Physiological and Behavioral

Cues t o Disturbances in Childbirth

Mary I. Crawford, C.N.M., Ed. D.

Dr. Ckawford is Associate Dean, Department of Nursing, Faculty of Medicine, Columbia university; and Director 01 Nursing, The Presbyterian Hospital of New York City.

The major objective of this study was to develop a method which nur- ses not only can, but will, use to determine the need of women for emo- tional support during labor. Underlying Assumptions

The underlying assumption of the study was that the greater the fear or anxiety experienced by women during labor the greater the need for inten- sive and sustained emotional support during labor. Great variation is found among women in their need for emotional support during labor. Some wo- men, with sympathetic support from the nurse during the periods of great- est discomfort, appear to be able to maintain control and to work effec- tively with their contractions throughout their labor experience. Other wo- men completely lose control of their emotions and their behavior during labor. By the time this happens it is obvious that they are unusually fright- ened. Unfortunately this fear often is not recognized until it has become so intense that no amount of explanation or support is effective in helping the woman to regain control. Experience shows that often the infants of these women suddenly develop fetal distress or, in spite of seemingly strong and painful labor contractions, labor fails to progress as expected. In a few women, excessive fear is identified early. Intensive emotional sup- port is begun when the contractions are mild in intensity and widely spaced and continued throughout labor. In such cases, the skilled labor- morn nurse seems to be able to help these women to experience labor in a

*Read before the Thirteenth Annual Meeting of the American College o f Nurse- Midwifery, New York, New York. April 4-6, 1968.

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less traumatic, more satisfying, and comfortable manner. If. this kind of intensive and sustained emotional support were provided for every woman in labor it would be ideal, but the size of the staff which would be re- quired in the labor-room would seem to be financially impractical and ac- 'tually unnecessary. The labor-room nurse does need some procedure which will enable her to identify those women who, at the very beginning of la- bor, need this intensive and sustained emotional support. Such a procedure would also enable the nurse to improve her evaluations of the effectiveness of emotional support in labor. I t should prove useful in her efforts to de- termine what nursing measures are most effective in providing emotional support during labor.

Related to the underlying assumption, is another assumption that emo- tional tension is expressed through the sympathetic nervous system and can lead to constriction of the blood vessels and inhibition of muscle con- tractions in the uterus. Dick-Read1 believes that epinephrine, secreted in the blood stream for the purpose of defense, results in vasoconstriction in such organs as the kidney, the small intestine, and the pelvic viscera. When the blood supply to the powerfully active uterine muscle is restricted, the concentration of metabolites within the muscle fibers increases, causing se- vere pain throughout the whole muscle organ. The increased pain results in increased fear and a viscious cycle is set up. Metabolites become progres- sively irritating. Muscle power is dimished. Ultimately, tonic spasm and gross ischemia result.

support the assumption that emotional tension and anxiety are expressed through the sympathetic nervous system. Sub- jects who report fear and anxiety reactions to stress situations have been found to exhibit epinephrine-like physiologic reactions, and subjects who report anger reactions to stress situations have been found to exhibit norepinephrine-like physiologic reactions. Reynolds' demonstrated that intravenous administration of epinephrine inhibits contractions of the uterus during labor, and intravenous administration of norepinephrine en- hances contractions. Garcia6 found that blood epinephrine levels tend to be higher in women who were fearful of labor and much higher in women who developed uterine inertia.

The relationship between anxiety, as it is evaluated during pregnancy, and disturbances during labor has also been the subject of many investig- ations. Women who developed obstetrical complications during pregnancy, labor and delivery, or the postpartum period, or whose infants developed fetal complications, such as death, gross abnormality, or abnormal Apgar rating at birth, were found in one study' to score higher on two anxiety test batteries administered during the sixth month of pregnancy than did

Numerous

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women who developed no such complications. Different measures of anxi- ety during pregnancy have been used in other studies reporting positive relationships between scores on anxiety and maternal, fetal and/or neo- - natal complications of labor.8-'

