research and studies

Psychoprophylaxis in Midtrimester Abortions Cl,AUDlA ANUEHSON. H S N , MA, M N , BARBAHA CLANCY, ASN, M S N ,

Since controlled breathing and relaxution exercises had proven to be helpful to wonien laboring at full term, it seemed tliut these techniques could be extended to wonien experiencing midtrimester ubortions. A modified f o r m of the Luniuze method of psychoprophylaxis wus tuught to 15 midtrimester abortion putients. By using a questionnaire designed to elicit responses about the quality of nursing care received, their perceptions of nursing care were compared with those of a group of 15 midtrimester abortion patients who received only the routine nursing care. The group using breathing and relaxution exercises reported a significuntly more positive experience.

Women tend to be ambivalent about pregnancy during most of their reproductive years.’ Those who become pregnant and decide to in- terrupt the pregnancy usually have conflicts to resolve relating to illicit sex, guilt about the procedure, and/or their self-image in

Women who delay seeking an abortion until the second trimester have even greater feelings of shame, guilt, and ambivalence regarding their decision^.^ Their abdomens are enlarging, they have probably expe- rienced quickening, and it is not in- conceivable that they have heard fetal heart tones.

Patients are not the only people who experience conflict. Assisting with the abortion procedure may produce inner conflict in nurses who have been taught to “save lives.” This conflict may be resolved as the

nurse begins to focus on the patient as an individual in crisis5 Health care professionals must examine their feelings about abortion, since those with negative feelings often t r ansmi t t hese feelings to t h e

Personnel who feel nega- tively about abortion or about pa t i en t s exper ienc ing abor t ions should not care for such patients8

Purpose of Study Experts agree that, currently, nei-

ther the needs of patients seeking abortion nor the needs of nurses car- ing for patients are being adequately met.5s9-’0 The purpose of the present study was to determine whether one specific nursing action would im- prove care given to the patient as the patient perceives that care.

Patients experiencing an abortion in the second trimester have a labor process similar to that of patients de- livering a full-term fetus. The uterus must contract and the cervix must dilate in order for the fetus to be expelled. The major difference be- tween these two groups of patients is that one labors to deliver a live infant while the other labors to deliver a n aborted fetus.

Education and concentrated relax- ation and breathing exercises pro- duce a more controlled, positive ex- pe r i ence for bo th t h e pa t i en t s laboring and nurses caring for them. The same principles should apply to any patient in labor, whether she is experiencing a midtrimester abortion or a full-term delivery.

The hypothesis of the study, then,

was that utilization of a modified form of psychoprophylaxis would en- hance a woman’s participation in the labor process when experiencing a midtrimester abortion. Her prepara- tion for and participation in the labor processes would result in a more pos- itive perception of nursing care than if the method were not utilized.

Methods

The setting was a Midwest in- stitution which performs abortions in the first and second trimesters. The specialized abortion care unit was a 4-bed room in the maternity area, somewhat isolated from the labor and delivery area. During the day the unit had a nurse of its own. On the evening and night shifts, nursing staff was shared between the special- ized care unit and the labor and de- livery area.

The nursing care prior to delivery of the fetus was similar to that given patients laboring at full term. Hy- giene arid comfort needs were met. Foods and fluids were withheld once an active labor pattern had devel- oped. Orders for analgesia were writ- ten, and the nurse and patient judged when medication was to be given. Vital signs were taken every 5 minutes for four times after the in- traamniotic instillation and at least every 4 hours thereafter.

After the patient had aborted, her vital signs a n d b leeding were checked every. 15 minutes until stable, then hourly for four times. Approximately 4 hours after the abortion was completed, the patient was free to leave the institution. Patients were advised to return to their physician should pain, fever, excess bleeding, foul-smelling dis- charge, or depression occur. They were instructed on contraception during their hospitalization, and most left with a prescription for a n oral contraceptive.

A questionnaire was utilized to de- termine the patient’s perception of nursing care. (See Appendix.) The questionnaire included a series of 27 items relating to the patient’s stay in the institution. Approximately half of the items were stated in a positive manner; the remainder, in a nega- tive manner. This insured that the patient reading the statement would

29 November/December 1976 JOGN Nursing

not be able to make sweeping posi- tive or negative responses without some thought. Questions which re- lated directly to nursing care as well as to more general areas were in- cluded.

Two additional questions to which the patient could respond in a non- structured manner were used. One elicited suggestions for improving nursing care; another, for a com- parison of day, evening, and night nursing care. The last section re- quested demographic and personal data.

