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

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PRENATAL EDUCATION: ITS IMPACT ON SECOND STAGE BREATHING By BARBARA LANE SELWOOD B.S.N., The University 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 i n THE FACULTY OF GRADUATE STUDIES (Department of Health Care and Epidemiology) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 1984 © Barbara Lane Selwood, 1984 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by h i s or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. The University of B r i t i s h Columbia 1956 Main Mall Van couve r, Canada V6T 1Y3 Date ZJL£*J*«S/S-. /r<fy 6 (3/81) ABSTRACT An observational study of the impact of prenatal educa-t i o n on the conduct of second stage labour was conducted i n the Grace Hospital Low-Risk Labour and Delivery Module. The study participants, 35 prenatal class attenders and 15 non-attenders, were recruited following admission to the hospital during the f i r s t stage of labour. Data were c o l -lected u t i l i z i n g three data c o l l e c t i o n tools: a C h i l d b i r t h Observation Instrument; a Medical Record Data Form; and, a Postpartum Interview. Findings indicated that the majority of women i n the prenatal attender group (74.3%) were English speaking and Caucasian, while the majority of women i n the non-attender group (73.3%) were of Asian descent and did not have English as t h e i r main language. Fifteen (42.9%) i n the prenatal group, and 3 (20%) i n the non-attender group received epidural anesthesia during the f i r s t stage of labour. Eighteen (51.4%) of the attenders and 4 (26.6%) of the non-attenders required intervention (delivery by forceps or caesarean section); The majority (12 attenders and 2 non-attenders) received epidural anesthesia during the f i r s t stage of labour. The majority (62.9% and 66.7%) of attenders and non-attenders used Valsalva pushing throughout the second stage; with 37.1% and 33.3% respectively using spontaneous pushing. Overall 72% of the women were always instructed to use the Valsalva Maneuver and 28% received c o n f l i c t i n g guidance (spontaneous and Valsalva), when verbal instructions were given. Two prenatal attenders attributed the breathing tech-niques used to information received during prenatal classes. Four of the 5 non-attenders who used spontaneous pushing did so because they chose to ignore directions to use Valsalva pushing and used a spontaneous pushing approach. The findings f a i l e d to detect a s i g n i f i c a n t difference i n the study popula-t i o n due to 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 70.4 minutes for attenders and 71.6 minutes for non-attenders. For those women who used spontaneous pushing for the majority 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 for those using Valsalva pushing. Apgar scores were the same for both groups —20% scored less than seven and 80% with a score of seven or more at one minute after delivery. Since the study results f a i l e d to show that prenatal 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 for more discussion of the effects of the Valsalva maneuver during prenatal classes and a need for greater emphasis and practice of 'tools' which can be used i n coping with second stage contractions. i v TABLE OF CONTENTS Abstract i i L i s t of Tables v i i i L i s t of Figures x Acknowledgements x i CHAPTER I INTRODUCTION Introduction 1 Statement of the Problem 5 Purpose of the Study 5 Description of the Following Chapters 6 II REVIEW OF THE LITERATURE Physiological Considerations i n Pregnancy and C h i l d b i r t h 9 The Valsalva Maneuver 9 Respiratory Considerations During Pregnancy and C h i l d b i r t h 11 Cardiovascular Considerations During Pregnancy and C h i l d b i r t h 14 Acid-Base Metabolism i n Pregnancy and Ch i l d b i r t h 16 Previous Investigations of Second Stage Labour 19 Prenatal Class Preparation f o r Second Stage Labour 34 Investigations Regarding Consumer Sat i s -faction with Care Given During Labour 40 Research Model for Observing the Chil 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 Setting 57 Labour and Delivery Procedures 57 Sample Selection 60 Data Collection 61 Development of the Data Collection Tools ... 64 Chi l d b i r t h Observation Instrument 64 Medical Record Data Form 69 Interview Questionnaire 70 Data Analysis 72 Limitations 73 Assumptions 74 E t h i c a l Considerations 74 IV STUDY RESULTS Description of the Sample 77 Response Rate 77 Demographic Characteristics 79 Characteristics of Prenatal Class At tenders 87 Source of Prenatal Information 92 Labour and Delivery Experience of the Study Participants 95 Attendance of Support Person 97 Analgesia and Anesthesia Use i n Labour and Delivery 95 Electronic Fetal Monitoring 97 v i The Second Stage of Labour 97 Breathing Patterns During Second Stage Contractions 103 Episiotomy, Vaginal Laceration During Second Stage 119 Distrib u t i o n of Labour Times 120 Infant. Outcomes 127 Confidence, Perception of Labour and Delivery 132 V". SUMMARY AND DISCUSSION OF THE RESULTS, CONCLUSION, IMPLICATIONS AND RECOMMEN-DATIONS FOR FURTHER INVESTIGATION The Research Format and Character-i s t i c s of the Respondents 137 Labour and Delivery Experience 139 Second Stage Labour 140 Infant Outcomes 147 Confidence, Perception of Labour and Delivery 148 Conclusion 149 Implications of the Study 151 Recommendations for Further Investi-gation 155 References 157 APPENDICES A Submission to the University of B r i t i s h Columbia Screening Committee for Research and Other Studies Involving Human Sub-je c t s : Behavioural Sciences B Submission to the Grace Hospital Education and Research Coordinating Committee C Covering Letter and Consent to Study Par-t i c i p a n t s D Manual for 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 De f i n i t i o n of Terms v i i i LIST OF TABLES TABLE 4-1 Response Rate and Reason for Non-Par t i c i p a t i o n 78 4-2 Residence of the Study Participants 79 4-3 Age of the Study Participants 80 4-4 Country of Origin of the Study Participants 81 4-5 Length of Residency i n Canada 82 4-6 Language Best Understood by the Study Participants 83 4^7 Education Level of the Study Participants .. 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 Classes 88 4-10 Most Useful Information 90 4-11 Practice of Breathing/Relaxation Techniques 91 4-12 Primary Source of Information Regarding Pregnancy and Delivery 93 4-13 Epidural Anesthesia Use 96 4-14 Uterine A c t i v i t y During Observation Period 98 4-15 Intrapartum Complications 99 4-16 . Epidural Anesthesia and Intervention 101 4-17 Epidural Anesthesia of the Total Group and Interventions 102 4-18 Breathing Patterns of a l l Study Participants 104 i x TABLE 4-19 Breathing Patterns of Study Participants 106 4-20 Epidural Anesthesia and Breathing Patterns 108 4-21 Instruction/Guidance to the Study Participants During Contractions 110 4-22 Recorded Complication and Breathing Patterns 113 4-23 Interventions and Breathing Patterns 114 4-24 Fluency with English and Breath Pat-terns . 116 4-25 Fluency with English or Native Language by Caretakers and Breathing Patterns 117 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 Total Labour Time 124 4-30 Recorded Fetal Distress and Breathing Patterns 129 4-31 Apgar Scores One Minute After Delivery 130 4-32 Confidence Level for Labour and Delivery 132 4-33 Perception of the Labour/Delivery Experience 134 LIST OF FIGURES FIGURE 1 A Model of Maternal Coping During Labour and Delivery and Evaluation of the Child-b i r t h Experience ACKNOWLEDGEMENTS I would l i k e to express a sincere thank you to those who made t h i s study possible. F i r s t of a l l , I thank my thesis committee, Sam Sheps, Nancy Waxier-Morrison and Kirsten Webber for 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 to the Grace Hospital for allow-ing me access to t h e i r f a c i l i t i e s and to the s t a f f of the labour and delivery unit for t h e i r co-operation i n giving me the freedom to carry out my observations. A spec i a l thanks go to the women and t h e i r partners who participated i n the study and allowed me to be a part of the miracle of t h e i r child's b i r t h . Thanks also go to Margaret Powell for typing the f i n a l d r a ft. Lastly, but not least, I am especially grateful to my husband Russ, who without his encouragement and support t h i s thesis would not have been completed. CHAPTER I 1 INTRODUCTION Over the past decade there have been considerable changes i n the procedures and practices surrounding c h i l d -b i r t h . I t i s now a safer and presumably happier experience for women than i t has ever been. Maternal and neonatal mortality have dropped dramatically over the past f i f t y years. ( S t a t i s t i c s Canada, 1982). The t r a d i t i o n of the mother being alone and under heavy sedation has given way to one of active p a r t i c i p a t i o n . In preparation f o r t h i s b i r t h experience, prenatal information and care are ob-tained from a var i e t y of sources with medical practioners, nurses, and community health personnel being among the main sources. To a c t i v e l y p a r t i c i p a t e i n the b i r t h process, the need and demand f o r prenatal education classes has i n -creased greatly (Nelson, 1981) and each year community agencies and groups, p r i m a r i l y nurses, provide large num-bers of couples with information about pregnancy and s t r a t -egies f o r coping with labour and delivery. T r a d i t i o n a l l y , prenatal classes have included a discussion of the emot-ion a l and physical changes of pregnancy, the anatomical and physiological aspects of pregnancy and c h i l d b i r t h and instruction i n relaxation and breathing techniques based on the techniques of Drs. Read and Lamaze (Lamaze, 1970) or a modified Lamaze approach. For years there has been discussion regarding the various breathing patterns for the f i r s t stage of labour, but the breathing process f o r second stage has been neglec-ted by a l l but a few. (Benyon, 1957; Witzig-Boldt, 1971; Caldeyro-Barcia, 1979; Kitzinger, 1979; Noble, 1983). These c h i l d b i r t h advocates encouraged women to respond to t h e i r body urges when bearing down rather than being encouraged to a c t i v e l y bear down with sustained breath holding f o r the duration of a contraction. However, i n recent years, there has been increased concern about the manner i n which the second stage of labour has been con-ducted. (Dunn, 1976; • Caldeyro-Barcia, 1979; Kitzinger, 1979; Schneider, 1981; Noble, 1983). Women have been directed to push a c t i v e l y using long sustained expulsive e f f o r t s — t h e Valsalva Maneuver— during second stage con-tractions to shorten t h i s phase of labour (Williams Obstet-r i c s , 1980 p.445) on the basis that the o v e r a l l incidence of f e t a l distress r i s e s with increasing duration of the second stage (Moore, 1977). While studies (Pearson, 1974; Weaver et a l , 1977; Caldeyro-Barcia, 1979) have demonstra-ted that spontaneous maternal pushing e f f o r t s improve mat-ernal and f e t a l well-being and that use of the Valsalva maneuver during delivery may be detrimental to the health of the fetus and woman, there remains considerable con-troversy about "allowing" labouring women to use the spon-taneous pushing approach during second stage labour. Many practioners f e e l that the length of 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. Expectant women are provided with information about second stage labour, for example the anatomical and physiological process, range of maternal positions that may be used, and the use of a spontaneous pushing approach i n responding to her own body urges to bear down, yet contemporary practice i n the labour room does not necessarily follow t h i s philosophy. (Benyon, 1957; Caldeyro-Barcia, 1979; Schneider, 1981; Simpkin, 1981). Empirical observations of the environment and ex-perience of b i r t h have been rare. Research has generally emphasized s p e c i f i c events occurring i n the b i r t h exper-ience —medications and t h e i r possible influence on the mother and infant, complication rates or length of second stage labour (Hellman et a l , 1952; B a c k b i l l , 1979; Bergsjo and Haile, 1980). Other surveys focus on 'satisfaction with care' and indicate that most women give p o s i t i v e res-ponses to t h e i r treatment i n c h i l d b i r t h regardless of what has happened to them; when negative responses are expres-sed, they are dismissed as part of an "unrepresentative minority". The majority of women have been educated to be r e l a t i v e l y passive and eager to please, and do not wish to be regarded as troublesome; esp e c i a l l y i n t h e i r r e l i e f and pleasure at having produced a healthy c h i l d . (Riley, 1977; Danziger, 1979). Limited research has been done i n describing the experience of b i r t h i n r e l a t i o n to breath-ing techniques used by women during the delivery and exam-ini n g these techniques i n r e l a t i o n to prenatal preparation. Are they able to u t i l i z e the breathing techniques (that i s , spontaneous pushing i n second stage labour) recommended and practised i n prenatal education classes? Are de l i v e r -ing women given a choice regarding"; the types of breathing techniques they wish to use? The breathing techniques used by women during second stage labour and the s o c i a l interactions influencing these breathing techniques.' have not been extensively 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 to consider the s i t u a t i o n a l , s o c i a l and medical factors which may af-fect the responses, attitudes, and expectations of the woman i n labour. An understanding of the demands of the sett i n g including s o c i a l demands i s important i n the pre-dictions of maternal behaviour during delivery (Anderson and Standley, 1978). "An ecological approach to labour and delivery dictates that characteristics of the set t i n g and interactions between patients and s t a f f be elucidated i n any e f f o r t to predict behaviour of women i n c h i l d b i r t h " (Anderson and Standley, Training Tape, 1978). This study examined aspects of the b i r t h experience and the interac-tions between the s t a f f and patients during that time. The findings should prove useful to community health nurses, delivery room nurses and health care administrataors i n planning more ef f e c t i v e s t a f f inservice programs and com-munity health programs, and to researchers f o r leading to further study i n t h i s area. Statement of the Problem Current research demonstrates that use of the Val-salva Maneuver — t h e extended breath-holding technique--during delivery may be detrimental to the health of the fetus and woman. I t i s therefore suggested that pregnant women avoid the extended breath-holding techniques during second stage labour. (Benyon, 1957; Caldeyro-Barcia, 1979; Dunn, 1976). Many women attend prenatal education classes and receive information and practice breathing techniques to be used as alternatives to the Valsalva Maneuver. How-ever, at present l i m i t e d documentation has been made about t h e i r use during the delivery experience. Purpose of the Study The purpose of t h i s study was to describe the delivery experience of 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 or mismatch i n prenatal preparation f o r the second stage of labour. The primary objectives were: 1) to describe the breathing patterns used by the study participants during the second stage of labour. 2) to determine i f women who have prepared f o r c h i l d b i r t h by taking formal classes are more l i k e l y (than non-attenders) to use spontaneous pushing during the second stage of labour. 3) to describe other factors —breathing instructions by s t a f f , labour times, anesthesia and use of Elec-t r o n i c Fetal Monitoring, complications and interven-tions which may influence a woman's delivery. To provide a composite picture of the study p a r t i c i -pants, the secondary objectives were: 1) to describe selected characteristics of the prenatal attenders and non-attenders as i t related to t h e i r preparation and perception of the b i r t h experience. 2) to describe selected infant outcomes which may re-f l e c t on the conduct of the second stage of labour —evidence of f e t a l distress and Apgar scores. Description of the Following Chapters This thesis i s organized into f i v e chapters. Chapter I I consists of a review of selected related l i t e r a t u r e under the following headings: 1) physiological considerations i n pregnancy and c h i l d -b i r t h ; 2) previous investigations 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-tors and prenatal classes; 4) a review of surveys regarding consumer s a t i s f a c t i o n with care during c h i l d b i r t h ; and 5) the research model for observing the c h i l d b i r t h en-vironment . Chapter I I I describes the research methodology, giv-ing information about the study setting 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 V contains a summary and discussion of the results and the conclusion. Implications of t h i s study and recommendations for future study are outlined. CHAPTER I I REVIEW OF THE LITERATURE 8 Overview The readings reviewed pertain to the study's main question and investigations related to the topic of evalua-t 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. Physiological Considerations i n Pregnancy and C h i l d -b i r t h . Since research i n t h i s area i s f a i r l y extensive, selected focus research studies on the Valsalva maneuver, respiratory 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 Investigations 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 reveal c o n f l i c t i n g opinions and findings. Most of the investigations examined s p e c i f i c interventions or outcomes with very few addressing the use and effects of the Valsalva maneuver on the delivery outcome per se. 3. Prenatal Class Preparation f o r Second Stage Labour. Philosophies of several international prenatal edu-cators are reviewed. Also included i n t h i s section are the B.C. P r o v i n c i a l Health Ministry recommendations. 4'. Surveys Regarding Consumer Satisfaction with Care During C h i l d b i r t h . 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 for Observing the C h i l d b i r t h Environ-ment. The model or the o r e t i c a l framework used for t h i s study i s discussed. Physiological Considerations i n Pregnancy and C h i l d b i r t h The Valsalva Maneuver The Valsalva maneuver and i t s effects have been docu-mented since the 17th Century when the I t a l i a n physician Valsalva t r i e d to expel pus from the middle ear by a force-f u l expiratory e f f o r t against a closed g l o t t i s (Noble, 1978). The hemodynamic changes that occur during and after forced expiration of the Valsalva maneuver are w e l l docu-mented (Hamilton et a l , 1936; Elisberg, 1963; Sharpey-Schafer, 1965; Fox et a l , 1966; Curtin, 1969; Korner et a l , 1976). While studying the physiological relations between intrathoracic, 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) divided Valsalva's maneuver into four phases; the onset of stra i n i n g ; the period of st r a i n i n g ; the im-mediate release of the s t r a i n ; and the subsequent period of r e s t , t h i s l a s t phase r e s u l t i n g i n an 'overshoot 1 i n blood pressure. In Phase I, the onset of strai n i n g , there i s a sudden increase", i n blood pressure as str a i n i n g empties blood from the lungs to the periphery, and the increased intrathoracic pressure i s transmitted to the peripheral a r t e r i a l vessels. Sharpey-Schafer (1965) found that at t h i s time there i s minimal change i n the pulse pressure (difference between s y s t o l i c and d i a s t o l i c blood pressure) or heart rate. During Phase I I , the period of str a i n i n g , the intrathoracic pressure ex-ceeds the pressure i n the great system veins. As a re s u l t venous blood i s prevented from. returning to the thoracic cage and the cardiac output subsequently f a l l s and pulse pressure diminishes. A r e f l e x vasoconstriction 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. With Phase I I I , the sudden cessation of st r a i n i n g and loss of support of the intrathoracic pressure causes the a r t e r i a l pressure to f a l l by an amount equal to the f a l l i n the thoracic pressure (Sharpey-Schafer, 1965). In Phase IV, the period of rest, the blood held i n the ven-ous system by the increased intrathoracic pressure during s t r a i n i n g then enters the heart and i s pumped into the con-s t r i c t e d peripheral system. Thus, the r e f l e x vasoconstriction from Phase I I , results i n an 'overshoot 1, a rapid increase i n blood pressure (Hamilton et a l , 1936). 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 brady-cardia i s produced (Elisberg, 1963). The Valsalva maneuver has been extensively used as a test of c i r c u l a t o r y function i n heart disease (McGuire, 1949; Elisberg, 1963; Braunwald, 1965; and Curtin, 1969). They found that the response to the Valsalva maneuver i n cardiac patients to be different from the response i n 'nor-mal' patients studied by Hamilton et a l (1944) and Shar-pey-Schafer (1955). The responses to the Valsalva maneu-ver during the four phases occurred to a s i g n i f i c a n t l y lesser degree, with 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 cardiovascular and respiratory adjustments i n pregnancy are established by hormonal influence during the f i r s t trimester. Magnus-Levy f i r s t measured these changes i n 1904 and his findings were subsequently confirm-ed by Bonica (1967) and Marx et a l (1958). The most im-pressive and important respiratory changes are the increa-ses i n r e s t i n g v e n t i l a t i o n . Beginning i n the f i r s t t r i -mester the resting v e n t i l a t i o n progressively increases to a l e v e l 50 percent above normal at term. This increase i s achieved i n two ways: 1. an increase i n the respiratory rate from 14 to 16 inspirations per minute; and 2. a s i g n i f i c a n t increase i n the t i d a l volume, that i s the amount of a i r i n a single breath, of 40 percent. At term, the increase i n alveolar v e n t i l a t i o n i s approxi-mately 70 percent greater than i n the non-pregnant state. With a 50 percent increase i n resting v e n t i l a t i o n , a 20 percent increase i n oxygen consumption, and a 15 percent increase 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 pe r s i s t e n t l y raised. (The v e n t i l a t i o n equivalent i s expressed as the number of l i t r e s of a i r inhaled for each 100 ml. of oxygen consumption) (Bonica, 1973). These changes lead to a reduction i n alveo-l a r and a r t e r i a l CO ^  tensions and an accompanying increase i n oxygen tension and saturation. There are meagre data available on ve n t i l a t o r y changes during labour and or delivery. Boutourline-Young (1956) measured the alveolar CD^ i n unmedicated parturients several hours before and after delivery, and found a mean post delivery reduction i n alveolar CO ^  of 6mm Hg. below the average prelabour value of 31 mm Hg. Cole and Nainby-Luxmore (1962) measured respiratory volumes during c h i l d b i r t h and found a marked increase i n respiratory rate and t i d a l volume. Reid (1966) measured alveolar CO2 i n parturients with uncomplicated labours. He found the PaCO^ , between contractions to be 32 mm Hg. during early labour, 24 mm Hg. at the end of the f i r s t stage, and 26 mm Hg. during the second stage of labour. The type of breathing used was not specified. Bonica and Caldeyro-Barcia et a l (1973) studied the effects of pain, anxiety, and fear, as w e l l as the Valsalva Maneuver associated with the bearing-down r e f l e x of second stage. They were able to show a close correlation between p a i n f u l contractions and hyperventilation, and found a marked hyperventilation above prelabour v e n t i l a t i o n that caused a large although transient reduction of a r t e r i a l CG^. The re-f l e x bearing-down e f f o r t s further increase the intrauterine pressure thus distending the perineum. This causes additional pain which prompts the deli v e r i n g woman to ve n t i l a t e faster causing a reduction of the PaCG^. The changes i n lung volume and v e n t i l a t i o n contribute to an increasing e f f i c i e n c y of gaseous transfer between maternal blood and the alveolar a i r . This re s u l t s i n an eff e c t i v e reduction of carbon dioxide with an accompanying increase i n the tension of oxygen i n the a l v e o l i and the a r t e r i a l blood which i n turn enhances the transfer of these gases between mother and fetus. These changes ( i n respira-tory blood gas levels) make the woman i n c h i l d b i r t h more susceptible to changes i n blood gas levels than the non-pregnant woman. With hypoventilation or breath holding, she develops hypoxia, hypercapnia, and respiratory acidosis more r e a d i l y than does the nonpregnant woman. When hyperventilationi:* occurs and has preceded the Valsalva man-euver, the diminished PaCCL may cause maternal hypocapnia which causes vasoconstriction and can lead to f e t a l hyp-oxia and metabolic acidosis. Cardiovascular,'Cons iderations -;during:J:Prggnancycand C h i l d b i r t h During pregnancy there i s an increase i n blood volume and cardiac output. The blood volume i s increased approxi-mately 45 percent, to a maximum at 30 to 34 weeks gestation, with most of t h i s accounted for by-, venous d i l a t i o n , main-l y i n the skin and lower limbs. Pulmonary blood volume may also be increased during t h i s time. Cardiac output increases e a r l y i n pregnancy, reaching approximately 30 to 50 percent above non-pregnant levels at 28 weeks and then declining toward the non-pregnant l e v e l again at about 38 weeks or by term. Maternal posture has an important effect on cardiac output with a marked decline when the supine position i s assumed. Bieniarz, Maqueda- and Caldeyro-Barcia (1966) showed that there i s compression of the lower aorta by the uterus when i n the supine po s i t i o n during la t e pregnancy causing a mechanical obstruction of blood flow to the p e l v i c organs and lower limbs. Uterine contrac-tions and maternal hypotension also exaggerate t h i s e f f e c t . Wright, Morris, Osborn and Hart (1958) studied uter-ine c i r c u l a t i o n i n patients at term and found that the blood flow was within normal res t i n g l i m i t s i n 85 percent of the women tested during the early stage of labour; while i n the la t e stage of labour the blood flow was within nor-mal r e s t i n g l i m i t s i n less than 50 percent of these women. Cardiovascular changes occurring during labour and delivery depend on a number of factors: the method of delivery, the posi t i o n of the mother, the bearing-down e f f o r t s required to expel the baby, the type of anesthetic used, other medication effects, and maternal f l u i d intake. Hendricks and Quilligan (1956) and Adams and Alexander (1958) studied the effect of uterine contractions on card-iac output and a slowing of the heartbeat during uterine contractions. Bearing down using the Valsalva maneuver i n the second stage of labour has several effects on maternal cardio-vascular dynamics. The immediate effect of bearing-down i s to drive the blood from the lungs into the l e f t heart with a 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. With continuing breath holding, the blood pressure s t e a d i l y f a l l s , and with the release of the held breath there i s a rapid drop i n the blood pressure as the pulmonary vascular bed f i l l s . The degree of t h i s f a l l i s related to the length of time the Valsalva maneuver i s held. With subsequent bearing-down e f f o r t s there appears to be