary providers of antenatal care for all childbearing women; and midwives only provide intrapartum care to labouring women. Today midwifery as a profession in China has been marginalised. Pregnant women usually lack individualised continuity of care from midwives during the perinatal period. There have been few randomised controlled trials of midwifery care practice in mainland China.

OBJECTIVE

(1) To develop and implement a model of Chinese midwives' antenatal clinic service and (2) to explore its effect on childbirth outcomes, psychological state and satisfaction, for primiparae.

DESIGN AND METHODS

Two-group randomised controlled trial. One hundred and ten pregnant women were assessed for eligibility and invited to participate in either the intervention group (midwives' antenatal clinic service) or the control group (routine antenatal care) in the Obstetrics and Gynaecology Hospital of Fudan University from September 2011 to December 2011. Baseline data were collected, and then women were randomised to individual midwives' antenatal clinic care (intervention group) or regular antenatal clinic service by obstetricians and obstetric nurse (control group). The research hypothesis was that compared with regular obstetrician-led antenatal care, the midwives' antenatal clinic service would decrease the caesarean section rate, produce more favourable birth outcomes and women's greater satisfaction with care. Data were collected by retrospective review of case records and self-report questionnaires. The sample size of 110 was calculated to identify a decrease in caesarean birth from 70% to 40%. Birth outcomes, satisfaction and anxiety score in the two groups were compared.

SETTING

The midwives' antenatal clinic in the Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China.

PARTICIPANTS

55 women, attending the midwives' antenatal clinic (the intervention group) and 55 women, entering the control group.

RESULTS

Women in the intervention group were more likely than women in the control group to have a vaginal birth (35 [66.04%] versus 23 [43.40%]; 95% CI for difference 3.69-41.60). Women in the intervention group had a higher perinatal satisfaction but lower anxiety score than those in the control group. No differences were seen in neonatal Apgar score and in the amount of bleeding 2h post partum.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The midwives' antenatal clinic can decrease the rate of caesarean section and enhance women's satisfaction with midwifery care. Further research needs to be conducted to implement this model of care more widely. We will attempt to make midwifery care a true choice for Chinese women.

Supporting patients' birth plans: theories, strategies & implications for nurses

Pregnant women often create birth plans to specify their preferences for their labor and delivery. When nurses implement and advocate for women's birth plans, it increases women's autonomy and decision-making in the birth process and can lead to greater patient satisfaction. This article describes strategies for how nurses can help implement patients' birth plans, and discusses two psychological theories as a base for understanding nurses' roles in advocating for birth plans to improve patients' experiences.

In the Nepalese context, can a husband's attendance during childbirth help his wife feel more in control of labour?

Background

A husband’s support during childbirth is vital to a parturient woman’s emotional well-being. Evidence suggests that this type of support enables a woman to feel more in control during labour by reducing maternal anxiety during childbirth. However, in Nepal, where childbearing is considered an essential element of a marital relationship, the husband’s role in this process has not been explored. Therefore, we examined whether a woman in Nepal feels more in control during labour when her husband is present, compared to when another woman accompanies her or when she has no support person.

Methods

The study participants were low risk primigravida women in the following categories: women who gave birth with their husband present (n = 97), with a female friend present (n = 96), with mixed support (n = 11), and finally, a control group (n = 105). The study was conducted in the public maternity hospital in Kathmandu in 2011. The Labour Agentry Scale (LAS) was used to measure the extent to which women felt in control during labour. The study outcome was compared using an F-test from a one-way analysis of variance, and multiple regression analyses.

Results

The women who gave birth with their husband’s support reported higher mean LAS scores (47.92 ± 6.95) than the women who gave birth with a female friend’s support (39.91 ± 8.27) and the women in the control group (36.68 ± 8.31). The extent to which the women felt in control during labour was found to be positively associated with having their husband’s company during childbirth (β = 0.54; p < 0.001) even after adjusting for background variables. In addition, having a female friend’s company during childbirth was related to the women’s feeling of being in control during labour (β = 0.19; p < 0.001) but the effect size was smaller than for a husband’s company.

Conclusion

The results show that when a woman’s husband is present at the birth, she feels more in control during labour. This finding has strong implications for maternity practices in Nepal, where maternity wards rarely encourage a woman to bring her husband to a pregnancy appointment and to be present during childbirth.

