EXPECTED AND EXPERIENCED SOURCES OF STRESS

DURING LABOR AND DELiVERY

by

Erna E. Snelgrove-Clarke

Submitted in partial fuifillment of the requirements for the degree of Master of Nursing

Dalhousie University Halifax, Nova Scotia

Apd, 1997

O Copyright by Ema E. Snelgrove-Clarke. 1997

of Canada du Canada

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395 Wellington Street 395, nie Wellington Ottawa ON KIA ON4 OttawaON K1AON4 Canada Canada

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This work is dedicated

to my husband

Craig,

for his encouragement, love, and patience

TABLE OF CONTENTS

Page

TABLE OF CONTENTS

LlST OF TABLES viii

ABSTRACT

LlST OF ABBREVIATIONS AND SYMBOLS

ACKNOWLEDGEMENTS

CHAPTER: 1 INTRODUCTION Background of the Study Purpose of the Study Literature Review

Perceptions of Stressful Experiences during Pregnancy Women's Perceptions and Experience of Stressors during and Delivery

(1 ) Third Trimester (2) Period of Labor and Delivery (3) Postpartum Period

Factors / Features lnfluencing a Stressful Labor and Delivery Theoretical Frarnework Research Questions Definition of Terms

CHAPTER: 2 METWODOLOGY Research Design The Setting Population and Sample Characteristics of the Sample Data Collection Procedure l nstruments

Anxiety Labor and Delivery Stressors

Data Analysis Ethical Considerations

Protection of Su bjects Risk and Benefits

CHAPTER: 3 FlNDlNGS Introduction Antepartum Sources of Stress and Anxiety

Sources of Stress Anxiety

Postpartum Sources of Stress and Anxiety Sources of Stress Anxiety

Changes in Stressful Experiences and Anxiety from Antepartum to Pospartum Factors that Influence Anticipated Labor and Delivery Sources of Stress Factors that Influence Reported Stressors in Labor and Delivery Factors that influence the Difference in Expected and Experienced Sources of Stress during Labor and Delivery Postpartum Descriptions of Labor and Delivery Sources of Stress Summary

CHAPTER: 4 DISCUSSION 1 ntroduction Safe Passage

Expected Sou mes of Stress Experienced Sources of Stress Expected and Experknced Anxiety Levels

Factors l nfluencing Sources of Stress Pa rity Prenatal Classes Anxiety

Summary

CHAPTER: 5 SUMMARY, LIMITATIONS, AND 1MPLlCATIONS Summary Limitations Implications for Research Implications for Pracüce Conclusion

Appendix A Feelings of Childbirth Questionnaire (Tirne 1) Feelings of Childbirth Questionnaire (Time 2)

Appendix B Subscales of Feelings of Childbirth Questionnaire

Appendix C State Anxiety

Appendix D Trait Anxiety

Appendix E Dernographic Information Sheet - Part A Demographic information Sheet - Part B

Appendix F Nova Scotia Prenatal Scoring Form

Appendix G Consent Form

Appendix H Expected Sources of Stress-Time 1

Appendix I Experienced Sources of Stress-Time 2

REFERENCES

vii

LIST OF TABLES

TABLE

Demographic Data of Women Obtaining an Uncomplicated Labor and Delivery

Cronbach's Alpha Coefficient for the Feelings of Childbirth Questionnaire Total and Subscale Scores

Expected and Experienced Sources of Stress during Labor and Delivery

Labor and Delivery Sources of Stress Expressed in the Antepartum Period by Greater than 50% of Women

Experienced Sources of Stress during Labor and Delivery

Labor and Deiivery Sources of Stress Expressed in the Postparturn Period by Greater than 50% of Women

Changes in Women's Appraisal of Stressful Experiences in Labor and Delivery and Anxiety frorn the Antenatal Period to the Postpartum Period

PAGE

43

54

59

60

62

62

63

Predictors of Labor and Delivery Stressors during the Third Trimester 65

Predictors of Labor and Delivery Stressors during the Postpartum Period 66

Predictors of the Difference in Expected and Experienced Stressors during Labor and Delivery 67

Personal Descriptions of Sources of Stress Experienced during Labor and Delivery 69

viii

ABSTRACT

The purpose of this descriptive longitudinal study was to describe women's

perceptions of stressful experiences during labor and delivery. and the change in

these perceptions. Both the study design and interpretation of the findings were

guided by Lazarus's theory of stress and coping (Lazarus & Folkman, 1984) and

Rubin's theory of matemal identity (Rubin, 1984).

During the 36th to 38th week of pregnancy. and again in the irnmediate

postpartum period. 98 women who experienced an uncomplicated pregnancy

and labor and delivery completed the Feelings of Childbirth Questionnaire

(adapted from Glazef s 1985 Feelings of Pregnancy Questionnaire), the State-

Trait Anxiety lnventory (Spielberger. 1983). and a demographic information

sheet. This data was collected over a four month period and analyzed using

descriptive and summary statistics.

In both the antepartum and postparturn periods, women identified the

predominant sources of stress as being concems for the baby and for

themselves. Stressors for labor and delivery were reported with greater

frequency in the antepartum than in the postpartum period, with the greatest

change seen in the total stressor scores, the subscale scores of baby and

childbirth, and state anxiety scores. Parity and anxiety were the variables that

were most consistently related to women's scores on sources of stress. These

findings are significant for nursing practice, particularly with women who are

experiencing their first pregnancy and with women who have had a negative

experience with labor and delivery.

LIST OF ABBREVIATIONS AND SYMBOLS

IWK-Grace lzaak Walton Kiilam - Grace Health Centre for Children, Women

DPH

ELAU

LDRU

FOPQ

FOCQ

STAl

DIS

r

N

OC

)

(

M

SD

t

d f

P

R2

T

and Families

Department of Public Health

Early Labor Assessrnent Unit

Labor and Delivery Recovery Unit

Feelings of Preg nancy Questionnaire

Feelings of Child birth Questionnaire

State-Trait Anxiety l nventory

Demographic Information Sheet

Correlation

Number of members of a portion of the total sample

Alpha Coefficient

Greater than

Less than

Mean

Standard Deviation

T-test

Degrees of Freedom

Probability

Coefficient of Determination

T Statistic

ACKNOWLEDGEMENTS

There are many people who have supported me in the completion of this

thesis. My family has provided me with tremendous strength to see this work

through. Craig. my husband, has listened to my joys and frustrations for many

years now and has given far more than the promised 110%. My children, Avery

and Nathan, have helped me to understand not only the joys of motherhood, but

to remember to put my sources of stress into perspective. Not only have I carried

them through this process. but they have also carried me. My parents and sister

have been a great source of support. Without rny Dad and his patience, many

hours of data entry could have been many days. thanks.

My principal advisor, Dr. Judith Ritchie, has given me more than I can put

into words. Her guidance, encouragement, and listening has enabled me to

cornplete this process. Thank you Judi for knowing when to provide me with

direction and when to let me find the answers myself. I also owe a great deal of

thanks to the other members of my thesis cornmittee; Maoreen White, Dr. Cathy

Cervin, and Dr. Kit Bowen. Thanks to Maureen for the clinical perspective and

keeping me focused on Rubin, to Cathy for the rnultidisciplinary approach and to

Kit for her help with the analysiç and the e-mail correspondences.

My friends and collegues have been there for me without hesitation over

the past few years. Thank you al1 for your support and shoulders. Special thanks

to Joan, Marsha, and Karen for al1 the phone calls and advice on how to get

through just another crisis, Clare for her way with words and kids, and Judy for

xi

taking me through the final crisis.

Finally, thank you to al1 the women who participated in this study. Your

involvement contributed to a greater understanding of the matemal experïence.

xii

CHAPTER 1

lNTRODUCTlON

Background of the Study

Giving birth is an experience that women do not forget (Simkin, 1991,1992).

Various elements of labor and delivery, both the expected and unexpected,

shape it to be a stressfui experience; these elements include the potential loss of

control and concerns regarding the baby (Affonso & Mayberry, 1990; Arizimendi

& Affonso, 1987; Clark 8 Affonso, 1979; Drew, Salmon, & Webb, 1989; Highly &

Mercer, 1978; Hodnett & Butani, 1981 ; Morris, 1983; Rubin, 1984). While there

are positive aspects of this experience, these negative memories endure. The

researcher has observed during clinical practice that women. antenatally and

during labor, express commonly-reported concems or fears regarding their

experience, as well as individual stressors. The researcher has observed these

concems antenatally in childbirth classes and physicians' clinics, and dumg the

postpartum period. Identification of sources of stress for labor and delivery in

both the antenatal and postpartum period will provide information that can

increase the health professional's awareness of the matemal experience,

enhance support for this experience, and subsequently lead to improving the

childbean'ng experience and enhancing matemal adaptation (Affonso &

Maybeny, 1990; Arizimendi & Affonso, 1987; DiMatteo. Kahn, & Berry, 1993;

Gaffney, 1986; Klein-Danziger, 1979; Mercer, 1981, 1 985; Peterson & Mehl,

1978).

2

Research regarding the concems or fears involved with pregnancy reveals

sources of stress during labor and delivery. Sorne studies reveal stressors of

pregnancy (Affonso & Mayberry, I W O ; Arizimendi & Affonso, 1987; Glazer,I 980,

1985; Lederrnan, 1984; Lederman, Lederman, Work, & McCann 1979; Light and

Fenster, 1974; Simkin, 1986a, 1986b) while others describe perceptions of

childbirth (Butani 8 Hodnett, 1980; Cartwright, 1987; Clark, 1975; Fields, 1987;

Kirke. 1980a, 1980b; Sheilds, 1978). In addition, there are personal variables

(Areskog, Kjessler, 8 Uddenberg, 1982; Areskog, Uddenberg, & Kjessler, 1981 ;

Burstein, Kinch, & Stem, 1974; Fleissig, 1993; Jones, 1990; Kirke, 1980; Mercer,

1979; Rubin, 1984; Westbrook, 1978) and situational variables (Clark 8 Affonso,

1979; Morris, 1983; Rapheal-Leff, 1991 ) which influence feelings about the labor

and delivery experience. Although researchers have described various stressors.

there is, to date, no study focusing exclusively on specific events and situations

that are sources of stress for labor and delivery. In addition, there are no studies

of the differences between anticipated and experienced sources of stress during

labor and delivery.

A description of these sources of stress will provide nurses and other health

care professionals with information that may lead to a greater understanding of

the matemal experience. This information will be useful not only for care during

the prenatal period, but also for supporting a labor and delivery in a rnanner that

corresponds more closely to the needs and concerns of the laboring woman.

3

Purpose of the Study

The purpose of this study is to identify antepartum women's and postpartum

women's sources of stress related to labor and delivery, and to reveal the

change in these sources of stress from the antepartum period to the postpartum

period.

Literature Review

Perceptions of Stressful Experiences durina P-nancv

Pregnancy has been called a normative crisis (Osofsky & Osofsky, 1980), a

crisis (Dick-Read, 1944). a developmental process (Benedek, 1959) and a

psychological crisis (Deutsch, 1945). Many authors have identified stressful

experiences related to the childbearing and childbirth experience. These authors

use ternis such as stressful events, anxieties, fears, worries, and concems

synonymously to refer to stressful experiences. A variety of concerns present

themselves during pregnancy; however, several authors have concluded that

concems for baby and for self are the predorninant fearç during pregnancy

(Affonso & Mayberry, 1990; ArÏzimendi & Affonso, 1987; Deutsch, 1945; Glazer,

1980, 1985; Jones. 1990; Light & Fenster, 1974; Rubin, 1975; Standley, Soule,

& Copans, 1979).

Rubin (1975), through her clinical study of mothers during pregnancy,

identified matemal tasks in four broad interdependent areas: (a) seeking safe

passage for herself and her child through pregnancy, labor, and delivery, (b)

ensuring the acceptance of the child she bears by significant persons in her

4

family, O binding-in to her unknown child, and (d) leaming to give of herself.

Completion of these tasks through pregnancy, labor, and delivery, enable

adaptation to mothering. Rubin reported that the women had concems for baby

and seif throughout pregnancy and the birthing experience. Since Rubin's

pioneering work, several researchers have attempted to provide more detailed

and more quantitative information about matemal concems during pregnancy,

labor, and delivery. There is some difference of opinion as to which concems

dominate and which are present in any of the three trirnesters (Mercer, 1995).

Light and Fenster (1 974) administered a 60-item postpartum questionnaire to

202 randomly selected mothers during their postparturn hospitalization. These

women reported they had concems relating to the baby (87.56%). childbirth

(73.8%), subsequent pregnancies (57.07%). and themselves (51.55%). Building

on this research, and with a selected group of women from daily listings of

antenatal appointments, Glazer (1 980) identified specific concems and anxiety

levels arnong pregnant woman. Adapting Light and Fenster's (1 974) concerns

questionnaire, and using the Taylor Manifest Anxiety Scale, Glazer found a

statistically significant correlation between the level of anxiety and the number of

expressed concems (r=0.57). The concems questionnaire contained 62 items

that practitioners in maternity and pediatric nursing and prenatal patients had

reported in the literature. Each woman in Glazer's study identified at least one

concem, and 50% or more of the women identified 29 concems. The concems

expressed differed according to each trimester, and included issues related to

self, childbirth, effects on the baby, finances, family, and subsequent

pregnancies. These women were most concemed about their baby and childbirth

in al1 three trirnesters. However, Affonso and Mayberry (1 990) and Arizimendi

and Affonso (1987) reported that women's major womes related to the broader

issues of the self as well as to the baby. In this study a cross-sectional

convenience sample of 221 women participated; 81 were in the first trimester, 80

in the third trimester, and 60 in the post partum period. Unlike Rubin (1975) and

Glazer, these researchers did not include women in their second trimester

because of other research that demonstrated that the second trimester is the

period of lowest physiological stressors and a time of optimum adaptation to

gestation (Colman & Colman, 1971). The women identified a total of 1403 events

that they perceived as stressful. In al1 periods, the women most frequently

identified stressful events related to physical distress, body image, and concems

for the baby's welfare.

Jones (1 990) and Standley et al. (1 979) also investigated the common fears

and womes during pregnancy. Jones identified that the women most frequently

expressed concem for the baby. while Standley et al. reported anxiety

conceming the approaching labor and delivery and for the baby. Using a

convenience sample of 25 women, Jones (1990) sought to describe the

psychological self-assessrnent of pregnant women; using a questionnaire guide,

the women described their feelings in a structured way. The greatest fear

reported was whether the baby would be normal. Other fears included issues

6

related to body image, self-concept. matemal ability to cope, and relationships

with others. Standley et al. (1979) explored concems about the baby and the

approaching labor and delivery during interviews with 73 married Caucasian

women in their last month of pregnancy. The interviews contained seven

prenatal anxiety measures: general pregnancy anxiety, physical anxiety, anxiety

about fetus, childbirth anxiety, childcare anxiety, infant feeding anxiety and

psychiatric symptoms. Assigned a rating on a five-point scale by either a

psychiatrist or psychologist, the response to each question ranged from Iittle or

no anxiety to intense disruptive anxiety. The mean scores were generally toward

the low end of the scale, and the greatest anxiety expressed was about the

approaching labor and delivery and the well-being of the unbom child. Analyses

of the scores revealed high standard deviations; that is, there was considerable

variability in the women's response. Factor analyses of the seven prenatal

anxiety measures revealed that prenatal anxiety is a composite of several

distinct concems of pregnant women and can be separated into identifiable

components: pregnancy and childbirth, future parenting, and psychiatric

symptoms.

Heymans and Winter (1975) identified fears during pregnancy with 200

postpartum Israeli women. Within 48 hours of delivery these women were

questioned about fears and anxieties during pregnancy. The fears and anxieties

reported include concems for the baby and concems for the mother, such as

fear of pain and complications during labor and delivery. Women reported that

these fears were strongest during the third trimester.

Additional sources of stress have been identified during pregnancy. These

sources of stress include a woman's relationship wiih her mother (Deutsch,

1945; Ledeman, 1984; Lederman et al., 1978,1979;), and the acceptance of

her pregnancy (Condon 8 Watson, 1987; Lederman et al., 1979,1984; Salmon

& Drew, 1992). Deutsch (1945) reported that a woman's past identification with

her rnother affected her adaptation to pregnancy and mothering. Lederman et al.

(1 978. 1979) found a correlation between the progress of labor and the women's

relationship to her mother, as well as between this relationship and her

identification with the motherhood role. Lederman also reported that when a

pregnancy is unplanned and a woman's acceptance of the pregnancy is low, she

is less prepared for both childbirth and motherhood (1984). Lederman stated that

this woman "is more likely to have fears and conflicts conceming labor" (1 984, p.

18). Condon and Watson (1987) and Salmon and Drew (1992) supported this

finding. In a group of 110 prirniparous postpartum who rated their experience of

childbirth, Salmon and Drew (1992) reported that delivery was more distressing

when pregnancy was unplanned. Condon and Watson (1 987) identified the

planning of pregnancy as a risk factor for matemity "blues". These unresolved

conflicts confronted the pregnant woman during childbirth.

All of these researchers have revealed that perception and identification of

stressful experiences and events related to baby, self, and labor and delivery,

occur throughout pregnancy and the postpartum period. However, these (and

8

other) concems become more prevalent as birth approaches (Affonso &

Mayberry, 1 990).

Women's Perception and Experience of Stressors dunna Labor and Deliven,

The third trimester, the intraparturn period, and the postpartum period are

time frames in which various researchers have chosen to investigate the

stressful experiences of labor and delivery. The reported fears and concems are

multifaceted and aften wincide with one another. Although the concems do

overlap, they will be presented separately and described according to their

prevalence in each time period.