a cumulative ef-fect; a further r i s e i n blood pressure although there i s no greater increase i n intrathoracic pressure. The c r i t i c a l periods are at the time of release of the prolonged bearing-down e f f o r t when the blood pressure may f a l l to a c r i t i c a l -l y low l e v e l , or during repeated Valsalva maneuvers when the blood pressure may r i s e to a very high l e v e l . (Hansen and Ueland, 1973). The resul t for the woman i n c h i l d b i r t h i s that less blood i s being transported to the uterus, causing a drop i n the perfusion of blood i n the placenta and a drop i n oxygen getting to the fetus. Acid-Base Metabolism i n Pregnancy and Ch i l d b i r t h Changes i n v e n t i l a t i o n and lung volume contribute greatly to an increase of gaseous transfer between the maternal blood and the alveolar 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 dur-ing the regulation of respiration. Maternal blood pH i s on the alkalin e side of the normal range (7.37-7.45), while f e t a l blood pH i s on the ac i d i c side, approximately 7.32. This difference f a c i l i t a t e s the transfer of f e t a l CO2, meta-b o l i c acids and hydrogen ions to 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 respiratory component, which i s the response of the lungs to the carbon dioxide (PaC02 ) or the carbonic acid (H^CO^) concentration i n the blood; 3. " the metabolic component, which refers to the excess or d e f i c i t of the base bicarbonate (HCO^) regulated by the kidneys. The blood pH, the most e a s i l y measured factor, varies d i r e c t l y with the bicarbonate l e v e l i n the blood and inverse-l y with the a r t e r i a l carbon dioxide pressure (PaCC^). During voluntary hyperventilation, the c i r c u l a t a i n g H^CO^ (carbon dioxide i n solution) can be reduced causing an increase i n the blood pH. (Hansen et a l , 1973). Symptoms of respiratory a l k a l o s i s — p a l l o r , dizziness, euphoria, numbness and t i n g l i n g of extremities caused by vasoconstric-t i o n and the effects of calcium ion s h i f t s , are observed i f the pH i s elevated to 7.6 or more and PaCO ^  i s below 20 mm Hg (Hansen et a l , 1973). When there i s a high blood pH less oxygen i s bound to the hemoglobin. Carbon dioxide i s an important regulator of vascular tone, and by causing vessels to d i l a t e i t improves the blood flow thus e f f e c t -ing i t s own removal. In the absence of adequate PaCO2 le v e l s , c o nstriction of the blood vessels occurs. The t o t a l effect of these changes i s that less oxygen i s being transported by less blood, and when cardiac output and blood flow to 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 acidosis e x i s t s . Kastendieck et a l (1974) confirmed t h i s i n t h e i r study, t h e i r conclusions indicated that deceleration of the f e t a l heart rate at the end of second stage labour affected the degree of f e t a l acidosis. Wood et a l (1973) demonstrated that the f a l l i n f e t a l pH was dependent upon time. A l l d e l i v e r i e s i n t h i s study were hastened by using the following methods: ea r l y episiotomy, encouragement of active maternal bearing-down e f f o r t s , and by the use of forceps i f there were any delays. They concluded that the relationship found between maternal and umbilical vein blood base d e f i c i t for the t o t a l study group may explain the occurrence of f e t a l metabolic acidosis with prolonged pushing by the mother. Summary Normal respiratory and cardiovascular adjustments i n pregnancy create a hyperkinetic state i n the pregnant woman. The changes i n lung volume and v e n t i l a t i o n contrib-ute to an e f f i c i e n t gaseous transfer between maternal blood and the alveolar a i r which makes the woman i n c h i l d b i r t h ' more susceptible to changes i n the blood gas levels than the nonpregnant woman. One of the factors which affects r e s p i r a t i o n and gaseous transfer and puts a s t r a i n on the cardiovascular system i s breath-holding combined with s t r a i n -ing (Valsalva maneuver) during second stage. When the bearing down or breath-holding are strong and prolonged, the maternal a r t e r i a l blood pressure drops as a re s u l t of the drop i n cardiac output. This greatly reduces the blood flow to the uterus and placenta, r e s u l t i n g i n less oxygen being transported by less blood and less oxygen getting to the fetus ( f e t a l hypoxia) and creates the poten-t i a l for f e t a l acidosis (indicated by a prolonged decel-eration of the f e t a l heart rate after the contraction 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 f i n d -ings on the conduct and length of the second stage of labour and i t s effect on the fetus. Instructions to mothers on pushing during the second stage of labour range from advice not to push at a l l to the most common method which i s pro-longed breath holding while bearing down with maximum force. Humphrey et a l (1973) found that there was change i n the pH (-0.050) during second stage labour when delivery was conducted i n the dorsal recumbent posit i o n . Roemer et a l (1976) studied second stage labour i n r e l a t i o n to f e t a l pH i n over 4,000 vaginal de l i v e r i e s and concluded that, with good f e t a l pH values and correspondingly good Apgar scores, a f l e x i b l e management of the "time r u l e " was not necessarily detrimental to the fetus. Their con-clusions, based on findings which showed improved pH and blood gases of neonates born after a shorter second stage, were that i n general a shorter second stage i s better than a long one. In contrast to these findings, Klock's (1976) study concluded that the number of contractions with active maternal bearing down during second stage played a more important r o l e i n the well-being of the fetus than did the length of second stage labour. Perry and Potter (1979) showed evidence that e f f e c t i v e , voluntary pushing does shorten the second stage of labour. They evaluated the effectiveness i n primigravid and multi-gravid women who did or did not use diaphragmatic, abdominal vaginal pushing (Valsalva maneuver) during the second stage of labour. Their findings showed that for primigravid women with preparation and using the voluntary diaphragmatic, ab-dominal pushing technique, the mean time for the second stage of labour was 45 minutes. For the primigravid group not using t h i s technique the average duration of second stage labour was 68 minutes. For multiparous women using the voluntary abdominal-vaginal pushing technique, the mean time for the second stage of labour was 13 minutes versus 18 minutes for women not using the technique. They concluded that prenatally learned voluntary pushing technique did shorten the second stage of labour, esp e c i a l l y i n primiparous women. They also found that almost a l l women needed one or two contractions to get t h e i r pushing e f f e c t i v e l y organized. Bergsjo and Haile (1980) examined the duration of the second stage of labour, from f u l l d i l a t i o n of the cervix to the b i r t h of the c h i l d , during a three month period i n two Norwegian hospitals. Their data included the labours of 243 primiparous women and 392 multiparous women who gave b i r t h vaginally. The second stage of labour ranged from 15 minutes to 107 minutes i n primiparous women with an average of 34.6 minutes for those experiencing spontan-eous labour and a mean of 32.9 minutes for those who had induced labours. They also found that there was interven-t i o n (vacuum extraction, forceps and caesarean sections) i n the second stage of labour for 17.7 percent of the primi-paras. The authors concluded that reasonable l i m i t s for the duration of the second stage were 45 minutes for primi-parous women and 35 minutes for multi-parous women. After t h i s time they recommended intervention. The authors did not comment on the fact that the operative termination of labour after 40 minutes i n primiparous women as "more often performed to r e l i e v e fatigued mothers" than i n response to problems of f e t a l well-being. "The second stage.of1 labour i s the period of greatest physical s t r a i n on both mother anf fetus." A "wait and see" attitude with respect to i n t e r -vention "may have profound i l l effects on the mothers, who i n many cases look back upon th e i r labours as a shocking experience which they never want to repeat." (Bergsjo and Haile, 1980, p. 195). The authors d i d not look at the r e l -ationship between the active, 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) also examined the duration of the second stage of labour along with 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 vaginally. They examined the duration of second stage labour from f u l l d i l a t a t i o n of the cervix to the completed delivery of the infant for both white and black women. For primiparous b i r t h s they found that 62 percent of the white women and 81 percent of the black women had delivered within 60 minutes of commencement of second stage labour. Seventy-eight percent of the white women and 91 percent of the black women had delivered within 90 minutes of the onset of second stage labour. I t was noted that the second stage of labour lasted longer than 2 hours i n 13 percent of the white primiparas and i n only 5 percent of the black primiparas. The authors also noted that for a l l primiparous groups there was an increased f e t a l r i s k when the second stage was less than 30 minutes i n length, and an increased frequency of adverse effects when the second stage lasted beyond two hours. The authors did not spe-c i f y any relationship between the use of active, vigorous, pushing (Valsalva maneuver) and spontaneous pushing during the second stage. Several studies have looked at the relationship of the length of second stage labour with other variables. (Hellman et a l , 1952; Wood et a l , 1973; Cohen, 1977) Cohen studies primiparas comparing the length of second stage labour with Apgar scores and infant mortality. He conclu-ded that a long second stage labour does not adversely i n -fluence pe r i n a t a l or neonatal mortality i n primiparas and found no correlation between the frequency of low 5 minute Apgar scores and the length of second stage. In Helman's study of 13,377 deli v e r i e s he found that 77 percent were delivered within one hour of second stage and 92 percent within two hours (breathing techniques were not specified). He also concluded that there i s a correlation between the duration of the f i r s t and of the second stages of labour and that 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, that infant mortality r i s e s with the prolongation of both the f i r s t and second stages of labour. The f i r s t stage effect being apparent a f t e r a duration of 20 hours, while the increase i n f e t a l mortality takes place when the second stage has lasted more than 150 minutes. Wood investigated f e t a l well-being following 'fast' or 'normal' delivery. Women i n the 'fast' delivery group were given an early episiotomy, encouraged to bear down f o r c e f u l l y , and i n three cases assisted by forceps. Instruc-tions f o r bearing-down were not described nor was the manage-ment of the 'normal' delivery situations. The authors re-ported the mean time of second stage from f u l l d i l a t a t i o n of the cervix to be longer f o r the 'fast' group —34 ver-sus 32 minutes. They concluded that when considering the t o t a l study group, the s i g n i f i c a n t relationship between the maternal and umbilical vein blood base d e f i c i t suggests that maternal metabolic acidosis may explain the occurrence of f e t a l metabolic acidosis with prolonged pushing by the mother. Klock (1975) concluded from his studies that the number of contractions with active 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 did the t o t a l length of the second stage. U t i l i z i n g t h i s information Roemer et a l (1976) retrospectively analyzed over 4000 vaginal de l i v e r i e s with regard to the relationship of the length of the second stage to the f e t a l outcome of acid-base balance and Apgar scores. They found that i n approximately 4 percent of the sample the length of the second stage exceeded 1.5 hours, and nearly every 27th woman was bearing down more than 30 minutes. The good pH values, as indicated by pH values of less than 7.2 i n 13.4% and less than 7.1 i n only 1.5%, plus the reasonably good Apgar scores (92.9% scored between 7-10 at 1 minute) of the study population would indicate that a f l e x i b l e management (that i s , a longer second stage) of the 'time-rule 1 i s not neces-s a r i l y detrimental to the fetus. Not a l l practitioners examining c h i l d b i r t h have fav-oured the encouragement of 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 following t h e i r own in c l i n a t i o n s as to push-ing during second stage labour. One hundred low-risk primi-gravidas with vertex presentations were observed i n t h i s study and compared with 393 other low-risk primigravid ver-tex de l i v e r i e s occurring during the same period of time. For the 100 women i n the test group, no suggestion was made to the patient that she should push unless labour was not progressing s a t i s f a c t o r i l y . No other alterations were made i n the routine conduct (unspecified) of the cases. She reported that of the 100 cases, 83 delivered spontaneously with an average duration of the second stage being 1 hour and 3 minutes. Two cases had second stages l a s t i n g over 2 hours. The mean duration of the second stage f o r the controls was not specified, however the author alluded to no difference i n the length of second stage. Fifteen of the 83 babies weighed over eight pounds. Six of the hundred cases ended i n a forceps delivery, but the forceps rate for t h i s group was approximately one-half that of the control group of 393, which was 11.9 percent. The episiotomy rate for the test group was also less than that of the control group, 39 percent versus 63 percent. Benyon concluded that these results "show the effect of conducting the second stage along a pattern which reserves instruction i n pushing e n t i r e l y for those who have proved t h e i r need for 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 did women using f o r c e f u l , prolonged Val-salva pushing throughout the second stage. He studied pro-longed breath holding (The Valsalva maneuver) combined with bearing down e f f o r t s during the second stage of labour and t h e i r effects on the outcome of the labour and the welfare of the fetus. He defined 'prolonged breath holding' as l a s t i n g longer than 6 to 7 seconds. In Phase I, at the beginning of each bearing down e f f o r t , there i s a transient 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. Each bearing down e f f o r t caused a corresponding f a l l i n the f e t a l heart rate or Type I Dips (early decelerations), t h i s being caused by the f e t a l head being compressed more strongly while the woman i s bearing down. As the period of st r a i n i n g contin-ues, there i s increased intrathoraic pressure and a marked decrease i n cardiac 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 i n the a r t e r i a l pressure of the woman. With the f a l l i n a r t e r i a l pressure there i s a drop i n per-fusion of blood i n the placenta and a drop i n oxygen getting to the fetus. When the bearing down ef f o r t s are long, f e t a l hypoxia i s indicated as l a t e decelerations, that i s those occurring after the contraction or Type I I dips, on record-ings of the f e t a l heart rate. Caldeyro-Barcia also 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 a r t e r i a l blood pressure dropped to 70/50. This greatly reduces the blood flow to the placenta and produces marked f e t a l hypoxia which i s indicated by the decreased f e t a l heart rate. The heart beat which had been about 160 beats per minute before the contraction f e l l to between 100 and 130 beats a minute and the dip lasted long a f t e r the contraction had ended. This i s a prolonged deceleration and produces f e t a l acidosis. These Type I I Dips are also one of the indications of the need for interven-tions such as caesarean section. 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 of her arter-i a l blood. Therefore, when there i s prolonged bearing down e f f o r t with breath holding, the re s u l t i s not only a reduced blood flow to the placenta, but a decreased oxygen content i n the blood that does reach the placenta. I t i s the com-bination of these two factors that produces the f e t a l hypoxia. (Caldeyro-Barcia, 1978). When bearing down eff o r t s were spontaneously and nor-mally performed by the mother, Caldeyro-Barcia found no damaging effects on the fetus. With spontaneous bearing down e f f o r t s , l a s t i n g about f i v e seconds, there was only a transient effect on the f e t a l heart rate during each such e f f o r t , and no f a l l i n the f e t a l heart rate (Type I I Dips or l a t e decelerations) after the contraction. He found that f e t a l hypoxia can be avoided i f the mother bears down as she feels the need and without closing her g l o t t i s or prolonging the bearing down. At b i r t h he measured samples of umbilical a r t e r i a l blood for pH and PO _ and found the neonate much more l i k e l y to be acidotic and to have a low oxygen content when the mother had been bearing down with great strength and with the g l o t t i s closed for an extended period of time. When mothers were instructed to bear down as they f e l t the need, without t r y i n g to produce very strong or prolonged (more than 5 seconds) e f f o r t s , and without complete closure of the g l o t t i s , Caldeyro-Barcia found that the second stage of labour proceeded more slowly but the fetus was i n excellent condition. Following up on Caldeyro-Barcia's data, Bassel et a l (1980) studied the effects of maternal bearing down ef-fo r t s on maternal blood pressure and pulse pressure during and immediately a f t e r uterine contractions, and with and without voluntary bearing down e f f o r t s . They concluded that bearing down e f f o r t s are another mechanism by which d i s t a l and possibly uteroplacental blood flow can be pre-judiced, thus the avoidance of active bearing down ef f o r t s can be advantageous to the fetus at r i s k . In 1982 Barnett and Humenick examined the effect of long, hard Valsalva pushing during second stage and i t s effec t on f e t a l acidosis and neonatal Apgar scores. A l l women i n the study were delivered i n the semi-recumbent pos i t i o n . Those i n the control group were instructed to take long Valsalva pushes throughout second stage contrac-tions, and those i n the experimental group were instructed to 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 (open g l o t t i s pushing). This method i s s i m i l a r to that advocated by Witzig-Boldt (1971). Upon delivery cord blood was taken from a l l babies and analyzed for pH, pCC^, and pC^, and base excess. A l l women i n the study were 'low r i s k ' upon entering second stage labour. The longest second stage i n the experimental group (open g l o t t i s pushing) was 80 minutes, compared to 37 minutes i n the control (Valsalva) group. The average length of pushing e f f o r t s f o r the Valsalva pushing group was 8.56 seconds versus 3.01 seconds for 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 for the Valsalva pushing group. Due to the small sample s i z e , a s i g n i f i c a n t difference could not be detected. The authors did f i n d a s i g n i f i c a n t difference (using the t-test) i n the mean venous umbilical blood pH, and i n PO2 for both umbilical venous and a r t e r i a l blood values. Differences i n the mean values for the pCG^ and Base Excess for the umbilical 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 s i g n i f i c a n t . Apgar scores for a l l the infants were excellent, 8 or 9 at one minute and 9 or 10 at f i v e minutes. Two infants i n the long Valsalva groups had severe decelerations during the l a s t few minutes before b i r t h but those were not re-fle c t e d i n the Apgar scores or 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 to each woman's average length of contraction frequency, contraction dura-t i o n , pushing e f f o r t and length of second stage. Only the relationship 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 et a l (1982) support those of Wood et a l (1979) who found that women who had s l i g h t l y longer second stages from the onset of pushing had babies with higher mean umbilical artery and vein pH values. Their findings also support those of Cohen (1977) that longer second stage labours are not necessarily associated with lower Apgar scores or lower umbilical artery and vein blood PO2 or pH values i n fetuses with normal heart rates at the sta r t of the second stage of labour. Barnett and Humenick found a high correlation between length of pushing e f f o r t and frequency of contractions among long Valsalva type pushers. One explanation offered was that when contractions are fu r -ther apart women have more energy to push long and hard and that contraction frequency may be a more important v a r i -able than length and strength of pushes. Nelson et a l (1980) examined the effects of the Le-boyer method of delivery. In th i s c l i n i c a l t r i a l , 56 wo-men were randomly assigned to either a Leboyer or a con-ventional delivery. The Leboyer de l i v e r i e s took place i n the woman's bed i n the labour room; were l i t with a single lamp; had a room temperature of 27 degrees Celsius; and draping was minimized with a single s t e r i l e sheet under the buttocks. The infant received skin-to-skin contact on the mother's abdomen and was massaged by the mother. The cord was cut after i t stopped pulsating and a warm bath given by the father. Sound levels were reduced to a minimum. The conventional d e l i v e r i e s took place i n a delivery room; had a room temperature of 24° C; and were l i t with overhead fluorescent l i g h t s . Standard s t e r i l e draping was used. The cord was cut within 60 seconds of delivery, the baby was wrapped i n a blanket and returned to the mother. No p a r t i c u l a r attention was given to sound l e v e l s . A l l d e l i v e r i e s were conducted with an "equally gentle" approach (undefined). Their results f a i l e d to f i n d any clear cut advantages of the iLeboyer; method. They did f i n d that mothers i n the Lkeboyer group had s t a t i s t i c a l l y s i g n i f i c a n t shorter f i r s t stage labours than those i n the control group — t h i s may have been a placebo effect since these patients were using a new technique and association between the, expectation of a l a t e r p ositive experience and a decreased length of the f i r s t stage of labour i s consistent with the position that psychological factors influence the physical progress of labour (Newton, 1977). However, they found no s t a t i s t i c a l l y s i g n i f i c a n t difference i n the length of the second stage nor i n the number of interventions i n the two groups. There were no s t a t i s t i c a l l y s i g n i f i c a n t differences i n either maternal or infant morbidity. Dif-ferences i n the mother's reported s a t i s f a c t i o n with the b i r t h experience were also not s t a t i s t i c a l l y s i g n i f i c a n t . One of the explanations offered f o r these results was that no differences were found i n behavioural outcomes because only minimal differences were found between the methods of delivery since the i n s t i t u t i o n supports the use of a "gentle management" (undefined) i n the conduct of the second stage. They conclude that a "gentle conven-t i o n a l " delivery can produce s i m i l a r outcomes as achieved by the Leboyer approach. Rosenberg et a l (1981) investigated the d i s t r i b u t i o n of complications of labour and delivery among healthy women who had uncomplicated pregnancies (defined as one for which neither a complication of pregnancy nor a pre-e 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 c e r t i f i c a t e s f i l e d with the New York C i t y Department of Health during a three year period. They found a labour and delivery complication rate of 21.0 percent i n a group of apparently healthy women with no known prenatal complications which was consistent with findings reported by Nesbitt (1969), Hobel (1973), and Sokol (1977) i n large-scale c l i n i c a l studies. The rates of recorded complications of labour and delivery were found to vary considerably among age, race, marital, educational, medical service and prenatal care subgroups. However, they did f i n d that the recorded com-p l i c a t i o n s of labour and delivery following apparently uncomplicated antepartum courses more frequently among women who had i n i t i a t e d prenatal care e a r l i e r i n pregnancy, among private patients, white women, married women, better educated women and women i n t h e i r late twenties, compared with younger mothers. Among t h e i r explanations for these differences were: patients i n higher socioeconomic cate-gories receiving more aggressive o b s t e t r i c a l care r e s u l t i n g i n an increaseiin medical:, and su r g i c a l interventions; anatomic variations among the races r e s u l t i n g i n diff e r e n t incidence of cephalopelvic disproportion, which could account for a lower incidence of complication i n non-whites; and differences due to the p o s s i b i l i t y of iatrogenic factors. Summary. The adjustments i n respiratory and cardiovascular systems occurring during pregnancy and t h e i r affect on the acid base metabolism have been c l e a r l y documented. However, the documented effects of these changes on the woman and her dependent fetus during labour and delivery are less clear. The few studies i n t h i s area indicate that the use of prolonged bearing down accompanied by breath holding (Valsalva maneuver) has implications for the cardio-vascular system causing dramatic fluctuations i n the blood pressure which i n turn affect the acid base metabolism of the woman i n c h i l d b i r t h . A number of studies have demon-strated that with prolonged bearing down and breath holding the blood flow, and subsequently the amount of oxygen reach-ing the fetus i s decreased. This i n turn creates the po-t e n t i a l for f e t a l hypoxia and f e t a l acidosis. The studies reviewed reveal c o n f l i c t i n g opinions on the conduct of the second stage. Although there i s a com-plex interaction betweeni/multiple variables including the frequency and duration of contractions, length of second stage, position f o r delivery and the length and type of pushing e f f o r t , i n general, those studies advocating a more f l e x i b l e management ( i . e . allowing a more 'gentle' and longer approach to second stage), demonstrated that a longer second stage i s not necessarily associated with an increase i n maternal or f e t a l morbidity. unless contra-indicated by maternal and f e t a l complications at the star t of the second stage of labour, a woman's own desires and reflexes i n pushing should be supported by her attendants. Prenatal Class Preparation f o r Second Stage Labour The re s u l t s of studies such as those done by Benyon (1957) and Caldeyro-Barcia (1979) have supported the philoso-phies of c h i l d b i r t h educators such as Sheila Kitzinger and Elizabeth Noble i n t h e i r advocacy that the preparation of pregnant women f o r second stage labour change from the encouragement of active pushing with the breath held for as long as possible during second stage contractions, to one of teaching the woman to trust and work with her body i n ' l i s t e n i n g ' to the contractions. Their philosophy and the philosophy adopted by many c h i l d b i r t h educators i s one of allowing the amount of e f f o r t required for each contraction and the timing of that e f f o r t to be dictated by the uterus i t s e l f . " I t i s commonly a matter of str a i n i n g and pushing to force the baby down through the b i r t h canal, a process during which the women go red 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 with t h e i r desperate at-tempt to push the head a l i t t l e lower (With) attempts of t h i s kind to accelerate the second stage...the woman quickly becomes exhausted and loses her a b i l i t y for neuro-muscular 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 of 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 of the delicate adjust-ment necessary to allow the baby to be eased out slowly and gently, rather than to be pro-pe l l e d l i k e a cork out of a champagne bo t t l e . " (Kitzinger, 1977, p.231) Because not a l l second stage contractions are a l i k e , some are powerful, others gentle, Kitzinger advocates that a woman who has been taught to trust and work with her body instead of f i g h t i n g and denying i t , can respond approp-r i a t e l y to the diff e r e n t contractions i f given emotional support to do so. Rarely i s any contraction " a l l push". Instead the urge to bear down comes i n different waves with each contraction, sometimes missing a contraction altogether. She states 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 primipar-ous d e l i v e r i e s , the woman wants to push, and w i l l bear down spontaneously. Kitzinger advocates that i n the second stage the woman: "meets her contraction with slow, steady breathing,., meanwhile concentrating on the wave of the contraction, and waiting for i t to b u i l d up. As i t becomes more powerful and impelling, she moves up to a quicker, shallower breathing, u n t i l she i s doing mouth-centered breathing. The surge of de-s i r e to bear down comes towards her, and she automatically finds herself breathing rather more rapidly, with more pronounced, but not heavy, rapid breathing. Suddenly her breath i s held -involuntarily as the urge to bear down becomes.overpowering. She holds her breath at t h i s point, her l i p s parted, jaw relaxed as she continues to hold her breath, head i n c l i n e d forward on her chest, arms and shoulders relaxed, "leaning" on the contrac-t i o n as she does so, and allowing the bear-ing down movement to pass down through the uterus u n t i l the vagina opens up. As soon as the surge recedes she returns to mouth-center-ed breathing, waiting 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 with-out s t r a i n i n g two or four times with each con-t r a c t i o n .... returning to the slower deeper 'resting breath' at the end of the contraction." (Kitzinger, 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 exertion". The emphasis i s on relaxation and breathing which provides consistency through the entire preparatory and labour ex-perience. This philosophy i s never reversed to accommodate tensing the body and holding the breath during the delivery phase. She advocates the use of forced exhalation during the second stage of labour allowing the abdominal muscles to work strongly against resistance. She states: "The mother pushes out the baby with her exhaled breath, t y p i c a l l y a grunt or a groan; p a r t i a l closure of her g l o t t i s breaks her breath. Her abdominal mus-cles shorten most e f f e c t i v e l y on out-ward breath, and draw i n , pressing on the uterus i n the way that toothpaste i s squeezed from a tube. I f a mother labours with insight, then her body can work e f f e c t i v e l y without undue exertion. Instead of using f o r c e f u l techniques that consume energy, the mother can relax and wait for her baby to lead the way." (Noble, 1983, p.83) Forced exhalation i s provided i n the throat by p a r t i a l closure of the g l o t t i s and i s heard i n the form of spontan-eous grunts and groans, "the noise of work, not pain" (Noble, 1978). 