Obstetric and psychological effects of psychoprophylactic preparation for childbirth

Pain Management in Obstetrics

Critical care clinicians may be called on to care for a laboring woman. Comprehension of the anatomic changes associated with pregnancy, and labor and birth, is essential. A working knowledge of the current options for pain management in labor, both pharmacologic and nonpharmacologic, is necessary to facilitate patient-centered care. Pharmacologic options include intravenous or intramuscular agents, inhalational agents, and neuraxial anesthesia. Each modality has contraindications, risks, and benefits that must be considered when choosing the most appropriate method.

How do the accounts of the patients on pregnancy and birth process enlighten medical team in terms of narrative ethics?

OBJECTIVE

The aim of this study is to evaluate the relationship between the patient and the physician, midwife and nurse during the process of pregnancy and birth, and to ascertain the importance of communication within this relationship; find out the experiences of patients about the communication process.

METHODS

Three hundred eighty-eight people were interviewed about the pregnancy and birth process. Chi square (chi(2)) and t-tests were used for the statistical evaluation of the data. Forty-nine pregnant women, who were participating in any pregnancy training program, were asked to write down their experiences related to the pregnancy and birth process in a notebook. Thirty-two (65.3%) of these notebooks were taken back 3 months after the delivery, and these notebooks were evaluated within the framework of "narrative ethics" and common themes were found out in order to be discussed in this paper.

RESULTS

It is found out that communication skills of doctors and midwives/nurses were of primary importance for all the participants.

CONCLUSION

Pregnancy and birth are special processes and being informed is of great importance in this process. Every woman has a story to tell about her pregnancy and birth processes.

PRACTICE IMPLICATION

These findings may contribute to the development of new hypotheses. Hence, similar research projects should be conducted, and the findings should be compared.

Conceitualização pelas enfermeiras de preparação para o parto

Estudo descritivo, exploratório e qualitativo, realizado mediante a utilização da Técnica de Delphi com amostra de 32 enfermeiras especialistas em Enfermagem de Saúde Materna e Obstétrica que exercem funções em 3 hospitais e 9 centros de saúde do distrito do Porto, norte de Portugal. Teve como objetivos: 1. identificar as idéias e concepções consensuais que um grupo de enfermeiras possui sobre a Preparação para o Parto; 2. saber quais as fontes de informação que consensualmente são mais utilizadas pelas enfermeiras; 3. saber qual a sua aceitação acerca de programas sobre Preparação para o Parto como forma da grávida ter um trabalho de parto ativo. Os resultados revelaram que a Preparação para o Parto é, segundo as enfermeiras estudadas, um momento de educação para a saúde, que envolve procedimentos técnicos, educacionais, relacionais e informativos; de grande importância para a grávida e para a enfermeira, desenrolando-se desde o início da gravidez até o puerpério, como um meio de alterar comportamentos errados com vistas a um resultado esperado com ganhos de saúde para a grávida e sua família.

Maternity satisfaction studies and their limitations: "What is, must still be best"

BACKGROUND

Health policymakers throughout the developed world are paying close attention to factors in maternity care that may influence women's satisfaction. This paper examines some of these factors in the light of observations from previous studies of satisfaction with health services.

METHODS

The Scottish Birth Study, a cross-sectional questionnaire survey, sought the views of all women in Scotland delivering during a 10-day period in 1998. A total of 1,137 women completed and returned questionnaires (response rate = 69%).

RESULTS

Women were overwhelmingly satisfied with their prenatal, intrapartum, and postnatal care. As is common in this type of study, reports of dissatisfaction were relatively low. However, differences occurred in satisfaction levels between subgroups; for example, the fewer the number of caregivers the woman had during childbirth, the more likely she was to be satisfied with the care received. A range of factors appeared to influence reported satisfaction levels, such as characteristics of the care provided and the woman's psychosocial circumstances.

CONCLUSIONS

In addition to the inherent limitations of satisfaction studies found in the literature, problems may arise if such surveys are used uncritically to shape the future provision of maternity services, because service users tend to value the status quo over innovations of which they have no experience. Therefore, although satisfaction surveys have a role to play, we argue that they should only be used with caution, and preferably as part of an array of tools.

