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Perinatal Predictors of Pain and Distress During labor Michael Wuitchik, Ph.D., Kathlyn Hesson, M.Sc., and Donald A. Bakal, Ph.D. ABSTRACT: We sought to determine whether women’s attitudes and concerns, confidence in ability to control pain, and practice of pain-control techniques would predict pain and coping or distress-related thought during labor. During the third trimester of their pregnancies, 115 women completed the prenatal self-evaluation inventory and measures of confidence and practice of pain-control techniques. During the latent ( S 3 cm), active (4-7 cm), and transition ( 2 7 cm) phases of labor, interviews were conducted to assess levels of pain and the content of women’s cognitive activity on a continuum that ranged f r o m coping-related thought to distress-related thought. Women’s conjldence in their ability to use relaxation techniques and their reported practice of pain-control strategies did predict lower levels of pain and greater copingrelated thought during latent labor, but failed to account for pain or coping-distress in active or transition phases of labor. High scores on the Prenatal Self-Evahation Inventory fear of pain and helplessness scale predicted high levels of distress during latent labor. Two other scales, concern for self and baby and acceptance of pregnancy, were significant predictors of pain and distress in active and transitional labor. The results suggest that, with the shift from latent to active labor, women’s fundamental concerns and anxieties become manifest, and may take precedence over the skills acquired through childbirth education in moderating experienced pain and distress. (BIRTH 17:4, December 1990)
The understanding of psychological contributions to the labor process has benefited from the study of third-trimester attitudes and beliefs about labor as well as from the study of thoughts, feelings, and pain occurring during labor. For example, Lederman and colleagues found that specific conflicts surrounding the acceptance of pregnancy and expressed during the third trimester predicted anxiety and epinephrine levels during active labor (1). A second perinatal cognitive dimension, concern for safety of self and baby, predicted the duration of active labor (2). This concern for safety factor was described as a stable personality trait of mothers during pregnancy that predicted the degree of subjective distress during active labor (3). Much of the current predictive research has been limited to the study of psychological and physiologMichael Wuitchik is director of Behavioral Health Services, Canmore General Hospital. Address correspondence to Dr. Michael Wuitchik, Behavioral Health Services, Canmore General Hospital, Box 130, Canmore, Alberta, Canada TOL OMO.
ical events occurring during active labor. There is some evidence, however, that events during early or latent labor are equally significant for understanding the psychobiologic basis of labor. Self-reported pain during latent labor, for example, was inversely related to the efficiency of latent labor (rate of cervical dilation), whereas a high level of distress measured during the same phase was inversely related to the efficiency of active and second-stage labor (4). Women who experience high levels of distress during early labor may be expressing a trait characterized by helplessness and fear toward the entire pregnancy and childbirth experience. Some evidence suggests that this trait is present throughout labor and operates independently of ongoing pain. We observed, for example, that distress levels in a pain-free group of women with epidural anesthesia were similar to those reported by women laboring without such anesthesia ( 5 ) . In this study we examined whether women’s attitudes and beliefs as assessed by the Prenatal
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Self-Evaluation Inventory (PSEI) (3) could predict pain and distress in the latent, active, and transitional phases of labor, and also if the observed relationships were labor phase-specific. The predictive value of women’s confidence during the third trimester in the use and practice of pain control strategies was also examined. Including this variable allowed us to compare the relative influence of maternal attitudes and beliefs, and prenatal pain-control techniques, during each phase of labor. Methods