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 relax and stretch. 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 also advocated Witzig-Boldt's p r i n c i p l e s of the exhale breathirigc technique. With t h i s type of breathSmgg rapid dramatic fluctuations i n blood pressure and cardio-vascular dynamics are minimized and normal oxygen-carbon dioxide exchange i s maintained. Using the p r i n c i p l e s of forced exhalation: "a woman begins each contraction by set-t i n g the thorax and abdominal muscles with a held breath. This i s followed by a slow prolonged exhalation through pursed l i p s . During the next inhalation of a i r , which usually occurs spontaneously i n f i v e to s i x seconds, the thorax and abdominal muscles w i l l continue to stay fixed, thus preventing retra c t i o n of the fetus." ... -,mr>\ (McKay, 1981, p.1019) Another c h i l d b i r t h educator, Penny Sirtpkin (1981) advocates a few general p r i n c i p l e s when teaching expectant parents about the conduct of second stage. These include: 1. the importance of relaxing the perineum; 2. the importance of responding to her own urges, bearing down when, and for as long as her body demands i t ; and 3. the importance of the need to stop pushing during 'crowning' of the f e t a l head. She states that "women need to know that they may l e t out a i r during pushes. They may make a noise. They may hold t h e i r breath for a few seconds, and they may change positions". She believes that with t h i s good understanding of what to expect, and with support for t h e i r spontaneous pushing s t y l e s , some women w i l l bear down using a Valsalva maneuver (rarely l a s t i n g over s i x seconds); some women w i l l use the forced exhalation 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 Valsalva maneuver. The International C h i l d b i r t h Education Association, ICEA, (1982) had also reviewed the l i t e r a t u r e regarding the management of second stage labour i n respect to mat-ernal breathing techniques to be used during contractions. They also advocated a gentler approach to the second stage with the woman u t i l i z i n g gravity to the best advantage and bearing down when and as long and as strongly as each contraction i t s e l f dictates. The philosophies of the B r i t i s h Columbia P r o v i n c i a l Health Department and the Metropolitan Vancouver Health Department are also based on the studies previously reviewed. In The Perinatal Fitness Manual, the breathing techniques and rationale are explained as follows: 1) Make yourself comfortable with your head and shoulders elevated, knees bent and apart, p e l v i c f l o o r relaxed. 2) Take a cleansing breath at the st a r t of the contrac-t i o n ; then with chin forward, mouth and jaw re-laxed, take a moderate breath i n . 3) With legs apart, slowly release the breath as you push down through your vagina using your abdominal muscles. 4) Repeat as needed through the contraction. 5) Take several cleansing breaths and relax back gently as the contraction ends. These breathing techniques are recommended for use when you have the urge to bear down and the doctor asks you to push. In the second stage of labour i f your baby i s being born too quickly, a panting breath helps to control the urge to push, gives the perineum time to stretch f u l l y , and allows the baby's head to come gently. The breathing technique which may be used at t h i s stage of the delivery i s described as follows: 1) Position as for 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 contraction. 3) Avoid tensing your abdominal muscles and continue your p e l v i c f l o o r relaxation. 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 prenatal classes, had been taught breathing tech-niques for the second stage of labour based on the philoso-phies advocating the "spontaneous" or "exhale" pushing techniques. I t i s on the u t i l i z a t i o n of these techniques that many of the l a t e r comparisons and comments are made. Investigations Regarding Consumer Satisfaction with 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 with maternity care have been conducted. Generalizations from t h e i r findings i s often l i m i t e d due to the sampling technique used, the emphasis on narrow concepts of the woman's experience, or physiological 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 rates or medication. used). (Nunnally et a l , 1974; Scaer et a l , 1978; Sullivan et a l , 1981; and Pridham et a l , 1983). Almost a l l of the studies report a generally po s i t i v e evaluation of care. However, Sullivan and Beeman (1981 and 1982) report that methodological problems such as the following are inherent i n measuring s a t i s f a c t i o n with maternity care: 1. Patients are reluctant to c r i t i c i z e t h e i r care-givers, esp 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 favour-able environment for subsequent evaluations of the care received (the opposite might also be true). 2. A inpatient's s a t i s f a c t i o n with care i s based on his or her perception of several dimensions of caregiver con-duct and communication. Di Matteo and Hay's (1980) res-earch has shown that technical competence, emotional support and communication are highly correlated and that a patient's perception of technical competence i s influenced l a r g e l y by the other measures of rapport. These measures include feelings that the medical s t a f f communicated with 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. In spite of the attention given to maternity care by popular magazines and i n d i v i d u a l groups, many women do not perceive that alternatives e x i s t i n t h e i r own mater-n i t y care. Most are dependent on caregivers to advise and d i r e c t them. Riley (1977) looked at "What Do Women Want?—The Question of Choice i n the Conduct of Labour" and found from his ethnographical research that only minimal information i s given to maternity patients about options available to them. What may appear as the expression of free choice may not be when the r e a l alternatives are con-sidered and the circumstances of the decision are taken into account. For example, i f only a few women object to remaining f l a t on t h e i r backs during labour, but i f i t i s also clear that t h i s i s an i n e f f i c i e n t position for labour, then there i s every reason to offer everyone a l t e r n -ative and better positions, regardless of the fact that only a minority of the women may have complained about t h i s aspect of care. This analogy may also be applied to other practices i n o b s t e t r i c a l care; for example, routine electronic f e t a l monitoring, withholding of f l u i d s , intraven-ous f l u i d administration routinely, episiotomy, and the extended breath holding Valsalva technique often used during second stage of labour. These expressions of patient pref-erences are directed towards wider options and an extension of general humanitarian treatment. Patient d i s a f f e c t i o n with maternity care was noted as long ago as 1961 when a B r i t i s h publication Human Relations i n Obstetrics acknow-ledged the existence of d i f f i c u l t y i n t h i s f i e l d . The conclusion of that investigation was that new maternity units should be planned to be as f l e x i b l e as possible so that consideration can be given to the mother's wishes. Danziger (1979) looked at the content and s t y l e of interaction between s t a f f members and patients. The data were derived from conversations during labour and examined for<congruence versus c o n f l i c t of interests between the labouring women and the s t a f f experts for whom c h i l d b i r t h represents a series of work routines. Interactions of the obstetricians, family practioners, and nurses with patients and t h e i r partners were observed and recorded over a nine month period. The findings showed: 1. There was a major theme i n provider-patient interaction i n the medical professional's attempts to assert control over the s o c i a l process of labour. Apart from those com-pl i c a t i o n s needing r a d i c a l intervention there are a variety of drug options, nursing s t a f f protocols, monitoring and assessment technologies, and supportive and coaching tech-niques that can be used throughout c h i l d b i r t h . The author found that the patients were not usually presented with these treatment choices. Despite the wide range of anal-gesic aids and techniques f o r the stimulation of labour that can dramatically affect the qu 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 to the next i n the st y l e and content of interactions between s t a f f members and patients. 2. Danziger also found that i n r e l a t i o n to the communica-t i o n between caregiver and patient, constraints upon the interaction appear mutual yet they d i d not evolve from a negotiation of the normative rules of the s i t u a t i o n . The guidelines for conduct are taken as preconceived for ind i v i d u a l patients by both parties with s t a f f making assump-tions 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. Individual patients directed themselves to b i r t h i n g i n t h e i r own private way and to somehow avoid disrupting the s t a f f . Neither party seemed to be aware of the extent to which t h e i r perspectives diverged. Women who handled contractions 'quietly' were not interrupted whereas patients who i n response to contrac-tions acted out despair and anguish by screaming, writhing, or thrashing about i n bed were highly sanctioned. This l a t t e r behaviour was viewed as unacceptable and often led to medical intervention, usually i n the form of verbal ad-monishments of the administration of pain-relieving drugs. Among themselves, s t a f f members viewed such patients with h o s t i l i t y or p i t y for "not being able to t a k e ! i t " . I f med-ic a t i o n i s not appropriate or warranted, the s t a f f member may intervene with harsh instructions to quieten the pat-ient. This type of t a l k suggests to the patient that the appropriate response to contractions i s to 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 with the pain of contractions. Danziger found that the rules for proper b i r t h i n g conduct were l a i d down for , rather than negotiated with, i n d i v i d u a l patients. The operating norm j u s t i f i e d as r e l e -vant to the in t e r n a l experience of coping, appears to bear more c l e a r l y upon s t a f f work routines than i t does upon the experience of contractions. Patients by and large conform to and accept these normative constraints and r a r e l y question the rules as conveyed, much less disregard or v i o l a t e them. B i r t h i n g women and t h e i r support partners defer to the i m p l i c i t rules and regulations of s t a f f members. I t was found that patients who do not behave i n the expected manner and who openly of f e r dissident views-:, are treated as i f they are v i o l a t i n g accepted norms. When patients made requests for non-routine variations on procedures, they are barely acknowledged, given some vague assurances, then largely disregarded. Suspicious reactions to a doctor's plans for interven-t i o n are usually met with the doctor's h o s t i l e ^declaration of his superior a b i l i t y to judge, based on years of experi-ence. This c l a s s i c a l use of authority s t r i p s the lay per-son's perspective of any v a l i d i t y i n comparison to the expert 1s p r i v i l e g e d access to information. The patient i s l e f t with no option but to conform to the passive stereo-type and place complete trust i n the doctor's autonomy. 5. Patients frequently r e f r a i n from expressing t h e i r views or questioning the s t a f f . Throughout the course of labour, neither the s t a f f members nor the patients learn much about the other's very different concerns. While there may be some exchange of information, the s t a f f sought only minimal information as to the woman's experience of labour; and the patients obtained only bare knowledge of the prognostic evaluation of t h e i r labour. B a s i c a l l y , the patients' perception of the si t u a t i o n remains unexplored, irrelevant to the course of labour. I t was as i f the women's views:; had no effect upon the physiological events. Only her expressions of pain or 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 period. In measuring s a t i s f a c t i o n with maternity care they questioned the women on prenatal, labour and delivery, and post partum care. The findings on labour and delivery 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 care that the ind i v i d u a l experiences seemed to^ d i f f e r greatly. Some of the unsolicited comments ranged from the very p o s i t i v e "the OB s t a f f was excellent", to the negative complaints of lack of attention, i n s e n s i t i v i t y and incompetence. The studies also found that many of the women offe r i n g highly negative comments s t i l l checked as "satisfactory" the response to questions r e l a t i n g to o v e r a l l labour and delivery care. The strong association found between perception of care and l e v e l of expressed s a t i s f a c t i o n with prenatal care i s also evident with labour and delivery care. Res-pondents who f e l t that t h e i r caregivers did not communicate with them about t h e i r labour and delivery experience were more l i k e l y to be unhappy with that experience. They found that women do have preferences about how labour and delivery events are managed. Their data showed among other things the desire to use breathing and relaxation tech-niques. The extent to which preferences were honoured varied depending on the procedure. For example, the wish for a c h i l d b i r t h coach was honoured for 82 percent of the res-pondents requesting i t , while the choice of atmosphere (dim l i g h t s , quiet music, warm shower, etc.) was honoured for only 23 percent of the respondents. Because few women act u a l l y rated t h e i r labour and delivery experience nega-t i v e l y , those with u n f u l f i l l e d preferences responded that t h e i r labour and delivery experience was 'satisfactory' instead of 'very satisfactory'. Sullivan and Beeman also found that women hesitate to c r i t i c i z e maternity care. Their explanation f o r the pos i t i v e evaluation of deficient care i s the joy sur-rounding the a r r i v a l of a healthy baby which legitimizes the entire pregnancy experience and creates a favourable halo. In 1981 they found that a majority of women said t h e i r care was sat 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 delivery. An additional explanation offered i s the more subtle effect of s o c i a l i z a t i o n of women as po t e n t i a l maternity patients. With the rapid decline i n maternal mortality during the 1930s, a s o c i a l consensus was created about the r o l e of medical practioners as i n t e r v e n t i o n i s t i c caregivers with women as passive recipients of that care. This brought with i t a potential for communication problems and the loss of decision making, which most women tolerate or accept as part of the modern science of obstetrics. The results of Sullivan and Beeman's survey suggests that: "a more personal, more sa t i s f a c t o r y course of care depends on more attention (being given) to the inter-personal relationships between care-takers and patients 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 to es-t a b l i s h a good rapport with t h e i r patients, they w i l l be advocates for t h e i r patients' desires con-cerning the management of labour and delivery." (Sullivan and Beeman, 1982, p.329) Research Model for 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 pr i m a r i l y descriptive. Shaw (1974) focused on labour and delivery as the physical, emotional, and s o c i a l conclusion to preg-nancy. 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 controlled studies (Scott and Rose, 1976; Beck, 1978) focusing on s p e c i f i c practices to be used by labouring women, but off e r l i t t l e information on the events of c h i l d -b i r t h . In other studies, (Brown et a l . , 1972; Davenport-port-Slaek and Baylan, 1975) observations were provided by nurses or physicians who were participants i n the care as w e l l as acting 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 offers a direct approach to a detailed study of c h i l d b i r t h . Drawn from ethnology t h i s method focuses on human behaviour i n natural settings which are not manipu-lated by the researcher. The observations become more refined as the investigator looks for trends i n what i s observed and establishes categories or events or behaviours. With t h i s model, codes are assigned 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 i n t e r -ventions and s o c i a l behaviours, and themes of verbal conver-sations with the labouring woman. The focus of the observa-t i o n i s the woman i n labour. This model of c h i l d b i r t h data c o l l e c t i o n allows for p l u r a l i s t i c recording and analy-s i s , taking into account ra p i d l y changing behaviours of several people simultaneously. I t does not r e l y on retros-pective impressions and interpretations as the sole data source. A schematic diagram demonstrating'.; the relationships between the psychological, physiological and environmental factors i s shown i n Figure I. (Standley and Nicholson, 1980). This model highlights 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 ch a r a c t e r i s t i c s ; b) pregnancy-related factors; and C h i l d b i r t h Environment Stim u l i General teterminants. a. background and personal charac-t e r i s t i c s b. pregnancy-related factors c. physical and s o c i a l environ-ment Cognitive Appraisal of. Chi l d b i r t h Psycho-Physiological Adaptability a. psychological perspective b. preparation c. "support-a b i l i t y " Outcome I: Ch i l d b i r t h Competence a. psychological comfort b. functional a b i l i t y Outcome I I : Postpartum C h i l d b i r t h Affect Figure 1. A model of maternal coping during labour and delivery and evaluation of the c h i l d b i r t h experience. o (c) the physical and s o c i a l environment. Background and personal characteristics serve as resources i n a woman's a b i l i t y to cope with the c h i l d b i r t h exper-ience. Pregnancy-related factors such as a fe e l i n g of physical or psychological w e l l being during pregnancy are important for the woman entering c h i l d b i r t h . The physical and s o c i a l environments are ref l e c t e d i n the amounts of stress and support a woman experiences, and contribute to a woman's expectations, behaviour and evaluation of c h i l d b i r t h . The cognitive appraisal of c h i l d b i r t h i s the woman's expectations for labour and delivery. Because c h i l d b i r t h i s an experience which i s anticipated over a period of time, plans can be made for coping with that experience. The psychophysiological adaptability component of the model encompasses coping s k i l l s of the cognitive and physiological kind. The psychological perspective involves the minimiza-t i o n of the seriousness of the c r i s i s of c h i l d b i r t h and putting the experience into the long-term perspective. Preparation for c h i l d b i r t h involves seeking relevant information i n preparation f o r labour and delivery, and learning s p e c i f i c procedures such as breathing and relaxa-t i o n techniques that w i l l enable the woman to deal with the ^discomforts of the labour and delivery. The "support-a b i l i t y " component of adaptability i s related to a woman's a b i l i t y to 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 s t i m u l i component of the model focuses on the system, of influences which impact on a woman's behaviour during labour and delivery. Aspects of t h i s component are shown by the nature of the husband-wife interaction and the support and dir e c t i o n the woman receives from others, i . e . hospital s t a f f , throughout her labour and delivery experience. Two components complete the model of maternal coping with 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 to control her behaviour and to ass i s t i n the delivery of her c h i l d without showing signs of psycho-l o g i c a l distress or functional i n a b i l i t y . (Lieberman, 1975). Prenatal factors and the c h i l d b i r t h experience i t s e l f contribute to the f i n a l component of the model, the post partum e f f e c t . How a woman feels p h y s i c a l l y and emotionally immediately after 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 to the c h i l d b i r t h environ-ment s t i m u l i . Because labour and delivery are an ongoing process, a woman's c h i l d b i r t h competence at any given time impacts on the behaviours of those supporting her during t h i s time, her husband or partner, nurses, and the physician. The behaviours of these people i n turn affect the behaviour of the labouring woman. Ch i l d b i r t h i s comprised of psychosocial as we l l as physiological events. A woman's interactions with other people are increas-i n g l y seen as c r i t i c a l influences on the psychology and physiology of a woman's be-haviour 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 -vestigator s p e c i f i c a l l y looked at the relationship between the following 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 for c h i l d b i r t h sought to a i d i n coping with the delivery s i t u a t i o n . Summary. A review of the' l i t e r a t u r e reveals considerable docu-mentation on the physiological changes which have an effect on pregnant women. . Cardiovascularoand respiratory adjust-ments are established by hormonal influence during the f i r s t trimester of pregnancy and contribute to an e f f i c i e n t gaseous transfer between maternal blood and alveolar a i r . This makes the woman i n c h i l d b i r t h more susceptible to changes i n the blood gas levels than the non-pregnant woman. The Valsalva maneuver commonly used during c h i l d b i r t h affects respirations and puts a s t r a i n on the cardiovascular system including dramatic fluctuations i n blood pressure. Changes i n the blood pH and CO 2 pressure are most s i g n i f i c a n t during the regulation of respiration (which includes the Valsalva maneuver). The studies reviewed provided a variety of opionions regarding the causitive factors of hypoxia and fetal;, acidosis; including a reduction of c i r c u l a t i n g CO^ (carbon dioxide i n solution); pro-longed pushing accompanied by breath holding by the mother; use of the dorsal recumbent position; and the number of contractions with active maternal bearing down. The review of previous investigations revealed c o n f l i c t -ing opinions and findings on the conduct and length of the second stage and i t s effects on the fetus. Many of the studies looked at 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 to f e t a l Apgar scores while only a few (Klock, Benyon, Caldeyro-Barcia, Barnett and Humenick), examined the effects of the breathing techniques used by the parturient and the effects on the delivery outcome. 