Third Trimester

The third trimester is described by Lubin, Gardener, and Roth (1 975) as a

time when anxiety levels are high and women are rnost vulnerable to stress.

According to the results of several studies, the concems that dominate this

period in relation to labor and delivery include: loss of control, changes in body

imagelself esteem, inadequate infonnationlexplanationç, staff-patient

relationships, frequent or painful interventions. pain, issues related to

environment, concem for self, and concem for baby.

Rubin (1975) has identified the safe passage for baby and self as key

matemal tasks of pregnancy. Safe passage relates to the concems and fears

that other authors express as concems for self (survival, body image and

control), concems for the baby, issues related to support, and the birth

environment. The inability to accomplish the task of safe passage predisposes a

woman to a possible stressfil experience of pregnancy (Rubin, 1975). The

threats and dangers of pregnancy are prominent in the third trimester, and the

concem for baby and self cannot be separated. Rubin described the woman's

sense of vulnerability to danger from the environment and of her changing body

image. Women want to get rid of the pregnancy, yet do not want to go into labor.

Rubin stated, "AI1 the threats of al1 the three trirnesters are reconstituted into one

condensed episode for labor and delivery" (p. 147). However, the sources of

stress revealed in the third trimester may have a tremendous impact on the labor

and delivery experience (Lederman, 1986).

Fears of loss of control. Rapheal-Leff (1 991 ) concluded, based on clinical

experience and her research, that the fear of losing control is related to

expectations of overwhelming agony during the birth experience. Also based on

clinical experience and research studies. Highley and Mercer (1 978) stated that

"a woman approaching labor is particularly concemed about her behavior and

her ability to maintain control of it" (p. 39). A woman fears that, as labor

progresses, she will lose her self control. Areskog et al. (1 981) reported that 6%

of the women surveyed during their 31st to 33rd week of pregnancy (regarding

their feelings of anticipated delivery) experienced severe fear of delivery; 17%

experienced moderate fear. They noted that fear of not controlling oneself during

delivery was an aspect among women with severe fear. The issue of control also

emerged in another study in which, as part of a larger study focusing on

women's views of the childbirth experience, Mackey (1 990) focused on women's

1 0

preparation for childbirth. During tape recorded interviews at 36 to 38 weeks, 61-

Lamaze prepared mamed multigravidae women described their preparations for

childbirth. The vast rnajority (72%) of women described the ideal birth experience

as one in which they rnanaged well. For these women, being in control of their

own behavior (pain, self, and contractions) during labor and delivery defined

managirtg well. Through three semi-structured interviews w%h 32 primigravidas

during the last trimester of pregnancy, Lederman et al. (1979) and Lederman

(1984) identified the components of loss of control and the components of other

psychosocial variables relevant to pregnancy and labor and delivery. They

reported that the women's fears related to control in labor included: (a) loss of

control over the body. (b) loss of control over emotions, and O loss of control

over the extent to which a woman can trust the medical and nursing staff, her

husband, and others.

Affonso and Mayberry (1 990) and Arkirnendi and Affonso (1 987) identified

labor and delivery events as high-intensity stressors related to fear of delivery

and occumng in the third trimester. Unfortunately, the researchers did not

identify the particular events associated with these fears. However, the fears

may be related to some of the issues that others have described as loss of

control.

Concems about bodv imaae. Concems related to body image rnay be a result

of the concem of loss of control. Rubin (1968, 1984) held that body image

centers on structure and function of the body, its parts, and its contents. She

11

reported that when a laboring woman was not in cuntrol of her bodily functions.

or when these functions became involuntary. the woman became distressed.

Rubin (1968) stated "loss of control produces shamen (p. 23). Ledeman et al.,

1979. Lederman. 1984. and Raphael-Leff (1991) also have reported fears

related to body image during labor and delivery. Raphael-Leff (1991) stated that

women dread losing touch with familiar body senses. while Ledeman et al.

(1979) and Ledeman ('l984) report that loss of control over body image

stemmed from loss of control over body functions such as occurs during

contractions and pushing before the second stage of delivery.

Concems about sufficient information and staff-patient relationshios. Some

women have reported concems and fears about stafflpatient relations during

labor and delivery. In anticipation of childbirth, women have reported concems

about: (a) the provision of information and explanations, (b) interactions that

foster depersonalization (Raphael-Leff. 1991). or O the ability to trust the medical

and nursing staff (Ledeman et al.. 1979 & Lederman, 1984). A lack of persona1

attention and respect from health professionals during a previous hospital

experience may be a stressor that influences a laboring woman's perception of

her upcoming experience (Lederman. 1984).

Concems of pain. Women have reported the perception of pain-imposed

stress as they approach the birthing experience. However. only three authors

have described explicit concems about pain prior to delivery. Raphael-Leff

(1 991 ) described women's fear of anticipating childbirth as dreading being

"unable to evaluate her own pain threshold or make sense of the strange

sensations engulfing her (p. 239). This author also made note of the isolation

wornen experienced behind the bamer of pain. Clark (1975) reported fear of pain

among expectations of labor and delivery with 24 expectant mothers. of whom

13 were primigravidas and 1 1 were multigravidas. Primiparas with both positive

and negative labor experiences reported fear of pain. In a group of nine

multiparas with a positive experience in labor, one reported the expectation of

fear in labor. Representation of fear of pain in labor and delivery among

multiparas with a negative attitude involved two of the 24 women in this study.

The women in Lederman et al.'s (1 979) study identified the fear of pain as

threatening (Lederman, 1984). Ledeman reported. however, that the pain of

labor "was often perceived as a trigger for the loss of control" (p.144).

Concems for the environment. Raphael-Leff (1 991 ) referred to fear of the

clinical atmosphere of the delivery room and to fear of being attached to

machines. Morris (1983) also made reference to the uncornfortable architecture

of most labor wards. He commented that along with this design and structure

goes a generally tense and anxious staff.

Concem for self and concem for babv. Many authors have identified women's

concerns for self and baby during the third trimester. This concem has referred

generally to the potential for laboring women to face bodiiy damage, harm, and

even death (Raphael-Leff, 1991 ). The primiparas in Clark's (1 975) study reported

concem for self and baby when discussing their fear of labor and delivery. When

13

grouped according to either a positive or negative experience, only one primipara

who had a negative experience denied feeling fear for herself or her infant before

experiencing labor. Of the nine multiparas with a positive labor experience, two

reported having had concern for the baby; none of these women reported fear

for self. In the multiparas women experiencing a negative attitude toward labor, a

rnother who lost her first child shottly after birth reported she felt fear for self and

baby. Women with severe fear of delivery (Areskog et al., 1981) reported, "shape

and well-being of the unbom child and fear of physical damage to the women

herself (rupture)" as concems (p.265). Mackey (1 990) identified similar findings

with her study sample. Women defined prerequisites to the ideal labor and

delivery experience, which included having a healthy baby and no complications.

Arizimendi and Affonso (1 987), and Affonso and Mayberry (1 990), specifically

identified baby welfare in the category of frequent stressors and stressors of high

intensity. Although not identified as a category, concem for self was represented

by the categories of bodykelf image, family stressors, and emotional stressors.

Period of Labor and Delivery

Several authors have used case studies, clinical experience and observations

to describe stressful experiences during labor and delivery. Clark and Affonso

(1979) stated that during pregnancy "stress is cumulative and appears to reach a

climax with the approaching labor and delivery" (p. 346).

Loss of control. Clark and Affonso acknowledged that the intrapartal period is

a time of increased stress and that a woman's loss of control during labor and

14

delivery predispose her to a stressful experience. Rubin (1 984) reported that

time and space in labor performance was an important issue of self-control. She

concluded that it was the woman's concem for safe passage, her own

intadness, and the survival of the baby that were most important. Losing control

over bodily functions and contents can "influence a woman's reactions and

coping ability during the critical period of labor and delivery" (Angelini, 1978, p.

45). Angelini contended that it was the loss of contents from within the body and

the intrusive procedures from outside the body that contributed to the

stressfulness of the experience (1 978). Morris (1 983) reported loss of control in

relation to pain and length of labor. In his 1978 study of 55 patients (as cited in

Morris, 1983), 13 of 37 primiparas described losing control, and three of the 18

multiparas also described losing control.

Pain. Rubin (1968b) observed pain as an experience in the body image that

was concentrated in labor and delivery. She held that with the potential danger of

loss of wholeness (due to pain), the emotions of anxiety, fear, and even panic

acted as signalling and arousal functions. Rubin (1 984) recognized the

helpfulness of the presence of another person who was willing to help and able

to restore the "pain-dissipated body boundaries by proximity alone" (p. 82). This

other person refers to the husband andlor the medical and nursing staff. She

also found that abandonment and isolation contributed stress to the already

taxing situation of pain.

Stafflpatient interaction. In an ethnographic study, Klein Danziger (1 979)

15

observed the interaction of 25 women wïth staff members during the early stage

of labor. She found that the major theme in the provider-patient interaction was

the attempt to assert control over the social process of labor. Providers

attempted to maintain control over both the physiological and social processes of

labor. Klein Danziger reported that there was a routinized manner of

interpersonal interaction with each patient and that. during the eariy stages of

labor, women were provided with general rather than specific information.

Providers feared that too much information would be more stressful for the

laboring women. Staff rnembers assumed they knew the needs of the women.

They did not often seek the women's view of the birthing experience, and only

recognized or dealt with the expression of pain during the labor. Klein Danziger

described the importance of communication, and its influence on both the

childbirth experience and initial parenting. Rubin (1984), Morris (1 983). and Clark

and Affonso (1 979) have al1 acknowledged the importance of verbal

communication between the laboring women and the health professionals. They

concluded that explanations of events and procedures, along with adequate

discussion, aided the laboring woman's knowledge of the birthing process and

subsequently decreased any fears and anxieties she experienced.

Environment. Clark and Affonso (1979) described the hospital environment as

a potential source of anxiety to the laboring women. The hospital's physical

structure, its organization, routines, equipment, and even the health

professionals themselves al1 contnbuted to sensory overload. Examples of

16

sensory overioad included inappropriate conversation among health

professionals, strange procedures and equipment, rapidly-occurring stimuli (such

as one-time explanation of procedures), unanticipated events, and even labor

progress. They concluded that laboring women may become anxious when they

have to cope with more than just their labor (Clark & Affonso. 1979). A woman

may also experience sensory deprivation during her labor and delivery due to al1

the restrictions placed upon her (Clark 8 Affonso, 1979). A prolonged labor

increases the chance of isolation from friends and family.

Postpartum Period

Some researchers have examined, during the postpartum period, concems

women revealed about their labor and delivery experience. Affonso and

Maybeny (1990) and Arizimendi and Affonso (1 987) reported that women

identified specific stressful experiences of labor and delivery in the post partum

period. Unpleasant aspects of labor and delivery inciuded: pain, loss of control,

interaction with others. and interventions. When researchers interviewed women

dunng the postpartum period. the women reported that they experienced several

sources of stress during labor and delivery. These sources of stress were both

similar to and different from those reported in the third trimester. For example,

Affonso and Mayberry (1 990) and Arizimendi and Affonso (1 987) reported

worries about labor and delivery as high intensity stressors in bath the third and

postpartum period. The intensity of these fears, however, were higher in the

postpartum period than in the third. The fear of labor and delivery in the

17

postpartum period was both related to the events and the outcornes of labor and

delivery. In the third trimester. the fears concemed just the events of labor and

delivery. It is important to note. though. that a different sample of women

participated in each period.

Concems reaardina ~ a i n and loss of control. Postpartum women commonly

have identified dissonance between their expected and experienced levels of

pain in labor and delivery. In an exploratory study. Stolte (1 987) interviewed 70

women 24 to 72 hours post partum. Stolte asked these women what aspects of

labor and delivery they would describe as different or the same as their

expectations. Women responded to open-ended questions and provided 75

statements about things that were the same as expected, and 169 statements

about things that were different. Pain was identified as a category in response to

both these questions. The women also reported other aspects in which

differences from and similarities to expectations included their general

impression, help from health professionais, procedures, support person, and the

infant. The majority of woman had experiences in labor and delivery that were

different from what they expected. Stolte concluded that having to cope with

differences in expected experiences while coping with utetine contractions is a

burden. It was the differences in expectations that were meaningful, not whether

the differences were better or worse than expected. DiMatteo et al. (1 993) found

that 44 new rnothers in focus groups discussed five themes related to the labor,

birth, and post partum experience. Mothers revealed the almost consistent

18

surprise and shock "at how painful and physically threatening childbirth was" (p.

206). One wornan stated, "No rnatter how much they teach you in Lamaze, it

never really gives you an idea of the real pain" (DiMatteo et al., 1993, p. 302).

Some authors have reported that acquiring pain relief restored the labonng

woman's sense of control. Highley and Mercer (1 978) reported a case study of a

laboring woman. This woman felt she was able to regain control and handle her

labor and delivery once she obtained regional anesthesia. Butani and Hodnett

(1980) interviewed 50 mothers about their perceptions of labor and their principal

concems about their experience. The rnothers most often described pain and

loss of control as unpleasant aspects. The mothers' concerns were grouped into

four areas: (a) preparation, control, and attitudes about self in labor; (b)

expectations of labor. O perceptions of specific aspects of labor, and (d) overall

subjective evaluation of the labor experience. As a whole, these concerns

confirmed the influence of the interrelationship of maintenance of control,

realization of expectations, and maintenance of self-esteern on the perceptions

of a recent labor experience.

Several researchers. using very diverse research methods, have found that

issues of control dominate women's memories of and feelings about labor and

delivery. Women's long-term perceptions of their first birth experience reveal that

those with the highest long-term satisfaction ratings felt in control of their

experience. Simkin (1 99l,l992) compared 20 women's short-tem and long-

term memories and perceptions and found that the women had intense

19

mernories. These birth experiences occurred 15 to 20 years eariier. They

described factors that contributed to a positive experience, which included

control, accamplishing something important, self-confidence and self-esteem,

and professional support. Simkin reported that control was important for al1

women. Other authors have confirmed that satisfaction and a woman's

perception of the labor and birth experience have been associated with her

participation in decision making (Séguin et al., 1989), loss of autonomy, and

control (DiMatteo et al., 1993). 60th authors commented on the influence of

personal control on the birth process. Morris (as cited in Morris, 1983) identified

the indicators of unmet expectations, pain, and length of labor as variables that

influenced a woman's disappointment with her performance. These women saw

disappointment with performance as loss of control. Loss of control occurred in

13 primiparas and three multiparas. Highley and Mercer (1 978) reported that

spatial and temporal control, along with control in decision making, contributed to

a woman's sense of loss during labor and delivery. In their case-study report of a

laboring woman's experience they found that when staff moved a wornan from

one area to another, when they failed to recognize her previous and personal life

experiences, and when the laboring woman perceived an altered body image,

loss of control was experienced. Regaining control, however, enabled this

laboring woman to face and handle the subsequent steps in her birthing process.

Butani and Hodnett (1980) found that 38% of the primiparas in their study

reported that they had regrets about their behaviour. These wornen felt they had

20

shown loss of control. A smaller portion (24%) of rnultiparas who voiced concem

about their behaviour also cited loss of control as the dominant issue.

Concems reaardina information and stafflpatient interactions. Stafflpatient

interactions and the provision of information and explanations are also issues

that contribute to the perception of a stresshl experience in labor and delivery.

The way in which staff treated women (Simkin, 1991, 1992) influenced their

satisfaction with the labor and delivery experience. Even when expectations are

not met, women have reported that they felt supported and less fearful when

they received information and explanations regarding the baby's health (McKay

& Yager Smith, 1993) and regarding the emotional and physical demands of

labor (Cartwright, 1987; McKay & Yager Smith, 1993; Kirke, 1980b; DiMatteo et

a1.,1993; Séguin et al., 1989; Butani & Hodnett, 1980; Fleissig, 1993). McKay

and Yager Smith commented that "women need validation of the normalcy of

what they are experiencing, and specific infomation and direction to help them

cope" (1 993, p. 143); they also stated that there are many unexpressed fears

during labor and delivery. Information giving and sharing were productive in that

they empowered women and enabled them to make choices.

Concems reaardina labor and deliverv events. Arizimendi and Affonso (1 987)

and Affonso and Mayberry (1990) described postpartum women's reports of

intense high-stress concems and fears regarding events in labor and delivery.

The specific events that contributed to the reported stress intensity were not

identified. Simkin (1 986a, 1986b) camed out the only study that specifically

21

measured stressful labor and delivery events. She said that excessive stress is

detrimental to labor progress, and to fetal and neonatal well-being. The 159

postpartum women, participants in the researcher's postpartum childbirth reunion

classes, responded to the Childbirth Events Stress Suivey. The survey consisted

of 29 policies, procedures, and environmental factors common to labor and

delivery, factors that Simkin considered to be controllable in that they could be

modified or avoided. The women rated the events on a six-point scale from not

applicable to most stressful. Labor events most frequently identified as highly

stressful by 25 percent or more women included: labor induction or augmentation

with oxytocin, administration of anesthesia, restriction to bed, forcep delivery,

vacuum extractor delivery, limited time with baby, and circumcision.

The identification of controllable events is but one component of stressful

events reported by women during the postpartum period of their labor and

delivery experiences. Women have reported that they feel a variety of concems

regarding labor and delivery events. Kirke (1980b) found that women were

generally favorable with the procedures they experienced. These procedures

included: pain relief. induction, forcep delivery, intravenous infusion, continuous

fetal monitoring, and the fetal scalp electrode. However, neariy one-third of

women in another study (Butani & Hodnett, 1980) expressed uncertainty about

fetal monitoring because it affected personal comfort. Nearly half of the women

who experienced induction also expressed regrets. Through various methods, al1

of these researchers have identified a variety of stressful labor and delivery

events.