A second assumption related to the underlying assumption, therefore; was that women who need intensive and sustained emotional support throughout labor were those women who developed u-terine dysfunction or whose infants developed physiologic disturbances related to hypoxia. In this study, uterine dysfunction included the following complications: Pri- mary and secondary uterine inertia, endometritis, third stage uterine atony, excessive blood loss, postpartum temperature elevation, and pro- longed labor. Physiologic disturbances in the infant related to hypoxia included: meconium stained amniotic fluid with vertex presentation, fetal heart rate below 1 10, Apgar rating of less than seven at birth, and stillbirth or respiratory complication during the first week of life, with no evidence of developmental abnormalities or fetal distress at the beginning of labor.

The underlying problem of the study was how a nurse may differentiate the woman with high anxiety from all other women in labor. Problems of validity, reliability, and practicality all had to be faced in developing a method to assist the nurse in making such differentiations. Validity, of course, was of primary importance. The nurse had to be able to predict as accurately as possible the kind of emotional support each woman needed. Since this method was being developed for use in a clinical situation, the investigator also had to recognize the need for practicality and ready avail- ability. The method of estimation developed should not require compli- cated or expensive equipment, nor should it increase, t o any appreciable extent, the amount of time required to admit a woman in labor. The method also had to be reasonably reliable. One nurse should be able to assess the needs of a woman in labor and reach approximately the same conclusion as any other nurse assessing the needs of the same woman at the same time. Neither of these nurses would be able to give her full atten- tion to this assessment because she would have other duties to perform in the clinical situation.

The time required and the cost of giving anxiety test batteries during pregnancy is prohibitive under the plan of production line care presently being provided in this country for women in the lower socioeconomic group. These women seem to have a very negative attitude toward paper and pencil tests of any kind and particularly toward psychologic tests. Such tests would have to be administered individually and the questions asked directly by the nurse. Anxiety test batteries present an additional problem in that they are usually designed to measure anxiety as a person-

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ality trait, and many of the scores are based on defensive responses. If a person has learned to make successful defensive responses, it may well be that the physiologic responses which would theoretically lead to uterine ischemia and muscle fatigue in labor would be minimized.

Breggin," in his review of the literature on the psychophysiology of anxiety postulates that patterns of responding to anxiety with physiologic symptoms result in learned associations. These symptoms, themselves, can then elicit and reinforce further anxiety, producing a self-generating, spi- raling anxiety reaction. If this is true, women who have developed a habit of responding to anxiety with epinephrine-like symptoms will develop much more extreme symptoms when placed in an anxiety-provoking situa- tion than will women who have not developed such a habit. If Dick-Read's theory is correct, the more severe the sympathetic nervous system re- sponse the more intense the vasoconstriction which is likely to occur in the uterine muscle and the greater the possiblity of inhibition of muscle contractions or placental insufficiency due to inadequate blood supply. Testing Measures Developed

The selection of the measures included in the instruments was based on the assumption that the method developed should be able to detect those women who have a high degree of fear or anxiety at the beginning of la- bor, but they should also be able to determine whether these women tend to respond to other anxiety-provoking situations with physiologic symp- toms. Two instruments were developed in this study. A questionnaire on symptoms of muscle tension reported during pregnancy was designed to serve as an index of whether or not women have developed a habit of re- sponding to anxiety with physiologic symptoms. An observation guide for rating physiologic and behavioral symptoms of anxiety at the time that the woman was being admitted to the hospital in labor was designed to deter- mine whether or not labor was an anxiety-provoking situation for that wo- man.

Muscle tension is one of the most thbroughly studied physiologic re- sponses to anxiety. Women with high anxiety scores on the Freeman Scale and on the Taylor Manifest Anxiety Scale have been found to exhibit large increases in skeletal muscle tension measured electromyographically, while women with low anxiety scores exhibit very little increase.' ' The same thing has been found in studying psychoneurotic patients as compared with controls. One study developed an interview guide for scoring clinical evidence of muscle tension in patients with diagnoses of anxiety and neuroses. Those patients who experienced tension and anxiety subjectively were found to have the highest muscle tension measured electromyo- graphically. The questionnaire on muscle tension symptoms developed for

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the present study was adapted from the interview guide discussed above. It was then refined as a result of two pilot studies. Women were asked to fill out this questionnaire during the third trimester of pregnancy.

