research and studies

Maternal Attitudes in Prepared and Unprepared Cesarean Deliveries GEORGIANA HART, RN, MSN

Cesarean preparation classes were instituted at an Eastern hospital and are described here briejy. One hundred and for&-three prepared and unprepared women delivering vaginally and by cesarean during a six-week period at that hospital were tested with the Maternal Attitude to Pregnancy Instrument. Prepared cesarean women had a signzjicantly greater desire for active participation in the delivery than women unprepared f o r cesarean delivery. Multiparous cesarean-delivery mothers wi th previous vaginal deliueries had a signtnificantb more positiue attitude than those who had never delivered vaginally.

In 1960 the incidence of cesarean deliveries was 1 out of every 20 preg- nancies. By 1976, at least 1 in 10 to 1 in 8 births resulted in cesarean deliv- ery.’ In many metropolitan hospi- tals, probably more than 30% of de- liveries are now by cesarean. The rate may continue to increase since current practice is to perform repeat cesareans2 and they are being con- sidered more frequently for physio- logic abnormalities (e.g., diabetes or cardiac disease), a compromised fetus, or failure to progress in deliv- ery.

Stresses specific to the cesarean mother are compounded by those of vaginal delivery, such as the process of labor itself, which for the first- time cesarean mother may be longer in dura t ion . Many cesarean mothers’ reaction to this stress has been to demand cesarean delivery preparation. A number of organiza- tions now provide such preparation. The organizations are family-cen- tered, maximize the mother’s and fa- ther’s active participation in the de- livery, offer them a measure of knowledge about and control over their experience, and help them deal

with unresolved feelings and atti- tudes.

At the time of this study, no pre- vious research on the maternal atti- tudes of cesarean-prepared women had been published. Research on preparation for vaginal delivery deals mainly with the relationship of preparation to physiologic signs (e.g., Apgar score, length of labor, fetal distress). However, studies on the psychologic aspects of delivery after preparation do have relevance for cesarean births.” ”

Zemlick and Watson’ found that the extent to which the pregnancy is pleasurable, the child wanted, and motherhood accepted, relates signifi- cantly to a positive prenatal and birth adjustment as measured in clinical observations by the obstetri- cian. Using the Parental Attitude Research Instrument (PARI),8 Fer- reira” found a significant correlation of more positive parental attitude with infants’ adaptive behavior in the nursery (less crying, less irritabi- lity, more sleep, and increased feed- ing).

Preparation has been found to correlate positively with positive ma-

ternal attitude. Tanzer“’ stated that preparation affects one psychologi- cal variable in particular: “Only the a t t i tude toward pregnancy and childbirth was changed-and for the better.” Chertok found that the ef- fects of highly negative attitudes to- ward labor were much reduced for a prepared woman.’’ Zax and Same- roff” used the Maternal Attitude to Pregnancy Instrument (MAPl)” in their study and found that after preparation there were significant improvements in attitudes both to- wards active participation in deliv- ery and about the infant.

In this study we attempted to as- certain whether women who have participated in our cesarean prepa- ration classes at Jamaica Hospital have a more positive attitude toward pregnancy, delivery, and the infant than women who have not had such preparation.

The Cesarean Preparation Classes Cesarean preparation classes,

taught by an RN, were offered in the maternity clinic and in the labor rooms of the hospital. The educator was able to prepare those cesarean- delivery mothers in whom cephalo- pelvic disproportion or breech was the reson for a previously unex- pected first cesarean delivery. (There were no cases of eclampsia or emer- gency heart disorders preceding any of the cesarean deliveries during this study .) One-to-one sessions with each woman lasted between 50 minutes and 2 hours, and included:

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Table 1. Cesarean Prepared and Cesarean Unprepared Scores on MAPI

Cesarean Cesarean prepared unprepared Probability ( N = 17) ( N = 21)

Mean total score 125.29 122.76 .129 Mean score on Factor I 57.00 56.38 .364 Mean score on Factor II 26.35 26.48 ,220 Mean score on Factor 111 9.53 8.76 .041 Mean score on Factor IV 28.53 27.81 -226

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1. Reasons for cesarean delivery in general and for t he individual woman. Definition of dystocia, ceph- alopelvic disproportion, transverse lie, shoulder presentation, abnormal or weak contractions. Discussion, where appropriate, of fetal distress, uterine hemorrhage, and prolapsed cord.

