TUFF Associations Labour Outcomes Acta

8/13/2019 TUFF Associations Labour Outcomes Acta

1/7

Acta Obstetricia et Gynecologica. 2010; 89: 794800

MAIN RESEARCH ARTICLE

Psychoprophylaxis during labor: associations with labor-relatedoutcomes and experience of childbirth

MALIN BERGSTRM1, HELLE KIELER2 & ULLA WALDENSTRM1

1Department of Womens and Childrens Health, Karolinska Institutet, Stockholm, Sweden, and

2Centre for

Pharmacoepidemiology (CPE), Department of Medicine, Karolinska Institutet, Stockholm, Sweden

AbstractObjective. To study whether use of psychoprophylaxis during labor affects course of labor and experience of childbirth innulliparous women. Design. Cohort study. Setting. Women were recruited from 15 antenatal clinics in Sweden betweenOctober 2005 and January 2007. Sample.A total of 857 nulliparous women with a planned vaginal delivery. Methods.Usingdata from a randomized controlled trial of antenatal education where the allocated groups were merged, we compared course oflabor and experience of childbirth between women who used psychoprophylaxis during labor and those who did not. Data werecollected by questionnaires in mid-pregnancy and three months after birth, and from the Swedish Medical Birth Register.Logistic regression was used to assess associations. Main outcome measures.Mode of delivery, augmentation of labor, length oflabor, Apgar score, pain relief and experience of childbirth as measured by the Wijma Delivery Experience Questionnaire.Results.Use of psychoprophylaxis during labor was associated with a lower risk of emergency cesarean section (adjusted oddsratio (OR) 0.57; 95% condence interval (CI) 0.370.88), but an increased risk of augmentation of labor (adjusted OR 1.68;95% CI 1.232.28). No statistical differences were found in length of labor (adjusted OR 1.32; 95% CI 0.951.83), Apgarscore < 7 at ve minutes (adjusted OR 0.82; 95% CI 0.332.01), epidural analgesia (adjusted OR 1.13; 95% CI 0.841.53) orfearful childbirth experience (adjusted OR 1.04; 95% CI 0.621.74). Conclusion.Psychoprophylaxis may reduce the rate of

emergency cesarean section but may not affect the experience of childbirth.

Key words: Psychoprophylaxis, cesarean section, augmentation of labor, pain relief, experience of childbirth

Introduction

Psychoprophylaxis is a method for coping with laborpain by using patterned breathing techniques andrelaxation. It is widely practiced by birthing womenin many Western societies. Through regular practiceduring pregnancy and by responding to simulatedcontractions, the woman is expected to react in the

same way when experiencing real contractions duringlabor (1) according to Pavlovs theory of conditionedresponse (2). The method was developed in Russiaand then spread to Western Europe (3,4). In the1960s, psychoprophylaxis was used by about half ofall women who gave birth in France (5). In Sweden itwas introduced in the beginning of the 1970s, lost

popularity two decades later (6) and is now regainingpopularity (7). In the United States, a survey from2006 reported that nearly 50% of women used breath-ing techniques during labor (8), as did 74% in aCanadian survey from 2009 (9).

The experience of labor pain is complex, involvingphysiological, cognitive as well as psychologicaldimensions (10). Psychoprophylaxis is assumed to

affect all these dimensions: physiologically by improv-ing oxygenation and reducing muscle tension, cogni-tively by focusing on breathing and relaxation insteadof pain as such, and psychologically by reducing fearand improving the sense of personal control (4).Simkin and Bolding suggested that relaxation andbreathing techniques may contribute more to a

Correspondence: Malin Bergstrm, Department of Womens and Childrens Health, Retzius vg 13, Karolinska Institutet, SE-171 77 Stockholm, Sweden.E-mail: [email protected]

(Received 14 August 2009; accepted 10 February 2010)

ISSN 0001-6349 print/ISSN 1600-0412 online 2010 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)

DOI: 10.3109/00016341003694978


2/7

womans ability to cope with labor pain rather thanactually reducing the pain (11).