Unmet Expectations. The varÎety of concems and fears presented in this

literature review overiap, and are not present with al1 wornen. Discussing these

events, interactions, and perceptions in ternis of expectations is another way to

address the stressful experiences of labor and delivery. Stolte stated that "the

kinds of expectations Vary among women, as does how realistic they are; some

expectations may help a woman to cope with labor while others rnay cause

anxiety and decrease her ability to cope" (1987, p. 99). Women May have certain

expectations regarding aspects of their labor and delivery, such as control over

emotions, actions, and pain perception; professional and social support;

interpersonal relationships with the staff; and procedures or interventions

(Highley & Mercer, 1978; Stolte, 1987; DiMatteo et al., 1993; Butani & Hodnett,

1980; Willmuth, 1975). Whether it is a concem with a specific event, interaction,

or with the expectations for the entire birthing process, "the labor experience

influences not only the woman's attÏtudes about herself but also her attitudes

towards her child" (Butani & Hodnett, 1980, p. 75). Failure to identify and review

these events, interactions, and experiences may mean that women cany these

unresolved stressful experiences with them into their daily lives. This carry-over

may not only affect their mernories (Simkin, 1991, 1992), but also their abilities to

cope (Arizimendi & Affonso, 7987).

Factors/Features lnfluencina a Stressful Labor and Deliverv Ex~erience

A variety of factors influence a woman's perception regarding a stressful labor

and delivery experience. Although disagreement exists among some

researchers, the researcher will review the major factors that have been

identified.

Anxietv. Reports of the relationship between state andlor trait anxiety and the

labor and delivery expenence are abundant. The relationship between anxiety in

pregnancy and labor and delivery has been demonstrated in monkeys

(Adamsons, Mueller-Heubach, & Myers, 1971 ), sheep (Greiss & Van Wilkes,

1964) and in humans. It is reported that matemal anxiety may have an impact on

perinatal events. Matemal anxiety in sheep and monkeys was measured

according to catecholamine levels. Reduced uterine blood flow and fetal distress

in monkeys and sheep were related to catecholamine effects (Adamsons et al.,

1971 ; Greiss & VanWilkes, 1964). Researchers have reported that anxiety

influences length of labor (Lederman et al., 1978, 1979). administration of

regional anesthesia (Standley et al. 1979). delivery complications (Crandon,

1979a), and fetal heart rate patterns (Ledeman et al., 1981). It is also reported

that anxiety influences the newbom's apgar scores (Crandon, 1979b; Lederman

et al., 1981 ), postpartum depression (Knight & Thirkettle, l987), matemal-fetal

attachment (Gaffney, 1986), and matemal-fetal interaction (Farber, Vaughn, &

Egeland, 1981 ). For the purposes of this review, only materna1 anxiety levels

associated wiai th2 expected and experienced sources of stress during labor

and delivery will be discussed.

Lederman et al. (1979) reported that mothers' scores on the trait anxiety scale

24

had a low positive correlation with fear of helplessness. fear of loss of control,

fear of pain, and fear of loss of self esteem. Lederman et al. stated that Trait

anxiety was not predictive of the specific fears conceming labor revealed in the

interviews" (p. 96). However, Glazer (1980) reported that the number of a

pregnant woman's expressed concems showed a statistically significant

correlation with her trait anxiety level. In 1985. Glazer found a significant

relationship between pregnant women's (N=108) state anxiety levels and

stressors of pregnancy dunng the third trimester. Also using a prenatal measure

of anxiety and a state anxiety scale, Scott-Heyes (1 982) reported that women

(N=25) demonstrated "a tendency for higher anxiety to be related to more

negative anticipations of childbirth" (p. 54); in the postparturn period with a total

sample of 59, those women who reported their experience more favorably had

significantly lower levels of anxiety.

Astbury (1 980) identified childbirth as a psychological crisis. In a prospective

study with 90 primigravidae, significant changes in state and trait anxiety

occurred frorn Iate pregnancy to the postpartum period. The women reported a

lower state and trait anxiety during the postpartum period than in their third

trimester. Astbury suggested that the higher trait scores revealed in the third

trimester was related to the women's inabiltty to discriminate between curent

states of feeling and general states of feeling.

These researchers have used different instruments to assess anxiety levels,

measured different types of anxiety, and measured anxiety at different time

periods. Collectively.

relationship between

25

however, they obtained one common finding: a significant

a pregnant woman's anxiety scores and her sources of

stress dunng pregnancy.

Aue. Many researchers believe that older pregnant or childbearing women

express less anxiety and experience of stress than younger wornen. Burstein,

Kinch, and Stem (1 974) studied the relationship between matemal anxiety

du ring pregnancy (N=61) and birth weight. While there was no relationship

between pennatal anxiety and infant birth weight, there was a significant

correlation between anxiety and the woman's age. These researchers concluded

that anxiety in pregnancy decreases with age. Standley et al. (1979) revealed

that younger women were more likely to be anxious about pregnancy and

childbirth. Glazer's (1 980, 1985) findings are also in agreement with a negative

correlation between age and anxiety levels in pregnant women. Younger (1 991 )

tested a model for parenting stress arnong 101 mothers of young infants and

reported moderate negative correlation between labor and delivery stress and

age.

lnsufficient or conflicting information is viewed as another source of stress

during labor and delivery. Cartwright (1987) identified age as a variable

associated with women's views regarding information provid ed by rnidwives and

doctors during labor and delivery. Older women felt they received adequate

information. Fleissig (1993) also reported on the provision of information during

labor and delivery. Even though primiparae were more likely than multiparae to

26

be less satisfied with the provision of information, both primiparae and multiparae

under the age of 30 reported not being satisfied.

Kirke (1980b) and Areskog et al. (1981) do not support the notion of age

infiuencing the experience. Kirke (1 980a. 1980b) did not find an association with

a women's age and overall levels of satisfaction and Areskog et al. (1 981 ) did

not find that age was related to the presence of anxiety. Nonetheless, based

upon the studies reviewed, the majority of researchers reported that the younger

a pregnant or childbeafing women. the greater the nurnber of sources of stress

revealed during labor and delivery.

Parity. There is considerable agreement about the quantity and quality of

fears, anxieties, and concems of the primigravida and the rnultigravidas.

Bumstein et al. (1974) reported a moderate negative correlation with the number

of pregnancies and matemal anxiety. The greater the number of pregnancies,

the less the anxiety. However. those women who knew someone who had a

miscaniage had a greater mean anxiety score than women who did not. The

parity of the wornen knowing someone who had a miscarriage was not reported.

Glazer (1 980, 1985) found that women with higher stressor scores tended to

have fewer pregnancies, but the difference was not statistically significant.

Butani and Hodnett (1 980) found expectations and personal behaviour to be

two potential sources of stress among primiparae and multiparae. Both negative

views regarding the experience and regrets about personal behaviour were

reported more frequently among the primiparae then the multiparae.

27

Light and Fenster (1974) reported that "al1 patients expenence anxiety at

some time during their pregnancyn (p. 46). These researchers found a significant

difference between primiparas and multiparas in relation to frequency of

expressed concems. Primiparas reported more concem regarding pain in

childbirth and the baby's condlion at childbirth, whereas the multiparas reported

a higher incidence of concems related to family and subsequent pregnancies.

Areskog et al. (1 981) stated that nulliparous women reported anxiety more

frequently than parous women (Pc0.05). However, parous women who

experienced previous traumatic deliveries reported the most severe fear of

childbirth. Clark (1 975) reported that prirniparae more often than multiparae had

unrealistic expectations, and that wornen with such expectations had more

distress during labor than women whose expectations were judged to be

realistic. Similarly, Heymans and Winter (1 975) reported that a greater

percentage of primiparous mothers expressed fears conceming their infant than

multiparous mothers.

Kirke (1 980b), Cartwright (1975), and Lederman et al., (1 979) disagreed.

These authors reported that primiparas did not have more concems, fears, and

anxieties than multiparas. Mercer (1 979) acknowledged that the multipara may

not be offered the opportunity to discuss her fears of the approaching Iabor

because the health provider assumes that the woman's previous experience

enables her to know what to expect. Westbrook (1979), in her study of 200

women having their first child, revealed that their anxiety regarding mutilation

28

was significantly less than the that reported by women having their second or

third child.

Although differences have been found among primiparae and multiparae

regarding reported fean and concems, al1 pregnant women experience at least

one concem regarding pregnancy and birth (Glazer, 1980). The majority of

information presented in this review, however, identifies a trend among wornen

with fewer pregnancies reporting more sources of stress during labor and

delivery.

Prenatal Education. There are also reports of the influence that prenatal

classes have on the labor and delivery experience. Astbury (1980), Zax,

Sameroff, and Famum (1 975), and Huttel, Mitchell, Fischer, and Meyer (1 972)

reported no differences in anxiety during labor among women attending or not

attending prenatal classes. Zax et al. (1975) found that there were no significant

differences between experirnental and control groups on overall scores to assess

antenatal anxiety and attitudes toward pregnancy. However, there were

differences on factor scores of attitude with regards to the wish to play an active

role in labor and delivery, and positive feelings towards the baby. Huttel et al.

(1 972) administered their instruments antenatally and in the postparturn and,

despite the failure to reveal a difference in the woman's anxiety scores, found

that women who attended prenatal classes were in better control, demanded

significantly less pain medication, and experienced a more overall positive birth

experience than the experimental group (no classes). Astbury (1980) measured

2 9

state and trait anxiety prior to, during, and following delivery. The findings

supported childbirth as a psychological crisis because of the signficant changes

in state and trait anxiety from the antenatal period to the postpartum. There

were. however, no significant changes in anxiety in either the experimental

(prenatal classes) or control group (no prenatal classes) during labor.

Other studies, however, have supported a relationship between prenatal

classes and the labor and delivery experience and describe the effect of

childbirth preparation. Stolte (1 987) reported that prepared women were more

likely to report unexpected events, while Standley et al. (1979) revealed a

significant Iink between preparation for childbirth and anxiety about pregnancy

and childbirth. In addition, researchers have reported anxiety levels associated

with: finding preparation helpful (Mackey, 1990). increasing control of labor and

delivery (Willmouth. 1975). and enabling women to be more aware of the labor

and delivery experience and, subsequently. to have a positive reaction to

childbirth (Doenng & Entwisle, 1975, 1976). Shearer (1 995) has concluded that

many factors affect birth and parents' expectations of it. Her explanation

provided support for the varying reported effects childbirth preparation has on

the stressfui experience of labor and delivery. Although there has been limited

demonstration of any effect of antenatal classes, other than using significantly

less pain-relief medication during labor, there are benefits in some aspects of

satisfaction with child birth (En kin. Keirse, Renfrew, & Neilson, 1 995).

Relationship Status. Various researcherç have described a wornen's

30

relationship status as a factor contributing to her sources of stress during labor

and delivery. Glazer (1 980, 1985) reported a significant negative correlation

between number of concerns a woman expresses and the length of time with her

partner. While Fleissig (1 993) isolated a specific stressful event and reported that

women not living with their partner were less satisfied with the information they

received from staff during childbirth. This finding is not consistent. however, with

Kirke's (1 980) research. He reported that there was no association between

satisfaction with communication and the mothers' personal characteristics.

The research available on relationship status and its influence on concerns

during pregnancy is inconsistent and limited. The inconsistencies among these

findings rnay be accounted for by the way each researcher looked at a woman's

relationship. Glazer (1 980, 1985) asked wornen about the length of relationship.

Fleissig (1 993) requested their marital status, and Kirke (1 980) also asked

marital status but simply requested a yeslno response.

Socioeconomic Class and Education. There are conflicting reports regarding

the influence of socioeconomic class and education on the incidence of stress

and anxiety. Westbrook (1 979) found the socioeconomic status of 200 women

completing their first childbearing year to be related to the ways in which women

experienced and coped with childbearing. Women were divided into three

socioeconomic groups: upper middle class, middle class, and working class.

Middle class women expressed the most negative attitude toward labor. These

women were most fearful of the physical process of childbearing. Glazer (1980.

31

1985) found a significant negative correlation between the frequency of stressor

scores identified and a woman's income: women with higher stressor scores

tended to be less wealthy. However, she found a nonsignificant correlation

between stressor scores and general education: however women with higher

stressor scores tended to be less educated.

Most researchers, however, have exarnined the women's education level in

relation to stressful experiences. Light and Fenster (1974) found a highly

significant difference between women with high school education (or less) and

women with an education beyond high school, in relation to frequency of

expressed concems. These concerns - related to childbirth, famiiy, subsequent

pregnancy, and finances - increased as education levels decreased. Standley et

al. (1 979) also reported that less educated women were more likely to be

anxious about pregnancy and childbirth. In contrast, Younger (1991) reported

that education was positively related to a stressful view of pregnancy. Other

researchers (Areskog et a1.i 981 ; Fleissig 1993; Jones, 1990; Kirke 1980) have

found no relationship between education and stressful experiences of labor and

delivery.

Considerable evidence is reported for factors that influence the labor and

delivery experience. These include anxiety, age, parity, attendance at prenatal

classes, education, and relationship status. The literature, however, is less

consistent in reporting the influence of socioeconomic class on the sources of

stress during labor and delivery.

32

Theoretical Framework

This study is designed within Lazarus's cognitive-phenomenological theory of

stress and coping (Lazams, 1966; Lazarus & Folkrnan, 1984; Lazarus & Launier,

1978). In order to use Lazanis' work to reflect the matemal experience, the

researcher incorporated Rubin's theory of matemal identity into the framework

for the study (Rubin, 1961 a. 1961 b, 1967a, 1967b, 1968a, l968b, 1975). Rubin's

description of matemal subjective experience aids in the identification of sources

of stress during labor and delivery.

Lazarusts theory identifies two processes: cognitive appraisal of events, and

coping. This study will focus on the cognitive appraisal of events. During

appraisal of an event, the individual judges the importance of the event for his or

her well being (Lazarus & Launier, 1978). This judgement is continuous and ever

changing. Cognitive appraisal is "the mental process of placing any event in one

of a series of evaluative categories related either to its significance for the

person's well-being (primary appraisal) or to the available coping resources and

options (secondary appraisal)" (Lazarus & Launier, 1 978). Cognitive appraisals

occur in a relationship between the person and the environment in which the

stressful event is occumng. This relationship is unique and diversified (Lazarus &

Folkman, 1984). For the purposes of this research, the appraisal process of

interest is primary appraisal.

In a primary appraisal, an event may be considered (a) irrelevant, (b) benign-

positive, or O stressful. If an encounter cames no implication for a person's well-

33

being, the situation is irrelevant. If the encounter preserves or enhances well-

being, or promises to do sol it is benign-positive. Both of these categories are

nonstressful. A stressful situation occurs when a person appraises a relationship

between the penon and the environment as exceeding his or her available

resources and taxing his or her well-being. (Lazarus & Folkman, 1984). When

damage has already occurred in an encounter, the appraisal is of ham/loss;

when there is potential for harm or loss. the appraisal of the stressful event is

one of threat. On the other hand, a person appraising a stressful event as a

challenge focuses on the potential growth in the situation and centers around

pleasurable emotions. Although considered individually, threat and challenge

appraisals can occur simultaneously. Their relationship may also change as the

experience evolves. What was initially seen as threatening may later be

perceived as a challenge as a result of coping efforts or changes in the

environment that occurred during the experience.

These broad categories of pt-irnary appraisal - harm-loss, threat, and

challenge - may be further subdivided into a variety of subtypes. The loss rnay

refer to ioss of one's self-esteem, beliefs, or some aspect of self (Lazanis &

Launier, 1978). Threat indicates "threat to one's physical integrityt' (Lazarus &

Launier, 1978, p. 395). focuses on potential ham. and is identified by negative

emotions such as fear, anxiety and anger. Threat appraisal allows anticipatory

coping. As a result. women may be able to "plan for it and work through some of

the difficulties in advance" (Lazanis & Folkman, 1984, p. 33). Like threat,

34

challenge may assume many types; these subtypes depend on the functions,

values, motives, or commitrnents at stake (Lazarus & Launier, 1978).

Both personal and situational factors influence the stressful appraisal of an

encounter (Lazarus 8 Folkman, 1984). Personal factors include commitrnents

and beliefs. Commitments represent what is important to a person, influencing

appraisal through three methods: (a) guiding people into and away from

situations that can challenge or threaten, benefit or hann them, (b) shaping cue-

sensitivity, and O through their relationship to wlnerability (Lazarus 8 Folkman,

1984). Beliefs are personally formed and shape the understanding of the

encounter. They can be based upon traditional views or leamed, or corne from

experience. Generally, beliefs are understood without being openly expressed,

and we become aware of their influence when there is a loss of belief. Finally,

beliefs can be both general and specific, especially those concemed with

personal control.

Situational factors that influence appraisal include novelty, predictability,

event uncertainty, imminence, duration, temporal uncertainty, ambiguity, and the

timing of stressful events in the life cycle. Situational factors have the potential

for creating threat. The importance of the personal and situational factors is

deterrnined by the individual's cognitive processes. These situational and

personal factors, together with the cognitive processes, provide an explanation

for the variations and similarities among individuals in a similar situation. Rubin's

theory supports the variation of sources of stress among women during labor

35

and delivery.

