Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Prenatal education : its impact on second stage breathing Selwood, Barbara Lane 1984

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1984_A6_7 S44.pdf [ 7.73MB ]
Metadata
JSON: 831-1.0042272.json
JSON-LD: 831-1.0042272-ld.json
RDF/XML (Pretty): 831-1.0042272-rdf.xml
RDF/JSON: 831-1.0042272-rdf.json
Turtle: 831-1.0042272-turtle.txt
N-Triples: 831-1.0042272-rdf-ntriples.txt
Original Record: 831-1.0042272-source.json
Full Text
831-1.0042272-fulltext.txt
Citation
831-1.0042272.ris

Full Text

PRENATAL EDUCATION: ITS IMPACT ON SECOND STAGE BREATHING By BARBARA LANE SELWOOD B.S.N., The U n i v e r s i t y of B r i t i s h Columbia, 1974  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE  in  THE FACULTY OF GRADUATE STUDIES (Department of Health Care and Epidemiology)  We accept t h i s t h e s i s as conforming to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA September ©  1984  Barbara Lane Selwood, 1984  In p r e s e n t i n g  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of  requirements f o r an advanced degree at the  the  University  of B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make it  f r e e l y a v a i l a b l e f o r reference  and  study.  I  further  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may  be granted by  department o r by h i s or her  the head o f  representatives.  my  It i s  understood t h a t copying or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l gain  s h a l l not be  allowed without my  permission.  The  U n i v e r s i t y of B r i t i s h Columbia  1956  Main Mall  V6T  1Y3  Van couve r , Canada  Date  6  (3/81)  ZJL£*J*«S/S-.  /r<fy  written  ABSTRACT An observational study o f the impact of p r e n a t a l education in The 15  on the conduct of second stage  labour was conducted  the Grace H o s p i t a l Low-Risk Labour and D e l i v e r y Module. study  participants,  non-attenders,  were r e c r u i t e d f o l l o w i n g admission  h o s p i t a l during the f i r s t lected u t i l i z i n g Observation  35 p r e n a t a l c l a s s attenders and  stage of labour.  three data c o l l e c t i o n  Instrument;  a Medical  Data were c o l -  tools:  Record  t o the  a Childbirth  Data  Form; and,  a Postpartum Interview. Findings prenatal Caucasian,  i n d i c a t e d that the m a j o r i t y o f women i n the  attender  group  (74.3%) were E n g l i s h speaking and  while the m a j o r i t y of women i n the non-attender  group (73.3%) were of Asian descent  and d i d not have E n g l i s h  as  (42.9%) i n the p r e n a t a l  their  main  language.  Fifteen  group, and 3 (20%) i n the non-attender  group r e c e i v e d e p i d u r a l  anesthesia during the f i r s t stage of labour.  Eighteen (51.4%)  of the attenders and 4 (26.6%) o f the non-attenders intervention The  majority  (delivery  by forceps  (12 attenders  or caesarean  and 2 non-attenders)  required section); received  e p i d u r a l anesthesia during the f i r s t stage o f labour. The m a j o r i t y  (62.9%  and 66.7%) o f attenders  and non-  attenders used V a l s a l v a pushing throughout the second stage; w i t h 37.1% and 33.3% r e s p e c t i v e l y using spontaneous pushing. O v e r a l l 72% o f the women were always i n s t r u c t e d t o use the Valsalva  Maneuver  and 28% received  conflicting  guidance  (spontaneous given.  and  Valsalva),  when v e r b a l  instructions  were  Two p r e n a t a l attenders a t t r i b u t e d the breathing tech-  niques used t o information received during p r e n a t a l c l a s s e s . Four of  the  5 non-attenders who  used spontaneous pushing  d i d so because they chose t o ignore d i r e c t i o n s t o use V a l s a l v a pushing and used a spontaneous pushing approach.  The f i n d i n g s  f a i l e d t o detect a s i g n i f i c a n t d i f f e r e n c e i n the study populat i o n due t o the l i m i t e d sample s i z e . The o v e r a l l second stage duration was attenders  and  71.6  minutes  70.4 minutes f o r  f o r non-attenders.  For those  women who used spontaneous pushing f o r the m a j o r i t y of t h e i r contractions the second stage was 75.6 minutes and 81.3 minutes respectively;  and,  68.3  minutes and 68.0 minutes f o r those  using V a l s a l v a pushing. Apgar scores were the same f o r both groups — 2 0 % scored less  than seven and 80% w i t h a score of seven or more at  one minute a f t e r d e l i v e r y . Since the study r e s u l t s f a i l e d t o show that p r e n a t a l classes have a s i g n i f i c a n t impact on the conduct of second stage, there i s a need f o r more discussion of the e f f e c t s of for  the V a l s a l v a maneuver during prenatal classes and a need greater emphasis  and p r a c t i c e of  'tools' which can be  used i n coping w i t h second stage contractions.  iv TABLE OF CONTENTS Abstract  i i  L i s t o f Tables  viii  L i s t of Figures  x  Acknowledgements  xi  CHAPTER I INTRODUCTION Introduction  1  Statement of the Problem  5  Purpose of the Study  5  D e s c r i p t i o n of the Following Chapters  6  I I REVIEW OF THE LITERATURE P h y s i o l o g i c a l Considerations i n Pregnancy and C h i l d b i r t h The V a l s a l v a Maneuver Respiratory Considerations During Pregnancy and C h i l d b i r t h Cardiovascular Considerations During Pregnancy and C h i l d b i r t h Acid-Base Metabolism i n Pregnancy and Childbirth  9 9 11 14 16  Previous I n v e s t i g a t i o n s of Second Stage Labour  19  Prenatal Class Preparation f o r Second Stage Labour  34  Investigations Regarding Consumer S a t i s f a c t i o n w i t h Care Given During Labour  40  Research Model f o r Observing the C h i l d b i r t h Environment  48  V  Research Model f o r Observing the C h i l d b i r t h Environment  48  CHAPTER I I I RESEARCH METHODOLOGY The Research S e t t i n g Labour and D e l i v e r y Procedures  57 57  Sample S e l e c t i o n  60  Data C o l l e c t i o n  61  Development o f the Data C o l l e c t i o n Tools ...  64  C h i l d b i r t h Observation Instrument  64  Medical Record Data Form  69  Interview Questionnaire  70  Data A n a l y s i s  72  Limitations  73  Assumptions  74  E t h i c a l Considerations  74  IV STUDY RESULTS D e s c r i p t i o n o f the Sample  77  Response Rate  77  Demographic C h a r a c t e r i s t i c s  79  C h a r a c t e r i s t i c s o f Prenatal Class At tenders  87  Source o f Prenatal Information  92  Labour and D e l i v e r y Experience o f the Study P a r t i c i p a n t s  95  Attendance o f Support Person  97  Analgesia and Anesthesia Use i n Labour and D e l i v e r y E l e c t r o n i c F e t a l Monitoring  95 97  The Second Stage o f Labour Breathing Patterns During Second Stage Contractions  97 103  Episiotomy, Vaginal Laceration During Second Stage  119  D i s t r i b u t i o n o f Labour Times  120  Infant. Outcomes Confidence, Perception of Labour and D e l i v e r y V". SUMMARY AND DISCUSSION OF THE RESULTS, CONCLUSION, IMPLICATIONS AND RECOMMENDATIONS FOR FURTHER INVESTIGATION  127 132  The Research Format and Characteri s t i c s of the Respondents  137  Labour and D e l i v e r y Experience  139  Second Stage Labour Infant Outcomes  140 147  Confidence, Perception o f Labour and D e l i v e r y  148  Conclusion  149  Implications o f the Study Recommendations f o r Further I n v e s t i gation  151  References  157  155  vi  APPENDICES A  Submission t o the U n i v e r s i t y of B r i t i s h Columbia Screening Committee f o r Research and Other Studies Involving Human Subj e c t s : Behavioural Sciences  B  Submission t o the Grace H o s p i t a l Education and Research Coordinating Committee  C  Covering L e t t e r and Consent t o Study Participants  D  Manual f o r N a t u r a l i s t i c Observation of the C h i l d b i r t h Environment  E  C h i l d b i r t h Observation Instrument Record Sheet Used i n This Study  F  Postpartum Interview Questionnaire  G  Medical Record Data Form  H  Employment Categories  I  D e f i n i t i o n of Terms  viii LIST OF TABLES  TABLE 4-1  Response Rate and Reason f o r NonParticipation  78  4-2  Residence of the Study P a r t i c i p a n t s  79  4-3  Age of the Study P a r t i c i p a n t s  80  4-4  Country of O r i g i n of the Study Participants  81  4-5  Length of Residency i n Canada  82  4-6  Language Best Understood by the Study Participants Education L e v e l of the Study P a r t i c i p a n t s ..  83 84  4-8  Type of Employment of the Study P a r t i c i pants  86  4-9  Main Reason f o r Attending Prenatal  4^7  Classes  88  4-10  Most Useful Information  90  4-11  P r a c t i c e of Breathing/Relaxation Techniques Primary Source of Information Regarding  91  4-12  Pregnancy and D e l i v e r y 4-13  E p i d u r a l Anesthesia Use  4-14  Uterine A c t i v i t y During  93 96 Observation  Period 4-15 4-16 4-17 4-18  Intrapartum Complications . E p i d u r a l Anesthesia and Intervention E p i d u r a l Anesthesia of the T o t a l Group and Interventions Breathing Patterns of a l l Study Participants  98 99 101 102 104  ix TABLE 4-19  Breathing Patterns of Study P a r t i c i p a n t s  106  4-20  E p i d u r a l Anesthesia and Breathing Patterns  108  Instruction/Guidance t o the Study P a r t i c i p a n t s During Contractions  110  Recorded Complication and Breathing Patterns  113  4-23  Interventions and Breathing Patterns  114  4-24  Fluency w i t h E n g l i s h and Breath Patterns .  116  4-25  Fluency w i t h E n g l i s h or Native Language by Caretakers and Breathing Patterns  117  4-21 4-22  4-26  Episiotomy, Vaginal Laceration During Second Stage  119  4-27  Length of the F i r s t Stage of Labour  121  4-28  Length of Second Stage of Labour  123  4-29  D i s t r i b u t i o n of T o t a l Labour Time  124  4-30  Recorded F e t a l D i s t r e s s and Breathing Patterns Apgar Scores One Minute A f t e r Delivery  4-31 4-32 4-33  129 130  Confidence L e v e l f o r Labour and Delivery  132  Perception of the Labour/Delivery Experience  134  LIST OF FIGURES  FIGURE 1  A Model of Maternal Coping During Labour and D e l i v e r y and Evaluation of the C h i l d b i r t h Experience  ACKNOWLEDGEMENTS  I would l i k e  t o express a sincere  thank you t o those  who made t h i s study p o s s i b l e . First  o f a l l , I thank my t h e s i s committee, Sam Sheps,  Nancy Waxier-Morrison and K i r s t e n Webber f o r t h e i r guidance, expertise  and e d i t o r i a l  comments  throughout  the research  process. Appreciation  i s extended t o the Grace H o s p i t a l f o r allow-  ing me access t o t h e i r f a c i l i t i e s and t o the s t a f f o f the labour  and d e l i v e r y u n i t  f o r t h e i r co-operation  i n giving  me the freedom t o c a r r y out my observations. A special who p a r t i c i p a t e d  thanks  go t o the women and t h e i r partners  i n the study and allowed me t o be a part  of the miracle of t h e i r c h i l d ' s b i r t h . Thanks a l s o go t o Margaret Powell f o r t y p i n g the f i n a l draft. Lastly,  but not l e a s t , I am e s p e c i a l l y g r a t e f u l t o my  husband Russ, who without h i s encouragement and support t h i s t h e s i s would not have been completed.  1 CHAPTER I  INTRODUCTION  Over the past  decade there have been considerable  changes i n the procedures and p r a c t i c e s surrounding c h i l d birth.  I t i s now a s a f e r and presumably happier experience  f o r women than i t has ever been. mortality years.  have dropped  Maternal and neonatal  d r a m a t i c a l l y over the past  ( S t a t i s t i c s Canada, 1982).  fifty  The t r a d i t i o n o f the  mother being alone and under heavy sedation has given way t o one o f a c t i v e p a r t i c i p a t i o n . birth  experience,  In preparation f o r t h i s  p r e n a t a l information and care are ob-  t a i n e d from a v a r i e t y o f sources w i t h medical p r a c t i o n e r s , nurses,  and community h e a l t h personnel  being  among the  main sources. To need  actively  participate  i n the b i r t h process, the  and demand f o r p r e n a t a l education c l a s s e s has  creased  greatly  (Nelson,  1981) and each year  in-  community  agencies and groups, p r i m a r i l y nurses, provide l a r g e numbers o f couples w i t h information about pregnancy and s t r a t egies f o r coping w i t h labour and d e l i v e r y .  Traditionally,  p r e n a t a l c l a s s e s have included a d i s c u s s i o n o f the emotional  and p h y s i c a l  changes o f pregnancy, the anatomical  and p h y s i o l o g i c a l aspects o f pregnancy and c h i l d b i r t h and  instruction on  i n relaxation  the techniques  and breathing  techniques  based  of Drs. Read and Lamaze (Lamaze, 1970)  or a modified Lamaze approach. For  years  there  has been d i s c u s s i o n regarding the  various breathing patterns f o r the f i r s t stage of labour, but the breathing process f o r second stage has been neglect e d by a l l but a few. Caldeyro-Barcia, These  childbirth  (Benyon, 1957; W i t z i g - B o l d t , 1971;  1979; K i t z i n g e r , advocates  encouraged  t o t h e i r body urges when bearing encouraged  to actively  bear  holding f o r the duration recent  years,  there  1979;  Noble,  1983).  women t o respond  down r a t h e r than being  down w i t h  sustained  of a c o n t r a c t i o n .  breath  However, i n  has been increased concern about the  manner i n which the second stage of labour has been conducted. 1979;  (Dunn, 1976; • Caldeyro-Barcia, Schneider,  1981;  Noble, 1983).  d i r e c t e d t o push a c t i v e l y using efforts — t h e  1979;  Kitzinger,  Women have been  long sustained expulsive  V a l s a l v a Maneuver— during second stage con-  t r a c t i o n s t o shorten t h i s phase of labour (Williams Obstetrics, of  1980 p.445) on the b a s i s that the o v e r a l l incidence  fetal  distress  second stage  rises with  (Moore, 1977).  i n c r e a s i n g duration o f the  While studies (Pearson, 1974;  Weaver e t a l , 1977; Caldeyro-Barcia, 1979) have demonstrat e d that spontaneous maternal pushing e f f o r t s improve mate r n a l and f e t a l well-being and that use of the V a l s a l v a maneuver during d e l i v e r y may be detrimental t o the h e a l t h  of  the fetus  and woman, there remains considerable  t r o v e r s y about  "allowing" labouring women t o use the spon-  taneous pushing approach during second stage labour. practioners  con-  Many  f e e l that the length o f the second stage must  not exceed 2 hours (Schneider, 1981) and t h i s i s more l i k e l y to occur when spontaneous pushing i s used. are  provided w i t h  information  Expectant women  about second stage labour,  f o r example the anatomical and p h y s i o l o g i c a l process, range of  maternal p o s i t i o n s that may be used, and the use of a  spontaneous pushing approach i n responding t o her own body urges t o bear down, yet contemporary p r a c t i c e i n the labour room does not n e c e s s a r i l y f o l l o w t h i s philosophy. 1957;  Caldeyro-Barcia,  1979; Schneider,  (Benyon,  1981; Simpkin,  1981). Empirical  observations of the environment  perience o f b i r t h have been r a r e . emphasized ience  specific  events  mother and i n f a n t ,  Research has g e n e r a l l y  occurring  — m e d i c a t i o n s and t h e i r  i n the b i r t h exper-  possible  influence  Haile,  1980).  on the  complication r a t e s o r length of second  stage labour (Hellman e t a l , 1952; B a c k b i l l , and  and ex-  Other  surveys focus on  1979; Bergsjo 'satisfaction  w i t h care' and i n d i c a t e that most women give p o s i t i v e r e s ponses t o t h e i r treatment i n c h i l d b i r t h regardless of what has happened t o them; when negative responses are expressed,  they are dismissed as part  minority".  o f an "unrepresentative  The m a j o r i t y o f women have been educated t o  be r e l a t i v e l y passive and eager t o please, and do not wish to  be regarded as troublesome;  and pleasure a t having produced 1977;  Danziger,  1979).  especially i n their r e l i e f a healthy c h i l d .  (Riley,  L i m i t e d research has been done  i n d e s c r i b i n g the experience of b i r t h i n r e l a t i o n t o breathing techniques used by women during the d e l i v e r y and exami n i n g these techniques i n r e l a t i o n t o p r e n a t a l p r e p a r a t i o n . Are  they able t o u t i l i z e  the breathing techniques  (that  i s , spontaneous pushing i n second stage labour) recommended and p r a c t i s e d i n p r e n a t a l education c l a s s e s ?  Are d e l i v e r -  ing women given a choice regarding"; the types o f breathing techniques  they wish  t o use?  used by women during second interactions  The breathing techniques  stage  labour and the s o c i a l  i n f l u e n c i n g these breathing techniques.' have  not been e x t e n s i v e l y documented. In the c h i l d b i r t h s e t t i n g i t i s necessary t o consider the s i t u a t i o n a l , s o c i a l and medical f a c t o r s which may a f fect  the responses,  woman i n labour.  attitudes,  and expectations o f the  An understanding o f the demands o f the  s e t t i n g i n c l u d i n g s o c i a l demands i s important i n the predictions and  o f maternal behaviour  Standley, 1978).  during d e l i v e r y  "An e c o l o g i c a l approach  (Anderson t o labour  and d e l i v e r y d i c t a t e s that c h a r a c t e r i s t i c s o f the s e t t i n g and i n t e r a c t i o n s between p a t i e n t s and s t a f f be e l u c i d a t e d i n any e f f o r t t o p r e d i c t behaviour of women i n c h i l d b i r t h "  (Anderson and Standley, T r a i n i n g Tape, 1978). examined aspects o f the b i r t h experience tions  between the s t a f f  This study  and the i n t e r a c -  and p a t i e n t s during t h a t  time.  The f i n d i n g s should prove u s e f u l t o community h e a l t h nurses, delivery  room nurses  and h e a l t h care  administrataors i n  planning more e f f e c t i v e s t a f f i n s e r v i c e programs and community  h e a l t h programs,  and t o researchers  f o r leading  t o f u r t h e r study i n t h i s area.  Statement of the Problem Current salva  research demonstrates that use o f the V a l -  Maneuver  —the  extended  breath-holding  technique--  during d e l i v e r y may be detrimental t o the h e a l t h o f the fetus and woman.  I t i s therefore suggested  that pregnant  women avoid the extended breath-holding techniques second stage labour.  during  (Benyon, 1957; Caldeyro-Barcia, 1979;  Dunn, 1976). Many women receive be  attend  prenatal  education  classes and  information and p r a c t i c e breathing techniques t o  used as a l t e r n a t i v e s  t o the V a l s a l v a Maneuver.  How-  ever, a t present l i m i t e d documentation has been made about t h e i r use during the d e l i v e r y experience.  Purpose o f the Study The  purpose  of t h i s  study was t o describe the d e l i v e r y  experience o f women having t h e i r f i r s t babies i n an attempt  to determine i f there i s a match o r mismatch i n p r e n a t a l preparation  f o r the second stage of labour.  The primary  o b j e c t i v e s were: 1)  t o describe the breathing patterns used by the study p a r t i c i p a n t s during the second stage o f labour.  2)  t o determine i f women who have prepared f o r c h i l d b i r t h by t a k i n g formal classes are more l i k e l y (than nonattenders)  t o use spontaneous  pushing  during the  second stage o f labour. 3)  t o describe  other  factors —breathing  instructions  by s t a f f , labour times, anesthesia and use o f E l e c t r o n i c F e t a l Monitoring, complications and i n t e r v e n t i o n s which may influence a woman's d e l i v e r y . To provide a composite p i c t u r e o f the study p a r t i c i pants, the secondary o b j e c t i v e s were: 1)  t o describe s e l e c t e d c h a r a c t e r i s t i c s o f the p r e n a t a l attenders  and non-attenders  as i t r e l a t e d t o t h e i r  preparation and perception of the b i r t h experience. 2)  t o describe s e l e c t e d infant outcomes which may r e flect  on the conduct of the second stage of labour  — e v i d e n c e of f e t a l d i s t r e s s and Apgar scores.  D e s c r i p t i o n o f the Following Chapters This t h e s i s i s organized i n t o f i v e chapters. II  c o n s i s t s o f a review  of s e l e c t e d r e l a t e d  under the f o l l o w i n g headings:  Chapter  literature  1)  p h y s i o l o g i c a l considerations i n pregnancy and  child-  birth; 2)  previous i n v e s t i g a t i o n s  of the second  stage of l a -  bour; 3)  a  review  of  the philosophies of c h i l d b i r t h  educa-  t o r s and p r e n a t a l classes; 4)  a review of surveys regarding consumer s a t i s f a c t i o n w i t h care during c h i l d b i r t h ; and  5)  the research model f o r observing the c h i l d b i r t h  en-  vironment . Chapter  I I I describes the research methodology, g i v -  ing information about the study s e t t i n g and the development and usage of the data c o l l e c t i o n instruments used i n t h i s study. Chapter IV presents the r e s u l t s of the study. Chapter results  and  V contains a summary and d i s c u s s i o n of the the conclusion.  Implications of t h i s  and recommendations f o r future study are o u t l i n e d .  study  8 CHAPTER I I REVIEW OF THE LITERATURE  Overview The readings  reviewed p e r t a i n t o the study's  main  question and i n v e s t i g a t i o n s r e l a t e d to the t o p i c of evaluat i o n of c h i l d b i r t h .  The l i t e r a t u r e i s reviewed under f i v e  headings: 1.  P h y s i o l o g i c a l Considerations  i n Pregnancy and C h i l d -  birth. Since  research  in this  area  is fairly  extensive,  s e l e c t e d focus research studies on the V a l s a l v a maneuver, r e s p i r a t o r y and  cardiovascular dynamics and  the  acid-base  metabolism i n pregnancy and c h i l d b i r t h are discussed. 2.  Previous I n v e s t i g a t i o n s of Second Stage Labour. A l i m i t e d number of research studies have been done  i n t h i s area and r e v e a l c o n f l i c t i n g opinions and f i n d i n g s . Most of the i n v e s t i g a t i o n s examined s p e c i f i c i n t e r v e n t i o n s or outcomes w i t h very few of  the use  and e f f e c t s  the V a l s a l v a maneuver on the d e l i v e r y outcome per  3.  Prenatal Class Philosophies  cators  are  the B.C. 4'.  addressing  of  se.  Preparation f o r Second Stage Labour. s e v e r a l i n t e r n a t i o n a l p r e n a t a l edu-  reviewed.  Also  included  i n t h i s s e c t i o n are  P r o v i n c i a l Health M i n i s t r y recommendations.  Surveys  Regarding  During C h i l d b i r t h .  Consumer  Satisfaction with  Care  In recent years a l i m i t e d number of consumer surveys of maternity  care have been conducted and they are d i s -  cussed. 5.  Research Model f o r Observing the C h i l d b i r t h Environment. The  model or t h e o r e t i c a l  framework used  for this  study i s discussed.  P h y s i o l o g i c a l Considerations i n Pregnancy and C h i l d b i r t h  The V a l s a l v a Maneuver The V a l s a l v a maneuver and i t s e f f e c t s have been documented s i n c e the 17th Century when the I t a l i a n p h y s i c i a n V a l s a l v a t r i e d t o expel pus from the middle ear by a f o r c e ful  expiratory effort  1978).  against  a closed g l o t t i s  (Noble,  The hemodynamic changes that occur during and a f t e r  forced e x p i r a t i o n of the V a l s a l v a maneuver are w e l l documented  (Hamilton  Schafer,  et a l , 1936; E l i s b e r g ,  1963;  Sharpey-  1965; Fox et a l , 1966; C u r t i n , 1969; Korner et  a l , 1976). While  studying  the p h y s i o l o g i c a l r e l a t i o n s between  i n t r a t h o r a c i c , i n t r a s p i n a l and a r t e r i a l pressure,  Hamilton  et a l (1936) d i v i d e d Valsalva's maneuver i n t o four phases; the  onset of s t r a i n i n g ; the p e r i o d of s t r a i n i n g ; the im-  mediate release of the s t r a i n ; and the subsequent p e r i o d of r e s t ,  this  blood pressure.  l a s t phase r e s u l t i n g  i n an 'overshoot  1  in  In  Phase I , the onset  of s t r a i n i n g , there i s a sudden  increase", i n blood pressure as s t r a i n i n g empties blood  from  the lungs t o the periphery, and the increased i n t r a t h o r a c i c pressure  i s transmitted t o the p e r i p h e r a l a r t e r i a l v e s s e l s .  Sharpey-Schafer change  (1965) found that at t h i s time there i s minimal  i n the pulse pressure  (difference  between  systolic  and  d i a s t o l i c blood pressure) or heart r a t e .  II,  the p e r i o d of s t r a i n i n g , the i n t r a t h o r a c i c pressure ex-  ceeds the pressure  i n the great system v e i n s .  During Phase  As a r e s u l t  venous blood i s prevented from. r e t u r n i n g t o the t h o r a c i c cage and the c a r d i a c output subsequently f a l l s and pulse pressure diminishes.  A r e f l e x v a s o c o n s t r i c t i o n occurs at the end of  t h i s phase causing a r i s e i n both the transmural and i n t r a luminal pressure. straining causes the In  With  Phase I I I , the sudden c e s s a t i o n of  and l o s s of support o f the i n t r a t h o r a c i c pressure  the a r t e r i a l pressure t o f a l l by an amount equal t o  fall  i n the t h o r a c i c pressure  (Sharpey-Schafer,  1965).  Phase IV, the p e r i o d of r e s t , the blood h e l d i n the ven-  ous  system  by the increased i n t r a t h o r a c i c  pressure  during  s t r a i n i n g then enters the heart and i s pumped i n t o the cons t r i c t e d p e r i p h e r a l system. from  Phase I I , r e s u l t s  Thus, the r e f l e x v a s o c o n s t r i c t i o n  i n an 'overshoot ,  i n blood pressure (Hamilton e t a l , 1936).  1  a r a p i d increase  As the a o r t i c pres-  sure r i s e s the baroreceptors are stimulated and a r e f l e x bradyc a r d i a i s produced ( E l i s b e r g , 1963).  The a  Valsalva  t e s t of  1949;  maneuver has  been e x t e n s i v e l y  used  c i r c u l a t o r y f u n c t i o n i n heart disease  E l i s b e r g , 1963;  They found that  the  Braunwald, 1965; response t o  and  as  (McGuire,  C u r t i n , 1969).  the V a l s a l v a maneuver i n  cardiac p a t i e n t s to be d i f f e r e n t from the response i n 'normal'  patients  pey-Schafer  studied by  (1955).  Hamilton et  The  a l (1944) and  Shar-  responses t o the V a l s a l v a maneu-  ver during the four phases occurred t o a s i g n i f i c a n t l y l e s s e r degree, w i t h  the  absence of  the  bradycardia  being  of  the  greatest importance.  Respiratory Considerations During Pregnancy and C h i l d b i r t h Normal in the  cardiovascular  pregnancy are first  ed  respiratory  and  Magnus-Levy f i r s t  the  during  measured  these  and h i s f i n d i n g s were subsequently confirmThe  most  important r e s p i r a t o r y changes are the  in resting ventilation.  mester  adjustments  hormonal influence  by Bonica (1967) and Marx et a l (1958).  pressive ses  e s t a b l i s h e d by  trimester.  changes i n 1904  and  resting  increa-  Beginning i n the f i r s t  v e n t i l a t i o n progressively  t o a l e v e l 50 percent above normal at term.  im-  tri-  increases  This  increase  i s achieved i n two ways: 1.  an  increase  i n the  r e s p i r a t o r y r a t e from  14  16 i n s p i r a t i o n s per minute; and 2.  a  significant  increase  i n the  tidal  volume,  that i s the amount of a i r i n a s i n g l e breath,  to  of 40 percent. At term, the increase i n a l v e o l a r v e n t i l a t i o n i s approximately 70 percent  greater than i n the non-pregnant s t a t e .  With a 50 percent percent  increase  increase  increase  i n r e s t i n g v e n t i l a t i o n , a 20  i n oxygen consumption, and a 15 percent  i n the Basal Metabolic Rate (BMR), the v e n t i l a -  t i o n equivalent  f o r oxygen i s p e r s i s t e n t l y r a i s e d .  v e n t i l a t i o n equivalent i s expressed of  (The  as the number of l i t r e s  a i r inhaled f o r each 100 ml. o f oxygen consumption)  (Bonica, 1973).  These changes lead t o a reduction i n alveo-  l a r and a r t e r i a l CO ^ tensions and an accompanying increase in  oxygen tension and s a t u r a t i o n . There are meagre data a v a i l a b l e on v e n t i l a t o r y changes  during  labour  and o r d e l i v e r y .  Boutourline-Young  (1956)  measured the a l v e o l a r CD^ i n unmedicated p a r t u r i e n t s s e v e r a l hours before  and a f t e r  d e l i v e r y reduction  d e l i v e r y , and found a mean post  i n a l v e o l a r CO ^ of 6mm Hg. below the  average prelabour value of 31 mm Hg. Cole volumes  and Nainby-Luxmore  during  childbirth  (1962) measured r e s p i r a t o r y  and found  i n r e s p i r a t o r y r a t e and t i d a l volume. alveolar  CO2  a marked  increase  Reid (1966) measured  i n p a r t u r i e n t s w i t h uncomplicated  labours.  He found the PaCO^ , between contractions t o be 32 mm Hg. during e a r l y labour, stage,  24 mm Hg. at the end of the f i r s t  and 26 mm Hg. during the second stage of labour.  The type of breathing used was not s p e c i f i e d .  Bonica  and Caldeyro-Barcia  e f f e c t s o f pain,  et a l (1973) studied the  anxiety,  and fear, as w e l l as the V a l s a l v a  Maneuver associated w i t h  the bearing-down r e f l e x of second  stage.  They were able t o show a close  p a i n f u l contractions hyperventilation large flex  c o r r e l a t i o n between  and h y p e r v e n t i l a t i o n ,  and found a marked  above prelabour v e n t i l a t i o n  although t r a n s i e n t bearing-down  caused  reduction o f a r t e r i a l CG^.  efforts  pressure thus distending  that  further  a  The r e -  increase the i n t r a u t e r i n e  the perineum.  This causes a d d i t i o n a l  pain which prompts the d e l i v e r i n g woman t o v e n t i l a t e  faster  causing a reduction o f the PaCG^. The to  changes  an increasing  i n lung  volume and v e n t i l a t i o n  efficiency  o f gaseous t r a n s f e r  maternal blood and t h e a l v e o l a r effective  reduction  o f carbon  air. dioxide  contribute between  This r e s u l t s  i n an  w i t h an accompanying  increase  i n the tension o f oxygen i n the a l v e o l i  arterial  blood which i n turn enhances the t r a n s f e r of these  gases between mother and fetus. tory  blood  she  These changes ( i n r e s p i r a -  gas l e v e l s ) make the woman i n c h i l d b i r t h more  susceptible pregnant  and the  t o changes  woman.  develops  i n blood gas l e v e l s than the non-  With hypoventilation  hypoxia, hypercapnia,  or breath  holding,  and r e s p i r a t o r y  more r e a d i l y than does the nonpregnant woman.  acidosis  When  hyperventilationi:* occurs and has preceded the V a l s a l v a maneuver, the diminished PaCCL may cause maternal hypocapnia  which  causes  vasoconstriction  and can lead t o f e t a l hyp-  o x i a and metabolic a c i d o s i s .  Cardiovascular,'Cons i d e r a t i o n s -;during:J:Prggnancycand  Childbirth  During pregnancy there i s an increase i n blood volume and c a r d i a c output. The blood volume i s increased approximately 45 percent, t o a maximum at 30 t o 34 weeks g e s t a t i o n , w i t h most o f t h i s accounted f o r by-, venous d i l a t i o n , mainly  i n the s k i n and lower limbs.  may a l s o be increased during t h i s increases to  early  50 percent  i n pregnancy,  Pulmonary blood volume time.  Cardiac output  reaching approximately  above non-pregnant l e v e l s  30  a t 28 weeks and  then d e c l i n i n g toward the non-pregnant l e v e l again a t about 38 weeks o r by term. effect  Maternal posture has an important  on c a r d i a c output w i t h a marked d e c l i n e when the  supine p o s i t i o n i s assumed.  B i e n i a r z , Maqueda- and Caldeyro-  B a r c i a (1966) showed that there i s compression o f the lower aorta  by the uterus when i n the supine p o s i t i o n  l a t e pregnancy causing a mechanical  during  o b s t r u c t i o n o f blood  flow t o the p e l v i c organs and lower limbs.  Uterine contrac-  t i o n s and maternal hypotension a l s o exaggerate t h i s e f f e c t . Wright, M o r r i s , Osborn and Hart (1958) s t u d i e d u t e r ine  circulation  i n p a t i e n t s a t term  and found  that the  blood flow was w i t h i n normal r e s t i n g l i m i t s i n 85 percent of the women t e s t e d during the e a r l y stage o f labour; w h i l e  in  the l a t e stage of labour the blood flow was w i t h i n nor-  mal r e s t i n g l i m i t s i n l e s s than 50 percent of these women. Cardiovascular  changes  occurring  during  d e l i v e r y depend on a number of f a c t o r s : delivery,  the p o s i t i o n  of the mother,  labour and  the method of the bearing-down  e f f o r t s r e q u i r e d t o expel the baby, the type of anesthetic used, other medication e f f e c t s , and maternal Hendricks  and Q u i l l i g a n  fluid  (1956) and Adams and  intake.  Alexander  (1958) s t u d i e d the e f f e c t of u t e r i n e contractions on cardiac  output  and a slowing of the heartbeat during u t e r i n e  contractions. Bearing down using the V a l s a l v a maneuver i n the second stage  of labour  vascular is  has s e v e r a l e f f e c t s  dynamics.  on maternal c a r d i o -  The immediate e f f e c t  of bearing-down  t o d r i v e the blood from the lungs i n t o the l e f t  with  a rise  i n systolic  and d i a s t o l i c blood  heart  pressure.  With continuing breath holding, the blood pressure s t e a d i l y falls,  and w i t h the r e l e a s e of the h e l d breath there i s  a r a p i d drop i n the blood pressure as the pulmonary v a s c u l a r bed f i l l s . of  time  The degree o f t h i s f a l l i s r e l a t e d t o the length the V a l s a l v a maneuver i s held.  bearing-down e f f o r t s fect;  a further r i s e  With  subsequent  there appears t o be a cumulative e f i n blood pressure although there i s  no greater increase i n i n t r a t h o r a c i c pressure.  The c r i t i c a l  periods are at the time of r e l e a s e of the prolonged bearingdown e f f o r t when the blood pressure may f a l l t o a c r i t i c a l -  ly  low l e v e l ,  o r during repeated  V a l s a l v a maneuvers when  the blood pressure may r i s e t o a very high l e v e l . and Ueland, is  that  1973).  less  blood  (Hansen  The r e s u l t f o r the woman i n c h i l d b i r t h i s being  transported t o the uterus,  causing a drop i n the p e r f u s i o n of blood i n the placenta and a drop i n oxygen g e t t i n g t o the f e t u s .  Acid-Base Metabolism i n Pregnancy and C h i l d b i r t h Changes greatly  i n ventilation  and lung  t o an increase of gaseous  volume c o n t r i b u t e  t r a n s f e r between the  maternal blood and the a l v e o l a r a i r (Bonica, 1973).  