Despite the extensive use of psychoprophylaxis,scientic evaluations are scarce. A Cochrane reviewof complementary and alternative therapies for pain

management in labor included only one trial ofpsychoprophylaxis and this study suffered frommethodological decits (12). Another review ofnon-pharmacological pain relief also concluded thatrandomized controlled trials were lacking (11).Observational studies report that women nd breath-ing and relaxation techniques effective and helpful incoping with labor pain, but do not evaluate the effectthey may have on labor outcomes (6,8,11,13). In ourrecently published randomized controlled trial, theTUFF trial (KCTR CT20080007), we found thatincluding psychoprophylaxis in antenatal educationhad no effect on subsequent use of epidural analgesia,

labor outcomes or experience of childbirth (14).Though the ndings suggest that preparing forpsychoprophylaxis during pregnancy is not effective,it is still unclear whether use of psychoprophylaxisduring labor might affect these outcomes.

The aim of this study was to investigate associationsbetween use of psychoprophylaxis during labor andcourse of labor and experience of childbirth.

Material and methods

Study population and recruitment

For the purpose of this study, we used data from theTUFF trial of two models of antenatal education, oneof which included psychoprophylactic preparation.Associations between use of psychoprophylaxis andexperience of childbirth and labor-related outcomeswere compared between users of psychoprophylaxisand non-users, regardless of their group assignment inthe trial. Recruitment took place between October2005 and February 2007, and women were eligible forthe study if they were nulliparous, Swedish-speakingand attending any of the 15 antenatal clinics that hadvolunteered to participate in the trial. The clinics werespread over Sweden and were all part of and fundedby the public sector. The women were recruited bytheir antenatal care midwife at approximately 19gestational weeks. All who were included were askedto ll in two questionnaires, therst in mid-pregnancyand the second three months after birth. Moredetailed information about the trial has been pub-lished elsewhere (14,15).

Of approximately 1,300 women who were eligiblefor the trial, 1,087 agreed to participate and 986completed the follow-up questionnaire. Of these

women, 878 had a planned vaginal delivery, andanswered the specic questions related to courseand outcomes of labor. In addition to womensself-reported data, we used data from the MedicalBirth Register (16). We excluded 21 women for

whom we could not access register data or whereregister data were incongruent with self-reportedmode of delivery. Of the remaining 857 women,486 (57%) used psychoprophylaxis during laborand 371 (43%) did not.

Of the 486 women who used psychoprophylaxisduring labor, 351 (72%) had attended antenatal clas-ses to prepare for this method: 315 within the frame ofthe trial, 36 in private classes and 399 (82%) hadpracticed the techniques at home during pregnancy.Of the 371 women who did not use psychoprophylaxisduring labor, 113 (31%) had attended psychoprophy-laxis classes during pregnancy within the trial and 165

(44%) had practiced at home.

Background characteristics

From the mid-pregnancy questionnaire, we obtainedinformation about socioeconomic background, heightand pre-pregnancy weight, emotional and physiolog-ical wellbeing during pregnancy and expectations ofchildbirth and parenthood. The Wijma DeliveryExpectancy Questionnaire, W-DEQ A, a scale withhigh validity and reliability, was used to measureantenatal fear of childbirth (17). The W-DEQ A

includes 33 items with six-point response scales cov-ering various feelings and cognitive appraisal of child-birth. The maximum score is 165 and a high scoreindicates a higher degree of fear. Cutoff for fear ofchildbirth during pregnancy was set at > 84 (18).Information about smoking in early pregnancy, ges-tational length and birth weight was obtained from theMedical Birth Register (16).

Explanatory and outcome variables

The explanatory variable was womens use of psycho-prophylaxis during labor, and this information wasbased on womens self-reports in the follow-up ques-tionnaire. Such information was not available in theMedical Birth Register.

Information about course of labor and experienceof childbirth was obtained from the follow-up ques-tionnaire. Data on mode of delivery were validated bycomparing with data from the Medical Birth Register.Emergency cesarean section was dened as cesareansection preceded by labor, and instrumental deliveryincluded forceps and vacuum extraction. Length of

Psychoprophylaxis during labor 795


3/7

labor was dened as length from onset of regularcontractions with ve minutes interval, to birth.Data on Apgar score at ve minutes were collectedfrom the Medical Birth Register.