Rubin (1 961 a, 1975) developed a framework of Matemal ldentity and the

Matemal Experience based on a comprehensive study of the multifaceted

processes involved in the developrnent of the matemal identity. Multifaceted

processes - for example. the matemal tasks - provide us with themes for the

potential sources of stress for the childbearing experience. These themes are

concem for child, self, and family. Rubin (1968b. 1970) describes body image

and time and space in childbearing as concepts in the development of matemal

identity. Alterations in these concepts occur in the pursuit of the matemal tasks,

with these concepts providing a conceptual framework for grouping the

concems. Examination of the multifaceted processes of the "details of personal

and interpersonal behaviour promotes a developmental thrust that serves a

woman well in mothering later" (Rubin, 1984. p. 53).

The matemal tasks described by Rubin include seeking safe passage,

seeking acceptance. binding-in, and the giving of self. These tasks are present in

various degrees throughout the experience of pregnancy and childbirth.

Behaviors (and situations) related to seeking and ensuring safe passage involve

concems for both baby and self. Labor and delivery concems related to seeking

and ensuring safe passage include: survival. body image. control, support, and

environment. These issues rnay raise the woman's anxiety level and are further

infiuenced by her beliefs, knowledge, and case history (Rubin, 1984). A woman's

work toward acceptance by others and binding-in involves both a relationship

36

between the child and individuals in the woman's world and between the child

and the wornan herself. This relationship between the woman and her worid is

incremental and reaches itç peak during labor and delivery. Marital status has a

significant influence upon this (Rubin, 1984). The most intricate and complex

task of pregnancy, giving of oneself, involves the pregnant woman giving

physically, psychologically, and socially. As labor and delivery approaches a

wornan feels that she has ver- little to give. Receiving from others, especially her

partner, during labor and delivery is important at this time. 'The giving of one's

time; of caring attention, interest, or concem; of companionship in stress and in

pleasure; and of relief from degradation" (Rubin. 1984, p. 69) is the hallmark of

matemal behaviour.

Body image, along with tirne and space in pregnancy, are the women's

concepts. These change during the tnmesters of pregnancy and subsequently

contribute to the formation of the matemal identity. Body image includes

structure and function of the body, its parts, and its contents. Pain is also

considered an experience in body image. Time and space refer to the

experience of both personal time and space in pregnancy and childbirth, and to

social time and space. An exarnple is the concem of self-control in relation to

time and space for the laboring wornan.

Taking into account Lazanis' relationship between the individual and the

event, and Rubin's identification of the multifaceted processes of pregnancy and

childbearing, these frameworks provide appropriate guidelines for research into

the sources of stress for the woman experiencing labor and delivery. Both

Lazarus and Rubin identified that stressors/concems may change during the

course of an event and that the determinants, the personal and situational

factors, influence the appraisal of the event. Lazanis provided definition for the

sources stress and identified the deteminants which influence stress in a

particular encounter. Rubin reinforced the idea that labor and delivery is the end

point of the potentially-stresshl pregnancy experience, and she identified the

sources of stress related to the labor and delivery experience.

This study will focus on the encounter of labor and delivery, and the

perceived sources of stress experienced by childbearing women in the third

trimester and the immediate postpartum period. The purposes of the study are

(1) to describe the sources of stress expected and experienced by women during

labor and delivery, and (2) to compare the change in these sources of stress.

Research Questions

1. What sources of stress related to la bor and delivery do women identify during

the third trimester of pregnancy and in the immediate postpartum period?

2. Does the appraisal of stressful experiences in labor and delivery change from

the antenatal period to the postpartum period?

3. What is the relationship between the stressors identified in the third trimester

of pregnancy and matemal age, relationship status, parity, education, anxiety,

and attendance at prenatal classes?

4. What is the relationship between the stressors identified in the immediate

38

postpartum period and matemal age, relationship status. parity, education.

anxiety, and attendance at prenatal classes?

5.What are the effects of matemal age, relationship status, parity, education,

anxiety, and attendance at prenatal classes on the differences in expected and

experienced stressors related to labor and delivery?

Definition of Tenns

Third trimester - fetal gestational age (assessed by last menstrual period andlor

ultrasound estimation) of 32 weeks to 38 weeks.

Postpartum - the period following delivery of the placenta up to hospital

discharge andlor 72 hours.

Sources of stress I stressors - any event, interaction, or situation that a

childbearing women appraises as taxing or exceeding her resources; in

this study sources of stress will be operationalized as frequency and

intensity scores on the Feelings of Childbirth Questionnaire (FOCQ).

Labor and delivery - the process of regular contractions that requires admission

to the Labor and Delivery Unit (LDRU), to the delivery of the placenta.

CHAPTER 2

METHODOLOGY

Research Design

This study used a descriptive longitudinal design to describe wornen's

perceptions of stressful experiences during labor and delivery, and the change in

these perceptions over time.

The Setting

The study was camed out wRh childbearhg women who gave birth at the

lzaak Walton Killam - Grace Health Centre for Children, Women, and Families

(IWK-Grace). The Centre provides family-centred matemity care to childbearing

women and their farnilies who are from the metropolitan Halifax area or referred

from other health centres in the Maritime provinces. The IWK-Grace is the only

hospital in Metropolitan Halifax which provides support for labor and delivery.

Labor assessment at the IWK-Grace is camed out in the Early Labor

Assessrnent Unit (ELAU). Following confirmation of labor, a woman is admitted

to the Labor and Delivery Recovery Unit (LDRU) where one-to-one nursing care

is provided. Women experiencing uncomplicated labor and deliveries labor,

deliver, and recover in one room. Once the recovery period is complete, women

and their babies are transferred to the postpartum unit. Currently, postpartum

services for an uncomplicated labor and delivery are provided for up to 48 hours.

In 1994, 5372 women delivered at the IWK-Grace (Allen, 1995). Of these

39

women. 72% experienced low-risk pregnancies, the majority of whom were

followed by family physicians and seen in their private offices. Spontaneous

vaginal deliveries were accounted for by 67% of the women who delivered at the

IWK-Grace. The remaining delivery experiences included 21 % cesarean

sections, 10% forceps (vaginal), and 2% vacuum extractions. Some of the

medical interventions that occurred at this Centre included: inductions (23%),

oxytocin augmentations (1 7%). episiotomies (27%), lacerations (36%). epidurals

for vaginal deliveries (50%). and manual removal of placenta (3%). Intramuscular

and intravenous analgesia is used by 43% of the women delivering at the Centre

and 22% of the population use entonox. Prenatal classes, attended by 36% of

the women. are offered primarily by the Department of Public Health (DPH) and

the IWK-Grace Health Centre.

Population and Sample

The target population included women attending prenatal care from the

Halifax area who were in the third trimester of an uncomplicated pregnancy and

who maintained this uncomplicated status throughout labor and delivery. The

sample was a nonprobability convenience sample of 98 women; in comparing

means and to detect an effect size of 0.40, power of 0.80, and a = 0.05, a

sample size of 98 women was required (Brink & Wood, 1994). Taking into

account a 34% attrition rate due to complicated deliveries, it was expected that it

would be necessary to recniit 147 women during the antenatal perÏod (time 1).

Women were recruited from those attending the IWK-Grace prenatal classes,

41

and ftorn those women receiving Gare from physicians' prenatal clinics, and

private offices. These settings were chosen to ensure sarnple heterogeneity for

data collection. To participate in the study, women met the inclusion criteria and

were available at the time of data collection to be recmited. Inclusion criteria

were as follows:

1) the woman had either reached the age of majority (19 years) or was an

emancipated minor;

2) the woman's pregnancy was between 32 and 38 weeks gestation;

3) the woman was expected to defiver a healthy infant; and

4) the woman could read and speak English.

Women were excluded from this sample if, during pregnancy or labor and

delivery, they experienced any of the following:

1) high risk pregnancy (Appendix Ç) as indicated by a score >3 (excluding age

and parity) on the Nova Scotia Prenatal Scoring Forrn. This form is a tool used to

identify the total risk score. The score is then recorded in the appropriate box on

a womants prenatal record.

2) a complicated labor and vaginal delivery. This referred to a birth expenence

that required medical or surgical interventions, excluding artificial rupture of

membranes, episiotorny, lacerations, epidurals and other forms of pain relief,

intravenous infusion, intravenous antibiotics, scalp electrode, continuous fetal

monitoring. and oxytocin augmentation.

3) delivery of an infant c 38 weeks or > 42 weeks gestation.

42

4) delivery of a stillbom infant or a neonatal death.

5) admission of an infant to the Special Neonatal Care Unit for more than 24

hours.

6) release of the infant for adoption.

Characteristics of the Sample

The sample at time 1 consisted of 151 women experiencing uncomplicated

pregnancies. One hundred sixty-six women were approached to participate. The

most frequent reason provided for non-participation was unwillingness to take

the time required to complete the questionnaires. At time 2, 98 of the 151 original

participants had maintained an uncomplicated status throughout labor and

delivery, and 93 provided complete data sets at time 1 and time 2. Four women

did not retum their questionnaires and 1 retumed an incomplete questionnaire.

The women's age ranged from 16 years to 39 years, with a mean age of

27.78 years and a mode of 30.0. The majority of women had a post secondary

education, while the level of education ranged from less than high school to post

graduate education. Most of the women (88.8%) had partners. The majority of

women (44%) were prirnigravidas; for 32% this was their second pregnancy; and

24% had experienced two or more pregnancies. Most women (60.2%) did not

attend prenatal classes. Class attendance ranged from one to two classes

(8.2%), three to four classes (17.3%), to five or more classes (14.3%). A

summary of the women's demographic data is presented in Table 1.

Table 1

Demoaaohic Data of Woman Obtainina an Oncomplicated Labor and

Delivew

Characteristics Mean(sd) Range % of Women(N=98)

Educational Level Less than high school - Completed high school - Some post secondary - University degree - Post graduate studies -

Relationship Status Single - - Partner - -

Number of Pregnancies 1.81(0.81) 1 - 7 One pregnancy Two pregnancies Three or more pregnancies

Prenatal class attendance no classes - 1-2 classes - 3-4 classes - 5 or more classes -

In 1995, 4420 mothers frorn Halifax County, delivered infants at the IWK-

Grace weighing greater than 500 grams (Allen, 1996). Of these women, the

majority were between 25 and 29 years of age (32%), 46% were first time

mothers, 37% were experiencing their second pregnancy, and 17% three or

44

more pregnancies. Prenatal classes were attended by 49% of the population and

the majority of the women were married (69%) or were living common-law (9%).

These statistics from Halifax County are fairiy consistent with the profile of the

women participating in this study. The exception to this similarity was attendance

at prenatal classes. More women from Halifax county as a whole attended

prenatal classes than did the women participating in this study.

Data Collection

The study was designed as a longitudinal study in which each woman

described her concems or stressors and her level of anxiety at two time points:

1) during 36 to 38 weeks of pregnancy, and 2) within 12 - 72 hours of delivery.

The researcher recniited a convenience sample of 151 women who attended

either one of the final prenatal class sessions at the IWK-Grace, a prenatal

appointment at their physician's prenatal clinic, or private office. Once the

women consented to participate, the initial data collection took place at their

convenience in the 36th to 38th week period. Following delivery, final data

collection was carried out. At both time penods, the women completed the

Feelings of Childbirth Questionnaire (FOCQ) (see Appendix A, B) and State-Trait

Anxiety lnventory (STAI; Spielberger, 1983) (see Appendix C, D). Demographic

information was also collected (see Appendix E). It took approximately 10 to 20

minutes to complete these forms.

The FOCQ was based on Glazer's (1985) Feelings of Pregnancy

Questionnaire (FOPQ) and adapted for this study. The FOPQ identified the

45

nurnber and intensity of stressors during pregnancy. Glazer's instrument elicited

stressors about the baby, self, health care, childbirth, family and friends,

finances, and subsequent pregnancies. With permission from Glazer (personal

communication, November 30, 1995). the researcher modified the instrument to

identify the number and intensity of concems during childbirth. The STAl is a

self-administered tool designed in h o parts to assess: (a) state anxiety or

current feelings of apprehension, nervousness and worry, and (b) trait anxiety or

how people generally feel. Each fom contains a 20 item scale. F inally, the

demographic information was obtained in two parts. The study participants

completed Part A by providing information about their age, relationship status,

parity, education level, Family Physician, due date, and whether or not they were

attending prenatal classes. The medical information to complete Part B was

obtained by reviewing the woman's health record after delivery, and recording

length of labor, complications and medical interventions, method of delivery,

apgar scores, episiotorny andfor lacerations, and pain medication received. In

addition, the researcher asked women attending prenatal classes the number of

classes attended; each woman was also asked whether the physician who . assisted in the delivery of her infant was her own physician, a physician she had

previously met, or a physician whom she did not know.

Procedure

Prior to implementing this study, ethical approval was obtained from the

Human Ethics Review Cornmittee of the Faculty of Graduate Studies, Dalhousie

4 6

University. and the Research Cornmittee of the Grace site of the IWK-Grace

Health Centre. The following people were contacted to explain the study and

elicit their support: (a) the Nursing Manager of the Perinatal Centre, (b) Prenatal

Instructorç at the IWK-Grace, O Physicians and Nursing staff in the Family

Physician Clinic of the Perinatal Centre, the Spryfieid single parent group, and

private physician offices.

The study was introduced to potential participants at either their childbirth

class or prenatal visits with their family physician. Within these groups, al1 women

who met the inclusion criteria and wRh whom the researcher had the opportunity

to describe the study were invited to participate. If a woman was interested in

participating, the researcher reviewed the details of the study and asked her to

sign a consent form (see Appendix G). The readability level of the consent f om

was assessed with an attempt to maintain the reading level at or below Grade 9.

The women retaineci a copy of the consent fom. The interested women from

prenatal classes provided their home nurnbers for contact. These wornen were

met at their convenience, at an agreed upon location, either within or outside

their homes. Contact with women from physician clinics and private offices was

made through the receptionist or the nurse. Information regarding the study was

provided to these receptionists and nurses. If they judged a woman to be a

potential participant, the researcher approached her during a ch ic or office visit.

Initial data collection was either completed prior to their appointment with the

physician or immediately following the appointment. This process of data

collection at time 1 wntinued until 151 women consented to participate.

Each woman completed three instruments and a Demographic Information

Sheet (DIS) antenatally, and three instruments following delivery. The woman

completed the DIS Part A after infoned consent was provided, and then were

asked to complete the TraitlState Anxiety Scales and the FOCQ. Written

instructions for the Anxiety Scales were included in the instrument. The women

were encouraged to respond to the FOCQ by anticipating the sources of stress

they would experience during labor and delivery. Both instruments were

presented in a booklet. The order of the instruments were:

1 ) State Anxiety Scale, 2) Trait Anxiety Scale, and 3) the FOCQ.

The researcher was present at each data collection session and addressed

questions that arose regarding instructions or phrasing of questions. The most

common question was related to uncertainty about the meaning of indecisive.

When asked this word's meaning, the researcher would redirect the question and

ask the participant what they thought the meaning was. A response was always

given. The women were then encouraged to use their own explanation as the

basis for answenng the question. The women took a break between instruments

if required.

On a daily basis, the researcher checked the hospital's Meditech computer

information system for each woman's notice of delivery and current hospital

location. Following delivery, each woman was contacted to complete the

instruments at a convenient time. The instruments were left with each wornan for

48

cornpletion and the researcher retumed to pick them up either later that day or

the following day. If a woman gave birth and left the hospital before the

researcher was able to contact her. she was wntacted by telephone to arrange

a convenient means to complete the instruments. This involved meeting the

participant at a location of her choice, or mailing her the instruments with a self-

addressed stamped envelope included. All questionnaires received following

hospital discharge were obtained within one to two weeks of the woman's

delive ry.

At time 2 the women were asked to respond to the FOCQ according to the

sources of stress they experienced during labor and delivery. They were also

provided with documentation space, at the end of the FOCQ, to record other

sources of stress during labor and delivery that were not included on the

instrument. The postpartum version of the FOCQ was worded to ask each

woman to "think back" on her labor and delivery and indicate how she felt about

each item. These items were reworded to be appropriate for responses after

delivery.

Part B of the DIS was completed by the researcher following delivery. using

information obtained from the woman's health record. Data collection du ring

Time 2 was camed out until98 women expenencing uncomplicated labor and

deliveries completed their questionnaires.

Instruments

Anxiety

The State-Trait Anxiety lnventory (STAI-Fom X) was originally published by

Spielberger, Gorsuch, and Lushene, 1970. In 1979, however, a major revision of

the scale was initiated based on research results with the original inventory.

(Form Y, Appendix C & D) (Spielberger, Vaggs; Barker, Donham, & Westbeny,

1980). A self-reported scale for measuring state and trait anxiety, the STAl has

been used extensively in research and clinical practice. The test form is two

sided, with SAnxiety on one side and T-Anxiety on the other. The STAl was

developed for use with high school students, college students, and adults; it has

also been useful with junior high students. This inventory has no time limit and

may be given individually or to groups. College students generally require 10

minutes to complete both sides (Spielberger, 1983).

Instructions for using this inventory are printed on the fom and instructions

are different for the two sides of the inventoiy. "State" instructions require the

perçons to indicate, on a four-point scale, how they are currently feeling in

relation to 20 self4escriptive statements. "Trait" instructions require the persons

to indicate how they generally feel with participants once again responding to 20

statements by circling their response on a four-point scale. Whether

administered in a gtoup or individually, it is helpful to have the study participants

read the instructions silently while the researcher reads them aloud.

When administerîng both sides of the inventory, the S-Anxiety scale should be

50

adrninistered first because this scale is "designed to be sensitive to the

conditions under which the test is adrninistered" (Spielberger, 1983. p. 1 1 ).