Changes  i n blood pH and CO ^ pressure are the most s i g n i f i c a n t duri n g the r e g u l a t i o n of r e s p i r a t i o n .  Maternal blood pH i s  on the a l k a l i n e s i d e of the normal range (7.37-7.45),  while  f e t a l blood pH i s on the a c i d i c s i d e , approximately 7.32. This d i f f e r e n c e f a c i l i t a t e s the t r a n s f e r of f e t a l CO2, metabolic  acids and hydrogen ions t o the mother.  A constant  blood pH i s maintained by: 1.  the buffer-base  system,  of which hemoglobin i s  an important component; 2.  the r e s p i r a t o r y component, of the lungs the  t o the carbon  carbonic a c i d  which i s the response dioxide (PaC02 ) o r  (H^CO^) concentration i n the  blood; 3. "  the metabolic excess  component,  or d e f i c i t  of  which r e f e r s  t o the  the base bicarbonate  (HCO^)  regulated by the kidneys. The blood pH, the most e a s i l y measured f a c t o r , v a r i e s d i r e c t l y w i t h the bicarbonate l e v e l i n the blood and inversely  with  During  the  arterial  carbon  dioxide pressure  v o l u n t a r y h y p e r v e n t i l a t i o n , the  (carbon  d i o x i d e i n s o l u t i o n ) can  be  (PaCC^).  circulataing reduced  causing  increase i n the blood pH.  (Hansen et a l , 1973).  of  —pallor,  respiratory  alkalosis  H^CO^  dizziness,  an  Symptoms euphoria,  numbness and t i n g l i n g of e x t r e m i t i e s caused by v a s o c o n s t r i c tion  and the e f f e c t s of calcium i o n s h i f t s , are  i f the pH 20 mm Hg  i s elevated t o 7.6  observed  or more and PaCO ^ i s below  (Hansen et a l , 1973).  When there i s a high blood  pH l e s s oxygen i s bound t o the hemoglobin.  Carbon dioxide  i s an important r e g u l a t o r of v a s c u l a r tone, and by causing vessels t o d i l a t e i t improves the blood flow thus e f f e c t i n g i t s own levels,  removal.  constriction  In the absence of adequate PaCO2 of  the  blood  v e s s e l s occurs.  The  t o t a l e f f e c t of these changes i s that l e s s oxygen i s being transported  by  less  blood,  and  when c a r d i a c output  and  blood flow t o the uterus and placenta are diminished, the p o t e n t i a l f o r hypoxia and f e t a l a c i d o s i s e x i s t s . Kastendieck study,  their  the f e t a l  et  al  (1974) confirmed  conclusions  indicated  heart r a t e at the end  that  in  their  d e c e l e r a t i o n of  of second stage  a f f e c t e d the degree of f e t a l a c i d o s i s . demonstrated that the f a l l  this  labour  Wood et a l (1973)  i n f e t a l pH was dependent upon  time. the  A l l d e l i v e r i e s i n t h i s study were hastened by using following  methods:  of a c t i v e maternal  early  episiotomy,  bearing-down e f f o r t s ,  of forceps i f there were any delays.  encouragement  and by the use  They concluded that  the r e l a t i o n s h i p found between maternal and u m b i l i c a l v e i n blood base d e f i c i t f o r the t o t a l study group may e x p l a i n the occurrence  o f f e t a l metabolic a c i d o s i s w i t h prolonged  pushing by the mother.  Summary Normal  respiratory  and cardiovascular  adjustments  i n pregnancy create a h y p e r k i n e t i c s t a t e i n the pregnant woman.  The changes i n lung volume and v e n t i l a t i o n c o n t r i b -  ute t o an e f f i c i e n t gaseous t r a n s f e r between maternal blood and  the a l v e o l a r a i r which makes the woman i n c h i l d b i r t h '  more s u s c e p t i b l e t o changes i n the blood gas l e v e l s the nonpregnant woman.  than  One o f the f a c t o r s which a f f e c t s  r e s p i r a t i o n and gaseous t r a n s f e r and puts a s t r a i n on the cardiovascular system i s breath-holding combined w i t h s t r a i n ing  ( V a l s a l v a maneuver) during  second  stage.  When the  bearing down or breath-holding are strong and prolonged, the  maternal  arterial  blood  pressure  of the drop i n cardiac output.  drops as a r e s u l t  This g r e a t l y reduces the  blood flow t o the uterus and placenta, r e s u l t i n g i n l e s s oxygen being  transported by l e s s  blood and l e s s  oxygen  g e t t i n g t o the fetus ( f e t a l hypoxia) and creates the poten-  tial  for f e t a l  a c i d o s i s ( i n d i c a t e d by  a prolonged  decel-  e r a t i o n of the f e t a l heart r a t e a f t e r the c o n t r a c t i o n has ended).  Previous Investigations of Second Stage Labour The  l i t e r a t u r e reveals c o n f l i c t i n g opinions and  find-  ings on the conduct and length of the second stage of labour and  i t s effect  pushing  on  the  fetus.  I n s t r u c t i o n s t o mothers on  during the second stage of labour range from advice  not t o push at a l l to the most common method which i s prolonged breath holding while bearing down w i t h maximum f o r c e . Humphrey et i n the pH was et  (1973) found  that  i n the  (1976) studied second stage  that,  w i t h good f e t a l pH  values  Apgar  scores,  management of  clusions,  i n over  labour  pH  not  change  d o r s a l recumbent p o s i t i o n .  fetal  was  there was  (-0.050) during second stage labour when d e l i v e r y  conducted al  al  a  in relation  4,000 v a g i n a l d e l i v e r i e s  flexible  and  and  the  to  concluded  correspondingly  good  "time r u l e "  n e c e s s a r i l y detrimental to the f e t u s . based on  Roemer  Their con-  f i n d i n g s which showed improved pH  and  blood gases of neonates born a f t e r a shorter second stage, were that i n general a shorter second stage i s b e t t e r than a long one.  In contrast t o these f i n d i n g s , Klock's  study concluded maternal important  bearing role  (1976)  that the number of contractions w i t h a c t i v e down during  second  i n the well-being of  stage the  played  a more  fetus than d i d  the length o f second stage labour. Perry and Potter (1979) showed evidence voluntary pushing They evaluated  that effective,  does shorten the second stage  o f labour.  the e f f e c t i v e n e s s i n p r i m i g r a v i d and m u l t i -  gravid women who d i d o r d i d not use diaphragmatic, abdominal v a g i n a l pushing of labour.  ( V a l s a l v a maneuver) during the second stage  Their f i n d i n g s showed that f o r p r i m i g r a v i d women  w i t h preparation and using the voluntary diaphragmatic, abdominal pushing technique, the mean time f o r the second stage of labour was 45 minutes. this was  technique  For the p r i m i g r a v i d group not using  the average duration o f second stage  68 minutes.  abdominal-vaginal  labour  For multiparous women using the voluntary pushing  technique,  the mean time  f o r the  second stage o f labour was 13 minutes versus 18 minutes f o r women not using the technique. learned  v o l u n t a r y pushing  They concluded that p r e n a t a l l y  technique  d i d shorten the second  stage of labour, e s p e c i a l l y i n primiparous women. found  t h a t almost  They a l s o  a l l women needed one o r two contractions  t o get t h e i r pushing e f f e c t i v e l y organized. Bergsjo  and H a i l e  (1980) examined the duration o f  the second stage o f labour, from f u l l d i l a t i o n of the c e r v i x t o the b i r t h  of the c h i l d ,  i n two Norwegian h o s p i t a l s . of  243 primiparous  during a three month p e r i o d Their data included the labours  women and 392 multiparous women who  gave b i r t h v a g i n a l l y .  The second stage o f labour ranged  from 15 minutes t o 107 minutes  i n primiparous women w i t h  an average of 34.6  minutes f o r those experiencing  eous labour and a mean of 32.9 induced tion  labours.  spontan-  minutes f o r those who  had  They a l s o found that there was i n t e r v e n -  (vacuum e x t r a c t i o n , forceps  and  caesarean  sections)  i n the second stage of labour f o r 17.7 percent of the p r i m i paras.  The  authors  concluded  that reasonable  limits  for  the duration of the second stage were 45 minutes f o r p r i m i parous women and this not  time  35 minutes f o r multi-parous women.  they recommended i n t e r v e n t i o n .  The  After  authors d i d  comment on the f a c t that the operative termination of  labour a f t e r 40 minutes i n primiparous women as "more often performed  to  relieve  f a t i g u e d mothers"  t o problems of f e t a l well-being. is  than  i n response  "The second stage.of1 labour  the p e r i o d of greatest p h y s i c a l s t r a i n on both mother  anf f e t u s . " A "wait and see" a t t i t u d e w i t h respect t o i n t e r vention  "may  have profound  i n many cases  ill  e f f e c t s on the mothers,  look back upon t h e i r labours as a  experience which they never want t o repeat." H a i l e , 1980, ationship  p. 195).  between the  who  shocking  (Bergsjo and  The authors d i d not look at the r e l a c t i v e , vigorous  pushing  procedures  or spontaneous pushing on the frequency of operative i n t e r ventions during the second stage^df^.labour. Niswander and Gordon (1972) a l s o examined the d u r a t i o n of the second stage of labour along w i t h many other labour variables.  A large sample of o b s t e t r i c a l records were ex-  amined —29,989 women whose babies were i n a vertex presen-  t a t ion  and who gave b i r t h v a g i n a l l y .  duration  o f second  stage  labour from  They examined the full  d i l a t a t i o n of  the c e r v i x t o the completed d e l i v e r y of the i n f a n t f o r both white and b l a c k women. that  For primiparous b i r t h s they found  62 percent of the white women and 81 percent of the  black women had d e l i v e r e d w i t h i n 60 minutes of commencement of second stage labour.  Seventy-eight percent of the white  women and 91 percent of the b l a c k women had d e l i v e r e d w i t h i n 90 minutes noted  of the onset  that the second  2 hours  of second  stage labour.  I t was  stage of labour l a s t e d longer than  i n 13 percent o f the white primiparas and i n only  5 percent o f the black primiparas.  The authors a l s o noted  that f o r a l l primiparous groups there was an increased f e t a l r i s k when the second stage was l e s s than 30 minutes i n length, and an increased frequency of adverse e f f e c t s when the second stage  l a s t e d beyond two hours.  The authors d i d not spe-  c i f y any r e l a t i o n s h i p between the use of a c t i v e , vigorous, pushing  (Valsalva maneuver) and spontaneous pushing during  the second stage. Several the  s t u d i e s have looked  l e n g t h o f second  stage  a t the r e l a t i o n s h i p o f  labour w i t h other v a r i a b l e s .  (Hellman e t a l , 1952; Wood e t a l , 1973; Cohen, 1977) Cohen studies  primiparas  comparing  the length of second  labour w i t h Apgar scores and i n f a n t m o r t a l i t y .  stage  He conclu-  ded that a long second stage labour does not adversely i n fluence p e r i n a t a l o r neonatal m o r t a l i t y i n primiparas and  found no c o r r e l a t i o n between the frequency of low 5 minute Apgar scores and the length of second stage.  In Helman's  study o f 13,377 d e l i v e r i e s he found that 77 percent were d e l i v e r e d w i t h i n one hour of second  stage and 92 percent  w i t h i n two hours (breathing techniques were not s p e c i f i e d ) . He a l s o concluded that there i s a c o r r e l a t i o n between the duration o f the f i r s t  and o f the second stages of labour  and t h a t the prolongation of both the f i r s t and second stages of labour has a d e f i n i t e influence upon postpartum hemorrhage; and,  t h a t i n f a n t m o r t a l i t y r i s e s w i t h the prolongation of  both the f i r s t and second stages of labour. e f f e c t being apparent  The f i r s t stage  a f t e r a duration of 20 hours, w h i l e  the increase i n f e t a l m o r t a l i t y takes place when the second stage has l a s t e d more than 150 minutes. Wood or  investigated  'normal' d e l i v e r y .  were  given an e a r l y  fetal  well-being following  'fast'  Women i n the ' f a s t ' d e l i v e r y group episiotomy, encouraged  t o bear  f o r c e f u l l y , and i n three cases a s s i s t e d by forceps.  down  Instruc-  t i o n s f o r bearing-down were not described nor was the management of the 'normal' d e l i v e r y s i t u a t i o n s .  The authors r e -  ported the mean time of second stage from f u l l of sus  dilatation  the c e r v i x t o be longer f o r the ' f a s t ' group — 3 4 v e r 32 minutes.  total  study  They concluded that when considering the  group,  the s i g n i f i c a n t  relationship  between  the maternal and u m b i l i c a l v e i n blood base d e f i c i t  suggests  that maternal metabolic a c i d o s i s may e x p l a i n the occurrence  of  f e t a l metabolic  a c i d o s i s w i t h prolonged  pushing  by the  mother. Klock (1975) concluded  from h i s studies that the number  of contractions w i t h a c t i v e maternal pushing e f f o r t s played a more important  r o l e i n the well-being of the fetus than  d i d the t o t a l length of the second stage. information  Utilizing this  Roemer e t a l (1976) r e t r o s p e c t i v e l y analyzed  over 4000 v a g i n a l d e l i v e r i e s w i t h regard t o the r e l a t i o n s h i p of the length o f the second stage t o the f e t a l outcome of acid-base  balance  approximately  and Apgar scores.  4 percent  They found that i n  o f the sample the length o f the  second stage exceeded 1.5 hours, and n e a r l y every 27th woman was  bearing down more than 30 minutes.  as  i n d i c a t e d by pH values  The good pH values,  o f l e s s than 7.2 i n 13.4% and  l e s s than 7.1 i n only 1.5%, plus the reasonably scores  good Apgar  (92.9% scored between 7-10 a t 1 minute) o f the study  population would i n d i c a t e that a f l e x i b l e management (that i s , a longer second stage) o f the 'time-rule  1  i s not neces-  s a r i l y detrimental t o the f e t u s . Not oured  a l l p r a c t i t i o n e r s examining c h i l d b i r t h have fav-  the encouragement o f f o r c e f u l expulsive e f f o r t s by  the d e l i v e r i n g woman.  A pioneering study by Benyon (1957)  advocated women f o l l o w i n g t h e i r own i n c l i n a t i o n s as t o pushing during second stage labour. gravidas  with  vertex  One hundred l o w - r i s k p r i m i -  presentations were observed i n t h i s  study and compared w i t h 393 other l o w - r i s k p r i m i g r a v i d ver-  tex  deliveries  o c c u r r i n g during the same p e r i o d of time.  For the 100 women i n the t e s t group, no suggestion was made to the p a t i e n t that she should push unless labour was not progressing s a t i s f a c t o r i l y . in  the r o u t i n e conduct  No other a l t e r a t i o n s were made  (unspecified) of the cases.  She  reported that o f the 100 cases, 83 d e l i v e r e d spontaneously w i t h an average duration o f the second stage being 1 hour and  3 minutes.  2 hours.  Two cases had second stages l a s t i n g over  The mean duration of the second stage f o r the  c o n t r o l s was not s p e c i f i e d , however the author a l l u d e d t o no  difference  i n the length of second stage.  the 83 babies weighed over eight pounds. cases  ended  F i f t e e n of  S i x of the hundred  i n a forceps d e l i v e r y , but the forceps r a t e  f o r t h i s group was approximately one-half that o f the c o n t r o l group o f 393, which was 11.9 percent.  The episiotomy r a t e  f o r the t e s t group was a l s o l e s s than that o f the c o n t r o l group, these  39 percent versus 63 percent. results  "show the e f f e c t  Benyon concluded that  of conducting the second  stage along a p a t t e r n which reserves i n s t r u c t i o n i n pushing e n t i r e l y f o r those who have proved t h e i r need f o r i t . " In 1979, Caldeyro-Barcia reported that women who pushed 'spontaneously'  as they f e l t  the need had s l i g h t l y longer  second stages than d i d women using f o r c e f u l , prolonged V a l s a l v a pushing throughout the second stage.  He s t u d i e d pro-  longed breath holding (The V a l s a l v a maneuver) combined w i t h bearing down e f f o r t s during the second stage of labour and  t h e i r e f f e c t s on the outcome of the labour and the welfare of  the f e t u s .  lasting  He defined  longer than  'prolonged  6 t o 7 seconds.  breath holding' as In Phase I , a t the  beginning o f each bearing down e f f o r t , there i s a t r a n s i e n t r i s e i n s y s t o l i c and d i a s t o l i c blood pressure. down e f f o r t caused a corresponding  Each bearing  f a l l i n the f e t a l heart  r a t e o r Type I Dips ( e a r l y d e c e l e r a t i o n s ) , t h i s being caused by the f e t a l head being compressed more s t r o n g l y while the woman i s bearing down.  As the p e r i o d o f s t r a i n i n g c o n t i n -  ues, there i s increased i n t r a t h o r a i c pressure and a marked decrease  i n c a r d i a c output and s y s t o l i c and d i a s t o l i c blood  pressure, c l e a r l y seen as congestion on the mother's face. The longer the bearing down breath holding e f f o r t , the more marked the f a l l With the f a l l  i n the a r t e r i a l pressure  o f the woman.  i n a r t e r i a l pressure there i s a drop i n per-  f u s i o n o f blood i n the placenta and a drop i n oxygen g e t t i n g to  the fetus.  hypoxia  When the bearing down e f f o r t s are long, f e t a l  i s i n d i c a t e d as l a t e d e c e l e r a t i o n s , that i s those  o c c u r r i n g a f t e r the c o n t r a c t i o n o r Type I I d i p s , on recordings o f the f e t a l heart r a t e . Caldeyro-Barcia a l s o demonstrated that when the breath holding and bearing down were very strong and l a s t i n g longer than  15 seconds, maternal  to 70/50. and  a r t e r i a l blood pressure dropped  This g r e a t l y reduces the blood flow t o the placenta  produces  the decreased  marked  fetal  hypoxia  f e t a l heart r a t e .  which i s i n d i c a t e d by  The heart beat which had  been about 160 beats per minute before the c o n t r a c t i o n f e l l to  between 100 and 130 beats  a minute and the d i p l a s t e d  long a f t e r the c o n t r a c t i o n had ended. d e c e l e r a t i o n and produces f e t a l  This i s a prolonged  acidosis.  These Type I I  Dips are a l s o one of the i n d i c a t i o n s o f the need f o r i n t e r v e n t i o n s such as caesarean s e c t i o n . When the mother i s holding her breath, not only i s there a decrease i n maternal  a r t e r i a l pressure,  but t h i s  i s accompanied by a f a l l i n the oxygen content o f her a r t e r i a l blood.  Therefore, when there i s prolonged bearing down  e f f o r t w i t h breath holding, the r e s u l t i s not only a reduced blood flow t o the placenta, but a decreased  oxygen content  in  I t i s the com-  the blood that does reach the placenta.  b i n a t i o n o f these two f a c t o r s that produces the f e t a l hypoxia. (Caldeyro-Barcia, 1978).  mally  When bearing down e f f o r t s were spontaneously  and nor-  performed by the mother, Caldeyro-Barcia  found no  damaging e f f e c t s on the f e t u s .  With spontaneous bearing  down e f f o r t s ,  seconds, there was only  l a s t i n g about f i v e  a t r a n s i e n t e f f e c t on the f e t a l heart r a t e during each such e f f o r t , and no f a l l or  late  i n the f e t a l heart r a t e (Type I I Dips  decelerations) a f t e r  the c o n t r a c t i o n .  He found  that f e t a l hypoxia can be avoided i f the mother bears down as  she f e e l s  the need and without c l o s i n g her g l o t t i s o r  prolonging the bearing down.  At b i r t h he measured samples  of u m b i l i c a l a r t e r i a l blood f o r pH and PO _ and found the  neonate much more l i k e l y t o be a c i d o t i c and t o have a low oxygen content when the mother had been bearing down w i t h great s t r e n g t h and w i t h the g l o t t i s c l o s e d f o r an extended p e r i o d o f time.  When mothers were i n s t r u c t e d t o bear down  as they f e l t the need, without t r y i n g t o produce very strong or  prolonged  (more than  5 seconds) e f f o r t s ,  and without  complete c l o s u r e of the g l o t t i s , Caldeyro-Barcia found that the second stage  of labour proceeded more s l o w l y but the  fetus was i n e x c e l l e n t c o n d i t i o n . Following up on Caldeyro-Barcia's data, Bassel e t a l (1980) s t u d i e d the e f f e c t s  o f maternal  bearing down e f -  f o r t s on maternal blood pressure and pulse pressure during and  immediately  without  after  u t e r i n e c o n t r a c t i o n s , and w i t h and  v o l u n t a r y bearing  that bearing down e f f o r t s distal  down e f f o r t s . are another  They  concluded  mechanism by which  and p o s s i b l y u t e r o p l a c e n t a l blood flow can be pre-  judiced, thus the avoidance  o f a c t i v e bearing down e f f o r t s  can be advantageous t o the fetus at r i s k . In 1982 Barnett long, effect  hard  and Humenick examined the e f f e c t o f  V a l s a l v a pushing  on f e t a l  during  second stage  and i t s  a c i d o s i s and neonatal Apgar scores. A l l  women i n the study were d e l i v e r e d i n the semi-recumbent position.  Those i n the c o n t r o l group were i n s t r u c t e d t o  take long V a l s a l v a pushes throughout  second stage contrac-  t i o n s , and those i n the experimental group were i n s t r u c t e d t o push when they f e l t the urge while l e t t i n g some a i r out  of  the mouth and making a sound  This  (open g l o t t i s  method i s s i m i l a r t o that advocated  (1971).  pushing).  by W i t z i g - B o l d t  Upon d e l i v e r y cord blood was taken from a l l babies  and analyzed f o r pH, pCC^, and pC^, and base excess. A l l women i n the study were stage labour. group  (open g l o t t i s pushing)  length  upon e n t e r i n g second  The longest second stage i n the experimental  37 minutes i n the c o n t r o l  was  'low r i s k '  of pushing  efforts  was 80 minutes,  (Valsalva) group.  compared t o The average  f o r the V a l s a l v a pushing  group  8.56 seconds versus 3.01 seconds f o r the open g l o t t i s  pushing group.  The average second stage of the open g l o t t i s  group was 43.6 minutes versus 24.6 minutes f o r the V a l s a l v a pushing group.  Due t o the s m a l l sample s i z e , a s i g n i f i c a n t  d i f f e r e n c e could not be detected. The  authors d i d f i n d  a significant  d i f f e r e n c e (using  the t - t e s t ) i n the mean venous u m b i l i c a l blood pH, and i n PO2 f o r both  umbilical  venous  and a r t e r i a l  blood values.  Differences i n the mean values f o r the pCG^ and Base  Excess  f o r the u m b i l i c a l a r t e r i a l and venous blood were not s t a t i s t i c a l l y significant. Apgar  scores  f o r a l l the infants  were e x c e l l e n t ,  or 9 at one minute and 9 or 10 a t f i v e minutes.  8  Two i n f a n t s  i n the long V a l s a l v a groups had severe d e c e l e r a t i o n s during the  last  few minutes before b i r t h but those were not r e -  f l e c t e d i n the Apgar scores o r the blood gases.  Fetal a r t e r i a l  and venous blood pH was examined i n r e l a t i o n t o each woman's  average length o f c o n t r a c t i o n frequency, c o n t r a c t i o n durat i o n , pushing e f f o r t and length of second stage.  Only the  r e l a t i o n s h i p between a r t e r i a l pH and contraction frequency was s t a t i s t i c a l l y s i g n i f i c a n t . The  findings  of Barnett  e t a l (1982) support  those  of Wood e t a l (1979) who found that women who had s l i g h t l y longer with  second stages from the onset of pushing had babies higher  mean u m b i l i c a l a r t e r y and v e i n pH values.  Their f i n d i n g s a l s o support those of Cohen (1977) that longer second  stage  labours  are not n e c e s s a r i l y associated  with  lower Apgar scores or lower u m b i l i c a l a r t e r y and v e i n blood PO2 o r pH values  i n fetuses w i t h normal heart rates at the  s t a r t o f the second stage o f labour. found a high  Barnett and Humenick  c o r r e l a t i o n between length o f pushing e f f o r t  and frequency o f contractions among long V a l s a l v a type pushers. One  explanation  ther  apart  o f f e r e d was that when contractions are f u r -  women have more energy t o push long  and hard  and that c o n t r a c t i o n frequency may be a more important v a r i able than length and strength of pushes. Nelson e t a l (1980) examined the e f f e c t s of the Leboyer method o f d e l i v e r y .  In t h i s c l i n i c a l t r i a l ,  men were randomly assigned  t o e i t h e r a Leboyer o r a con-  ventional in  delivery.  The Leboyer  the woman's bed i n the labour  d e l i v e r i e s took  56 wo-  place  room; were l i t w i t h a  s i n g l e lamp; had a room temperature o f 27 degrees C e l s i u s ; and the  draping was minimized w i t h a s i n g l e s t e r i l e sheet under buttocks.  The i n f a n t received  skin-to-skin  contact  on  the  The  mother's abdomen and  cord was  bath given  cut  by  was  massaged by the mother.  a f t e r i t stopped p u l s a t i n g and  the  father.  a warm  Sound l e v e l s were reduced to  a minimum. The  conventional  room; had  a room temperature of 24° C;  overhead was  d e l i v e r i e s took place  fluorescent  used.  lights.  The cord was  i n a delivery  and were l i t w i t h  Standard  sterile  draping  cut w i t h i n 60 seconds of d e l i v e r y ,  the baby was wrapped i n a blanket and returned to the mother. No  p a r t i c u l a r a t t e n t i o n was  given  to  sound l e v e l s .  All  d e l i v e r i e s were conducted w i t h an "equally gentle" approach (undefined). Their r e s u l t s f a i l e d to f i n d any c l e a r cut advantages of  the  the  iLeboyer;  Lkeboyer  first  stage  t h i s may  method.  group had labours  They d i d f i n d statistically  that mothers i n  significant  than those i n the  shorter  c o n t r o l group  —  have been a placebo e f f e c t since these p a t i e n t s  were using  a  expectation  of a l a t e r p o s i t i v e experience and a decreased  length  of  new  the  technique  first  and  stage of  a s s o c i a t i o n between  labour  i s consistent  the,  with  the p o s i t i o n that p s y c h o l o g i c a l f a c t o r s influence the p h y s i c a l progress no  of  labour  statistically  the  second  the  two  stage  groups.  (Newton, 1977).  significant nor  i n the  However, they found  d i f f e r e n c e i n the number of  There were no  length  of  interventions  in  statistically  significant  d i f f e r e n c e s i n e i t h e r maternal or i n f a n t morbidity.  Dif-  ferences  i n the mother's  b i r t h experience One was  s a t i s f a c t i o n w i t h the  were a l s o not s t a t i s t i c a l l y  of the explanations  significant.  o f f e r e d f o r these  results  that no d i f f e r e n c e s were found i n behavioural outcomes  because  only  methods  of d e l i v e r y since  use  reported  minimal  d i f f e r e n c e s were found between the the i n s t i t u t i o n  o f a "gentle management"  of the second stage. tional" by the  (undefined)  supports the  i n t h e conduct  They conclude that a "gentle conven-  d e l i v e r y can produce s i m i l a r outcomes as achieved Leboyer approach.  Rosenberg e t a l (1981) i n v e s t i g a t e d the d i s t r i b u t i o n of  complications  o f labour  women who had uncomplicated  and d e l i v e r y among pregnancies  healthy  (defined as one  f o r which n e i t h e r a complication of pregnancy nor a pree x i s t i n g disease was noted on the b i r t h c e r t i f i c a t e ; ) . They examined  240,000 b i r t h  certificates  filed  with  the New  York C i t y Department o f Health during a three year p e r i o d . They found of  21.0 percent  a labour  and d e l i v e r y complication  i n a group o f apparently  rate  healthy women  w i t h no known p r e n a t a l complications which was consistent with  f i n d i n g s reported  by Nesbitt  (1969),  Hobel  (1973),  and Sokol (1977) i n l a r g e - s c a l e c l i n i c a l s t u d i e s . The  rates  of recorded  complications  o f labour and  d e l i v e r y were found t o vary considerably among age, marital, subgroups.  educational,  medical  s e r v i c e and p r e n a t a l  race, care  However, they d i d f i n d that the recorded com-  plications  o f labour  uncomplicated  and d e l i v e r y  antepartum  courses  following  more  apparently  frequently  among  women who had i n i t i a t e d p r e n a t a l care e a r l i e r i n pregnancy, among p r i v a t e p a t i e n t s , white women, married women, b e t t e r educated women and women i n t h e i r l a t e twenties, compared w i t h younger mothers. differences  Among t h e i r explanations  were: p a t i e n t s  i n higher  gories r e c e i v i n g more aggressive in  an i n c r e a s e i i n medical:,  f o r these  socioeconomic  cate-  o b s t e t r i c a l care r e s u l t i n g  and s u r g i c a l  interventions;  anatomic v a r i a t i o n s among the races r e s u l t i n g i n d i f f e r e n t incidence of cephalopelvic d i s p r o p o r t i o n , which could account f o r a lower incidence  of complication  i n non-whites; and  d i f f e r e n c e s due t o the p o s s i b i l i t y of i a t r o g e n i c f a c t o r s . Summary. The systems the  acid  adjustments occurring  i n respiratory  during  pregnancy  and  cardiovascular  and t h e i r  base metabolism have been  clearly  a f f e c t on documented.  However, the documented e f f e c t s o f these changes on the woman and her dependent fetus during are  less clear.  The few studies  labour and d e l i v e r y  i n this  area i n d i c a t e  that the use o f prolonged bearing down accompanied by breath holding (Valsalva maneuver) has i m p l i c a t i o n s f o r the c a r d i o vascular system causing pressure  which  i n turn  dramatic f l u c t u a t i o n s i n the blood a f f e c t the a c i d base metabolism  of the woman i n c h i l d b i r t h .  A number o f studies have demon-  s t r a t e d that w i t h prolonged bearing down and breath holding  the blood flow, and subsequently ing the fetus i s decreased.  the amount o f oxygen reach-  This i n turn creates the po-  t e n t i a l f o r f e t a l hypoxia and f e t a l a c i d o s i s . The  studies  reviewed  reveal  conflicting  opinions on  the conduct o f the second stage.  Although there i s a com-  plex  variables  i n t e r a c t i o n betweeni/multiple  frequency stage,  and a  of contractions, length of second  p o s i t i o n f o r d e l i v e r y and the length and type of  pushing more  and duration  i n c l u d i n g the  effort,  flexible longer  longer  i n general, management  those  ( i . e . allowing  approach t o second  second stage  studies  stage),  advocating  a more  a  'gentle'  demonstrated  that  i s not n e c e s s a r i l y associated w i t h  an increase i n maternal o r f e t a l morbidity.  unless contra-  i n d i c a t e d by maternal  and f e t a l complications at the s t a r t  of the second stage  o f labour, a woman's own desires and  r e f l e x e s i n pushing should be supported by her attendants.  P r e n a t a l Class Preparation f o r Second Stage Labour The  results  of studies such as those  done by Benyon  (1957) and Caldeyro-Barcia (1979) have supported the p h i l o s o phies o f c h i l d b i r t h educators E l i z a b e t h Noble i n t h e i r pregnant  women f o r second  encouragement as  such as S h e i l a K i t z i n g e r and  advocacy that the preparation of stage  o f a c t i v e pushing  labour  change from the  w i t h the breath  long as p o s s i b l e during second stage  held f o r  contractions, t o  one  of teaching the woman t o t r u s t and work w i t h her body  in  'listening'  t o the c o n t r a c t i o n s .  Their philosophy and  the  philosophy  adopted  one  of allowing  by many c h i l d b i r t h  the amount of e f f o r t  educators i s  required  f o r each  c o n t r a c t i o n and the timing of that e f f o r t t o be d i c t a t e d by the uterus  itself.  " I t i s commonly a matter o f s t r a i n i n g and pushing t o force the baby down through the b i r t h canal, a process during which the women go r e d i n the face, when t h e i r neck muscles stand out r i g i d and hard, and when they puff and grunt w i t h t h e i r desperate a t tempt t o push the head a l i t t l e lower (With) attempts of t h i s k i n d t o accelerate the second stage...the woman q u i c k l y becomes exhausted and loses her a b i l i t y f o r neuromuscular awareness and control...She f o r f e i t s the capacity f o r acute s e n s i t i v i t y , p a r t i c u l a r l y o f the area around the b i r t h canal i t s e l f and on the perineum, so that she i s incapable o f the d e l i c a t e adjustment necessary t o allow the baby t o be eased out s l o w l y and gently, rather than t o be prop e l l e d l i k e a cork out o f a champagne b o t t l e . " ( K i t z i n g e r , 1977, p.231) Because not a l l second stage contractions are a l i k e , some a r e powerful,  others gentle, K i t z i n g e r  a woman who has been taught t o t r u s t  advocates that  and work w i t h her  body instead o f f i g h t i n g and denying i t , can respond appropriately  t o the d i f f e r e n t  support t o do so. Instead with  the urge  each  altogether.  contractions  i f given  emotional  Rarely i s any contraction " a l l push". t o bear down comes i n d i f f e r e n t  contraction, She s t a t e s  sometimes  missing  a  waves  contraction  that f o r a great part of the second  stage contractions i n many labours, p a r t i c u l a r l y i n primiparous  deliveries,  the woman wants t o push, and w i l l  down spontaneously.  Kitzinger  bear  advocates that i n the second  stage the woman: "meets her c o n t r a c t i o n w i t h slow, steady breathing,., meanwhile concentrating on the wave of the c o n t r a c t i o n , and w a i t i n g f o r i t t o b u i l d up. As i t becomes more powerful and i m p e l l i n g , she moves up t o a quicker, shallower breathing, u n t i l she i s doing mouth-centered breathing. The surge o f des i r e t o bear down comes towards her, and she a u t o m a t i c a l l y f i n d s h e r s e l f breathing rather more r a p i d l y , w i t h more pronounced, but not heavy, r a p i d breathing. Suddenly her breath i s h e l d - i n v o l u n t a r i l y as the urge t o bear down becomes.overpowering. She holds her breath a t t h i s p o i n t , her l i p s parted, jaw relaxed as she continues t o hold her breath, head i n c l i n e d forward on her chest, arms and shoulders relaxed, "leaning" on the contract i o n as she does so, and a l l o w i n g the beari n g down movement t o pass down through the uterus u n t i l the vagina opens up. As soon as the surge recedes she returns t o mouth-centered breathing, w a i t i n g f o r the next surge, holds her breath again when the urge reaches i t s peak, and so on. In t h i s way she can bear down w i t h out s t r a i n i n g two o r four times w i t h each cont r a c t i o n .... r e t u r n i n g t o the slower deeper ' r e s t i n g breath' a t the end o f the c o n t r a c t i o n . " ( K i t z i n g e r , 1977, p. 237) Noble (1976) u t i l i z e s the theory of Witzig-Boldt (1972) and  has as her key theme  "exhalation during e x e r t i o n " .  