Even if a woman has developed a habit of responding to anxiety with physiologic symptoms, this is not likely to result in a complication of la- bor, if labor itself is not an anxiety-provoking situation for her. Since the average woman in labor is in no mood for filling out questionnaires, it was necessary to use physiologic and behavioral measures to identify the wo- man for whom labor was anxiety-provoking. The need for using multiple measures for this purpose has been pointed out in the literature.” Even though patterns of autonomic responses have been found to be reproduci- ble over time and consistent over different stressors for the same indivi- dual, they have also been found to differ from one individual to another. A multitude of physiologic and behavioral measures have been found to increase with environmental stress or to be associated with the presence of anxiety. Those wluch seemed to meet the criteria of not requiring any complicated or expensive equipment and not appreciably increasing the amount of time required for a nurse to admit a woman in labor, were tested in one of the pilot studies. Four measures were selected and refined for use in the observation guide.

Summary of Findings All of the 504 subjects in the final study were registered patients in the

antepartal clinic of one large urban medical center. Approximately one- third of these women were Spanish speaking. The major hypothesis of the study was that women who report more than average symptoms of muscle tension during pregnancy and, in addition, demonstrate at the beginning of labor more than average physiologic and behavioral signs commonly asso- ciated with anxiety would develop physiologic disturbances related to uterine dysfunction, or their infants would develop physiologic distur- bances related to hypoxia. This hypothesis was confirmed in the study. Highly significant differences in the number of women who developed physiologic disturbances were found between the group which scored above the median on both instruments and the group which scored at or below the median on one or both instruments.

Figure 1 shows the incidence of physiologic disturbances. The solid line in the upper part of each graph indicates the total percentagz of patients who developed any kind of physiologic disturbance, either related to uterine dysfunction or related to hypoxia in the infant. Approximately 48% of the 206 primiparas in the study developed such disturbances. Con- sidering only the 105 primiparas who reported more than average symp- toms of muscle tension during pregnancy, the percentage of physiologic

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P E R

c loo E N T *O

60 F

s 4 0 U B J 20 E

c o T S

Fig. 1. Incidence of physiological disturbances. T- Total subjects in stated category included in the study. Q- Group reporting above average muscle tension symptoms during pregnancy. R- Group rated above average on signs of emotional tension early in labor. B- Group scoring above average on both instruments.

disturbances increased to over 50%. It increases to over 61% if we select out only the 80 primiparas who were rated above average on physiologic and behavioral signs of emotional tension at the beginning of labor. Use of both of these instruments provides the most effective means of identifying these women. Forty primiparas (approximately 19%) of all the primiparas included in the study scored above the median on both instruments. Of these, 72%% developed physiologic disturbances, For the multipara, the incidence of physiologic disturbances was much lower. However, the trend is in the same direction. Of the 298 multiparas included in the study, 50 (or 17%) scored above the median on both instruments. Forty-four per cent of the 50 developed physiologic disturbances in contrast to approxi- mately 29% of all the multiparas in the study.

The percentage of those whose infants developed physiologic distur- bances related to hypoxia is shown by the dotted line in Figure 1 , and the percentage who developed physiologic disturbances related to uterine

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dysfunction is shown by the dashed line. Referring only to the dotted line in each graph, note that the percentage whose infants developed physio- logic disturbances related to hypoxia was much the same for primiparas and for multiparas, 22 and 19% respectively. Considering only the patients who scored above the median on each of the instruments exactly the same trend is found for primiparas and for multiparas as was found for all physiologic disturbances combined. Again, the use of both instruments provides the most effective means of identifying the woman whose infant will develop physiologic disturbances related to hypoxia. One other finding lends support to the theory that anxiety results in some kind of vasoconstrictive action and, as a consequence, to a decrease in oxygen sup- ply to the fetus. A significant negative correlation was found between Apgar rating of the infant at birth and score above the median on both instruments. In other words the infants of those women who scored above the median on both instruments tended to have lower Apgar scores at birth than did the infants of women who scored below the median on one or both instruments.