Control in childbirth: a concept analysis and synthesis

AIM

To report a concept analysis of control in childbirth.

BACKGROUND

Control has a variety of definitions from a wide range of disciplines. In childbirth, however, the concept is more tenuous and depends on the context. It can be viewed in relationship to a woman's body and labour progression, pain, environment and the ability to request her method of birth.

DATA SOURCES

Medline, CINAHL and PsycINFO databases were searched between 1970-2011 using the keywords, 'control', 'childbirth', 'labour' and 'delivery'.

REVIEW METHODS

Walker and Avant's method of concept analysis was used for this review. In addition, cases were placed before defining attributes as recommended by Risjord.

RESULTS

Four attributes of control were identified: decision-making, access to information, personal security and physical functioning. Antecedents include pregnancy and expectations of the birth. Consequences include childbirth satisfaction, childbirth experience, emotional well-being, fulfilment and the transition into motherhood. A model case, contrary case and borderline case are described.

CONCLUSION

Clarifying the definition of control in childbirth and defining its attributes can help inform women and maternity providers throughout the world. This analysis provides clarity to a previously tenuous concept and allows practitioners to better understand the critical relationship between control in childbirth and satisfaction with the childbirth experience. It also has the potential to affect perinatal outcomes and subsequently healthcare costs.

Pain and emotions reported after childbirth and recalled 6 months later: the role of controllability

The aim of this longitudinal study was twofold: to investigate the relationship between subjectively evaluated control, positive and negative emotional feelings, and pain intensity during childbirth; to assess the recall of these aspects of childbirth experience 6 months after delivery. Participants were 123 women who delivered naturally and spoke fluent Italian. Results showed that both immediately after delivery and 6 months later, higher subjective controllability was related to less severe reported pain, more intense positive emotions and less intense negative emotions. Furthermore, although there was no significant bias in the vividness of the recall, 6 months after delivery women reported higher subjective controllability, more intense positive emotions, less intense negative emotions and less intense pain. It is concluded that in preparing women for childbirth, two aspects deserve particular attention: the enhancement of subjectively perceived controllability and the possibility to work on both negative and positive emotions.

Childbirth experience questionnaire (CEQ): development and evaluation of a multidimensional instrument

Background

Negative experiences of first childbirth increase risks for maternal postpartum depression and may negatively affect mothers' attitudes toward future pregnancies and choice of delivery method. Postpartum questionnaires assessing mothers' childbirth experiences are needed to aid in identifying mothers in need of support and counselling and in isolating areas of labour and birth management and care potentially in need of improvement. The aim of this study was to develop and evaluate a questionnaire for assessing different aspects of first-time mothers' childbirth experiences.

Methods

Childbirth domains were derived from literature searches, discussions with experienced midwives and interviews with first-time mothers. A draft version of the Childbirth Experience Questionnaire (CEQ) was pilot tested for face validity among 25 primiparous women. The revised questionnaire was mailed one month postpartum to 1177 primiparous women with a normal pregnancy and spontaneous onset of active labor and 920 returned evaluable questionnaires. Exploratory factor analysis using principal components analysis and promax rotation was performed to identify dimensions of the childbirth experience. Multitrait scaling analysis was performed to test scaling assumptions and reliability of scales. Discriminant validity was assessed by comparing scores from subgroups known to differ in childbirth experiences.

Results

Factor analysis of the 22 item questionnaire yielded four factors accounting for 54% of the variance. The dimensions were labelled Own capacity, Professional support, Perceived safety, and Participation. Multitrait scaling analysis confirmed the fit of the four-dimensional model and scaling success was achieved in all four sub-scales. The questionnaire showed good sensitivity with dimensions discriminating well between groups hypothesized to differ in experience of childbirth.

Conclusion

The CEQ measures important dimensions of the first childbirth experience and may be used to measure different aspects of maternal satisfaction with labour and birth.

Effects of a pushing intervention on pain, fatigue and birthing experiences among Taiwanese women during the second stage of labour

OBJECTIVES

To evaluate maternal labour pain, fatigue, duration of the second stage of labour, the women's bearing-down experiences and the newborn infant Apgar scores when spontaneous pushing is used in an upright position.