The  emphasis i s on r e l a x a t i o n and breathing which provides  consistency through the e n t i r e preparatory and labour experience.  This philosophy i s never reversed t o accommodate  t e n s i n g the body and holding the breath during the d e l i v e r y phase.  She advocates the use of forced exhalation during  the second stage of labour a l l o w i n g the abdominal muscles to work s t r o n g l y against r e s i s t a n c e .  She s t a t e s :  "The mother pushes out the baby w i t h her exhaled breath, t y p i c a l l y a grunt or a groan; p a r t i a l c l o s u r e of her g l o t t i s breaks her breath. Her abdominal musc l e s shorten most e f f e c t i v e l y on outward breath, and draw i n , p r e s s i n g on the uterus i n the way that toothpaste i s squeezed from a tube. I f a mother labours w i t h i n s i g h t , then her body can work e f f e c t i v e l y without undue e x e r t i o n . Instead of using f o r c e f u l techniques that consume energy, the mother can r e l a x and wait f o r her baby t o lead the way." (Noble, 1983, Forced  e x h a l a t i o n i s provided  p.83)  i n the  throat by  partial  closure of the g l o t t i s and i s heard i n the form of spontaneous  grunts  and  (Noble, 1978).  groans,  "the noise of work, not p a i n "  Only when a i r i s released from above ( f o r -  ced exhalation) i s s t r a i n avoided and the perineum allowed to r e l a x and s t r e t c h . McKay (1981) reviewed the t r a d i t i o n a l methods employed for  the conduct  of second  stage labour and a l s o advocated  Witzig-Boldt's p r i n c i p l e s of the exhale breathirigc technique. With  this  type of breathSmgg r a p i d  dramatic  fluctuations  i n blood pressure and cardio-vascular dynamics are minimized and  normal oxygen-carbon d i o x i d e exchange i s maintained.  Using the p r i n c i p l e s of f o r c e d e x h a l a t i o n : "a woman begins each c o n t r a c t i o n by s e t t i n g the thorax and abdominal muscles w i t h a h e l d breath. This i s followed by a slow prolonged e x h a l a t i o n through pursed l i p s . During the next i n h a l a t i o n of a i r , which u s u a l l y occurs spontaneously i n f i v e t o s i x seconds, the thorax and abdominal muscles w i l l continue t o stay f i x e d , thus preventing r e t r a c t i o n of the f e t u s . " ... -,mr>\ (McKay, 1981, p.1019)  Another advocates  childbirth  educator,  Penny  Sirtpkin  (1981)  a few general p r i n c i p l e s when teaching expectant  parents about the conduct o f second stage.  These include:  1.  the importance o f r e l a x i n g the perineum;  2.  the importance  o f responding t o her own urges,  bearing down when, and f o r as long as her body demands i t ; and 3.  the importance o f the need t o stop pushing during 'crowning' of the f e t a l head.  She let  states  that  "women need t o know that they may  out a i r during pushes.  They may make a noise.  They  may h o l d t h e i r breath f o r a few seconds, and they may change positions". of  She b e l i e v e s that w i t h t h i s good understanding  what t o expect, and w i t h support f o r t h e i r spontaneous  pushing s t y l e s , some women w i l l bear down using a V a l s a l v a maneuver  (rarely  lasting  over  s i x seconds);  some women  w i l l use the forced e x h a l a t i o n technique, l e t t i n g out a i r and shortening the abdominal muscles.  Rarely w i l l a woman  spontaneously use the prolonged V a l s a l v a maneuver. The ICEA,  International  (1982) had a l s o  Childbirth reviewed  Education  Association,  the l i t e r a t u r e regarding  the management o f second stage labour i n respect t o mate r n a l breathing techniques t o be used during c o n t r a c t i o n s . They a l s o advocated a gentler approach t o the second stage with  the woman u t i l i z i n g  gravity  t o the best  advantage  and bearing down when and as long and as s t r o n g l y as each  contraction i t s e l f d i c t a t e s . The Health  philosophies  of the B r i t i s h Columbia  Department and the Metropolitan  Provincial  Vancouver Health  Department are a l s o based on the studies p r e v i o u s l y reviewed. In The P e r i n a t a l F i t n e s s Manual, the breathing  techniques  and r a t i o n a l e are explained as f o l l o w s : 1)  Make  yourself  shoulders  comfortable  with  your  head and  elevated, knees bent and apart, p e l v i c  f l o o r relaxed. 2)  Take a cleansing breath at the s t a r t of the contract i o n ; then w i t h c h i n forward, mouth and jaw r e laxed, take a moderate breath i n .  3)  With you  legs push  apart,  s l o w l y release the breath as  down through your vagina  using  your  abdominal muscles. 4)  Repeat as needed through the c o n t r a c t i o n .  5)  Take  s e v e r a l cleansing breaths  and r e l a x back  gently as the c o n t r a c t i o n ends. These breathing you  techniques  are recommended f o r use when  have the urge t o bear down and the doctor asks you  to push. In the second stage of labour i f your baby i s being born too q u i c k l y , a panting breath  helps  t o c o n t r o l the  urge t o push, gives the perineum time t o s t r e t c h f u l l y , and  allows the baby's head t o come gently.  technique  The breathing  which may be used at t h i s stage of the d e l i v e r y  i s described as f o l l o w s : 1)  P o s i t i o n as f o r pushing breath.  2)  With head back and mouth open, pant l i g h t l y and b r i s k l y through c o n t r a c t i o n .  3)  Avoid tensing your abdominal muscles and continue your p e l v i c f l o o r r e l a x a t i o n .  A l l of the women p a r t i c i p a t i n g i n t h i s study and who had attended p r e n a t a l c l a s s e s , had been taught breathing techniques f o r the second stage of labour based on the p h i l o s o phies  advocating  techniques.  the "spontaneous"  o r "exhale"  I t i s on the u t i l i z a t i o n of these  pushing  techniques  that many of the l a t e r comparisons and comments are made.  Investigations Regarding Consumer S a t i s f a c t i o n w i t h Care Given During Labour In recent years a l i m i t e d number of consumer surveys on  s a t i s f a c t i o n w i t h maternity care have been  conducted.  Generalizations from t h e i r  f i n d i n g s i s often l i m i t e d due  to  used,  the sampling  technique  the emphasis on narrow  concepts of the woman's experience, o r p h y s i o l o g i c a l i n d i c a t ors of d i f f i c u l t y i n b i r t h (pain tolerance, length of labour, complication r a t e s o r medication. used). 1974;  Scaer e t a l , 1978; S u l l i v a n e t a l , 1981; and Pridham  et a l , 1983).  Almost a l l of the studies report a g e n e r a l l y  p o s i t i v e e v a l u a t i o n of care. (1981  (Nunnally e t a l ,  However, S u l l i v a n and Beeman  and 1982) report t h a t methodological  problems  such  as  the f o l l o w i n g are inherent  i n measuring  satisfaction  w i t h maternity care: 1.  P a t i e n t s are r e l u c t a n t t o c r i t i c i z e t h e i r care-givers,  e s p e c i a l l y i n o b s t e t r i c a l care.  The a r r i v a l of a healthy  baby can overshadow negative experiences and create a favourable  environment  f o r subsequent  evaluations o f the care  received (the opposite might a l s o be t r u e ) . 2.  A inpatient's s a t i s f a c t i o n w i t h care i s based on h i s  or her perception of s e v e r a l dimensions of caregiver conduct  and communication.  D i Matteo and Hay's (1980) r e s -  earch has shown that t e c h n i c a l competence, emotional  support  and communication are h i g h l y c o r r e l a t e d and that a p a t i e n t ' s perception by  of t e c h n i c a l competence i s influenced l a r g e l y  the other measures of rapport.  feelings  that  the medical  staff  These measures include communicated w i t h  them  (exchanged information that they could understand) as w e l l as  cared  about them as people  (showed warmth and compas-  sion) i n the medical care envounter. 3. by  In s p i t e popular  of the a t t e n t i o n given  magazines  and i n d i v i d u a l  t o maternity  care  groups, many women  do not perceive that a l t e r n a t i v e s e x i s t i n t h e i r own maternity and  care. direct  Want?—The  Most are dependent on caregivers t o advise them. Question  Riley  (1977) looked at "What Do Women  of Choice  i n the Conduct of Labour"  and found from h i s ethnographical research that o n l y minimal information  i s given t o maternity p a t i e n t s about options  a v a i l a b l e t o them.  What may appear as the expression of  f r e e choice may not be when the r e a l a l t e r n a t i v e s are considered  and the circumstances  i n t o account.  o f the d e c i s i o n are taken  For example, i f only a few women object  to  remaining  flat  on t h e i r  backs during labour, but i f  it  i s a l s o c l e a r that t h i s i s an i n e f f i c i e n t p o s i t i o n f o r  labour, then there i s every reason t o o f f e r everyone a l t e r n ative  and b e t t e r p o s i t i o n s ,  only  regardless of the f a c t  a m i n o r i t y of the women may have complained  t h i s aspect o f care.  This  analogy  may  also  that about  be a p p l i e d  t o other p r a c t i c e s i n o b s t e t r i c a l care; f o r example, r o u t i n e e l e c t r o n i c f e t a l monitoring, withholding of f l u i d s , i n t r a v e n ous  fluid  administration routinely,  episiotomy,  and the  extended breath holding V a l s a l v a technique often used during second stage o f labour.  These expressions o f p a t i e n t p r e f -  erences are d i r e c t e d towards wider options and an extension of  general  humanitarian  treatment.  w i t h maternity care was noted  Patient disaffection  as long ago as 1961 when  a B r i t i s h p u b l i c a t i o n Human Relations i n O b s t e t r i c s acknowledged  the existence of d i f f i c u l t y  conclusion  o f that  investigation  u n i t s should be planned  i n this  field.  The  was that new maternity  t o be as f l e x i b l e as p o s s i b l e so  that consideration can be given t o the mother's wishes. Danziger  (1979) looked at the content  and s t y l e o f  i n t e r a c t i o n between s t a f f members and p a t i e n t s .  The data  were d e r i v e d from conversations during labour and examined  for<congruence versus  conflict  of i n t e r e s t s between the  labouring women and the s t a f f experts represents the  a series  o f work r o u t i n e s .  obstetricians, family  patients  and t h e i r  in  practioners,  partners  over a nine month period. 1.  f o r whom c h i l d b i r t h I n t e r a c t i o n s of and nurses  were observed  with  and recorded  The f i n d i n g s showed:  There was a major theme i n provider-patient i n t e r a c t i o n the medical p r o f e s s i o n a l ' s  attempts t o assert c o n t r o l  over the s o c i a l process o f labour.  Apart from those com-  p l i c a t i o n s needing r a d i c a l i n t e r v e n t i o n there are a v a r i e t y of  drug options,  nursing  assessment technologies,  s t a f f p r o t o c o l s , monitoring and and supportive  and coaching tech-  niques that can be used throughout c h i l d b i r t h . found  that  the p a t i e n t s were not u s u a l l y presented  these treatment choices. gesic  aids  The author  Despite  with  the wide range o f a n a l -  and techniques f o r the s t i m u l a t i o n o f labour  that can d r a m a t i c a l l y a f f e c t the q u a l i t y of the labouring experience,  the author observed l i t t l e v a r i a t i o n from one  case t o the next i n the s t y l e and content o f i n t e r a c t i o n s between s t a f f members and p a t i e n t s . 2.  Danziger a l s o found that i n r e l a t i o n t o the communica-  t i o n between caregiver interaction a The  and p a t i e n t , c o n s t r a i n t s upon the  appear mutual  negotiation guidelines  yet they d i d not evolve  of the normative r u l e s  from  of the s i t u a t i o n .  f o r conduct a r e taken as preconceived f o r  i n d i v i d u a l p a t i e n t s by both p a r t i e s w i t h s t a f f making assump-  t i o n s about the categories of needs of b i r t h i n g women that f i t t h e i r conceptions of t h e i r own work. directed and  themselves t o b i r t h i n g  Individual patients  i n their  own p r i v a t e way  t o somehow avoid d i s r u p t i n g the s t a f f .  Neither p a r t y  seemed t o be aware of the extent t o which t h e i r perspectives diverged.  Women who handled contractions  ' q u i e t l y ' were  not i n t e r r u p t e d whereas p a t i e n t s who i n response t o contract i o n s acted out despair and anguish by screaming, w r i t h i n g , or  thrashing  about  l a t t e r behaviour to medical  i n bed were h i g h l y sanctioned.  was viewed as unacceptable  This  and often l e d  i n t e r v e n t i o n , u s u a l l y i n the form of v e r b a l ad-  monishments o f the a d m i n i s t r a t i o n of p a i n - r e l i e v i n g drugs. Among themselves, s t a f f members viewed such p a t i e n t s w i t h h o s t i l i t y o r p i t y f o r "not being able t o t a k e ! i t " . ication  i s not appropriate  may intervene w i t h harsh ient.  I f med-  o r warranted, the s t a f f member  i n s t r u c t i o n s t o quieten the pat-  This type of t a l k suggests t o the p a t i e n t that the  appropriate response t o contractions i s t o remain calm and quiet, presumably because such behaviour r e f l e c t s the a b i l i t y to cope w e l l w i t h the pain of c o n t r a c t i o n s . Danziger  found  conduct were l a i d  that  the r u l e s  with,  The operating norm j u s t i f i e d as r e l e -  vant t o the i n t e r n a l experience upon  birthing  down f o r , r a t h e r than negotiated  individual patients.  more c l e a r l y  f o r proper  of coping, appears t o bear  s t a f f work routines than i t does upon  the experience of c o n t r a c t i o n s .  Patients by and large conform t o and accept these normative constraints  and r a r e l y question  the r u l e s  much l e s s disregard o r v i o l a t e them. their  support  partners  defer  as conveyed,  B i r t h i n g women and  t o the i m p l i c i t  regulations of s t a f f members.  r u l e s and  I t was found that p a t i e n t s  who do not behave i n the expected manner and who openly o f f e r d i s s i d e n t views-:, are t r e a t e d as i f they are v i o l a t i n g accepted norms. variations  When p a t i e n t s made requests f o r non-routine  on procedures,  they  are b a r e l y  acknowledged,  given some vague assurances, then l a r g e l y disregarded. Suspicious reactions t o a doctor's plans f o r i n t e r v e n t i o n are u s u a l l y met w i t h the doctor's h o s t i l e ^ d e c l a r a t i o n of h i s superior a b i l i t y t o judge, based on years of e x p e r i ence.  This c l a s s i c a l use of a u t h o r i t y s t r i p s the l a y per-  son's perspective expert s 1  of any v a l i d i t y  p r i v i l e g e d access  i n comparison t o the  t o information.  The p a t i e n t  i s l e f t w i t h no option but t o conform t o the passive stereotype and place complete t r u s t i n the doctor's autonomy. 5.  Patients  views  frequently  or questioning  refrain  from  the s t a f f .  expressing  their  Throughout the course  of labour, n e i t h e r the s t a f f members nor the p a t i e n t s l e a r n much about  the other's  very  d i f f e r e n t concerns.  While  there may be some exchange of information, the s t a f f sought only minimal information labour; the  and the p a t i e n t s  prognostic  evaluation  as t o the woman's experience of obtained  only bare knowledge of  of t h e i r  labour.  Basically,  the p a t i e n t s ' perception of the s i t u a t i o n remains unexplored, i r r e l e v a n t t o the course o f labour.  I t was as i f the women's  views:; had no e f f e c t upon the p h y s i o l o g i c a l events.  Only  her expressions o f p a i n o r pain tolerance were recognized throughout the labour. Sullivan  and Beeman  (1981 and 1982) surveyed  1900  women who had given b i r t h during a four week p e r i o d . measuring s a t i s f a c t i o n w i t h maternity care they  In  questioned  the women on p r e n a t a l , labour and d e l i v e r y , and post partum care.  The f i n d i n g s on labour and d e l i v e r y care revealed  that the l e v e l of s a t i s f a c t i o n i s p o s i t i v e l y skewed.  How-  ever, the studies found that i t was during t h i s stage of maternity differ  care that the i n d i v i d u a l experiences  greatly.  seemed to^  Some of the u n s o l i c i t e d comments ranged  from the very p o s i t i v e  "the OB s t a f f was e x c e l l e n t " , t o  the negative complaints o f l a c k of a t t e n t i o n , i n s e n s i t i v i t y and  incompetence.  The studies also found that many of  the women o f f e r i n g h i g h l y negative comments s t i l l as  "satisfactory"  the response  t o questions  checked  relating to  o v e r a l l labour and d e l i v e r y care. The care  strong  and l e v e l  a s s o c i a t i o n found between perception o f o f expressed  satisfaction  with  prenatal  care i s a l s o evident w i t h labour and d e l i v e r y care.  Res-  pondents who f e l t that t h e i r caregivers d i d not communicate w i t h them about t h e i r labour and d e l i v e r y experience were more  likely  t o be unhappy w i t h that experience.  They  found  that women do have preferences about how labour and  d e l i v e r y events are managed. things  Their data showed among other  the d e s i r e t o use breathing  niques.  and r e l a x a t i o n  The extent t o which preferences were honoured v a r i e d  depending on the procedure.  For example, the wish f o r a  c h i l d b i r t h coach was honoured f o r 82 percent pondents (dim  requesting  lights,  i t , w h i l e the choice  actually rated their tively,  of the r e s -  o f atmosphere  quiet music, warm shower, etc.) was honoured  f o r o n l y 23 percent o f the respondents.  their  tech-  those labour  Because few women  labour and d e l i v e r y experience nega-  w i t h u n f u l f i l l e d preferences and d e l i v e r y  experience  responded that  was  'satisfactory'  instead o f 'very s a t i s f a c t o r y ' . Sullivan to  criticize  and Beeman a l s o found  that women h e s i t a t e  maternity  explanation f o r the  positive  evaluation  rounding  the a r r i v a l  the  entire  halo.  care  Their  of deficient  care i s the j o y sur-  of a healthy baby which  pregnancy experience  In 1981 they  their  care.  found  legitimizes  and creates a favourable  that a m a j o r i t y o f women s a i d  was s a t i s f a c t o r y  even when t h e i r  caregivers  never explained what they were doing i n labour and d e l i v e r y . An a d d i t i o n a l explanation o f f e r e d i s the more s u b t l e e f f e c t of  s o c i a l i z a t i o n o f women as p o t e n t i a l maternity p a t i e n t s .  With  the r a p i d  1930s, medical  a social  d e c l i n e i n maternal  m o r t a l i t y during the  consensus was created about the r o l e o f  p r a c t i o n e r s as i n t e r v e n t i o n i s t i c  caregivers  with  women as passive with  r e c i p i e n t s o f that care.  This brought  i t a p o t e n t i a l f o r communication problems and the  l o s s o f d e c i s i o n making, which most women t o l e r a t e o r accept as part o f the modern science of o b s t e t r i c s .  The r e s u l t s  of S u l l i v a n and Beeman's survey suggests t h a t : "a more personal, more s a t i s f a c t o r y course of care depends on more a t t e n t i o n (being given) to the i n t e r - p e r s o n a l r e l a t i o n s h i p s between caretakers and p a t i e n t s and greater f l e x i b i l i t y i n c l i n c i c a l procedures. I f caretakers work t o est a b l i s h a good rapport w i t h t h e i r p a t i e n t s , they w i l l be advocates f o r t h e i r p a t i e n t s ' d e s i r e s concerning the management o f labour and d e l i v e r y . " ( S u l l i v a n and Beeman, 1982, p.329) Research Model f o r Observing the C h i l d b i r t h Environment Research  models  that  attempt  to explain  behaviour  and events i n the c h i l d b i r t h environment have been p r i m a r i l y descriptive.  Shaw (1974) focused on labour and d e l i v e r y  as the p h y s i c a l , emotional, and s o c i a l conclusion t o pregnancy.  She focused on the various expecatations and anx-  i e t i e s women have about t h e i r labours.  Others have attemp-  ted c o n t r o l l e d studies (Scott and Rose, 1976; Beck, 1978) focusing  on s p e c i f i c  p r a c t i c e s t o be used by labouring  women, but o f f e r l i t t l e information on the events o f c h i l d birth.  In other s t u d i e s , (Brown e t a l . , 1972; Davenport-  port-Slaek and Baylan, 1975) observations  were  provided  by nurses o r physicians who were p a r t i c i p a n t s i n the care as w e l l as a c t i n g as the observer. Anderson and Standley's  (1977) n a t u r a l i s t i c  observa-  t i o n model o f f e r s a d i r e c t of  childbirth.  approach  t o a detailed  study  Drawn from ethnology t h i s method focuses  on human behaviour i n n a t u r a l s e t t i n g s which are not manipulated  by the researcher.  refined  The observations become more  as the i n v e s t i g a t o r  looks f o r trends i n what i s  observed and e s t a b l i s h e s categories o r events o r behaviours. With  t h i s model, codes are assigned t o behaviours  which  are observed, recording observable features o f the woman's physical state, in  the i d e n t i t y  and i n t e r a c t i o n s  o f persons  the labour d e l i v e r y room, a v a r i e t y o f medical  inter-  ventions and s o c i a l behaviours, and themes o f v e r b a l conversations w i t h the labouring woman. tion  i s the woman i n labour.  The focus of the observaThis model o f c h i l d b i r t h  data c o l l e c t i o n allows f o r p l u r a l i s t i c r e c o r d i n g and analysis,  taking into  account  r a p i d l y changing  s e v e r a l people simultaneously. pective  behaviours o f  I t does not r e l y on r e t r o s -  impressions and i n t e r p r e t a t i o n s  as the s o l e data  source. A schematic  diagram  demonstrating'.;  the r e l a t i o n s h i p s  between t h e p s y c h o l o g i c a l , p h y s i o l o g i c a l and environmental factors  i s shown  i n Figure  I . (Standley and Nicholson,  1980).  This model h i g h l i g h t s data which are provided by  the c h i l d b i r t h instrument'. General  determinants  influencing  coping  outcome are  a)  background and personal c h a r a c t e r i s t i c s ;  b)  pregnancy-related f a c t o r s ; and  Childbirth Environment Stimuli  General  teterminants.  a.  background and personal characteristics  b.  pregnancyrelated factors  c.  p h y s i c a l and s o c i a l environment  Cognitive Appraisal o f . Childbirth  PsychoPhysiological Adaptability a.  psychological perspective  b.  preparation  c.  "supportability"  Outcome I I : Postpartum Childbirth Affect  Outcome I : Childbirth Competence a.  psychological comfort  b.  functional ability  Figure 1. A model of maternal coping during labour and d e l i v e r y and evaluation of the c h i l d b i r t h experience. o  (c)  the p h y s i c a l and s o c i a l environment.  Background and personal c h a r a c t e r i s t i c s serve as resources in  a woman's a b i l i t y  ience.  t o cope w i t h the c h i l d b i r t h  Pregnancy-related  factors  such  exper-  as a f e e l i n g o f  p h y s i c a l o r p s y c h o l o g i c a l w e l l being during pregnancy are important and  social  stress to  f o r the woman e n t e r i n g c h i l d b i r t h . environments are r e f l e c t e d  and support  i n the amounts o f  a woman experiences,  a woman's expectations, behaviour  The p h y s i c a l  and c o n t r i b u t e  and e v a l u a t i o n of  childbirth. The c o g n i t i v e a p p r a i s a l o f c h i l d b i r t h i s the woman's expectations f o r labour and d e l i v e r y . is  an experience  time, plans  Because c h i l d b i r t h  which i s a n t i c i p a t e d over  a period of  can be made f o r coping w i t h that experience.  The psychophysiological a d a p t a b i l i t y component o f the model encompasses coping s k i l l s of the c o g n i t i v e and p h y s i o l o g i c a l kind. tion  The p s y c h o l o g i c a l perspective involves the minimizao f the seriousness o f the c r i s i s  putting  the experience  Preparation information  into  the long-term  for childbirth  techniques  involves seeking relevant  such as breathing and r e l a x a -  that w i l l enable  the woman t o deal w i t h  the ^discomforts o f the labour and d e l i v e r y . ability"  perspective.  i n preparation f o r labour and d e l i v e r y , and  l e a r n i n g s p e c i f i c procedures tion  o f c h i l d b i r t h and  The "support-  component o f a d a p t a b i l i t y i s r e l a t e d t o a woman's  a b i l i t y t o request reassurance and emotional support during her c h i l d b i r t h experience. The  c h i l d b i r t h environment  model focuses  s t i m u l i component of the  on the system, o f influences which  on a woman's behaviour during labour and d e l i v e r y .  impact Aspects  of t h i s component are shown by the nature of the husbandwife  i n t e r a c t i o n and the support and d i r e c t i o n the woman  receives  from others, i . e . h o s p i t a l s t a f f , throughout her  labour and d e l i v e r y experience. Two components complete  the model o f maternal coping  w i t h the b i r t h experience and d i r e c t l y r e f l e c t the labour/ delivery  process.  The c h i l d b i r t h competence  component  i s a woman's a b i l i t y t o c o n t r o l her behaviour and t o a s s i s t i n the d e l i v e r y o f her c h i l d without showing signs o f psychological  distress  or functional  inability.  (Lieberman,  1975). P r e n a t a l factors  and the c h i l d b i r t h experience i t s e l f  c o n t r i b u t e t o the f i n a l component of the model, the post partum e f f e c t .  How a woman f e e l s p h y s i c a l l y and emotionally  immediately a f t e r the b i r t h influences her impression of the c h i l d b i r t h experience. A feedback  loop  i s included i n the model from the  c h i l d b i r t h competence component t o the c h i l d b i r t h environment s t i m u l i .  Because labour and d e l i v e r y are an ongoing  process, a woman's c h i l d b i r t h competence a t any given time impacts  on the behaviours  of those supporting her during  t h i s time, her husband or partner, nurses, and the p h y s i c i a n . The behaviours  o f these people i n turn a f f e c t the behaviour  of the labouring woman. C h i l d b i r t h i s comprised of psychosocial as w e l l as p h y s i o l o g i c a l events. A woman's i n t e r a c t i o n s w i t h other people are i n c r e a s i n g l y seen as c r i t i c a l influences on the psychology and physiology o f a woman's behaviour i n labour and c h i l d b i r t h . " (Standley and Nicholson, 1980 p.19) Using  the c h i l d b i r t h observation instrument,  the i n -  v e s t i g a t o r s p e c i f i c a l l y looked at the r e l a t i o n s h i p between the f o l l o w i n g components of the model: a)  the background  and personal  characteristics;  b) the  c h i l d b i r t h competence; c) the c h i l d b i r t h environment s t i m u l i ; and  d) the preparation  f o r c h i l d b i r t h sought t o a i d i n  coping w i t h the d e l i v e r y s i t u a t i o n . Summary. A review o f the' l i t e r a t u r e reveals considerable documentation on the p h y s i o l o g i c a l changes which have an e f f e c t on  pregnant women. . Cardiovascularoand  ments  are e s t a b l i s h e d by hormonal  r e s p i r a t o r y adjusti n f l u e n c e during the  f i r s t t r i m e s t e r of pregnancy and contribute t o an e f f i c i e n t gaseous t r a n s f e r between maternal This  makes the woman  blood and a l v e o l a r a i r .  i n childbirth  more s u s c e p t i b l e t o  changes i n the blood gas l e v e l s than the non-pregnant woman. The V a l s a l v a maneuver commonly used during c h i l d b i r t h a f f e c t s r e s p i r a t i o n s and puts a s t r a i n on the cardiovascular system  i n c l u d i n g dramatic f l u c t u a t i o n s i n blood pressure. Changes i n the blood pH and CO 2 pressure significant  during  are most  the r e g u l a t i o n of r e s p i r a t i o n  includes  the V a l s a l v a maneuver).  provided  a variety  The studies  (which reviewed  of opionions regarding the c a u s i t i v e  f a c t o r s of hypoxia and fetal;, a c i d o s i s ; i n c l u d i n g a reduction of c i r c u l a t i n g  CO^  (carbon dioxide i n s o l u t i o n ) ;  pro-  longed pushing accompanied by breath holding by the mother; use  o f the d o r s a l recumbent p o s i t i o n ;  and the number of  contractions w i t h a c t i v e maternal bearing down. The review of previous i n v e s t i g a t i o n s revealed c o n f l i c t ing  opinions  and f i n d i n g s on the conduct and length of  the  second stage  and i t s e f f e c t s on the f e t u s .  Many of  the s t u d i e s looked a t the duration of second stage among s p e c i f i c groups or i t s r e l a t i o n t o f e t a l Apgar scores while only  a few (Klock, Benyon, Caldeyro-Barcia, Barnett and  Humenick), examined the e f f e c t s of the breathing techniques used  by the p a r t u r i e n t and the e f f e c t s  outcome.  on the d e l i v e r y  These l a t t e r studies found that a f l e x i b l e manage-  ment ( i . e . longer) of the conduct of second stage was not n e c e s s a r i l y associated w i t h an increased f e t a l or maternal morbidity.  Therefore,  unless  c o n t r a i n d i c a t e d by  fetal  or maternal complications at the s t a r t of the second stage of labour a woman's own desires and wishes should be supported . P r e n a t a l educators  support  the 'spontaneous' approach  to handling the contractions of the second stage o f labour. They recommend that women l i s t e n t o t h e i r body and t o bear down when, and f o r as long as her body demands i t a l l o w i n g the  amount o f e f f o r t  required  the t i m i n g of that e f f o r t itself.  f o r each c o n t r a c t i o n and  t o be d i r e c t e d by the uterus  Other educations a l s o advocate the use of a modi-  f i e d V a l s a l v a maneuver — e x h a l i n g s l o w l y through a p a r t i a l l y closed  glottis  and bearing  down spontaneously  when the  body demands i t . A l i m i t e d number of consumer surveys g e n e r a l l y revealed that women h e s i t a t e t o c r i t i c i z e maternity care. surrounding  The j o y  the a r r i v a l of a healthy baby l e g i t i m i z e s the  pregnancy and c h i l d b i r t h experience and creates a favourable halo regardless o f the type o f care received. An provides  Observation  of the C h i l d b i r t h  the framework f o r t h i s  study  Environment  Model  i n that i t allows  n a t u r a l i s t i c observation of the woman i n labour and those supporting  her during  the c h i l d b i r t h  manipulation o f any o f the events  experience  without  observed.  The research methodology i s presented i n Chapter I I I .  CHAPTER I I I  RESEARCH METHODOLOGY  Overview The  o b j e c t i v e o f t h i s study i s t o describe the breath-  i n g techniques used during the d e l i v e r y experience o f p r i m i parous women i n r e l a t i o n t o t h e i r p r e n a t a l preparation and to  the d i r e c t i o n they r e c e i v e d from  in childbirth.  those  assisting  them  A d e s c r i p t i v e design was s e l e c t e d .  Direct observation o f the d e l i v e r y experience, r e l e v a n t medical  information from  records, and a postpartum  view were used t o c o l l e c t data. oh  the s i t u a t i o n a l  woman's responses,  factors  They provided information  which  interactions  inter-  may a f f e c t with  those  a labouring assisting i n  the b i r t h process, p r e n a t a l preparation, breathing techniques used, and b a s i c medical information. Direct observation of an event does not r e l y on r e t r o spective source  impressions and i n t e r p r e t a t i o n s as the s o l e data  (Deoring and E n t w i s t l e , 1975).  A personal i n t e r v i e w  gives higher response r a t e s than a s e l f - a d m i n i s t e r e d questionnaire  because there i s completion  of t h i s p o r t i o n o f  the data c o l l e c t i o n and underreporting i s reduced et a l , 1975; Aday et a l ,  (Warviac  1981).  This chapter describes the methodology o f t h i s the  research  setting,  sample  selection,  data  study:  collection  development of the data c o l l e c t i o n t o o l s , and data analysis.  Also described are the l i m i t a t i o n s , assumptions and  e t h i c a l considerations of the study. The Research S e t t i n g This study took place i n the Grace H o s p i t a l , a  120  bed t e r t i a r y care f a c i l i t y o f f e r i n g comprehensive p e r i n a t a l services  to  r e s i d e n t s of  B r i t i s h Columbia.  Vancouver  and  the province  of  Grace H o s p i t a l i s the p r i n c i p a l obstet-  r i c a l care and teaching h o s p i t a l i n B r i t i s h Columbia. Although  the h o s p i t a l has been p r o v i d i n g o b s t e t r i c a l  care t o the c i t i z e n s of Vancouver and environs s i n c e 1927, i t r e l o c a t e d t o the new 120 bed f a c i l i t y i n 1982 (Children's, Grace and Shaughnessy H o s p i t a l , 1982).  In 1983,  7356 moth-  ers were d e l i v e r e d (Grace H o s p i t a l , 1983 O b s t e t r i c a l S t a t i s t tics). A.  Labour and D e l i v e r y Procedures Following admission and assessment, expectant mothers are assigned t o i n d i v i d u a l labour d e l i v e r y rooms  which  have  incorporated new  concepts  in  o b s t e t r i c a l p r a c t i c e , such as the use of a combined labour, d e l i v e r y and recovery room, the u n r e s t r i c ted  attendance  persons trically ited  of the  f a t h e r and  other  support  during and a f t e r the b i r t h , modern e l e c operated  b i r t h i n g beds a l l o w i n g unlim-  p o s i t i o n s f o r use  during  the  labour  and  delivery,  and each room being equipped w i t h an  easy c h a i r , shower f a c i l i t i e s and decor t o help provide  a  'home-like  1  atmosphere.  