One hundred fifteen nulliparous women were recruited through family and obstetric practitioners and the hospital prenatal program. During prenatal visits physicians gave women a brief description of the study, and those who were interested were contacted directly by the first author. The first author also attended prenatal education classes at the hospital to invite women to participate. Women were told that the investigators were interested in learning about thoughts and pain during labor. At the time the third trimester PSEI questionnaires were completed, all of the women considered themselves to be at low obstetric risk. Postpartum chart reviews revealed that on admission to the hospital 13 women had high obstetric risk scores. Volunteers were excluded if they reported a history of premature labor between 16 and 36 weeks, uterine surgery, multiple gestation, diabetes, heart disease, renal disease, or drug abuse. Informed, written consent was obtained in the third trimester. Because of universal health care in Canada, antenatal care was similar for all of the women, including the content of prenatal education. The median age was 27 years, and the median educational level was 14.0 years. Pain and thoughts were recorded during three phases of labor: latent ( ~ cm), 3 active (4-7 cm), and transition ( 2 7 cm), by the first author in taperecorded interviews. Subjective pain was assessed with the Present Pain Intensity scale (PPI) (6), a verbal rating scale consisting of adjectives ranging from “no pain” to “excruciating.” The PPI correlated 0.85 latent, 0.76 active, and 0.70 transition, with a visual analog scale administered concurrently. We previously reported that the PPI in latent labor was a strong predictor of labor (efficiency) (4). A think-aloud method was used to assess thoughts about coping and distress (7-9). Subjects were asked, “Would you please tell me what you think about or what is going on in your mind during
a contraction?” This was followed with a query, “Anything else?” Responses were tape-recorded and transcribed for coding by three female graduate students in psychology. Each statement, or thought unit, was first coded for the presence or absence of coping-related and distress-related content. Thought units coded as coping included positive references to the use of attention diversion, physical distraction, sensation acknowledgment, coping self-statements, and support from loved ones. Thought units coded as distress included negative self-statements, fears of catastrophe, and concerns regarding lack of progress. (The complete coding manual is available from the first author.) The total number of thought units for each woman was then scored on a 5-point scale ranging from solely coping-related 1 through solely distress-related 5. Transcripts with an equal number of coping and distress references were scored 3 , whereas those that were predominantly but not exclusively oriented toward coping or distress were scored 2 or 4, respectively. A separate rating was derived for each labor phase. Interrater reliability (percentage of transcripts scored identically by the three raters) was 0.94. Our previously reported findings (4) that high distress during latent labor predicted duration of each phase of labor, type of delivery, fetal heart rate decelerations in active labor, and requests for pediatric assistance supports the predictive validity of this measure. Perinatal concerns were assessed during the third trimester with the PSEI (3). Subjects were given the PSEI during prenatal classes and returned the completed questionnaire when they arrived at the hospital. The PSEI provides scores on seven subscales: 1) Well-being of Self and Baby, 2) Acceptance of Pregnancy, 3) Identification with Motherhood Role, 4) Preparation for Labor, 5 ) Fear of Pain and Helplessness, 6) Relationship with Mother, and 7) Relationship with Husband. Lederman’s previous work (3) suggested that the subscales have high predictive validity regarding events in labor. The reliabilities of the scales (Cronbach’s alpha) ranged from 0.73 to 0.87. The itemscale validity of the instrument was assessed through a principal components analysis of the items making up the seven subscales. The analysis yielded seven similar factors that accounted for 47.7% of the common variance. Correlations between the Lederman subscale scores and the factor derived scores ranged from 0.78 to 0.97, indicating a strong association between the two sets of scores. Practice and confidence in prepared childbirth techniques was assessed with a brief questionnaire
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that was administered on admission to the hospital. Using 9-point Likert scales, women indicated how often per week they had practiced breathing and relaxation exercises, effleurage, pelvic exercises, and other techniques, and the degree of confidence they had in their ability to apply them. To assess the importance of physical and obstetric factors, maternal weight and height, fetal size and position during labor, and gestational age were recorded by chart review. Two demographic variables, education and religion, were obtained in a postpartum interview. Results
The sample size was reduced by late arrival of laboring women or the interviewer, by women progressing quickly and missing an assessment, or occurrence of cephalopelvic disproportion or cesarean section. Sample sizes for pain and coping-distress data differed within phases and from phase to phase because of interruptions or poor-quality tape recordings. Pearson correlations between PPI and copingdistress scores, and PSEI scores, Prenatal Practice and Confidence scores, and Physical and Demographic variables are presented in Table 1. High scores on the Acceptance of Pregnancy scale reflected difficulty accepting the pregnancy, and high scores on the Preparation for Labor scale reflected lack of perceived preparation. The Acceptance of Pregnancy scale correlated positively with the PPI and coping-distress measures across all phases of