DESIGN

Quasi-experimental study.

SETTING

Medical centre in Taichung, Taiwan.

PARTICIPANTS

66 Women giving birth at the hospital, with 33 primigravidas assigned to each group.

INTERVENTIONS

During the second stage of labour, the women in the experimental group pushed from an upright position and were given support to push spontaneously; the women in the control group pushed from a supine position and were supported via Valsalva pushing.

OUTCOME MEASURES

Pain scores were recorded at two evaluation time points: at 10 cm of cervical dilation and one hour after the first pain score evaluation. One to four hours after childbirth, the trained nurses collected the fatigue and pushing experience scores.

FINDINGS

The women in the experimental group had a lower pain index (5.67 versus 7.15, p = 0.01), lower feelings of fatigue post birth (53.91 versus 69.39, p < 0.001), a shorter duration of the second stage of labour (91.0 versus 145.97, p = 0.02) and more positive labour experiences (39.88 versus 29.64, p < 0.001) compared with the control group. There was no significant difference in the Apgar score for newborn infants during either the first minute (7.70 versus 7.73, p = 0.72) or the fifth minute (8.91 versus 8.94, p = 0.64).

KEY CONCLUSIONS

The pushing intervention during the second stage of labour lessened pain and fatigue, shortened the pushing time and enhanced the pushing experience.

IMPLICATIONS FOR PRACTICE

Pushing interventions can yield increased satisfaction levels for women giving birth.

The benefits of antenatal education for the childbirth process in Spain

BACKGROUND

Childbirth has changed dramatically over the past 40 years, although antenatal education (AE) has not. This education has been shown to be beneficial in some countries but not in others.

OBJECTIVE

The objective of this study was to assess the benefits of AE during the childbirth process, controlling for the possible confounding effects of other variables and involving a comprehensive assessment of the birth process.

METHOD

A prospective observational study was conducted in Bizkaia, Spain, to follow 616 low-risk pregnant nulliparous women aged 18-42 years until childbirth. Women who had attended different numbers of AE sessions were compared in terms of the following: whether they arrived at hospital in established labor, whether they received epidural anesthesia before the active phase of the birth, length of the first and second stages (i.e., dilation and delivery), anxiety (Hospital Anxiety and Depression Scale), type of birth, perineal injury, satisfaction with the experience, and the 5-minute Apgar score. Results were adjusted by age, nationality, educational level, social class, personality, and the hospital where the birth occurred.

RESULTS

Spanish women who had attended AE classes experienced less anxiety during birth than those who had not (Hospital Anxiety and Depression Scale score adjusted difference = -1.5, 95% confidence interval = -0.1 to -3.0), whereas the opposite was found for immigrant women (adjusted difference = 2.4; 95% confidence interval = -0.6 to 5.4; AE x Nationality interaction, p = .02). No dose-response relationship was found between AE and anxiety, and no benefits were seen for the other variables.

DISCUSSION

Antenatal education is not found to be associated with benefits during childbirth. Subsequent research should be focused on redesigning and assessing AE in light of the current needs of women.

Midwives' experience of encountering women with posttraumatic stress symptoms after childbirth

OBJECTIVE

To describe midwives' experience of encountering women with posttraumatic stress symptoms after childbirth.

STUDY DESIGN

Semi-structured interviews with eight midwives with experiences of encountering women with posttraumatic stress symptoms after childbirth. Data were analyzed using thematic content analysis.

RESULT

The midwives encountered women with severe experiences after a childbirth, which had affected their lives. The midwives thought that they had to reflect on their own attitude and use their gentleness as they responded to the women's stories. By listening to and enabling the women to express their feelings and tell their stories, the midwives thought that they could confirm the women's experience. The midwives thought that they could support women who had lost confidence to give birth but also thought that cesarean section did not solve the women's problems.

CONCLUSION

Training of midwives is necessary to increase awareness of the cause of women's posttraumatic stress symptoms. It is urgent to optimize the implementation of new research into practical reality to raise the quality of care of women with fear of childbirth. Childbirth is an important experience that can influence a woman's well-being and her connection to the child. Posttraumatic stress symptoms should be identified in an early stage/pregnancy to allow early treatment on the right level of care.