Do antenatal classes benefit the mother and her baby?

OBJECTIVE

To examine the characteristics of women attending antenatal classes and evaluate the effects of these classes on mothers' and babies' health.

METHODS

A population-based observational study on care during pregnancy, delivery and in the postnatal period was carried out in 1995-96. A total of 9004 women resident in 13 regions of Italy who delivered in a 4-month period were interviewed. The outcomes studied were attendance at antenatal classes, Cesarean section, bottle feeding, satisfaction with the experience of childbirth, knowledge of contraception, breast feeding and baby care.

RESULTS

A total of 2065 (23.0%) women attended antenatal classes. Women without previous children, those with a higher level of education and office workers were more likely to attend classes. Women who attended antenatal classes had a much lower risk of Cesarean section and were about half as likely to bottle feed while in hospital compared with non-attenders. They received better information on contraception, breast feeding and baby care. Women who attended classes and applied the techniques learned were more satisfied with the experience of childbirth.

CONCLUSION

Antenatal classes seem to improve women's knowledge and competence. This may provide a defence against the tendency to overmedicalize pregnancy and childbirth.

Maternal perceptions of labor with fetal monitoring by pulse oximetry in a research setting

OBJECTIVE

Little research has evaluated maternal experience with fetal pulse oximetry for fetal surveillance. The purpose of this study was to compare maternal perceptions of labor with intrapartal cardiotocography with or without fetal pulse oximetry in a research setting.

METHODS

One hundred women with vaginal, vertex deliveries and uncomplicated fetal outcomes were enrolled. The study group was a subset of 50 mothers who had participated in a pulse oximetry trial. The control group of 50 mothers was monitored by cardiotocography only. Both groups were matched for age, parity, weeks of gestation, epidural anesthesia use, and duration of labor. A global measure of maternal perception of labor was established by experience with labor, general attitude toward monitoring devices, satisfaction with monitoring, nursing and medical care, and anxiety, each of which was evaluated separately. The mothers in the study group were also interviewed about aspects related to the fetal pulse oximetry research setting, such as information, movement restriction, discomfort, care, privacy, and safety. The questionnaires were based on a standardized rating scale model, and the interviews were conducted two to four days after delivery. The results were analyzed by chi-squared, paired t test, and ANOVA.

RESULTS

No significant differences were observed between the study and control participants in any parameter concerning the maternal perception of labor. Mothers' experiences with pulse oximetry as assessed by interview was overwhelmingly positive.

CONCLUSIONS

Fetal monitoring by pulse oximetry in a research setting did not affect maternal perceptions of labor. Mothers' experiences with pulse oximetry were highly positive, suggesting that research in fetal pulse oximetry need not compromise maternal perceptions of labor.

Prenatal care

This paper describes the psychological and psychosocial aspects of prenatal care, which are believed to be of particular importance for medical/psychological practice. The emotional changes that "normally" take place during pregnancy are surveyed and evidence is provided linking these changes with potential adverse effect on pregnancy and labour. The salience of anxiety and life stresses in pregnancy research is highlighted as well as their intricate inverse relationship with social support. Antenatal classes are offered as an example of social support provision. The different kinds of such classes and evaluation of their effectiveness are briefly presented, as well as a number of controlled trials of enhanced support during pregnancy. Finally, the effect provision of prenatal care has on women as well as their role in their own care are raised. The need is stressed for further sophisticated longitudinal and multivariate research exploring further the causative links between quality of prenatal care, pregnancy outcome, and subsequent child development.