Cut-off for fearful childbirth experience on the

W-DEQ version B was set at >

84 (18). This scalehas the same structure as W-DEQ A, described above.The overall experience of childbirth was measured bya single-item question with ve response alternativeswhich were dichotomized to positive experience (verypositive and positive) and negative experience(both positive and negative, negative and verynegative) (19). Score 7 on a Likert scale rangingfrom 0 to 7 was dened as worst imaginable pain.

Statistical analysis

Statistical analyses were conducted in SPSS 15.0(SPSS, Chicago, IL, USA). Associations betweenuse of psychoprophylaxis and background and birthcharacteristics were calculated by bivariate analyses.Background data for the women are presented asnumbers and percentages or means and standarddeviations. For each woman, we calculated thepre-pregnancy body mass index (BMI) by weight(kg)/height2 (m), mean and median length of labor(hours). Continuous data were compared by Studentst-test and categorical data by chi-squared tests.p-Value < 0.05 was considered statistically signicant.Cronbachs alpha scores for the standardized instru-

ments are presented. The correlation between use ofpsychoprophylaxis and antenatal fear of childbirth wascalculated by Spearmans rank correlation, whichmeasures ranks instead of mean values and is suitablefor ordinal or nominal data. To control for potentialconfounders, we used logistic regression analyses toassess associations between use of psychoprophylaxisduring labor and mode of delivery (spontaneous vag-inal/emergency cesarean section/instrumental vaginaldelivery), induction and augmentation of labor, Apgarscore 30), antenatalfear of childbirth (W-DEQ A > 84), smoking in earlypregnancy (no smoking vs. any smoking) and birth

weight (< 2,500, 2,5004,500, > 4,500 grams). Theregional ethical review board in Stockholm approvedthe study (File record 978/31).

Results

Women who used psychoprophylaxis during laborwere older (p = 0.003), more often Swedish-born(p < 0.001), more educated (p < 0.02) and had ahigher total household income (p = 0.03) comparedwith women who did not use psychoprophylaxis(Table 1). Also, their pregnancy was more oftenplanned (p =0.04). No statistically signicant differ-ences were found in pre-pregnancy BMI, smokingin early pregnancy, self-rated health during preg-nancy or expectations of upcoming motherhood.Expected use of pharmacological pain relief (epidural

analgesia, pethidine/morphine or N2O) did not differsignicantly between users and non-users of psycho-prophylaxis. In contrast, expected use of non-pharmacological pain relief was associated withsubsequent use of psychoprophylaxis: shower/bath(p = 0.005) and acupuncture (p


4/7

The total mean score on the W-DEQ B was 50.6(SD 25.4) in women who used psychoprophylaxis and49.8 (SD 24.6) in those who did not (p = 0.65).Assessment of childbirth as a positive or verypositive experience differed only slightly betweenthe groups (OR 1.16; CI 0.891.52). Furthermore,there was no statistical difference in memory of labor

pain: mean 5.2 (SD 1.4) versus 5.1 (SD 1.7) on aLikert scale (p = 0.35).

Adjusting for potential confounders had only minoreffects on the risk estimates (Table 2).

Discussion

In this cohort study, we found that women who usedpsychoprophylaxis during labor had a lower risk ofemergency cesarean section compared with thosewho did not use the method. Experience of childbirth,memory of labor pain and use of pharmacological painrelief did not differ between users and non-users, butother methods of non-pharmacological pain relief weremore common in those who practiced psychoprophy-laxis. Women who used psychoprophylaxis were older,more often had a planned pregnancy and also a more

favorable socioeconomic background, which is in linewith previous reports of participants in antenatal edu-cation and psychoprophylactic preparation (20,21).