2. Description of regional and general anesthesia, and procedures for each, as well as the use of oxygen for the infant.

3. Description of preoperative pro- cedures, such as the intravenous in- fusions, catheters and their func- tions, scrubbing, and draping of the abdomen.

4. Explanation of the operation, different types of incisions, and their repair.

5. An outline of the role of the fa- ther, appropriate to the mother’s de- cision, as to how he can be support- ive, informative, and sharing with the mother.

6. A brief comparison of the cesa- rean newborn and the vaginally de- livered newborn.

7. A brief outline of postoperative nursing care explaining the need for initial deep breathing and leg move- ment, then walking within the first 24-48 hours, and the availability of pain medication. Mothers were reas- sured that breastfeeding was possible and that support was available.

The session ended with a ques- tion-and-answer period.

Materials and Methods

One hundred and fifty-eight women who delivered at Jamaica Hospital, New York, between March 4 and April 15, 1978, were asked to complete a questionnaire. One hun- dred and forty-three women com- pleted it; 14 women either did not

complete the questionnaire or did not return it; one woman refuse to participate.

The 143 women were divided into four groups according to type of de- livery and preparation: 1) 17 women delivered cesarean and were pre- pared; 2) 21 women delivered cesa- rean having neither cesarean nor La- maze t ra ining; 3) 18 women delivered vaginally having Lamaze training; and 4) 87 women delivered vaginally with no childbirth prepa- ration. The relevant findings fo this study concern the first two groups alone.

The Maternal Attitude to Preg- nancy Instrument (MAPI) was used. It consists of 48 statements for which the respondent is asked to indicate agreement to disagreement on a 4- point scale, with a possible range of 48 to 192 in total score. A more posi- tive maternal attitude is indicated by a higher score. The instrument it- self was designed for use before childbirth but has been tested for re- l iabi l i ty with 145 pos tpar tum women.” (Concurrent validity with the PAR1 was also determined by the authors of the MAPI on Factors I1 and IV.)

There are four factors covered by the MAPI: 1) sense of acceptance of pregnancy and viewing labor and delivery without fear, e.g., “The de- livery is a frightening part of preg- nancy.” 2) Feelings of well-being and pride of pregnancy, e.g., “A woman looks her best during her pregnancy.” 3) Desire for active par- ticipation in delivery and breastfeed- ing, e.g., “Putting the mother to sleep during birth can hurt the baby.” 4) Feelings toward the baby, e.g., “Most pregnant women do not really care if they have a boy or girl.”

A printed preface of the test was read to all the subjects, stating they

could choose not to participate. This was in accordance with the specifica- tions of the hospital’s legal depart- ment in the interest of protecting pa- tients’ rights. The women were asked also to fill out a separate page of ob- stetric and demographic data (i.e., date and type of preparation, years of education) that could not be gath- ered from the chart. Each woman was given the instructions and was told that questionnaires would be collected ina half hour. None of the fathers for the cesarean-prepared births were present during delivery.

Results Among women giving birth by ce-

sarean delivery, those who had cesa- rean-delivery preparation scored sig- nificantly higher in desire for active participation in delivery than those unprepared for cesarean delivery (Factor 111 of the MAPI). (For de- grees of freedom of 1, P .05 = 4.1. There are fewer than 5 chances in 100 that these differences in prepara- tion occurred by chance.)

There was no significant differ- ence between first cesarean delivery mothers (scoring 124.2) and those with one or more cesarean deliveries (123.2). However, cesarean delivery women who had experienced one or more vaginal deliveries (mean MAPI score 125.72) scored signifi- cantly higher than women who had not delivered vaginally prior to their cesarean (120.38). (For degrees of freedom of 1, P .O 1 = .9. There is less than 1 chance in 100 that the differ- ence occurred by chance.)

Discussion Though total scores for cesarean-

prepared mothers were numerically higher than unprepared, the differ- ence was not statistically significant. This is consistent with Zax and Sameroffs findings.‘‘ Some might argue, therefore, that preparation makes no significant difference. However, 27 subjects taking the MAPI argued they could not possi- bly know about “most” women based on their own individual expe- rience; 20 of the 48 questions on the MAPI begin with the words “most” or “many”.