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 necessarily associated with an increased f e t a l or maternal morbidity. Therefore, unless contraindicated by f e t a l or maternal complications at the st a r t of the second stage of labour a woman's own desires and wishes should be sup-ported . Prenatal educators support the 'spontaneous' approach to handling the contractions of the second stage of labour. They recommend that women l i s t e n to t h e i r body and to bear down when, and for as long as her body demands i t allowing the amount of e f f o r t required for each contraction and the timing of that e f f o r t to be directed by the uterus i t s e l f . Other educations also advocate the use of a modi-f i e d Valsalva maneuver — e x h a l i n g slowly through a p a r t i a l l y closed g l o t t i s and bearing down spontaneously when the body demands i t . A li m i t e d number of consumer surveys generally revealed that women hesitate to c r i t i c i z e maternity care. The joy surrounding the a r r i v a l of a healthy baby legitimizes the pregnancy and c h i l d b i r t h experience and creates a favourable halo regardless of the type of care received. An Observation of the Ch i l d b i r t h Environment Model provides the framework for t h i s study 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 experience without manipulation of any of the events observed. The research methodology i s presented i n Chapter I I I . CHAPTER I I I RESEARCH METHODOLOGY Overview The objective of t h i s study i s to describe the breath-ing techniques used during the delivery experience of primi-parous women i n r e l a t i o n to t h e i r prenatal preparation and to the dir e c t i o n they received from those a s s i s t i n g them i n c h i l d b i r t h . A descriptive design was selected. Direct observation of the delivery experience, relevant medical information from records, and a postpartum i n t e r -view were used to c o l l e c t data. They provided information oh the s i t u a t i o n a l factors which may affect a labouring woman's responses, interactions with those a s s i s t i n g i n the b i r t h process, prenatal preparation, breathing techniques used, and basic medical information. Direct observation of an event does not r e l y on re t r o -spective impressions and interpretations as the sole data source (Deoring and Entwistle, 1975). A personal interview gives higher response rates than a self-administered ques-tionnaire because there i s completion of t h i s portion of the data c o l l e c t i o n and underreporting i s reduced (Warviac et a l , 1975; Aday et a l , 1981). This chapter describes the methodology of t h i s study: the research setting, sample selection, data c o l l e c t i o n development of the data c o l l e c t i o n tools, and data analy-s i s . 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 Setting This study took place i n the Grace Hospital, 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 perinatal services to residents of Vancouver and the province of B r i t i s h Columbia. Grace Hospital i s the p r i n c i p a l obstet-r i c a l care and teaching hospital i n B r i t i s h Columbia. Although the hospital has been providing o b s t e t r i c a l care to the c i t i z e n s of Vancouver and environs since 1927, i t relocated to the new 120 bed f a c i l i t y i n 1982 (Children's, Grace and Shaughnessy Hospital, 1982). In 1983, 7356 moth-ers were delivered (Grace Hospital, 1983 Obstetrical S t a t i s t t i c s ) . A. Labour and Delivery Procedures Following admission and assessment, expectant mothers are assigned to i n d i v i d u a l labour delivery rooms which have incorporated new concepts i n o b s t e t r i c a l practice, such as the use of a combined labour, delivery and recovery room, the unrestric-ted attendance of the father and other support persons during and after the b i r t h , modern elec-t r i c a l l y operated b i r t h i n g beds allowing unlim-i t e d positions for use during the labour and delivery, and each room being equipped with an easy chair, shower f a c i l i t i e s and decor to help provide a 'home-like 1 atmosphere. The labour delivery area has 15 delivery suites and i s d i v i -ded into two modules. The high-risk module, has 4 delivery suites and manages the labour and delivery of those women who have been i d e n t i f i -ed"" by t h e i r physician or the assessment nursing s t a f f as being 'at r i s k ' for known or possible complications of t h e i r pregnancy and or labour and delivery. The operating theatres are also located i n t h i s area. The study was conducted i n the low-risk labour delivery module, which has 11 delivery-suites and i s generally used by women who are expected to follow a normal course of labour and delivery. During labour the status of a woman could change from low-risk to high-risk. No attempt was made to exclude these women unless a medical emergency arose where maternal or f e t a l w e l l being were compromised or delivery was by caesarean section p r i o r to the commencement of second stage labour. There are a large number of professionals working i n the Labour/Delivery area with approxi-mately 150 labour delivery room nurses rotating through the unit and more than 200 family physi-cians having p r i v i l e g e s to deliver babies there. There are also approximately 30 obstetricians on the hospital s t a f f . The nursing 1 care i s provided to patients using a "primary care" philosophy. This means that one nurse i s the main provider of nursing care throughout each 12 hour work period. Other s t a f f nurses are involved when r e l i e v i n g f o r the primary nurse during break periods or i f a nurse has any concerns or questions about her patient. Assignment of nurses to patients i s done at the discretion of the nurse i n charge on that day. The nurse i n charge i s responsible for the unit for a p a r t i c u l a r 12 hour work period. She i s usually one of the more experienced labour delivery nurses and attempts to keep abreast of the progress of a l l the women on the unit. She i s also available to assist s t a f f nurses regarding any of the patient's care. There i s also a nurse c l i n i c i a n available f o r consultation and teaching at a l l times. With the large number of s t a f f working on the unit, i t was possible for the investigator to observe many s t a f f members as they related to the b i r t h i n g mother. Staff on the labour delivery unit also i n c l u -ded Medical Student Interns (4th year medical students) who rotated through the unit for the purpose of gaining experience i n the management of women during labour and delivery. They com-pleted patient h i s t o r i e s , followed women through-out the course of labour and participated i n the delivery under the direc t i o n of the family physician or obstetrician. Physicians enrolled i n a residency program i n obstetrics were also available to a l l s t a f f on a consultative or on an intervention basis should the need arise at any time during the course of labour or delivery. Consultant obstetricians were also used at the disc r e t i o n of the family physician as the need arose. Sample Selection Selection of the participants was based on those who were admitted to the Grace Hospital Labour Delivery Unit between March 16, 1984 and. A p r i l 21, 1984. An attempt was made to include a l l e l i g i b l e women admitted during the study period. A sample size of between 40 and 60 p a r t i c i -pants was desired with equal numbers of prenatal attenders and non-attenders i n each group. During the study period 65 of the 75 e l i g i b l e women agreed to par t i c i p a t e . However, due to complications of labour r e s u l t i n g i n delivery by caesarean section (during the f i r s t stage of labour) and deliveries occurring when the observer wasn't present, a f i n a l sample of 50 women was obtained — 35 prenatal attenders and 15 non-attenders. Due to the large numbers of women having t h e i r f i r s t baby attending prenatal education programs (Robertson, 1983) a larger number of non-attenders could not be recruited during the available study period. Participants were required to meet the following c r i t e r i a : 1) they were admitted and delivered t h e i r babies i n the 'low-risk' Labour Delivery Unit during the study period; 2) they were del i v e r i n g t h e i r f i r s t babies; 3) there was a gestational age of at least 37 weeks; 4) they were anticipating a vaginal b i r t h on ad-mission; 5) they did not encounter medical emergencies where maternal or f e t a l well-being were compromised; 6) they were w i l l i n g to par t i c i p a t e for the delivery observation and the postpartum interview; 7) i f not English speaking, had access to an English speaking interpreter. Data Collection Following approval of the study by the Grace Hospital Education and Research Committee and the University of B r i t i s h Columbia Ethics Committee, the Director of Nurs-ing and the Co-ordinator of the Labour Delivery Unit were contacted by the investigator to explain the study and arrange an orientation to the unit. Sampling began on a d a i l y basis between March 17, 1984 and continued u n t i l A p r i l 21, 1984. Because of the unp r e d i c t a b i l i t y of the 'length of a woman's labour' and 'when babies would be born', the investigator averaged 14 to 16 hours d a i l y waiting for suitable candidates to be admitted i n active labour and subsequently deliver t h e i r babies. Arrangements were made to contact the c l i n i c i a n on duty each time the investigator came into the unit . The nature of the study was explained to each charge nurse and primary care nurse encountered p r i o r to approaching a prospective study participant. Consultation was under-taken with the charge nurse regarding the s u i t a b i l i t y of patients meeting the study c r i t e r i a before requesting t h e i r p a r t i c i p a t i o n . Upon approaching each e l i g i b l e participant, the i n v e s t i -gator explained the nature of the study, answered any ques-tions and handed out a covering l e t t e r (see Appendix C). Subjects, 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 pa r t i c i p a t i o n was voluntary. I t was also stressed that participants could withdraw from the study at any time. A signed consent was obtained from those who agreed to par t i c i p a t e . (See Appendix C). I t was stressed that the presence of the investigator in' the delivery room was only as an observer to record the events of the b i r t h and at no time would the investigator request the participant to a l t e r any events i n her b i r t h plan. A l l 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 participants once the data c o l l e c t i o n was. complete. A separate record was kept of the names and corresponding number code. I f consent for p a r t i c i p a t i o n was received, information for the Medical Record Data Sheet was abstracted from the patient's hospital record. When the participants were examined by the attending s t a f f and determined to be i n the second stage of labour, the investigator entered the labour delivery room, sat at the back of the room and began recording the b i r t h events using the adaptation of the Ch i l d b i r t h Observation Instrument (Anderson and Standley, 1977). For the women having a vaginal delivery, recording of the events of c h i l d b i r t h continued u n t i l 'crowning', whereas for those women requiring caesarean section, observa-t i o n and recording terminated when the decision was made to do the caesarean section. Following delivery, information d i r e c t l y r e l a t i n g to the b i r t h i t s e l f was obtained from the hospital b i r t h records to complete the Medical Record Data Form. The participants were interviewed at t h e i r bedside, one or two days following delivery using the Postpartum Interview Questionnaire. Development of the Data Collection Tools The data were collected u t i l i z i n g three tools: 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 Observation Instrument used for data c o l l e c t i o n was an adaptation of the Observation Instrument developed by Anderson and Standley (1977) of the C h i l d and Family Research Branch of 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 direct observation method was chosen because: 1) the method focuses on human behaviour i n natural settings. 2) the s e t t i n g i s not manipulated by the researcher. 3) the method provides a means for con-t i n u a l systematic data c o l l e c t i o n of the observable features of the woman's physical state, the i d e n t i f i c a t i o n and interactions of persons who are i n the labour delivery room, a variety of medical interventions and s o c i a l and verbal conversations with the d e l -i v e r i n g woman. 4) i t does not r e l y on retrospective impres-sions and interpretations as sole 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 for assignment of codes to observed behaviours. The specified behaviours are time-sampled i n cycles of 30 seconds for observation followed by 30 seconds for recording throughout the observa-t i o n period. The recording sheet i s designed so that 10 minutes of r e a l time, that i s , 10 observe-record cycles, are entered on each sheet. (See Appendix D) The observation i s focused on the woman i n labour with several indices being used to define her physical state i n every 30 second i n t e r v a l . F i r s t , the presence or absence of a contraction i s recorded. In addition, the woman's pattern of breathing and degree of muscular tension as expressed on her face and i n her extrem-i t i e s are recorded. Vocalizations covering a range of affect (laughing, crying, screaming, or moaning) as w e l l as body movement, q u i e t l y stable or rapid, thrashing movement i s recorded. Body;' position i s also noted for each i n t e r v a l , these include l y i n g on her back, on either side, standing or s i t t i n g . These categories are mutually exclusive with one category being coded f o r each i n t e r v a l . The second group of categories are concerned with the extent and nature of the s o c i a l and medical interactions experienced by the woman. In each 30 second i n t e r v a l the proximity of the father, nurse, physician, and any other person i s noted r e l a t i v e to the labouring woman. Three proximities are specified: direct face-to-face contact, near her side, and distant from her on the periphery of the room. Eight categories are used to describe the behavioural interations with the woman. Four categories r e f e r to supportive s o c i a l interactions conversation, touching, o f f e r i n g a comfort item and modeling breathing techniques. Four addition-a l categories describe interactions that are medically oriented: performance of a maintenance task, examination of the woman, administration of medication, and attention to the f e t a l moni-toring equipment. These categories are not mutual-l y exclusive. For each i n t e r v a l i n which the woman i s involved i n conversation the content of the conversation i s recorded using nine categories. Five categories describe supportive or f a i r l y neutral conversation themes: the woman's w e l l being, the baby, the relationship between the two people interacting, breathing techniques and non-delivery themes. Four categories are coded when conversations refer s p e c i f i c a l l y to medically related topics: the course of labour, the woman's pain, medication, and hospital or medical procedures. Again these categories are not mutually exclusive. A column was also p r o v i -ded f o r the notation of s p e c i f i c events which may rel a t e to the woman and the course of her delivery. A complete description of the Obser-vation Instrument and an example of the record-ing sheet are given i n Appendix D. An adaptation of Anderson and Standley's Observation Instrument was used for recording the events of c h i l d b i r t h i n t h i s study. The changes made included: elimination of the vocal-i z a t i o n , movement, position and proximity cate-gories. Pertinent d e t a i l s from these columns were recorded i n the "Notes" column. For each i n t e r v a l i n which the category "Converse" was coded i n the Event column, the informational content of the verbal exchange was recorded i f i t related to a woman's use of breathing techniques or patterns. Categories giving conversational themes r e l a t i n g to breathing patterns included: 'push for an extended time', 'take a deep breath, hold i t and push', 'push as you f e e l the urge to do so', and other breathing patterns such as deep breathing or panting. An example of the adapted C h i l d b i r t h Observation Instrument i s given i n Appendix E. A videotape appropriate for i n i t i a l t r a i n i n g i n use of the observation instrument was obtained from the National I n s t i t u t e of Chi l d Health and Human Development i n Bethesda, Maryland. The tr a i n i n g tape included an introduction to natural-i s t i c observation i n general, and the c h i l d b i r t h instrument i n p a r t i c u l a r , and demonstrations of each of the behaviours which could be coded. I t featured an action sequence of a couple i n labour, t h e i r nurse and obstetrician. A sample coding sheet with the correct codes for the preced-ing 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 con-tinued. The videotape was reviewed by the i n -vestigator u n t i l better than 90% agreement was achieved within each coding category; t h i s was s i m i l a r to the coding accuracy of the s t a f f re-searchers u t i l i z i n g the o r i g i n a l Observation Instrument. (Standley and Nicholson, 1980.) B. Medical Record Data Form The medical Record Data Sheet was constructed from the Perinatal Data Sheet and Labour Delivery Record, which are completed on a l l patients at the Grace Hospital. This data source augmented the delivery observations and the postpartum interview information and provided basic medical information. No d i f f i c u l t y was expected i n obtain-ing and recording t h i s information and pretesting was not done. The medical record data sheet i s divided into two compoments. F i r s t , information on the pregnancy and delivery including complications of the pregnancy and intraparatum period, length of each stage of labour, delivery type, epis-iotomy, laceration, anesthesia and c l a s s i f i c a t i o n by delivering physician. Second, relevant infant outcomes were abstrac-ted from the Labour Delivery Record. This i n f o r -mation included: b i r t h weight, use of Electronic Fetal Monitoring, Apgar scores and f e t a l distress or abnormalities. (See Appendix G). C. Interview Questionnaire P r i o r to the study, preliminary arrangements were made for data c o l l e c t i o n . The questionnaire, to be administered by the investigator i n the form of a postpartum interview was reviewed by several Community Health Nurses who teach prenatal classes, and by selected primiparous women who received routine postnatal v i s i t s by the invest-igator. The review was conducted to est a b l i s h the c l a r i t y of questions which had not been used by other investigators. Suggestions f o r revi s i o n were implemented and the questionnaire retested. The pretest participants were one to two weeks postpartum and were therefore further from t h e i r experiences than the study respondents. Even though infant care and feeding were primary con-cerns at t h i s time, r e c a l l and perceptions of the delivery experience were s t i l l v i v i d , and mothers r e a d i l y discussed them. The interview questionnaire was divided into three sections. F i r s t , there i s information on the woman's medical care during pregnancy and delivery, preceptions of labour, support persons present, usage of breathing techniques during the labour and b i r t h experience and sources of prenatal information. The second section sought information from those women who attended some form of prenatal education. This information included the source of prenatal education classes and a description of the content of the classes attended, support person attendance, reasons for prenatal class attendance, breathing techniques taught and t h e i r perceived value to the woman during her labour and delivery experience. The f i n a l section of the interview question-naire provides demographic information on the population sampled, including age, et h n i c i t y , main language of communication, occupation and educational background of the study participant. The interview questionnaire i s contained i n Appen-dix F. Data Analysis Data from the C h i l d b i r t h Observation Instrument, the Postpartum Interview Questionnaire and the Medical Record Data Form were coded using coding forms for computer analy-s i s . The S t a t i s t i c a l Package for Social Sciences was used for analyses of prenatal attenders and non-attenders with respect to the following: 1) differences i n the d i s t r i b u t i o n of the selected demo-graphic characteristics —age, country of o r i g i n , residency i n Canada, language, education and employ-ment . 2. differences i n the d i s t r i b u t i o n of data related to the breathing patterns used by the study participants and the dir e c t i o n they received from those attending the b i r t h . 3. differences i n the d i s t r i b u t i o n of events which may affect the s t y l e or method of delivery — l a b o u r times, anesthesia, electronic f e t a l monitoring, complica-tions and interventions. 4. differences i n the d i s t r i b u t i o n of the selected char-a c t e r i s t i c s of the study participants r e l a t i n g to t h e i r preparation for and perception of the b i r t h —reason for attendance at prenatal classes, 'most useful' information, practice of learned breathing techniques (for prenatal attendees), confidence for the labour and delivery experience and perception of that experience. Differences i n sources of i n f o r -mation were also examined. 5. differences i n the selected infant outcomes which may r e f l e c t on the conduct of the second stage of lab-our —recorded f e t a l distress and Apgar scores. The chi-square test was used to test for differences i n 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 lim i t e d to women who were del i v e r i n g babies when the investigator was on the unit. 2) Due to the small sample size and the irr 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 a bias may exi s t due to the type of person who agreed to par t i c i p a t e i n the study. 4) The information obtained during the postpartum i n t e r -view was retrospective and i s therefore subject to the l i m i t a t i o n s of self-reported retrospective data. 5) Information collected during the postpartum interview may be influenced by the fact that the participant has a healthy baby and may temper her views of the delivery experience. 6) The findings of the study are generalizable only to a population of labouring women with s i m i l a r low-risk characteristics 7. Sampling took place during the months of March and A p r i l , 1984, therefore some seasonal bias may have been present. Assumptions 1) Participants i n the study w i l l report information they obtained i n prenatal education accurately or with a small degree of error i n r e l a t i o n to "own per-sonal knowledge". 2) The presence of the investigator i n the delivery room w i l l not influence the participant or 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 as s i s t i n g i n 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 unit . E t h i c a l Considerations Written and verbal explanations by the investigator were given to a l l subjects (see Appendix C). Subjects were also informed they could withdraw from the study at any time or refuse to pa r t i c i p a t e without prejudicing t h e i r present or future care at the Grace Hospital. Anonymity and c o n f i d e n t i a l i t y of the responses was stressed. The C h i l d b i r t h Observation Instrument, Medical Record Data Form and the Postpartum Questionnaire were submitted for e t h i c a l review to the University of B r i t i s h Columbia Screen-ing Committee f o r Research Involving Human Subjects: Be-havioural Sciences. The procedure of the study, handling of data to ensure c o n f i d e n t i a l i t y and the benefits, costs and r i s k s to participants were cr i t i q u e d and found not to vi o l a t e the rights of human subjects. (See Appendix A). A s i m i l a r submission was made to the Grace Hospital Education and Research Co-ordinating Committee requesting permission to carry out the study i n t h e i r f a c i l i t y (see Appendix B). Their l e t t e r of approval i s included with t h i s Appendix. The study was then c a r r i e d out following 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 Hospital, the major maternity f a c i l i t y i n B r i t i s h Columbia. The study cohort were women deli v e r i n g t h e i r f i r s t babies con-sidered to be 'low-risk' patients and who agreed to p a r t i c i -pate. Data c o l l e c t i o n , on a d a i l y basis 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 - the Ch i l d b i r t h Observation Instrument, the Medical Record Data Form, and the Postpartum Interview Question-naire. Data was analyzed using the S t a t i s t i c a l Package for S ocial Sciences. The findings are presented i n Chapter IV. CHAPTER IV STUDY RESULTS Overview The major findings of the study are presented i n four sections. The f i r s t section provides a description of the response rate, the demographic characteristics regard-ing preparation for c h i l d b i r t h . The second section des-cribes the delivery experience of the study participants: selected events which may affect the method or st y l e of delivery and breathing patterns used by the women, and t h e i r r e l a t i o n to those events. The t h i r d section describes infant outcomes which may r e f l e c t on the conduct of the second stage. F i n a l l y , the fourth section describes con-fidence levels; arid perceptions of the delivery experience retrospectively. Findings are summarized at the end of each section. The study participants were c l a s s i f i e d into those who had attended prenatal classes during t h i s pregnancy and those who had not attended any formal classes as de-fined. P r i o r to the study, attendance was defined as being present at one-half or more of the classes offered i n the prenatal series. Prenatal instructors from four groups were consulted and a l l indicated that at least one-half of the series must be attended to provide an adequate l e v e l of preparation f o r the delivery experience. A usual series was from 5 to 10 classes with the average number being about 7 classes i n a series. Of the 50 study participants, '35 (70%) had attended prenatal classes and 15 (30%) did not have formal prenatal education as defined; of those 2 had attended some classes but did not f u l f i l the c r i t e r i a for the study. Prenatal class attendance was the primary independent variable of interest i n the study and the analysis w i l l focus on t h i s . Description of the Sample Response Rate An attempt was made to include a l l e l i g i b l e women deli v e r i n g during the study observation period. Of the possible 75 women e l i g i b l e , 65 agreed to pa r t i c i p a t e giving a response rate of 86.7%. As shown i n Table 4-1, i n 9 (12%) of the cases the participant required medical i n t e r -vention by caesarean section p r i o r to entering 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 further 6 (8%) were eliminated because they delivered when the observer was not present. Reasons for t h i s include: 1) co-inciding d e l i v e r i e s 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 for Non-Participation Total e l i g i b l e Absolute % of Total women Frequency Sample Total e l i g i b l e 75 100.0 Study Participants 50 66.7 Reasons for non-p a r t i c i p a t i o n : 1) patient declined 10 13.3 2) required caesarean section p r i o r to second stage 9 12.0 3) delivered when ob-server not present 5 6.7 4) coinciding d e l i v e r i e s 1 1.3 Total: • 75 100.0 Residence of the Study Participants The d i s t r i b u t i o n of residence for 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 Participants Area of Prenatal Non 8 of Total Residence Attenders Attenders Sample No. (%) No (%) • No. (%) Vancouver C i t y (17) (48.5) ( I D (73.4) (28) (56) 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 Other 3 _3 8.6 _2 13.3 _5 10.0 Total: 35 100.0 15 100.0 50 100.0 alncludes Surrey, Coquitlam and New Westminster. Maternal Age For the prenatal attenders the mean age was 28 years (the median 29 years); whereas the mean age (as w e l l as the median age) was 26 years for the non-attenders. As shown i n Table 4-3, eighty percent (80%) of the non-attenders were between the ages of 21 and 30 years whereas the prenatal attenders tended to be s l i g h t l y older, with 80% between the ages of 26 and 36 years. Table 4-3 Ages of the Study Participants Age (Years) Prenatal Non % of Total Attenders Attenders 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 Total: 35 100.0 15 100.0 50 100.0 Country of Origin Table 4-4 gives the country of o r i g i n ; there was a s i g n i f i c a n t difference i n the study participants who were born i n Canada, the United States or England compared to other countries: of those who attended a prenatal education program the majority, 27 (77.1%) were born i n Canada, the United States or England, whereas only 1 (6.7%) of the non-attenders who participated i n the study was born i n one 2 of these three countries ( X ^ ) = 18.3, p 4..001). The major-itycdf the non-attenders group were from one of the Asian countries. Table 4-4 Country of Origin of the Study Participants Country Prenatal Attenders Non Attenders % of Total Sample No. (%) No. (%) No. (%) Canada, United States, England 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 China - - 3 20.0 3 3.0 Other 3 •A 11.5 JS 20.0 _1_ 14.0 Total: 35 100.0 15 100.0 50 100.0 aIncludes Burma, Czechoslovakia, Holland, India, Indonesia, Japan and Switzerland. Length of Residency i n Canada Twenty-four (48%) of the study participants were born i n Canada. Others i n the sample had l i v e d i n Canada from one month to 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 resided i n Canada longer than 10 years being more l i k e l y to have attended prenatal classes 2 (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 Total Sample No. (%) No. . (%) No. (%) 1 year or less 1 2.9 2 13.3 3 6.0 2 - 5 years 4 11.4 10 66.6 14 28.0 6 - 1 0 years 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 Canadian born 23 65.7 _1 6.7 24 48.0 Total: 35 100.0 15 100.0 50 100.0 Language The language best understood by the study participants (those who had English as the best understood language com-2 pared to other languages) was s i g n i f i c a n t ("X(j_) = 15.4, p<.001). English (82%) was predominantly the best understood language of those women attending prenatal classes, whereas Chinese, Philippino, Punjabi or Vietnamese (80.1%) were the best understood languages of the non-attenders. Frequencies of the best understood languages are shown i n Table 4-6. Table 4-6 Language Best Understood by the Study Participants Language Prenatal Attenders Non Attenders % of Total 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 Total: 35 100.0 15 100.0 50 100.0 Education Most of the study participants had Grade 12 or further education (90%) with 62.9% of the prenatal attender group and 46.7% of the non-attender groups having post secondary education: no s i g n i f i c a n t difference could 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 levels of education attained by the study group. I t i s of interest to note that there was a greater proportion of prenatal attenders who had less than grade 12 education (11.4%) than non-attenders (6.6%). Table 4-7 Education Levels of the Study Participants Highest Level of Prenatal Education Attenders Non Attenders Cumulative Total No. (%) No. (%) No. (%) Grades 1 - 1 1 4 11.4 1 6. 