The labour  d e l i v e r y area has 15 d e l i v e r y s u i t e s and i s d i v i ded  into  has  4  two modules.  delivery  The h i g h - r i s k  suites  module,  and manages the labour  and d e l i v e r y o f those women who have been i d e n t i f i ed""  by t h e i r physician  staff  as being  complications and  o r the assessment nursing  'at r i s k '  f o r known o r p o s s i b l e  of t h e i r pregnancy and o r labour  delivery.  The operating theatres  are a l s o  located i n t h i s area. The  study  was conducted  labour  delivery  suites  and i s generally  expected and  module, which  to follow  delivery.  woman could  i n the low-risk has 11 delivery-  used by women who are  a normal course  During  labour  of labour  the status  change from low-risk  of a  to high-risk.  No attempt was made t o exclude these women unless a medical emergency arose where maternal o r f e t a l w e l l being were compromised o r d e l i v e r y was by caesarean  section  prior  t o the commencement  of second stage labour. There  are a large  number o f p r o f e s s i o n a l s  working i n the Labour/Delivery area w i t h  approxi-  mately 150 labour d e l i v e r y room nurses r o t a t i n g  through the u n i t and more than 200 f a m i l y p h y s i cians having p r i v i l e g e s t o d e l i v e r babies there. There  are a l s o  approximately 30  obstetricians  on the h o s p i t a l s t a f f . The  nursing  1  care  i s provided t o p a t i e n t s  using a "primary care" philosophy.  This means  that one nurse i s the main provider o f nursing care throughout each 12 hour work p e r i o d . staff the  nurses primary  are involved nurse  Other  when  relieving for  during break  periods or i f  a nurse has any concerns or questions about her patient.  Assignment  o f nurses t o p a t i e n t s i s  done at the d i s c r e t i o n of the nurse i n charge on that day. The  nurse i n charge i s responsible f o r the  u n i t f o r a p a r t i c u l a r 12 hour work p e r i o d . is  usually  delivery  She  one of the more experienced labour  nurses  and  attempts  t o keep  abreast  of the progress o f a l l the women on the u n i t . She  i s also  available  to assist  staff  regarding any of the p a t i e n t ' s care.  nurses  There i s  a l s o a nurse c l i n i c i a n a v a i l a b l e f o r c o n s u l t a t i o n and teaching at a l l times. of  With the large number  s t a f f working on the u n i t ,  i t was p o s s i b l e  f o r the i n v e s t i g a t o r t o observe many s t a f f members as they r e l a t e d to the b i r t h i n g mother.  S t a f f on the labour d e l i v e r y u n i t also i n c l u ded  Medical  Student  Interns  students) who rotated purpose o f gaining of women during  ( 4 t h year  medical  through the u n i t  f o r the  experience i n the management  labour  and d e l i v e r y .  They com-  p l e t e d p a t i e n t h i s t o r i e s , followed women throughout  the course  o f labour  and p a r t i c i p a t e d i n  the  d e l i v e r y under the d i r e c t i o n o f the f a m i l y  physician o r o b s t e t r i c i a n . Physicians  e n r o l l e d i n a residency  program  i n o b s t e t r i c s were a l s o a v a i l a b l e t o a l l s t a f f on  a consultative  should  the need  o r on an i n t e r v e n t i o n  basis  a r i s e a t any time during the  course o f labour o r d e l i v e r y . Consultant at  obstetricians  were  the d i s c r e t i o n of the f a m i l y  also  used  physician  as  the need arose. Sample S e l e c t i o n S e l e c t i o n of the p a r t i c i p a n t s was based on those who were admitted t o the Grace H o s p i t a l Labour D e l i v e r y between March 16, 1984 and. A p r i l was made t o include the study period.  a l l eligible  21, 1984.  Unit  An attempt  women admitted  during  A sample s i z e of between 40 and 60 p a r t i c i -  pants was desired w i t h equal numbers of prenatal  attenders  and non-attenders i n each group. During the study period 65 o f the 75 e l i g i b l e women  agreed t o p a r t i c i p a t e .  However, due t o complications o f  labour r e s u l t i n g i n d e l i v e r y by caesarean s e c t i o n (during the  first  stage of labour) and d e l i v e r i e s  the observer wasn't present, a f i n a l was obtained —  o c c u r r i n g when  sample o f 50 women  35 p r e n a t a l attenders and 15 non-attenders.  Due t o the large numbers o f women having t h e i r f i r s t baby attending a  p r e n a t a l education  programs  l a r g e r number o f non-attenders  (Robertson, 1983)  could not be r e c r u i t e d  during the a v a i l a b l e study p e r i o d . P a r t i c i p a n t s were r e q u i r e d t o meet the f o l l o w i n g c r i t e r i a : 1)  they in  were  admitted  the 'low-risk'  and d e l i v e r e d Labour D e l i v e r y  their  babies  Unit during  the study p e r i o d ; 2)  they were d e l i v e r i n g t h e i r f i r s t babies;  3)  there was a g e s t a t i o n a l age of at l e a s t 37 weeks;  4)  they were  anticipating  a vaginal b i r t h  on ad-  mission; 5)  they d i d not encounter medical emergencies where maternal o r f e t a l w e l l - b e i n g were compromised;  6)  they were w i l l i n g t o p a r t i c i p a t e f o r the d e l i v e r y observation and the postpartum interview;  7)  i f not E n g l i s h speaking, had access t o an E n g l i s h speaking i n t e r p r e t e r . Data C o l l e c t i o n  Following approval o f the study by the Grace H o s p i t a l  Education  and Research  B r i t i s h Columbia  Committee and the U n i v e r s i t y of  E t h i c s Committee, the D i r e c t o r of Nurs-  i n g and the Co-ordinator of the Labour D e l i v e r y Unit were contacted  by the i n v e s t i g a t o r  t o explain  the study and  arrange an o r i e n t a t i o n t o the u n i t . Sampling 1984  began on a d a i l y  b a s i s between March 17,  and continued u n t i l A p r i l 21, 1984.  Because of the  u n p r e d i c t a b i l i t y of the 'length of a woman's labour' and 'when babies 14  would be born',  t o 16 hours  the i n v e s t i g a t o r  averaged  d a i l y w a i t i n g f o r s u i t a b l e candidates t o  be admitted i n a c t i v e labour and subsequently d e l i v e r t h e i r babies. Arrangements were made t o contact the c l i n i c i a n on duty each time the i n v e s t i g a t o r came i n t o the u n i t . nature and  of the study was explained t o each  primary  care  nurse  encountered  a prospective study p a r t i c i p a n t . taken w i t h the charge patients  meeting  prior  charge  The nurse  t o approaching  Consultation was under-  nurse regarding the s u i t a b i l i t y of  the study  criteria  before requesting  their participation. Upon approaching each e l i g i b l e p a r t i c i p a n t , the i n v e s t i gator explained the nature of the study, answered any questions  and handed out a covering l e t t e r  Subjects,  (see Appendix C).  were informed that anonymity and c o n f i d e n t i a l i t y  of the observations and responses would' be maintained and participation  was voluntary.  I t was a l s o s t r e s s e d that  participants  could withdraw  A signed consent participate.  from the study a t any time.  was obtained from those who agreed t o  (See Appendix C).  I t was stressed that the  presence o f the i n v e s t i g a t o r in' the d e l i v e r y room was o n l y as an observer t o record the events of the b i r t h and a t no  time  would  the i n v e s t i g a t o r  request  the p a r t i c i p a n t  t o a l t e r any events i n her b i r t h plan. All  three  data c o l l e c t i o n  tools  were number  coded  so that names d i d not appear on any of them, preserving the anonymity of the p a r t i c i p a n t s once the data c o l l e c t i o n was. complete.  A separate record was kept o f the names  and corresponding number code. I f consent f o r p a r t i c i p a t i o n was received, information f o r the Medical Record Data Sheet was abstracted from the patient's  hospital  record.  When the p a r t i c i p a n t s  examined by the attending s t a f f the second  were  and determined t o be i n  stage of labour, the i n v e s t i g a t o r entered the  labour d e l i v e r y room, sat at the back o f the room and began recording  the b i r t h  events  using the adaptation o f the  C h i l d b i r t h Observation Instrument  (Anderson and Standley,  1977). For of  the women having a v a g i n a l d e l i v e r y ,  the events  of c h i l d b i r t h continued u n t i l  recording 'crowning',  whereas f o r those women r e q u i r i n g caesarean s e c t i o n , observation  and recording terminated when the d e c i s i o n was made  to do the caesarean s e c t i o n .  Following to  delivery,  the b i r t h i t s e l f was  information  directly  relating  obtained from the h o s p i t a l b i r t h  records t o complete the Medical Record Data Form. The one  participants  or two  were interviewed at t h e i r  days f o l l o w i n g  delivery  using the  bedside, Postpartum  Interview Questionnaire. Development of the Data C o l l e c t i o n Tools The data were c o l l e c t e d u t i l i z i n g three t o o l s : 1)  A C h i l d b i r t h Observation Instrument;  2)  Medical Record Data Form; and  3)  A Postpartum Interview Questionnaire. A.  C h i l d b i r t h Observation Instrument The C h i l d b i r t h  for  data  Observation  c o l l e c t i o n was  Observation  Instrument  an  Instrument  used  adaptation of  the  developed  by  Anderson  and Standley (1977) of the C h i l d and Family Research Branch of the N a t i o n a l I n s t i t u t e of C h i l d Health and  Human The  Development  direct  in  Bethesda,  observation  method  Maryland. was  chosen  because: 1)  the method focuses on  human behaviour  in natural settings. 2)  the s e t t i n g researcher.  i s not manipulated by  the  3)  the method provides a means f o r continual  systematic  data  c o l l e c t i o n of  the observable features of the woman's physical and  state,  the  interactions  identification  of persons  who are  i n the labour d e l i v e r y room, a v a r i e t y of  medical  i n t e r v e n t i o n s and  social  and v e r b a l conversations w i t h the d e l i v e r i n g woman. 4)  i t does not r e l y on r e t r o s p e c t i v e impressions and i n t e r p r e t a t i o n s as s o l e data source.  In  the C h i l d b i r t h  Observation  Instrument  developed by Anderson and Standley (1977) commonly occurring  events  are grouped  into  categories  f o r assignment of codes t o observed behaviours. The  specified  cycles  behaviours  of 30 seconds  are time-sampled  in  f o r observation followed  by 30 seconds f o r recording throughout the observation so  period. that  The recording sheet  10 minutes o f r e a l  i s designed  time, that i s , 10  observe-record c y c l e s , are entered on each sheet. (See Appendix D) The in  observation  labour  define  i s focused  with several indices  her p h y s i c a l  state  on the woman being  i n every  used t o 30  second  interval. a  First,  contraction  the presence o r absence o f  i s recorded.  In a d d i t i o n , the  woman's pattern of breathing and degree of muscular tension as expressed on her face and i n her extremities  are recorded.  range  of a f f e c t  or  V o c a l i z a t i o n s covering  (laughing,  moaning) as w e l l  crying,  a  screaming,  as body movement, q u i e t l y  s t a b l e o r r a p i d , thrashing movement i s recorded. Body;' p o s i t i o n i s a l s o noted f o r each i n t e r v a l , these include l y i n g on her back, on e i t h e r s i d e , standing or s i t t i n g .  These categories are mutually  e x c l u s i v e w i t h one category being coded f o r each interval. The with  second group o f categories are concerned  the extent  medical  and nature  of the s o c i a l and  i n t e r a c t i o n s experienced  by the woman.  In each 30 second i n t e r v a l the proximity of the father,  nurse,  p h y s i c i a n , and any other  i s noted r e l a t i v e t o the labouring woman. proximities contact,  are s p e c i f i e d :  near  her s i d e ,  direct  person Three  face-to-face  and d i s t a n t  from her  on the periphery o f the room. Eight behavioural  categories  are used t o describe the  interations with  the woman.  Four  categories r e f e r t o supportive s o c i a l i n t e r a c t i o n s  conversation,  touching,  o f f e r i n g a comfort  and modeling breathing techniques. al  categories  describe  item  Four a d d i t i o n -  i n t e r a c t i o n s that are  m e d i c a l l y oriented: performance o f a maintenance task,  examination  of medication,  o f the woman, a d m i n i s t r a t i o n  and a t t e n t i o n t o the f e t a l moni-  t o r i n g equipment.  These categories are not mutual-  l y exclusive. For is  Five  i s recorded  categories  neutral being,  and  interval  i n which the woman  involved i n conversation  conversation  two  each  using nine  describe  conversation  the content  categories.  supportive  themes:  o f the  or  fairly  the woman's w e l l  the baby, the r e l a t i o n s h i p between the  people  interacting,  non-delivery  themes.  breathing Four  techniques  categories are  coded when conversations  refer specifically to  medically r e l a t e d topics:  the course of labour,  the  woman's pain,  medical  medication,  procedures.  Again these categories are  not mutually e x c l u s i v e . ded  f o r the notation  and h o s p i t a l o r  A column was a l s o p r o v i of s p e c i f i c  events which  may r e l a t e t o the woman and the course delivery. vation  o f her  A complete d e s c r i p t i o n of the Obser-  Instrument and an example of the record-  ing sheet are given i n Appendix D.  An  adaptation  o f Anderson  Observation  Instrument  the  of c h i l d b i r t h  events  was used  changes made included: ization,  interval coded  i n which  The  and p r o x i m i t y catefrom these  i n the "Notes" column. the category  i n the Event  content  study.  e l i m i n a t i o n o f the v o c a l -  Pertinent d e t a i l s  were recorded  Standley's  f o r recording  i n this  movement, p o s i t i o n  gories.  and  column,  columns For each  "Converse" was  the i n f o r m a t i o n a l  o f the v e r b a l exchange was recorded i f  i t r e l a t e d t o a woman's use o f breathing techniques or  patterns.  Categories  themes r e l a t i n g  g i v i n g conversational  t o breathing patterns  'push f o r an extended time', hold  i t and push',  do so', and other  as  deep breathing adapted  'take a deep breath,  'push as you f e e l the urge  to  the  included:  breathing  o r panting.  Childbirth  patterns  such  An example of  Observation  Instrument  i s given i n Appendix E. A videotape appropriate f o r i n i t i a l t r a i n i n g i n use o f the observation instrument was obtained from the National I n s t i t u t e of C h i l d Health and Human  Development  i n Bethesda,  Maryland.  The  t r a i n i n g tape included an i n t r o d u c t i o n t o n a t u r a l i s t i c observation i n general, and the c h i l d b i r t h instrument  i n particular,  and  demonstrations  of each of the behaviours It  featured  labour,  an  which could be coded.  a c t i o n sequence of a couple  t h e i r nurse and o b s t e t r i c i a n .  in  A sample  coding sheet w i t h the c o r r e c t codes f o r the preceding  30  second observation  i n t e r v a l was  inserted  i n each 30 second i n t e r v a l while the audio continued.  The  vestigator achieved  videotape  until  was  reviewed  b e t t e r than 90%  agreement  w i t h i n each coding category;  s i m i l a r t o the coding accuracy searchers  utilizing  Instrument. B.  by the i n -  the  (Standley  was  of the s t a f f r e -  original and  this  was  Observation  Nicholson,  1980.)  Medical Record Data Form  The medical Record Data Sheet was  constructed  from the P e r i n a t a l Data Sheet and Labour D e l i v e r y Record, which are the the  completed on  Grace H o s p i t a l . delivery  a l l p a t i e n t s at  This data source  observations  and  the  augmented postpartum  i n t e r v i e w information and provided b a s i c information.  medical  No d i f f i c u l t y was expected i n o b t a i n -  ing and recording t h i s information and p r e t e s t i n g was not done. The into  two  pregnancy  medical  record  compoments. and  data  First,  sheet  information on  delivery including  of the pregnancy and  i s divided the  complications  intraparatum p e r i o d , length  of  each  iotomy,  stage  of labour,  laceration,  delivery  type,  epis-  anesthesia and c l a s s i f i c a t i o n  by d e l i v e r i n g p h y s i c i a n . Second, relevant i n f a n t outcomes were abstracted from the Labour D e l i v e r y Record. mation included:  This i n f o r -  b i r t h weight, use o f E l e c t r o n i c  F e t a l Monitoring, Apgar scores and f e t a l d i s t r e s s or abnormalities. C.  (See Appendix G).  Interview Questionnaire P r i o r t o the study, p r e l i m i n a r y arrangements  were made f o r data c o l l e c t i o n . to  be administered  The questionnaire,  by the i n v e s t i g a t o r  form o f a postpartum  i n the  interview was reviewed by  s e v e r a l Community Health Nurses who teach p r e n a t a l classes,  and by s e l e c t e d primiparous  women who  received r o u t i n e p o s t n a t a l v i s i t s by the i n v e s t igator.  The review  was conducted  to establish  the c l a r i t y o f questions which had not been used by other i n v e s t i g a t o r s .  Suggestions f o r r e v i s i o n  were implemented and the questionnaire r e t e s t e d . The p r e t e s t p a r t i c i p a n t s postpartum  were one t o two weeks  and were therefore f u r t h e r from t h e i r  experiences  than  the study  respondents.  though i n f a n t care and feeding were primary cerns the  at t h i s delivery  time,  recall  experience were  Even con-  and perceptions of still  vivid,  and  mothers r e a d i l y discussed them. The  interview  questionnaire  i n t o three s e c t i o n s . on  d e l i v e r y , preceptions  the  usage  labour  divided  F i r s t , there i s information  the woman's medical  present,  was  care during pregnancy and of labour,  o f breathing  and b i r t h  support  persons  techniques  during  experience  and sources o f  p r e n a t a l information. The those  second  s e c t i o n sought  women who attended  education.  This  of  education  prenatal  of the content person  perceived  some form o f p r e n a t a l  classes and a d e s c r i p t i o n  of the classes attended, reasons  support  f o r prenatal  breathing techniques value  from  information included the source  attendance,  attendance,  information  taught  class  and t h e i r  t o the woman during her labour  and d e l i v e r y experience. The naire  f i n a l s e c t i o n of the interview question-  provides  population main  demographic  sampled,  language  information  including  o f communication,  age,  ethnicity,  occupation  educational background of the study The  on the  and  participant.  interview questionnaire i s contained i n Appen-  d i x F.  Data A n a l y s i s Data from the  C h i l d b i r t h Observation  Postpartum Interview Questionnaire  Instrument,  the  and the Medical Record  Data Form were coded using coding forms f o r computer analysis.  The S t a t i s t i c a l Package f o r S o c i a l Sciences was  used  f o r analyses of p r e n a t a l attenders and non-attenders  with  respect to the f o l l o w i n g : 1)  d i f f e r e n c e s i n the d i s t r i b u t i o n of the s e l e c t e d demographic  characteristics  —age,  country  of  origin,  residency i n Canada, language, education and  employ-  ment . 2.  d i f f e r e n c e s i n the  distribution  of data r e l a t e d  to  the breathing patterns used by the study p a r t i c i p a n t s and  the d i r e c t i o n they received from those  attending  the b i r t h . 3.  d i f f e r e n c e s i n the  distribution  of events  which  may  a f f e c t the s t y l e or method of d e l i v e r y — l a b o u r times, anesthesia,  electronic  fetal  monitoring,  complica-  t i o n s and i n t e r v e n t i o n s . 4.  d i f f e r e n c e s i n the d i s t r i b u t i o n of the s e l e c t e d characteristics their  the  preparation  —reason useful'  study f o r and  f o r attendance information,  techniques the  of  labour  at  participants relating perception  the  birth  prenatal classes,  'most  p r a c t i c e of  learned  ( f o r p r e n a t a l attendees), and  of  to  d e l i v e r y experience  breathing  confidence and  for  perception  of that  experience.  Differences  i n sources o f i n f o r -  mation were a l s o examined. 5.  differences reflect  i n the s e l e c t e d i n f a n t outcomes which may  on the conduct of the second stage o f l a b -  our — r e c o r d e d f e t a l d i s t r e s s and Apgar scores. The chi-square t e s t was used t o t e s t f o r d i f f e r e n c e s in  the d i s t r i b u t i o n  of selected c h a r a c t e r i s t i c s .  The s i g n i f i c a n t l e v e l used was p <. .05. Limitations 1)  The sample was l i m i t e d t o women who were d e l i v e r i n g babies when the i n v e s t i g a t o r was on the u n i t .  2)  Due t o the small sample s i z e and the i r r e g u l a r numbers i n each group, differences between the groups may not be detectable.  3)  Because p a r t i c i p a t i o n was voluntary due  a bias may e x i s t  t o the type o f person who agreed t o p a r t i c i p a t e  i n the study. 4)  The information view the  5)  was r e t r o s p e c t i v e  during the postpartum i n t e r and i s therefore  subject t o  l i m i t a t i o n s of s e l f - r e p o r t e d r e t r o s p e c t i v e  Information  c o l l e c t e d during  may  be influenced  has  a healthy  delivery 6)  obtained  the postpartum  by the f a c t  baby and  that  data.  interview  the p a r t i c i p a n t  may temper her views of the  experience.  The f i n d i n g s  o f the study  a population  of labouring women w i t h s i m i l a r l o w - r i s k  characteristics  are generalizable  only t o  7.  Sampling April,  took place during the months of March and  1984, therefore some  seasonal b i a s may have  been present. Assumptions 1)  Participants they  i n the study  obtained  will  report  i n p r e n a t a l education  information  accurately or  w i t h a small degree of e r r o r i n r e l a t i o n t o "own personal knowledge". 2)  The presence will  of the i n v e s t i g a t o r i n the d e l i v e r y room  not i n f l u e n c e the p a r t i c i p a n t  o r the attending  s t a f f i n t h e i r management of the b i r t h experience. 3)  The care given by various s t a f f involved i n a s s i s t i n g in  the c h i l d b i r t h  process  i s representative of the  care provided by a l l s t a f f on the u n i t . E t h i c a l Considerations Written were given  and v e r b a l explanations by the i n v e s t i g a t o r t o a l l subjects  (see Appendix C).  Subjects  were a l s o informed they could withdraw from the study at any time o r refuse t o p a r t i c i p a t e without p r e j u d i c i n g t h e i r present and  o r f u t u r e care at the Grace H o s p i t a l .  c o n f i d e n t i a l i t y of the responses  Childbirth  Observation  Form and the Postpartum  Instrument,  Anonymity  was s t r e s s e d . Medical  Record  The Data  Questionnaire were submitted f o r  e t h i c a l review t o the U n i v e r s i t y of B r i t i s h Columbia Screening  Committee f o r Research  I n v o l v i n g Human Subjects:  Be-  h a v i o u r a l Sciences.  The procedure  of the study, handling  of data t o ensure c o n f i d e n t i a l i t y and the b e n e f i t s , costs and  risks  violate A  t o p a r t i c i p a n t s were c r i t i q u e d and found not t o  the r i g h t s of human subjects. similar  Education  submission  and Research  was made t o the Grace H o s p i t a l  Co-ordinating Committee requesting  permission t o c a r r y out the study Appendix B ) . this  Their l e t t e r  Appendix.  (See Appendix A ) .  i n t h e i r f a c i l i t y (see  o f approval  The study was then  i s included w i t h  c a r r i e d out f o l l o w i n g  approval of these two committees.  Summary In  summary, the research methodology i s described i n  t h i s chapter.  The study took place i n Grace H o s p i t a l , the  major maternity f a c i l i t y cohort  were  women  i n B r i t i s h Columbia.  delivering  their f i r s t  The study babies  con-  sidered t o be 'low-risk' p a t i e n t s and who agreed t o p a r t i c i pate.  Data  collection,  on a d a i l y b a s i s between March:  16, 1984 and A p r i l 21, 1984, was by three data- c o l l e c t i o n tools Record naire. for IV.  - the C h i l d b i r t h Observation Data  Instrument,  Form, and the Postpartum  Data was analyzed  S o c i a l Sciences.  the Medical  Interview  using the S t a t i s t i c a l  QuestionPackage  The f i n d i n g s are presented i n Chapter  CHAPTER IV  STUDY RESULTS Overview The major f i n d i n g s of the study are presented i n four sections.  The f i r s t  section  provides  a d e s c r i p t i o n of  the response r a t e , the demographic c h a r a c t e r i s t i c s regarding preparation f o r c h i l d b i r t h .  The second  section  des-  c r i b e s the d e l i v e r y experience o f the study p a r t i c i p a n t s : s e l e c t e d events which may a f f e c t delivery  and breathing patterns used  t h e i r r e l a t i o n t o those events.  by the women, and  The t h i r d s e c t i o n describes  infant  outcomes which may r e f l e c t  second  stage.  fidence  the method or s t y l e of  on the conduct  of the  F i n a l l y , the f o u r t h s e c t i o n describes con-  levels; arid perceptions of the d e l i v e r y  retrospectively.  experience  Findings are summarized at the end of  each s e c t i o n . The study  participants  who had attended  were  classified  into  p r e n a t a l c l a s s e s during t h i s  those  pregnancy  and those who had not attended any formal c l a s s e s as defined. Prior  t o the study,  attendance was defined as being  present a t one-half or more of the c l a s s e s o f f e r e d i n the prenatal were  series.  Prenatal instructors  consulted and a l l i n d i c a t e d  from  four groups  that at l e a s t  one-half  of the s e r i e s must be attended t o provide an adequate l e v e l  of preparation f o r the d e l i v e r y experience. was  from  A usual s e r i e s  5 t o 10 classes w i t h the average  number being  about 7 classes i n a s e r i e s . Of  the 50 study p a r t i c i p a n t s , '35 (70%) had attended  p r e n a t a l c l a s s e s and 15 (30%) d i d not have formal p r e n a t a l education as defined; of those 2 had attended some classes but d i d not f u l f i l the c r i t e r i a f o r the study. class  attendance was the primary independent  Prenatal  variable of  i n t e r e s t i n the study and the a n a l y s i s w i l l focus on t h i s .  D e s c r i p t i o n o f the Sample Response Rate An  attempt  delivering  was made t o include a l l e l i g i b l e women  during the study observation p e r i o d .  Of the  p o s s i b l e 75 women e l i g i b l e , 65 agreed t o p a r t i c i p a t e g i v i n g a response  r a t e o f 86.7%.  As shown i n Table 4-1, i n 9  (12%) o f the cases the p a r t i c i p a n t r e q u i r e d medical i n t e r vention by caesarean s e c t i o n p r i o r t o e n t e r i n g the second stage of labour.  These women were not followed postpartum,  nor were they included i n the study r e s u l t s . A f u r t h e r 6 (8%) were e l i m i n a t e d because they d e l i v e r e d when the observer was not present. 1)  co-inciding  deliveries  Reasons f o r t h i s include: of study  participants;  and 2)  d e l i v e r i e s when the observer was not present.  Table 4-1 Response Rate and Reasons f o r Non-Participation  Total e l i g i b l e women  Absolute Frequency  % of T o t a l Sample  Total e l i g i b l e  75  100.0  Study P a r t i c i p a n t s  50  66.7  10  13.3  Reasons f o r nonparticipation : 1)  patient declined  2)  required caesarean section p r i o r to second stage  9  12.0  3)  d e l i v e r e d when observer not present  5  6.7  4)  coinciding deliveries  1  1.3  75  100.0  Total:  •  Residence of the Study P a r t i c i p a n t s The d i s t r i b u t i o n of residence f o r the 50 study p a r t i c i pants i s presented i n Table 4-2.  Table 4-2 Residence of the Study P a r t i c i p a n t s Area of Residence  Vancouver C i t y  Prenatal Attenders  Non Attenders  8 of T o t a l Sample  No.  No  No.  (%)  (73.4) (28)  (56)  (%)  (17) (48.5)  (ID  (%) •  Burrard Unit  4  11.4  3  20.0  7  14.0  West Unit  3  8.6  -  -  3  6.0  Mid-Main Unit  1  2.8  1  6.7  2  4.0  North Unit  5  14.3  6  40.0  11  22.0  East Unit  1  2.8  1  6.7  2  4.0  South Unit  3  8.6  -  -  3  6.0  Richmond  2  5.7  1  6.6  3  6.0  Bumaby  9  25.7  1  6.7  10  20.0  North Vancouver  3  8.6  -  -  3  6.0  West Vancouver  1  2.9  -  -  1  2.0  _3  8.6  _2  13.3  _5  10.0  35 100.0  15  100.0  50  100.0  Other  3  Total: a  l n c l u d e s Surrey, Coquitlam and New Westminster.  Maternal Age For the p r e n a t a l attenders the mean age was 28 years (the median 29 y e a r s ) ; whereas the mean age (as w e l l as the median age) was 26 years f o r the non-attenders.  As  shown i n Table 4-3, e i g h t y percent (80%) of the non-attenders were between the ages of 21 and 30 years whereas the p r e n a t a l attenders  tended  t o be s l i g h t l y o l d e r , w i t h 80% between  the ages of 26 and 36 years.  Table 4-3 Ages o f the Study P a r t i c i p a n t s  Age (Years)  Prenatal Attenders  Non Attenders  % of T o t a l Sample  No.  No.  No.  (%)  (%)  (%)  20 and under  2  5.7  1  6.7  3  6.0  21 - 25  5  14.3  5  33.3  10  20.0  26 - 30  18  51.4  7  46.7  25  50.0  31 - 35  8  22.9  2  13.3  10  20.0  36 - 40  _2  5.7  —  —  _2  4.0  35  100.0  15  100.0  50  100.0  Total:  Country of O r i g i n Table  4-4  significant  gives  the country  d i f f e r e n c e i n the  born i n Canada, the United other c o u n t r i e s :  of o r i g i n ;  there was  study p a r t i c i p a n t s who  were  States or England compared t o  of those who attended a p r e n a t a l education  program the majority, 27  (77.1%) were born i n Canada, the  United States or England, whereas only 1 (6.7%) of the attenders  who  a  participated  i n the  study was  non-  born i n  one  2 of these three countries ( X ^ ) i t y c d f the non-attenders  =  18.3, p 4..001).  group were from one  The major-  of the Asian  countries. Table  4-4  Country of O r i g i n of the Study P a r t i c i p a n t s Country  Prenatal Attenders  Non Attenders  % of T o t a l Sample  No.  (%)  No.  No.  (%)  27  77.1  1  6.7  28  56.0  Philippines  2  5.7  3  20.0  5  10.0  Hongkong  2  5.7  2  13.3  4  8.0  Vietnam  -  -  3  20.0  3  6.0  -  -  3  20.0  3  3.0  •A  11.5  JS  20.0  _1_  14.0  100.0  15  100.0  50  100.0  Canada, United States, England  China Other  3  Total: a  35  (%)  I n c l u d e s Burma, Czechoslovakia, Holland, I n d i a , Indonesia, Japan and Switzerland.  Length of Residency i n Canada Twenty-four i n Canada.  (48%) of the study p a r t i c i p a n t s were born  Others i n the sample had l i v e d i n Canada from  one month t o over 15 years.  There was a s i g n i f i c a n t d i f -  ference i n those who had r e s i d e d i n Canada longer than 10 years being more l i k e l y t o have attended p r e n a t a l 2  classes  (X (J) = 16.8, p < .001) as evidenced i n Table 4-5.  Table 4-5 Length of Residency i n Canada Length (Years) Prenatal Attenders  Non Attenders  % of T o t a l Sample  No.  (%)  No..  (%)  No.  1 year or l e s s  1  2.9  2  13.3  3  6.0  2-5  4  11.4  10  66.6  14  28.0  2  5.7  1  6.7  3  6.0  1 1 - 1 5 years  3  8.6  1  6.7  4  8.0  16+  2  5.7  -  -  2  4.0  23  65.7  _1  6.7  24  48.0  35 100.0  15  100.0  50  100.0  years  6-10  years  Canadian born Total:  (%)  Language The language best understood by the study p a r t i c i p a n t s (those who had E n g l i s h as the best understood language  com-  2 pared t o other languages) was s i g n i f i c a n t ("X(j_)  15.4, p<.001).  =  E n g l i s h (82%) was predominantly the best understood language of those women attending p r e n a t a l c l a s s e s , whereas Chinese, Philippino, understood  Punjabi or Vietnamese languages  of  (80.1%) were  the non-attenders.  the best  Frequencies  of the best understood languages are shown i n Table 4-6. Table 4-6 Language Best Understood by the Study P a r t i c i p a n t s Language  Prenatal Attenders  Non Attenders  % of T o t a l Sample  No.  (%)  No.•  (%)  No.  (%)  English  29  82.8  3  20.6  32  64.0  Chinese  3  8.5  8  53.4  11  22.0  Philippino  1  2.9  2  13.4  3  6.0  German  1  2.9  -  -  1  2.0  Japanese  1  2.9  -  -  1  2.0  Punjabi  -  -  1  6.7  1  2.0  Vietnamese  —  —  _1  6.7  _1  2.0  35  100.0  15  100.0  50  100.0  Total:  Education Most of the study p a r t i c i p a n t s had Grade 12 or f u r t h e r education  (90%) w i t h 62.9%  and 46.7%  of the non-attender  education:  no  significant  of the p r e n a t a l attender group groups having post  difference  could  secondary  be  detected  2 1«89, p > . l ) .  =  Table 4-7 presents the d i s t r i b u t i o n  of the l e v e l s of education a t t a i n e d by the study group. It  i s of  proportion  interest  to note  that there was  of p r e n a t a l attenders who  had  less  a greater than  grade  12 education (11.4%) than non-attenders (6.6%). Table  4-7  Education Levels of the Study P a r t i c i p a n t s Highest L e v e l of Education  Prenatal Attenders  Non Attenders  Cumulative Total  No.  (%)  No.  No.  (%)  4  11.4  1  6. 6  5  10.0  9  25.7  7  46. 7  16  42.0  Technical T r a i n i n g 4  11.4  4  26. 7  8  58.0  College Diploma  5  14.3  -  5  68.0  13  37.2  _3  20. 0  16  100.0  35  100.0  15  100. 0  50  100.0  Grades  1-11  Grade 12  University Total:  (%)  -  Employment Forty  (80%) of the study p a r t i c i p a n t s were employed  p r i o r t o confinement. (40%) in  o f the p r e n a t a l attenders were a t l e a s t  employed  a semi-professional c a p a c i t y whereas o n l y 1 (6.7%) o f  the non-attenders participants at  As shown i n Table 4-8, f o r t y percent  unskilled  had s i m i l a r  employment.  Of those study  employed 8.6% o f the attenders were employed or semi-skilled  types of employment whereas  40% of the non-attenders were employed i n u n s k i l l e d o r semis k i l l e d jobs, which was s i g n i f i c a n t (•'X^  =  5.84, p <.025).  