Evaluation of the effects of a birth plan on Taiwanese women's childbirth experiences, control and expectations fulfilment: a randomised controlled trial

BACKGROUND

In many western countries, pregnant women often prepare birth plans, outlining how they would like their childbirth experiences to proceed. However there have been no experimental studies to evaluate the effect of birth plans.

OBJECTIVE

The objective of this research was to evaluate the effects of birth plans on women's fulfilment of their childbirth expectations, their control over the birth process, and overall experiences.

DESIGN

A randomised, single-blind controlled trial study design was used.

SETTINGS

This study involved seven hospitals and 10 obstetricians in Taiwan.

PARTICIPANTS

Participants included primiparous women, each under the care of one of seven Taiwanese medical facilities, and who had been pregnant for at least 32 weeks. They were also at least 18 years old, and had no pregnancy complications. An exclusion criterion was elective caesarean as a mode of delivery. A total of 296 women in hospital clinics who met the study criteria were allocated by block randomisation to experimental (n=155) or control (n=141) groups.

METHODS

The women completed their basic personal information and a childbirth expectations questionnaire when they were recruited. One day after delivery, all the participants completed a questionnaire about the childbirth experience, control and fulfilment of their childbirth expectations.

RESULTS

The experimental group had a statistically higher degree of positive childbirth experiences than that of the control group (t=2.48, p=0.01). The experimental group also showed a higher degree of childbirth control (t=9.60, p<0.001). There were no noticeable differences in mean values between the experimental and control groups in prenatal birth expectations, but a significant difference (t=2.63, p=0.01) in the degree of fulfilment of their childbirth expectations after delivery. On a subscale measuring the fulfilment of childbirth expectations, there was a statistically higher degree of mastery and participation (t=3.74, p<0.001) in the experimental group than in the control group.

CONCLUSIONS

The results justify the clinical implementation of birth plans. Providing birth plans in medical facilities is an effective means of fulfilling pregnant women's childbirth expectations, of affording them a larger degree of control over the birth process, and for their overall positive experiences. Birth plans are acceptable and feasible in maternity care.

Measurement of maternal perceptions of support and control in birth (SCIB)

BACKGROUND

High control and support during labor are associated with improved birth outcomes and increased maternal satisfaction with the birth experience, but measures of control and support are varied and often unidimensional. This paper reports the development and validation of a questionnaire measure of support and control in birth for use in research on birth experience and outcomes.

METHODS

Study 1 interviewed women after birth (n = 10) to identify important dimensions of control and support. In study 2 (n = 402), the Support and Control in Birth (SCIB) questionnaire was developed, with three dimensions of internal control, external control, and support, which was completed by women who had given birth.

RESULTS

Principal components analysis identified a 33-item, three-component solution, which accounted for 55% of the variance and had good reliability (Cronbach's alpha 0.86-0.93).

CONCLUSIONS

Overall, these studies suggest the SCIB provides a reliable and comprehensive measure of support and control in birth.

The Effects of Childbirth Self‐Efficacy and Anxiety During Pregnancy on Prehospitalization Labor

OBJECTIVE

To describe levels of anxiety and self-efficacy for childbirth in nulliparous women during the late third trimester and to identify relationships among those variables, prehospitalization labor pain, management strategies, and hospital admission status.

DESIGN

A longitudinal, descriptive study.

PARTICIPANTS

Thirty-five English-speaking nulliparous women, 18 to 40 years of age, more than or equal to 38 week's gestation, with uncomplicated pregnancies. All participants had a significant other (husband or partner) and attended childbirth education programs.

MAIN OUTCOME MEASURES

Spielberger Trait Anxiety Inventory, Prenatal Self-Evaluation Questionnaire, Childbirth Self-Efficacy Inventory, McGill Pain Questionnaire-Short Form, postpartum interviews, and medical records review.

RESULTS

Prenatal anxiety was significantly related to self-efficacy for childbirth in late pregnancy, labor pain, number of hours at home in labor, and admitting cervical dilation. The number of management strategies used was related to pain scores during labor before hospital admission. Women who spent longer periods of time at home in labor arrived at the hospital with a greater cervical dilation.

CONCLUSIONS

Antenatal characteristics influence intrapartal outcomes in nulliparas. Labor environment, at home and in the hospital, is recognized as an important component of the first childbirth experience.