When responding to the S-Anxiety scale, the four points are described as: (1 )

not at all, (2) somewhat, (3) moderately so, and (4) very much so. When

responding to the T-Anxiety scale, the four points are described as: (1) alrnost

never, (2) sometimes, (3) often, and (4) alrnost always.

The respondent scores each item on the STAI from one to four. Anxiety-

present items receive a score corresponding to that seen on the test score. The

anxiety-absent items are reversed in swring. The absence of anxiety is

represented by a high rating on 10 of the S-Anxiety and nine of the T-Anxiety

items. Scores for both the S-Anxiety and T-Anxiety scales can Vary from a

minimum of 20 to a maximum of 80. Permission to reproduce this instrument was

obtained from Mind Garden (1 983).

More than 5000 subjects were tested in the construction and standardization

of the revised version, Fom Y (Spielberger, 1983). Factor analyses have

presented clear-cut distinctions between state and trait anxiety, and reliability for

STAl has been assessed using stability and interna1 consistency. Stability was

rneasured by test-retest coefficients. As expected, the T-Anxiety scale coefficient

was relatively high and the SAnxiety scale was low. T-Anxiety retest correlations

ranged from .65 to -75, while the stability coefficient for S-Anxiety ranged from

.34 to .62. "Relatively low stability coefficients were expected for the S-Anxiety

scale because a valid measure of state anxiety should refiect the influence of

51

unique situational factors that exist at the time of testingn (Spielberger, 1983, p.

31). Alpha coefficients for the Fom Y SAnxiety and T-Anxiety are reported for

samples of working adults, students, and military recruits. The SAnxiety alphas

were above .90 for al1 but one of the samples, in which it was 0.86. The alpha

coefficient for the T-Anxiety scale were also high (-89 to .91). Cronbach's alpha

scores for state and trait anxiety in this study revealed Time 1 coefficients of 0.91

for S-Anxiety and 0.90 for T-Anxiety, and Time 2 coefficients of 0.94 for S-

Anxiety and 0.91 for T-Anxiety.

"Individual STAl items were required to meet validity criteria at each stage of

the test developrnent process in order to be retained for further evaluation and

validation" (Spielberger, 1983, p. 32). Finally, evidence of the concurrent,

convergent, divergent, and construct validity of the STAl scales has been

established (Gaudry & Poole, 1975).

Labor and Delivery Stressors

The FOCQ (Appendix A) is a questionnaire adapted from the FOPQ

developed by Glazer (1985). The FOPQ was designed to identify numbers and

intensity of stressors during pregnancy. Glazer's instrument elicits concems

about the baby, self, health care, childbirth, family and friends, finances, and

subsequent pregnancies. The questionnaire requires responses ranging from (1 )

not at al1 stressfiil, (2) somewhat stressful, (3) moderately stressful, to (4) very

much so stressful.

The FOCQ was adapted from this instrument with permission to include 55

52

items from the original 78 items on the FOPQ. The content for the FOCQ was

validated by a panel of experts, which wnsisted of a perinatal nurse educator, a

labor and delivery staff nurse, and a pennatal nurse consultant who assisted in

determining the appropriateness of the FOCQ for this study. These experts were

asked to review the FOPQ. and to i d e n f i items on the instrument that could be

a potential source of stress during labor and delivery, and to delete those items

that would not be identified as a source of stress. The researcher originally

identified 27 items for deletion. Agreement was reached between the researcher

and the perinatal nurse consultant on 23 of the 27 items. Following discussion,

agreement was reached to delete only those 23 items. The perinatal nurse

educator, following her review of the FOPQ, chose to delete 24 of the 27 items.

Agreement, however, was reached between the researcher and the perinatal

nurse educator to maintain the deletion of that one extra item. 100% agreement

with the inclusion of the 55 items for the FOCQ was received from the labor and

delivery staff nurse.

The FOCQ includes those concerns in the FOPQ that could be potential

sources of stress during labor and delivery from the categories about the baby

(1 2/ 16), self (1411 8), health care (9/ 1 O), childbirth (1 011 O), and family and friends

(9114) (see Appendix B). One concem from the category of subsequent

pregnancies was identified as relating to labor and delivery (#19). This item was

added to the category "self", increasing the total items in this category to 15. The

answer format to these items was changed from Glazeh (1985) instrument. The

53

"does not apply" category was deleted. The remaining categories, however, were

unchanged; "not at al1 stressful" received O points; "somewhat stressful" received

1 point; "moderately stressful", 2 points; and "very much so stressful", 3 points.

The possible range of scores is from O to a high of 165.

The FOPQ is a reliable instrument for pregnant women and their partners

(Glazer, 1984). Glazer reported that the alpha coefficient for women was 0.96

and the split-half coefficient for women was 0.94. All of the subscales had

reliability coefficients greater than 0.70. The test-retest reliability coefficient for

women was 0.91. Considenng the instruments utilized by Glazer, the FOPQ,

STAI, and POMS; the FOPQ was considered a valid instrument because of the

ability of all the instruments to discriminate between the concepts of anxiety and

stressors. Glazer also revealed a significant relationship between the scores on

the FOPQ and women's self reported amounts of stress during pregnancy.

In this study, issues of the reliability and validity of the FOCQ were

addressed in relation to intemal consistency of the instrument and content

validity. lntemal consistency provides a useful measure of reliability when the

variable being measured is a changeable one (Brink & Wood, 1994). Content

validity, a self-evident measure, involves "cornparhg the content of the

measurement technique to the known literature on the topic and validating the

fact that the tool does represent the literature accurately" (Brink & Wood, 1994,

p. 176).

lntemal consistency was established using Cronbach's alpha coefficient. The

findings are presented in Table 2.

Table 2

Cronbach's abha coefficient [= 1 for the FOCQ total and subscale scores (N = 93)

Time 1 = Time 2-

FOCQ (total scores) 0.94 Su bscales Scores: Baby 0.77

Self 0.82 Healthcare 0.77 Child birth 0.89 Farnily and Friends 0.65

-- - --

Content validity was established in part by the fact that Glazer's (1 985)

questionnaire was adapted based on the research literature that is available

regarding the concems of women during labor and delivery. The panel of nursing

experts assisted in determining the appropriateness of the FOCQ for this study.

Data Analysis

Descriptive statistics were used for the sample demographic data, total

scores on the FOCQ. and subscales of the FOCQ and are displayed in tables.

Summary statistics were used to describe the influencing variables.

The data were analyzed to determine the relationship between sources of

stress and influencing variables at both the antenatal period (Time 1) and the

postpartum period (Time 2). and to detemine changes between these two time

periods. Regression analyses were used to determine the relationship between

55

infiuencing variables, matemal age, relationship status, parity, education,

anxiety, and attendance at prenatal classes, and the FOCQ total scores and

subscale scores for both frequency and intensity. Paired t-tests were used to

compare the mother's responses to the FOCQ and subscales in the antenatal

period and postpartum periods.

The women's descriptions of other sources of stress were analyzed to

detemine whether there were issues that were omitted from the scale. These

issues are presented descriptively.

Ethical Considerations

Protection of Su biects

Only women who met the eligibility criteria were approached to participate.

The researcher explained the study to each woman and indicated my interest in

studying the types of concems woman have about labor and delivery

experience; at this time, the researcher also explained that participation was

voluntary and that there were no known risks or benefitç involved in their taking

part. The women were asked to read and sign a consent form, of which they

were given a copy to keep. After the researcher explained the study, the women

were also told that they could withdraw from the study at any time, and that their

decision to take part or not would have no effect on their medical or nursing care.

Names of women who decided to participate are confidential, and a coding

system was maintained to identify the data sets for each woman. Only the

researcher has access to this coding system. which was kept separate frorn the

56

instruments. The list of names was destroyed following analysis of data, and only

grouped data reported.

Risks and Benefits

There were negligible risks to the women as a result of pamcipating in the

study. However, one benefit may be the identification of sources of stress for

labor and delivery either antenatally or in the post partum period. This

identification may have enab!ed a woman not only to deal with an issue in the

present. but to prevent carry-over of the source of stress into elher her labor and

delivery or postpartum experience.

CHAPTER 3

FlNDlNGS

Introduction

The women in this study reported greater anticipated, than experienced,

sources of stress for labor and delivery. Their most frequently reported stressors

were concems for childbirth, the baby, and thernselves. The relationship

between the independent variables (wornen's age. relationship status. parity,

education, state and trait anxiety, and attendance at prenatal classes) and the

dependent variables (the rnother's sources of stress during labor and delivery)

varied from the anteparturn to the postparturn period. Both trait anxiety and parity

were consistent predictors of stressors in the anteparturn period, and state

anxiety was the dominant predictor during the postpartum. The women also

indicated several additional sources of stress related to labor and delivery that

did not appear on the FOCQ. These common thernes were generally related to

the concerns women had about childbirth.

Antepartum Sources of Stress and Anxiety

Sources of Stress

During their third trimester, all women identified at least one of the items on

the FOCQ as being an anticipated source of stress for labor and delivery (see

Appendix H). The possible range of scores was O to 155, and the women's

scores in this study ranged from 3.00 to 109.00 (M=43.62, SD=22.67), (see

57

Table 3). Overall, the concems identified within the subscale 'childbirth'

represented the highest anticipated stressors for labor and delivery (M=15.07,

SD=6.96). and contributed the rnost to the total FOCQ score. More than 50% of

the wornen identified al1 10 elements of childbirth as sources of stress (see Table

4). Their most frequently-indicated stressors concemed any unexpected thing

that might happen during labor and delivery, the pain in childbirth, and

complications occurring in labor. The second highest anticipated stress subscale

was the 'baby' (M=10.02, SD=5.12). Nearly al1 women were concerned about 'the

baby's condition at birth' and about 'whether their baby would be healthy and

normal'. More women endorsed these two items than any other items on the

FOCQ. In total, 4 of the 12 items related to the baby were reported by more than

50% of wornen as being stressful. Women also identified stressors from the 'self

subscale (M=9.96. SD=7.00). Most women identified stressors related to

'discornforts they were having', to 'womes', and to 'concems regarding their

health'. Greater than 50% of the women identified six of the 15 items from the

subscale 'self as sources of stress. Sources of stress related to 'healthcare'

(M=4.73, SD=4.25)and 'family and friends' (M=3.84, SD=3.62) were reported

less frequently. In total. 23 items were identified by more than 50% of the women

as being 'somewhat' to 'very rnuch' stresshl during the third trimester of

pregnancy. These stressors are presented in Table 4.

Table 3 Ex~ected Sources of Stress Durina Labor and Delivery

Scale # items on sale min-max score median M SD

FOCQ 55 3-1 09 39.5 43.62 22.67 Subscales:

Childbirth 10 0-29 14 15.07 6.96 Baby 12 1 -24 10 10.02 5.1 2 Self 15 0-29 8 9.96 7.00 Healthcare 9 0-1 8 3 4.74 4.25 Family & Friends 9 0-1 4 3 3.84 3.62

Table 4 Labor and Del'nrev Sources of Stress Ex~ressed in the

Ante~artum Period bv Greater than 50% of Women (Na81

Sources of Stress % of Women M

CHILDBIRTH Any unexpected thing that rnight happen during childbirth The pain in childbirth Complications occumng in labor Being tom when the baby is bom Losing the baby in labor and delivery The medication you might receive dunng childbirth Your condition dunng childbirth The cut the doctor makes when the baby is delivering Losing control in labor Being able to have the type of birth experience you want

BABY Your baby's condition at birth If your baby will be healthy and normal Something happening to the baby because of something that rnight happen during labor Something happening to the baby because of somettiing inherited

SELF The discornforts you're having Being womied Your own health Being a good mother Being depressed Gaining too much weight

HEALTHCARE Whether the nurses wiII give you good care Your doctor being with you

FAMILY AND FRIENDS If your partner understands your changing feelings and problems

Anxiety

The mothers' state anxiety scores ranged from a minimum of 20.00 to a

61

maximum of 62.00 (M=37.47, SD=IO.41). Their trait anxiety scores ranged from

a minimum of 20.00 to a maximum of 58.00 (M=35.29, SD=8.71). The possible

anxiety scores ranged from 20 to 80.

Postpartum Sources of Stress and Anxietv

Sources of Stress

During the immediate postpartum period, al1 women identified at Ieast one of

the items on the FOCQ as having been stressful during labor and delivery (see

Appendix 1). Their scores ranged from 3.00 to 99.00 (M=31.99, SD=20.86) (see

Table 5). The experienced sources of stress from the 'childbirth' subscale

represented the greatest stressors encountered (M42.26, SD=7.00). More than

50% of the mothers identified 9 of the 10 items in this scale as being stressful.

More than 90% of women rated 'the pain in childbirth' as having been a source of

stress during labor and delivery (see Table 6). The second most frequently-

reported experienced stress scale was the 'baby' (M=7.91. SD4.93). More than

50% of the women identified three (of a possible 12) baby-related items as

having been stressful; concems frequently identified were 'whether the baby

would be healthy and normal' and 'the baby's condition at birth'. Concems from

the subscale 'self were next (M=7.31, SD=6.19). More than 50% of the women

encountered 3 of the 15 items regarding self as having been stressful duting

labor and delivery. The most frequently-reported experienced source of stress

were 'the women's discomforts'. In total. 15 items related to labor and delivery

were identified by greater than 50% of the women as being 'somewhat' to 'very

much' stressful during the irnmediate postpartum period. These stressors are

presented in Table 6.

Table 5

Exmrienced Sources of Stress Durina Labor and Delivew Scale # of items on scale min-max score rnedian M SD

FOCQ 55 3-99 29 31 9 9 20.86 Su bscales:

Childbirth 10 0-27 12 12.26 7.00 Self 15 0-29 5 7.3 1 6.1 9 Baby 12 0-1 9 6 6.91 4.63 Healthcare 9 0-1 4 2 3.05 3.42 Family & Friends 9 0-1 5 2 2-45 2.96

Table 6 Labor and Delivew Sources of Stress Exnressed in the

Post~artum Perfod bv Greater than 50% of Women (N=93\

Sources of Stress % Women M

CHILDBIRTH The pain in childbirth 91% 3.27 Any unexpected thing that rnight happen during childbirth 72% 2.33 Complications occumng in labor 71 % 2.39 The medication you rnight receive during childbirth 67% 2.35 Being tom when the baby is bom 64% 2.15 Your condition during childbirw 60% 2.04 Losing control in labor 59% 2.15 Losing the baby in labor and delivery 59% 2.1 8 Being able to have the type of birth experience you wanted 55% 2.04

BABY If your baby would be healthy and normal Your baby's condition at birth Something happening to the baby because of something that might happen during labor

SELF The discornforts you were having 83% 2.83 Being womed 53% 1.88 Your own health 50% 1 -80

Anxietv

The mothers' state anxiety scores ranged frorn a minimum of 20.00 to a

maximum of 68.00 (M=33.46, SD= 11 .O1 ). Trait anxiety scores ranged frorn a

minimum of 20.00 to a maximum of 57.00 (M=33.43, SD=8.52).

Chanaes in Stressful Experiences and Anxiety from Antepartum to

Postpartum

A paired t-test was used to determine the presence of statistically significant

differences in the FOCQ scores, in its subscale scores. and in the anxiety scores

from the antenatal period to the postpartum period. At the postpartum rating,

mothers reported significantly fewer concems on al1 subscales, as well as

significantly less anxiety. The greatest change was in the FOCQ total scores, in

the baby and childbirth subscale scores, and in state anxiety scores. These

differences are presented in Table 7.

Table 7

Changes in Women's A ~ ~ r a i s a i of Stressful Exileriences in Labor and Delivew and Anxietv

fmm the Antenatal Period to the Post~artum Period

Scale Mean Difference (sd) t (df) P

FOCQ 12.1 6 (1 6.68) 7.03 (92) Su bscales:

Baby 3.1 2 (4.32) 6.96 (92) Childbirth 3.00 (5.30) 5.46 (92) Self 2.85 (5.27) 5.21 (92) Healthcare 1.72 (3.01) 5.51 (92) Family & Friends 1.47 (3.32) 4.28 (92)

State Anxiety 3.86 (i 2.67) 2.95 (93) Trait Anxiety 1.81 (6.47) 2.69 (92)

64

Factors that Influence Anticipated Labor and Delivew Sources of Stress

Stepwise multiple regression analyses were used to detemine the

relationship between stressors identified in the third trimester of pregnancy and

the independent variables (matemal age, marital status. parity. education, state

and trait anxiety, and attendance at prenatal classes). Trait and state anxiety and

nurnber of pregnancies explained 36% of the variance in the FOCQ score. Trait

anxiety scores were positively associated with the 'total stress scores' (R2 =

21%), and the subscale scores of 'self (R2 = 20%), 'healthcare' (R2 = 14%),

'childbirth' (R2= IO%), and 'family and friends' (R2 = 10%). The number of

pregnancies a women had experienced was negatively related to stressors

conceming 'childbirth' (R2 = 21 %). State anxiety score was a significant predictor

for the baby subscale score (R2 = 18%). These regression results are presented

in Table 8.

Predictors of Labor and Delivew Stressors duiincr the Third Trimester IN = 981

Scale Variables Unique Cumulative Beta T SigT R~ R~

FOCQ Trait Anxiety # of pregnancies S tate Anxiety

Baby State Anxiety Education # of pregnancies

Self Trait Anxiety # of pregnancies

Healthcare Trait Anxiety Education

Childbirth # of pregnancies Trait Anxiety

Family & Trait Anxiety Friends

Factors that Influence Re~orted Stressors in Labor and Delivew

Again, stepwise multiple regression was used to analyze the relationship

between the independent variables (materna! age, relationship status, parity,

education, anxiety (state and trait, time 1 and time 2). and attendance at prenatal

classes) and the labor and delivery stressors identified in the immediate

postpartum period. State and trait anxiety explained 26% of the variance in the

experienced stress score. State anxiety scores (tirne 2) had a significant positive

association with the total FOCQ scores and with al1 subscde scores. It was the

most important predictor of stress scores in al1 cases and was the only predictor

of sources of stress when postpartum women were asked about their childbirth.