6 5 10.0 Grade 12 9 25.7 7 46. 7 16 42.0 Technical Training 4 11.4 4 26. 7 8 58.0 College Diploma 5 14.3 - - 5 68.0 University 13 37.2 _3 20. 0 16 100.0 Total: 35 100.0 15 100. 0 50 100.0 Employment Forty (80%) of the study participants were employed p r i o r to confinement. As shown in Table 4-8, f o r t y percent (40%) of the prenatal attenders were at least employed i n a semi-professional capacity whereas only 1 (6.7%) of the non-attenders had simi l a r employment. Of those study participants employed 8.6% of the attenders were employed at u n s k i l l e d 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 or semi-s 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 of Prenatal Classes Attended Of the 35 study participants who had prenatal education 23 (65.7%) women attended Community Health Agencies; and 12 (34.3%) women enrolled i n prenatal programs offered by provate sponsors. The p r i v a t e l y sponsored classes included those offered by: Grace Hospital, Vancouver C h i l d b i r t h As-sociation and private 'midwives'. The curriculum of the classes was very s i m i l a r i n re-l a t i o n to the didactic information provided on labour and delivery and breathing techniques for coping with c h i l d -b i r t h . Table 4-8 Type of Employment of the Study Participants Type; of Prenatal Non % of Total Employment Attenders Attenders Sample No. (%)'. No. (%) No. (%) Executives, profes s ionals and managers 11 31.4 1 6.7 12 24.0 Administrative personnel, own-ers of small i n -dependent busin-ess , semi-prof-essionals 3 8.6 3 6.0 C l e r i c a l , technicians 4 11.4 2 13.3 6 12.0 S k i l l e d 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 Unemployed _1 2.9 — _ _1 2.0 Total: 35 100.0 15 100.0 50 100.00 For examples of employment r e f e r to Appendix H. (From Myers, J. and B. Roberts, 1958 p.40) Reason for Attending Prenatal Classes Those study participants who stated that they attended prenatal classes during t h e i r pregnancy were asked to i n -dicate.; the most important reason for attending and what they considered the most useful information i n the classes. Table 4-9 provides the main reasons for attending prenatal classes. A d i s t i n c t i o n was made between relaxation and breathing exercises and information about the labour and delivery process. Nine participants (25.7%) gave breathing and relaxation techniques as the main reason for attending; 24 (68.5%) stated that information on the labour and d e l i v -ery process was the most important. Together these cate-gories represent 94.2% of the t o t a l reasons stated for prenatal class attendance. There was undoubtedly some overlapping of reasons and when asking for the most important reason, not a l l reasons for attending are given. Table 4-9 Main Reason f o r Attending Prenatal Classes Reason f o r Attending Absolute Relative Frequency Frequency (%) Process of Labour and Delivery 24 68.5 Breathing and Relaxa-t i o n Instruction 9 25.7 Fetal Development Newborn Care Other 3 _2 5.8 Total: 35 100.0 Includes physician r e f e r r a l and information on family relationship changes with a newborn. Because the questions were asked soon after the delivery experience, the re p l i e s may have been influenced by that experience. Most Useful Class Information Prenatal attenders were asked to indicate the informa-t i o n they found to be the most useful. No attempt was made to determine which classes were act u a l l y attended, but by d e f i n i t i o n prenatal class attenders were present at 50 percent or more. Table 4-10 provides data concerning preferences about the most useful information. One person (2.9%) was not able to single out the most useful information. Labour and delivery information together with relaxation and breath-ing techniques accounted for 85.7 percent of the responses to t h i s question. This was somewhat less than the propor-t i o n indicating these were t h e i r most important reason for attending prenatal classes. Two (5.6%) participants chose complications of Labour and Delivery (both required delivery by caesarean section a f t e r being i n the second stage of labour for a period of time); 1 (2.9%) indicated n u t r i t i o n and 1 (2.9%) indicated postpartum care as the most useful class. No one mentioned newborn care as being of prime importance for attendance at prenatal classes. Table 4-10 Most Useful Information Most Useful Information Absolute Relative Frequency Frequency (%) 25.7 60.0 5.6 2.9 2.9 Process of Labour and Delivery 9 Breathing and Relaxa-t i o n Techniques 21 Complications of Labour/ Delivery 2 Nutritio n 1 Postpartum Care 1 Newborn Care Unable to name most use-f u l information _JL Total: 35 2.9 100.0 Practice of Breathing Techniques Learned As can be seen from Table 4-11, only 7 (20%) of the participants who attended prenatal indicated that they practised any of the breathing and relaxation techniques on a regular basis (5 or more times per week). When com-bined 27 (77.1%) indicated p r a c t i c i n g either one to two times per week or not at a l l . This i s an extremely high proportion when compared to the 60 percent who indicated the breathing and relaxation was the most useful class and that labour and delivery information and breathing techniques together accounted f o r 94.2 percent of the main reasons for prenatal class attendance. Table 4-11 Practice of Breathing/Relaxation Techniques Practice .:. Absolute Relative (Frequency/Week) Frequency Frequency (%) Not at a l l 16 45.7 Not often (1-2) 11 31.4 Sometimes (3-4) 1 2.9 Often (5+) 7 20.0 Total: 35 100.0 Attendance of Husbands or Partners at Prenatal Thirty-four (97.1%) of those participants i n the pre-natal classes had either t h e i r husbands or a partner accom-pany them to at least a portion of the classes: 17 (50%) of the husbands or support persons attended a l l of the prenatal classes; and 5 (14.7%) missed one class i n the series. Source of Prenatal Information The study participants received information about t h e i r pregnancy, labour and delivery from many sources. An attempt was made to establish which source was considered the primary source. These data are presented i n Table 4-12. Attenders chose prenatal classes as t h e i r primary source of information. Source of information between the attenders and non-attenders varies greatly. Non-attenders were more l i k e l y to indicate r e l a t i v e s or friends as t h e i r source of information. This may indicate less of a tendency to use outside resources or lack of knowledge of resources available. Table 4-12 Primary Source of Information Regarding Pregnancy and Delivery Source of In- Prenatal Non % of Total formation Attenders Attenders 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 14.3 4 26.7 9 18.0 Other 3 _2 5.7 _1 6.7 _J3 6.0 Total: ;35 100.0 15 100.0 50 100.0 Other Includes medical t r a i n i n g background, rented f i l m s . Summary: Of the 50 study participants, 35 (70%) attended pre-natal classes or f u l f i l l e d the c r i t e r i a for the study. There were s i g n i f i c a n t differences between the pre-natal attenders and the non-attenders. The woman attending prenatal classes tended to be s l i g h t l y older than the non-attender (28 versus 26 years); to be born i n Canada, the United States or England (77.1%), as opposed to an Asian country (73.3%) for the non-attenders; to have l i v e d i n Canada for a longer period of time; and to 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 prenatal attenders had a higher l e v e l of employment. Prenatal classes did not reach the non-English (primary language) population i n t h i s study even though the majority resided i n the C i t y of Vancouver. On the other hand, over one-half (51.5%) of the prenatal attenders l i v e d i n the surrounding communities but chose to deliver at Grace Hos-p i t a l . The majority of prenatal classes are provided by Com-munity Health Agencies (65.7%). The main reason for pre-natal class attendance i s information about labour and delivery and breathing and relaxation s k i l l s (94.2%) to aid i n coping with the b i r t h , yet only 22.9% of the prenatal attenders practised any of the techniques learned — 3 or more times per week. The d i v e r s i t y of the two groups i n the study was also evident i n r e l a t i o n to the sources of information regarding the pregnancy and delivery. Prenatal attenders r e l i e d heavily on t h e i r prenatal classes for information while the non-attenders obtained t h e i r information from family and friends. Labour and Delivery Experience of the Study Participants The labour and delivery experience of both prenatal attenders and non-attenders i s described as follows: atten-dance of support person; analgesia and anesthesia use; electronic f e t a l monitoring; events of the second stage including breathing patterns of the woman i n r e l a t i o n to those events. Attendance of Support Person A l l of the study participants had a family member or fr i e n d present during t h e i r labour and delivery exper-ience. Five (10%) of the study participants had two or more persons present at the delivery — t h e s e were either family members or friends. Analgesia and Anesthesia Use i n Labour and Delivery  Use of Analgesia Of the study participants requiring analgesia during the course of t h e i r labours, 4 (11.4%) women attended pre-natal classes and 4 (26.7%) were non-attenders. Use of Anesthesia Seventeen (48.6%) of those who attended prenatal c l a s -ses received an Epidural anesthetic during t h e i r labour/del-ivery, 2 (5.7%) of the women were given Epidurals during course of the second stage of labour to f a c i l i t a t e a forceps delivery; while only 3 (20%) of the non-attenders received an Epidural during the course of t h e i r labours. M l four women who were delivered by caesarean section a f t e r the commencement of the second stage of labour had t h e i r Epi-dural anesthesia i n place p r i o r to the commencement of the second stage. These data are shown i n Table 4-13. Ten (28.6%) of the prenatal class attenders used Entonox or 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%) did not have any anesthesia. Table 4-13 Epidural Anesthesia Use Anesthesia Use Prenatal Non % of Total Attenders Attenders Sample No. (%) No. (%) No. (%) Had Epidural 17 48.6 3 20 20 40.0 No Epidural 18 51.4 12 80 30 60.0 Total: 35 100.0 15 100.0 50 100.0 ~X J = 2.5, p } .1 Non-attenders delivered 3 (20%) infants whose Apgar score was less than 7; 2 had Epidural anesthesia and required delivery by either forceps or caesarean section. Electronic Fetal Monitoring Use of the electronic f e t a l monitor (EFM) was recorded i n the Labour/Delivery Record. Twenty-two (62.9%) of the prenatal attender group and 3 (20%) of the non-attender group received electronic f e t a l monitoring during the labour 2 and delivery 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^) = 6-09, p <.025). Thus, prenatal attenders i n the study received EFM proportionately more than three times as frequently than did non-attenders. The Second Stage of Labour The second stage of labour of a l l study participants was observed and observations were recorded each minute using the time-sampling approach previously described. The events and behaviours observed and recorded include: presence or absence of contractions; intrapartum complica-tions; interventions and epidural use; and breathing pat-terns of the woman i n r e l a t i o n to the d i r e c t i o n received from her caretakers, selected events of the b i r t h and selec-ted demographic ch a r a c t e r i s t i c s . Labour times were also recorded. Uterine A c t i v i t y Table 4-14 r e f l e c t s the uterine a c t i v i t y , that i s the presence or absence of a contraction during the observation periods. Table 4-14 Uterine A c t i v i t y During Observation Period Uterine A c t i v i t y Contraction/ Both 3 Rest Total: Prenatal Attenders No. (%) 1095 49.9 1138 51.0 2233 100.0 Non Attenders No. (%) 446 48.0 482 52.0 928 100.0 % of Total Sample No. 1541 1620 3161 (%) 48.8 51.2 100.0 Includes observation periods where there i s a uterine contraction and observation periods where both a con-t r a c t i o n and rest period occur i n any portion of the time-sampling i n t e r v a l . The proportion of the observation time when the women were having uterine contractions was v i r t u a l l y the same—49.9% for the prenatal attenders and 48% for the non-attenders. Intrapartum Complications Table 4-15 presents the intrapartum complications ex-perienced by the study group. Of significance i s the fact that 22 (62.9%) of the prenatal attenders were l i s t e d asj. having experienced a complication whereas only 3 (20%) of the non-attenders were l i s t e d as having an intrapartum com-p l i c a t i o n (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 Attenders Non % of Total Attenders Sample No. (%) No. (%) No. (%) N i l 13 37.1 12 80.0 25 50.0 Failure to descend, For-ceps rotation, CPD, C/S 7 20.0 2 13.3 9 18.0 Slow descent i n Second Stage 5 14.3 - - 5 10.0 Decelerations of Fetal Heart Rate 4 11.4 1 6.7 5 10.0 Meconium staining 2 5.7 - - 2 4.0 Long Labour 1 2 . 9 - - 1 2.0 Other a _3 8.6 _- - _3 6.0 Total: 35 100.0 15 100.0 50 100.0 aIncludes rapid second stage, decreased amount of amnio-t i c f l u i d , augmented labour and postpartum hemorrhage. Epidural Anesthesia and Intervention As stated previously, 17 (48.6%) of the prenatal at-tenders and 3 (20.0%) of the non-attenders received e p i -dural anesthesia. As shown i n Table 4-16, 14 (40.0%) of the attenders and 2 (13.3%) of the non-attenders also re-quired intervention (either by forceps or caesarean section) during the second stage. Prenatal attenders had more than twice the rate of epidurals and three times the rate of i n t e r -ventions than did. the non-attenders when epidural anesthesia was used. Although not s t a t i s t i c a l l y s i g n i f i c a n t when ex-amining the two groups separately, there was a s i g n i f i c a n t difference (as shown i n Table 4-17) when combining a l l study participants i n r e l a t i o n to epidural use and intervention. Table 4-16 Epidural Anesthesia and Intervention (C/S, Forceps) Intervention occurred No intervention Total: Intervention Prenatal Attenders Epidural Anes. Yes No 14 4 (.40.0) (11:4) 3 14 (8.6) (40.0) 17 18 (48.6) (51.4) Non Attenders Epidural Anes. Yes No 2 2 (13.3) (13. 3) 1 10 (6.7) (66. 7) 3 12 (20.0) (90. 0) % of Total Sample Epidural Anes. Yes- No 16 6 (32.0) (12. 0) 4 24 (8.0) (48. 0) 20 30 (40.0) (60. 0) Table 4-17 Epidural Anesthesia of the Total Group and Intervention Intervention Epidural No Epidural % of Total (C/S, Forceps) Anes. Anes. Sample No. O, "o No. o, "O No. o, o Intervention occurred 16 32. .0 6 12. .0 22 44. .0 No intervention _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 push-ing i n which the woman accommodated her breathing and pushing i n response to her body urges to bear down or any pushing where the breath was not held longer than 6-7 seconds; and, Valsalva pushing i n which the woman was ac 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 contraction. Table 4-18 represents the d i s t r i b u t i o n of the breathing patterns f o r the study participants showing either spontaneous pushing or Valsalva pushing as greater than 60 percent of the time i n which t h e i r contractions were observed. The proportion of prenatal attenders and non-attenders who used spontaneous pushing was r e l a t i v e l y s i m i l a r —37.1% and 33.3% respectively. From these data the majority (62.9%) of prenatal attenders (those provided with information regard-ing spontaneous pushing) used the Valsalva pushing during t h e i r second stage contractions. Table 4-18 Breathing patterns of a l l study participants Breathing Pattern Spontaneous Pushing > 60% of Con-tractions Valsalva Pushing > 60% of con-tractions Total: Prenatal Attenders No. (%) 13 37.1 22 62.9 35 100.0 Non Attenders No. (%) 5 33.3 10 66.7 15 100.0 % of Total Sample No. (%) 18 36.0 32 64.0 50 100.0 •Includes de l i v e r i e s by forceps and caesarean section. -V 2 X ( l ) n- S-In Table 4-19 the d i s t r i b u t i o n of 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 Valsalva pushing were very s i m i l a r . The mean duration of second stage for women using spontaneous pushing for more than 60% of t h e i r contractions was 75.6 minutes for prenatal attenders and 81.3 minutes for non-attenders, and for women using V a l -salva pushing f o r more than 60% of t h e i r contractions, the mean durations were 68.3 minutes and 68.0 minutes for prenatal attenders and non-attenders respectively. Table 19 * Breathing Patterns of Study Participants Breathing Prenatal Non % of Total Pattern Attenders Attenders Sample No. (%) No. (%) No. (%) Spontaneous Pushing > 60% of Con-tractions 5 29.4 3 27.3 8 28.6 Valsalva Pushing 12 70.6 8 72.7 20 71.4 > 60% of Con-tractions Total: 17 100.0 11 100.0 28 100.0 *Excludes forceps and caesarean section d e l i v e r i e s . Spontaneous Pushing Greater than 60 percent of the Contractions: Prenatal Non Attenders Attenders Range: 28 - 175 min. 29 - 120 min. Median: 63 min. 95 min. Mean: 75.6 min 81.3 min. Valsalva Pushing Greater than 60 percent of the Contractions: Prenatal Non Attenders Attenders Range: 19 - 181 min. 24 - 153 min. Median: 56 min. 64 min. Mean: " 68.3 min. 68.0 min. Epidural Anesthesia and Breathing Patterns The women who had Epidural anesthesia used Valsalva pushing much more than spontaneous pushing. Prenatal at-tenders used Valsalva pushing almost four times more than spontaneous pushing and for non-attenders Valsalva pushing was used twice as frequently. These data are shown i n Table 4-20. Table 4-20 Epidural Anesthesia and Breathing Patterns Breathing Pattern Spontaneous pushing > 60% of contrac-tions Valsalva pushing > 60% of contrac-tions Total: Prenatal Attenders Epidural Anes. Yes 3 (8.6) 12 (34.3) 15 (42.9) No. (25.7) 11 (31.4) 20 (57.1) Non Attenders Epidural Anes. Yes No. 1 4 (6.7) (26.7) 2 8 (13.3) (53.3) 3 12 (20.0) (80.0) % of Total Sample Epidural Anes. Yes No 4 13 (8.0) (26.0) 14 19 (28.0) (38.0) 18 32 (36.0) (64.0) *Two epidurals were given during second stage to f a c i l i t a t e a forceps delivery. Guidance Regarding Breathing During Contractions Instructions given to the women during contractions were grouped according to the various combinations of care-givers and support persons present. The categories of breathing patterns used by the women i n r e l a t i o n to the instructions given to them were: a l l i n -structions given were f o r Valsalva pushing; a l l instructions were encouraging spontaneous pushing; and, instructions giv-ing c o n f l i c t i n g (spontaneous and Valsalva) guidance regarding pushing were given. As shown i n Table 4-21, the majority of women were en-couraged to use Valsalva pushing by t h e i r caregivers and support persons during second stage contractions; with 68.6% of the prenatal attenders and 80% of the non-attenders being encouraged to use Valsalva pushing. In none of the del i v e r -ies was the woman encouraged to use spontaneous pushing by a l l of her attendants during second stage contractions. It i s interesting to note that when there was c o n f l i c t i n g guidance given to the woman the majority of women i n the prenatal group used spontaneous pushing (25.7%) versus 5.7% for Valsalva pushing; i n the non-attender group the opposite was true with 6.7% using spontaneous pushing and 13.3% using Valsalva pushing. Of the non-attenders who used spontaneous pushing and were encouraged to use Valsalva pushing or had received con-f l i c t i n g guidance, none had English as t h e i r main language. Table 4-21 Instruction/Guidance to the Study Participants During Contractions Prenatal Attenders Instruction A l l A l l Con-Vals. Spont. f l i c t -ing. Non Attenders Instruction A l l A l l Con-Vals. Spont. f l i c t -ing % of Total Sample Instruction A l l A l l Con-Vals. Spont. f l i c t -ing Spontaneous pushing > 60% of contrac-tions 4 (11.4) 9 (25.7] 4 (26.7) 1 (6.7) 8 (16.0) 10 (20.0) Valsalva pushing j> 60% of contrac-tions Total: 20 (57.2) 24 (68.6) 2. 5.7) 11 (31.4) 8 (53.3) 12 (80.0) 2 (13.3) 3 (20.0) 28 (56.0) 36 (72.0) 4 (8.0) 14 (28.0) Of the four prenatal attenders who used spontaneous pushing although guided to use Valsalva pushing, two women had li m i t e d English and used what they termed " f e l t best"; one woman (English speaking) stated the Valsalva pushing was too d i f -f i c u l t f o r her to maintain so she did what was comfortable for her; and the t h i r d woman did spontaneous pushing whenc-. there wasn't any conversation during the contractions and used Valsalva pushing during those contractions when she was t o l d to do so. Of the prenatal attenders receiving c o n f l i c t i n g informa-t i o n and able to use spontaneous pushing: two were following verbal, hand and/or model breathing provided by the support person throughout each contraction; 2 were encouraged to use spontaneous pushing by t h e i r physician; and, f i v e were encouraged i n using spontaneous pushing by the nurse. In a l l the del i v e r i e s where the woman used a spontaneous pushing approach i n second stage a l l had either t h e i r support person or one of the caregivers (usually the nurse) take the dominant supporting r o l e . The two women whose partners gave them active directions during t h e i r contractions were among those that had practised the breathing techniques on a regular basis (5. or more times per week), as a res u l t of the information received i n prenatal classes. Recorded Complications and Breathing Patterns Table 4-22 gives the recorded complications and the type of breathing used during the second stage contractions. Overall Valsalva pushing during second stage contractions had a greater association with complications than- did spontan-eous pushing; t h i s was p a r t i c u l a r l y evident among the prenatal attenders i n which 14 (40.0%) of those with complications used Valsalva 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 for intervention—forceps and caesarean section. For both the prenatal attender and the non-attender group the proportions who did spontaneous pushing for more than 60 percent of second stage contractions and Valsalva pushing more than 60 percent of second stage con-tractions and requiring intervention were s i m i l a r . For pre-natal attenders 8 (22.9%) who used spontaneous pushing and 10 (28.5%) who used Valsalva pushing required intervention while f o r the non-attender group 2 (13.3%) required interven-t i o n when using either type of second stage pushing. The non-attenders had a greater proportion of women (no intervention) who used Valsalva pushing (53.4%) and a greater proportion who used spontaneous pushing (20%) than the prenatal attenders, whose proportions were 34.3% and 14.3% respectively. Table 4-22 Recorded Complication and Breathing Patterns Breathing Pattern Prenatal Attenders Complication Spontaneous pushing > 60% of Contrac-t i o n Valsalva pushing > 60% of Con-tr a c t i o n Yes 8 ;No (22.9) (13.3) 14 8 (40.0) (22.8) Total: 22 (62.9) 13 (37.1) Non % of Total Attenders Sample Complication Complication Yes . „,No Yes ..