Psychological Responses to the Use of the Fetal Monitor During Labor MONICA N. STARKMAN,
MD
Fetal monitoring, a major advance in obstetrical care, transforms the labor room into an intensive care setting. The psychological effects of this new technology were investigated by means of structured interviews with 25 postpartum women. The multiplicity of psychological responses obtained are described. The relationship of demographic, obstetrical, and psychosocial variables to women's overall positive or negative reaction to the monitor was investigated. Personality characteristics and life experiences with pregnancy and childbirth were factors that shaped the manner in which the monitor was experienced. The effect of fetal monitoring on maternal anxiety is discussed. The impact of mechanization on the total experience of childbirth is noted.
INTRODUCTION Fetal monitoring is a major scientific and clinical advance in obstetrical care. Electronic measurement of uterine contractions and fetal heart rates during labor provides the opportunity for early identification of fetal distress and intervention before irremedial brain damage or death has occurred. The use of the fetal monitor, however, transforms the labor room into an intensive care setting. Sensing devices must be positioned, often by the insertion of a catheter into the uterus and the attachment of an electrode to the presenting part of the fetus. These measurement devices are connected by wires to recording equipment, which transcribes the data onto paper and also emits continuous clicks whose frequency corresponds with the fetal heart rate. Hospital staff must attend the machine, scan it for data, and make
Assistant Professor and Chief of the Adult Service Consultation-Liaison Program, Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan 48104. Received for publication November 10,1975; Revision received February 17, 1976.
adjustments when mechanical difficulties occur. Sensors, wires, recording equipment, and continuous mechanical sounds thus become prominent features in the environment and experience of both physician and patient. Cardiac monitors have been utilized in intensive care and coronary care units for many years, and several studies have investigated their psychological impact (1, 2). The use of fetal monitors in the labor room differs from cardiac monitoring in several respects. Childbirth is essentially an anticipated and desired peak experience of life, not an illness. In addition, cardiac monitoring is continuous over a period of time that includes both acute illness and recuperation, whereas fetal monitoring takes place during the relatively brief but tumultuous process of labor. In order to gain insight into the psychological effects of the new obstetrical technology, the author interviewed a group of women in whom the fetal monitor had been used during labor. The study focused on the exploration of the range of responses to the fetal monitor and the elucidation of factors that shape the patient's experience of it. In this report,
Psychosomatic Medicine Vol. 38, No. 4 (July-August 1976) Copyright © 1976 by the American Psychosomatic Society, Inc. Published by American Elsevier Publishing Company, Inc.
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particular attention is given to the effect of the monitor on maternal anxiety and on the total experience of childbirth.
METHODS
The Setting of the Study The setting of the study was a large university medical center. At this hospital, obstetric patients are seen either as private patients of the attending staff or in the clinic by resident physicians under the supervision of the senior staff. Because the hospital is a regional referral center, many patients have a history of prior obstetrical difficulties. When obstetric patients are enrolled at the hospital, they and their husbands are offered a hospital tour, which is usually taken during the third trimester of pregnancy. As part of the tour, a brief description and discussion of the fetal monitor is given. Another source of information about the fetal monitor is at Lamaze childbirth classes, which are available in the city. Patients also learn about the monitor from their reading and reports from friends. In the labor room, several monitors are available. They are used in the following circumstances: in high-risk pregnancies such as with diabetic women; when meconium-stained amniotic fluid is seen; in premature labor; when labor is prolonged with poor progress; when labor is induced; and in normal labors if the monitor is available.
Obtaining the Sample All private and clinic patients in whom the fetal monitor was used were considered as subjects for the study. For each woman so identified, permission of the attending obstetrician was first obtained, and the patient's name was then placed on a list to be interviewed. In one instance, permission was not granted because the infant was critically ill and the obstetrician felt the interview might further upset the patient. In two other instances, the obstetrician deemed the patient too ill to be interviewed. Patients were seen on an unselected basis while they were still in the hospital and interviewed in order of delivery date. Because of the time delay between delivery date and interview (mean: 3 days; range: 1 to 7 days), women who had had cesarean sections and were therefore in the hospital for a longer period of time had a greater probability of being interviewed. 270
Description of the Sample There were 25 women in the sample. Thirteen women were private patients and 12 were clinic patients. The mean age was 26, with a range of 16 to 40 and a median of 26. Twenty-four patients were Caucasian and one was black. There was a spectrum of educational levels, with 11 patients having a high school degree or less, 10 with some college experience or a college degree, and 4 with a postgraduate or professional degree. Three of the 25 women were single. Six of the 25 current pregnancies were unplanned. Two of the women had a history of psychotic illness that had necessitated psychiatric hospitalization. A third patient had a history of depression following life stresses. Three patients were diabetic, and one patient had systemic lupus erytheraatosus. During the current pregnancies, one patient had had severe pre-eclampsia and another had had thrombophlebitis, both necessitating prepartum hospitalizations. Fifteen patients had just experienced their first delivery of a full-term living infant. Of these, two women had had a previous first trimester spontaneous abortion, while two others had a history of a fetal loss in the second or third trimester of pregnancy. Nine patients had just experienced their second delivery of a full-term living infant. Of these nine patients, one had previously delivered a stillborn infant, one had a history of three pregnancies, which all resulted in second trimester fetal losses, and three had had one or more early spontaneous abortions. The remaining patient in the sample had just experienced her fourth delivery of a full-term living infant. Seven of the 25 women had delivered their current pregnancies by cesarean section. All of the newborn infants were alive and well.