66

Trait anxiety was positively associated with sources of stress on both the 'total

stress scores' and the 'family and fnends' subscale scores. The predictor

variables for sources of stress experienced in labor and delivery are presented in

Table 9.

Table 9

Predictors of Labor and Delivent Stressors in the Post~artum Period !N=94

Scale Variables Unique Cumulative Beta T Sig T R2 R2

FOCQ State Anxiety (time 2) .218 .218 .392 Trait Anxiety (time 1 )

Baby State Anxiety (tirne 2) Educaüon Single

Self State Anxiety (time 2) Age

Healthcare State Anxiety (time 2) Education

Childbirth State Anxiety (time 2)

Family & State Anxiety (tirne 2) Friends Trait Anxiety (tirne 2)

Factors that Influence the Difference in the Expected and Experienced

Sources of Stress durina Labor and Delivew

Stepwise multiple regression analyses were used to determine the

relationship between the difference in the women's expected and experienced

sources of stress during labor and delivery, and the independent variables. State

and trait (time 1 and difference) were the anxiety variables entered into this

analyses. Being single was the greatest predictor (R2 = 8%) of the difference in

67

expected and experienced sources of stress during labor and delivery, and in the

difference in scores related to the baby (R2 = 13%). A woman's parity explained

some of the variability in the differences in the 'childbirth' subscales (R2 = 8%)

and the 'self subscales (R2 = 8%). The greater the number of pregnancies, the

smaller the decrease in the stress scores. The results of the regression analysis

to predict the difierences in the expected and experienced stressors scores are

presented in Table 10.

Table 10

Predictors of the Difference in the Ex~ected and Ex~erienced

Stressors durina Labor and Delivery (N-93)

Scales Variables Unique R2

Cumulative Beta T Sig T R2

FOCQ Single .O79 .O79 229 2.25 .O27 # of pregnancies .O46 -124 - .219 - 2.15 ,034

Baby Single .131 .131 -283 2.76 .O07 State Anxiety (tirne 1 ) .O46 -1 78 .229 2.24 .O28

Self # of Pregnancies ,079 ,079 - .246 - 2.45 .O16 Trait Anxiety (tirne 1 ) .O48 .127 -221 2.20 .O30

Chi ldbirth # of pregnancies .O83 .O83 - -253 - 2.53 ,013 Trait Anxiety Difference .O47 -1 30 -220 2.20 .O30

Heaithcare No variables entered / removed for this block

Family & Friends No variables entered / rernoved for this block.

Post~artum Descriptions of Labor and Delivery Sources of Stress

The mothers were asked during the postpartum period to identify the sources

68

of stress experienced during labor and delivery that were not included on the

FOCQ. Twenty-three of the women provided personal concems. These

responses were categorized under the appropriate scales of the FOCQ. The

childbirth subscale contained the majority of personal responses. Table 11

provides these personal descriptions of sources of stress experienced during

labor and delivery. The women's descriptions are grouped under the subscale

item to which they most dosely related. Only two items were not related to

individual items contained on the FOCQ.

Table 11 Personal Descrl~tions of Sources of Stress Exoerienced Durina Labor and Delivew

l tem Scale

CHI LDBIRTH Any unexpected thing that rnight happen during labor and delivery

- sent home cause too busy for induction - tirne, how much to get to the hospital - is this really labor? - why won? rny placenta deliver? will I go to the OR? - found vomiting distressing, physically, and emotionally - is the baby ever coming out, desperation

Your condition during childbirth - worrïed about having strength to deliver, too tired - too tired to push

The medication you might receive during childbirth - pain relief not coming quick enough once decided wanted it - pain relief not adequate, told it would be

The pain in childbirth - afraid the pain would never end, how could 1 handle it? - pain too intense at the end to push through, disturbing and frustrating

Losing control in labor - womed l'd lose control with my breathing

Being able to have the type of birth experience you wanted - getting through it (L&D) as quick as possible - number of hours in hard labor - feeling of inadequacy - isolation during labor - will I rnake it to the hospital in üme? - disappointment I expectation of epidural not met in labor, too fast, low platelets - felt that I was going to be alone - videos that made it seem so easy

HEALTHCARE Your doctor being with you

- no family practice doctor available to deliver my baby - womed doctor wouldn't rnake it in time - doctor getting there on time - physician not present for deliver (stranger)

Whether the doctors / nurses will give you good care - lack of explanation when baby was distressed

SELF Taking care of your baby's physical needs

- worried about breastfeeding and having complications FAMILY AND FRIENDS

If you partner understands your changing feelings and problems - concemed how husband was coping seeing wife in so much pain

OTHER - womed about having a bowel rnovement dunng labor and delivery - bowel rnovement on the table

Surnmarv

During the antepartum period. women were most concemed about childbirth,

their baby, and themselves. Virtually al1 were concemed about the baby being

healthy and normal, and about the baby's condition at birth. More than 90% of

women anticipated having at least some concems regarding childbirth. Sources

of stress were reported significantly more often in the antepartum than in the

postpartum period; similady, anxiety levels were generally higher in the

antepartum than the postpartum period.

State and trait anxiety were both significant predictors of the total stress

scores in the antepartum and the postpartum perïod. These and a variety of

other variables accounted for the variance in the subscale scores at both tirne 1

and time 2. In the third trimester, trait anxiety contributed to the explanation of

the variability in al1 stress scales wlh the exception of the baby scale. Also,

during this antenatal period, a woman's parity was related to various stress

scores. As the number of a woman's pregnancies increased, her scores on the

FOCQ, baby, self, and childbirth scales al1 decreased. During the postpartum

period , state anxiety (time 2) contributed sig nificantly towards predicting

experienced stressors in al1 labor and delivery scales. 60th par@ and

relationship status were related to the differences in expected and experienced

sources of stress. These scales included the FOCQ, self. childbirth, and baby.

The womens' personal postpartum descriptions of sources of stress experienced

during labor and delivery revealed a tendency to report concems predominantly

related to items in the childbirth subscale.

CHAPTER 4

DISCUSSION

Introduction

The findings of this study are consistent with the matemal tasks identified in

Rubinls (1 984) theoretical framework and support the theory that personal and

situational factors help shape the meaning of an experience (Lazarus &

Folkman, 1984). The influence of such factors, however. is quite limited; the

most prominent in this study include parity and anxiety. These findings are

consistent with other studies that show little or no relationship between stressors

and personal and situational factors. The majority of studies that reported a

relationship between these variables and stressors of pregnancy had a different

study design and were older (Light & Fenster, 1974; Standley et al., 1979). In

this study, findings conceming the expected and experienced sources of stress

during labor and delivery are quite similar to those reported in previous studies;

these sources of stress include the baby and the concems women have for

themselves ( Affonso & Maybeny, 1990; Arizimendi & Affonso, 1987; Glazer,

1980,1985). Although women reveal a variety of labor and delivery stressors

during pregnancy and in the postpartum, they consistently report their concems

for the baby and themselves.

Safe Passaae

The interplay of matemal tasks in pregnancy contributes to the development of

the matemal identity (Rubin, 1984). Safe passage is one such task, and is the

72

73

process by which women "seek and ensure safe passage (physically) through

pregnancy and childbirth" (Rubin, 1984, p. 54). It contributes to al1 other matemal

tasks and is ensured by gathering data about various concems and then

processing this collected information. The women in this study made clear that

concems related to safe passage are the major focus of their sources of stress

during labor and delivery. Each trimester is accompanied by different concems.

Prominent in the third trimester are concems for baby and self. Rubin

commented that these concems cannot be separated, and that the anticipated

events of labor and delivery will act on both mother and infant; "labor and

delivery' she stated, "are seen as a double jeopardy to self and child" (1984, p.

55). The women in this study provided strong support for Rubin's conclusion by

reporting that, for them, the most stressful anticipated and experienced aspects

of labor and delivery included concerns surrounding the baby, childbirth, and self

- results similar to previous research findings (Affonso & Mayberry, 1990;

Arizirnendi & Affonso, 1987; Glazer, 1980, 1985; Heymans & Winter, 1975;

Jones, 1990; Light & Fenster, 1974; Rubin, 1975; Standley et al., 1979).

However, It is worth noting that in this study, although women identified sources

of stress, their level of concern is predorninately rated as somewhat to

moderately stressful.

Expected Sources of Stress

During the antepartum period, women rate the 'anticipated' labor and delivery

sources of stress of childbirth and the baby as being the most stressful, concems

74

parallel with Glazer's (1985) findings. Almost all of the women in this study

identify 'the baby's condition at birth' and icvhether the baby would be healthy and

normal' as anticipated sources of stress for their impending labor and delivery,

and the overall scores for these items are higher than for other items. This

pattern of frequency and intensity is similar to that reported by Glazer (1 985).

When anticipating stressful childbirth events, the women in this study are

concerned about 'any unexpected thing that might happen during labor and

delivery', followed by concems about 'pain in childbirth', and 'complications

occumng in labor'. Glazer (1985) found a slightly dHerent order of these top

three concems, as the women in her study most frequently identified 'pain in

childbirth', followed by 'any unexpected thing that might happen during childbirth',

and (last in both studies) 'complications occurring in labot. Previous researchers

also identified comparable concems related to childbirth and the baby in the

antepartum period (Affonso 8 Maybeny, 1990; Arizimendi & Affonso, 1987;

Jones. 1990; Standley et al., 1979).

In these stodies the women reported their concems during pregnancy, and

not specifically in relation to labor and delivery. The use of an itemized list in this

and other research studies may sewe to artificially separate a woman's third

trimester concems about baby and self. Rubin's description of womens'

subjective experience in childbearing were based on observations of a naturalist

in the field. She and others listened and observed white providing nursing care.

Patterns in both Rubin's in-depth qualitative work as well as more quantitative

75

approaches suggest that ensuring safe passage in the third trimester means not

only that what endangers the mother endangers the baby, but also that many

women's anticipated concems are related specifically to the event of labor and

delivery. whether they are asked about concems of pregnancy or concems

related to labor and delivery.

Experienced Sources of Stress

The women report that the most stressful concems they actually experienced

were about childbirth, themselves. and their baby. 'The pain in childbirth' is

identified by the majonty of women as stressful during labor and delivery.

Heymans and Winter (1975) had similar findings, while other researchers

(Affonso & Maybeny, 1990; Arizimendi & Affonso, 1987;Light & Fenster, 1974)

identified pain in childbirth as a concem. but not the most stressful concem. The

women in both the cuvent study and Glazer's (1985) were the most stressed

about 'the pain in childbirth' when asked about sources of stress they

expenenced during birthing.

The second rnost reported source of stress in this study is an item from the

scale conceming the women themselves, with postpartum wornen frequently

endorsing 'the labor and delivery discomforts' they had. A majority of women also

report experiencing concems about labor and delivery items related to their

baby; in particular, concems about 'the baby being healthy and nomal' and 'the

ba by's condition at birth'. Althoug h sources of stress identified after labor and

delivery are consistent with previous research findings, their ranking is different

76

(Affonso & Mayberry, 1990; Heymans & Winter, 1975; Light & Fenster, 1974).

These researchers reported that, after delivery, the rnost frequently-reported

pregnancy concems were for the infant, while the woments concems for

themselves were not reported as frequently. The difference in findings between

the current study and previous research may be explained by differences in

study design. The present study asked mothers during the postpartum period to

reveal sources of stress they experienced during labor and delivery. The other

researchers asked mothers during the postpartum period to identify stressors in

pregnancy. In addition, the fact that the mothers reported pain as the most

frequent source of stress experienced during labor and delivery suggests that,

having experienced an uncomplicated birth experience, they have been

reassured of their infants' health. and the reflection of their birth experience is

now centered on themselves. This finding illustrates the taking-in phase of the

restoraüve period in the postpartum (Rubin, 1961); that is, women need to review

what happened during labor and delivery before they can move on to what is

real.

The results of these studies (Affonso & Mayberry, 1990; Heymans & Winter,

1975; Light & Fenster, 1974) suggest that safe passage is a matemal task that

does not end with the birth of an infant, but is canied through to the postpartum

(or taking-in) phase, so that women can assimilate the events of their birth

experience and move on. The dominant labor and delivery concems reported in

both the antepartum and postpartum period are comparable. The daference lies,

77

however, in both the frequency and ranking of these sources of stress. That is,

the mothers did not al1 experience stress from al1 of the issues they expected,

and they experience stress from some areas they did not expect. Fewer

postpartum women reported that they had experienced labor and delivery

sources of stress in al! the scales with overall FOCQ scores and scores on

scales reflecting the baby and childbirth decreasing the most. Arizimendi and

Affonso (1 987) and Affonso and Mayberry (1 990) reported a different outcome.

Women in their third trimester and in the immediate postpartum period identified

both baby welfare concems and labor and delivery issues as the top two most

intense pregnancy sources of stress. However, the mothers reported the

intensity of fears conceming labor and delivery issues to be higher in the

postpartum than in the antepartum period. The Affonso and colleagues' findings

of a higher rating of labor and delivery issues in the postpartum period contrast

to the current study. There are three possible explanations for these differences.

First, the stressors identfied in the third trimester and in the postpartum pen'od

were reported by two different groups of women. Secondly, women were

included in the study regardless of complication status during pregnancy, in fact,

during the course of their pregnancies, 32% of the women who participated in

the postpartum group had experienced complications. Finally, the stressors were

reported six weeks postpartum.

In the current study, the differences in the expected and experienced sources

of stress rnay suggest that women, regardless of parity, are stressed about the

78

unknown and, as a result, have a more intense appraisal of stressful events prior

to an anticipated experience. Women awaiting their first births may be appraising

the anticipated event as a threatening or harmful experience. while those women

retuming for another birth experience may be anticipating a iabor and delivery

comparable to their previous one, especially if there are issues that were

unresolved. Following delivery, it is possible that the women participating in this

current study may have found it difficult to assess the birth experience negatively

because of their uncomplicated status, the birth of a healthy infant, the timing of

data collection, and the resulting 'halo effect'. "Negative feelings may take longer

to surface due to the 'halo effect' after birth" (Shearer, 1995, p. 27).

Ex~ected and Experienced Anxiety Levels

Changes from the antepartum to the postpartum periods were also revealed

in both the state and trait anxiety anticipated and experienced by mothers.

Women were significantly less anxious in the immediate postpartum period, with

the greatest change ocwmng with state anxiety. Spielberger (1 983) reports that

state anxiety scores are generaliy higher than trait scores when adrninistered

under stressful situations. The antepartum levels of both state and trait anxiety,

in this and in previous research (Glazer, 1980; 1985; Ledeman et al.. 1979), are

comparable to noms based on data available for working adults, college

students, high school students, and military recruits (Spielberger, 1983). This

suggests that pregnancy and childbirth are not always a crisis - at Ieast not for

everyone during the third trimester and immediate postpartum period in

uncomplicated pregnancy and birth.

The change in anxiety scores from the anteparturn to the postpartum period

in the current study is similar to that reported by Astbury (1 980) and Scott-Heyes

(1 982). Scott-Heyes (1 982) revealed lower postpartum state anxiety levels when

women evaluated their birth experience more favorably. Astburyts (1 980)

research findings revealed a significant decrease in both state and trait anxiety,

with the most marked change occumng with state anxiety. Although the change

in trait anxiety was not anticipated in either the Astbury or current study, Astbury

(1980) suggested that "the change in trait anxiety may be seen as a failure on

the part of subjects to discriminate between current states of feelings and

general states of feelings" (p. 13). This rnay suggest that in the last four weeks of

pregnancy, concerns with pregnancy and childbearing are intenvoven and it may

be too difficuit for women to differentiate their feelings.

Factors Influencinci Sources of Stress

Cognitively appraising an encounter or situation means to focus on its

meaning or significance for well-being (Lazarus & Folkman, 1984). Prirnary

appraisal is a process entailed in the materna1 task of seeking safe passage

(Rubin, 1984) dumg which a pregnant woman continuously seeks out

information about the impending birth of her child. Both of these processes

depend upon personal and situational factors to shape their meaning; however,

in this study only parity and anxiety were consistently related to the women's

levels of concems. The dernographic variables of education, relationship status,

80

and age had little relationship to the labor and delivery sources of stress. The

relationships that were identified were negatively associated. Hence, the

variables most salient for this discussion are parity, anxiety, and attendance at

prenatal classes.

Pari@

The number of pregnancies a woman expenences is a significant predictor of

both the anticipated sources of stress during labor and delivery, and the

dDHerence in the expected and experienced sources of stress. Parity accounts for

between 6% and 20% of the variance in their anticipated childbirth concems,

total stressors scores, scores about thernselves, and stressors conceming the

baby. The womens' anticipated labor and delivery stressors on each of these

scales decrease as the number of pregnancies increase. A number of

researchers have reported similar patterns (Areskog et al., 1981. 1983; Burstein

et al.. 1974; Butani & Hodnett, 1980; Clark, 1975; Glazer, 1980, 1985; Heymans

& Winter, 1975; Light & Fenster, 1974;). Clark (1 975), Areçkog et al. (1 981,

1983). and Heymans and Winter (1 975) al1 found significant differences in the

fears of labor and delivery reported by primiparous women and multiparous

women. Although the difference was not significant in al1 previously reported

studies, the direction was the same. One can speculate that the anticipation of a

new experience brings with it a variety of concems, and that having previous

experience with childbirth means less sources of stress. However, Kirke (1980b).