labor, the association being strongest during transitional labor (r = 0.41; P < 0.01). The scale Concern for Self and Baby correlated significantly with pain measured during the active (r = 0.27; P < 0.05) and transitional (r = 0.51; P < 0.001) phases. High scores on the Preparation for Labor scale were also associated with high levels of pain during each phase of labor, the association being most pronounced during transitional labor (r = 0.35; P < 0.05). Women with high scores on the Fear of Pain and Helplessness scale also scored high on the PPI and coping-distress measures across all three phases. The remaining scales failed to correlate with pain or degree of coping or distress during any of the phases. With the exception of Practice of Breathing, practice of pain-control techniques did not correlate with reported pain or coping-distress scores. Higher levels of practice of breathing were associated with reduced distress in latent labor (r = -0.23; P < 0.05). Women's confidence in their ability to use relaxation was inversely correlated with PPI scores in latent labor (r = -0.27; P < 0.01) and coping-distress in active labor (r = -0.22; P < 0.05). Education correlated negatively with coping-distress scores in the latent (r = -0.24; P < 0.05) and transition phases (r = -0.37; P < 0.05), and with PPI scores in the active (r = -0.28; P < 0.05) and transition phases (r = -0.23; P < 0.05). Higher levels of education were related to less pain and more coping-related thought. Analysis of variance
Table 1. Correlations of Predictor Variables with Pain (PPI) and Coping-Distress (C-D) During Three Phases of Labor ~
PPI (n =63-73)
C-D (n = 63-76)
PPI (n = 57-64)
C-D (n = 60-66)
PPI (n = 35-39)
PSEI subscales Concern for self and baby
Acceptance of pregnancy Preparation for labor Fear of pain and helplessness Confidence in relaxation Practice of breathing Obstetric risk Education
- 0.23* ~
* P < 0.05.
f P < 0.001. # P < 0.01.
-0.27$ -0.23* 0.21"
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Table 2. Prediction of Pain (PPI): Stepwise Multiple Regression Analyses of Three Phases of Labor Criterion
PPI latent PPI active PPI transition
Confidence in relaxation Religion, Concern for self & baby Concern for self & baby
indicated that Catholics reported less pain in active labor than either the Protestant or no-religion groups [F(2,65) = 4.59; P < 0.0131. There were no differences in coping-distress scores among the religious groups. A composite of obstetric factors associated with complications in labor predicted high PPI scores in the latent phase (r = 0.21; P < 0.05). Risk was not correlated with coping-distress in any phase. A relationship was also found between fetal position and coping-distress scores in latent labor; women with fetuses in the occiput posterior position displayed more distress-related thought than did those with fetuses in the occiput transverse or anterior positions (F = 3.18; P = 0.052). No relationship was found between pain, coping, or distress and maternal weight, height, weight-height ratio, dilatation atta.ined prior to membrane rupture, fetal size, or gestational age. To determine the strength and reliability of the relationships between predictor variables and pain and coping-distress, separate stepwise multiple regression analyses were conducted using PPI and coping-distress scores for latent, active, and transition phases as criterion variables. Predictor variables having significant zero-order correlations with criterion variables were entered in a stepwise fashion in all analyses. The three religious orientations were coded as dummy variables and entered with the other variables. The results of the multiple regression analyses for pain and coping-distress are presented in Tables 2 and 3, respectively. The amount of variance in pain scores accounted for by predictor variables increased with each successive phase of labor, increasing from 7% in latent labor to 26% in transition. The predictor variables for pain changed from one phase to the next: confidence in the use of relaxation accounted for significant variance during latent labor; Concern for Self and Baby and religion contributed to significant variance during active labor and transition. The PSEI scale Fear of Pain and Helplessness predicted distress during the latent labor phase, and reported Practice of Breathing was associated with
reduced distress during this phase. The scale Acceptance of Pregnancy accounted for a significant amount of the variance in distress during both the active and transitional phases. Women who were less accepting of their pregnancies evidenced more distress during these phases of labor. Discussion