Type o f P r e n a t a l Classes Attended Of the 35 study p a r t i c i p a n t s who had p r e n a t a l education 23  (65.7%) women attended  Community Health Agencies; and  12  (34.3%) women e n r o l l e d  i n p r e n a t a l programs o f f e r e d by  provate sponsors.  The p r i v a t e l y sponsored c l a s s e s included  those o f f e r e d by: Grace H o s p i t a l , Vancouver C h i l d b i r t h Ass o c i a t i o n and p r i v a t e The lation  curriculum o f the classes was very s i m i l a r i n r e t o the d i d a c t i c  delivery birth.  'midwives'.  information provided on labour and  and breathing techniques  f o r coping w i t h  child-  Table 4-8 Type of Employment of the Study P a r t i c i p a n t s Type; o f Employment  Prenatal Attenders  Non Attenders  % of T o t a l Sample  No.  (%)'.  No.  No.  (%)  11  31.4  1  12  24.0  Administrative personnel, owners o f small i n dependent business , semi-professionals  3  8.6  3  6.0  Clerical, technicians  4  11.4  2  13.3  6  12.0  Skilled  8  22.9  2  13.3  10  20.0  Semi-skilled  1  2.9  5  33.3  6  12.0  Unskilled  2  5.7  1  6.7  3  6.0  Housewife  3  8.5  3  20.0  6  12.0  Student  2  5.7  1  6.7  3  6.0  _1  2.9  —  _  _1  2.0  35  100.0  15  100.0  50  100.00  Executives, profes s i o n a l s and managers  Unemployed Total:  (%)  6.7  For examples of employment r e f e r t o Appendix H. (From Myers, J . and B. Roberts, 1958 p.40)  Reason f o r Attending Prenatal Classes Those study p a r t i c i p a n t s who s t a t e d that they  attended  p r e n a t a l classes during t h e i r pregnancy were asked t o i n dicate.; the most important  reason f o r attending and what  they considered the most u s e f u l information i n the c l a s s e s . Table 4-9 provides the main reasons f o r attending p r e n a t a l classes.  A distinction  was made between r e l a x a t i o n and  breathing exercises and information about the labour and d e l i v e r y process.  Nine p a r t i c i p a n t s (25.7%) gave breathing  and r e l a x a t i o n techniques  as the main reason f o r attending;  24 (68.5%) s t a t e d that information on the labour and d e l i v ery  process was the most important.  gories  represent  prenatal  class  94.2% o f the t o t a l attendance.  Together these catereasons s t a t e d f o r  There was undoubtedly some  overlapping of reasons and when asking f o r the most important reason, not a l l reasons f o r attending are given.  Table 4-9 Main Reason f o r Attending Prenatal Classes Reason f o r Attending  Absolute Frequency  Relative Frequency (%)  Process of Labour and Delivery  24  68.5  Breathing and Relaxation Instruction  9  25.7  _2  5.8  35  100.0  F e t a l Development Newborn Care Other  3  Total:  Includes p h y s i c i a n r e f e r r a l and information on f a m i l y r e l a t i o n s h i p changes w i t h a newborn.  Because the questions were asked soon a f t e r the d e l i v e r y experience, experience.  the r e p l i e s may  have been influenced by t h a t  Most Useful Class Information Prenatal attenders were asked t o i n d i c a t e the information  they found  t o be the most u s e f u l .  No attempt  made t o determine  which  but  p r e n a t a l c l a s s attenders were present  by d e f i n i t i o n  c l a s s e s were a c t u a l l y  was  attended,  at 50 percent o r more. Table 4-10 provides data concerning preferences about the most u s e f u l  information.  One person  able t o s i n g l e out the most u s e f u l  (2.9%) was not  information.  Labour  and d e l i v e r y information together w i t h r e l a x a t i o n and breathi n g techniques accounted f o r 85.7 percent of the responses t o t h i s question. tion for  indicating  This was somewhat l e s s than the proporthese  were  their  attending p r e n a t a l c l a s s e s .  most Two  important  reason  (5.6%) p a r t i c i p a n t s  chose complications of Labour and D e l i v e r y (both r e q u i r e d delivery  by caesarean  s e c t i o n a f t e r being i n the second  stage o f labour f o r a p e r i o d of time); 1 (2.9%) i n d i c a t e d nutrition  and 1 (2.9%)  most u s e f u l c l a s s .  i n d i c a t e d postpartum  care as the  No one mentioned newborn care as being  of prime importance f o r attendance a t p r e n a t a l c l a s s e s .  Table 4-10 Most Useful Information Most Useful Information  Absolute Frequency  Process o f Labour and Delivery  9  Breathing and Relaxat i o n Techniques  21  Relative Frequency (%) 25.7 60.0  Complications o f Labour/ Delivery  2  Nutrition  1  Postpartum Care  1  2.9  _JL  2.9  35  100.0  5.6 2.9  Newborn Care Unable t o name most usef u l information Total:  P r a c t i c e o f Breathing Techniques  Learned  As can be seen from Table 4-11, only 7 (20%) of the participants practised  who  attended  prenatal indicated  they  any of the breathing and r e l a x a t i o n techniques  on a r e g u l a r b a s i s (5 o r more times per week). bined  that  When com-  27 (77.1%) i n d i c a t e d p r a c t i c i n g e i t h e r one t o two  times per week o r not a t a l l .  This i s an extremely high  proportion when compared t o the 60 percent who i n d i c a t e d the  breathing and r e l a x a t i o n  and  that  was  labour and d e l i v e r y  the most u s e f u l  class  information and breathing  techniques together accounted f o r 94.2 percent of the main reasons f o r p r e n a t a l c l a s s attendance.  Table 4-11 P r a c t i c e of Breathing/Relaxation Techniques P r a c t i c e .. (Frequency/Week) :  Absolute Frequency  Relative Frequency (%)  Not a t a l l  16  45.7  Not o f t e n (1-2)  11  31.4  Sometimes (3-4)  1  2.9  Often (5+)  7  20.0  Total:  35  100.0  Attendance of Husbands o r Partners at P r e n a t a l Thirty-four  (97.1%) of those p a r t i c i p a n t s i n the pre-  n a t a l c l a s s e s had e i t h e r t h e i r husbands or a partner accompany them t o a t l e a s t a p o r t i o n of the c l a s s e s : 17 (50%) of  the husbands o r support  prenatal classes;  persons  attended  and 5 (14.7%) missed  a l l of the  one c l a s s i n the  series.  Source o f P r e n a t a l Information The their  study  pregnancy,  participants labour  received  information  about  and d e l i v e r y from many sources.  An attempt was made t o e s t a b l i s h which source was considered the 4-12.  primary  source.  Attenders  These data are presented  chose p r e n a t a l classes as t h e i r  source of information.  i n Table primary  Source of information between the  attenders and non-attenders  varies greatly.  Non-attenders  were more l i k e l y t o i n d i c a t e r e l a t i v e s o r f r i e n d s as t h e i r source of information. This may i n d i c a t e l e s s of a tendency to use outside resources or lack of knowledge of resources available.  Table 4-12 Primary Source o f Information Regarding Pregnancy and D e l i v e r y Source o f I n formation  Prenatal Attenders  Non Attenders  % of T o t a l Sample  No.  (%)  No.  (%)  No.  (%)  Prenatal Classes  25  71.5  -  -  25  50.0  Physician  1  2.8  2  13.3  3  6.0  Relative  -  -  3  20.0  3  6.0  Friend  2  5.7  5  33.3  7  14.0  Books  5  4  26.7  9  18.0  Other  3  Total: Other  14.3  _2  5.7  _1  6.7  _J3  6.0  ;35  100.0  15  100.0  50  100.0  Includes medical t r a i n i n g background, rented films.  Summary: Of  the 50 study p a r t i c i p a n t s ,  35 (70%)  attended  pre-  n a t a l classes o r f u l f i l l e d the c r i t e r i a f o r the study. There  were  significant  differences  n a t a l attenders and the non-attenders. prenatal  classes  attender  (28 versus  United country  States (73.3%)  tended  between  the pre-  The woman attending  t o be s l i g h t l y older than the non-  26 years);  o r England  t o be born  (77.1%),  as opposed t o an Asian  f o r t h e non-attenders;  Canada f o r a longer p e r i o d  i n Canada, the  of time;  t o have l i v e d i n  and t o have  English  as t h e i r main language. While education at the post secondary l e v e l was s i m i l a r the p r e n a t a l attenders had a higher l e v e l of employment. Prenatal classes d i d not reach the non-English  (primary  language) population i n t h i s study even though the m a j o r i t y r e s i d e d i n the C i t y of Vancouver. one-half  On the other hand, over  (51.5%) of the p r e n a t a l attenders  surrounding  lived  i n the  communities but chose t o d e l i v e r at Grace Hos-  pital. The  m a j o r i t y of p r e n a t a l classes are provided by Com-  munity Health Agencies (65.7%). natal  class  delivery  attendance  and breathing  The main reason f o r pre-  i s information  about  labour  and r e l a x a t i o n s k i l l s  and  (94.2%) t o  a i d i n coping w i t h the b i r t h , yet only 22.9% of the p r e n a t a l attenders  p r a c t i s e d any of the techniques  learned — 3 o r  more times per week. The also  diversity  evident  regarding relied while  of the two groups i n the study  i n relation  t o the sources  the pregnancy and d e l i v e r y .  was  of information  Prenatal  attenders  h e a v i l y on t h e i r p r e n a t a l classes f o r information the non-attenders  f a m i l y and f r i e n d s .  obtained  their  information  from  Labour and D e l i v e r y Experience o f the Study P a r t i c i p a n t s The labour and d e l i v e r y experience o f both p r e n a t a l attenders and non-attenders i s described as f o l l o w s : attendance  o f support  electronic  fetal  person;  a n a l g e s i a and anesthesia use;  monitoring; events  o f the second  stage  i n c l u d i n g breathing patterns o f the woman i n r e l a t i o n t o those events.  Attendance o f Support Person All or  o f the study p a r t i c i p a n t s  had a f a m i l y member  f r i e n d present during t h e i r labour and d e l i v e r y exper-  ience.  Five (10%)  more persons  o f the study p a r t i c i p a n t s had two o r  present a t the d e l i v e r y — t h e s e were e i t h e r  f a m i l y members o r f r i e n d s .  Analgesia and Anesthesia Use i n Labour and D e l i v e r y Use o f Analgesia Of the study p a r t i c i p a n t s r e q u i r i n g a n a l g e s i a during the course o f t h e i r labours, 4 (11.4%) women attended pren a t a l classes and 4 (26.7%) were non-attenders.  Use of Anesthesia Seventeen  (48.6%) o f those who attended p r e n a t a l c l a s -  ses r e c e i v e d an E p i d u r a l anesthetic during t h e i r labour/delivery,  2 (5.7%) o f the women were given E p i d u r a l s during  course o f the second stage of labour t o f a c i l i t a t e a forceps  d e l i v e r y ; while o n l y 3 (20%) of the non-attenders an E p i d u r a l during the course of t h e i r labours. women who were d e l i v e r e d by caesarean  received M l four  s e c t i o n a f t e r the  commencement of the second stage o f labour had t h e i r  Epi-  d u r a l anesthesia i n place p r i o r t o the commencement of the second stage.  These data  are shown i n Table 4-13.  (28.6%) of the p r e n a t a l c l a s s attenders  Ten  used Entonox o r  received a Pudendal Block anesthesia. Two  (13.3%) of the non-attenders  i n the study  group  used Entonox or received a Pudendal Block type of anesthesia; One (6.7%) d i d not have any anesthesia.  Table 4-13 E p i d u r a l Anesthesia Use Anesthesia Use  Prenatal Attenders  Non Attenders  % of Total Sample  No.  (%)  No.  (%)  No.  (%)  Had E p i d u r a l  17  48.6  3  20  20  40.0  No E p i d u r a l  18  51.4  12  30  60.0  Total:  35  100.0  15  50  100.0  ~X  J  = 2.5, p  } .1  80 100.0  Non-attenders  delivered 3  (20%)  infants  whose Apgar  score was l e s s than 7; 2 had E p i d u r a l anesthesia and r e q u i r e d d e l i v e r y by e i t h e r forceps or caesarean s e c t i o n .  E l e c t r o n i c F e t a l Monitoring Use  of the e l e c t r o n i c f e t a l monitor  (EFM) was  recorded  i n the Labour/Delivery Record.  Twenty-two (62.9%) of the  prenatal  (20%)  attender  group  and  3  of the  non-attender  group received e l e c t r o n i c f e t a l monitoring during the labour 2 and d e l i v e r y which was s t a t a i s t i c a l l y s i g n i f i c a n t (X^) p <.025). EFM  Thus, p r e n a t a l attenders  p r o p o r t i o n a t e l y more than  =  6-09,  i n the study received  three  times  as f r e q u e n t l y  than d i d non-attenders. The Second Stage of Labour The was  observed  using The  second stage  the  events  presence tions;  and  of  labour of a l l study p a r t i c i p a n t s  observations  time-sampling and  were recorded  approach  behaviours  observed  each minute  p r e v i o u s l y described. and  recorded i n c l u d e :  or absence of c o n t r a c t i o n s ; intrapartum complicai n t e r v e n t i o n s and  e p i d u r a l use;  terns of the woman i n r e l a t i o n  and  breathing pat-  t o the d i r e c t i o n r e c e i v e d  from her caretakers, s e l e c t e d events of the b i r t h and s e l e c ted demographic c h a r a c t e r i s t i c s . Labour times were a l s o recorded.  Uterine A c t i v i t y Table 4-14 r e f l e c t s  the u t e r i n e a c t i v i t y , that i s the  presence or absence of a c o n t r a c t i o n during the observation periods.  Table 4-14 Uterine A c t i v i t y During Observation Uterine Activity  Period  Prenatal Attenders  Non Attenders  % of T o t a l Sample  No.  No.  No.  (%)  (%)  (%)  Contraction/ Both  1095  49.9  446  48.0  1541  48.8  Rest  1138  51.0  482  52.0  1620  51.2  2233  100.0  928  100.0  3161  100.0  3  Total:  Includes observation periods where there i s a u t e r i n e c o n t r a c t i o n and observation periods where both a cont r a c t i o n and r e s t p e r i o d occur i n any p o r t i o n of the time-sampling i n t e r v a l .  The proportion of the observation having for  uterine  time when the women were  contractions was v i r t u a l l y the same—49.9%  the p r e n a t a l attenders  and 48% f o r the non-attenders.  Intrapartum Complications Table  4-15  presents the intrapartum complications ex-  perienced by the study group. that  22  Of s i g n i f i c a n c e i s the f a c t  (62.9%) of the p r e n a t a l attenders were l i s t e d asj.  having experienced a complication whereas o n l y 3 (20%) of the non-attenders were l i s t e d as having an intrapartum complication  (the same proportions that had  EFM).  For  the  t o t a l study population, 25 (50%) of the women were c l a s s i f i e d as having a complication. Table  4-15  Intrapartum Complications Complication  Nil  Attenders  Non Attenders  % of T o t a l Sample  No.  (%)  No.  (%)  No.  (%)  13  37.1  12  80.0  25  50.0  7  20.0  2  13.3  9  18.0  Failure to descend, Forceps r o t a t i o n , CPD, C/S Slow descent i n Second Stage Decelerations of F e t a l Heart Rate  5  14.3  -  -  5  10.0  4  11.4  1  6.7  5  10.0  Meconium s t a i n i n g  2  5.7  2  4.0  Long Labour  1 2 . 9  Other  a  Total: a  - -  -  1  2.0  _3  8.6  _-  -  _3  6.0  35  100.0  15  100.0  50  100.0  I n c l u d e s r a p i d second stage, decreased amount of amniot i c f l u i d , augmented labour and postpartum hemorrhage.  E p i d u r a l Anesthesia and Intervention As tenders  stated previously, and 3  17 (48.6%) of the p r e n a t a l a t -  (20.0%) of the non-attenders r e c e i v e d e p i -  d u r a l anesthesia.  As shown i n Table 4-16, 14 (40.0%) of  the attenders and 2 (13.3%) of the non-attenders a l s o r e quired i n t e r v e n t i o n  ( e i t h e r by forceps or caesarean s e c t i o n )  during the second stage.  Prenatal attenders had more than  twice the r a t e of epidurals and three times the r a t e of i n t e r ventions than did. the non-attenders when e p i d u r a l anesthesia was used.  Although not s t a t i s t i c a l l y  amining the two groups difference  s i g n i f i c a n t when ex-  separately, there was a s i g n i f i c a n t  (as shown i n Table 4-17) when combining a l l study  participants  i n relation  t o e p i d u r a l use and i n t e r v e n t i o n .  Table 4-16 E p i d u r a l Anesthesia and Intervention  Intervention (C/S, Forceps) Intervention occurred No i n t e r v e n t i o n Total:  Prenatal Attenders Epidural Anes.  Non Attenders E p i d u r a l Anes.  % of T o t a l Sample E p i d u r a l Anes.  Yes  Yes  Yes-  No  No  No  14 (.40.0)  4 (11:4)  2 (13.3)  2 (13. 3)  16 (32.0)  6 (12. 0)  3 (8.6)  14 (40.0)  1 (6.7)  10 (66. 7)  4 (8.0)  24 (48. 0)  17 (48.6)  18 (51.4)  3 (20.0)  12 (90. 0)  20 (40.0)  30 (60. 0)  Table 4-17 E p i d u r a l Anesthesia of the T o t a l Group and Intervention Intervention (C/S, Forceps)  Epidural Anes.  No E p i d u r a l Anes.  % of T o t a l Sample  No.  No.  No.  o, o  O, "o  o, "O  Intervention occurred  16  32..0  6  12..0  22  44..0  No i n t e r v e n t i o n  _4  8.,0  24  48..0  28  56..0  Total:  20  40..0  30  60..0  50  100..0  X  n  }  =  15.18, p < .001  Breathing Patterns During Second Stage Contractions During  second stage contractions the breathing patterns  of the women were c l a s s i f i e d i n two ways: spontaneous pushing i n which the woman accommodated her breathing and pushing i n response t o her body urges t o bear down o r any pushing where the breath was not h e l d longer than 6-7 seconds; and, V a l s a l v a pushing  i n which the woman was a c t i v e l y using long  sustained expulsive e f f o r t s ( l a s t i n g longer than 8-10 seconds) throughout the c o n t r a c t i o n . Table 4-18 represents  the d i s t r i b u t i o n o f the breathing  patterns f o r the study p a r t i c i p a n t s showing e i t h e r spontaneous pushing  o r V a l s a l v a pushing  as greater than  60 percent o f  the time i n which t h e i r contractions were observed. The proportion o f p r e n a t a l attenders who  used spontaneous pushing  and  33.3% r e s p e c t i v e l y .  and non-attenders  was r e l a t i v e l y s i m i l a r  —37.1%  From these data the m a j o r i t y (62.9%)  of p r e n a t a l attenders (those provided w i t h information regarding  spontaneous pushing) used  t h e i r second stage c o n t r a c t i o n s .  the V a l s a l v a pushing  during  Table 4-18 Breathing patterns of a l l study p a r t i c i p a n t s Breathing Pattern  Prenatal Attenders  Non Attenders  % of T o t a l Sample  No.  (%)  No.  (%)  No.  (%)  13  37.1  5  33.3  18  36.0  V a l s a l v a Pushing > 60% of contractions  22  62.9  10  66.7  32  64.0  Total:  35  100.0  15  100.0  50  100.0  Spontaneous Pushing > 60% of Contractions  •Includes d e l i v e r i e s by forceps and caesarean s e c t i o n . -V 2 ( l ) X  n  - S  In  Table  4-19 the d i s t r i b u t i o n  o f breathing patterns  i s given when forceps and caesarean d e l i v e r i e s are excluded. Again, the proportions using spontaneous pushing and V a l s a l v a pushing were very s i m i l a r . for  women using  their and  The mean duration o f second stage  spontaneous pushing  f o r more than  60% o f  contractions was 75.6 minutes f o r p r e n a t a l attenders  81.3 minutes f o r non-attenders,  s a l v a pushing  and f o r women using V a l -  f o r more than 60% of t h e i r c o n t r a c t i o n s , the  mean durations were 68.3 minutes and 68.0 minutes f o r p r e n a t a l attenders and non-attenders r e s p e c t i v e l y .  Table 19 * Breathing Patterns o f Study P a r t i c i p a n t s Breathing Pattern  Prenatal Attenders  Non Attenders  % of Total Sample  No.  (%)  No.  (%)  No.  (%)  5  29.4  3  27.3  8  28.6  12  70.6  8  72.7  20  71.4  100.0  28  100.0  Spontaneous Pushing > 60% of Contractions V a l s a l v a Pushing > 60% of Contractions Total:  17  100.0  11  *Excludes forceps and caesarean s e c t i o n d e l i v e r i e s . Spontaneous Pushing Greater than 60 percent o f the Contractions: Prenatal Attenders  Non Attenders  Range:  28 - 175 min. 29 - 120 min.  Median:  63 min.  95 min.  Mean:  75.6 min  81.3 min.  V a l s a l v a Pushing Greater than 60 percent of the Contractions: Prenatal Attenders  Non Attenders  Range:  19 - 181 min.  24 - 153 min.  Median:  56 min.  64 min.  68.3 min.  68.0 min.  Mean:  "  E p i d u r a l Anesthesia and Breathing Patterns  The  women who  had E p i d u r a l  anesthesia used  pushing  much more than spontaneous  tenders  used V a l s a l v a pushing almost  spontaneous  pushing  Prenatal a t -  four times more than  and f o r non-attenders V a l s a l v a  was used twice as frequently. 4-20.  pushing.  Valsalva  pushing  These data are shown i n Table  Table  4-20  E p i d u r a l Anesthesia and Breathing Patterns  Breathing Pattern Spontaneous pushing > 60% of contractions V a l s a l v a pushing > 60% of contractions Total:  Prenatal Attenders Epidural Anes.  Non Attenders E p i d u r a l Anes.  % of T o t a l Sample E p i d u r a l Anes.  Yes  Yes  Yes  No.  No.  No  3 (8.6)  (25.7)  1 (6.7)  4 (26.7)  4 (8.0)  13 (26.0)  12 (34.3)  11 (31.4)  2 (13.3)  8 (53.3)  14 (28.0)  19 (38.0)  15 (42.9)  20 (57.1)  3 (20.0)  12 (80.0)  18 (36.0)  32 (64.0)  *Two epidurals were given during second stage t o f a c i l i t a t e a forceps d e l i v e r y .  Guidance Regarding Breathing During Contractions Instructions were grouped  given  t o the women during  contractions  according t o the various combinations o f care-  givers and support persons present. The categories o f breathing patterns used by the women i n r e l a t i o n t o the i n s t r u c t i o n s given t o them were: a l l i n s t r u c t i o n s given were f o r V a l s a l v a pushing; a l l i n s t r u c t i o n s were encouraging spontaneous  pushing; and, i n s t r u c t i o n s g i v -  ing c o n f l i c t i n g (spontaneous and V a l s a l v a ) guidance regarding pushing were given. As shown i n Table 4-21, the m a j o r i t y of women were encouraged  t o use V a l s a l v a  pushing  by t h e i r  caregivers and  support persons during second stage contractions; w i t h 68.6% of the p r e n a t a l attenders and 80% o f the non-attenders being encouraged t o use V a l s a l v a pushing. i e s was the woman encouraged all It  In none o f the d e l i v e r -  t o use spontaneous  o f her attendants during second  stage  pushing by  contractions.  i s i n t e r e s t i n g t o note that when there was c o n f l i c t i n g  guidance  given t o the woman the m a j o r i t y of women i n the  p r e n a t a l group used spontaneous  pushing (25.7%) versus 5.7%  f o r V a l s a l v a pushing; i n the non-attender group the opposite was true w i t h 6.7% using spontaneous pushing and 13.3% using V a l s a l v a pushing. Of the non-attenders who used  spontaneous  pushing and  were encouraged t o use V a l s a l v a pushing o r had r e c e i v e d conf l i c t i n g guidance, none had E n g l i s h as t h e i r main language.  Table 4-21 Instruction/Guidance t o the Study P a r t i c i p a n t s During Contractions  Conflicting.  All Vals.  4 (11.4)  9 (25.7]  4 (26.7)  20 (57.2)  2. 5.7)  24 (68.6)  11 (31.4)  All Vals. Spontaneous pushing > 60% of contractions V a l s a l v a pushing j> 60% of contractions Total:  All Spont.  % of T o t a l Sample Instruction  Non Attenders Instruction  Prenatal Attenders Instruction  8 (53.3) 12 (80.0)  All Spont.  Conflicting  All Vals.  All Spont.  Conflicting  1 (6.7)  8 (16.0)  10 (20.0)  2 (13.3)  28 (56.0)  4 (8.0)  3 (20.0)  36 (72.0)  14 (28.0)  Of the four p r e n a t a l attenders who used spontaneous pushing although guided t o use V a l s a l v a pushing, two women had l i m i t e d English  and used what they termed  "felt  best";  one woman  (English speaking) stated the V a l s a l v a pushing was too d i f ficult for  f o r her t o maintain  her;  comfortable  and the t h i r d woman d i d spontaneous pushing whenc-.  there wasn't used  so she d i d what was  any conversation  Valsalva  pushing  during  during those  the contractions and contractions  when she  was t o l d t o do so. Of the p r e n a t a l attenders r e c e i v i n g c o n f l i c t i n g  informa-  t i o n and able t o use spontaneous pushing: two were f o l l o w i n g v e r b a l , hand and/or model breathing provided by the support person use  throughout  each c o n t r a c t i o n ;  2 were encouraged t o  spontaneous pushing by t h e i r p h y s i c i a n ; and, f i v e were  encouraged i n using  spontaneous pushing by the nurse.  In  a l l the d e l i v e r i e s where the woman used a spontaneous pushing approach i n second stage a l l had e i t h e r t h e i r support person or one o f the caregivers ( u s u a l l y the nurse) take the dominant supporting r o l e . The two women whose partners gave them a c t i v e d i r e c t i o n s during t h e i r contractions were among those that had p r a c t i s e d the breathing techniques  on a regular b a s i s (5. or more times  per week), as a r e s u l t of the information received i n p r e n a t a l classes.  Recorded Complications and Breathing Patterns Table  4-22  gives  the recorded  complications  and the  type of breathing used during the second stage c o n t r a c t i o n s . Overall  V a l s a l v a pushing  during  second  stage  contractions  had a greater a s s o c i a t i o n w i t h complications than- d i d spontaneous pushing; t h i s was p a r t i c u l a r l y evident among the p r e n a t a l attenders  i n which 14 (40.0%) of those  with  complications  used V a l s a l v a pushing and 8 (22.9%) used spontaneous pushing.  Interventions and Breathing Patterns Table  4-23 presents the data on the breathing patterns  and the need f o r i n t e r v e n t i o n — f o r c e p s and caesarean s e c t i o n . For  both  the p r e n a t a l  attender  and the non-attender  group the proportions who d i d spontaneous for  more than 60 percent  V a l s a l v a pushing  pushing  o f second stage contractions and  more than 60 percent  of second stage  t r a c t i o n s and r e q u i r i n g i n t e r v e n t i o n were s i m i l a r . n a t a l attenders  con-  For pre-  8 (22.9%) who used spontaneous pushing and  10 (28.5%) who used V a l s a l v a pushing  required i n t e r v e n t i o n  w h i l e f o r the non-attender group 2 (13.3%) required i n t e r v e n t i o n when using e i t h e r type of second stage The non-attenders (no  had a  greater  pushing.  proportion  i n t e r v e n t i o n ) who used V a l s a l v a pushing  (53.4%) and a  greater proportion who used spontaneous pushing than  the p r e n a t a l  attenders,  and 14.3% r e s p e c t i v e l y .  of women  (20%)  whose proportions were 34.3%  Table 4-22 Recorded Complication and Breathing Patterns  Breathing Pattern  Spontaneous pushing > 60% of Contraction V a l s a l v a pushing > 60% of Contraction Total:  Prenatal Attenders Complication  Non Attenders Complication  % of T o t a l Sample Complication  Yes  ;No  Yes  Yes  8 (22.9)  (13.3)  2 (14.3)  14 (40.0)  8 (22.8)  22 (62.9)  13 (37.1)  1 9 (6.7) 3 ;20.0)  . „,No  ..-.No  3 (20.0)  10 (20.0)  8 (16.0)  (60.0)  15 (30.0)  17 (34.0)  12 (80.0)  25 (50.0)  25 (50.0)  U)  Table 4-23 Interventions and Breathing  Breathing Pattern  Spontaneous pushing 60% of contractions V a l s a l v a pushing 60% of contractions Total:  Patterns Prenatal Attenders  Non Attenders  % of T o t a l Sample  Intervention  Intervention  Intervention  Yes  No  Yes  No  Yes  No  8 (22.9)  5 (14.3)  2 (13.3)  3 (20.0)  10 (20.0)  (16.0;  10 (28.5)  12 (34.3]  2 (13.3)  8 (53.4)  12 (24.0)  20 (40.0)  18 (51.4)  17 (48.6)  4 (26.6)  11 (73.4)  22 (44.0)  28 (56.0)  8.  •Includes forceps and caesarean s e c t i o n b i r t h s  h-  1  In both groups the mean time f o r second stage was s i m i l a r (excluding i n t e r v e n t i o n s ) . and  For both the p r e n a t a l attenders  the non-attenders, those who used spontaneous  pushing  had s l i g h t l y longer second stages than those who used V a l salva  pushing;  prenatal  76.6 minutes  attenders  versus  and 81.3 minutes  68.3 minutes versus  f o r the  68.0 minutes  f o r the non-attenders ( r e f e r t o Table 4-19).  Fluency w i t h E n g l i s h i n R e l a t i o n t o Breathing Patterns Used Table 4-24 shows the breathing patterns when E n g l i s h was not the best understood language o f the study p a r t i c i p a n t s . Table 4-25 shows the data when adjusted f o r those p a r t i c i p a n t s who  received verbal  directions  i n their  native  language  ( E n g l i s h o r another language) from: t h e i r attending nurse; t h e i r partner; and o r t h e i r p h y s i c i a n when he o r she was present  and speaking t o the woman during the d e l i v e r y .  When the mother was conversing w i t h one o f her caregivers or support persons i n her native language, over four times the number o f p r e n a t a l attenders (28.6%) used  spontaneous  pushing (most were E n g l i s h speaking) as d i d the non-attenders (6.7%). Of  the p r e n a t a l attenders using spontaneous  2 were encouraged  pushing,  t o do so by t h e i r p h y s i c i a n , 5 by the  nurse and 2 by t h e i r p a r t n e r s . Regardless o f language s k i l l s nurses who encouraged  spontaneous  pushing always  spoke t o  the woman i n a s o f t , pleasant and encouraging v o i c e as w e l l as p r o v i d i n g a great d e a l of p h y s i c a l contact during t h i s  Table 4-24 Fluency w i t h English and Breathing Patterns of the Study P a r t i c i p a n t s Breathing Pattern  Prenatal Attenders Non-English  Spontaneous Pushing > 60% of Contractions V a l s a l v a Pushing > 60% of Contractions Total:  3 .. (8.6)  3 (8.6) 6 (17.2)  % of T o t a l Sample  Non Attenders  English  Non-English  10 (28.6)  4 (26.7)  1 :(6.7)  7 (14.0)  11 (22.0)  8 (53.3)  2 (13.3)  11 (22.0)  21 (42.0)  12 (80.0)  3 (20.0)  18 (36.0)  32 (64.0)  19 (54.2) 29 (82.8)  English  Non-English  English  Table 4-25 * Fluency of E n g l i s h or Native Language by Caretakers and Breathing Patteerns of the Study P a r t i c i p a n t s Prenatal Attenders Breathing Pattern Spontaneous pushing > 60% of Contractions V a l s a l v a pushing > 60% of Contractions Total:  Non-Similar Language  % of T o t a l Sample  Non Attenders  Similar Language  3 (8.6)  10 (28.6)  1 (2.8)  21 (60.0)  4 (11.4)  31 (88.6)  Non-Similar Language  4 , (26.7)  4 (26.7) 8 (53.4)  Similar Language  Non-Similar Language  Similar Language  1 (6.6)  7 (14.0)  11 (22.0)  6 (40.0)  5 (20.0)  27 (54.0)  7 (46.6)  12 (24.0)  38 (76.0)  •Adjusted f o r the nurse who spoke the woman's native language, the partner who gave d i r e c t i o n s i n the native language, and the p h y s i c i a n who spoke the n a t i v e language during the time he was present i n the room.  time t o convey support and a f e e l i n g o f "your're doing w e l l " to the woman.  S i m i l a r l y , the physicians and support persons  gave v e r b a l support and frequent encouragement t o the woman throughout  her contractions  without exhorting  her t o "push  harder". Of  the non-attenders  p h y s i c i a n encouraged  using  spontaneous  pushing, one  the woman i n her use o f t h i s approach.  The other 4 (26.7%) non-attenders who used spontaneous pushing, even when encouraged  t o use V a l s a l v a , s t a t e d that they d i d  so because i t ' f e l t b e t t e r ' and chose not t o l i s t e n t o t h e i r caretakers. The  majority  o f women who used  V a l s a l v a pushing d i d  so because they were i n s t r u c t e d t o do so; 21 (60.0%) o f the prenatal  attenders and 6 (40.0%) o f the non-attenders d i d  V a l s a l v a pushing f o r the m a j o r i t y o f t h e i r second stage cont r a c t i o n s when the woman was spoken t o i n her native language. Even when the language spoken  i n the d e l i v e r y room was not  s i m i l a r t o the woman's—both the one (2.8%) p r e n a t a l attender and the 4 (26.7%) non-attenders  who used V a l s a l v a pushing,  s t a t e d they 'did what they were t o l d ' as implied by the tone of v o i c e of the s t a f f o r through d i r e c t i o n s relayed v i a the woman's partner.  Episiotomy, Vaginal Laceration During Second Stage Table  4-26  gives the d i s t r i b u t i o n  o f episiotomy and  v a g i n a l l a c e r a t i o n s f o r a l l study p a r t i c i p a n t s having a v a g i n a l delivery.  Table 4-26 Episiotomy, Vaginal Laceration i n Second Stage Event  Episiotomy Episiotomy and Laceration  Attenders  Non-Attenders  % of T o t a l Sample  No.  (%)  No.  (%)  No.  (%)  16  50.0  10  71.4  26  56.5  6  18^75  1  (68.75) Laceration  6  18.75  Intact Perineum  _4  12.5  *Total:  32  100.0  J-l±  15.2 (71.7)  7  (78.6) 3  14  21.4  9  19.6  -  _4  8.7  100.0  46  100.0  •Excludes the 3 attenders and 1 non-attender who were d e l i v e r e d by caesarean s e c t i o n a f t e r the commencement of second stage labour. T h i r t y - t h r e e (71.7%) of the study p a r t i c i p a n t s had an e p i s i o t omy; 22 (68.8%) of the p r e n a t a l c l a s s attenders and 11 (78.6%) of the non-attenders.  S i x (18.8%) of the attenders and 3  (21.4%) of the non-attenders but  had a f i r s t  was noted is,  o r second  were not given an episiotomy degree v a g i n a l l a c e r a t i o n .  that when a spontaneous d e l i v e r y occurred  It (that  no i n t e r v e n t i o n ) 40.9% o f the p r e n a t a l attenders were  net given an episiotomy while o n l y 18.2% of the were not given an episiotomy.  non-attenders  Four (8.7%) of the study par-  t i c i p a n t s were d e l i v e r e d w i t h an i n t a c t perineum (that i s , not having e i t h e r an episiotomy or l a c e r a t i o n r e q u i r i n g suturing;  a l l of whom had attended p r e n a t a l c l a s s e s .  D i s t r i b u t i o n of Labour Times In  t a b l e 4-27  the d i s t r i b u t i o n  of the  length of  the  f i r s t stage of labour f o r a l l study p a r t i c i p a n t s i s presented. Fourteen non-attenders  (40.0%) of the attenders and 10 (66.7%)of the completed the  first  stage of  labour  i n less  than 10 hours, and a greater proportion (22.9%) of p r e n a t a l attenders (versus 13.3% f o r non-attenders) had a f i r s t of labour l a s t i n g longer than 16 hours. f i r s t stage of labour was  2 hours,  The  stage  range f o r the  10 minutes t o 28 hours,  50 minutes f o r p r e n a t a l attenders and  1 hour 30 minutes t o  18 hours 30 minutes f o r non-attenders. Tables 4-28 stage  labour  and 4-29  and  required e i t h e r  total  present the d i s t r i b u t i o n s of second labour  times,  a forceps or caesarean  excluding those  who  d e l i v e r y during the  second stage. Ten  (58.7%) of the p r e n a t a l attenders had a second stage  of s i x t y minutes or l e s s , whereas o n l y 3 (27.3%) of the nonattenders less.  completed  the  second  stage  i n s i x t y minutes or  I t i s i n t e r e s t i n g t o note that by 90 minutes  76.4%  Table 4-27 Length of the F i r s t Stage of Labour Duration of F i r s t Stage i n Hours  Attenders  Non Attenders  % of T o t a l Sample  No.  No.  (%)  No.  (%)  1  6.7  1  2.0  (%)  1 hour 1  :;2  2  *4  •1  2.9  1  6.7  2  4.0  4  6  4  11.4  • 3  20.0  7  14.0  6  8  4  11.4  3  20.0  7  14.0  8  10  5  14.3  2  13.3  7  14.0  10  12  6  17.1  1  6.7  7  14.0  12  14  3  8.6  1  6.6  4  8.0  14  16  4  11.4  1  6.7  5  10.0  _8  22.9  2_  13. 