Interview After demographic and historical data were obtained, the structured interview began by asking for the patient's overall general reaction to the fetal monitor. The interview continued with questions pertaining to the patient's sources of prepartum information about the monitor and her initial response to this information. The patient was asked about concerns she might have had about labor and delivery before the monitor was introduced into the labor room. Also elicited was the explanation given by the obstetric staff as to why the monitor was being used, and the patient's response to this explanation. She was asked to describe her feelings about the monitor during the course of labor and the effect of the
Psychosomatic Medicine Vol. 38, No. 4 (July-August 1976)
PSYCHOLOGICAL RESPONSES TO USE OF FETAL MONITOR monitor on her interaction with husband and physicians. Finally, patients were invited to offer suggestions concerning the use of fetal monitors. Scoring and Statistical Analysis
A multiplicity of responses to the fetal monitor were given by the women interviewed and are described below. It should be emphasized that this represents the range of responses given by the sample as a whole. Any individual woman gave only a small number of responses.
For purposes of analysis, the patient's general reaction to the monitor was scored in the following manner. The response was rated as "positive" if positive features only were mentioned. Within this group, some of the responses were strongly positive, in that The Fetal Monitor as a Protector great enthusiasm and gratitude were expressed for the use of the monitor. Other responses were moderThe monitor was often seen as an extenately positive, with the monitor being seen as a benefit in labor. Still others were weakly positive, in sion of the physician. Women spoke of the that the monitor was stated to be all right with little special reassurance they felt in the preselaboration of its value. The remaining responses, ence of the monitor, particularly when the rated as "negative," were those in which physical and /or emotional disadvantages were mentioned. doctor was absent from the room (12 reSome of these responses were entirely negative while sponses). The protective power of the others occurred in combination with some positive machine was also verbalized as its ability comments. to control the doctor, such as "telling" The following demographic variables were him /her it was necessary to reexamine the studied: patient's age (years); patient's educational patient (three responses). level (up to high school diploma or beyond high The monitor sometimes became inschool diploma); husband's occupation (blue collar or white collar). Obstetrical variables studied were vested with magical powers. It became a parity (primiparous or multiparous); problems in protection against disaster, an omniscient, previous pregnancies (problems or no problems); omnipotent agent that guaranteed that the maternal illness during the current pregnancy (present or absent); threatened loss of the current pre- baby would survive (three responses). gnancy (present or absent); obstetrical problems occurring during the current labor (present or absent); Example. The patient was a 34-year-old and the type of monitor used (external or internal). Also studied were the existence of prior psychiatric married nurse who had a tragic obstetrical illness (present or absent); planning made for the history. She had had one ectopic precurrent pregnancy (planned or unplanned); and the gnancy and three fetal deaths at 6 months manner in which the initial prepartum introduction gestation. This was her second full-term to the existence of the monitor was presented and pregnancy and she had one living child at accepted (positive or negative). home. During this pregnancy, the patient's The likelihood of a relationship between a positive or negative reaction to the monitor and each of the father had told her that both he and her above variables (except age) was tested by placing mother were very worried that she might the data into a series of two by two tables and asses- die during delivery. The patient found this sing the resulting cell frequency distributions by such an unusual statement that she found means of a Fisher Exact Probabilities test. Student's herself thinking about it a great deal. t = test was used to assess the difference in mean age During early labor, she was very conbetween positive and negative responders to the cerned about the baby. She heard the monitor. nurses comment that they had listened to the fetal heart tones and they were 80 beats RESULTS per minute. As a nurse, she knew that this The Variety of Psychological Responses was an abnormally low rate. She was also to the Fetal Monitor worried about her father's remark, which Psychosomatic Medicine Vol. 38, No. 4 (July-August 1976)
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kept coming to her mind throughout the communicated for and about them to their labor. doctor, who would "know everything that She had read about the fetal monitor, but was happening to me just by watching the had not known that they had it at the hos- machine" (two responses). pital. Once the monitor was in place and Several women reported having diffioperative, she felt grateful and reassured culty in reaching out to their doctor verwhen she could see for herself that the fetal bally at a time when they very much heart tones recorded by the monitor were wanted and needed a sense of interaction at the normal rate of 120 beats per minute. (two responses). These women comThe patient recalled: "I suddenly felt that mented that the monitor provided a conif my father was right and I was going to crete subject for discussion, which made it die, at least the baby would make it. The easier for them to initiate a