Looking at the dashed lines on each graph in Figure 1, we find support for the theory that anxiety leads to inhibition of uterine muscle contrac- tions and results in uterine dysfunction only for primiparas. The percent- age of multiparas who developed physiologic disturbances related to uter- ine dysfunction was practically the same for those who scored above the median on both instruments as it was for all the multiparas included in the study. Note the difference in the percentage of primiparas in comparison to the percentage of multiparas who developed this kind of disturbance. Thirty-four per cent of the primiparas, but only about 13% of the multi- paras, developed uterine dysfunction. The incidence of physiologic distur- bances related to hypoxia, on the other hand, was much the same for infants of primiparous women as it was for infants of multiparous women. Since labor tends to be considerably shorter in multiparas, one might sus- pect that the excitatory effect of epinephrine on the smooth muscles of the arteries is more rapid than the inhibitory effect on the smooth muscles of the uterus. Another explanation may be related to the fact that the uterine muscle has less work to do during labor in the multipara. In spite of inefficient contractions, extreme muscle fatigue, therefore, would be less likely to occur.

Figure 2 illustrates that there is some indication that the definition of uterine dysfunction used in this study may have been too broad. These findings are shown only for primiparas because the percentage of multi- paras who developed physiological disturbances related to uterine dys- function was too small to be broken down in this way. The solid line at

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P E R

C

N T

0 F

S U

J

50

40

30

20

B lo

Total Total

Dysfunction Dysfunction

/ /

/’ Third Stage Atony

Excess Blood Loss P. P. Temp. Elevation

# dN:rimary inertia Secondary Inertia Endometritis Prolonged Labor

T Q R B E 0; C T Q R B T S

Fig. 2. Incidence of uterine dysfunction in primiparas. T- Total subjects in stated category included in the study. Q- Group reporting above average muscle tension symptoms during pregnancy. R- Group rated above average on signs of emotional tension early in labor. B- Group scoring above average on both instruments.

the top in both graphs represents the percentage of primiparas who devel- oped any type of physiologic disturbance related to uterine dysfunction. The dashed line on the left, however, represents only those primiparas who developed either primary inertia, secondary inertia, or endometritis. (Note that this line shows the same trend as that for all types of uterine dysfunc- tion shown above.) In fact, the slope is much steeper when only these three complications are included in the definition of uterine dysfunction. The dashed line on the right represents only those primiparas who devel- oped third stage uterine atony, excessive blood loss, postpartum tempera- ture elevation, and prolonged labor.

Only the rating scale for physiological and behavioral symptoms at the beginning of labor is of any help in screening women who developed these complications. The two instruments combined appear to have been of no help. Correlations between length of labor and score above the median on both instruments were also found to be insignificant. Women who scored

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above the median on both of these instruments did not tend to have longer labors than those who scored below the median on one or both tistru- ments. Third stage uterine atony, excessive bloodJoss, postpartum temper- ature elevation, and prolonged labor were included in the definition of uterine dysfunction because it was thought that they could be related to extreme muscle fatigue. However, they may also be the result of trauma, mechanical interference during second stage, timing of medication, anes- thesia, infections which had their origin prior to labor, use of different kinds of medication to stimulate contractions, even physical condition and nutritional status. The number of women who developed uterine inertia, or were diagnosed as uterine inertia, was quite small. In this study, it was nine per cent for primiparas and less than two per cent for multiparas. However, uterine inertia is the only complication which is directly related to the theory that anxiety results in the secretion of relatively large amounts of epinephrine into the blood stream during labor, and that this epinephrine can inhibit contractions of the uterus. Unless it is possible to limit the complications included in the definition of uterine dysfunction to those directly related to extreme muscle fatigue, it will probably be necessary to include only primary and secondary uterine inertia in this definition.