Group A consisted of 15 patients who had elective midtrimester abor- tions dur ing May 1974. These patients received routine nursing care. After they aborted and had gone through a recovery period, the questionnaire was administered.

T h e investigator told these patients that the institution was con- cerned with giving the best possible care to all patients and that one way to evaluate care was to ask patients to give their opinions regarding how they perceived nursing care. Patients were asked to complete the question- naire honestly and were assured ano- nymity and privacy. Each patient completed the questionnaire and re- turned it to the investigator before leaving the hospital.

Group B consisted of 15 patients who had elective midtrimester abor- tions in June 1974. After the patient was settled in her bed in the special- ized care unit, and before the in- traamniotic instillation, the in- vestigator saw her for the first time. Patients were asked if they knew what labor would be like. Al l patients knew they would experience labor, and some had experienced la- bor during previous pregnancies. Ini- tial instruction on controlled relaxa- tion and breathing was instituted at this time.

After the instillation but before the labor began, the investigator re- turned to reinforce the earlier dis- cussion. I t was felt that patients would be more receptive at this time since the anxiety of the instillation procedure itself produced selected recall. A t this point demonstrations and return demonstrations took place. Patients’ questions were also answered.

Whenever possible, friends and/ or relatives were included in the instructions. The role of coach was explained as consisting of rubbing the patient’s back, stroking her abdo- men, and assisting with slow chest breathing. The friend or relative served as a complement to the efforts of nursing personnel and was not ex- pected to be the primary coach. Par- ticipating personnel were all familiar with and used the Lamaze method of preparation.

The purpose and methodology were explained to all the nursing staff involved in the care of Group B patients. If dificulties arose in terms of coaching or staffing, the in-

1 was a widow. In Group B, 11 were single, 1 was married, and 3 were separated.

Of the patients in Group A, 10 listed their religious preferences as Protestant; 2, no preference. In Group B, 12 were Protestant, 1 was Catholic.

Occupations of the women in Group A were listed as follows: 3 stu- dents, 3 clerks or secretaries, 2 wait- resses, 2 housewives, and 5 “no occu- pations. In Group B, 4 were students, 2 were clerks or secretaries, 2 were factory workers, and 1 each was a housewife, sales clerk, waitress, nurse’s aide, dispatcher, and photog- rapher.

9 ,

vestigator was available as primary coach. An instruction sheet exdain- Of Responses ing positioning, back rubbing, strok- Responses were analyzed and ing, and slow chest breathing was scored on a scale from 1 to 4, with 4 given to patients and staff. indicating the most positive possible

After the patient had aborted the response to each question and 1 in- fetus, she completed the question- dicating the least positive response. naire in the same manner as Group Several statements were left blank by A. several patients and were scored 2.5,

Characteristics of the Sample The questionnaire section on de-

mographic data was completed by 12 of the 15 patients in Group A and by all patients in Group B. The age range in Croup A was 14-40 years, with a mean age of 21.4. The age range in Group B was 15-29 years, with a mean age of 19.7.

In Group A, 8 patients were single, 2 were married, 1 was separated, and

a neutral response. The highest score possible, indicating a positive hospi- tal experience, was 108 (27 ques- tions). As can be seen from Table 1, the range of scores for Group A was 66-96 and the range of group B was

A Student t test was performed comparing the sample means, and a t value of 2.4366 was obtained. (The critical value of t required for a sig- nificance at the 0.05 level is 2.048.)

78-105.

fable 1. Scores From Ouestionnaire for Midtrimester Abortion Patients (High scores indicate a positive hospital experience.)

Group A (Routine care) Group B (Lamaze)

Score Patient Score Patient

A- 1 73 B- 1 105 A-2 75 B-2 78 A-3 90 8-3 93.5 A-4 90 8-4 85.5 A-5 89 B-5 89 A-6 83 B-6 93.5 A-7 79 8-7 101 A-8 94 B-8 90.5 A-9 88 B-9 82 A-10 96 8-10 101.5 A-1 1 76 B-11 95.5 A-1 2 79 8-12 104 A-13 78.5 8-13 83.5 A-14 66 8-14 81 A-15 96 8-15 88

ZA = 83.5 itB = 91.4

30 November/ December 1976 JOCN Nursing

Hence, the data supported the hy- pothesis.

Sixteen questions, the responses tr, which were directly related to the nursing care received, were identi- fied. The tvtal responses in Group A to these questions were compared to those of Group B. The average dif- ference between the total scores for the nu r s ing (1 u e s t io n s be tween Groups A and B was 5.156 with a standard deviation of 3.60, while the difference between the two groups on the total scores of the non-nursing questions was 2.273, with a standard deviation of 3.61. These differences between the nursing and non-nurs- ing questions was found to be signifi- cant a t the 5% level ( t = 2.10), in- dicating that a significantly greater difference was found in perception of nursing care than in perception of other hospitalization experiences. (See Table 2 . )

The next section of the question- naire was a series of two open-ended questions relating to the nursing care received during the hospitalization.