The correlational findings of this study illustrate the importance of studying separately the events associated with latent, active, and transitional labor. A previous paper (4) noted that high levels of pain during latent labor may contribute to or be part of a psychobiologic process that delays initiation of active labor. Predicting levels of pain during this phase from third trimester and other antenatal variables proved to be difficult. Confidence in the ability to relax was the strongest predictor of pain during latent labor. Whether women engaged in distress-versus coping-related thought in latent labor was predicted by the Fear of Pain and Helplessness scale. This scale contains items specific to fear of pain and feelings of helplessness and loss of control. Reported practice in breathing had a moderating effect on this fear. It is significant that the two prenatal childbirth training (PCT) variables, confidence in ability to relax and frequency of reported practice, exerted their attenuating effects on pain and distress only during the latent labor phase. Neither variable accounted for significant variance during active and transitional labor. Although PCT is known to reduce subjective pain during labor, the relief obtained is generally modest (10-12). An inverse relationship has been reported between actual use of pain-control techniques and progression through labor, indicating that a reevaluation of the presumed relationship between coping processes and active labor efficiency may be in order (13). Our data suggest that the psychological management of active labor may be much more difficult than generally assumed, especially when one considers that childbirth training information is most
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Table 3. Prediction of Coping-Distress (C-D): Stepwise Multiple Regression Analyses of Three Phases of Labor Criterion
C-D active C-D transition
Fear of pain & helplessness, practice of breathing Acceptance of pregnancy Acceptance of pregnancy
often presented in a group context without due regard for individual differences in women’s ways of coping, both with latent labor and with the severe pain and distress that may accompany active and transition stages. We previously suggested that latent labor cognitive activity (coping- vs distress-related thought) may have maximum impact during active labor and may be driven by individual factors that often override short-term training strategies
(4). Evidence for the roles of personality and constitutional predictors of active labor pain was observed with the PSEI scale Concern for Self and Baby. This scale predicted pain both during active and transition phases, with the strongest prediction occurring with the latter. It is interesting that this third-trimester variable was observed by Lederman et al. (2) to predict duration of active labor. Two independent reports now demonstrate the discriminant validity of the Concern for Self and Baby subscale. What it is about this scale that provides for highly specific prediction of psychobiologic events associated with active labor must be determined. Unlike the other Lederman scales, this subscale has a baby focus and associated most negative outcomes, including possible loss of baby, abnormal baby, and complications. Lederman et al. (2) proposed that the scale is measuring a highly specific anxiety trait of mothers that is manifested during pregnancy. At the same time, however, it may be reflecting a broader-based anxiety trait associated with catastrophic thinking in general. Acceptance of pregnancy was the second PSEI subscale to predict events during active and transition labor. Women whose scores reflected regret about pregnancy experienced high levels of distress during both active and transitional labor. Conversely, those who were more accepting of pregnancy demonstrated coping thoughts during these phases. Lederman et al. (1) noted a similar association between this scale and distress and epinephrine levels during active labor. Sociocultural variables also predicted pain and
distress across the three phases of labor. Education was inversely correlated with pain or distress in each of the phases. Education did not, however, reach significance in the regression analyses. Religion appeared as a significant predictor of pain during active labor only, with Catholic women reporting the lowest pain levels. Overall, the results point to a shift in the psychologic variables mediating pain and coping or distress across the three phases of labor. Pain and distress during latent labor were predicted by thirdtrimester Fear of Pain and Helplessness and confidence and practice of relaxation and breathing techniques. During active and transition phases, Acceptance of Pregnancy and Concern for Self and Baby were the critical predictors. Thus, with a shift to active labor, a woman’s more fundamental fears and anxieties as well as attitudes toward being pregnant are manifested and begin to influence both psychological and physiological events. Reducing these fears and concerns will prove difficult, but their recognition by educators is an important first step. References 1.
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