The emergency cesarean section rate in the studypopulation (14.5%) was slightly higher than thenational rate of 13% in all women giving birth inSweden in 2006 (16). One explanation contributingto this difference could be the higher mean birthweight in our study sample compared with the generalpopulation: 3,519 versus 3,419 grams (22). Theremay be different explanations for the associationbetween psychoprophylaxis and a lower rate of emer-gency cesarean sections. Obviously women in the

psychoprophylaxis group were more motivated totake an active part in the birth process by moreextensive training during pregnancy. This mighthave boosted their condence and ability to endurea longer labor, and as a consequence some cesareansections may have been avoided. It is also possible thatwomen who were strongly committed to the use ofpsychoprophylaxis had more negative attitudes tomedical interventions, which may have affected thebehavior of the birth attendant to postpone a decisionabout terminating labor by a cesarean section. Also,more active coaching by the partner with whom thewoman had practiced psychoprophylaxis at homeduring pregnancy might have improved condenceand ability to endure a longer labor. Another expla-nation for the lower rate of cesarean section in womenwho used psychoprophylaxis might be that there arephysiological benets of the patterned breathing andrelaxation, which is assumed to increase energy andlower the risk of ineffective contractions (4). How-ever, we have no data in this study to support such anexplanation and concede that more research is neededto explore the potential physiological mechanisms ofpsychoprophylaxis. Yet another explanation could be

Table 1. Characteristics of users and non-users of psychoprophyl-axis during labor.

Usersn = 486

Non-usersn = 371

Characteristics n % n %

Maternal age1625 102 21 108 29.42629 173 35.7 120 32.73035 185 38.1 109 29.736 or older 25 5.2 30 8.2

Married or cohabiting 471 96.9 356 96Born in Sweden 464 95.7 329 89.6Education

Elementary school 9 1.9 11 3High school 192 39.8 177 48.4College or university 281 58.3 178 48.6

Total household incomeper month*

Low 137 29.5 133 38.1Middle 128 27.6 90 25.8

High 199 42.9 126 36.1Pre-pregnancy BMI< 25 358 75.1 264 72.52530 91 19.1 69 19> 30 28 5.9 31 8.5

Pregnancy planned 392 80.7 279 75.2Smoking in early pregnancy 16 3.4 20 5.7Wanted a cesarean section 25 5.1 26 7Fear of childbirth:W- DEQ A > 84**

76 15.7 66 18

Self-rated health inmid-pregnancy as very good

174 35.8 150 40.4

Had very positive expectationsof upcoming motherhood

443 91.2 335 90.3

Expected use of pain relief

Epidural analgesia 173 35.6 145 39.1N2O 404 83.1 291 78.4Pethidine/morphine 30 6.2 36 9.7Bath/shower 264 54.3 166 44.7Acupuncture 117 24.1 49 13.2

Birth characteristicsGestational length 37 weeks 463 95.3 355 95.7

Birth weight< 2,500 grams 13 2.7 9 2.42,5004,500 grams 453 93.4 354 95.4> 4,500 grams 19 3.9 8 2.2

*Low 24,000 SEK, Middle 24,00129,999 SEK, High 30,000SEK.

**Cronbach

s alpha 0.93.Note: BMI, body mass index; W-DEQ, Wijma delivery expectancyquestionnaire.

Psychoprophylaxis during labor 797


5/7

that an emergency cesarean section did not givewomen the opportunity to use psychoprophylaxis,which would then explain why the rate was higherin non-users. However, we believe this explanation isunlikely, considering that psychoprophylaxis usuallyis practiced from the early onset of labor, and themean length of labor was only 1.5 hours shorteramong non-users compared with those who usedpsychoprophylaxis.

The lack of association between use of psychopro-phylaxis and experience of childbirth or memory oflabor pain was unexpected, since psychoprophylaxis isassumed to increase a womans feeling of controlduring labor, a feeling previously reported to beassociated with a positive childbirth experience(19,23). Emergency cesarean section as well as

augmentation of labor has been associated with anegative birth experience (19), and the possible effectsof these factors may have canceled each other out.The nding that psychoprophylaxis was not associ-ated with a more positive birth experience is sup-ported by the results of our randomized controlledtrial, which showed that antenatal training in psycho-prophylaxis did not affect the birth experience (14).

Psychoprophylaxis did not reduce the need foradditional pharmacological pain relief. Today, psy-choprophylaxis is considered a method for improvinga womans ability to cope with labor contractions andincreasing personal control during labor, rather thanreducing pain (11,2427). Women seem to use themethod to calm down, as a distraction or as a way tocontrol panic (28), and to complement rather than

Table 3. Comparisons of experience of childbirth in users and non-users of psychoprophylaxis during labor expressed as crude and adjustedOR with 95% CI.