-.No 2 3 10 8 (14.3) (20.0) (20.0) (16.0) 1 9 15 17 (6.7) (60.0) (30.0) (34.0) 3 12 25 25 ;20.0) (80.0) (50.0) (50.0) U) Table 4-23 Interventions and Breathing Patterns Breathing Pattern Prenatal Attenders Intervention Yes No Spontaneous pushing 60% of contrac-tions Valsalva pushing 60% of contrac-tions Total: 8 5 (22.9) (14.3) 10 (28.5) 18 (51.4) 12 (34.3] 17 (48.6) •Includes forceps and caesarean section births Non Attenders % of Total Sample Intervention Intervention Yes No Yes No 2 3 10 8 . (13.3) (20.0) (20.0) (16.0; 2 8 12 20 (13.3) (53.4) (24.0) (40.0) 4 11 22 28 (26.6) (73.4) (44.0) (56.0) h-1 In both groups the mean time for second stage was si m i l a r (excluding interventions). For both the prenatal attenders and the non-attenders, those who used spontaneous pushing had s l i g h t l y longer second stages than those who used Val-salva pushing; 76.6 minutes versus 68.3 minutes for the prenatal attenders and 81.3 minutes versus 68.0 minutes for the non-attenders (refer to Table 4-19). Fluency with English i n Relation to Breathing Patterns Used Table 4-24 shows the breathing patterns when English was not the best understood language of the study participants. Table 4-25 shows the data when adjusted for those participants who received verbal directions i n t h e i r native language (English or another language) from: t h e i r attending nurse; t h e i r partner; and or t h e i r physician when he or she was present and speaking to the woman during the delivery. When the mother was conversing with one of her caregivers or support persons i n her native language, over four times the number of prenatal attenders (28.6%) used spontaneous pushing (most were English speaking) as did the non-attenders (6.7%). Of the prenatal attenders using spontaneous pushing, 2 were encouraged to do so by t h e i r physician, 5 by the nurse and 2 by t h e i r partners. Regardless of language s k i l l s nurses who encouraged spontaneous pushing always spoke to the woman i n a sof t , pleasant and encouraging voice as w e l l as providing a great deal of physical contact during t h i s Table 4-24 Fluency with English and Breathing Patterns of the Study Participants Breathing Pattern Spontaneous Pushing > 60% of Contrac-tions Valsalva Pushing > 60% of Contrac-tions Total: Prenatal Attenders Non Attenders % of Total Sample Non-English English Non-English English Non-English English 3 .. (8.6) 3 (8.6) 6 (17.2) 10 (28.6) 19 (54.2) 29 (82.8) 4 (26.7) 1 :(6.7) 8 2 (53.3) (13.3) 12 3 (80.0) (20.0) 7 (14.0) 11 (22.0) 18 (36.0) 11 (22.0) 21 (42.0) 32 (64.0) Table 4-25 * Fluency of English or Native Language by Caretakers and Breathing Patteerns of the Study Participants Breathing Pattern Prenatal Attenders Non-Similar Similar Language Language Non Attenders % of Total Sample Non-Similar Similar Non-Similar Similar Language Language Language Language Spontaneous pushing > 60% of Contrac-tions Valsalva pushing > 60% of Con-tractions Total: 3 (8.6) 1 (2.8) 4 (11.4) 10 (28.6) 21 (60.0) 31 (88.6) 4 , (26.7) 4 (26.7) 8 (53.4) 1 7 (6.6) (14.0) 6 5 (40.0) (20.0) 7 12 (46.6) (24.0) 11 (22.0) 27 (54.0) 38 (76.0) •Adjusted for the nurse who spoke the woman's native language, the partner who gave directions i n the native language, and the physician who spoke the native language during the time he was present i n the room. time to convey support and a feel i n g of "your're doing w e l l " to the woman. Si m i l a r l y , the physicians and support persons gave verbal support and frequent encouragement to the woman throughout her contractions without exhorting her to "push harder". Of the non-attenders using spontaneous pushing, one physician encouraged the woman i n her use of t h i s approach. The other 4 (26.7%) non-attenders who used spontaneous pushing, even when encouraged to use Valsalva, stated that they did so because i t ' f e l t better' and chose not to l i s t e n to t h e i r caretakers. The majority of women who used Valsalva pushing d i d so because they were instructed to do so; 21 (60.0%) of the prenatal attenders and 6 (40.0%) of the non-attenders did Valsalva pushing for the majority of t h e i r second stage con-tractions when the woman was spoken to i n her native language. Even when the language spoken i n the delivery room was not sim i l a r to the woman's—both the one (2.8%) prenatal attender and the 4 (26.7%) non-attenders who used Valsalva pushing, stated they 'did what they were t o l d ' as implied by the tone of voice of the s t a f f or through directions 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 of episiotomy and vaginal lacerations for a l l study participants having a vaginal delivery. Table 4-26 Episiotomy, Vaginal Laceration i n Event Attenders Episiotomy Episiotomy and Laceration Laceration Intact Perineum *Total: No. (%) 16 50.0 6 18^75 (68.75) 6 18.75 _4 12.5 32 100.0 Second Stage Non-Attenders No. (%) 10 71.4 1 3 14 % of Total Sample No. (%) 26 56.5 J-l± 7 15.2 (78.6) (71.7) 21.4 9 19.6 - _4 8.7 100.0 46 100.0 •Excludes the 3 attenders and 1 non-attender who were delivered by caesarean section a f t e r the commencement of second stage labour. Thirty-three (71.7%) of the study participants had an e p i s i o t -omy; 22 (68.8%) of the prenatal class attenders and 11 (78.6%) of the non-attenders. Six (18.8%) of the attenders and 3 (21.4%) of the non-attenders were not given an episiotomy but had a f i r s t or second degree vaginal laceration. I t was noted that when a spontaneous delivery occurred (that i s , no intervention) 40.9% of the prenatal attenders were net given an episiotomy while only 18.2% of the non-attenders were not given an episiotomy. Four (8.7%) of the study par-ti c i p a n t s were delivered with an intact perineum (that i s , not having either an episiotomy or laceration requiring sutur-ing; a l l of whom had attended prenatal classes. Distr i b u t i o n of Labour Times In table 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 for a l l study participants i s presented. Fourteen (40.0%) of the attenders and 10 (66.7%)of the non-attenders completed the f i r s t stage of labour i n less than 10 hours, and a greater proportion (22.9%) of prenatal attenders (versus 13.3% for non-attenders) had a f i r s t stage of labour l a s t i n g longer than 16 hours. The range for the f i r s t stage of labour was 2 hours, 10 minutes to 28 hours, 50 minutes for prenatal attenders and 1 hour 30 minutes to 18 hours 30 minutes for non-attenders. Tables 4-28 and 4-29 present the d i s t r i b u t i o n s of second stage labour and t o t a l labour times, excluding those who required either a forceps or caesarean delivery during the second stage. Ten (58.7%) of the prenatal attenders had a second stage of s i x t y minutes or less, whereas only 3 (27.3%) of the non-attenders completed the second stage i n s i x t y minutes or less. I t i s interesting to 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 1 hour 1 :;2 2 *4 4 6 6 8 8 10 10 12 12 14 14 16 16+ Total: Attenders No. (%) •1 2.9 4 11.4 4 5 6 3 11.4 14.3 17.1 8.6 4 11.4 _8 22.9 35 100.0 Non Attenders No. (%) 1 1 • 3 3 2 1 1 1 2_ 15 6.7 6.7 20.0 20.0 13.3 6.7 6.6 6.7 13. 3 100.0 % of Total Sample No. (%) 1 2 7 7 7 7 4 5 10 2.0 4.0 14.0 14.0 14.0 14.0 8.0 10.0 20.0 50 100.0 Median: Mean: 11 hours 20 minutes 7 hours 50 minutes 10 hours 9 minutes 8 hours 54 minutes of the prenatal 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% respectively. The mean duration of second stage labour was almost the same— 70.4 minutes f o r attenders and 71.6 minutes for non-attenders. On the other hand the shortest unassisted second stages were 19 minutes f o r a prenatal attender and 24 minutes f o r a non-attender. The longest unassisted second stages were 181 minutes and 153 minutes for attenders and non-attenders res-pectively. Over 47 percent (47.1%) of the prenatal attenders com-pleted labour i n less than nine hours; for non-attenders t h i s proportion was 54.5%; and the mean t o t a l labour times were also very s i m i l a r — 9 hours 48 minutes and 9 hours 43 minutes for attenders and non-attenders respectively (exclud-ing 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 Total Sample No. (%) No. (%) No. (%) 19 minutes 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 - - 1 9.1 1 3.6 140 - 159 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 11 100.0 28 100.0 Mean: 70.4 minutes 71 .6 minutes •Excludes forceps d e l i v e r i e s and caesarean section d e l i v e r i e s . Table 4-29 •Distribution of Total Labour Time Total Labour i n Hours 5 7 9 11 13 15 17 19 5 7 9 11 13 15 17 19 21 21+ Total: Prenatal Attenders No. (%) 2 11.8 Non Attenders % of Total Sample 11.8 23.5 11.8 11.8 17.6 5.9 5.8 17 100.0 2 .4 2 2 3 1 No. 1 3 2 2 -1 2 (%) 9.1 27.2 18.2 18.2 9.1 18.2 11 100.0 No. 3 5 6 4 2 4 3 28 (%) 10.7 17.9 21.4 14.3 7.1 14.3 10.7 3.6 100.0 Mean: 9 hours, 48 min. 9 hours 43 min. •Excludes forceps and caesarean d e l i v e r i e s ocurring i n the,1 second.. stage. Summary A l l of the 50 study participants had a family member or f r i e n d present during the labour and delivery. The labour and delivery experiences of the prenatal attenders and non-attenders had some si m i l a r i t i e s . - but also many differences. Prenatal attenders had a higher proportion (48.6%) of epidural anesthesia than did the non-attenders (20%); they had a s i g -n i f i c a n t l y higher proportion of EFM (62.9% versus 20%) and recorded intrapartum complications (62.9% versus 20.0%). While the proportion of observation time when the women were having uterine contractions was very s i m i l a r — 4 9 . 9 % for the prenatal attenders and 48% f o r the non-attenders, the experience of b i r t h was not. Of the 15 (42.$%) prenatal attenders who had epidurals p r i o r to t h e i r second stage, 12 (34.3%) required intervention, and for the non-attender group, of the 3 (20.0%) women having epidurals, 2 (13.3%) required intervention. When examining the study group as a whole unit there was a s i g n i f i c a n t difference i n the number of interventions required by those women who had epidurals and those women who did not (p. < .001). The proportion of prenatal attenders and non-attenders who used spontaneous pushing was r e l a t i v e l y s i m i l a r — 2 9 . 4 % and 27.3% respectively (excludes d e l i v e r i e s by forceps and caesarean section). The mean duration of the second stage (excluding interventions) was also s i m i l a r between the groups— 75.6 minutes and 81.3 minutes for attenders and non-attenders who used spontaneous pushing f o r more than 60% of t h e i r contractions and with s l i g h t l y shorter times of 68.3 minutes and 68.0 minutes for those women i n the two groups who used Valsalva pushing f o r more than 60% of t h e i r contractions. Most women used Valsalva pushing (62.9% and 66.7% for the two groups) during second stage contractions. For both groups they did so mainly because a l l guidance given during the second stage was for Valsalva pushing. Only 4 (11.4%) of the prenatal attenders and 4 (26.7%) of the non-attenders did spontaneous pushing despite being instructed to use the Valsalva method. Nine (25.7%) of the prenatal attenders and 1 (6.7%) of the non-attenders used spontaneous pushing despite receiving c o n f l i c t i n g instructions regarding pushing ( i . e . both spontaneous and Valsalva). For most of these women one of the caregivers or the support person assumed the dominant coaching role and the woman followed those instructions f o r the majority of her contractions. There d i d not seem to be an association between the need for interventions and spontaneous pushing as the prop-ortion of women using spontaneous pushing and requiring intervention i n both groups was less than for those women who used Valsalva pushing for the majority of t h e i r contractions. The language s k i l l s 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 with English not being the primary language, several women chose to ignore the instruction given them and use the type of breathing (spontaneous pushing) which ' f e l t best' at the time. The assumption by the caregivers was that the woman could not understand the instructions even though model breathing and a sharp, d i r e c t i n g tone.of voice was often used. For the prenatal attenders who did not have English as t h e i r main language, a l l but one of the caregivers supported spontaneous pushing and the women were able to follow t h e i r own in 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 of labour—8 hours 54 minutes while f o r the prenatal attenders the mean duration was 10 hours, 9 minutes. The mean duration of the second stage (excluding interventions) was v i r t u a l l y i d e n t i c a l — 7 0 . 4 minutes and 71.6 minutes for prenatal attenders and non-attenders respectively. The t o t a l labour times were also s i m i l a r (excluding interventions) with the mean time being 9 hours, 48 minutes for prenatal attenders and 9 hours, 43 minutes for non-attenders. Infant Outcomes Infant outcomes which may r e f l e c t the conduct of the second stage w i l l be described for the following: recorded f e t a l distress and Apgar scores. Recorded Fetal Distress Fetal distress was recorded on the Labour-Delivery Re-cord. As indicated i n Table 4-30, 10 (28.67%) of the neonates 128 of prenatal attenders were recorded as having sortie f e t a l distress and three (20%) of the neonates of non-attenders were recorded as having f e t a l distress during the intrapartum. The recorded reasons f o r the f e t a l distress were:• f e t a l heart rate decelerations at the commencement of second stage (2); f e t a l heart rate decelerations during and after second stage contractions (6); meconium staining (4); and a combination of meconium staining and decreased f e t a l heart rate (1). Of those women whose infants were recorded as having f e t a l d i s t r e s s , only 2 (1 prenatal attender and 1 non-attender) did not have epidural anesthesia. Seven (70%) prenatal attenders whose infants were re-corded as having f e t a l d i s t r e s s , used Valsalva pushing dur-ing the majority of t h e i r second stage contractions and 2 (13.3%) of the non-attenders whose infants were recorded as having f e t a l d i s t r e s s , used Valsalva pushing during the majority of t h e i r second stage contractions as shown i n Table 4-30. Thus, 9 of the 13 (62.9%) neonates were recorded as having f e t a l distress when the women used Valsalva pushing during i.the majority of t h e i r second stage contractions. Apgar Scores Table 4-31 presents the data concerning Apgar scores at one minute a f t e r delivery. In Nucholl's l i s t of c l a s s i -f i c a t i o n of neonatal complications he considered an Apgar Table 4-30 Recorded Fetal Distress and Breathing Patterns Prenatal Attenders Fetal Distress Yes No Spontaneous Pushing > 60% of Contrac-tions 3 9 (8.6) (25.7; Valsalva Pushing > 60% of Contrac-tions 7 16 (20.0) (45.7; Total: 10 (28.6) 25 (71.4 Non Attenders % of Total Sample Fetal Distress Fetal Distress Yes No Yes No 1 4 4 13 (6.7). (26.7) (8.0) (26.0) 2 8 9 24 (13.3, (53'.3).- (18.0) (48.0) 3 12 13 37 (20.0) (80.0) (26.0) (74.0) score of less than 'seven' on a scale of ten to be a compli-cation. Table 4-31 Apgar Scores One Minute After Delivery Apgar Score at 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 - 1 0 28 80.0 12 80.0 40 80 Total: 35 100.0 15 100.0 50 100.0 Mean Apgar Score: 8 8.2 Of the study participants, 10 delivered infants whose Apgar score was less than 7. Prenatal attenders delivered 7 (20%) infants whose Apgar score was less than 7; 4 had Epidural anesthesia; and 4 required delivery by forceps. Non-attenders delivered 3 (20%) infants whose Apgar score was less than 7; 2 had an Epidural and required delivery by forceps or caesarean section. One woman whose infant was delivered with a low Apgar score did not have any anes-t h e t i c and delivered spontaneously. Two infants delivered having a low one minute Apgar score were diagnosed as having either a congenital anomoly or trauma during b i r t h — n e i t h e r of these women had any anesthesia—both were prenatal atten-ders. One woman, a non-attender, whose infant had a low Apgar score delivered spontaneously and did not have any anesthesia. Summary Recorded f e t a l distress was noted for 10 (28.6%) of the infants of prenatal attenders and for 3 (20.0%) of the infants of non-attenders. A greater proportion (20.0%) of the infants of the prenatal attender group were classed as having f e t a l distress when the woman was using Valsalva pushing than were the infants of the non-attender group (13.3%). Of consideration here i s the fact that the women i n the prenatal group had more EFM, more epidural anesthesia, and more intervention which may influence the diagnosis of f e t a l d i s t r e s s . The proportion of infants having Apgar scores of seven or greater at 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 also s i m i l a r — 8 for the infants of prenatal attenders and 8.2 for the infants of the non-attenders. Even with the greater amount of EFM used for the prenatal group (presumably because of i d e n t i f i e d r i s k s or possible r i s k s of the infant) the infant outcome was not better than the non-attender group i f the Apgar score i s the measurement used to indicate the status of the infant. 132 Confidence, Perception of Labour and Delivery An attempt was made to determine how confident the study participants f e l t about t h e i r labour and delivery (as that time approached) and t h e i r perception of the ex-perience soon after the delivery. For prenatal attenders an attempt was made to get t h e i r perception of the breathing patterns used during the second stage and why they were used. Tables 4-32 and 4-33 provides these data. Table 4-32 Confidence Level f o r Labour and Delivery Confidence Prenatal Non % of Total Level Attenders Attenders 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 Total: 35 100.0 15 100.0 50 100 Twenty-eight (80.0%) of the Prenatal Class Attenders stated that they were at least 'confident' f o r t h e i r labour and delivery experience p r i o r to the event, whereas only 10 (66.6%) of the Non-Attenders were at least 'confident' p r i o r to delivery. Twnety percent of the Prenatal Attenders stated that they were 'not very confident' while 33.4 per-cent of the Non-Attenders gave t h i s i n d i c a t i o n . Of the 28 prenatal attenders who f e l t at least confident f o r the b i r t h experience, 24 (85.7%) of them indicated they f e l t 'well prepared' as a r e s u l t of the classes. Those who did not f e e l 'well prepared' as a re s u l t of the classes gave the following as reasons: not attending a l l of the classes for complete information; and f a i l u r e to practice the breath-ing techniques to know how to do them w e l l . Perception of Labour and Delivery As indicated i n Table 4-33, thirty-seven percent of the prenatal attenders indicated t h e i r perception of the labour and delivery experience was 'better': than expected' whereas only 13.3% of the non-attenders f e l t t h e i r experience was 'better than expected'. Another difference of note was i n the 'worse than expected' perception with 42.9% of the prenatal attenders versus 73.4% of the non-attenders st a t i n g t h e i r perception of labour and delivery 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 prenatal attenders' a b i l i t y to use the breathing techniques taught i n prenatal classes for use during the second stage of labour. Four of the women were unable to state i f any s p e c i f i c Table 4-33 Perception of the Labour/Delivery Experience Perception of Prenatal Non % of Total Experience Attenders Attenders Sample No (%) No. (%) No. (%) Better than expected 13 37.1 2 13.3 15 30 As expected 7 20.0 2 13.3 9 18 Worse than expected 15 42.9 11 73.4 26 52 Total: 35 100.0 15 100.0 50 100 method was taught or talked about i n t h e i r prenatal classes. Of the remaining women, a l l were able to describe the tech-nique that had been taught i n t h e i r classes. Only two women i n the prenatal attender group gave c o n f l i c t i n g information to what was observed; one stated that she had used and had been encouraged to use spontan-eous pushing when she had been observed to use Valsalva pushing greater than 60% of the time and was a c t i v e l y encour-aged to use t h i s technique by her support person and care-givers. The other woman stated that she wanted to use an exhale"type breath but used Valsalva pushing as directed by the s t a f f ; she was observed to do spontaneous pushing (although not exhale) greater than 60% of the time and was encouraged to do so by her partner and the attending nurse. Only 2 of the prenatal attenders attributed the breath-ing techniques used to what they had been taught i n prenatal classes. For both women t h e i r support person assumed the dominant labour support r o l e and used either vocal and or model breathing guidance throughout the second stage con-tractions . Summary Prenatal attenders expressed more feelings of confidence (80.0%) i n preparation f o r the b i r t h experience than did the non-attenders (66.7%). They also perceived t h e i r labour and delivery experience to be 'as expected' or 'better than expected' more often than did the non-attenders (57.1%,versus 26.6%). Even though the prenatal attenders required a greater number of interventions than did the non-attenders,- fewer attenders perceived the b i r t h experience as 'worse than expected' as compared to the non-attenders (42.9% versus 73.4%). The majority (88.6%) of the prenatal attenders were able to describe the breathing recommended i n t h e i r prenatal classes for use during the second stage of labour. However, only 2 (5.7%) of the women attributed t h e i r breathing tech-niques (used during second stage) to information obtained from t h e i r classes. The majority (94.3%) of women were able to accurately describe the breathing techniques used during second stage and attributed t h i s to following the instructions of t h e i r caregivers or support person. CHAPTER V SUMMARY AND DISCUSSION OF THE RESULTS, CONCLUSION, IMPLICATIONS AND RECOMMENDATIONS FOR FURTHER INVESTIGATION Overview In t h i s chapter the research format and the resu l t s of the study are discussed. F i r s t , the research format and the demographic characteristics of the participants i n the study are discussed. This i s followed by a discussion of the labour and delivery experience of the study p a r t i c i -pants; a b r i e f discussion of the infant outcomes; and a b r i e f discussion of the women's perception of t h e i r b i r t h experrience. A conclusion, implications of the study and recommendations for further investigation conclude the presen-ta t i o n of the study. The Research Format and Characteristics of the Respondents An observation of the delivery experience p a r t i c u l a r l y i n r e l a t i o n to the type of breathing used by the women during second stage contractions, was conducted i n the major mater-n i t y f a c i l i t y i n the Vancouver area. The study participants, 50 women (66.7% of those e l i g i b l e ) who were having t h e i r f i r s t c h i l d , were recruited following admission to hospital during the f i r s t stage of labour. A l l women were considered to be 'low-risk' on admission to hosp i t a l . Sixty percent of the reasons for non-participation were not related to re 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 prenatal education program during t h e i r pregnancy; of those prenatal attenders 48.6% were residents of Vancouver with the remainder l i v i n g i n the surrounding communities. Of the non-attenders, 73.3% resided i n Vancouver. The mean age of the prenatal attenders was 28 years, s l i g h t l y older than the mean age of 26 years for the non-attenders. Of the study participants, 77.1% of the prenatal attenders were born i n Canada, the United States or England, whereas only 6.7% of the non-attenders were born i n one of these countries. There was found to be a s i g n i f i c a n t difference (p<.001) i n the country of o r i g i n ; residency i n Canada 10 years or more; language best understood and type of employment. The education l e v e l of the prenatal attenders was s l i g h t l y higher with 62.9% having post secondary educations while only 46.7% of the non-attenders had post secondary education. Prenatal class attenders tended to be i n t h e i r mid to late twenties, Caucasian and English speaking. They had attained grade 12 or better education and were employed i n a s k i l l e d or higher l e v e l position. The non-attenders a l -though having attained grade 12 education were l i k e l y to be employed i n a s k i l l e d or lesser type position, not fluent i n English, to have l i v e d i n Canada ten years or less, having come from one of the Asian countries. The number of non-attenders who were from the non-English speaking section of the community was si m i l a r to the 1983 study of Robertson which found that a large proportion of women i n certain areas of Vancouver receiving post-natal services did not have English as t h e i r main language and do not search out community health services during pregnancy. Labour and Delivery Experience... .. . The o v e r a l l rate of women receiving epidural anesthesia during labour/delivery was 40% with prenatal attenders receiv-ing the greatest proportion (34% of the t o t a l study population). Only one of the women who received an epidural during the f i r s t stage of labour did not have electronic f e t a l monitor-ing during that time as w e l l . In the prenatal attender group, 15 (42.9%) received epidural anesthesia during the f i r s t stage, a l l had EFM, and a l l were recorded as having some form of complication on the Labour-Delivery Record. In the non-attender group, 3 (20%) had epidural anesthesia and 3 (20%) had EFM (only 2 had epidurals also), of those who had EFM, 2 were recorded as having an intrapartum complication also. The large proportion of prenatal attenders receiving epidural anesthesia i s consistent with the findings of 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 to reduce fear, anxiety and tension, and should t h e o r e t i c a l l y reduce pain), the majority of women i n t h e i r study requested epidural anesthesia. The differences between the two groups i n r e l a t i o n to epidural anesthesia use seems to support Kleins (1982) suggestion that "a request f o r epidural anesthesia by a woman i n labour i s c u l t u r a l l y determined" (p. 357). He believes that epidural anesthesia has been widely accepted by an "uninformed public" who are aware of the a v a i l a b i l i t y of them but unaware of t h e i r inherent r i s k s . A l l of the prenatal attenders i n t h i s study would have received some information on epidurals i n t h e i r prenatal classes thus being aware of t h e i r a v a i l a b i l i t y . Non-attenders, who were mostly new Canadians, did not have access to t h i s information as e a s i l y 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 of Labour Eighteen (51.4%) of the prenatal attenders required intervention (delivery by forceps or caesarean section), while 4 (26.6%) of the non-attender group required interven-t i o n . For the majority (12 at tender and 2 non-attender) there seemed to have been some association with receiving epidural anesthesia. I t supports the findings of Pearson and Hoult et a l (1977) that the use of t h i s type of interven-t i o n , while reducing pain, may resul t i n a distressed infant, malposition, and the need for forceps delivery and midforceps rotation. The study findings also support Dunn's b e l i e f 141 that the frequent use of interventions (such as epidural anesthesia) i n modern obstetric management "have almost become part of the r i t u a l of modern delivery" (p.790). Breathing Patterns During Second Stage Labour Although the prenatal attenders and the non-attenders have dif f e r e n t backgrounds and preparation the proportion of uterine contractions observed during the second stage observation period were almost i d e n t i c a l — 4 9 % and 48% respect-i v e l y for each group. The proportion of women who used spontaneous pushing was also s i m i l a r , 37.1 percent and 33.3 percent for both the prenatal attenders and the non-attenders. The majority (62.9% and 66.7%) of the attenders and non-attenders used Valsalva pushing throughout the second stage. The expectation that women who take prenatal classes i n preparation for c h i l d b i r t h would use spontaneous breathing techniques during second stage i s not confirmed; due to the small sample size a s t a t i s t i c a l l y s i g n i f i c a n t difference could not be detected. When examining the influences on women i n using the breathing techniques described several factors emerged: 1. o v e r a l l 72% of the women were always instructed, when verbal instructions were given, to push using the Valsalva Maneuver, during the second stage; 2. 