The findings of this study support the theory that women who have developed a habit of responding to anxiety with epinephrine-like symp- toms, will tend to develop much more extreme symptoms when placed in an anxiety-provoking situation than will women who have not developed such a habit. Figure 3 indicates how effective we would be in selecting women for intensive and sustained support during labor, using the differ- ent kinds of instruments which were available in this study. The upper line in each graph indicates the percentage of those patients who would be selected for support using each kind of instrument, and the lower line indi- cates the percentage of those selected who would be expected to develop physiologic disturbances if they did not receive intensive and sustained emotional support throughout labor. Remember, no attempt was made in this study to determine if these women would or would not develop these physiologic disturbances if they did not receive this intensive and sustained emotional support. It was an assumption of the study that they would not. However, if these two instruments prove to be effective, it will be possible to study this in a much more objective manner than has been possible in the past. If no instruments were available to us, our only alternative would be to select all of the patients admitted to the hospital in labor for inten- sive and sustained emotional support.

In this study, approximately 48% of all the primiparas and 29% of all

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P E R

c 100 E N T 80

O 6 0 F

40 U B J 20 E

T Q R B MULTl PARA

Fig. 3. Efficiency of selection for support in labor. T- Total subjects in stated category included in the study. Q- Group reporting above average muscle tension symptoms during pregnancy. R- Group rated above average on signs of emotional tension early in labor. B- Group scoring above average on both instruments.

the multiparas developed physiologic disturbances. Using only the ques- tionnaire the number of women selected for support would decrease to about half the total group, but the gap is not narrowed between those selected for support and those who actually need this support. Using only the ratings of physiologic and behavioral signs of anxiety at the beginning of labor, this gap does begin to narrow, but it is only when both instru- ments are used that these two lines really converge. Using both instru- ments, it is possible to select approximately one woman out of every five at the time she is being admitted to the hospital in labor, and predict that she will develop a physiologic disturbance related to uterine dysfunction or her infant will develop a physiologic disturbance related to hypoxia. Predictions would be correct over half of the time. For primiparas, pre- dictions would be correct over 70% of the time. The incidence of compli- cations was 67% higher for primiparas than for multiparas. Correct predic- tions are especially important, therefore, for the primipara and turn out to be much more accurate for the primipara.

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Instrument Developed is Rough Screening Measure It should be emphasized that this is not a precision instrument. This is a

rough instrument which may turn out to be effective for screening pur- poses. It is not a diagnostic instrument. The need for using multiple measures in identifying anxiety in the stress situation was quite apparent in this study. Different individuals were found to exhibit different physio- logic and behavioral responses to anxiety. In addition, the reliability of the ratings was about the same as the average reliability for any instrument using ratings, about .55. This means that there is one chance in three that the rating made on any individual by any nurse may differ from that indi- vidual’s true score by one and one-third points. Unfortunately, in the relia- bility study, it was not possible for two nurses to rate the woman at exact- ly the same period of time. It was not possible to provide training for the nurses doing the rating. The reliability of this instrument, therefore, needs to be studied further. It is, at least, as good as any instrument now avail- able which can be used for this purpose.

Both of these instruments were found to be practical and economical, and both can be reproduced by any inexpensive method, such as dupli- cating or mimeographing. Interviews during one of the pilot studies indi- cated that the questions on the questionnaire were easy to understand. No resistance was encountered from any of the more than 2,000 women who were asked to fill out this questionnaire. Nurses who were interviewed con- cerning the guide for Evaluation of Emotional Tension on Admission in Labor ) reported no difficulty in using this instrument as part of the re- ported no difficulty in using this instrument as part of the required to ad- mit a woman in labor.

Thus, in one setting at least, these instruments seem to have potential for helping nurses to select those women who need intensive and sustained emotional support throughout labor. What is needed now is to have these instruments tested critically in other geographical areas and environmental settings, and with other cultural and economic groups. Only after this has been accomplished will we know whether or not it is possible to generalize the results of this study to the majority of settings in this country.