Outcomes

Usersn = 486

Non-usersn = 371

Crude OR 95% CI Adjusted OR* 95% CIn % n %

Fearful childbirth experience: W-DEQ B >84** 43 8.9 35 9.6 0.91 0.571.46 1.04 0.621.74Overall positive childbirth experience*** 237 48.9 167 45.1 1.16 0.891.52 1.12 0.831.5Worst imaginable pain**** 91 18.8 82 22.3 0.81 0.581.13 0.87 0.611.25

*Adjusted for maternal age, country of birth (Sweden vs. other), educational level, pre-pregnancy BMI, antenatal fear of childbirth (W-DEQ A> 84), smoking in early pregnancy and birth weight.**Cronbachs alpha 0.94.***Overall childbirth experience assessed as very positiveor positive.****Memory of labor pain rated as 7 on a Likert scale where 7 = worst imaginable pain.Note: OR, odds ratio; CI, condence interval; BMI, body mass index; W-DEQ, Wijma delivery expectancy questionnaire.

Table 2. Comparisons of course of labor between users and non-users of psychoprophylaxis during labor expressed as crude and adjusted ORwith 95% CI.

Outcomes

Usersn =486

Non-usersn =371

Crude OR 95% CI Adjusted OR* 95% CIn % n %

Mode of deliverySpontaneous vaginal 357 73.3 260 70.1 1.18 0.881.6 1.25 0.891.74Emergency cesarean section 57 11.7 64 17.3 0.64 0.430.94 0.57 0.370.88Instrumental vaginal delivery 73 15 47 12.6 1.22 0.821.81 1.19 0.781.82

Labor outcomesInduction of labor 74 15.2 66 18 0.82 0.571.18 0.89 0.61.33Augmentation of labor 329 68 207 55.9 1.67 1.262.21 1.68 1.232.28Labor 9 hours** 216 49.8 131 42.7 1.33 0.991.79 1.32 0.951.83Apgar 84), smoking in early pregnancy and birth weight.**Median length of labor was 9 hours.Note: OR, odds ratio; CI, condence interval; BMI, body mass index; W-DEQ, Wijma delivery expectancy questionnaire.

798 M. Bergstrm et al.


6/7


7/7

24. Christiaens W, Bracke P. Assessment of social psycho-logical determinants of satisfaction with childbirth in across-national perspective. BMC Pregnancy Childbirth.2007;7:26.

25. Goodman P, Mackey MC, Tavakoli AS. Factors related tochildbirth satisfaction. J Adv Nurs. 2004;46:2129.

26. McCrea BH, Wright ME. Satisfaction in childbirth and per-ceptions of personal control in pain relief during labour. J AdvNurs. 1999;29:87784.

27. Slade P, MacPherson SA, Hume A, Maresh M. Expectations,experiences and satisfaction with labour. Br J Clin Psychol.1993;32(Pt 4):46983.

28. Spiby H, Slade P, Escott D, Henderson B, Fraser RB.Selected coping strategies in labor: an investigation ofwomens experiences. Birth. 2003;30:18994.

29. Luke B, Brown MB. Elevated risks of pregnancy complica-tions and adverse outcomes with increasing maternal age.Hum Reprod. 2007;22:126472.

30. Montan S. Increased risk in the elderly parturient. Curr OpinObstet Gynecol. 2007;19:1102.

31. Cesaroni G, Forastiere F, Perucci CA. Are cesarean deliveriesmore likely for poorly educated parents? A brief report fromItaly. Birth. 2008;35:241

4.

32. Linton A, Peterson MR, Williams TV. Effects of maternalcharacteristics on cesarean delivery rates among U.S. Depart-ment of defense healthcare beneciaries, 19962002. Birth.2004;31:311.

33. Jun Zhang KF. Whats the relative risk?: a method of correct-ing the odds ratio in cohort studies of common outcomes.

JAMA. 1998;280:16901.

800 M. Bergstrm et al.

Documents

TUFF Associations Labour Outcomes Acta