28 percent of the women received c o n f l i c t i n g guid-ance regarding the breathing technique to use; and 3. the primary language of the delivering women wase of importance i n that ;±bv set up a communication bar 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 English was not the primary language. Regardless of information received at prenatal classes regarding breathing techniques, only two prenatal attenders attributed t h e i r breathing techniques used to the information they had been taught i n classes. They were also among the group of people who practised 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 verbal directions during each contraction while the other support person did model breathing and used hand directions throughout each contraction. The support person automatically assumed th i s r o l e at the commencement of second stage and the attending s t a f f seldom made any at-tempts to overrule that guidance. The remaining prenatal attenders who used spontaneous pushing f o r the majority of t h e i r second stage contractions (and received c o n f l i c t i n g instructions) followed the instruc-tions of the dominant person guiding them—the nurse or physic-ian. In f i v e d e l i v e r i e s the nurse took on the primary support r o l e . She spent most of the time at the woman's bedside t a l k i n g to her i n a calm, reassuring manner, always of f e r i n g encouraging words. On several occasions other medical person-nel would t e l l the woman to push hard with the breath held but these p a r t i c u l a r nurses continued to speak to the woman in the same manner, keeping the woman's attention focused on her directions. In two de l i v e r i e s the physician was present during the entire second stage and favoured spontaneous pushing. During one of the del i v e r i e s the nurse (who encouraged Valsalva) became non-verbal after approximately ten minutes; she carried on with the monitoring duties but offered no further verbal comments to the mother u n t i l a fter the baby was delivered. In the other delivery the physician stated that he wished the woman to be "allowed to push as she f e l t the need" to do so; t h i s occurred while he was i n the delivery room but the woman was encouraged to do Valsalva 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 prenatal classes took t h e i r directions 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 while the observer was present) i f they had any preferences regarding the type of breathing or positioning they wished to use during second stage. Neither had t h e i r request to do spontaneous pushing acknowledged. One of the women requested to "squat arid do spontaneous push-ing" and received the reply, "squatting i s d i f f i c u l t with the epidural" making no comment about choice of breathing technique. This woman was then instructed to do Valsalva pushing. toother woman (who had requested to do spontaneous pushing on a written b i r t h plan and was having a pre c i p i t a t e delivery) was very f o r c e f u l l y t o l d to "push as hard as you can—take a deep breath and push"—even with acknowledgement of the precipitate delivery. Although the woman referred to her b i r t h plan the reply was "I have not read your b i r t h plan". The majority of women and partners who were instructed and followed the directions for Valsalva pushing never ques-tioned any s t a f f about the technique nor did they make any requests regarding preferences for the management of second stage. Yet a l l of the women were able to state that they did not do the spontaneous breathing taught i n t h e i r prenatal classes; they just followed directions from the s t a f f . The observation of the treatment of the women i n t h i s study support the findings of Sullivan and Beeman (1981-1982) and Danziger (1978). Most of the women and t h e i r part-ners became passive i n that they followed directions from the s t a f f with very few. challengess to the procedures and routines i n the delivery room. When requests were made re-garding the conduct of second stage they were barely acknow-ledged then often disregarded. Complications and Breathing Patterns The study participants who used Valsalva pushing during second stage contractions had a greater number of complications than those participants who used spontaneous pushing. Nine of the 13 infants were recorded as having f e t a l distress when the women used Valsalva pushing during the majority of t h e i r second stage contractions; 6 of those 9 were record-ed as having early and lat e f e t a l heart rate decelerations ( l a s t i n g a f t e r the contraction i s over). These findings are s i m i l a r to those of Caldeyro-Barcia (1979) and Humphrey (1973); who support less encouragement of active bearing down due to the association with f e t a l hypoxia, indicated by l a t e f e t a l heart rate decelerations (Type I I Dips). These lat e f e t a l heart decelerations are r e a d i l y observed when electronic f e t a l monitoring i s used and may be interpreted as a complication r e s u l t i n g i n delivery by forceps or caesarean section. Among the prenatal attender group there was a greater need for intervention among those women who used Valsalva pushing than among those who used spontaneous pushing. How-ever, t h i s difference was not seen i n the non-attender group, most l i k e l y due to the low frequency of epidural anesthesia i n t h i s group. Many (34.3%) of the women i n the prenatal attender group who had epidural anesthesia and also required intervention, were directed to use Valsalva pushing during t h e i r contractions. Language S k i l l s Language s k i l l s are of importance i n the woman's a b i l i t y to understand and converse with her caregivers (mainly the nurse). While the number of those with a non-similar language was small i n the prenatal attender group i t was interesting to observe that regardless of language s k i l l s the o v e r a l l proportion . of attenders and non-attenders using spontaneous pushing and Valsalva pushing was si m i l a r — 3 7 . 2 % (attenders) versus 33.4% (non-attenders) for spontaneous pushing and 68.8% (attenders) versus 66.6% (non-attenders) for Valsalva pushing. A l l women revealed that although not having English 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 directions to 'push' and instead followed t h e i r body urges to push when they f e l t the need to do so. I t was easier for those women to disregard directions when the main language of the patient and caregivers were d i f f e r e n t . Labour Times The t o t a l labour times for the prenatal 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 respectively. The o v e r a l l second stage duration of both groups was also s i m i l a r (70.4 minutes and 71.6 minutes). For those women who used spontaneous pushing for the majority of t h e i r contractions the second stage was s l i g h t l y longer for both groups (75.6 minutes and 81.3 minutes) pernatal attenders and non-attenders respec-t i v e l y (versus 68.3 minutes and 68.0 minutes for those using Valsalva pushing). These differences i n durations support Caldeyro-Barcia (1979) and Perry and Potter's (1979) results of a longer second stage when spontaneous pushing i s used. Although the additional time added to second stage i s r e l a -t i v e l y short, the question remains for the c l i n i c i a n , 'Does that added time have any detrimental effect on the fetus?' Information from Caldeyro-Barcia (1979) and Bassell (1980) suggest i t does not, providing the fetus i s doing w e l l . Infant Outcomes The proportion of infants whose Apgar scores at one minute after delivery were less than seven (20%) and seven or greater (80%) was i d e n t i c a l for both groups. However, the proportions having Electronic Fetal Monitoring d i f f e r e d considerably with 62.9% of the prenatal attenders and 20% of the non-attenders receiving electronic f e t a l monitoring. This seemed to have an association to the corresponding use of epidural anesthesia. With the o v e r a l l rate of elece-t r o n i c f e t a l monitoring being 50% f o r the study group and the numbers of recorded f e t a l distress being 26% for the whole group, suggestions by Dunn (1976) and Schneider (1981) that electronic f e t a l monitoring l i k e , other interventions 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, to be true. Confidence, Perception of Labour and Delivery Women who attended prenatal classes expressed greater confidence p r i o r to t h e i r labour and delivery experience and perceived t h e i r b i r t h experience to be better than those women who d i d not attend prenatal classes. Regardless of the greater numbers of interventions prenatal attenders exper-ienced, they expressed more pos i t i v e feelings about t h e i r experience. As with Danziger's (1979) findings, most of the women's comments about t h e i r delivery indicated that there were no alternatives f o r them and that the experience— however d i f f i c u l t was worth i t because they have a healthy c h i l d . I l l u s t r a t e d by the fact that not a l l prenatal attenders were able to describe the breathing techniques taught i n t h e i r classes and only two women attributed t h e i r breathing to the information received i n prenatal classes indicates that women do not receive s u f f i c i e n t information and the guidance and practice needed regarding the use of alternative breathing approaches to make any appreciable impact on the conduct of the second stage of labour. Conclusion The purpose of t h i s study was to describe the breathing techniques used by women during the second stage of labour and to determine i f women who take prenatal education are more l i k e l y (than non-attenders) to use spontaneous pushing during second stage contractions. The prenatal attenders had an average age of 28 years and the non-attenders an average age of 26 years. The major-i t y of women i n the prenatal attender group were Caucasian, English speaking and were employed at a s k i l l e d l e v e l or better (74.3%). The majority of women i n the non-attenders group were born i n one of 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 l e v e l or less (80.0%). Prenatal class attenders had a higher rate of epidural anesthesia (48.6% versus 20.0%) during t h e i r labour and d e l i v -ery, a higher rate of electronic f e t a l monitoring (62.9% versus 20.0%) during labour and delivery, a higher rate of recorded intrapartum complications (62.9'% versus 20.0%), and a higher rate of interventions during delivery (51.4% versus 26.6%) than did those women i n the non-attender group. The proportion of prenatal attenders and non-attenders who used spontaneous pushing f o r more than 60% of t h e i r con-tractions was almost i d e n t i c a l— 2 9 . 4 % for prenatal attenders and 27.3% f o r non-attenders. Only two women i n the prenatal attender group attributed t h e i r approach to second stage breathing to information they acquired through attendance at prenatal classes. The majority of women i n both the pre-natal 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 to use the extended breath holding technique, the Valsalva maneuver. When using the Valsalva maneuver many of the women were re-ported as having a complication of f e t a l distress involving l a t e f e t a l heart rate decelerations which are a re s u l t of the physiological effects of the Valsalva maneuver used by the women during second stage contractions. The t o t a l duration of labour was si m i l a r between the two groups; with the second stage of labour (excluding i n t e r -ventions) for those women using spontaneous pushing (75.6 minutes f o r prenatal attenders and 81.3 minutes for non-attenders) being s l i g h t l y longer than for those women using Valsalva pushing (68.3 minutes and 68.0 minutes for prenatal attenders and non-attenders respectively). In conclusion, the findings that prenatal attenders have more epidural anesthesia which then has a 'domino' ef-fect on subsequent practice; i n the c h i l d b i r t h process and the fact that only 2 of 35 women who attended prenatal educa-t i o n could attribute 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 of labour) indicates there i s a need for better prep-aration i n coping with the experience of c h i l d b i r t h . Implications of the Study 151 The reported findings of t h i s study have the following implications: 1. Prenatal education programs to expectant parents should be adapted to provide: - more information and emphasis on strategies which can be used i n coping with pain during c h i l d b i r t h . - more discussion regarding the effects of the Valsalva 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 relaxation and techniques which can be used during labour and delivery. - greater emphasis and practice of s p e c i f i c tools which can be used i n coping with second stage contractions (e.g. verbal directions, v i s u a l directions, the v a r i e t y of positions available) which could enhance the use of spontaneous pushing. - greater direction for the support person such that he/she feels comfortable i n supporting and d i r e c t i n g the woman i n her use of spontaneous pushing during second stage labour. 2. Those who teach the prenatal education programs should be frequently updated on the most recent research f i n d -152 ings related to the effects of the Valsalva Maneuver and the conduct of 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 of the primary care during labour and delivery should be updated on the s k i l l s of breathing and relaxation techniques to be used i n the management of labour i n an attempt to minimize the use of epidural anesthesia during the f i r s t stage of labour. 4. Since the labour and delivery room nurses were a major influence on the breathing patterns of women during second stage, nursing personnel should be provided with current research findings and information on c h i l d b i r t h philosophies. 5. Since labour and delivery nurses are one of the major influences on a woman's behaviour during labour and delivery, greater emphasis should be placed on s t a f f education regarding strategies which might be used by the de l i v e r i n g woman and her partner to enhance t h e i r b i r t h process. 6. Nursing and medical students should be provided with current research findings and information on the effects of the Valsalva maneuver and strategies for managing the second stage of labour. Since physicians also provide dir e c t i o n to the woman during the second stage of labour, they should become fa m i l i a r with current research on the conduct of the second stage of labour as i t relates to the Valsalva maneuver and i t s effects on the f e t a l heart rate which may lead to unnecessary interventions. Since physicians provide a major portion of the prenatal health care to pregnant women, they should take advantage of t h e i r p o t e n t i a l to educate expectant mothers on the implications of epidural anesthesia during labour and encourage t h e i r c l i e n t s to learn techniques for use i n coping with the pain of c h i l d b i r t h . Pregnant women should consider having a labour support person (besides her husband) present during c h i l d b i r t h to provide companionship, encouragement and to ass i s t the woman i n the use of learned coping s k i l l s . New and innovative methods for teaching expectant parents s k i l l s for coping with c h i l d b i r t h should be continually t r i e d by health educators and evaluated for effectiveness. Planners of prenatal education programs i n collaboration with researchers, must specify more d e f i n i t e l y the change/ outcome i t expects i n program participants i n order that appropriate measurement techniques may be established. Planners of community based programs should l i n k with representatives of the medical community, labour and delivery room, and consumers who are concerned with the delivery of pe r i n a t a l care, i n an attempt to provide a r e a l i s t i c and uniform philosophy which can be used i n the preparation of expectant parents and carried through to the b i r t h experience. Recommendations for Further Study 155 Based on the findings of t h i s study, the following recom-mendations for further research are recommended. 1. A prospective study should be conducted on a larger sample, preferably i n a number of f a c i l i t i e s , to investigate the influences on a woman's a b i l i t y to cope with the pain of labour, the need for anesthesia, and the breathing strateg-ies i n the second stage of labour. 2. Further study needs to be conducted on the effects of the Valsalva maneuver on the woman and fetus during labour and delivery. 3. Further investigation should be conducted on the i n c i d -ence of s p e c i f i c complications of labour and delivery follow-ing epidural anesthesia. 4. There i s a need to examine i n greater depth, which coping strategies are most effec t i v e i n dealing with the pain of labour and delivery. 5. Additional research to develop e f f i c i e n t and eff e c t i v e teaching methods directed at providing the coping s k i l l s for labour and delivery i s warranted. 6. 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Obstetric Delivery Today: For Better or for Worse? The Lancet. A p r i l , 790-793. Elisberg, E.I. (1963). Heart Rate Response to the Valsalva Maneuver as a Test of Circulatory Integrity. Journal  of American Medical Association, 186, 200-205. Enkin, M.W., Smith, S.L., Dermer, S.W., and Emmett, J.O. (1972). An Adequately Controlled Study of the Ef f e c t i v e -ness of PPM Training. In Psychosomatic Medicine i n  Obstetrics and Gynecology (pp. 62-67). Edited byb;, N. Moris. Basel: S. Karger. Fleury, P.M. (1967). Maternity Care: Mothers Experiences  of C h i l d b i r t h , London: George Allen & Unwin Limited. Fox, I . J . , Crowley, P., Grace, J.B.,-& Wood, E.H. (1966). Effects of the Valsalva 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). Alternatives 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. 287-301). Edited by P. Ahmed. 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Journal of Nursing Midwifery, 26(2), 13-22. Noble, E. (1976). Essential Exercises for the Childbearing  Year. Boston: Houghton M i f f l i n Company. Noble, E. (1978). Rationale for Prenatal and Postpartum Exercises. In Kaleidoscope of Childbearing: Prepara-t i o n , B i r t h and Nurturing (pp. 9tfl2:)J.- Edited by P. Simpkin and C. Reinke. Seattle: Pennypress. Nuckolls, K.B., Cassell, J.C. & Kaplan, B. (1972). Psycho-s o c i a l Assets, L i f e C r i s i s and the Prognosis of Pregnancy. American Journal of Epidemiology, 95(15), 431-440. Nunnally, D.M. & Aguiar, M.B. (1974). Patients Evaluation of Their Prenatal and Delivery Care. Nursing Research, 23(6), 469-474. Perry, L. & Potter, C. (1977). Pushing Technique and the Duration of 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). Birthing Normally: A Personal Growth  Approach to Ch i l d b i r t h . Berkeley: Mindbody Press. Pridham, K.F. & Schutz, M.E. (1983). Parental Goals and the Bir t h i n g Experience. Journal Gynecological Nursing, 12(1), 50-55. Pritchard, J.A. & MacDonald, P.C. (Eds.). (1980). William's  Obstetrics. (pp. 405-434), New York: Appleton-Century-Crofts. Re i d , D.H.S. (1966). Respiratory Changes i n Labour. The  Lancet 1, 784-785. Riley, E.M.D. (1977). What Do Women Want? — The Question of Choice i n the Conduct of Labour. In Benefits and  Hazards of the New Obstetrics, (pp. 62-71). Edited by T. Chard and M. Richards. Philadelphia:^. J.B. L i p -pincott Company. Roberts, J. (1980). Alternative Positions for C h i l d b i r t h — P a r t I I : Second Stage of Labour. Journal of Nurse-Midwifery, 25(5), 13-19. Robertson, A. (1983). Perinatal Review — Phase I I . Vancouver Health Department. Roemer, V.K., Harms, K., Buess, H. & Horvath, T.J. (1976). Response of Fetal Acid-Base Balance to Duration of Second Stage of Labour. International Journal of Gynecology  and Obstetrics, 14, 455-471. Rosenberg, S.N., Albertsen, P.C., Jones, E. & Roberts, R. (1981). Complications of Labor and Delivery -.Following Uncomplicated Pregnancy. Medical Care, 19(1), 68-79. Scaer, R., & Korte, D. (1978). MOM Survey: Maternity Options for 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 Delivery i n the Case Room: A C r i t i c a l Appraisal. Canadian Medical  Journal, 125, 350-352. Scott, J.R. & Rose, N. (1976). Effect of Psychoprophylaxis (Lamaze) on Labor and Delivery i n Primiparas. New England  Journal of Medicine, 29(22), ,1205-1207. Sharpey-Schafer, E.P. (1965). Effect of Respiratory Acts on the Cir c u l a t i o n . In Handbook of Physiology, (pp. 1875-1885). Edited by W.F. Hamilton. 3(2). Washington: American Physiological Society. Shereshefsksy, P.M. & Yarrow, L.J. (Eds.) (1973). Psycho- l o g i c a l Aspects of a F i r s t Pregnancy and Early Postnatal  Adaption. New York: Raven. Sokol, R.J., Rosen, M.G. & Stojkov, J. (1977). C l i n i c a l Application of High Risk Scoring on an Obstetric Service. American Journal of Obstetrics and Gynecology, 128, 652-656. Standley, K. (1981). Researach on Ch i l d b i r t h Toward an Under-standing of Coping. In Pregnancy, C h i l d b i r t h and Parent-hood, (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 the C h i l d b i r t h Environment: A Research Model. B i r t h and  the Family Journal, 7(1), 15-20. S t a t i s t i c s Canada (1982). Births 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 Division, V i t a l S t a t i s t i c s and Disease. Stewart, D. & Stewart, L. (Eds), (1976). Safe Alternatives  i n C h i l d b i r t h . North Carolina: NAPSAC, Incorporated. Stewart, M.A. & Wanklin, J. (1978). Direct and Indirect Measures of Patient Satisfaction with Physicians' Services. Journal of Community Health, 3(3), 195-204. Sulli v a n , D.A. & Beeman, R. (1982). Satisfaction With Mater-n i t y Care: A Matter of Communication and Choice. Medical Care, 20(3), 321-330. Sulli v a n , D.A. & Beeman, R. (1981). Satisfaction with Post-partum Care: Opportunities for Bonding, Reconstructing the B i r t h and Instruction. B i r t h and the Family Journal, 8(3), 153-159. Trandel-Korenchuk, D. (1982). Informed Consent Client P a r t i -cipation i n C h i l d b i r t h Decisions. Journal of Gyneco-l o g i c a l Nursing, 11(6), 379-381. Wood, C, Ng, K.H., Hounslow, D. & Benning, H. (1973). Time— An Important Variable i n Normal Delivery. Journal of  Obstetrics and Gynecology of the B r i t i s h Commonwealth, 80, 295-300. Warwiac, D.P. & Lininger, C.A. (1975). The Sample Survey: Theory and Practise, (pp.72-75). New York: McGraw H i l l Book Company. Winner, C.L. & Romney, S.L. (1966). Cardiovascular Responses to Labour and Delivery. American Journal of Obstetrics  and Gynecology. 95, 1104-1114. Wolkind, S. & Zajcek, E. (Eds.). (1981). Pregnancy: A  Psychological and Sociological Study. London: Academic Press. Wright, H.P., Morris, N., Osborn, S.B., & Hart, A. (1958). Effect i v e Uterine Blood Flow During Labour. American  Journal of Obstetrics and Gynecology,. 75, 3-10. Young, D. (1982). Changing Ch i l d b i r t h : Family B i r t h i n the  Hospital. New York: C h i l d b i r t h Graphics Limited. APPENDIX A Submission To The University of B r i t i s h Columbia Screening Committee for Research and Other Studies Involving Human Subjects Behavioural Sciences D E S C R I P T I O N OF P O P U L A T I O N PAGE Z 11 HOW MANY SUBJECTS WILL BE USED? s i x t y 12 WHO IS BEING RECRUITED? ' — — - _ — 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 ARE THE SUBJECTS BEING RECRUITED AND SELECTED? (if initial contact is by letter, attach a cop.: UBC policies prohibit initial contact hy telephone) By p e r s o n a l c o n t a c t 1* WHAT ARE THE CRITERIA FDR THEIR SELECTION? P r i m i p a r o u s women who e n t e r 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 d u r i n g the s t u d y p e r i o d . D E S C R I P T I O N OF M E T H O D O L O G Y A N D P R O C E D U R E S 15 SUMMARY (must be complete in this space) The s t u d y w i l l use a co m b i n a t i o n o f t h r e e methods f o r d a t a c o l l e c t i o n . 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 environment u s i n g an 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 the 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 method 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 pe 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 sy s t e m o f c a t e g o r i e s a r e time-sampled i n c y c l e s o f 30 seconds f o r o b s e r v a t i o n and 30 seconds f o r r e c o r d i n g . 2) one-two days 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 above 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 and d e l i v e r y w i l l be o b t a i n e d from t h e p a t i e n t ' m e d i c a l r e c o r d . The s t u d y w i l l be r e c o r d e d i n t h e form r e q u i r e d f o r an 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 Care and E p i d e m i o l o g y a t UBC. 16 WHERE WILL THE PROJECT BE CONDUCTED? (roora or area) The Grace H o s p i t a l 1? WHO WILL ACTUALLY CONDUCT THE STUDY? (e.g. principal investigator, .;. B a r b a r a Selwood 18 HOW WILL THE PROJECT BE EXPLAINED TO THE SUBJECTS? P e r s o n a l e x p l a n a t i o n p l u s e x p l a n a t o r y l e t t e r . DESCRIPTION OF HKTHOnOUHlY ASP mVLIXIKKS (cant) PAGE 3 19 HOW WILL YOU MAKE IT CLEAR TO Tl-E SUBJECTS THAT THEIR PARTICIPATION IS VOLUNTARY AND THAT TVCV MAY WITHDRAW FROM THE STUDY AT ANY TIME THEY WISH TO DISCONTINUE PARTICIPATION? jgfc 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 ; i t i s w r i t t e 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 YOUR PROJECT UTILIZE. (check) X D QUESTIONNAIRES (submit s ccpy) ^ X n INTERVIEWS (submit sample of questions) ) Combined X n OBSERVATIONS (subir.it a brief description) ° TESTS s^ubmit a brixf description) D A T A 21 WHO WILL HAVE ACCESS TO THE GATHERED DATA? (e.g., committee members, government agencies, others. Please R e s e a r c h and T h e s i s Committee specify.) 22 HOW WILL CONFIDENTIALITY OF THE DATA BE 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 be used on a u e s t i o n a l r e i n s t e a d o f names 23 HOW WILL THE DATA BE RECORDED? (instruments, notes, etc.) O b s e r v a t i o n i n s t r u m e n t r e c o r d i n g s h e e t Q n p R t 1 n n a l r e d u r i n g the i n t e r v i e w 21, WHAT ARE THE PLANS FOR FUTURE USE OF DATA AS PART OF THIS STUDY OR USE BEYOND THIS STUDY? None 25 HOW WILL THE DATA BE DESTROYED AND WHEN? By f i r e a t the end o f the stu d y B E N E F I T S . C C S T S . R I S K S 26 WHAT ARE THE POTENTIAL BENEFITS TO THE SUBJECTS? M i n i m a l 27 WHAT MAY BE REVEALED THAT IS NOT CURRENTLY KNOWN? The match o r mismatch 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 b r e a t h 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 d u r i n g thi£ time . 