Editor’s Note: Space commitments preclude the inclusion of the Ques- tionnaire and the Observation Guide. They may be obtained by contacting the author.

References 1. DICK-READ, GRANTLY: Psychosomatic Aspects of Pregnancy. In, KROGER,

WILLIAM s. AND FREED, S . CHARLES: Psychosomatic Gynecology. Wilshire Book Co., Hollywood, Calif., 1962.

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2. FUNKENSTEIN, D. H.: The Physiology of Fear and Anger. Sci. Am.,

3. SCHACTER, JOSEPH: Pain, Fear and Anger in Hypertensives and Normotensives. Psychosomatic Med., XIX: 17-29, January-February 1957.

4. SILVERMAN, A. J.; COHEN, S . I. AND ZUIDEMA, G. D.: Psychophysiological Investigation in Cardiovascular Stress. Am. J. Psychiat., CXIII:691-693, February 1957.

5 . REYNOLDS, S . R. M.; HARRIS, J. S . AND KAISER, I. H.: Clinical Measurement of Uterine Forces in Pregnancy and Labor. Charles C Thomas, Pub., Springfield, Ill., 1954.

6. GARCIA, C. R. AND GARCIA, E. S.: Epinephrine-Like Substances in the Blood and Their Relation to Uterine Inertia. Am. J . Obst. & Gynec., LXV:812-817, April 1955.

7. MC DONALD, R. L.; GYNTHER, A. C. AND CHRISTAKOS, A. C.: Relations Between Maternal Anxiety and Obstetric Complications. Psychosomatic Med.. XXV:357-363, April 1963.

8. DAVIDS, ANTHONY AND DE VAULT, SPENCER: Maternal Anxiety During Pregnancy and Childbirth Abnormalities. Psychosomatic Med., XXIV:464470, May 1962.

9. GRIMM, ELAINE R.: Psychological Tension in Pregnancy. Psychosomatic Med., XMII:520-527, June 1961.

10. KLEIN, HELEN T.: Maternal Anxiety and Abnormalities of Birth: Relationship Between Anxiety Level During Pregnancy and Maternal Fetal Complications. Yeshiva Univ. Unpublished Doctoral Dissertation, 1963.

11. BREGGIN, PETER, R.: The Psychophysiology of Anxiety. J. New. & Mental Dis., CXXXIX: 558-568, December 1964.

12. BALSHAM, IRIS D.: Muscle Tension and Personality in Women. Arch. Cen’l. Psychiaty, VII:436-448, May 1962.

13. GOLDSTEIN, IRIS B.: Physiological Responses in Anxious Women Patients. Arch. Gen’I. Psychiatry. X: 382-388, April 1964.

14. MALMO, ROBERT B.: Anxiety and Behavioral Arousal. Psychological Rev., LXIV:276-291, May 1957.

15. MARTIN, BARCLAY: The Assessment of Anxiety by Physiological Behavioral Measures. Psycho. Bull, LVIII:234-255, March 1961.

Columbia-Presbyterian Hospital 622 W. 168th Street

New York, New York 10032

CXCII:74-80, 1955.

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BULLETIN OF THE ACNM

Luncheon Meeting. Convention, 1968 at Park-Sheraton, New York.

Annual Meeting of the ACNM

Were you in the picture at our New York meeting last spring? We hope you’ll be attending our convention this year. It will be held at the Sheraton-Belvedere, Baltimore, Maryland. Circle the dates, April 15, 16 and 17 on your calendar. Highlights will include Dr. Allan Barnes as the keynote speaker and the gala celebration dinner Thursday evening, April 16, honoring the merger of the American Association of Nurse-Midwives and the American College of Nurse-Midwifery. This dinner will be a fund raising event for the ACNM Foundation.

Registration is $15.00 for Members for all meetings including two luncheons. Registration for non-Members is $5 .OO per afternoon meeting on Wednesday and Thursday. See you in Baltimore!

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Annual Meeting of the ACNM

Dr Harris speaks at the Open Meelings.

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Dorothea Lang at the podium.