3  10  20.0  35  100.0  50  100.0  16+ Total:  15  100.0  Median:  11 hours 20 minutes  7 hours 50 minutes  Mean:  10 hours  8 hours 54 minutes  9 minutes  of  the p r e n a t a l  attenders and 72.7% of the non-attenders  had completed second stage and by 120 minutes the proportions were v i r t u a l l y the same—82.3% and 81.8% r e s p e c t i v e l y .  The  mean duration of second stage labour was almost the same— 70.4 minutes f o r attenders and 71.6 minutes f o r non-attenders. On the other hand the shortest unassisted second stages were 19 minutes f o r a p r e n a t a l attender and 24 minutes f o r a nonattender.  The longest unassisted  second  stages were 181  minutes and 153 minutes f o r attenders and non-attenders r e s pectively. Over 47 percent (47.1%) o f the p r e n a t a l attenders completed this  labour i n l e s s  than  nine hours; f o r non-attenders  proportion was 54.5%; and the mean t o t a l labour times  were a l s o v e r y s i m i l a r — 9  hours  48 minutes and 9 hours 43  minutes f o r attenders and non-attenders r e s p e c t i v e l y (excluding forceps and caesarean d e l i v e r i e s ) .  Table 4-28 •Length of Second Stage of Labour Minutes i n Second Stage Labour  Prenatal Attenders  Non Attenders  % of T o t a l Sample  No.  No.  (%)  No.  (%)  (%)  1  5.9  -  -  20 - 29  2  11.7  2  18.2  4  14.3  30 - 39  2  11.7  1  9.1  3  10.7  40 - 49  3  17.6  -  -  3  10.7  50 - 59  2  11.8  -  -  2  7.1  60 - 69  2  11.8  3  27.2  5  17.8  70 - 79  -  -  1  9.1  1  3.6  80 - 89  1  5.9  1  9.1  2  7.1  90 - 99  -  -  _1  9.1  1  3.6  100 - 109  1  5.9  1  3.6  110 - 119 .  -  -  120 -129  -  140 - 159  19 minutes  -  -  -  -  -  1  9.1  1  3.6  1  5.9  1  9.1  2  7.1  160 - 179  1  5.9  -  -  1  3.6  180 - 199  1  5.9  -  -  1  3.6  200+  -  -  -  —  —  —  Total:  17 100.0  28  100.0  Mean:  70.4 minutes  11  100.0  71 .6 minutes  •Excludes forceps d e l i v e r i e s and caesarean s e c t i o n deliveries.  Table  4-29  • D i s t r i b u t i o n of T o t a l Labour Time  T o t a l Labour i n Hours  Prenatal Attenders  Non Attenders  % of T o t a l Sample  No.  (%)  No.  No.  (%)  5  2  11.8  1  9.1  3  10.7  5  7  2  11.8  3  27.2  5  17.9  7  9  .4  23.5  2  18.2  6  21.4  9  11  2  11.8  2  18.2  4  14.3  11  13  2  11.8  2  7.1  13  15  3  17.6  -1  9.1  4  14.3  15  17  1  5.9  2  18.2  3  10.7  17  19  19  21  (%)  5.8  3.6  21+ Total:  17  Mean:  100.0  9 hours, 48 min.  11  100.0  28  9 hours 43 min.  •Excludes forceps and caesarean d e l i v e r i e s o c u r r i n g i n the, second.. stage. 1  100.0  Summary All  o f the 50 study p a r t i c i p a n t s had a f a m i l y member  or f r i e n d present during the labour and d e l i v e r y . and  The labour  d e l i v e r y experiences o f the p r e n a t a l attenders  attenders  and non-  had some s i m i l a r i t i e s . - but a l s o many d i f f e r e n c e s .  Prenatal attenders had a higher proportion (48.6%) o f e p i d u r a l anesthesia  than d i d the non-attenders (20%); they had a s i g -  nificantly  higher  recorded  proportion  intrapartum  of EFM (62.9% versus 20%) and  complications  (62.9%  While the proportion of observation were for  having  uterine  the p r e n a t a l  contractions  attenders  12  who had epidurals  (34.3%) required  20.0%).  time when the women  was very  similar—49.9%  and 48% f o r the non-attenders,  the experience of b i r t h was not. attenders  versus  Of the 15 (42.$%) p r e n a t a l  prior  to their  second  stage,  i n t e r v e n t i o n , and f o r the non-attender  group, o f the 3 (20.0%) women having e p i d u r a l s , 2 (13.3%) required  intervention.  When examining the study group as  a whole u n i t there was a s i g n i f i c a n t d i f f e r e n c e i n the number of  i n t e r v e n t i o n s required  by those women who had epidurals  and those women who d i d not (p. < .001). The  proportion  o f p r e n a t a l attenders  who  used  and  27.3% r e s p e c t i v e l y (excludes  and non-attenders  spontaneous pushing was r e l a t i v e l y  caesarean s e c t i o n ) .  similar—29.4%  d e l i v e r i e s by forceps and  The mean duration  o f the second stage  (excluding i n t e r v e n t i o n s ) was a l s o s i m i l a r between the g r o u p s — 75.6  minutes and 81.3 minutes f o r attenders and non-attenders  who  used  spontaneous  pushing f o r more than  60% o f t h e i r  contractions and w i t h s l i g h t l y shorter times o f 68.3 minutes and 68.0 minutes f o r those women i n the two groups who used V a l s a l v a pushing f o r more than 60% o f t h e i r c o n t r a c t i o n s . Most women used V a l s a l v a pushing (62.9% and 66.7% f o r the two groups) during second stage contractions.  For both  groups they d i d so mainly because a l l guidance given during the second stage was f o r V a l s a l v a pushing.  Only 4 (11.4%)  of the p r e n a t a l attenders and 4 (26.7%) of the non-attenders did  spontaneous  pushing  the V a l s a l v a method.  despite being  instructed  t o use  Nine (25.7%) o f the p r e n a t a l attenders  and 1 (6.7%) o f the non-attenders used spontaneous  pushing  despite r e c e i v i n g c o n f l i c t i n g i n s t r u c t i o n s regarding pushing (i.e.  both spontaneous  and V a l s a l v a ) .  For most o f these  women one o f the caregivers o r the support person assumed the  dominant  coaching r o l e  and the woman followed those  i n s t r u c t i o n s f o r the m a j o r i t y of her contractions. There  d i d not seem t o be an a s s o c i a t i o n between the  need f o r interventions and spontaneous pushing as the proportion  o f women using spontaneous  intervention  pushing  and r e q u i r i n g  i n both groups was l e s s than f o r those women  who used V a l s a l v a pushing f o r the m a j o r i t y o f t h e i r c o n t r a c t i o n s . The  language  skills  of the women p a r t i c u l a r l y i n the  non-attender group, had an influence on the type of breathing used because w i t h E n g l i s h not being the primary s e v e r a l women chose  t o ignore the i n s t r u c t i o n  language,  given them  and  use the type o f breathing  ' f e l t best' a t the time. was  that  The assumption by the caregivers  the woman could  not understand the i n s t r u c t i o n s  even though model breathing voice was often used.  (spontaneous pushing) which  and a sharp,  d i r e c t i n g tone.of  For the p r e n a t a l attenders  who  did  not have E n g l i s h as t h e i r main language, a l l but one o f the caregivers  supported spontaneous pushing and the women were  able t o f o l l o w t h e i r own i n c l i n a t i o n s regarding pushing s t y l e . The  non-attender group had a shorter mean duration of  the f i r s t  stage o f l a b o u r — 8  hours 54 minutes while f o r the  p r e n a t a l attenders the mean duration was 10 hours, 9 minutes. The mean duration o f the second stage (excluding i n t e r v e n t i o n s ) was  virtually  i d e n t i c a l — 7 0 . 4 minutes and 71.6 minutes f o r  p r e n a t a l attenders and non-attenders r e s p e c t i v e l y . labour  times  were  also  w i t h the mean time being  similar  (excluding  The t o t a l  interventions)  9 hours, 48 minutes f o r p r e n a t a l  attenders and 9 hours, 43 minutes f o r non-attenders.  Infant Outcomes Infant  outcomes which may r e f l e c t  the conduct o f the  second stage w i l l be described f o r the f o l l o w i n g :  recorded  f e t a l d i s t r e s s and Apgar scores.  Recorded F e t a l D i s t r e s s F e t a l d i s t r e s s was recorded cord.  on the Labour-Delivery Re-  As i n d i c a t e d i n Table 4-30, 10 (28.67%) o f the neonates  128 of  p r e n a t a l attenders were recorded as having sortie  distress  and three (20%)  o f the neonates  fetal  o f non-attenders  were recorded as having f e t a l d i s t r e s s during the intrapartum. The  recorded  reasons  f o r the f e t a l  distress  were:•  f e t a l heart r a t e decelerations at the commencement o f second stage (2); f e t a l heart r a t e decelerations during and a f t e r second  stage contractions (6); meconium s t a i n i n g  (4); and  a combination o f meconium s t a i n i n g and decreased f e t a l heart r a t e (1). Of those women whose i n f a n t s were recorded as having f e t a l d i s t r e s s , only 2 (1 p r e n a t a l attender and 1 non-attender) d i d not have e p i d u r a l anesthesia. Seven  (70%) p r e n a t a l attenders whose i n f a n t s were r e -  corded as having f e t a l d i s t r e s s , used V a l s a l v a pushing during  the m a j o r i t y o f t h e i r  second  stage contractions and  2 (13.3%) o f the non-attenders whose i n f a n t s were recorded as having f e t a l d i s t r e s s , used V a l s a l v a pushing during the majority  of t h e i r  Table 4-30.  second  stage  contractions as shown i n  Thus, 9 o f the 13 (62.9%) neonates were recorded  as having f e t a l d i s t r e s s when the women used V a l s a l v a pushing during i.the m a j o r i t y of t h e i r second stage c o n t r a c t i o n s .  Apgar Scores Table  4-31 presents the data concerning Apgar scores  at one minute a f t e r d e l i v e r y . fication  In Nucholl's l i s t of c l a s s i -  o f neonatal complications he considered an Apgar  Table 4-30 Recorded F e t a l Distress and Breathing Patterns Prenatal Attenders  Spontaneous Pushing > 60% of Contractions V a l s a l v a Pushing > 60% of Contractions Total:  % of T o t a l Sample  Non Attenders  F e t a l Distress  Fetal Distress  Fetal Distress  Yes  Yes  Yes  No  3 (8.6)  9 (25.7;  7 (20.0)  16 (45.7;  10 (28.6)  25 (71.4  1 4 (6.7).  No  No  (26.7)  4 (8.0)  13 (26.0)  2 (13.3,  8 (53'.3).-  9 (18.0)  24 (48.0)  3 (20.0)  12 (80.0)  13 (26.0)  37 (74.0)  score of l e s s than 'seven' on a scale of t e n t o be a complication.  Table 4-31 Apgar Scores One Minute A f t e r D e l i v e r y Apgar Score a t One Minute  Prenatal Attenders  Non Attenders  % of Total Sample  No.  (%)  No.  (%)  No.  (%)  0-3  1  2.9  -  -  1  2  4-6  6  17.1  3  20.0  9  18:-  7-10 Total:  28  80.0  12  80.0  40  80  35  100.0  15  100.0  50  100.0  Mean Apgar Score:  Of  8  8.2  the study p a r t i c i p a n t s ,  Apgar score was l e s s than 7. 7 (20%)  10 d e l i v e r e d Prenatal  i n f a n t s whose  attenders  delivered  i n f a n t s whose Apgar score was l e s s than 7;  4 had  E p i d u r a l anesthesia; and 4 required d e l i v e r y by forceps. Non-attenders  delivered  3  (20%) i n f a n t s  whose  score was l e s s than 7; 2 had an E p i d u r a l and required by was  forceps  o r caesarean s e c t i o n .  delivered with  thetic  Apgar  delivery  One woman whose  infant  a low Apgar score d i d not have any anes-  and d e l i v e r e d  spontaneously.  Two i n f a n t s  delivered  having a low one minute Apgar score were diagnosed as having either  a congenital  anomoly o r trauma during  birth—neither  of these women had any a n e s t h e s i a — b o t h were prenatal  atten-  ders.  One woman, a non-attender, whose i n f a n t had a low  Apgar score  d e l i v e r e d spontaneously and d i d not have any  anesthesia.  Summary Recorded the  fetal  d i s t r e s s was noted f o r 10 (28.6%) o f  i n f a n t s o f p r e n a t a l attenders  infants  o f non-attenders.  and f o r 3 (20.0%) o f the  A greater  proportion  (20.0%)  of the i n f a n t s o f the p r e n a t a l attender group were classed as having f e t a l d i s t r e s s when t h e woman was using V a l s a l v a pushing  than were the i n f a n t s  (13.3%).  of the non-attender group  Of consideration here i s the f a c t that the women  i n the p r e n a t a l group had more EFM, and  more  more e p i d u r a l anesthesia,  i n t e r v e n t i o n which may influence  the diagnosis  of f e t a l d i s t r e s s . The  proportion o f i n f a n t s having Apgar scores o f seven  or greater a t one minute was i d e n t i c a l — 8 0 . 0 % f o r both groups. The mean Apgar scores were a l s o s i m i l a r — 8 f o r the i n f a n t s of p r e n a t a l attenders attenders. the or not  Even w i t h  and 8.2 f o r the i n f a n t s of the nonthe greater amount o f EFM used f o r  p r e n a t a l group (presumably because of i d e n t i f i e d possible  risks  risks  of the i n f a n t ) the i n f a n t outcome was  b e t t e r than the non-attender group i f the Apgar  score  i s the measurement used t o i n d i c a t e the status o f the i n f a n t .  132  Confidence, Perception o f Labour and D e l i v e r y An study  attempt  was made t o determine  participants  felt  about  their  how confident the labour  and d e l i v e r y  (as that time approached) and t h e i r perception of the experience soon a f t e r  the d e l i v e r y .  For p r e n a t a l attenders  an attempt was made t o get t h e i r perception o f the breathing patterns used.  used  during  the second stage  and why they were  Tables 4-32 and 4-33 provides these data.  Table 4-32 Confidence L e v e l f o r Labour and D e l i v e r y Confidence Level  Prenatal Attenders  Non Attenders  % of T o t a l Sample  'No.  (%)  No.  (%)  No.  (%)  Very Confident  14  40.0  2  13.3  16  32  Confident  14  40.0  8  53.3  22  44  Not Very Confident  _7  20.0  _5  33.4  12  24  15 100.0  50  100  Total:  Twenty-eight  35 100.0  (80.0%) of the P r e n a t a l Class  Attenders  stated that they were at l e a s t  'confident' f o r t h e i r labour  and  t o the event,  10  d e l i v e r y experience  prior  whereas o n l y  (66.6%) o f the Non-Attenders were at l e a s t  prior to delivery.  'confident'  Twnety percent of the P r e n a t a l Attenders  s t a t e d t h a t they were 'not very confident' while 33.4 percent  of the Non-Attenders gave t h i s  indication.  Of the  28 p r e n a t a l attenders who birth  experience,  'well prepared' not  feel  24  f e l t at l e a s t confident f o r the  (85.7%) of them i n d i c a t e d they  as a r e s u l t of the c l a s s e s .  'well prepared'  the f o l l o w i n g as reasons:  as  felt  Those who  did  a r e s u l t of the classes gave  not attending a l l of the classes  f o r complete information; and f a i l u r e to p r a c t i c e the breathing techniques t o know how t o do them w e l l .  Perception of Labour and D e l i v e r y As the  i n d i c a t e d i n Table  prenatal  labour  attenders  4-33,  t h i r t y - s e v e n percent  i n d i c a t e d t h e i r perception  and d e l i v e r y experience  was  'better': than  of  of the  expected'  whereas only 13.3% of the non-attenders f e l t t h e i r experience was  'better than  was  i n the  the  prenatal  expected'.  Another  'worse than expected' attenders  versus  d i f f e r e n c e of  note  perception w i t h 42.9%  73.4%  of the  of  non-attenders  s t a t i n g t h e i r perception of labour and d e l i v e r y was  'worse  than a n t i c i p a t e d . 1  Prenatal Attenders Perception of Breathing Techniques Taught During the postpartum interview questions were designed to determine the perception of the p r e n a t a l attenders' to  use the breathing techniques  taught  ability  i n p r e n a t a l classes  f o r use during the second stage of labour. Four of the women were unable t o s t a t e i f any  specific  Table 4-33 Perception o f the Labour/Delivery Experience  Perception o f Experience  Prenatal Attenders  Non Attenders  % of Total Sample  No  (%)  No.  (%)  No.  (%)  13  37.1  2  13.3  15  30  7  20.0  2  13.3  9  18  11 73.4 15 100.0  26 50  52 100  B e t t e r than expected As expected Worse than expected Total:  15 42.9 35 100.0  method was taught o r t a l k e d about i n t h e i r p r e n a t a l c l a s s e s . Of the remaining women, a l l were able t o describe the technique that had been taught i n t h e i r c l a s s e s . Only two women conflicting  i n the p r e n a t a l  attender group  gave  information t o what was observed; one stated  that she had used and had been encouraged t o use spontaneous pushing  when she had been observed t o use V a l s a l v a  pushing greater than 60% o f the time and was a c t i v e l y encouraged t o use t h i s technique by her support person and caregivers.  The other woman stated that she wanted t o use an  exhale"type breath by  the s t a f f ;  but used V a l s a l v a  she was observed  pushing  as d i r e c t e d  t o do spontaneous pushing  (although not exhale) greater than 60% of the time and was encouraged t o do so by her partner and the attending nurse.  Only 2 o f the p r e n a t a l attenders a t t r i b u t e d the breathing techniques used t o what they had been taught i n p r e n a t a l classes.  For both women t h e i r support person assumed the  dominant labour support r o l e and used e i t h e r v o c a l and o r model breathing guidance  throughout  the second  stage con-  tractions .  Summary Prenatal attenders expressed more f e e l i n g s o f confidence (80.0%) i n preparation f o r the b i r t h experience than d i d the non-attenders (66.7%).  They also perceived t h e i r labour  and d e l i v e r y experience t o be 'as expected' o r 'better than expected' more often than d i d the non-attenders (57.1%,versus 26.6%).  Even though the p r e n a t a l attenders required a greater  number o f i n t e r v e n t i o n s than d i d the non-attenders,- fewer attenders  perceived the b i r t h  experience as 'worse  expected'  as compared t o the non-attenders  than  (42.9% versus  73.4%). The  m a j o r i t y (88.6%) of the p r e n a t a l attenders were  able t o describe the breathing recommended i n t h e i r p r e n a t a l classes f o r use during the second stage o f labour. However, o n l y 2 (5.7%) o f the women a t t r i b u t e d t h e i r breathing techniques (used during second  stage) t o information obtained  from t h e i r c l a s s e s . The m a j o r i t y (94.3%) o f women were able t o a c c u r a t e l y  describe the breathing  techniques used during second stage  and a t t r i b u t e d t h i s t o f o l l o w i n g caregivers or support person.  the i n s t r u c t i o n s of t h e i r  CHAPTER V  SUMMARY AND DISCUSSION OF THE RESULTS, CONCLUSION, IMPLICATIONS AND RECOMMENDATIONS FOR FURTHER INVESTIGATION  Overview In of  this  chapter the research format  the study  and  are discussed.  the demographic  First,  characteristics  and the r e s u l t s  the research format o f the p a r t i c i p a n t s  i n the study are discussed. This i s followed by a d i s c u s s i o n of  the labour and d e l i v e r y experience o f the study p a r t i c i -  pants; brief  a brief  discussion of the infant  outcomes; and a  d i s c u s s i o n of the women's perception o f t h e i r  experrience.  birth  A conclusion, i m p l i c a t i o n s o f the study and  recommendations f o r f u r t h e r i n v e s t i g a t i o n conclude the present a t i o n of the study.  The Research Format and C h a r a c t e r i s t i c s o f the Respondents An observation of the d e l i v e r y experience p a r t i c u l a r l y i n r e l a t i o n t o the type of breathing used by the women during second stage contractions, was conducted i n the major matern i t y f a c i l i t y i n the Vancouver area.  The study p a r t i c i p a n t s ,  50 women (66.7% o f those e l i g i b l e ) who were having t h e i r first  c h i l d , were r e c r u i t e d f o l l o w i n g admission t o h o s p i t a l  during the f i r s t stage of labour. A l l women were considered to be 'low-risk' on admission t o h o s p i t a l .  S i x t y percent of  the reasons f o r n o n - p a r t i c i p a t i o n were not r e l a t e d t o r e f u s a l to p a r t i c i p a t e . Of the respondents,  35 (70.0%) had attended a p r e n a t a l  education program during t h e i r pregnancy;  of those p r e n a t a l  attenders 48.6% were r e s i d e n t s of Vancouver w i t h the remainder l i v i n g i n the surrounding communities.  Of the non-attenders,  73.3% r e s i d e d i n Vancouver. The mean age of the p r e n a t a l attenders was 28 years, s l i g h t l y o l d e r than the mean age of 26 years f o r the nonattenders.  Of the study p a r t i c i p a n t s , 77.1% of the p r e n a t a l  attenders were born i n Canada, the United States or England, whereas o n l y 6.7% of the non-attenders were born i n one of these c o u n t r i e s . There was found in  t o be a s i g n i f i c a n t  the country of o r i g i n ;  more; language  difference  (p<.001)  residency i n Canada 10 years o r  best understood and type of employment.  The  education l e v e l of the p r e n a t a l attenders was s l i g h t l y higher w i t h 62.9% having post secondary educations while o n l y 46.7% of the non-attenders had post secondary education. Prenatal c l a s s late  attenders tended t o be i n t h e i r mid t o  twenties, Caucasian  attained a skilled  grade  and E n g l i s h  They had  12 or b e t t e r education and were employed i n  o r higher l e v e l p o s i t i o n .  though having  speaking.  attained  grade  The non-attenders a l -  12 education were l i k e l y t o  be employed i n a s k i l l e d or l e s s e r type p o s i t i o n , not f l u e n t i n E n g l i s h , t o have l i v e d i n Canada ten years o r l e s s , having  come from one of the Asian countries. attenders  who were from  The number o f non-  the non-English  speaking  section  of the community was s i m i l a r t o the 1983 study o f Robertson which found that a large proportion o f women i n c e r t a i n areas of Vancouver r e c e i v i n g p o s t - n a t a l services d i d not have E n g l i s h as t h e i r main language and do not search out community h e a l t h s e r v i c e s during pregnancy.  Labour and D e l i v e r y Experience... ... . The  o v e r a l l r a t e o f women r e c e i v i n g e p i d u r a l anesthesia  during l a b o u r / d e l i v e r y was 40% w i t h p r e n a t a l attenders r e c e i v ing the greatest proportion (34% o f the t o t a l study population). Only one o f the women who received an e p i d u r a l during the f i r s t stage o f labour d i d not have e l e c t r o n i c f e t a l monitoring during that time as w e l l . 15  (42.9%)  stage,  received  In the p r e n a t a l attender group,  epidural  anesthesia  a l l had EFM, and a l l were recorded  form o f complication on the Labour-Delivery non-attender (20%) EFM,  group, 3 (20%)  the f i r s t  as having Record.  some  In the  had e p i d u r a l anesthesia  and 3  had EFM (only 2 had epidurals a l s o ) , o f those who had 2 were recorded  also.  during  as having  an intrapartum  complication  The large proportion of p r e n a t a l attenders r e c e i v i n g  e p i d u r a l anesthesia i s consistent with the f i n d i n g s o f Melzack et  a l (1981) who studied pain  during  c h i l d b i r t h and found  that despite prepared c h i l d b i r t h t r a i n i n g (which i s designed t o reduce f e a r , anxiety and tension, and should t h e o r e t i c a l l y  reduce p a i n ) , the majority o f women i n t h e i r study e p i d u r a l anesthesia.  requested  The d i f f e r e n c e s between the two groups  i n r e l a t i o n t o e p i d u r a l anesthesia use seems t o support K l e i n s (1982) suggestion by  that  a woman i n labour  "a request  f o r epidural  anesthesia  i s c u l t u r a l l y determined"  (p.  357).  He b e l i e v e s that e p i d u r a l anesthesia has been widely accepted by an "uninformed p u b l i c " who a r e aware o f the a v a i l a b i l i t y of them but unaware o f t h e i r prenatal  attenders  i n this  inherent  study  risks.  A l l of the  would have received some  information on epidurals i n t h e i r p r e n a t a l classes thus being aware o f t h e i r a v a i l a b i l i t y . new  Non-attenders, who were mostly  Canadians, d i d not have access t o t h i s information as  easily  so may not have known of the a v a i l a b i l i t y of such  r e l i e f measures.  Second Stage o f Labour Eighteen intervention  (51.4%)  o f the p r e n a t a l  ( d e l i v e r y by forceps  attenders  required  o r caesarean  section),  while 4 (26.6%) of the non-attender group r e q u i r e d i n t e r v e n tion. there  For the m a j o r i t y  (12 at tender  and 2 non-attender)  seemed t o have been some a s s o c i a t i o n w i t h r e c e i v i n g  epidural  anesthesia.  I t supports  the f i n d i n g s o f Pearson  and Hoult e t a l (1977) that the use o f t h i s type of i n t e r v e n t i o n , while reducing p a i n , may r e s u l t i n a d i s t r e s s e d i n f a n t , malposition, and the need f o r forceps d e l i v e r y and midforceps rotation.  The study  findings  also  support Dunn's b e l i e f  that  the frequent  anesthesia)  use o f interventions  i n modern  (such  o b s t e t r i c management  as e p i d u r a l  "have  almost  become part o f the r i t u a l o f modern d e l i v e r y " (p.790).  Breathing Patterns During Second Stage Labour Although have of  the p r e n a t a l attenders  different  uterine  backgrounds  contractions  and the non-attenders  and preparation  observed  during  the proportion  the second  stage  observation p e r i o d were almost i d e n t i c a l — 4 9 % and 48% respectively  f o r each group.  spontaneous pushing  The proportion o f women who used  was also s i m i l a r ,  37.1 percent  percent f o r both the p r e n a t a l attenders and the The  majority  (62.9%  and 33.3  non-attenders.  and 66.7%) o f the attenders  and non-  attenders used V a l s a l v a pushing throughout the second stage. The  expectation  preparation techniques small  that  women who take  p r e n a t a l classes i n  f o r c h i l d b i r t h would use spontaneous during second stage  sample  size  a  i s not confirmed;  statistically  significant  breathing due t o the difference  could not be detected. When examining  the influences on women i n using the  breathing techniques described s e v e r a l f a c t o r s emerged: 1.  overall  verbal  72% of the women were always i n s t r u c t e d , when  i n s t r u c t i o n s were given, t o push using the V a l s a l v a  Maneuver, during the second stage; 2.  28 percent o f the women received c o n f l i c t i n g guid-  141  ance regarding the breathing technique t o use; and 3.  the  primary language  of the d e l i v e r i n g women wase of  importance i n that ;±bv set up a communication b a r r i e r  (whether  r e a l or perceived) between many s t a f f members and the d e l i v e r ing woman when E n g l i s h was not the primary language. Regardless of information r e c e i v e d at p r e n a t a l c l a s s e s regarding breathing techniques, o n l y two p r e n a t a l attenders a t t r i b u t e d t h e i r breathing techniques used t o the information they had been taught i n c l a s s e s . group of people who  They were a l s o among the  p r a c t i s e d f i v e or more times per week.  In both cases the partner took the dominant r o l e i n d i r e c t i n g and  supporting the woman throughout  the second  stage;  one  support person gave v e r b a l d i r e c t i o n s during each c o n t r a c t i o n w h i l e the other support person d i d model breathing and used hand d i r e c t i o n s person  throughout  each  a u t o m a t i c a l l y assumed t h i s  contraction. role  The  support  at the commencement  of second stage and the attending s t a f f seldom made any a t tempts t o overrule that guidance. The  remaining  p r e n a t a l attenders who  used  spontaneous  pushing f o r the m a j o r i t y of t h e i r second stage c o n t r a c t i o n s (and r e c e i v e d c o n f l i c t i n g i n s t r u c t i o n s ) followed the i n s t r u c t i o n s of the dominant person guiding them—the nurse or p h y s i c ian. role.  In f i v e d e l i v e r i e s the nurse took on the primary support She  spent  most of the time at the woman's bedside  t a l k i n g t o her i n a calm, r e a s s u r i n g manner, always o f f e r i n g encouraging words.  On s e v e r a l occasions other medical person-  nel  would t e l l the woman t o push hard w i t h the breath h e l d  but these p a r t i c u l a r nurses continued t o speak t o the woman in  the same manner, keeping the woman's a t t e n t i o n  focused  on her d i r e c t i o n s . In  two d e l i v e r i e s the p h y s i c i a n was present during the  e n t i r e second stage and favoured spontaneous pushing. one  o f the d e l i v e r i e s  the nurse  (who encouraged  During  Valsalva)  became non-verbal a f t e r approximately ten minutes; she c a r r i e d on w i t h the monitoring duties but o f f e r e d no f u r t h e r v e r b a l comments t o the mother u n t i l a f t e r the baby was d e l i v e r e d . In  the other d e l i v e r y the p h y s i c i a n stated that he wished  the woman t o be "allowed t o push as she f e l t the need" t o do so; t h i s occurred while he was i n the d e l i v e r y room but the woman was encouraged  t o do V a l s a l v a pushing when he l e f t  the room and spontaneous pushing resumed when he returned. The other women and t h e i r partners who had taken p r e n a t a l classes took t h e i r d i r e c t i o n s from the s t a f f present i n the room.  Only on two occasions were the women asked  (at the  commencement of the second stage w h i l e the observer was present) if  they had any preferences regarding the type o f breathing  or p o s i t i o n i n g they wished t o use during second stage. had  their  request  t o do spontaneous pushing  Neither  acknowledged.  One o f the women requested t o "squat arid do spontaneous pushing" the  and r e c e i v e d the r e p l y ,  "squatting i s d i f f i c u l t  with  e p i d u r a l " making no comment about choice o f breathing  technique. pushing.  This woman was then toother  i n s t r u c t e d t o do V a l s a l v a  woman (who had requested t o do spontaneous  pushing on a w r i t t e n b i r t h p l a n and was having a p r e c i p i t a t e d e l i v e r y ) was very f o r c e f u l l y t o l d t o "push as hard as you can—take of  a deep breath and push"—even w i t h acknowledgement  the p r e c i p i t a t e d e l i v e r y .  Although  the woman r e f e r r e d  t o her b i r t h p l a n the r e p l y was " I have not read your b i r t h plan". The m a j o r i t y o f women and partners who were i n s t r u c t e d and followed the d i r e c t i o n s f o r V a l s a l v a pushing never quest i o n e d any s t a f f about the technique nor d i d they make any requests regarding preferences f o r the management of second stage.  Yet a l l o f the women were able t o s t a t e that they  d i d not do the spontaneous breathing taught i n t h e i r p r e n a t a l c l a s s e s ; they j u s t followed d i r e c t i o n s from the s t a f f . The study  observation of the treatment of the women i n t h i s  support  the f i n d i n g s  1982) and Danziger (1978). ners  of S u l l i v a n  and Beeman  (1981-  Most of the women and t h e i r p a r t -  became passive i n that they followed d i r e c t i o n s  from  the s t a f f w i t h very few. challengess t o the procedures and routines i n the d e l i v e r y room.  When requests were made r e -  garding the conduct o f second stage they were b a r e l y acknowledged then often disregarded.  Complications and Breathing The  Patterns  study p a r t i c i p a n t s who used V a l s a l v a pushing during  second stage contractions had a greater number of complications than those p a r t i c i p a n t s who used spontaneous pushing. of  Nine  the 13 i n f a n t s were recorded as having f e t a l d i s t r e s s  when the women used V a l s a l v a  pushing  during  the majority  of t h e i r second stage contractions; 6 o f those 9 were recorded  as having e a r l y and l a t e f e t a l heart r a t e  (lasting  a f t e r the contraction  i s over).  are s i m i l a r t o those o f Caldeyro-Barcia (1973);  who support  less  decelerations These f i n d i n g s  (1979) and Humphrey  encouragement o f a c t i v e  down due t o the a s s o c i a t i o n w i t h  fetal  hypoxia,  bearing indicated  by l a t e f e t a l heart r a t e decelerations (Type I I Dips). late  fetal  electronic  heart  decelerations  These  are r e a d i l y observed when  f e t a l monitoring i s used and may be i n t e r p r e t e d  as a complication r e s u l t i n g i n d e l i v e r y by forceps o r caesarean section. Among the prenatal need  attender  group there was a greater  f o r i n t e r v e n t i o n among those women who used  Valsalva  pushing than among those who used spontaneous pushing.  How-  ever, t h i s d i f f e r e n c e was not seen i n the non-attender group, most l i k e l y due t o the low frequency of e p i d u r a l in  this  attender  group.  anesthesia  Many (34.3%) o f the women i n the p r e n a t a l  group who had e p i d u r a l anesthesia  and also required  i n t e r v e n t i o n , were d i r e c t e d t o use V a l s a l v a pushing t h e i r contractions.  during  Language S k i l l s Language s k i l l s are o f importance i n the woman's a b i l i t y to understand and converse w i t h her caregivers nurse).  While the number of those w i t h a non-similar language  was small i n the p r e n a t a l attender to  observe that regardless  proportion . o f attenders  group i t was i n t e r e s t i n g  o f language s k i l l s  versus  33.4% (non-attenders) (attenders)  pushing.  versus  the o v e r a l l  and non-attenders using spontaneous  pushing and V a l s a l v a pushing was s i m i l a r — 3 7 . 2 %  68.8%  (mainly the  f o r spontaneous  (attenders) pushing and  66.6% (non-attenders) f o r V a l s a l v a  A l l women revealed that although not having E n g l i s h  as t h e i r main language they understood 'push' by the loudness or  tone of voice of the caregivers.  Several women chose  to ignore the d i r e c t i o n s t o 'push' and instead followed t h e i r body urges t o push when they f e l t the need t o do so.  I t was  e a s i e r f o r those women t o disregard d i r e c t i o n s when the main language of the p a t i e n t and caregivers were d i f f e r e n t .  Labour Times The  total  labour  times f o r the p r e n a t a l attender and  non-attender groups was almost i d e n t i c a l — 9 hours, 48 minutes and  9 hours, 43 minutes r e s p e c t i v e l y .  The o v e r a l l second  stage duration o f both groups was a l s o s i m i l a r (70.4 minutes and  71.6 minutes).  pushing  For those women who used spontaneous  f o r the m a j o r i t y of t h e i r  contractions the second  stage was 81.3  s l i g h t l y longer f o r both groups (75.6 minutes and  minutes) p e r n a t a l attenders  tively  and  non-attenders  respec-  (versus 68.3 minutes and 68.0 minutes f o r those using  V a l s a l v a pushing). Caldeyro-Barcia  These d i f f e r e n c e s i n durations  (1979) and Perry and Potter's (1979) r e s u l t s  of a longer second stage when spontaneous pushing Although  support  i s used.  the a d d i t i o n a l time added t o second stage i s r e l a -  t i v e l y short, the question remains f o r the c l i n i c i a n , 'Does that added time have any detrimental e f f e c t on the f e t u s ? ' Information  from  Caldeyro-Barcia  (1979) and  Bassell  (1980)  suggest i t does not, p r o v i d i n g the fetus i s doing w e l l .  