The first question asked for ways of improving the nursing care. For both Groups A and B the responses were generally positive. The primary dif- ference between groups was that 8 patients in Group A and 12 patients in Group B responded to the ques- tion.

Additional Information One patient asked the researcher if

she could keep the instruction sheet that she had been given. She stated that her sister-in-law was pregnant and that she knew the breathing and relaxation exercises would help her sister-in-law during labor.

One statement on the question- naire related to receiving pain medi- cation. While there was no signifi- cant difference between the groups, 1 patient in Group B left t he re- sponse column blank and 2 patients in Group B wrote that they had not needed pain medication. W e hope this could be attributed to their re- laxation and concentrated breathing exercises.

Table 2. Average of Scores for Individual Ouestions About Horpital Experiences of Midtrimester Abortion Patients (See Appendix)

Group A Group B Question (Routine care) (Lamaze)

1 2 *3 4 *5 6 7 ‘8 *9 ‘10 ‘1 1 12

*13 14

‘15 16 17 *18 *19 *20 *21 *22 23 24 *25 *26 *27

50 45 41 37 54 41 50 45.5 49 52 47 44 47.5 47 44 38 45.5 53 50 49 44 45.5 47.5 46.5 47 51 49

54 51 54.5 40 54 42 47.5 53 56 56 52 43 47 54 52 42.5 51.5 55.5 52 52 53 51.5 48 43 53 53.5 56

Denotes questions designated as relating to direct nursing care

November/December 1976 JOCN Nursing

Discussion ’I’he utilization of a modified form

of the Lamaze method of psycho- prophylaxis did significantly enhance a woman’s participation in the labor process when having a midtrimester abortion. Her preparation for and participation in the labor process re- sulted in a more positive perception of the nursing care given than when the method was not used.

Patients can easily be taught back massage, effleurage, and slow chest breathing after they are admitted to the institution. The method is car- ried out successfully with the coach- ing of a nurse who is sympathetic, patient, and supportive.

Staff can easily identify with their role since coaching allows the nurse to perform an independent nursing care function with the patient. All nursing skills may be utilized during the coaching period, and patients should benefit from improved nurs- ing care with the use of the method.

The use of the modified Lamaze method may even decrease the need for analgesia during labor. Based on the results of this study, utilization of the method should make the experi- ence more positive for both the patient and the staff.

References 1. Sandberg, Eugene, and Halph Ja-

cobs: “Psychology of the Misuse and Rejection of Contraception.” Ant J Obstet Gynecol 110227-242, 1971

2. Lessard, Suzannah: “Aborting a Fetus: ’Ihe Legal Hights, the Per- sonal Choice.” In Humun Sexuality: Coriteniporury Perspectives. Edited by Eleanor Morrison and Vera Boro- sage. Palo Alto, California, National Press Hooks, 1973, pp 264-269

3. Anonymous: ‘‘ I’crsoIid Experience at a Legal Abortion Center.” Am Nurs Jan 1972, pp 110-112

4. Kaltreider, Nancy: “Emotional Pat- terns Kelated to Delay in Decision to Seek Abortion, A Pilot Study.” Calif Med 118:23-25, 1973

5 . Freilich, Herbert: “New Liberal Abortion Laws; Issues and Prob-

32, 1971 6. (;endel, Evalyn, and Jimmie Glea-

son: “Education About Abortion.’’ Ant J Public lleulth 61:520-529, 1971

7. Harper, Mary, Betty Marcom, and

~PIIIS.” l losp Mullugt. Ma!,, pp 31-

31

8.

9.

10.

Victor Wall: “Abortion: Do Atti- tudcs of Nursing Personnel Affect the Patient’s Perception of Care?” Nurs Hes Jul/Aug 1972, pp 327-331 Juvera, Dolores: “Preparing Stu- dents for Abortion Care.” Nurs Out- look May 1971, pp 347-349 Char, Walter, and John McDermott: “Abortion and Acute Identity Crisis in Nurses.” A m J Psychiatry

Zahourek, Hothlyn: Therapeutic Abortion and Cultural Shock.” Nurs Forum 10( 1):8-17, 1 9 i l

128:952-957, 1972

tion for the Patient Undergoing Elec- tive Abortion.” Clin Obstet Gynecol

Whitley, Nancy: “Second Trimester Abortion.’’ JOCN Nurs Sept/Oct 1973, pp 1*5-21

Yaloff, Beverly, Margot Wade, and Mil- drrd Burlingame: “Nursing Care in an Abortion Unit.” Clin Obstet Gynecol

14:60-66, 1971

14:67-80, 1971

Address reprint requests to Claudia An- dcrsori, IiN, 1100 lh~iiili, Apt. 153, Austin, ’I’X 78723.

attended the University of Kansas J B S N , M N J a i d tlie llniversily of Missouri ( M A ) and lius taught maternity nursing at the former. M s . Anderson is a member of NAACOG, ANA, and Sigma Theta T U U .