The complexity of labor pain: experiences of 278 women

All women giving birth over a period of 2 weeks in a major city of Sweden, except non-Swedish speaking women and those with elective Caesarean sections, were asked about their experience of pain 2 days after the birth. The sensory (pain intensity) and effective (negative or positive experience) dimensions of pain, as well as need for pain relief during labor were explored. The 278 women who returned completed questionnaires (91%) reported high levels of pain, 41% worst imaginable pain, in spite of wide use of pharmacological pain relief. Only 9% had no analgesia. Pain was not an entirely negative experience, 28% assessing it as more positive than negative, suggesting that coping with pain is a rewarding experience for some women. More than 30 different explanatory variables were included in regression analysis to explain the variation in pain intensity and pain attitude scores, but only five contributed to the respective model. Most of the variables explaining pain intensity, namely anxiety during labor, expected pain, expected birth experience, midwife support and duration of labor, differed from the variables explaining attitude to pain. These were pain intensity, anxiety, expected birth experience physical well-being during pregnancy and emergency Caesarean section. The explanatory values were relatively low, especially for the model explaining pain intensity (R2 = 15%). The findings are discussed in the light of the different character and meaning of childbirth pain compared with pain related to disease.

A diagnostic model for the evaluation of childbirth and parenting education

A research study examined current issues in childbirth and parenting education in the Australian Capital Territory (ACT). In this article continuing official scepticism about the effectiveness of these programmes, despite evidence of consumer satisfaction and commitment from service providers, is noted. A critical review of the literature reveals the absence of a systematic framework for evaluation of childbirth education programmes. A framework which incorporates a methodology for health education planning and evaluation in a management context is proposed as a means of overcoming this deficiency. This framework enables a focus on the effectiveness of these health services from the perspective of both clients and providers, and identification of strategic measures for improving programme delivery and educational outcomes.

Satisfaction with childbirth: theories and methods of measurement

Two studies of women's birth experience emphasized the difficulty in evaluating satisfaction with the event. The first study used a quantitative, direct measure of satisfaction in which 91 postpartum women rated their satisfaction with labor and delivery overall and with different aspects of the experience. The second was a qualitative study that examined conceptual issues of women's satisfaction with childbirth using semistructured interviews with nine postpartum women. Content analysis was used to identify themes and categories that contributed to understanding why some women are satisfied and others dissatisfied with the birth experience. Both studies found support for a discrepancy theory of satisfaction. This paper discusses methodologic issues involved in measuring satisfaction with childbirth.

Multidimensional assessment of women's experience of childbirth: relationship to obstetric procedure, antenatal preparation and obstetric history

Primiparous postnatal patients (N = 110) rated their experience of childbirth on a 20-item questionnaire based on an earlier survey of women's spontaneous descriptions. Principal components analysis of the ratings identified three independent dimensions, describing feelings of fulfillment, distress and difficulty, respectively. Ratings by 104 primiparous antenatal patients in the third trimester yielded similar dimensions. The postnatal sample was divided, in turn, according to obstetric procedure at delivery, antenatal classes attended, whether the present pregnancy was planned and history of previous termination. Their experience of childbirth was compared on each dimension. Forceps and unassisted deliveries were experienced similarly. Caesarian section was a less difficult, but also less fulfilling and more distressing, experience than either of these. Delivery was less distressing in those who attended antenatal classes, but only one type of class was associated with more fulfilling birth. Finally, delivery was more distressing in women whose pregnancy was unplanned, or in whom a previous pregnancy had been terminated. Future controlled investigations will be incomplete unless each of the three dimensions is measured.

Predictors of a positive childbirth experience

Knowledge of childbirth, fears regarding pregnancy, locus of control, state anxiety, expectation of pain, and confidence in ability to control pain were examined as possible predictors of positive childbirth experience. Self-reports of these variables were collected from 30 primiparous women enrolled in prenatal courses, on three occasions: before the first class, after the last class, and 24 to 48 hours after delivery. The number of women completing postdelivery measures was 21. It was found that those who demonstrated greater knowledge of childbirth and higher confidence after classes subsequently reported a less painful childbirth. Of interest, those with higher levels of childbirth-related fear before classes reported experiencing less anxiety during labor and delivery. It was suggested that these women may have recognized and dealt with their concerns earlier. Psychologic factors that appear to be most predictive of a positive childbirth experience include knowledge, confidence, and anxiety. The present findings support the current emphasis in prenatal education on imparting knowledge, instilling confidence, and providing a forum for dealing with childbirth-related fears.