28 WHAT MONETARY COMPENSATION IS OFFERED TO THE SUBJECTS? None >9WHAT ARE THE COSTS TO THE SUBJECTS? (monetary, time ) T h i r t y t o f o u r t y - f i v e m i n u t e s f o r t h e i n t e r v i e w 10WHAT RISKS TO THE SUBJECT ARE MOST LIKELY TO SE ENCOUNTERED? (e.g. physical, psychological, sociological) None 1 WHAT APPROACH WILL YOU TAKE TO MINIMIZE THE 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 be made t o m i n i m i z e any p o s s i b l e r i s k s ana t o m a i n t a i n c o n f i d e n t i a l i t y . SUBJECT•S C O N S E N T PAGE <i 32 WHC WILL CONSENT? (chock) X n SUBJECT n PARENT/GUARO J AN 169 n AGENCY OFFICIAL(S) (sped f y:. e . g . school board, hospital director etc.) 33 WHAT IS THE COMPETENCE OF THE SUBJECT TO CONSENT? S a t i s f a c t o r y 34 HOW WILL THE CONSENT FORMS OR QUESTIONNAIRES BE EXPLAINED TO THE SUBJECTS? (consider language or any other barrier) P e r s o n a l e x p l a n a t i o n 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 BY MAIL SUBMIT A COPY OF THE EXPLANATORY LETTER AS WELL AS A COPY OF THE QUESTIONNAIRE '36 WRITTEN CONSENT (other than questionnaires - e.g., experiments, interviews, c j s p s t u d i e s ; I 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 AGENCY CONSENT 7.V 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 C H E C K L I S T OF ATTACHMENTS TO T H I S S U B M I S S I O N 38 CHECK ITEMS ATTACHED TO THIS SUBMISSION (incomplete submissions uill not be considered! o LETTER OF INITIAL CONTACT (item 13) X n QUESTIONNAIRES (items 20, 35) ) combined X n INTERVIEW QUESTIONS r i t e m 20) ) x a DESCRIPTION OF OBSERVATIONS (item 20) o TEST DESCRIPTION (item 20) X o EXPLANATORY LETTER WITH OUESTIONNAI RE(item 35) X n SUBJECT CONSENT FORM (item 32,35, 36) n PARENT/GUARDIAN CONSENT FORM ( i t e m 32,3b) X n AGENCY CONSENT (item 32,37; Conversa t ion Con t rac t i on Breath ing Tension Vocal isat ion M o v e m e n t Posi t ion Con t rac t i on Regular Relaxed Lai Smile M o v e m e n t Back Rest Deep Tense Cry Stahle Side B o t h Sha l low V Tense Scream Sil Pant M o a n S l H I K l Push X lirecjular Event Prox imi ty C o n t e n t In Room Converse Touch I tem Ma in tenance Exam Med ica t i on Equ ipment Brea th ing X Face Near Distant Labor W e l l Be ing Pain M e d i c a t i o n Procedure-Env i ronmen t Baby Relat ionship Brea th ing N o n Del ivery X f N Oh Notes Figure 1. Childbirth observation instrument recording sheet. o APPENDIX B Submission to the Grace Hospital Education and Research Coordinating Committee PURPOSE OF STUDY 172 The purpose of this project is to look at the prenatal education preparation for labour and delivery and i t s relationship to maternal coping with the actual delivery experience. STUDY POPULATION Sixty primiparous women, who agree to participate, w i l l be included in the study. The possibility of inclusion is governed by admission or delivery in the low risk labour delivery unit during the observation study dates. Attendance at formal prenatal education sessions is not a prerequisite. The women to be included must meet the following c r i t e r i a : - admission to or delivery in the low risk labour delivery unit during the study observation dates; - delivering f i r s t baby; - gestational period is not less than 37 weeks; - have vaginal deliveries; - do not encounter medical emergencies where maternal or fetal wellbeing are compromised; - agree to participate - delivery observation and post-natal interview. 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 participants: - self-identification, a brief explanation of the project with a request for their participation, and the provision of a written explanation of the project and a consent form. Following the recruitment process, as observer I w i l l have no interaction with the woman during her labour and delivery. Nor is there any participation in the care-giving. A l l data collection w i l l be carried out by myself thus no involvement or documentation by staff i s being requested. Data w i l l be collected from three sources in order to achieve the study purpose. F i r s t , by the observation and recording of events occuring in the birth experience. Second, by conducting a post-partum interview to get the participant's perspective of the delivery experience. Finally, by augmentation of this information with other data on the course of labour and delivery to be obtained from the medical record. A description of each of these means of data collection follows: 1. Observation of the Childbirth Environment. The observation instrument to be used was developed at the Child and Family Research Branch of the National Institute of Child Health and Human Development in Bethesda, Maryland. This instrument is currently being employed by the National Institute in research on material coping with labour and delivery. It is a method of recording naturalistic observations of the childbirth experience and focuses on human behaviour in settings which are not manipulated by the researcher. Using this instrument, codes w i l l be assigned to behaviours which are observed, recording observable features of the woman's physical state, the identity and interactions of persons in the labour/delivery room, a variety of medical interventions, and themes of verbal conversations with the labouring woman. The various categories are time-sampled in cycles of 30 seconds for observing and 30 seconds for recording. (Figure 1). In using this observation instrument previous researchers have found that the observer's presence seems to have l i t t l e impact on the behaviour of others in the labour/delivery room. • Once the participant consent is received the observer does not interact with the woman in labour or delivery, nor participate in the caregiving. Staff are not involved in any of the data gathering a c t i v i t i e s . 2. Post-Partum Interview. In order to get the participants perspective of the delivery experience the women participating in the study w i l l be requested to grant an interview 1-2 days following delivery. The interview w i l l involve about 20-30 minutes of their time. With the attainment of the woman's perception of her delivery experience i t can then be correlated to the observed situation and to any prenatal preparation undertaken. The interview w i l l be carried out by myself and follow a questionnaire format. (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 delivery would also be obtained from the medical record. (Attached - Part B of Data Sheets). APPENDIX C Covering Letter and Consent to Study Participants BIRTHING EXPERIENCE CONSENT FORM (For signature after oral presentation) I, , have been informed of the nature of the birth experience study and give my consent for Barbara Selwood to observe the delivery of my baby and interview me, 1-2 days following the birth. I have further been informed that the information provided is confidential 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 participate or withdraw from the study at any time. My participation w i l l in no way prejudice my care now or in the future. Signed . Date Witness , Date APPENDIX D Manual for 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 Ins t i tute of Chi ld Health and Human Development Bethesda, Maryland MANUAL FOR OBSERVATION OF THE CHILDBIRTH ENVIRONMENT 182 Introduction The Manual for Observation of the Chi ldb i r th Environment was developed to obtain systematic data on the physical state of a woman in mid-course of active labor and on the medical and social interact ions in which she is involved. The ident i ty of any person present in the labor room and the medical, ver-b a l , and physical interact ions engaged in the labor room and the medical, verbal , and physical interactions engaged in with the laboring woman are recorded. The focus of th i s ob-servation system is the woman in labor; her behavior is con-stant ly sampled whether she is alone or involved in any form of medical, verbal , or physical contact. Coding Procedure The observation system was designed to time-sample for one hour the woman's physical state and a l l interactions 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 period. A stopwatch is used to indicate the continuing cycles of 30-seconds-observe, 30-seconds-record, 30-seconds-observe, 30-seconds record, etc . The recording sheet (located at the end of the manual) is designed so that 10 observe-record cy-c 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 theoret ica l interes t : (1) the woman's physical s tate , (2) the degree of stimulus contact or depr 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 outl ined below: I . Physical State of the Laboring Woman A. Contraction C. Tension 1. Contraction 2. Resting 3. Both 1. Relaxed 2. Tense 3. Very Tense B. Breathing D. Vocal izat ion 1. 2. 3. 4. 5. 6. Regular Irregular Deep Shallow 1. 2. 3. 4. 5. Laugh or Smile Cry Scream Pant Push Moan None E. Body Movement 183 1. Movement 2. Stable F. Body Posi t ion 1. Back 2. Side 3. S i t 4. Squat I I . Stimulus Contact with the Laboring Woman A. Behavioral Events Directed B. Proximity 3. Item 4'. Maintenance 5. Exam 6. Medication 7. Equipment 8. Breathing 9. None of the above I I I . Verbal Communications Involving the Laboring Woman A. Conversation Content 1. Labor 2. Well-being 3. Pain 4. Medication 5. Procedure-Environment 6. Baby 7. Relationship 8. Breathing 9. Non-delivery Rating Scales Following the period of observation, f ive ratings of the soc ia l interact ions involving the laboring woman are made: 1. Physical Intimacy of Mother-Father Relationship 2. Quality of Mother-Father Relationship 3. Effectiveness of Mother-Father System in Comforting the Mother 4. Quality of Nursing Care 5. Quality of Physician Care to the Laboring Woman 1. 2. Converse Touch 1. Face 2. Near 3. Distant I . PHYSICAL STATE OF THE LABORING WOMAN 184 Contraction The presence and/or absence of a uterine contraction in the time-sampling interva l is a basic component of the laboring woman's physical s tate . Evidence of a contraction may come from any source such as the fe ta l monitor, the woman's expressions of incresed discomfort, and change in posi t ion and breathing. O r d i n a r i l y , when a woman is in active labor, there i s clear evidence from several sources that she i s ex-periencing a contract ion. The categories in th i s column are mutually exclus ive ; one category is coded in each time-samp-1ing i n t e r v a l . 1. Contraction: evidence of uterine contraction 2. Rest: period between contractions 3. Both: both a contraction and rest period occur in any proportion in the time-sampling interval Breathing The type of breathing predominating in the time-sampl-ing interval is recorded. If there i s a contract ion, the breathing during the contraction takes precedence. Deep and shallow breathing and panting and pushing are techniques of control led breathing designed to f a c i l i t a t e re laxat ion and diminish discomfort. The categories are mutually exclus ive; one category i s coded in each i n t e r v a l . 1. Regular: rhythmic breathing (usually not noticeable) 2. I rregular : Breathing not rhythmic, observable hold-ing of breath, gasping. 3. Deep: Quiet, relaxed deep chest breathing, approxi-mately 8 breaths per minute. 4. Shallow: Any var ia t ion of shallow chest breathing, approximately 20-26 breaths per minute. 5. Pant: Rapid panting with or without blowing 6. Push: Deep breath held while pushing fetus down b i r t h canal . Tension This judgment of the laboring woman's physical tension is based on f a c i a l expression and on the f l ex ion of upper extremities usually v i s i b l e outside of bed covers. These categories are mutually exclus ive ; one category is coded in each i n t e r v a l . 1. Relaxed: Normal f a c i a l expression and loose muscle tone in upper extremities 2. Tense: Grimaced f a c i a l expression or t ight muscle tone in upper extremities 3. Very Tense: Contorted f a c i a l expression or r i g i d c lu tch ing . Vocal izat ion Non-verbal vocal izat ions cover a range of affect . Code the predominant voca l izat ion i f more than one occurs, code "X" i f there are no non-verbal vocal izat ions during the time-sampling i n t e r v a l . 1. Laugh, Smile: Pleasant, amused expression of pos i-t i v e af fect . 2. Cry: Sobbing or tears 3. Scream: S h r i l l crying out 4. Moan: low-pitched anguished sound (not to be con-fused with audible i rregular breathing) Movement One indicator of phys ica l : state i s the presence or ab-sence of s i gn i f i cant 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 in each i n t e r v a l , ind ica t ing the presence or absence of such a c t i v i t y . 1. Movement: S igni f icant movement of extremities or body posi t ion 2. Stable: No s i gn i f i can t body movement Pos i t ion The posi t ion of the woman's body is coded in this column. Code that pos i t ion which predominates in the i n t e r v a l . 1. Back: Lying prone on back 2. Side: Lying prone on ei ther side 3. S i t : S i t t i n g unsupported or propped (as when head of the bed is raised) 4. Squat: S i t t i n g on heels or crouching on hands and knees I I . STIMULUS CONTACT WITH THE LABOURING WOMAN Behavioral Events Directed to the Labouring Woman Eight categories of observable behaviors have been de-fined for the father (F) , the nurse with primary responsib-i l i t y for the woman (N), the primary or attending obstetr ic ian (Ob), or any other person who is in the labor room during a time-sampling interval (e.g. f r i e n d , secondary nurse). These categories describing interact ive events are exhaustive but are not mutually exclus ive ; i . e . for any person more than one behavioral event can be recorded during a time-sampling i n t e r v a l . When none of the eight behavioral events defined below is observed for a person who is 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 non-interact ing person. 1. Converse: applies to any verbal interact ions between a person in the labor room and the woman in which the woman part ic ipates by (1) i n i t i a t i n g the conver-sation through a verbal izat ion of any type, or (2) responding verba l ly , nonverbally, or by l i s t e n -ing a t tent ive ly to a verbal izat ion directed to her. The informational content(s) of the conversation is recorded with Conversation Content codes des-cribed on page 7 of th i s manual. Conversations between people in the labor room in which the woman does not part ic ipate are not coded, even i f the verbal content relates to the woman (e.g. nurse asks obstetr ic ian to examine the woman; father ta lks 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: rest ing a hand on the woman's forehead; s t rok ing , caressing, or giving physical comfort to f a c i l i t a t e re laxa t ion . 3. Item: actions taken to aid in the comfort of the laboring woman which involve objects. Examples include: of fer ing ice chips , a c loth for the fore-head, or magazine; f l u f f i n g a p i l l o w ; covering the woman with an extra blanket. 187 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, pa lp i ta t ing the abdom-inal area, checking the perineum. 5. Exam: refers s p e c i f i c a l l y to an i n t e r n a l , vaginal exam given to the laboring woman. 6. Medication: administration of any medication to the woman, such as beginning an intravenous proced-ure or in ject ions of sedatives. 7. Equipment: doing breathing-relaxation techniques e i ther simultaneously with the woman or as a whole. Proximity to the Labouring Woman The distance between each person present in the labor room and the laboring woman is recorded each time-sampling interva l with one of three mutually exclusive proximity cate-gories . 1. Face: within three feet of the woman and posi-tioned so that eye-to-eye contact is poss ible . 2. Near: greater than three feet from the woman when at her wide. Also included are posit ions behind the head of the bed or at the foot of the bed. 3. Distant: greater than three feet from the woman and positioned away from the bed. I I I . VERBAL COMMUNICATIONS INVOLVING THE LABORING WOMAN 188 Content of Conversations For every time-sampling unit in which the category Con-verse 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 exclus ive ; during a time-sampl-ing interval 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" in the Conversation Content column. 1. Labor: reference to the course or progress or labour events such as contractions, cervica l d i c t a -t i o n , or pos i t ion of the fetus . 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: reference to the woman's physical or emotion-al discomfort (e.g. Does that hurt? It feels sore when you touch me.) 4. Medication: verba l iza t ion about any obstetr ic 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 regula-t ing temperature or l i g h t i n g in the room. 6. Baby: verbal izat ions about the infant-br ing-born as a person, not references to f e ta l v i t a l signs or pos i t ion , which would be coded as 'Labor' Content. Examples i n -clude: How is the baby taking a l l this? The baby is r e a l l y eager to appear. 7. Relat ionship: reference to the dyadic re la t ionship between the woman and another person present (e.g. You are helping me so much. I'm proud of you.) 8. Breathing: t a lk ing about techniques of breathing which aid the woman during contract ions. 9. Non-delivery: any verbal izat ion between the woman j_89 and another person to which one of the eight content themes defined above does not apply ( i . e . reference to any person or event which does not re late to the woman or the labor se t t ing ) . RATING SCALES 190 I . Physical Intimacy of Mother-Father Relat ionship: This scale describes the extent of touching and bodily contact in the couple's interact ion during labor. It is not an evaluative state-ment about the "close" or "dis tant" qua l i ty of the mother-father re l a t ionsh ip . The physical intimacy of the couple is a r e f l ec t ion of t h e i r own reaction to the presence of other persons as well as to the medical s i tuat ion and degree of discomfort experienced by the laboring woman. 1. Limited physical contact 2. Moderate amount of touching, soothing (e.g. holding hand, wiping face.) 3. Almost continual physical contact, holding, embracing. I I . Quality of Mother-Father Relationship Both the nature and amount of spouse interact ion contribute to th i s rat ing of the manner in which the couple experienced labor together. In addition to verbal and physical in teract ions , non-verbal dyadic responses such as eye-to-eye contact, respons iv i ty , compat ib i l i ty , and sharing of th i s experience between the partners contribute to th i s judgment of the qual i ty of mutual p a r t i c i p a t i o n . 1. Withdrawn-rejecting; l imited interact ion 2. Occasional involvement 3. Warm, involved interact ion I I I . Effectiveness of Mother-Father System in Comforting the Mother This scale i s an evaluative measure of the e f fec t ive-ness of the couple's interact ions in f a c i l i t a -t ing 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 re s s . A l l aspects of the dyadic re l a t ionsh ip- - physi-c a l , verbal , and emotional interactions—are considered in terms of the support they may 1 9 1 provide to the laboring woman. 1. Limited efforts to interact for support or comfort 2. Supportive efforts inadequate or inef fect ive 3. Synchronous interact ion ef fect ive in comfort-ing the mother IV. Quality of Nursing Care (primary nurse) In th i s scale , a nurse's interventions in the labor room are considered in terms of the i r approp-riateness 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 neces-sary nursing tasks in a s i tua t ion 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 appropriate-ly assume a primary interact ive r o l e . 1. Withdrawn-hostile 2. Supportive ef forts inadequate or inappropriate 3. F a c i l i t a t i n g and responsive V. Quality of Physician Care (primary obstetr ic ian) An obs t re t r i c i an 1 s interactions with the laboring woman may contribute to her physical comfort and emotional wel l-being. Supportiveness can be expressed in informative and sympathetic communication, a considerate attitude while performing medical procedures and respect for the laboring woman and her re lat ionship with the father . 1. Withdrawn-hostile 2. Supportive ef forts inadequate or inappropriate 3. F a c i l i t a t i n g and responsive CONTRACTION BREATHING TENSION VOCALIZATION MOVEMENT POSITION 9 10 Contraction Rest Both Regular Deep Shallow Pant Push I r regu lar Relaxed Tense Very tense Laf-smile Cry Scream Moan X Movement Stable Back Side S i t Squat CONVERSATION EVENT PROXIMITY CONTENT Name In room Converse Touch Item Maintenance Exam Medication Equipment Breathing X Face Near Distant Labor Wei1-being Pain Medication Procedure-environment Baby Relationship Breathing Nondelivery X F N Ob F N Ob F N Ob F N Ob F N Ob F N Ob F N Ob F N Ob F N Ob F N Ob APPENDIX E Ch i l d b i r t h Observation Instrvirnent Recording Sheet Used In This Study CONTRACTION BREATHING TENSION 9 10 Contraction Rest Both Regular Push-spon. Push-vals. Pant Shallow Deep I r regu la r Relaxed Tense V. Tense CONVERSATION EVENT CONTENT Converse Push-spont. Breathing Push-valsalva Touch Other breathing Item Equipment Maintenance In Room F N Ob F N Ob F N Ob F N Ob I-N Ob F N Ob F N Ob F N Ob F N Ob F N Ob APPENDIX F Postpartum Interview Questionnaire I.D.# Part A - Post-natal interview 196 Date of interview 1. Who delivered your baby? Fam.M.D. Consult. O.B.Res. Other 2. Was this the doctor who saw you during your pregnancy? No Yes 3. How much did your baby weigh? gm. 4. Did you have a boy or g i r l ? female male 5. Are you breast feeding your baby? 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 did you use in 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 delivery room? No Yes 10. Who was this person? 11. During the time you were in hospital did you receive any medication before your baby was born? No Yes Do you know the type? 197 12. Did you use any special breathing techniques during the delivery of your baby? No Yes If yes, what were they? Why did you use this method(s)? 13. Did you attend prenatal classes? No Yes If 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 this person? 13b. How many p.n. classes did you attend? - your partner? 13c. How many classes were in the series? 13d. What was your most important reason for attending p.n. classes? . — . 14. What happened in these classes?(/) - Process of labour and delivery - Infant care - Infant feeding - Relaxation - Breathing - labour - delivery - Other 14a. What do you consider was the - most useful class - least useful class 15. In your p.n. classes did you do breathing exercises in 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 delivery of your baby? No Yes , please describe: 18. How many times a week did you practice the breathing exercises outside the class 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 delivery. How does this compare with what you actually used? 20. How did your support person help you during your delivery? 21. Did he/she make suggestions about your breathing patterns? No Yes How? 22. Do you feel your p.n. classes prepared you - for labour? Yes No - for delivery? Yes No If yes, how? (note each sep.L/D) If no, what would you have liked to prepare you better? 23. Prior to your delivery would you describe your confidence 200 level 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 in preparing for your baby's birth? M.D. P.N. classes __Friends C.H.N. Other Books Titles Background Information The following information w i l l be used only to derive demographic data which describes the population being sampled. 25. Your age is years. 26. What country were you born in? Length of time in Canada (if not born here) 27. What language do you speak and understand the best? 28. What type of work did you do? 201 What type of work does your husband/partner do? 29. Educational background (/highest level completed) a) Grades 1-11 b) Grade 12 (High School Diploma) c) Technical Training d) College Diploma e) University Degree f) Other: APPENDIX G Medical Record Data Form Part B. Medical Record Information. 203 Residence Code V ( ), R , B , WV , NV , Other Pregnancy and Delivery. Maternal age years Date of Birth Time .— Gravity Parity Single Twin Complications of pregnancy: No Yes Complications intra parturn No Yes Labour length: Hours __; Stage 1 Stage 2 Stage 3 _ Presentation: Vx Br Other Delivery type: Sp LF MF HF Other Episiotomy: No Yes Laceration: No Yes Degree Delivery by: Fam. MD Consult. O.B. Res. Other Analgesic i n labour: No Yes Time 204 Anesthesia: Gen Epi Both N i l Ent Pud Both Local Other Infant Outcomes: Sex: Female Male. B i r t h Weight . gms. Fetal Monitoring: Contractions: N i l Ext. Int. Both Fetal Heart Rate: N i l Ext. Int. Both. Gestational Age Weeks Apgar Scores 1 min. __ 5 min. Major Congenital Abnormality: No Yes Evidence of Fetal d i s t r e s s : No Yes Breast Feeding: No Yes APPENDIX H Ertployment Categories Type of Ernployment Examples Executives, Professionals and Managers; - physician, lawyer, nurse, teacher, n u t r i t i o n i s t . Administrative personnel; - Owners of small independent business, semi-profession a l s . C l e r i c a l Technician; - Computer operators, secretary, i n d u s t r i a l technicians. S k i l l e d ; - Seamstress, f l o r i s t designer, hairdresser, store clerk Unskilled ; - Cook, dishwasher, waitress. APPENDIX I Defi n i t i o n of Terms D e f i n i t i o n of Terms acidosis — a pathologic condition r e s u l t i n g from accumulation of acid or depletion of the alkaline reserve ; (bicarbon-ate content) i n the blood and body tissues, and character-ized by an increase i n hydrogen ion concentration (decrease i n pH). a l k a l o s i s — a pathogenic condition r e s u l t i n g from accumula-t i o n of base, and characterized by decrease i n hydrogen ion concentration •(increase i n pH). Apgar Score — numeric expression of the condition of a new-born obtained by rapid assessment at 1, 5 and 15 minutes of age. Crowning — stage of delivery when the top of the f e t a l head can be seen at the vaginal opening. demographic characteristics — age, country of b i r t h , langu-age, education and type of employment. Etonox anesthesia — a mixture of 50 percent Oxygen and 50 percent Nitrous oxide breathed by the mother during the contraction; used as an a i d of pain control. Epidural 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 spinal cord) through the t h i r d , fourth 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 to f a c i l i t a t e delivery and to avoid laceration of the perineum. f i r s t stage of labour — the period from the onset of regular contractions to f u l l d i l a t a t i o n of the cervix. hypercapnia — excess of carbon dioxide i n the blood. hypocapnia — a deficiency of carbon dioxide i n the blood, r e s u l t i n g from hyperventilation and eventually leading to a l k a l o s i s . hypoxia — i n s u f f i c i e n t a v a i l a b i l i t y of oxygen to meet the needs of the body tissues. intrapartum complications — deviations from the normal process of c h i l d b i r t h . intervention (during second stage) — delivery by either forceps or caesarean section. laceration — a tear i n the perineum. low-risk — no known r i s k factors or complication of the pregnancy. n u l l i p a r a — a woman who had not yet carried a pregnancy to v i a b i l i t y (24 to 28 weeks gestation) PaCO^ — p a r t i a l pressure of carbon dioxide i n a r t e r i a l blood. PaG^ — p a r t i a l pressure of oxygen i n a r t e r i a l blood. parturient — a woman giving b i r t h . prenatal class attenders — pregnant women who attend one-half or more of a series of prenatal classes to be r e f e r -red to as 1attenders'. primipara — a woman bearing a c h i l d for the f i r s t time. Pudendal Block anesthesia — the inj e c t i o n of a l o c a l i z i n g anesthetizing drug into the pudendal nerve root i n order to produce numbness of the gen i t a l and perianal region. pulse presurs — the difference between s y s t o l i c and d i a s t o l i c blood pressure. respiratory acidosis — a state due to excess retention of carbon dioxide i n the body; hypercapnia. respiratory a l k a l o s i s — a state due to excess loss of carbon dioxide from the body. second stage of labour — the period from f u l l d i l a t a t i o n of the cervix to delivery of the fetus. series of prenatal classes — a set number of classes which focuses on aspects of prenatal care, preparation for labour and delivery, care of the newborn and postpartum period. spontaneous pushing — pushing as dictated by the body urges during second stage; bearing down when, and for 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 to be dictated by the contracting uterus. Valsalva maneuver — attempt to f o r c i b l y exhale with the breath held ( g l o t t i s closed) beyond f i v e or s i x seconds. 

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