Barbara Claiicy is an hsociute Professor of niutcmiity riursiiig ut the University of Kunsas. Her B S N is froni the University of Minnesota, and her graduate degree is froni the Cutliolic University of America. Slie is u nieniher of ANA and Sigma 7’1ieta ?’azi.

Supplemental Bibliography Hellman, Louis, and Jack Pritchard: C W -

liani’s OOstetr&s. New York, Apple- ton-Century-Crofts, 1971

Kallop, Deborah: ‘ I Preoperative Instruc-

Claudia Anderson is a candidate for a doctorate in niaternity nursing at the liniversity of Texas in Austin. She has

Ruth llnssiineiii. is an Assistant Professor in tlie Llepartnient of Biometry at the [Jniversity of Kansas. She is a gruduate of Duke University, and her M S isfrorn the University of North Carolina.

Appendix. Questionnaire for Evaluating Perception of Hospital Care as Received by Midtrimester Abortion Patients

Strongly Strongly On admission agree Agree Disagree disagree

1. I was not made to feel welcome on the unit. 2. The nurses informed me when I was admitted what I might

expect during my hospitalization. 3. The nurses comforted me. 4. The staff let me know that other professionals were available

5. The nurses made me feel as though I was a burden on them. 6. I had to wait for a long time before I was admitted. 7. My family or friends were treated in acourteous manner. 8. The nurse viewed me as just another patient-not an individual. 9. The nurses greeted me in a pleasant, cheerful manner.

if I desired to see them.

10. The nurses were too busy to bother with me. 11. The nurses tried to understand me as a person. 12. My call bell was not answered promptly. 13. The staff enjoyed taking care of me. 14. The nurses did not inform me of what would happen to me in the hospital. 15. The nurses stayed with me when I needed them. 16. My food was served attractively and was tasty. 17. I had to wait too long to get pain medicine from the nurses. 18. The nurses made me feel lonely. 19. I could ask the nurses for things without feeling like I was bothering them. 20. The nurses tried to understand me as a person. 21. I was a burden on the nurses. 22. I knew what to expect during my hospital stay. 23. Often I had to wait a long while before someone would answer my light. 24. I felt I could talk to the nurses about how I felt. 25. The nurses viewed me as a bad person. 26. My physical needs were not met adequately.

0 0 n 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0

0 0

0

32 November/Decemhcr 1976JOGN Nursing

Appendix (continued)

While I was in the hospital I would have liked to have seen the following persons (place an X in the appropriate places): -dietician -social worker -family planning counselor -priest -female counselor chaplain - male counselor

rabbi

~ public health nurse

Do you have any additional comments regarding your nursing care or your stay in the hospital? How might we improve your nursing care?

Was the care you received any different on the day, evening, or night shift? Please elaborate.

Age Marital status Occupation Religious preference a. Catholic b. Protestant c. Jewish d. None e. Other (Specify )

Admission date Discharge date

Thank you for your cooperation.

Perinatal Care

A symposium on Future Directions in Perinatal Care will be held at the New York Hilton Hotel in New York City on March 17-18, 1977. Sponsored by The National Foundation-March of Dimes, the sym- posium will be presented by the Columbia University College of Physi- cians and Surgeons and will be chaired by L. Stanley James, MD, Professor of Pediatrics and Obstetrics and Raymond L. Vande Wiele, MD, Professor and Chairman, Department of Obstettics/Gynecology.

The purpose of the symposium is to present the newest diagnostic and therapeutic techniques in obstetrical and newborn care, and it will include discussion of new problems relating to intensive care, i.e., financing, regionalization, consumer needs, and ethical dilemmas.

For further information write to Raymond L. Vande Wiele, MD, Co- Chairman, Symposium on Future Directions in Perinatal Care, Depart- ment of Obstetrics and Gynecology, College of Physicians and Sur- geons, Columbia University, 630 West 168th Street, New York, NY 10032.

r[ovember/Decemher 1976JOGN Nursing 33