Infant Outcomes The  proportion  minute a f t e r or greater  of  i n f a n t s whose Apgar  (80%)  was  identical  non-attenders  seemed t o  groups.  receiving electronic f e t a l  have an  f e t a l monitoring  seven  However,  of the p r e n a t a l attenders  a s s o c i a t i o n t o the  use of e p i d u r a l anesthesia. tronic  f o r both  one  E l e c t r o n i c F e t a l Monitoring d i f f e r e d  considerably w i t h 62.9%  This  at  d e l i v e r y were l e s s than seven (20%) and  the proportions having  of the  scores  and  20%  monitoring.  corresponding  With the o v e r a l l r a t e of e l e c e -  being  50%  f o r the study group  and  the numbers of recorded f e t a l d i s t r e s s being 26% f o r the whole group, suggestions by Dunn (1976) and Schneider (1981) that e l e c t r o n i c  fetal  monitoring  l i k e , other i n t e r v e n t i o n s has almost become  part of the r i t u a l of c h i l d b i r t h , may be proven, t o be t r u e .  Confidence, Perception o f Labour and D e l i v e r y Women who attended confidence  prior  p r e n a t a l classes expressed  to their  labour  and d e l i v e r y  greater  experience  and perceived t h e i r b i r t h experience t o be b e t t e r than those women who d i d not attend p r e n a t a l c l a s s e s .  Regardless o f  the greater numbers o f i n t e r v e n t i o n s p r e n a t a l attenders experienced,  they  experience. the  expressed As w i t h  more p o s i t i v e f e e l i n g s about Danziger's  women's comments about  their  their  (1979) f i n d i n g s , most o f d e l i v e r y i n d i c a t e d that  there were no a l t e r n a t i v e s f o r them and that the e x p e r i e n c e — however d i f f i c u l t  was worth i t because they have a healthy  child. I l l u s t r a t e d by the f a c t that not a l l p r e n a t a l attenders were  able  t o describe  the breathing  techniques  taught i n  t h e i r classes and only two women a t t r i b u t e d t h e i r breathing to that  the information  received  women do not receive  i n p r e n a t a l classes i n d i c a t e s sufficient  information and the  guidance and p r a c t i c e needed regarding the use o f a l t e r n a t i v e breathing  approaches t o make any appreciable impact on the  conduct o f the second stage o f labour.  Conclusion  The purpose o f t h i s study was t o describe the breathing techniques used by women during the second stage o f labour and  t o determine  more l i k e l y  i f women who take p r e n a t a l education are  (than non-attenders) t o use spontaneous  pushing  during second stage contractions. The p r e n a t a l attenders had an average age o f 28 years and the non-attenders an average age o f 26 years.  The major-  i t y o f women i n the p r e n a t a l attender group were Caucasian, English better  speaking and were employed a t a s k i l l e d (74.3%).  level or  The m a j o r i t y o f women i n the non-attenders  group were born i n one o f the Asian countries, had Chinese as t h e i r main language and were employed i n a s k i l l e d  level  or l e s s (80.0%). Prenatal c l a s s attenders had a higher r a t e of e p i d u r a l anesthesia (48.6% versus 20.0%) during t h e i r labour and d e l i v ery,  a higher r a t e  versus  f e t a l monitoring (62.9%  20.0%) during labour and d e l i v e r y , a higher r a t e o f  recorded and  of e l e c t r o n i c  intrapartum complications (62.9'%  a higher r a t e of interventions  versus  during d e l i v e r y  20.0%), (51.4%  versus 26.6%) than d i d those women i n the non-attender group. The proportion of p r e n a t a l attenders and non-attenders who used spontaneous pushing f o r more than 60% of t h e i r cont r a c t i o n s was almost i d e n t i c a l — 2 9 . 4 % f o r p r e n a t a l attenders and 27.3% f o r non-attenders. attender  group  attributed  Only two women i n the p r e n a t a l their  approach  t o second  stage  breathing  t o information  at p r e n a t a l c l a s s e s .  they  acquired  through  attendance  The m a j o r i t y o f women i n both the pre-  n a t a l attender and the non-attender groups followed the d i r e c tions  from the s t a f f a s s i s t i n g i n the b i r t h — m a i n l y t o use  the extended breath holding technique,  the V a l s a l v a maneuver.  When using the V a l s a l v a maneuver many o f the women were r e ported as having  a complication of f e t a l d i s t r e s s i n v o l v i n g  late  r a t e decelerations which are a r e s u l t o f  fetal  heart  the p h y s i o l o g i c a l e f f e c t s of the V a l s a l v a maneuver used by the women during second stage c o n t r a c t i o n s . The  total  duration  of labour  was s i m i l a r between the  two groups; w i t h the second stage of labour (excluding i n t e r ventions) minutes  f o r those women using spontaneous pushing (75.6 f o r prenatal  attenders)  attenders  and 81.3 minutes f o r non-  being s l i g h t l y longer than f o r those women using  V a l s a l v a pushing (68.3 minutes and 68.0 minutes f o r p r e n a t a l attenders and non-attenders r e s p e c t i v e l y ) . In  conclusion,  the f i n d i n g s  that  prenatal  attenders  have more e p i d u r a l anesthesia which then has a 'domino' e f f e c t on subsequent practice;  i n the c h i l d b i r t h process and  the f a c t that only 2 o f 35 women who attended p r e n a t a l educat i o n could a t t r i b u t e information from t h e i r classes as having a d i r e c t impact on t h e i r breathing s t y l e (during the second stage o f labour)  i n d i c a t e s there i s a need f o r b e t t e r prep-  a r a t i o n i n coping w i t h the experience of c h i l d b i r t h .  151  Implications of the Study  The  reported f i n d i n g s of t h i s study have the f o l l o w i n g  implications: 1.  Prenatal education programs t o expectant parents  should  be adapted t o provide: - more  information  and  emphasis  on  s t r a t e g i e s which  can be used i n coping w i t h pain during c h i l d b i r t h . - more d i s c u s s i o n regarding the e f f e c t s of the V a l s a l v a maneuver on the mother and her dependent fetus during the second stage of labour. - greater emphasis p r a c t i s i n g breathing and  techniques  which can  be  and r e l a x a t i o n  used during  labour  and  delivery. - greater emphasis and p r a c t i c e of s p e c i f i c t o o l s which can be used i n coping w i t h second stage contractions (e.g. v e r b a l d i r e c t i o n s , v i s u a l d i r e c t i o n s , the v a r i e t y of p o s i t i o n s a v a i l a b l e ) which could enhance the  use  of spontaneous pushing. - greater  direction  he/she f e e l s the  f o r the  comfortable  woman i n her  use  of  support  person such that  i n supporting and  directing  spontaneous pushing  during  second stage labour. 2.  Those who be  teach the p r e n a t a l education programs should  f r e q u e n t l y updated on the most recent research f i n d -  ings  r e l a t e d t o the e f f e c t s  o f the V a l s a l v a Maneuver  and the conduct o f second stage labour and the treatment of women during c h i l d b i r t h . 3.  Nursing s t a f f who provide most o f the primary care during labour of  and d e l i v e r y should  be updated  breathing and r e l a x a t i o n techniques  on the s k i l l s t o be used i n  the management o f labour i n an attempt t o minimize the use  o f e p i d u r a l anesthesia during the f i r s t  stage o f  labour. 4.  Since the labour and d e l i v e r y room nurses were a major influence  on the breathing  patterns  o f women during  second stage, nursing personnel should be provided w i t h current research f i n d i n g s and information on c h i l d b i r t h philosophies. 5.  Since  labour and d e l i v e r y nurses  influences  on a woman's behaviour  delivery,  greater  education  regarding  the  are one of the major  emphasis  should  during  labour and  be placed on s t a f f  s t r a t e g i e s which might be used by  d e l i v e r i n g woman and her partner t o enhance t h e i r  b i r t h process. 6.  Nursing  and medical  students  should be provided  with  current research f i n d i n g s and information on the e f f e c t s of  the V a l s a l v a maneuver and s t r a t e g i e s f o r managing  the second stage o f labour.  152  Since  physicians a l s o provide  during the second stage familiar  direction  t o the woman  o f labour, they should become  w i t h current research on the conduct o f the  second stage  o f labour as i t r e l a t e s  t o the V a l s a l v a  maneuver and i t s e f f e c t s on the f e t a l heart r a t e which may lead t o unnecessary i n t e r v e n t i o n s . Since physicians provide a major p o r t i o n of the p r e n a t a l h e a l t h care t o pregnant women, they should take advantage of t h e i r p o t e n t i a l t o educate expectant mothers on the implications encourage  of e p i d u r a l anesthesia during labour and  their  clients  t o l e a r n techniques  for  use  i n coping w i t h the pain o f c h i l d b i r t h . Pregnant women should consider having a labour person to  support  (besides her husband) present during c h i l d b i r t h  provide  companionship, encouragement and t o a s s i s t  the woman i n the use of learned coping s k i l l s . New and innovative methods f o r teaching expectant parents skills  f o r coping w i t h c h i l d b i r t h should be c o n t i n u a l l y  t r i e d by h e a l t h educators and evaluated f o r e f f e c t i v e n e s s . Planners o f p r e n a t a l education programs i n c o l l a b o r a t i o n w i t h researchers, must s p e c i f y more d e f i n i t e l y the change/ outcome  i t expects  i n program p a r t i c i p a n t s  i n order  that appropriate measurement techniques may be e s t a b l i s h e d .  Planners  of community based programs should  representatives  of  delivery  and  room,  the  medical  community,  consumers who  are  l i n k with labour  concerned  and with  the d e l i v e r y of p e r i n a t a l care, i n an attempt t o provide a in  r e a l i s t i c and the  uniform philosophy which can  preparation of  expectant  through t o the b i r t h experience.  parents  and  be  used  carried  155  Recommendations f o r Further Study  Based on the f i n d i n g s of t h i s study, the f o l l o w i n g recommendations f o r f u r t h e r research are recommended. 1.  A prospective  study  should  be conducted  on a l a r g e r  sample, p r e f e r a b l y i n a number of f a c i l i t i e s , t o i n v e s t i g a t e the  influences on a woman's a b i l i t y t o cope w i t h the pain  of labour, the need f o r anesthesia, and the breathing s t r a t e g ies i n the second stage o f labour. 2.  Further  study needs to be conducted on the e f f e c t s o f  the V a l s a l v a maneuver on the woman and fetus during  labour  and d e l i v e r y . 3.  Further i n v e s t i g a t i o n should be conducted on the i n c i d -  ence o f s p e c i f i c complications o f labour and d e l i v e r y f o l l o w ing e p i d u r a l anesthesia. 4.  There i s a need t o examine i n greater depth, which coping  strategies  are most e f f e c t i v e  i n d e a l i n g w i t h the pain o f  labour and d e l i v e r y . 5.  A d d i t i o n a l research  teaching  methods  t o develop e f f i c i e n t and e f f e c t i v e  d i r e c t e d a t p r o v i d i n g the coping  skills  for labour and d e l i v e r y i s warranted. 6. in  There i s need t o examine i n greater depth  the d i f f e r e n c e s  s t r a t e g i e s i n coping w i t h pain between the middle c l a s s  Caucasian  p r e n a t a l attender and the non-white  non-prenatal  attender who has l i m i t e d p r e n a t a l information. 7.  Since  labour  and d e l i v e r y  room  nurses  were  observed  and reported t o be a major influence on a woman's behaviour and  breathing techniques  labour and d e l i v e r y  used during d e l i v e r y ,  nurses  a survey o f  should be conducted t o i d e n t i f y  t h e i r philosohy and the information they give t o women and t h e i r partners during the b i r t h experience. 8.  Research!: studies should  be endeavoured t o study the  outcome o f " s a t i s f a c t i o n w i t h the b i r t h experience", o f women who  are able t o choose t h e i r own s t y l e of b i r t h and those  women b i r t h i n g i n the 'conventional environment'.  REFERENCES  Adams, J.Q. & Alexander, A. (1958). A l t e r a t i o n i n Cardiovascular Phsyiology During Labour. Obstetrics and Gynecology, 12:542-549. Anderson, B.J. & Standley, K. (1977). Method f o r N a t u r a l i s t i c Observation of the C h i l d b i r t h Environment. JSAS Catal o g of Selected Documents i n Psychology. 7(1), 6. Aday, L.A., S e l l e r s , C. & Anderson, R.M. (1981). P o t e n t i a l of L o c a l Health Surveys. A State of the A r t Summary. A.S.P.H. 71(8). Barnett, M.M. & Humenicks, S. (1982). Infant Outcome i n R e l a t i o n t o Second Stage Labour Pushing Method. B i r t h , 19(4), 221-228. B a s s e l l , G.M., Humayan, S.G. & Marx, G.F. (1980). Maternal Bearing-Down E f f o r t s — A n o t h e r F e t a l Risk? - O b s t e t r i c s and Gynecology, 56, 39-41. Beck, N.C. & H a l l , D. (1978). Natural C h i l d b i r t h : A Review and A n a l y s i s . O b s t e t r i c s and Gynecology, 54(3), 371379. Beck, N.C. & S i e g e l , L.J. (1980). Preparation f o r C h i l d b i r t h and Contemporary Research on Pain, Anxiety, and Stress Reduction: A Review and C r i t i q u e . Psychosomatic Medicine, 42(4), 429-447. Belsey, E.M., Rosenblatt, D.B., & Lieberman, B.A. (1981). The Influence of Maternal Analgesia on Neonatal Behavi o u r : I.Pethidine. B r i t i s h Journal of O b s t e t r i c s and Gynecology, 88:398-406. Beynon, C.L. (1957). The Normal Second Stage of Labour: A P l e a f o r Reform i n I t s Conduct. Journal of O b s t e t r i c s and Gynecology of the B r i t i s h Empire, 64(6), 815-820. Bergs j o , P. & H a i l e , C. (1980). Duration of the Second Stage of Labour. Acta O b s t e t r i c i a et Gynecologica Scandena v i a , 59:193-196. B i e n i a r z , J . , Maqueda, R., & Caldeyro-Barcia, R. (1966). Compression of Aorta by the Uterus i n Late Human Pregnancy. American Journal of O b s t e t r i c s and Gynecology, 95:795-808.  Bonica, J . J . (1967). P r i n c i p l e s and P r a c t i c e s of O b s t e t r i c Analgesia and Anesthesia. P h i l a d e l p h i a : F.A. Davis Company. Bonica, J . J . (1973). Maternal Respiratory Changes During Pregnancy and P a r t u r i t i o n . C l i n i c a l Anesthesia, 10(2), 1-19. Boutourline-Young, H., & Boutourline-Young, E. (1956) A l v e o l a r Carbon Dioxide Levels i n Pregnant P a r t u r i e n t s and L a c t a t i n g Subjects, Journal of Obstetrics and Gynecology of B r i t i s h Commonwealth, 63:509-528. Braunwald, E. (1965). C o n t r o l of V e n t r i c u l a r Man. B r i t i s h Heart Journal, 27, 1-16.  Function i n  Caldeyro-Barcia, R. (1979). The Influence of Maternal Bearingdown E f f o r t s during Second Stage on F e t a l Weil-Being. B i r t h and the Family Journal, 6(1), 17-21. Canadian P u b l i c Health A s s o c i a t i o n (1980). Guide t o Questionn a i r e Construction and Question W r i t i n g . Ottawa: The Canadian P u b l i c Health A s s o c i a t i o n . Chalmers, I . (1983). S c i e n t i f i c Inquiry and A u t h o r i t a r i a n i s m i n P e r i n a t a l Care and Education. B i r t h , 10(3), 151164. Clark, A.L., & Affonso, D.D. (1976). Childbearing: A Nursing Perspective. P h i l a d e l p h i a : F.A. Davis Company. Close, S. (1980). Birth P u b l i s h i n g Company.  Report.  Bristol,  England:  NFER  Cohen, :R.L. (1982). A Comparative Study of Women Choosing. Two D i f f e r e n t C h i l d b i r t h A l t e r n a t i v e s . B i r t h , 9(1), 13-19. Cohen, W.R. (1977). Influence of the Duration of Second Stage Labour on P e r i n a t a l Outcome and Puerperal Morbidity. O b s t e t r i c s and Gynecology, 49(3), 266-269. Cole,  P. V., & Nainby-Luxmoore, R.C. (1962). Respiratory Volumes i n Labour. B r i t i s h Medical Journal, 1, 11181119.  C u r t i n , B.C., Reick, K.L. (1969). E f f e c t s of B o d i l y P o s i t i o n on the S y s t o l i c Blood Pressure Response t o V a l s a l v a ' s Maneuver. Nursing Research^,. 18(2), 119-123.  Danziger, S.K. (1978). Uses of E x p e r t i s e i n Doctor-Patient Encounters During Pregnancy. S o c i a l Science and Medicine, 12, 359-367. Davenport-Slack, B.D. & Boylan, C.H. (1975). P s y c h o l o g i c a l Correlates of C h i l d b i r t h Pain. Psychosomatic Medicine, 36, 215-223. Doering, S.G. & E n t w i s t l e , D.R. (1975). Preparation During Pregnancy and A b i l i t y t o Cope w i t h Labour and Delivery. 'American Journal of Orthopsychiatry, 45, 825-837. Dunn, P.M. (1976). O b s t e t r i c D e l i v e r y Today: or f o r Worse? The Lancet. A p r i l , 790-793.  For B e t t e r  E l i s b e r g , E . I . (1963). Heart Rate Response t o the V a l s a l v a Maneuver as a Test of C i r c u l a t o r y I n t e g r i t y . Journal of American Medical A s s o c i a t i o n , 186, 200-205. Enkin, M.W., Smith, S.L., Dermer, S.W., and Emmett, J.O. (1972). An Adequately C o n t r o l l e d Study of the E f f e c t i v e ness of PPM T r a i n i n g . In Psychosomatic Medicine i n O b s t e t r i c s and Gynecology (pp. 62-67). E d i t e d byb;, N. Moris. B a s e l : S. Karger. Fleury, P.M. (1967). Maternity Care: Mothers Experiences of C h i l d b i r t h , London: George A l l e n & Unwin L i m i t e d . Fox,  I . J . , Crowley, P., Grace, J.B.,-& Wood, E.H. (1966). E f f e c t s of the V a l s a l v a Maneuver on Blood Flow i n the Thoracic Aorta i n Man. Journal of Applied Physiology, 21, 1553-1560.  Gordon, J.S. and Haire, D. (1981). A l t e r n a t i v e s i n C h i l d b i r t h . In Pregnancy, C h i l d b i r t h and Parenthood. (pp. 287301). E d i t e d by P. Ahmed. New York: E l s v i e r North Holand. Inc. Hamilton, W.F. (1936). P h y s i o l o g i c a l Relations Between I n t r a t h o r a c i c , I n t r a s p i n a l , and A r t e r i a l Pressure. Journal of American Medical A s s o c i a t i o n . 107, 853-856. Hansen, J.M. & Ueland, K. (1973). Maternal Cardiovascular Dynamics During Pregnancy and P a r t u r i t i o n . Clinical Anesthesia, 10(2), 21-36. Hellman, L.M. & Prystowsky, H. (1952). The Duration of the Second Stage of Labour. Americal Journal of O b s t e t r i c s and Gynecology, 63(2), 1223-1233.  Hendricks, C.H. & Q u i l l i g a n , E.J. (1956). Cardiac Output During Labour. American Journal of O b s t e t r i c s and Gynecology, 71, 953-972. Hobel, C.J., Hyvarainen, M.A., & Okada, D.M. (1973). Pren a t a l and Intrapartum High-Risk Screening. American Journal of O b s t e t r i c s and Gynecology, 117, 1-9. Hoult, I . J . , MacLennan, A.H., C a r r i e , E.L.S. (1977). Lumbar E p i d u r a l Analgesia i n Labour: R e l a t i o n t o F e t a l Malp o s i t i o n and Instrumental D e l i v e r y . B r i t i s h Medical Journal 1, 14-16. Kastendieck, E., Kunzel, W., & Zimmermann, P. (1974). Quantit a t i v e R e l a t i o n s h i p s Between Slowing of the F e t a l Heart Rate and Changes i n Base-Excess i n the Second Stage of Labour. Journal of P e r i n a t a l Medicine, 2, 106-109. K i r i t z , S., & Moos, R.H. S o c i a l Environments. 96-114.  (1974). P h y s i o l o g i c a l E f f e c t s of Psychosomatic Medicine, 36(2),  K i t z i n g e r , S. (1977). Education and Counselling f o r C h i l d b i r t h . New York: Schocken Books, pp. 231-241. K i t z i n g e r , S. (1977). Challenges i n Antenatal Education: A Fresh Look at the Second Stage. Nursing M i r r o r , July, 17-20. K i t z i n g e r , S., & Davis, J.A. (1978). Oxford U n i v e r s i t y Press.  The Place of Birthy.;Oxford  K l e i n , M. (1982). Comment of Labour i s S t i l l P a i n f u l . i a n Medical Journal, 126, 354-355.  Canad-  K l e i n , R., G i s t , N., Nicholson, J . , & Standley, K. (1981). A Study of Father and Nurse Support During Labour. B i r t h and the Family Journal, 8, 161-164. Korner, P.I., Tonkin, A.M., & Uther, J.B. (1976). Reflex and Mechanical C i r c u l a t o r y E f f e c t s of Graded V a l s a l v a Maneuvers i n Normal Man. Journal of A p p l i e d Physiology, 40(3), 434-440. Lee,  G., Matthews, M.B., and Sharpey-Schafer, E.P. (1954). The E f f e c t of the V a l s a l v a Manoeuvre on the Systemic and Pulmonary A r t e r i a l Pressure i n Man. B r i t i s h Heart Journal, 16, 311-316.  Lieberman, M.A. (1975). Adaptive Processes i n Late L i f e . In L i f e Span Developmental Psychology: Normative L i f e Crisis. (pp. 135-159). Edited by N. Datan and L. Ginsberg. New York: Academic Press. Low,.. J.A., Pancham, S.R., Worthington, D. & Boston, R.W. (1975). The Acid-Base and Biochemical C h a r a c t e r i s t i c s of Intrapartum F e t a l Asphyxia. American Journal of O b s t e t r i c i a n s and Gynecology, 2, 446-451. Macfarlane, A. (1977). The Psychology of C h i l d b i r t h . sachusetts: Harvard U n i v e r s i t y Press. McGuire, J . (1949). Bed Pan Deaths. Climate A s s o c i a t i o n , 60, 78-85.  Trans American  Mas-  Clinical  McKay, S. (1981). Second-Stage Labour — Has T r a d i t i o n Replaced Safety? American Journal of Nursing, 81, 10161019. Mehl,  L.E. (1977). Options Health, 2, 29-42.  i n Maternity Care.  Women and  Melzack, R., Taenzer, P., Feldman, P. & Kinch, R. (1981). Labour i s S t i l l P a i n f u l A f t e r Prepared C h i l d b i r t h T r a i n i n g . Canadian Medical Journal, 125, 357-363. Meyers, J . , & Roberts, B. (1958). Family and Class Dynamics i n Mental I l l n e s s , (p. 40), New York: John Wiley & Sons. Moore, W.M.O. (1977). The Conduct of the Second Stage. In B e n e f i t s and Hazards of the New O b s t e t r i c s , (pp. 116-125). E d i t e d by T. Chard and M. Richards. P h i l a d e l p h i a : J. B." L i p p i n c o t t Company. Motoyama, E.K., Acheson, F. & Rivard, G. (1966). E f f e c t s of Maternal H y p e r v e n t i l a t i o n on the The Lancet, 1, 286-288.  Adverse Foetus.  N e s b i t t , R.E.L. J r . & Aubrey, R.H. (1969). High Risk Obstetr i c s I I . American Journal of O b s t e t r i c s and Gynecology, 103, 972-985. Newfcony N." (1977). The E f f e c t of Fear and Disturbance on Labour. In 21st. Century O b s t e t r i c s Now! (pp. 61-71), E d i t e d by L. Stewart and D. Stewart. . North C a r o l i n a : Chapel H i l l . :  Nelson, N.M. (1981). A More Balanced Approach t o P r e n a t a l Education. Canadian Medical Journal, 125, 331-332.  Nelson, N.M., Enkin, M.W., S a i g a l , S., Bennett, K.J., M i l n e r , R., & Sackett, D. (1980). A Randomized C l i n i c a l T r i a l of the Leboyer Approach t o C h i l d b i r t h . The New England Journal o f Medicine, 302(12), 655-660. Niswander, K.R. & Gordon, M. (1972). The C o l l a b o r a t i v e P e r i n a t a l Study of the N a t i o n a l I n s t i t u t e o f N e u r o l o g i c a l Diseases and Stroke; The Women and Their Pregnancies. P h i l a d e l p h i a : Saunders Company. Noble, E. (1983). C h i l d b i r t h w i t h I n s i g h t . M i f f l i n Company.  Boston: Houghton  Noble, E. (1981). Controversies i n Maternal E f f o r t During Labour and D e l i v e r y . Journal o f Nursing Midwifery, 26(2), 13-22. Noble, E. (1976). E s s e n t i a l Exercises f o r the C h i l d b e a r i n g Year. Boston: Houghton M i f f l i n Company. Noble, E. (1978). Rationale f o r P r e n a t a l and Postpartum Exercises. In Kaleidoscope o f Childbearing: Preparat i o n , B i r t h and Nurturing (pp. 9tfl2:)J.E d i t e d by P. Simpkin and C. Reinke. S e a t t l e : Pennypress. Nuckolls, K.B., C a s s e l l , J.C. & Kaplan, B. (1972). Psychos o c i a l Assets, L i f e C r i s i s and the Prognosis o f Pregnancy. American Journal o f Epidemiology, 95(15), 431-440. Nunnally, D.M. & Aguiar, M.B. (1974). Patients E v a l u a t i o n of Their P r e n a t a l and D e l i v e r y Care. Nursing Research, 23(6), 469-474. Perry, L. & Potter, C. (1977). Pushing Technique and the Duration o f the Second Stage of Labour. The West V i r g i n i a Medical Journal, 75(2), 32-34. Peterson, G.H. (1981). B i r t h i n g Normally: A Personal Growth Approach t o C h i l d b i r t h . Berkeley: Mindbody Press. Pridham, K.F. & Schutz, M.E. (1983). P a r e n t a l Goals and the B i r t h i n g Experience. Journal Gynecological Nursing, 12(1), 50-55. P r i t c h a r d , J.A. & MacDonald, P.C. (Eds.). (1980). William's O b s t e t r i c s . (pp. 405-434), New York: Appleton-CenturyCrofts. Re i d ,  D.H.S. (1966). Respiratory Changes i n Labour. Lancet 1, 784-785.  The  R i l e y , E.M.D. (1977). What Do Women Want? — The Question of Choice i n the Conduct o f Labour. In B e n e f i t s and Hazards of the New O b s t e t r i c s , (pp. 62-71). Edited by T. Chard and M. Richards. Philadelphia:^. J.B. L i p p i n c o t t Company. Roberts, J . (1980). Alternative Positions f o r C h i l d b i r t h — P a r t I I : Second Stage o f Labour. Journal o f NurseMidwifery, 25(5), 13-19. Robertson, A. (1983). P e r i n a t a l Review — Phase I I . Health Department.  Vancouver  Roemer, V.K., Harms, K., Buess, H. & Horvath, T.J. (1976). Response o f F e t a l Acid-Base Balance t o Duration o f Second Stage o f Labour. I n t e r n a t i o n a l Journal o f Gynecology and O b s t e t r i c s , 14, 455-471. Rosenberg, S.N., Albertsen, P.C., Jones, E. & Roberts, R. (1981). Complications of Labor and D e l i v e r y -.Following Uncomplicated Pregnancy. Medical Care, 19(1), 68-79. Scaer, R., & Korte, D. (1978). MOM Survey: Maternity Options f o r Mothers -- What Do Women JWant i n Maternity Care/'' B i r t h and the Family Journal, 5(1), 20-26. Schneider, G. (1981). Management of Normal Labour and D e l i v e r y i n the Case Room: A C r i t i c a l A p p r a i s a l . Canadian Medical Journal, 125, 350-352. Scott, J.R. & Rose, N. (1976). E f f e c t of Psychoprophylaxis (Lamaze) on Labor and D e l i v e r y i n Primiparas. New England Journal of Medicine, 29(22), ,1205-1207. Sharpey-Schafer, E.P. (1965). E f f e c t o f Respiratory Acts on the C i r c u l a t i o n . In Handbook o f Physiology, (pp. 1875-1885). E d i t e d by W.F. Hamilton. 3(2). Washington: American P h y s i o l o g i c a l Society. Shereshefsksy, P.M. & Yarrow, L.J. (Eds.) (1973). Psychol o g i c a l Aspects of a F i r s t Pregnancy and E a r l y P o s t n a t a l Adaption. New York: Raven. Sokol, R.J., Rosen, M.G. & Stojkov, J . (1977). Clinical A p p l i c a t i o n o f High Risk Scoring on an O b s t e t r i c Service. American Journal o f O b s t e t r i c s and Gynecology, 128, 652-656. Standley, K. (1981). Researach on C h i l d b i r t h Toward an Understanding of Coping. In Pregnancy, C h i l d b i r t h and Parenthood, (pp. 213-223). Edited by P. Ahmed. New York: E l s v i e r North Holland, Inc.  Standley, K. & Nicholson, J . (1980). Observing C h i l d b i r t h Environment: A Research Model. Birth the Family Journal, 7(1), 15-20.  the and  S t a t i s t i c s Canada (1982). B i r t h s and Deaths, Summary L i s t of Causes. V i t a l S t a t i s t i c s Volume I . Ottawa: Health D i v i s i o n , V i t a l S t a t i s t i c s and Disease. Stewart, D. & Stewart, L. (Eds), (1976). Safe A l t e r n a t i v e s i n C h i l d b i r t h . North C a r o l i n a : NAPSAC, Incorporated. Stewart, M.A. & Wanklin, J . (1978). D i r e c t and I n d i r e c t Measures of Patient S a t i s f a c t i o n w i t h Physicians' S e r v i c e s . Journal of Community Health, 3(3), 195-204. S u l l i v a n , D.A. & Beeman, R. (1982). S a t i s f a c t i o n With Matern i t y Care: A Matter of Communication and Choice. Medical Care, 20(3), 321-330. S u l l i v a n , D.A. & Beeman, R. (1981). S a t i s f a c t i o n w i t h Postpartum Care: Opportunities f o r Bonding, Reconstructing the B i r t h and I n s t r u c t i o n . B i r t h and the Family Journal, 8(3), 153-159. Trandel-Korenchuk, D. (1982). Informed Consent C l i e n t P a r t i c i p a t i o n i n C h i l d b i r t h Decisions. Journal of Gynecol o g i c a l Nursing, 11(6), 379-381. Wood, C , Ng, K.H., Hounslow, D. & Benning, H. (1973). Time— An Important V a r i a b l e i n Normal Delivery. Journal of O b s t e t r i c s and Gynecology of the B r i t i s h Commonwealth, 80, 295-300. Warwiac, D.P. & L i n i n g e r , C.A. (1975). The Sample Survey: Theory and P r a c t i s e , (pp.72-75). New York: McGraw H i l l Book Company. Winner, C.L. & Romney, S.L. (1966). Cardiovascular Responses to Labour and D e l i v e r y . American Journal of O b s t e t r i c s and Gynecology. 95, 1104-1114. Wolkind, S. & Zajcek, E. (Eds.). (1981). Pregnancy: A P s y c h o l o g i c a l and S o c i o l o g i c a l Study. London: Academic Press. Wright, H.P., M o r r i s , N., Osborn, S.B., & Hart, A. (1958). E f f e c t i v e Uterine Blood Flow During Labour. American Journal of O b s t e t r i c s and Gynecology,. 75, 3-10. Young, D. (1982). Changing C h i l d b i r t h : Family B i r t h i n the H o s p i t a l . New York: C h i l d b i r t h Graphics L i m i t e d .  APPENDIX A  Submission  To  The U n i v e r s i t y of B r i t i s h Columbia Screening Committee f o r Research and Other Studies Involving Human Subjects Behavioural Sciences  DESCRIPTION  OF  POPULATION P A G E Z  11 HOW  M A N YS U B J E C T S WILL B E U S E D ?  sixty 12 WHO  IS BEING R E C R U I T E D ?  '  Women d e l i v e r i n g b a b i e s  —  —  -  _  —  i n the l o w - r i s k l a b o u r / d e l i v e r y u n i t o f  -±,hft_llT>?i(-P WnsnU.al . 13 HOW UBC  ARE T H ES U B J E C T S BEING R E C R U I T E D AND S E L E C T E D ? policies prohibit initial contact hy telephone)  By 1*  personal  (if  initial  contact  is  by  letter,  attach  a  cop.:  contact  W H A TA R ET H E CRITERIA F D R THEIR SELECTION?  P r i m i p a r o u s women who e n t e r t h e l o w - r i s k l a b o u r / d e l i v e r y u n i t during the study p e r i o d . DESCRIPTION  OF  METHODOLOGY  15 S U M M A R Y (must be  complete  in  AND this  PROCEDURES space)  The s t u d y w i l l u s e a c o m b i n a t i o n o f t h r e e m e t h o d s f o r d a t a collection. 1) O b s e r v a t i o n o f t h e c h i l d b i r t h e n v i r o n m e n t u s i n g a n o b s e r v a t i o n i n s t r u m e n t d e v e l o p e d a t t h e N.I.C.H.H.D. i n B e t h e s d a , M a r y l a n d . I t i s a m e t h o d f o r r e c o r d i n g o b s e r v a b l e f e a t u r e s o f t h e woman's p h y s i c a l s t a t e , t h e i d e n t i t y and i n t e r a c t i o n s o f p e r s o n s i n t h e d e l i v e r y room, a v a r i e t y o f m e d i c a l i n t e r v e n t i o n s and s o c i a l b e h a v i o u r s and themes o f v e r b a l c o n v e r s a t i o n s w i t h t h e l a b o u r i n g woman. The s y s t e m o f c a t e g o r i e s a r e t i m e - s a m p l e d i n c y c l e s o f 30 s e c o n d s f o r o b s e r v a t i o n a n d 30 s e c o n d s f o r r e c o r d i n g . 2) o n e - t w o d a y s f o l l o w i n g d e l i v e r y t h e woman w i l l be v i s i t e d by t h e r e s e a r c h e r f o r an i n t e r v i e w u s i n g t h e q u e s t i o n a i r e f o r m a t . 3) A u g m e n t a t i o n o f t h e a b o v e i n f o r m a t i o n w i t h m e d i c a l d a t a on t h e c o u r s e o f l a b o u r a n d d e l i v e r y w i l l be o b t a i n e d f r o m t h e p a t i e n t ' medical record.  The s t u d y w i l l be r e c o r d e d i n t h e f o r m r e q u i r e d f o r a n MSc t h e s i s i n H e a l t h Care P l a n n i n g f o r t h e Department o f H e a l t h C a r e a n d E p i d e m i o l o g y a t UBC.  16 W H E R E WILL T H EP R O J E C TB EC O N D U C T E D ? (roora or  The 1? WHO  Grace H o s p i t a l  WILL A C T U A L L YC O N D U C TT H ES T U D Y ?  Barbara 18 HOW  area)  principal  investigator,  .;.  Selwood  WILL T H EP R O J E C TB E EXPLAINED TO  Personal  (e.g.  T H E S U B J E C T S ?  explanation plus  explanatory l e t t e r .  DESCRIPTION OF HKTHOnOUHlY ASP mVLIXIKKS 19 H O W  WILL YOU  (cant)  P A G E 3  M A K E IT C L E A R TO Tl-E S U B J E C T ST H A T THEIR PARTICIPATION IS V O L U N T A R Y A N DT H A TT V C V M A Y  W T IH D R A W F R O M THE  S T U D Y AT  ANY  T h i s w i l l be s t a t e d i n t h e v e r b a l e x p l a n a t i o n ; on t h e l e t t e r o f e x p l a n a t i o n and c o n s e n t . 20 WILL Y O U RP R O J E C T UTILIZE. X  X  INTERVIEWS (submit  s ccpy)  ^  sample of questions)  n  O B S E R V A T O I N S (subir.it a brief  °  T E S T S ^submit a brixf  X  i ti s written  (check)  Q U E S T I O N N A I R E S (submit  D  n  jgfc  TIME T H E Y W I S H TO DISCONTINUE PARTICIPATION?  ) Combined  description)  description)  DATA  21 W H O  WILL H A V EA C C E S S TO T H EG A T H E R E D D A T A ? (e.g., committee  R e s e a r c h and T h e s i s 22 H O W  WILL CONFIDENTIALITY OF  members, government agencies,  others.  Committee  Please specify.)  T H ED A T AB E MAINTAINED?  S u b j e c t s names known o n l y t o r e s e a r c h e r . Numbers w i l l b e u s e d o n a u e s t i o n a l r e i n s t e a d o f names  23 H O W  WILL T H ED A T A BE R E C O R D E D ?  (instruments,  notes,  etc.)  Observation instrument recording sheet QnpRt1nnalre during the i n t e r v i e w 21, W H A TA R ET H EP L A N S FOR  F U T U R EU S EO FD A T AA SP A R T OF THIS S T U D Y OR U S EB E Y O N D THIS S T U D Y ?  None 25 H O W  WILL T H ED A T A BE D E S T R O Y E D AND W H E N ?  By  fire  BENEFITS.  a t t h e end o f t h e study  CCSTS.  RISKS  26 W H A TA R ET H E POTENTIAL BENEFITS T O T H E S U B J E C T S ?  Minimal 27 W H A T M A YB ER E V E A L E DT H A T IS NOT  C U R R E N T L Y K N O W N ?  The m a t c h o r m i s m a t c h o f p r e n a t a l p r e p a r a t i o n r e g a r d i n g t e c h n i q u e s f o r second s t a g e l a b o u r and what i s u t i l i z e d 28 W H A T M O N E T A R YC O M P E N S A T O I N IS O F F E R E DT O T H E S U B J E C T S ?  breathing d u r i n g thi£ time.  None > 9 W H A TA R ET H EC O S T S TO T H ES U B J E C T S ? (monetary,  Thirty  time )  t o f o u r t y - f i v e minutes f o r the i n t e r v i e w  1 0 W H A T RISKS T OT H ES U B J E C T ARE sociological)  M O S T LIKELY TO SE  E N C O U N T E R E D ? (e.g. physical,  psychological,  None 1W H A TA P P R O A C H WILL YOU  T A K E TO MINIMIZE T H E RISKS?  A p e r s o n a l approach A l l a t t e m p t s w i l l b e made t o m i n i m i z e a n y p o s s i b l e r i s k s a n a to maintain c o n f i d e n t i a l i t y .  CONSENT  SUBJECT•S 32  W H C WILL C O N S E N T ? X  33  P A G E  < i  (chock)  S U B J E C T  n  n  P A R E N T G / U A R O J AN  n  A G E N C Y OFFICIAL(S) (sped f y:. e . g . school  169 board, hospital  director  etc.)  W H A T IS T H EC O M P E T E N C EO FT H ES U B J E C TT O C O N S E N T ?  