The convergence between in-labor report and postpartum recall of parturition pain

This non-experimental study was designed to investigate the congruence between in-labor report and postpartum recall of labor pain as measured by the McGill Pain Questionnaire (MPQ). Fifty married parturients, ages 19 to 39 at term with a normal pregnancy, served as subjects. Analysis of variance showed that postpartum report of labor pain on the Present Pain Intensity scale of the MPQ was not consistently congruent with pain reported during labor. In contrast, the Pain Rating Index of the MPQ provided postpartum data that was congruent with the in-labor report. Significant interaction effects, however, suggested that postpartially the women tended to devaluate the pain of early labor and inflate the pain of transitional labor when compared to their in-labor report. Theoretical and practical implications of the results for the measurement of labor pain are discussed.

The role of the nurse in labor and delivery as perceived by nurses and patients

A study was conducted to examine the role of the labor and delivery room nurse as perceived by expectant mothers trained in the Lamaze method of preparation for childbirth (L/RC), expectant mothers not trained in the Lamaze method (RC), and labor and delivery room nurses. All expectant mothers received baseline prenatal education by attending Red Cross Preparation for Parenthood. Perceptions were measured through a Q-sort of 50 items constructed for this study. Each item described a nursing behavior in labor and delivery. Differences between Q-sorts of expectant mothers and labor and delivery room nurses were insignificant. The collected data showed that labor and delivery room nurses were meeting the expectations of expectant mothers, both trained and not trained in the Lamaze method. Perceptions of the nurse's role in labor and delivery differed slightly so that individualization of care is important.

Does participation in prenatal courses lead to heavier babies?

In a prospective epidemiologic survey of 1,676 primiparous women delivering in four Montreal hospitals during an eight-month period, we studied the impact of prenatal courses on birthweight, maternal weight gain, and cigarette smoking. Women who participated in prenatal courses were older and of higher socioeconomic status and were less likely to be smokers than non-participants. After adjustment for these differences, newborns of course participants had similar mean birthweights compared to those of non-participants (3286 grams vs 3271 grams), and the difference for maternal weight gain was substantially reduced. Most of the reduction in cigarette consumption occurred during the first three months of pregnancy, even among later participants, suggesting that something other than prenatal courses influenced cigarette smoking reduction in course participants. We conclude that as far as the birthweight objective is concerned, the format and content of prenatal courses (as currently constituted in the Montreal region) require re-examination, and new ideas and interventions need to be developed and tested.

A study of the effect of antenatal physiotherapy coaching on labour pain in the nullipara

An observational study was performed on nulliparous labour pain in an area with a low epidural rate which facilitated the comprehensive assessment of pain. Patients who had attended antenatal physiotherapy classes showed consistently less reaction to pain while experiencing the same level of perceived pain as the untrained. Duration of the first stage was the main factor associated with high pain levels. There was some evidence that training was particularly effective when there were fetal positional problems.

Perceptions of labour: discrepancies between midwives' and patients' ratings

Women's ratings of their experience of childbirth were compared with midwives' ratings of the women's experience. The midwives' ratings were significantly different from those of their patients. Midwives presented a more positive picture of the woman's experience than did the woman herself. Furthermore, the women reported using psychoprophylactic techniques for controlling discomfort for significantly more of the time than the midwives reported that the women used such techniques. The results are discussed in the context of similar findings reported in the literature.

Use of electromyographic and skin-conductance biofeedback relaxation training of facilitate childbirth in primiparae

Matched groups of primigravid women received one of three antenatal training programmes: normal antenatal classes, normal classes plus electromyography biofeedback relaxation training, or normal classes plus skin-conductance biofeedback relaxation training. Myographic training was found to be effective within conventional antenatal constraints, whereas skin-conductance training was not. The women reported use of biofeedback training and related skills to be of some benefit during early labour. However, no difference between effectively trained electromyographic, ineffectively trained skin-conductance and control groups was found on labour and delivery performance measures.