Also, the limitations of the study itself might indicate some reasons for

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the lack of statistical significance. The six weeks’ time of the testing pe- riod ruled out a women’s having the full group discussion course of at least three preparation sessions, given by the Cesarean Birth Associa- tion of America through Jamaica Hospital. Furthermore, absence of the father from the delivery room for Cesarean-prepared women is not the practice in many hospitals which have a longer history of teaching ce- sarean preparation. Jamaica Hospi- tal began this policy a year ago, and the first cesarean-prepared couple was in the delivery room on the last day of this study.

Therefore, it is conceivable that a study involving couples conducted over a longer period of time, with suitable changes in question word- ing, might yield different results.

The most interesting finding of significance was that cesarean mothers with a history of vaginal de- liveries scored more highly on the MAP1 than those cesarean mothers without previous vaginal deliveries. Self-image together with a higher degree of confidence and self-worth may have contributed to the higher scores for women who have “achieved” a vaginal delivery.

Regarding the numerically lower scores of those women having more tnan one cesarean delivery, it may be that sequential cesarean deliv- eries may compound emotional stress.“

Further studies might focus solely on the desire for active participation, which appears to be relevant for both cesarean and vaginal delivery mothers. Test questions might be improved and structured into a questionnaire to study the area of active participation and its relation- ship to postpartum recovery and pa- rental attitudes.

Nursing Implications The nurse preparing the cesarean

candidate, whether for emergency or anticipated operation, should be aware of the desire of many of these women for active involvement in the

delivery. This sensitivity allows the nurse better to assess each mother’s desire for participation and to assist her in making birth a more family- centered process, in accordance with the rules of the individual hospital and medical staff.

Within a day after the operation, depending on the mother, the nurse could begin to encourage the new mother to express her feelings as well as reinforce information given before the operation, such as the reason for the cesarean. Teachers of Lamaze classes, too, should recognize the im- portance of talking about cesarean delivery and comparing it to vaginal childbirth. Cesarean delivery, like vaginal delivery, could be taught as a family-centered birth proces~’~ and not as a complication of a “normal” procedure. Today’s couples, includ- ing those in Lamaze classes, who will deliver by cesarean section are not “abnormal”. Nurses and nurse prac- titioners can also make available names of physicians who do not rule out vaginal deliveries for preg- nancies following cesarean births to dissipate the edict, ‘Lance a cesarean, always a cesarean.”

Acknowledgments The author thanks Marcia Kass,

RN, Nancy Lee Krauter, Janet Key- metian, and Steve Salbod for their time and support. T h e article is based on work done at Pace Univer- sity Graduate School of Nursing.

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Jones OH: Cesarean section in pres- ent-day obstetrics. Am J Obstet Gynecol 126:520-529, 1976 Hibbard L: Changing trends in cesa- rean section. Am J Obstet Gynecol 125:798-804, 1976 Bing ED: The Adventure of Birth. New York, Simon and Schuster, 1970 Bradley RA: Husband-Coached Childbirth. New York, Harper & Row, 1974 Doering SG, Entwisle DH: Prepara- tion during pregnancy and ability to cope with labor and delivery. Am J Orthopsychiatry 75:825-837, 1975

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8. Schaeffer ES, Bell R Q Develop- ment of a parental attitude research instrument. Child Dev 29:339-361, 1958

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10. Tanzer D: Why Natural Childbirth? New York, Schocken Books, 1976, p 94

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12. Zax M, Sameroff AJ: Childbirth education, maternal attitudes and delivery. Am J Obstet Gynecol 123: 185- 190, 1975

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Address for correspondence: Georgiana Hart, RN, 121 Oakland Terrace, New- ark, NJ 07106.

Georgiana H a r t , a graduate of the Pace Universiy Graduate School of Nursing, is a public school nurse in Neward, New Jer- sey. A f e r receiving a B A in psychology at Rutgers Universiv in 1967, she taught ele- mentary school and

Spanish and then worked as a community men- tal health associate at St. Vincent’s Hospital, New York Ciy, before entering the nursing program at Pace.

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