Satisfactory 34  H O W WILL T H EC O N S E N TF O R M S O R QUESTIONNAIRES B E EXPLAINED T OT H ES U B J E C T S ? (consider  or  any other  language  barrier)  Personal  explanation  35 QUESTIONNAIRES  THE INTRODUCTORY PARAGRAPH HEADING THE QUESTIONNAIRE SHOULD PROVIDE A BRIEF SUMMARY THAT INDICATE* THE PURPOSE Or THE PROJECT, IHE BENEFITS TO BE DERIVED 6 A FULL DESCRIPTION OF THE PROCEDURES TO BE CARRIED OUT IN WHICH THE SUBJECTS ARE INVO.VED. THE FREEDOM OF THE SUBJECT . TO WITHDRAW AT ANY TIME OR TO REFUSE TO ANSWER ANY QUESTIONS WITHOUT PREJUDICE AND THE AMOUNT OF TIME REQUIRED OF THE SUBJECT MUST.BE STATED. INCLUDE THE STATEMENT THAT IF THE QUESTIONNAIRE IS COMPLETED IT WILL BE ASSUMED THAT CONSENT HAS BEEN GIVEN. FOR SURVEYS CIRCUITED THE QUESTIONNAIRE '36  WRITTEN C O N S E N T (other  BY MAIL SUBMIT A COPY OF THE EXPLANATORY LETTER AS WELL AS A COPY OF  than questionnaires  - e.g., experiments,  interviews,  cjsp studies;  UBC POLICY REQUIRES WRITTEN CONSENT IN ALL CASES. THE CONSENT FORM SHOULD CONTAIN ALL THE INFORMATION SUMMARIZED UNDER QUESTIONNAIRES. ABO'.T OR, IF AN ORAL PRESENTATION IS PLANNED, A SHORT STATEMENT OF WHAT WILL BE SAID SHOULD BE PROVIDED. IN EITHER CASE THE CONSENT FORM MUST INCLUDE A STATEMENT OF THE SUBJECT'S RIGHT TO WITHDRAW AT ANY TIME AND A STATEMENT THAT WITHDRAWAL WILL NOT PREJUDICE FURTHER TREATMENT, MEDICAL CARE OR INFLUENCE CLASS STANDING AS APPLICABLE. SUBMIT A COPY OF ALL CONSENT FORMS  37 A G E N C Y C O N S E N T  7V . THE CASE OF PROJECTS CARRIED OUT AT OTHER INSTITUTIONS, THE COMMITTEE REQUIRES WRITTEN PROOF THAT AGENCY CONSENT HAS BEEN RECEIVED. SOME EXAMPLES ARE: - Research carried out in a hospital - approval of hospital research or ethics committee - Resea rch carried out in a school - approval of School Board and/or Ft incip.il - Research carried out in a Provincial Health Agency - approval of Deputy Minister  CHECKLIST 38  OF  ATTACHMENTS T O T H I S  SUBMISSION  C H E C K ITEMS A T T A C H E DT O THIS SUBMISSION (incomplete o  X n  QUESTIONNAIRES (items  X n  INTERVIEW Q U E S T I O N S r i t e m 20)  x  a o  X o X  n  n  X  n  submissions  LETTER O F INITIAL C O N T A C T (item 13)  20, 35)  ) combined )  DESCRIPTION O FO B S E R V A T I O N S (item 20) T E S T DESCRIPTION (item 20) E X P L A N A T O R Y LETTER WITH OUESTIONNAI RE(item 35) S U B J E C TC O N S E N TF O R M (item  32,35, 36)  PARENT/GUARDIAN C O N S E N TF O R M  A G E N C YC O N S E N T  (item 32,37;  ( i t e m 32,3b)  uill  not be  considered!  I  Conversation Contraction  Breathing  Tension  Vocalisation  Movement  Position  Event  Proximity Content  Contraction Rest Both  Regular Deep Shallow Pant Push lirecjular  Relaxed Tense V Tense  Lai Smile  Movement Stahle  Back Side Sil  Converse Touch Item Maintenance Exam  Face Near Distant  Cry Scream Moan X  SlHIKl  Medication Equipment Breathing X  Labor Well Being Pain Medication ProcedureEnvironment Baby Relationship Breathing N o n Delivery X  In Room  Notes  f N Oh  Figure 1. Childbirth observation instrument recording sheet.  o  APPENDIX B  Submission t o the Grace H o s p i t a l Education and Research Coordinating Committee  PURPOSE OF STUDY  172 The purpose of t h i s project i s to look  at the prenatal  education  preparation for labour and d e l i v e r y and i t s relationship to maternal coping with the actual d e l i v e r y experience.  STUDY POPULATION  Sixty primiparous women, who agree to p a r t i c i p a t e , w i l l be in the study. or d e l i v e r y  included  The p o s s i b i l i t y of inclusion i s governed by admission i n the low r i s k  observation study dates.  labour  delivery  Attendance at formal  unit  during the  prenatal  education  sessions i s not a prerequisite.  The women to be included must meet the following  criteria:  - admission to or d e l i v e r y i n the low r i s k labour delivery unit during the study observation dates; - d e l i v e r i n g f i r s t baby; - gestational period i s not less than 37 weeks; - have vaginal d e l i v e r i e s ; - do not encounter medical emergencies where maternal or  fetal  wellbeing are compromised; - agree to p a r t i c i p a t e - d e l i v e r y interview.  observation  and  post-natal  METHODOLOGY 173 Recruitment of the study participants w i l l be by personal contact by myself during the 1st stage  of labour  to provide  the following  information to prospective p a r t i c i p a n t s : - s e l f - i d e n t i f i c a t i o n , a b r i e f explanation of the project a request for their p a r t i c i p a t i o n , and the provision  with of a  written explanation of the project and a consent form.  Following the recruitment  process,  as observer  I will  have no  interaction with the woman during her labour and d e l i v e r y .  Nor i s  there any p a r t i c i p a t i o n i n the care-giving.  A l l data  w i l l be carried out by myself thus no involvement  collection  or documentation  by s t a f f i s being requested.  Data w i l l be c o l l e c t e d from three sources i n order study purpose. occuring  F i r s t , by the observation and recording  i n the b i r t h  post-partum  to achieve the  experience.  Second,  interview to get the participant's  d e l i v e r y experience.  by  of  conducting  perspective  F i n a l l y , by augmentation of t h i s  A description of each of these  a  of the  information  with other data on the course of labour and d e l i v e r y to be from the medical record.  events  obtained means of  data c o l l e c t i o n follows:  1. Observation of the C h i l d b i r t h Environment.  The observation instrument to be used was developed at the C h i l d and Family Research Branch of the National Institute of C h i l d Health and  Human  Development  i n Bethesda,  Maryland.  This  currently being employed by the National Institute material coping with  labour  and d e l i v e r y .  instrument  is  i n research  on  I t i s a method of  recording n a t u r a l i s t i c observations of the c h i l d b i r t h experience and focuses on human behaviour the researcher.  i n settings which are not manipulated  Using t h i s instrument, codes w i l l  be  assigned  by to  behaviours which are observed, recording observable features of the woman's physical state, the i d e n t i t y and interactions of persons i n the labour/delivery room, a variety of medical themes of verbal  conversations  with  interventions, and  the labouring  various categories are time-sampled i n cycles  woman.  of 30  The  seconds for  observing and 30 seconds for recording. (Figure 1 ) .  In using t h i s observation instrument previous researchers have found that the observer's presence seems to have behaviour  of others  little  i n the labour/delivery  impact  room. •  on the  Once  the  p a r t i c i p a n t consent i s received the observer does not interact  with  the woman i n labour or d e l i v e r y , nor p a r t i c i p a t e i n the caregiving. Staff are not involved i n any of the data gathering a c t i v i t i e s .  2. Post-Partum Interview.  In order  to get the p a r t i c i p a n t s perspective  of the d e l i v e r y  experience the women p a r t i c i p a t i n g i n the study w i l l be requested to grant an interview 1-2 days following d e l i v e r y . The interview involve about 20-30 minutes of their time.  With the attainment  the woman's perception of her d e l i v e r y experience correlated to the observed  i t can then  will of be  s i t u a t i o n and to any prenatal preparation  undertaken.  The  interview  will  questionnaire format.  be  carried  out  by  myself  and  follow  a  (Attached - Part A of Data Sheets).  3. Medical Record Information.  To augment the  record  of  the  observer  and  the  report  of  the  participant data on the course of labour and d e l i v e r y would also obtained from the Sheets).  medical  record.  (Attached  -  Part  B  of  be  Data  APPENDIX C  Covering L e t t e r and Consent t o Study P a r t i c i p a n t s  BIRTHING EXPERIENCE CONSENT FORM (For signature a f t e r o r a l presentation)  I, , have been informed of the nature of the b i r t h experience study and give my consent for Barbara Selwood to observe the d e l i v e r y of my baby and interview me, 1-2 days following the b i r t h .  I have further been informed that the information provided i s c o n f i d e n t i a l and no identifying information w i l l be kept on any records following the completion of.the interview. I understand that I may decline to p a r t i c i p a t e or withdraw from the study at any time. My p a r t i c i p a t i o n w i l l i n no way prejudice my care now or i n the future.  Signed  Witness  .  ,  Date  Date  APPENDIX D  Manual f o r N a t u r a l i s t i c Observation Of The C h i l d b i r t h Environment  181  MANUAL FOR THE NATURALISTIC OBSERVATION OF THE CHILDBIRTH ENVIRONMENT  Barbara J . Anderson and Kay Standley Social  and Behavioral  Sciences Branch  National I n s t i t u t e of Child Health and Human Development Bethesda, Maryland  MANUAL FOR OBSERVATION OF THE CHILDBIRTH ENVIRONMENT Introduction The Manual for Observation of the C h i l d b i r t h Environment was developed to obtain systematic data on the physical state of a woman i n mid-course of active labor and on the medical and s o c i a l i n t e r a c t i o n s in which she is involved. The i d e n t i t y of any person present in the labor room and the medical, verb a l , and physical i n t e r a c t i o n s engaged in the labor room and the medical, v e r b a l , and physical i n t e r a c t i o n s engaged in with the laboring woman are recorded. The focus of t h i s observation system is the woman in labor; her behavior is cons t a n t l y sampled whether she is alone or involved i n any form of medical, v e r b a l , or physical contact. Coding Procedure The observation system was designed to time-sample f o r one hour the woman's physical state and a l l i n t e r a c t i o n s in the hospital labor room which involve the laboring woman." The time-sampling cycle is composed of a 30-second observing period followed immediately by a 30-second recording p e r i o d . A stopwatch i s used to indicate the continuing cycles of 30seconds-observe, 30-seconds-record, 30-seconds-observe, 30seconds r e c o r d , e t c . The recording sheet (located at the end of the manual) is designed so that 10 observe-record cyc l e s , i . e . , 10 minutes of real time, are entered on each sheet. Organization of the Observational  System  The categories of the observation system are organized into three areas of t h e o r e t i c a l i n t e r e s t : (1) the woman's physical s t a t e , (2) the degree of stimulus contact or d e p r i vation she experiences, and (3) verbal communications which involve the laboring woman. The behavioral categories which contribute to each of the three areas are outlined below: I.  Physical State of the Laboring Woman A.  Contraction 1. 2. 3.  B.  Contraction Resting Both  Breathing 1. 2. 3. 4. 5. 6.  C.  Regular Irregular Deep Shallow Pant Push  Tension 1. 2. 3.  D.  Relaxed Tense Very Tense  Vocalization 1. 2. 3. 4. 5.  Laugh or Smile Cry Scream Moan None  182  E.  Body Movement 1. 2.  F.  Body P o s i t i o n 1. 2. 3. 4.  II.  183  Movement Stable  Back Side Sit Squat  Stimulus Contact with the Laboring Woman A.  Behavioral Events Directed to the Laboring Woman 1. 2. 3. 4'. 5. 6. 7. 8. 9.  Converse Touch Item Maintenance Exam Medication Equipment Breathing None of the above  B.  Proximity 1. 2. 3.  Face Near Distant  I I I . Verbal Communications Involving the Laboring Woman A.  Conversation Content 1. 2. 3. 4. 5. 6. 7. 8. 9.  Labor Well-being Pain Medication Procedure-Environment Baby Relationship Breathing Non-delivery  Rating Scales Following the period of observation, f i v e ratings of the s o c i a l i n t e r a c t i o n s i n v o l v i n g the laboring woman are made: 1. 2. 3. 4. 5.  Physical Intimacy of Mother-Father Relationship Quality of Mother-Father Relationship Effectiveness of Mother-Father System in Comforting the Mother Quality of Nursing Care Quality of Physician Care  I.  PHYSICAL STATE OF THE LABORING WOMAN  184  Contraction The presence and/or absence of a uterine contraction in the time-sampling i n t e r v a l is a basic component of the laboring woman's physical s t a t e . Evidence of a contraction may come from any source such as the f e t a l monitor, the woman's expressions of incresed discomfort, and change in p o s i t i o n and breathing. O r d i n a r i l y , when a woman is in active l a b o r , there i s clear evidence from several sources that she i s experiencing a c o n t r a c t i o n . The categories in t h i s column are mutually e x c l u s i v e ; one category is coded in each time-samp1ing i n t e r v a l . 1.  Contraction:  evidence of uterine contraction  2.  Rest:  3.  Both: both a contraction and rest period occur any proportion i n the time-sampling i n t e r v a l  period between contractions in  Breathing The type of breathing predominating in the time-sampling i n t e r v a l is recorded. If there i s a c o n t r a c t i o n , the breathing during the contraction takes precedence. Deep and shallow breathing and panting and pushing are techniques of c o n t r o l l e d breathing designed to f a c i l i t a t e r e l a x a t i o n and diminish discomfort. The categories are mutually e x c l u s i v e ; one category i s coded i n each i n t e r v a l . 1.  Regular:  rhythmic breathing (usually not noticeable)  2.  I r r e g u l a r : Breathing not ing of breath, gasping.  3.  Deep: Quiet, relaxed deep chest breathing, mately 8 breaths per minute.  4.  Shallow:  Any v a r i a t i o n  rhythmic, observable  of  shallow chest  hold-  approxibreathing,  approximately 20-26 breaths per minute. 5.  Pant:  6.  Push: Deep breath held birth canal.  Tension is  Rapid panting with or without blowing while  pushing  fetus  down  This judgment of the laboring woman's physical tension based on f a c i a l expression and on the f l e x i o n of upper  extremities usually v i s i b l e outside of bed covers. These categories are mutually e x c l u s i v e ; one category is coded in each i n t e r v a l . 1.  Relaxed: Normal f a c i a l expression tone in upper extremities  2.  Tense: Grimaced f a c i a l expression tone in upper extremities  3.  Very Tense: Contorted clutching.  facial  and loose or  tight  expression  or  muscle muscle rigid  Vocalization Non-verbal v o c a l i z a t i o n s cover a range of a f f e c t . Code the predominant v o c a l i z a t i o n i f more than one occurs, code "X" i f there are no non-verbal v o c a l i z a t i o n s during the timesampling i n t e r v a l . 1.  Laugh, Smile: tive  Pleasant,  amused  expression  of  posi-  be  con-  affect.  2.  Cry:  Sobbing or tears  3.  Scream:  S h r i l l crying out  4. Moan: low-pitched anguished sound (not to fused with audible i r r e g u l a r breathing) Movement  One i n d i c a t o r of p h y s i c a l : state i s the presence or absence of s i g n i f i c a n t body movement in response to discomfort. Such movement i s abrupt, usually non-directed, and in the extreme has a thrashing q u a l i t y . Code one category i n each i n t e r v a l , i n d i c a t i n g the presence or absence of such a c t i v i t y . 1.  Movement:  Significant  movement  of  extremities  or  body p o s i t i o n 2.  Stable:  No s i g n i f i c a n t body movement  Position The p o s i t i o n of the woman's body is coded in t h i s column. Code that p o s i t i o n which predominates i n the i n t e r v a l . 1.  Back:  Lying prone on back  2.  Side:  Lying prone on e i t h e r side  3.  S i t : S i t t i n g unsupported of the bed i s raised)  4.  Squat: S i t t i n g knees  II.  on heels  or  propped  (as  when head  or crouching on hands  and  STIMULUS CONTACT WITH THE LABOURING WOMAN  Behavioral Events Directed to the Labouring Woman Eight categories of observable behaviors have been defined for the father ( F ) , the nurse with primary responsibi l i t y for the woman (N), the primary or attending o b s t e t r i c i a n (Ob), or any other person who is in the labor room during a time-sampling i n t e r v a l (e.g. f r i e n d , secondary nurse). These categories describing i n t e r a c t i v e events are exhaustive but are not mutually e x c l u s i v e ; i . e . for any person more than one behavioral event can be recorded during a time-sampling interval. When none of the eight behavioral events defined below i s observed for a person who i s in the labor room during the 30-second time-sampling i n t e r v a l , an "X" is recorded in the appropriate Event column to indicate the presence of a noni n t e r a c t i n g person. 1.  Converse: applies to any verbal i n t e r a c t i o n s between a person in the labor room and the woman in which the woman p a r t i c i p a t e s by (1) i n i t i a t i n g the conversation through a v e r b a l i z a t i o n of any type, or (2) responding v e r b a l l y , nonverbally, or by l i s t e n ing a t t e n t i v e l y to a v e r b a l i z a t i o n directed to her. The informational content(s) of the conversation i s recorded with Conversation Content codes described on page 7 of t h i s manual. Conversations between people in the labor room in which the woman does not p a r t i c i p a t e are not coded, even i f the verbal content r e l a t e s to the woman (e.g. nurse asks o b s t e t r i c i a n to examine the woman; father t a l k s with nurse about a hospital procedure).  2.  Touch: any physical contact with the woman which i s not an instrumental part of a medical procedure. Examples include: r e s t i n g a hand on the woman's forehead; s t r o k i n g , caressing, or giving physical comfort to f a c i l i t a t e r e l a x a t i o n .  3.  Item: actions taken to aid i n the comfort of the laboring woman which involve objects. Examples  include: o f f e r i n g ice c h i p s , a cloth for head, or magazine; fluffing a pillow; the woman with an extra blanket.  the forecovering  4.  Maintenance: behaviors directed to the woman which are instrumental to her medical care. Examples include: a l l nursing services such as taking blood pressure, changing bed pans, p a l p i t a t i n g the abdomi n a l area, checking the perineum.  5.  Exam: refers s p e c i f i c a l l y to an exam given to the laboring woman.  6.  Medication: administration of any medication to the woman, such as beginning an intravenous procedure or i n j e c t i o n s of sedatives.  7.  Equipment: doing breathing-relaxation techniques e i t h e r simultaneously with the woman or as a whole.  internal,  vaginal  Proximity to the Labouring Woman The distance between each person present in the labor room and the laboring woman is recorded each time-sampling i n t e r v a l with one of three mutually exclusive proximity categories . 1.  Face: within three feet of the woman and p o s i tioned so that eye-to-eye contact is p o s s i b l e .  2.  Near: greater than three feet from the woman when at her wide. Also included are positions behind the head of the bed or at the foot of the bed.  3.  Distant: greater than three feet and positioned away from the bed.  from  the  woman  187  III.  VERBAL COMMUNICATIONS INVOLVING THE LABORING WOMAN  Content of Conversations For every time-sampling unit in which the category Converse is coded in the Event column, the informational content of the verbal exchange is also recorded. Nine categories defining conversational themes have been defined. These nine categories are not mutually e x c l u s i v e ; during a time-sampling i n t e r v a l one conversation may contain more than one t o p i c . When the woman i n i t i a t e s a conversation, the relevant content category is c i r c l e d . If the category Converse is not coded in the Event column, record an "X" i n the Conversation Content column. 1.  Labor:  reference to the course or progress or labour events such as c o n t r a c t i o n s , c e r v i c a l d i c t a t i o n , or p o s i t i o n of the f e t u s .  2.  Wei 1-Being: concern for the physical or emotional comfort of the woman (e.g. How do you feel? Rub my back.)  3.  Pain:  4.  Medication: v e r b a l i z a t i o n about any obstetric medication or medication procedure.  5.  Procedure-Environment: reference to any hospital patient-care routine which affects the laboring woman such as changing sheets, using a bedpan, ordering meals, or regulat i n g temperature or l i g h t i n g in the room.  6.  Baby:  7.  R e l a t i o n s h i p : reference to the dyadic r e l a t i o n s h i p between the woman and another person present (e.g. You are helping me so much. I'm proud of you.)  8.  Breathing: t a l k i n g about techniques of breathing which aid the woman during c o n t r a c t i o n s .  reference to the woman's physical or emotional discomfort (e.g. Does that hurt? It f e e l s sore when you touch me.)  verbalizations about the infant-bringborn as a person, not references to f e t a l vital signs or p o s i t i o n , which would be coded as 'Labor' Content. Examples i n clude: How i s the baby taking a l l t h i s ? The baby i s r e a l l y eager to appear.  188  9.  Non-delivery: any v e r b a l i z a t i o n between the and another person to which one of the content themes defined above does not ( i . e . reference to any person or event does not r e l a t e to the woman or the setting).  woman eight apply which labor  j_89  RATING SCALES I.  190  Physical Intimacy of Mother-Father R e l a t i o n s h i p : This  scale describes the extent of touching and bodily contact in the couple's interaction during labor. It is not an evaluative s t a t e ment about the " c l o s e " or " d i s t a n t " quality of the mother-father r e l a t i o n s h i p . The physical intimacy of the couple is a r e f l e c t i o n of t h e i r own reaction to the presence of other persons as well as to the medical s i t u a t i o n and degree of discomfort experienced by the laboring woman.  II.  1.  Limited physical  contact  2.  Moderate amount of touching, holding hand, wiping face.)  3.  Almost continual embracing.  physical  soothing  contact,  (e.g.  holding,  Quality of Mother-Father Relationship Both  the nature and amount of spouse i n t e r a c t i o n contribute to t h i s r a t i n g of the manner in which the couple experienced labor together. In addition to verbal and physical i n t e r a c t i o n s , non-verbal dyadic responses such as eye-toeye contact, r e s p o n s i v i t y , c o m p a t i b i l i t y , and sharing of t h i s experience between the partners contribute to t h i s judgment of the q u a l i t y of mutual p a r t i c i p a t i o n .  1.  Withdrawn-rejecting; l i m i t e d i n t e r a c t i o n  2.  Occasional  3.  Warm, involved i n t e r a c t i o n  I I I . Effectiveness Mother  of  involvement  Mother-Father  System in Comforting  the  This scale i s an evaluative measure of the e f f e c t i v e ness of the couple's i n t e r a c t i o n s in f a c i l i t a t i n g the mother'sphysical comfort and sense of well-being and in a l l e v i a t i n g her d i s t r e s s . A l l aspects of the dyadic r e l a t i o n s h i p - - p h y s i c a l , v e r b a l , and emotional interactions—are  considered in terms of the support provide to the laboring woman.  IV.  1.  Limited comfort  efforts  to i n t e r a c t  2.  Supportive e f f o r t s inadequate or  3.  Synchronous i n t e r a c t i o n ing the mother  for  they may support  or  ineffective  effective  in  comfort-  Quality of Nursing Care (primary nurse) In t h i s s c a l e , a nurse's interventions in the labor room are considered in terms of t h e i r appropriateness to the laboring woman's physical and emotional needs. A responsive, f a c i l i t a t i n g nurse may unobtrusively perform only the necessary nursing tasks in a s i t u a t i o n where the mother and father are intensely involved in a manner supportive to the mother, or in another s i t u a t i o n , a f a c i l i t a t i n g nurse may appropriatel y assume a primary i n t e r a c t i v e r o l e .  V.  1.  Withdrawn-hostile  2.  Supportive e f f o r t s inadequate or  3.  F a c i l i t a t i n g and responsive  Quality of Physician Care (primary An  inappropriate  obstetrician)  obstretrician1s interactions with the laboring woman may contribute to her physical comfort and emotional w e l l - b e i n g . Supportiveness can be expressed in informative and sympathetic communication, a considerate attitude while performing medical procedures and respect for the laboring woman and her r e l a t i o n s h i p with the f a t h e r .  1.  Withdrawn-hostile  2.  Supportive e f f o r t s inadequate or  3.  F a c i l i t a t i n g and responsive  inappropriate  191  CONTRACTION  BREATHING  TENSION  VOCALIZATION  MOVEMENT  POSITION  EVENT  PROXIMITY  Contraction Rest Both  Regular Deep Shallow Pant Push Irregular  Relaxed Tense Very tense  Laf-smile Cry Scream Moan X  Movement Stable  Back Side Sit Squat  Converse Touch Item Maintenance Exam Medication Equipment Breathing X  Face Near Distant  In room F N Ob F N Ob F N Ob F N Ob F N Ob F N Ob F N Ob  F  9 10  N Ob F N Ob F N Ob  CONVERSATION CONTENT Labor Wei1-being Pain Medication Procedureenvironment Baby Relationship Breathing Nondelivery X  Name  APPENDIX E  C h i l d b i r t h Observation Instrvirnent Recording Sheet Used In This Study  CONTRACTION  BREATHING  TENSION  EVENT  Contraction Rest Both  Regular Push-spon. Push-vals. Pant Shallow Deep Irregular  Relaxed Tense V. Tense  Converse Breathing Touch Item Equipment Maintenance  In Room F N Ob F N Ob F N Ob  F  N Ob IN Ob F N Ob F N Ob  F  9 10  N Ob F N Ob F N Ob  CONVERSATION CONTENT Push-spont. Push-valsalva Other breathing  APPENDIX F  Postpartum Interview Questionnaire  I.D.# Part A - Post-natal interview  196  Date of interview 1. Who delivered your baby?  Fam.M.D.  O.B.Res.  Consult.  Other  2. Was t h i s the doctor who saw you during your pregnancy? No  Yes  3. How much d i d your baby weigh? 4. Did you have a boy or g i r l ?  gm. female  5. Are you breast feeding your baby?  male No  Yes _____  6. Would you describe your expectation/perception of your labour as (/) - much better than expected  - better than expected  - as expected  - worse than expected  - much worse than expected 7. What breathing patterns d i d you use i n your labour? (V5  8. Were they helpful?  No  Yes  ,elaborate  9. Did you have someone with you - in the labour room?  No  Yes  - in the d e l i v e r y room? No  Yes  10. Who was t h i s person?  11. During the time you were i n hospital d i d you receive any medication before your baby was born?  No  Yes  Do you know the type?  12. Did you use any special breathing techniques during the d e l i v e r y of your baby?  No  Yes  If yes, what were they?  Why d i d you use t h i s method(s)?  13. Did you attend prenatal classes?  No  Yes  I f no: would you t e l l me why you did not go to p.n. classes?  Go on to Question 23. If yes: where did you take prenatal classes? VHD  Grace  other  13a. Did someone attend the classes with you? No  Yes  Who was t h i s person? 13b. How many p.n. classes d i d you attend? - your partner? 13c. How many classes were i n the series? 13d. What was your most important reason for attending p.n. classes?  .  —.  197  14. What happened i n these classes?(/) - Process of labour and d e l i v e r y - Infant care - Infant feeding - Relaxation - Breathing - labour - delivery - Other  14a. What do you consider was the - most useful c l a s s - l e a s t useful c l a s s 15. In your p.n. classes d i d you do breathing exercises i n preparation for labour and delivery?  No  Yes  16. Would you please decribe the breathing techniques you were taught to be used during your labour:  17. In your p.n. classes, were you taught any breathing patterns to be used during the actual d e l i v e r y of your baby? No  Yes  , please describe:  18. How many times a week d i d you practice the breathing exercises outside the c l a s s setting? Not at a l l Not often (1-2)  „  Sometimes (3-4) Often  (5+)  19. You mentioned that you were taught (info from #17) breathing patterns to be used during the actual d e l i v e r y .  How does  t h i s compare with what you a c t u a l l y used?  20. How d i d your support person help you during your delivery?  21. Did he/she make suggestions about your breathing patterns? No  Yes  How?  22. Do you f e e l your p.n. classes prepared you - for labour?  Yes  No  - for delivery?  Yes  No  If yes, how? (note each sep.L/D)  I f no, what would you have l i k e d to prepare you better?  23. Prior to your d e l i v e r y would you describe your confidence l e v e l for your labour/delivery as - completely  confident  - very confident - confident - not very confident - not at a l l confident 24. Would you t e l l me where you obtained your information i n preparing for your baby's b i r t h ? M.D.  P.N. classes  Other  Books  Background  __Friends  C.H.N.  Titles  Information  The following information w i l l be used only to derive demographic data which describes the population being sampled.  25. Your age i s  years.  26. What country were you born in?  Length of time i n Canada ( i f not born here)  27. What language do you speak and understand the best?  200  28. What type of work d i d you do?  What type of work does your husband/partner do?  29. Educational background (/highest l e v e l completed)  a) Grades 1-11 b) Grade 12 (High School Diploma) c) Technical Training d) College Diploma e) University Degree f) Other:  201  APPENDIX G  Medical Record Data Form  Part B. Medical Record Information.  Residence Code V (  ), R  203  , B  , WV  , NV  ,  Other  Pregnancy and Delivery.  Maternal age  years  Date of B i r t h  Time  Gravity  Parity  .—  Single  Twin  Complications of pregnancy: No  Yes  Complications i n t r a parturn  Yes  Labour length:  Hours __;  Stage 1 Presentation:  No  Stage 2  Stage 3 _  Vx  Br  Delivery type: Sp  LF  Episiotomy:  No  Yes  Laceration:  No  Yes  MF  Other HF  Other  Degree  Delivery by: Fam. MD Other  Consult.  O.B.  Res.  Analgesic i n labour: Anesthesia:  Gen  No  Yes  Epi  Ent  Pud  Both  Time  204  Nil  Both  Local  Other  Infant Outcomes:  Sex:  Female  B i r t h Weight  Male. .  gms.  F e t a l Monitoring: Contractions:  Nil  Ext.  Int.  Both  F e t a l Heart Rate:  Nil  Ext.  Int.  Both.  Gestational Age Apgar Scores  Weeks 1 min. __ 5 min.  Major Congenital Abnormality: No  Evidence of F e t a l d i s t r e s s :  Breast Feeding:  No  Yes  No  Yes  Yes  APPENDIX H  Ertployment Categories  Type of Ernployment Examples  Executives, Professionals and Managers; - p h y s i c i a n , lawyer, nurse, teacher,  Administrative  nutritionist.  personnel;  - Owners of small independent business,  semi-profession  als.  Clerical  Technician;  - Computer operators, secretary, i n d u s t r i a l t e c h n i c i a n s .  Skilled ; - Seamstress, f l o r i s t designer, h a i r d r e s s e r , store c l e r k  Unskilled ; - Cook, dishwasher, w a i t r e s s .  APPENDIX I  D e f i n i t i o n of Terms  D e f i n i t i o n of Terms  a c i d o s i s — a pathologic c o n d i t i o n r e s u l t i n g from accumulation of a c i d or depletion of the a l k a l i n e reserve ; (bicarbonate content) i n the blood and body t i s s u e s , and characteri z e d by an increase i n hydrogen ion concentration (decrease i n pH). a l k a l o s i s — a pathogenic c o n d i t i o n r e s u l t i n g from accumulat i o n of base, and c h a r a c t e r i z e d by decrease i n hydrogen ion concentration •(increase i n pH). Apgar Score — numeric expression of the c o n d i t i o n of a newborn obtained by r a p i d assessment at 1, 5 and 15 minutes of age. Crowning — stage of d e l i v e r y when the top of the f e t a l head can be seen at the v a g i n a l opening. demographic c h a r a c t e r i s t i c s — age, country of b i r t h , language, education and type of employment. Etonox anesthesia — a mixture of 50 percent Oxygen and 50 percent Nitrous oxide breathed by the mother during the c o n t r a c t i o n ; used as an a i d of pain c o n t r o l . E p i d u r a l anesthesia — given during the f i r s t and/or second stage of labour; given on top of the dura (outermost covering of the s p i n a l cord) through the t h i r d , f o u r t h or f i f t h lumbar interspace. episiotomy — a s u r g i c a l i n c i s i o n of the perineum at the end of the second stage of labour t o f a c i l i t a t e d e l i v e r y and t o avoid l a c e r a t i o n of the perineum. f i r s t stage of labour — the p e r i o d from the onset of r e g u l a r contractions to f u l l d i l a t a t i o n of the c e r v i x . hypercapnia —  excess of carbon dioxide i n the blood.  hypocapnia — a d e f i c i e n c y of carbon d i o x i d e i n the blood, r e s u l t i n g from h y p e r v e n t i l a t i o n and e v e n t u a l l y leading to a l k a l o s i s . hypoxia — insufficient availability needs of the body t i s s u e s .  of oxygen t o meet the  intrapartum complications — process o f c h i l d b i r t h .  deviations  i n t e r v e n t i o n (during second stage) forceps or caesarean s e c t i o n .  —  from  the normal  d e l i v e r y by e i t h e r  l a c e r a t i o n — a t e a r i n the perineum. low-risk — no known r i s k pregnancy.  f a c t o r s o r complication o f the  n u l l i p a r a — a woman who had not yet c a r r i e d to v i a b i l i t y (24 t o 28 weeks gestation)  a pregnancy  PaCO^ — p a r t i a l pressure of carbon d i o x i d e i n a r t e r i a l blood. PaG^ — p a r t i a l pressure o f oxygen i n a r t e r i a l blood. p a r t u r i e n t — a woman g i v i n g b i r t h . p r e n a t a l c l a s s attenders — pregnant women who attend oneh a l f o r more of a s e r i e s of p r e n a t a l classes t o be r e f e r red t o as attenders'. 1  primipara — a woman bearing a c h i l d f o r the f i r s t time. Pudendal Block anesthesia — the i n j e c t i o n o f a l o c a l i z i n g a n e s t h e t i z i n g drug i n t o the pudendal nerve root i n order t o produce numbness of the g e n i t a l and p e r i a n a l region. pulse presurs — the d i f f e r e n c e between s y s t o l i c and d i a s t o l i c blood pressure. r e s p i r a t o r y a c i d o s i s — a s t a t e due t o excess r e t e n t i o n o f carbon dioxide i n the body; hypercapnia. r e s p i r a t o r y a l k a l o s i s — a s t a t e due t o excess l o s s o f carbon dioxide from the body. second stage o f labour — the p e r i o d from f u l l of the c e r v i x t o d e l i v e r y of the f e t u s .  dilatation  s e r i e s of p r e n a t a l classes — a set number of classes which focuses on aspects o f p r e n a t a l care, preparation f o r labour and d e l i v e r y , care o f the newborn and postpartum period.  spontaneous pushing — pushing as d i c t a t e d by the body urges during second stage; bearing down when, and f o r as long as the body demands i t , allowing the amount of e f f o r t and the timing of that e f f o r t t o be d i c t a t e d by the c o n t r a c t i n g uterus. V a l s a l v a maneuver — attempt t o f o r c i b l y exhale w i t h the breath h e l d ( g l o t t i s closed) beyond f i v e or s i x seconds.  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0042272/manifest

Comment

Related Items