Cartwright (1 975). Ledeman et al. (1 Wg), Mercer (1 979). and Westbrook

81

(1 979) do not support these findings. These researchers report that multiparous

women are concemed about difterent things and that these concems are not

necessarily reported less frequently. Also, a woman's previous labor and delivery

experience - especially if traumatic - may have a tremendous impact on various

aspects of her next birth (Areskog et al., 1981), thereby increasing her sources of

stress. Such aspects included for example, shape and wellbeing of the unbom

child and fear of not being able to control oneself during delivery. The findings of

the current study provide no evidence for that interpretation, with anticipated

sources of stress significantly decreasing as parity increased.

There was no relationship between parity and the women's experienced

sources of stress during labor and delivery, and no previous study has examined

the relationship between parity and reported stressors experienced during birth.

This finding suggests that, regardlesç of parity. the challenges of labor and

delivery are experienced (or at least recalled) in a similar way. This conclusion is

supported by the finding that par@ is a significant predictor in the differences

between what a wornen expects and what she experiences as a source of stress

during labor and delivery. It accounts for between 5% and 8% of the variance of

the difference in childbirth concems, concems about themselves, and total

stressor scores. As the number of pregnancies a women experiences increases,

the difference in her expected and experienced sources of stress during labor

and delivery decrease. It appears that a multiparous woman's cognitive appraisal

of her experience is more likely to be comparable to what she anticipates.

82

However, a woman's first birth experience is more favorable than expected in

areas affecting her 'overall labor and delivery' concems, and her specrfic

concems regarding 'childbirth' and 'herself.

Prenatal Classes

There is no relationship between attendance at prenatal classes and a

wornan's anticipated labor and delivery sources of stress. experienced labor and

delivery sources of stress, and the difference in the expeded and experienced

labor and delivery sources of stress. Some previous studies support (Hutte1 et

al.. 1972; Standley et al., 1979; Willmouth, 1975) and others refute (Astbury,

1980; Zax et al., 1975) the relationship between prenatal classes and the labor

and delivery experience. Enkin et al. (1995) stated that, because of the biases

introduced by study design, the results of previous studies "must be largely

discounted" (p. 19). The only significant (positive) effects of prenatal classes that

have been demonstrated are between attendance at classes and the use of

pain-relieving medications during labor. Enkin et al. rernind us that the effects of

prenatal classes depend upon a variety of factors: the characteristics of those

who attend, the teacher, and the objectives/purpose of the programme. It is

important to note that this study's participants who were involved in prenatal

classes had a wide variety of experiences, ranging from structured classes that

provided details of hospital routines, to classes suggesting alternatives to

conventional care. The majority of women participating in this study attended

classes that were more structured.

Anxiety

A wornan's level of anxiety is a signficant predictor of the anticipated sources

of stress during labor and delivery, the experienced sources of stress during

labor and delivery, and the dfierence in the expected and experienced sources

of stress. State anxiety accounted for 18% of the variance in the anticipated

stressors conceming the baby and was a significant predictor for total

anteparturn scores. A woman's stressors increased with each of these

anteparturn scales as her anxiety level increased, a finding consistent with

previous studies (Astbury, 1980; Glazer, 1 985; Scott-Heyes, 1982;) where a

woman's state anxiety was reported to have a relationship with third trimester

pregnancy and childbirth cuncems.

In the current study, state anxiety (time 2) also had a positive relationship with

the total and al1 subscale scores of experienced sources of stress during labor

and delivery. State anxisty accounted for between 13% and 22% of the variance

in the experienced stressors related to childbirth, the baby, healthcare, family

and friends, themselves, and to the total FOCQ score. This is similar to Scott-

Heyes' (1982) report that the overall evaluation of labor and delivery was related

to postnatal anxiety. This finding suggests that, for some women, more negative

experiences in labor and delivery left them more anxious than others.

State anxiety (time 1) accounts for approximately 5% of the variance in the

difference in sources of stress conceming the baby when relationship status is

controlled for. As a woman's state anxiety increases, the difference in her

84

expected and experienced sources of stress during labor and delivery regarding

her baby also increases. This difference suggests that a woman's cognitive

appraisal of experienced labor and delivery stressors is more likely to be

comparable to what she expected about her baby.

Trait anxiety accounts for between 10% and 21 % of the variance in a

woman's anticipated sources of stress concerning family and friends, childbirth,

healthcare, herself, and the total stressor score. A woman's stressors increased

with each of these antepartum scales as her anxiety level increased. This finding

is similar to previous research (Glazer, 1980), where trait anxiety increased with

increasing antepartum concerns. However, other researchers reported results

that are inconsistent with the current study (Levy & McGee, 1975; Ledeman et

al., 1979); in these cases, trait anxiety was not predictive of the specific

anticipated fears concerning labor and delivery. 60th studies had sample sizes

smaller than the current study and these samples may have been insufficient to

detect a difference.

When state anxiety score is taken into account, trait anxiety score does not

contribute significant extra predictive value for experiences sources of stress

during labor and delivery. This finding is sopported by Levy and McGee (1975)

who reported no relationship between trait anxiety and subjective outcornes of

labor and delivery. These researchers suggested using an instrument more

specific than that which measures trait anxiety; it is possible that this instrument

rnay be that which measures state anxiety. State anxiety score is a better

85

predictor of these scores than trait anxiety score. Trait anxiety also had little

relationship with the difference in the expected and experienced sources of

stress durhg labor and delivery. There has not been previous research in

relation to this finding. However, it appears trait anxiety is not a very useful

predictor of perceptions of labor and delivery experiences.

Summary

Throug h the cognitive process of primary appraisal (Lazarus & Folkman,

1984), women appraise their childbirth experience. The expected and

experienced sources of stress appraised in this study, predominantly those

concerning baby and self, are consistent with the concerns reported in Rubinfs

(1 984) framework. Both a wornan's personal and situational factors, mainly

parity and anxiety, help to shape the meaning of her birth experience.

No previous research study has described the sources of stress specific to

labor and delivery, and no previous studies have revealed the differences in the

expected and experienced sources of stress during labor and delivery. Earlier

studies have reported either antepartum or postpartum concerns of pregnancy

and childbearing. This current study was carried out to determine the stressors

identified when focused specifically towards iabor and delivery. The patterns in

this study are, overall, sirnilar ta previous research and have implications for both

research and practice.

CHAPTER 5

SUMMARY, LIMITATIONS, AND IMPLICATIONS

Summary

The purpose of this descriptive longitudinal study was to describe women's

perceptions of stressful experiences during labor and delivery, and the change in

these perceptions. Both the study design and interpretation of the findings were

guided by Lazarus's theory of stress and coping (Lazanis & Folkman, 1984) and

Rubin's theory of materna1 identity (Rubin, 1 984).

During the 36th to 38th week of pregnancy, and again in the immediate

postpartum period, 98 women who experienced an uncomplicated pregnancy

and labor and delivery, cornpleted the Feelings of Childbirth Questionnaire

(adapted from Glazer's 1985 Feelings of Pregnancy Questionnaire), the State-

Trait Anxiety lnventory (Spielburger, 1983), and a demographic information

sheet. This data was collected over a four month period and analyzed using

descriptive and sumrnary statistics.

In both the antepartum and postpartum period, women identified the

predominant sources of stress as being concerns for the baby and for

themselves. Stressors for labor and delivery were reported with greater

frequency in the antepartum than in the postpartum period. with the greatest

change seen in the total stressors scores, the subscale scores of baby and

childbirth, and state anxiety scores. Parity and anxiety were the variables that

were most consistently related to the women's sources of stress. These findings

86

87

are significant for nursing practice. particulariy with women who are experiencing

their first pregnancy and with women who have had a negative expenence with

labor and delivery.

Limitations

The generalizability of the findings is limited by several aspects of the study

design. The use of a convenience sample restrkted the representative nature of

this sarnple, and the inclusion criteria confined study participation to women

experiencing an uncomplicated pregnancy and labor and delivery. As a result of

the inclusion criteria, some women (N=53) were unable to continue with study

participation. The rnajority of women participating in the study were from

physician practices comprised mainly of women from central Halifax. Therefore.

it is possible that a particular portion of the population was underrepresented.

There also may have been confounding factors, such as previous obstetrical

history and current life circumstances. that were not identifiecl. These

confounding factors may have influenced the women's responses to their

questionnaires and subsequentiy the sources of stress expected and

experienced during labor and delivery. Participation in the study may in itself

have been a confounding variable and altered the women's perceptions by either

reducing or enhancing their perceptions of stress and anxiety.

Implications for Research

The participants in this study experienced no pregnancy or labor and delivery

complications. The study could therefore be repeated with the inclusion of

88

women experiencing complications in pregnancy or labor and delivery in order to

describe the sources of stress expected and experienced by this particular

group. This study could determine whether the sources of stress expected and

experienced during labor and delivery are different between the two groups of

women.

Further development of the FOCQ is necessary, based upon the mothers'

written comments on their postpartum questionnaires. The instrument did not

include al1 potential sources of stress, and the subscales of 'childbirth' and 'self

contained items that rnay have fit into either category. A doser analysis of this

instrument may serve to enhance its validity. The FOCQ should also undergo

further refinement and development. Factor analysis would permit "looking at the

convergent and discriminant validity of a large set of measures" (Polit & Hungler,

1995, p. 358). This refinement may also detemine whether there are any other

items that need to be added to the FOCQ and possibly whether the wording of

items captures the womens' understanding of the experience.

The sources of stress identified in this study are consistent with previous

research studies. It would now be appropriate to examine the effectiveness of

antepartum and postpartum nursing interventions to reduce these stressors and

to possibly improve outcomes such as women expenencing a more positive birth

experience and adaptation to the matemal role. These interventions could be

directed towards either reducing the sources of stress or enabhg women to

identiw potential stressors and thereby develop appropriate coping mechanisms.

89

The relationship between other personal and situational factors and expected

and experienced sources of stress could also be studied. For example, the

relationship between sources of stress and a woman's previous pregnancy could

be studied to determine the influence this factor may have on a woman's labor

and delivery experience.

A secondary analysis of the data would also be useful. For example, it may

be useful to explore whether the data of various groups (such as the women who

experienced more stress during labor and delivery, and those with anxiety scores

greater then the mean) have different expected and experienced sources of

stress during labor and delivery.

Implications for Practice

The findings of this study clarify and support our knowledge of both the

sources of stress that women expect and experience during labor and delivery,

and the factors that have a relationship with these stressors. These findings

reinforce the knowledge that a woman is most concerned about the baby and

herself, with the predominant sources of stress being concem for the baby being

'healthy and normal' and 'the pain in childbirth'. The findings also reveal that a

woman's panty and her level of anxiety play the greatest role in the relationship

with the sources of stress expected and experienced during labor and delivery.

The consistency of the above concems with previous research suggests that

these are significant sources of stress experienced by women. Interventions are

needed to address these concems; that is, nurses need to examine their practice

90

and review the way Gare is provided to pregnant women. Nursing interventions

should be aimed at identifjhg sources of stress expected and experienced

during labor and delivery, thereby promoting a positive birth experience. Nurses

need to work together with parents to explore and identify concems and to

develop ways to cope with these stressors. Nursing assessment plays a key role

in the interventions, which can occur throoghout pregnancy.

During the antepartum, intrapartum, and postpartum period, nurses should

provide care that addresses a woman's concems. Women may be helped to

identify their expected sources of stress through the Feelings of Childbirth

Questionnaire. This initial process of identification, whether during prenatal

classes or dunng individual prenatal visits, may help women to specify their

expected sources of stress. Discussion surrounding these concems may itself be

the intervention required to assist women to cope.

Identification and acknowledgernent of a women's sources of stress can be

camed not only from the anteparhm penod to the intrapartum pen'od, but right

through to postpartum. Debriefing of a woman's birth experience can be an

opportunity to assess experienced stressors; furthemore, assessment during the

postpartum period will enable women to review their birth experience, identify

concerns, and deal with these concems in a manner that promotes positive

outcornes.

Also significant in this study are the findings identifying the relationship that

parity and anxiety play with a women's sources of stress. Awareness of the

8

91

factors that contribute to a woman's sources of stress will help nurses to plan

and direct their care in a manner that is more individualized as it is based on

individual stressors rather than common stressors. Ongoing assessrnent,

recognition of the factors infiuencing sources of stress. as well as recognition of

these sources of stress themselves may not necessarily decrease the sources of

stress identified by wornen. It is expected that this process will, however, support

a woman's pregnancy experience and promote matemal adaptation.

Conclusion

The sources of stress identified by women in this study are similar to the

concems identified by Rubin (1984) and other researchers, and reinforce the

significance of women's appraisal of these concems during pregnancy and in the

postpartum period. Lazarus and Folkman's theory (1 984) that personal and

situational factors influence the stressful appraisal of an encounter is verified

here by the relationship that parity and anxiety play with the expected and

experienced sources of stress during labor and delivery. Both the recognition

and the identification of stressors and determinants influencing the appraisal of

labor and delivery may serve to guide the care provided by nurses throughout

pregnancy and into the postparturn period. It is possible that the provision of

such nursing care will have a positive impact on a woman's matemal experience,

and a similar influence on her memory of this significant event.

Appendix A

FEELINGS OF CHILDBIRTH QUESTIONNAIRE (Time 1 )

lnstnictions:

Most women who are getting close to having their baby think a lot about

things that may occur during labor and delivery. Those thoughts may or may not

be stressful and cause concem, fear, or worry. The following is a list of things

you might find stressful during your labor and delivery. For each item, please

circle the number which best indicates the level of concem/stress that you

believe you will have during labor and delivery.

O = means not at al1 stressful

1 = means somewhat stressful

2 = means moderately stressful

3 = means very much stressful

Example:

Your TV stops working. O 1 2 3

Please circle the nurnber which best describes how you believe you will feel about that particular item during labor and delivery. If an item does not apply to you, please circle not at a11 stressful.

O = means not at al1 stressful 1 = means somewhat stressful 2 = means moderately stressful 3 = rneans ver- rnuch stressfuI

1. Whether your baby wili be a 0 1 2 3 boy or a girl?

2. Not really wanting the baby? 0 2 3

3. Whether the doctor 0 1 2 3 will give you good are?

4. The pain in childbirth? 0 1 2 3

5. If your baby wiII be healthy and normal?

6. How you look? 0 1 2 3

7. Whether the nurses will 0 1 2 3 give you good care?

8. The medication you might 0 1 2 3 receive during childbirth?

9. Your baby's condition at 0 1 2 3 birth?

1 O. Your job? 0 1 2 3

1 1. Medical treatment you O 1 2 3 were given before knowing of your pregnancy?

O = means not at al1 stressful A = means somewhat stressful 2 = means moderately stressful 3 = means very much stressful

Any unexpected thing that might happen during childbirth?

If you partner will accept and love this baby?

If your baby will be good or bad?

Being too young to haveababy?

Whether dnigs you took during your pregnancy were unsafe?

Your condition during childbirth?

If your partner understands your changing feelings and problems?

Having more children than you want?

Being able to really love your baby?

Whether your partner will not be interested in you because of changes in your figure?

Being too old to have a baby?

Your doctor being with vou?

O = rneans not at al1 stressful 1 = means somewhat stressful 2 = means moderately stressfu1 3 = means very much stressf'ul

24. Being tom when the baby 0 1 2 3 is bom?

25. If your other children will 0 1 2 3 love and accept the baby?

26. Your own health? 0 1 2 3

27. Something happening to 0 1 2 3 the baby because of medicine you took?

28. Being worried? 0 1 2 3

29. Being able to follow the 0 1 2 3 diet your doctor ordered?

30. The cut the doctor makes 0 1 2 3 when the baby is delivering?

31. Who will care for your other 0 1 2 3 children while you are in labor and delivery?

32. Being depressed? O 1 2 3

33. Something happening to the 0 1 2 3 baby because you srnoke?

34. Gaining too much weight? 0 1 2 3

35. Something happening to 0 1 2 3 the baby because you drank alcoholic beverages?

O = means not at al1 stressful 7 = means sornewhat stressful 2 = means moderately stressful 3 = means very much stressfùl

Your relationship with 0 1 2 your rnothef?

Being able to talk to your 0 1 2 doctor about things bothering you?

Losing control in labor? 0 1 2

Something happening to 0 1 2 the baby because of something inherited (sornething that nins in the family)?

Something happening to the 0 1 2 baby because of an accident you had?

Having a baby dependent O 1 2 on you?

Being able to talk to nurses 0 1 2 about things bothering you?

Something happening to the 0 1 2 baby because of sornething that rnight happen during labor?

The discornforts you are 0 1 2 having ?

Being able to have the type 0 1 2 of birth expenence you want?

Your relationship with 0 1 2 your partner?

Something happening to the 0 1 2 baby because of your wonying?

O = rneans not at all stressful 1 = means sornewhat stressful 2 = rneans rnoderately stressful 3 = means very rnuch stressful

Being a good mother?

Complications occunng in labor?

Your relationship with your father'?

Something happening to the baby because of the birth control you used?

The pelvic (intemal) examinations?

Losing the baby in labor and delivery?

Your relationship with your friends?

Taking care of your baby's physical needs (like bathing, feeding. and dressing)?

FEELINGS OF CHlLDBlRTH QUESTIONNAIRE (Time 2)

Instructions:

Most women who have delivered their baby think a lot about things that

occurred during labor and delivery. Those thoughts may remind you of what you

found stressful and what things caused concem, fear, or worry. The following is a

list of things you might have found stresshil during your labor and delivery. For

each item, please circle the number which best indicates the Ievel of

concemlçtress that you believe you had during labor and delivery.

O = means not at al1 stressful

1 = means somewhat stressful

2 = means moderately so stressful

3 = means very much so stressful

Example:

YourTV stopped working. O 1 2 3

Thinking back to your labor and delivery, please circle the number which best describes how you remember feeling about that particular item durfng labor and delivery. If an item does not apply to you, please circle not at al1 stressful.

O = means not at al1 stressful 1 = rneans somewhat stressful 2 = means rnoderately so stresshl 3 = rneans very much so stressfut

Whether your baby would be a O 1 2 3 boy or a girl?

The baby not really being wanted?

Whether the doctor would give you good care?

The pain in childbirth?

If your baby would be healthy and normal?

How you looked?

Whether the nurses would give you good care?

The medication you rnight receive during childbirth?

Your baby's condition at birth?

Your job?

Medical treatment you were given before knowing of your pregnancy?

Any unexpected thing that might happen during ch ild birth?

If your partner would accept and love this baby?

If your baby would be good or bad?

Being too young to have a baby?

Whether dnigs you took during you pregnancy were unsafe?

Your condition during childbirth?

If your partner understood your changing feelings and pro blems?

Having more children than you wanted?

Being able to really love your baby?

Whether your partner would not be interested in you because of changes in your figure?

O = means not at al1 stressful 1 = means somewhat stressful 2 = means moderately so stressful 3 = means very much so stressful

Being too old to have a baby?

Whether your doctor would be able to help you?

Being tom when the baby is bom?

If your other children would love and accept the baby?

26. Your own health?

27. Something happening to the baby because of medicine you took?

28. Being womed?

29. Being able to follow the diet your doctor ordered?

30. The cut the doctor made when the baby is delivering?

31. Who would care for your other children while you are in labor and delivery?

32. Being depressed?

33. Something happening to the baby because you smoke?

34. Gaining too much weight?

35. Something happening to the baby because you drank alcoholic beverages?

O = rneans not at al1 stressful 1 = means somewhat stressful 2 = means moderately so stressful 3 = means very much so stressful

36. Your relationship with your mother?

37. Being able to talk to your doctor about things bothering you?

38. Losing wntrol in labor

O = rneans not at al1 stressful 1 = means somewhat stressful 2 = rneans moderately so stressful 3 = means very much so stressful

39. Something happening to O 1 2 3 the baby because of something inherited (something that nins in the family)?

40. Something happening to the baby because of an accident you had?

41. Having a baby dependent on you?

42. Being able to talk to nurses about things bothering you?

43. Something happening to the baby because of something that rnight happen during labor?

44. The discornforts you were having?

45. Being able to have the type of birth experience you wanted?

46. Your reiationship with your partner?

47. Something happening to the baby because of your worrying?

48. Being a good rnother?

49. Complications occumng in labor?

50. Your relationship with your father?

O = means not at al1 stressful 1 = means sornewhat stressful 2 = means moderately so stressful 3 = means very much so stressful

Something happening to the baby because of the birth wntrol you used?

The peivic (intemal) examinations?

Losing the baby in labor and delivery?

Your relationship with your friends?

Taking mre of your baby's physicai needs (iike bathing, feeding, and dressing)?

Please identify below, feelings, concems, and that were experienced dunng labor and delivery that are not listed in this questionnaire .....

Appendix B Subscales of Feelings of Childbirth Questionnaire

Baby 1. Whether your baby will be a boy or a girl? 5. If your baby will be healthy and normal? 9. Your baby's condition at birth? 14. If your baby will be good or bad? 27. Something happening to the baby because of rnedicine you took? 33. Something happening to the baby because you smoke? 35. Something happening to the baby because you drank alcoholic beverages? 39. Something happening to the baby because of something inherited

(something that runs in the family)? 40. Something happening to the baby because of an accident you had? 43. Something happening to the baby because of something that might happen

duhg labor? 47. Something happening to the baby because of your worrying? 51. Something happening to the baby because of the birth control you used?

Self 2. Not really wanting the baby? 6. How you look? 10. Your job? 15. Being too young to have a baby? 19. Having more children than you want? 20. Being able to really love your baby? 22. Being too old to have a baby? 26. Your own health? 28. Being womed? 32. Being depressed? 34. Gaining too much weight? 41. Having a baby dependent on you? 44. The discomforts you're having? 48. Being a good mother'? 55. Taking care of your babyBs physical needs (like bathing, feeding, and

dressing)?

Health Care 3. Whether the doctors will give you good care? 7. Whether the nurses will give you good care? Il. Medical treatment you were given before knowing of your pregnancy? 16. Whether dnigs you took during your pregnancy were unsafe? 23. Your doctor or nurse being able to help you?

29. Being able to follow the diet your doctor ordered? 37. Being able to talk to your doctor about things bothenng you? 42. Being able to talk to nurses about things bothenng you? 52. The pelvic (intemal) examination?

Child birth 4. The pain in childbirth? 8. The medication you might receive during childbirth? 12. Any unexpeded thing that might happen during childbirthl 1 7. Your condition during childbirth? 24. Being tom when the baby is bom? 30. The cut the doctor makes when the baby is delivering? 38. Losing control in labor? 45. Being able to have the type of birth expenence you want? 49. Complications occumng in laboi? 53. Losing the baby in labor and delivery?

Family and FrÎends 13. If your partner will love and accept the baby? 18. If your partner understands your changing feelings and problems? 21. Whether your partner will not be interested in you because of changes in

your figure? 25. If your other children will love and accept the baby? 31. Who will care for your other children while you are in labor and delivery? 36. Your relationship with your mother? 46. Ycur relationship with your partner? 50. Your relationship with your father? 54. Your relationship with your friends?

SELF-EVALUATION QUESTIONNAIRE STAI F o ~ Y-1

Please provide the following information:

Name Date S

Age Gender(Circe) M F T-

DIRECiïONS:

A number of statements which people have used to descfibe themselves are given belcnw Read each staternent and Vien cirde the appropriate nurnber to the dght of the rtaternent '! to indicate how you feel nght now. that is. at thr's moment . There are no nght or wmng answers . Do not spend too much time on any one statement but give the answer whi& seems to describe your present feelings best .

1 . 1 feei cairn ................. .. ................................................................................................... 1 2 3 4

3 . I am tense .............................................................................................................................. 1 2 3 4

4. Ifeelstrained ......................................................................................................................... 1 2 3 4

S. I feel at ease ................... .,. ...........................~.....~..................~...~........................~.~........~........ 1 2 3 4

6 . 1 tael upset ............................................................................................................................. 1 2 3 4

7 . 1 am presently worrying over possible misfortunes .................... .. ................................... 1 2 3 4

8 . 1 feel satisfied ........................................................................................................................ 1 2 3 4

9 . I feel frightened .................................................................................................................... 1 2 3 4

10 . 1 feel cornfortable .................................................................................................................. 1 2 3 4

1 1 . i feel self-confident .................................................. .................................................... 1 2 3 4

12 . I feel nervous ................................................................................................................... 1 2 3 4

14 . 1 feel indecisive ..................................................................................................................... 1 2 3 4

15 . 1 am relaxed ................ ... ................................................................................................. 1 2 3 4

16 . 1 feel content ....................~......~.............................................................................................. 1 2 3 4

18 . 1 feel conhsed ....................................................................................................................... 1 2 3 4

19 . 1 feel steady ......................................................................................................................... 1 2 3 4

20 . 1 feel pleasant .................................................................................................................... 1 2 3 4

106

O Copyright 1968. 1977 by Charles D . Spielberger . All nghts reserved . STAIP-AD Test Çorm Y

STAl Forrn Y-2

Name Date

DIRECT IONS

A number of statemenb which people have used to describe themselves are given below . Read each statement and then circle the appropriate value to the right of the statement to indicate how you genersily feel . mere are no right or wrong answers . Do not spend too much time on any one staternent but give the answer which seems to describe how you generally feel .

21 . 1 feel pleasant ................... ....... ..................................................................................... 1

22 . 1 fiel necvous and restless ..................................................................................................... 1

................... 23 . 1 feel satisfied with myself ... ....................................................................... 1

.................................................................... . 24 1 wish 1 could be as happy as others seem to be 1

25 . 1 fiel like a failure ................................................................................................................. 1

26 . 1 feel rested ............................................................................................................................ 1

27 . I "calm. cool, a d col lected" ...................................................................................... 1

.................................... 28 . I feel that difficulties are piling up so that 1 cannot overcome them 1

.................. 29 . 1 worry too much over something that really doesn't matter .... .............. 1

30 . 1 am happy .......................................................................................................................... 1

3 1 . I have disturbing thoughts ................................................................................................. 1

32 . I la& self-confidence ............................................................................................................ 1

33 . 1 feel secure ..........................~~............................................................................................... 1

34 . 1 m&e decisions easily .......................................................................................................... 1

35 . 1 feel inadequate ................................................................................................................... 1

36 . 1 am content ............ .. ......................................................................................................... 1

...................................... . 37 Some unimportant thought runs through my mind and bothea me 1

............................... 3 8 . 1 take disappointments so keenly that 1 can't put them out of my mind 1

................ 39 . 1 am a steady person .. ..........~............................................................................. 1

40 . 1 get in a state of tension or turmoil as 1 think over my recent concems and interests ......... 1

@ Copyright 1968. 1977 by Charles D . Spielberger . Ail rights reserved . STAIP-AD Test Fom Y

Appendix E Demographic 1 nfomation Sheet

fart A

Please complete the following information. This information will allow the researcher to detemine the differences and sirnilarities among the women participating in this study.

Name: Code #: Are you being delivered by a Family Physician? Yes

No

Age:

Education: less than high school cornpleted high school some post secondary universtty degree post graduate studies

Relationship Status: single partner divorcedfwidowed

Number of pregnancy? Previous labor and delivery experience: (including this one) positive

negative both positive and negative

Number of live births?

Are you attending prenatal classes? Yes No

What is the date you are due?

NOVA SCOTIA PRENATAL SCORING FORM 1 ) Score each qumon as indicated 2) Total each categary score at first vis& 3) Repeat at 36 weeks 4) Record on Prenatai Record

I REPRODUCTIVE HlSTORY

AGE

O

PARm 1 - 4

5 +

PAS1 OBSTETRICAL HISTORY

Habituai Abortion 1 lnfertility

PPH 1 Manuai Removal

6aby >9 Ibs. (4086 g.)

Baby c 5.5 Ibs (2500 g.)

PET I Hypttension C

Previous Cesarean

Stillbirth or Neonatol Oeatfi

Pmlonged Labour or Oitfiaitt Deiivaiy

Cltagoy l Score

Previow Gynecologtc Surgery = 1

Chronic rend disease = 2

Gestational diabetes - 1

Diabetes malitus = 3

Cardiac disease = 3

OTHEA MEDICAL DISORDERS

Chmnic bronchitis. lupus. etc.

%ore according to seventy (1 - 3)

Calegoy II Score

Ill1 PRESEHT PREGNANCY

0leeding > 20 weeks

Anemia c 1 O grn %

Hypertension

Premature rupture

of membranes

Smll for dates

Multiple pregnancy or Breecti or Malpresenmon

Calsgory Ill Score

TOTAL RlSK =RE n ln u I6 wau NOTE: LOW RISK = 0 - 2 HIGH RISK = 3 - 6 EXïREME RISK = w 7

Appendix G Consent Form

Investigator: Thesis Supendsoi-: Ema Snelgrove-Clarke, BN Dr. Judith Ritchie Graduate Student. School of Nursing Dalhousie University Dalhousie University School of Nursing Halifax, Nova Scotia Telephone: 494-26 1 1 Telephone: 429-1 71 6

The purpose of this study is to find out more about what wornen's concems are during labor and delivery.

If you agree to participate, you will be asked to complete three questionnaires on h o different occasions. once during the last weeks of pregnancy and once after your labor and delivery experience. The questionnaires are about your feelings and your concems during labor and delivery. They will take approximately 20 minutes to complete. Also, some personal background infomation will be requested. This includes your age. education, which pregnancy this is for you, relationship status. and attendance at prenatal classes. Medical infomation about your pregnancy and labor and delivery will be obtained from your hospital chart. To cornplete the questionnaires following delivery, you must meet several study cnteria.

The information obtained will not have your narne on it. A numerical wding system will be used to identify the women who participate. Your name and corresponding number will be kept separate from the questionnaires. Only the investigator will have access to this. When the results of the study are reported, your name will not be given.

The results of this study will provide infomation for health care professionals who Gare for women during their pregnancies and during labor and delivery. There are no risks or direct benefits to your participation in this study. You may refuse to participate or you may withdraw from the study at any time. Your decision will have no effect on your medical or nursing care.

If you have any questions, you rnay contact the investigator or her supervisor at the above nurnbers. A summary of the results of this study will be made available to you upon request.

I have read and understand the infomation given above and agree to participate in this study.

Date Mother

Date

III

I nvestigator

Appendix H

Expected Sources of Stress - Time 1

Subscales Not at al1 Somewhat Moderately Very Much Stressful Stresshl So Stressful So Stressful

4. The pain in childbirth 8. The medication you might receive during

childbirth 12. Any unexpected thing that might happen

during childbirth 17. Your condition during chlldblrth 24. Being tom when the baby is bom 30. The cut the doctor makes when the baby

r is delivering p 38. Losing control in labor

45. Belng able to have the type of blrth experience you want

49. Complications occunJng in labor 53. Losing the baby in labor and deilver- B ABY 1. Whether your baby will be a boy or a girl 5. If your baby will be healthy and normal 9. Your baby's condition at birth 14. f your baby wlll be good or bad 27. Something happening !O the baby because

of medicine you took 33. Something happening to the baby because

you smoke

Subscales Not at al1 Somewhat Moderatel y Very Much Stressful Stressful So Stressful So Stressful

Somethlng happening to the baby because you drank alcoholic beverages Something happening to the baby because of something inherited Somethlng happening to the baby because of an accident you had Something happening to the baby because of something that might happen during labor and delivery Something happening to the baby because of your worrying Something happening to the baby because of the birth control you used

SELF Not really wanting the baby How you look Your job Being too young to have a baby Having more children îhan you want Being able to really love your baby Being too otd to have a baby Your own health Belng worrted Being depressed Gaining too much weight Having a baby dependent on you The discomforts you are having Being a good mother Taking care of your baby's physical needs

Subscales Not at al1 Somewhat Moderatel y Very Much Stressfut Stressful So Stressful So Stresshl

HEACTHCARE 3. Whether the doctors will give you good care 56 26 11 5 7. Whether the nurses will give you good care 42 29 22 5 1 1. Medical treatrnent you were given before

knowing of your pregnancy 84 6 4 4 16. Whether drugs you took dunng your

pregnancy were unsafe 81 8 5 4 23. Your doctor being with you 44 33 14 7 29. Being able to follow the diet your doctor

ordered 70 17 4 7 37. k i n g able to talk to your doctor about things

bothering you 73 21 2 2 42. Belng able to talk to nurses about things

bothering you 65 28 5 O 52. The pelvic (intemal) examination 57 25 13 3

FAMILY AND FRJENDS 13. If your partner will love and accept the baby 83 18. If your partner understands your changing

feelings and problems 45 21. ~hether your partner will not be interested

In you because of changes in your figure 66 18 9 5 25. If your other children will love and accept

the baby 63 18 12 5 31. Who witl care for your other children while

you are In labor and dellvery 73 11 8 6 36. Your relationship with your mother 80 13 3 2 46. Your relationship with your partner 7 1 15 8 4 50. Your relationshlp with your father 88 5 3 2 P 54. Your relationship with your friends 80 16 2 O P tP

Appendix I Experienced Sources of Stress - Time 2

Subscales Not at al1 Somewhat Moderately Very Much Stressful Stressfut So Stressful So Stressful

4. The pain in childbirth 5 18 21 50 The medication you might teceive during childbirth Any unexpected thing that might happen during chiidbirth Your condition during childbirth Being tom when the baby is bom The cut the doctor made when the baby is delivering Losing control in labor Being able to have the type of birth experience you wanted Complications occuning in labor Losing the baby in labor and delivery

BABY 1. Whether your baby would be a boy

or a girl 80 5. If your baby would be healthy and normal 14 9. Your baby's condition at birai 14 14. If your baby would be good or bad 73 27. Something happening to the baby because

of medicine you took 7 1 33. Something happening to the baby because

you smoke 79

Su bscale Not at all Somewhat Moderately Very Much Stressful Stressful So Stressful So Stressful

HEALTHCARE 3. Whether the doctor would give you good care 7. Whether the nurses would give you good c m 11. Medical treatment you were given before

knowing of your pregnancy 16. Whether drugs you took dudng your

pregnancy were safe 23 Whether your doctor would be able to

help you 29. Being able to follow the diet your doctor

ordered 37, Being able to talk to your doctor about îhings

boîhering you 42. Being able to talk to nurses about things

bothering you 52. The pelvic (intemal) examination

FAMILY AND FRIENDS 13. If your partner would love and accept thls

baby 83 9 1 O 18. If your partner understood your changing

feelings and problems 53 23 12 5 21. Whether your partner would be interested

in you because of changes in your figure 71 17 4 1 25. If your other children would love and

accept the baby 67 14 9 3 31. Who would care for your other children

while you are in labor and delivery 78 11 1 4 36. Your relationship with your mother 8 1 9 1 2 l- 46. Your relaîionship with your partner 75 14 3 1 t-

\

Subscales Not at al1 Somewhat Moderately Very Much Stressful Stressful So Stressful So Stressful

50, Your relationship with your father 87 4 2 O 54. Your relationshlp with your friends 82 9 2 O

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