conversation monitor was watching it, keeping track of with their doctors. it. I knew that at least the baby would live, In one instance, the monitor was pereven if I didn't." ceived by the patient as an ally in overriding and overruling the ideas of the physiThe Monitor as an Extension cian: of the Patient This patient had had difficulties with Another response of patients was to her only other pregnancy, when the obstetview the machine as an extension of them- rician had initially doubted the existence selves in being the provider of information of the pregnancy despite the patient's necessary to the doctor. Several women adamant insistence that she was pregnant. commented that the machine could give After the pregnancy was documented, the doctors information about their con- bleeding ensued with continuing uncertractions that they could no longer do be- tainty about the death or survival of the cause of the administration of regional fetus until it was finally passed at 5 months gestation. Describing the current delivery, anesthesia (two responses). Some patients felt relieved of the re- the patient remarked: "I was sure I was in sponsibility of reporting contractions ac- labor, but the doctors didn't think so becurately to their physicians (two re- cause I was only two centimeters dilated sponses). This was related to the fear that after 8 hours of contractions. I was glad the misinformation would mislead the doctor monitor was there to prove that I was really and have an adverse effect on the doctor's in labor." decisions. Example. This patient had undergone an induction of labor. She commented: "It was good to see that the contractions were real and not psychological or my own impression. That way the doctor could get real information." The Monitor as an Aid in Communication Patients noted that they felt the monitor 272
The Monitor as an Extension of the Baby Patients commented that the clicks of the monitor confirmed to them constantly that the baby was alive (five responses). This aspect was particularly meaningful to those women who had lost a baby in the second or third trimester of pregnancy. Some patients pointed out that when they had experienced a moment of concern and asked the doctor how the baby was doing,
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the doctor would look at the monitor and be able to reassure them that the baby was doing well (three responses). Several women noted that they could confirm to themselves by direct observation of the output of the monitor that the infant was doing well (three responses). Although never mentioned overtly, it seemed that some women wondered whether the reassurance given by the physician was not the truth but merely an attempt to calm them. Their own direct perception and interpretation of the monitoring data became for them a more trustworthy source of reassurance. The Monitor Affecting Interactions with Husbands A frequent comment concerned the positive role of the monitor in facilitating the participation of husbands in the experience of labor (nine responses). These women noted that their husbands worked together with them by watching the tracing and alerting them that contractions were coming. Some pointed out that they really did not need to be told when a contraction was beginning, since they could sense this themselves. What they welcomed was the feeling of increased involvement of their husbands and the sharing of the experience. In one instance, the presence of the monitor contributed to the flight of the patient's husband from the labor room: The patient noted that her physician husband was very anxious because serious problems had arisen in previous labors. One full-term infant died in utero, and then fetal distress during the next labor necessitated an emergency cesarean section with a successful outcome. With this pregnancy, labor began prematurely and an alcohol drip was instituted in a fruitless
attempt to inhibit contractions. The patient recalled: "Then, the monitor began to show the fetal heart rate go down. It was so hard for my husband to see and hear it that he had to leave the room." The Monitor as a Distraction Patients commented that they could pass the time by watching the monitor. Women found it interesting to observe the recordings of the uterine and fetal heart rates. During early labor it was a diversion; during contractions later in labor it was a distraction (six responses). The Monitor as an Aid in Mastery Patients, particularly those utilizing the Lamaze method, frequently pointed out the usefulness of the cognitive information provided by the monitor (seven responses). Since they could be alerted that contractions were coming, they could get ready for their impact. Particularly useful was information that an individual contraction was passing its peak. The women felt that they could tolerate pain better knowing that the worst of each contraction had already been experienced. Similarly helpful was concrete evidence that the entire labor was almost over as indicated by the increased intensity and frequency of contractions. Competitive Feelings Toward the Monitor Although many women felt that the presence of the monitor facilitated a positive interaction with their husbands and physicians, several patients expressed feelings of resentment toward and jealousy of the monitor (three responses). They pointed out that physicians would hover
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about the monitor or that a husband might leave the bedside during a contraction in order to look at a distantly placed monitor, just when the patient wanted her husband with her.
responses). Women found it particularly frustrating when the monitor did not function accurately after they had suffered the disadvantages of discomfort and immobility. In addition, malfunctioning machinery resulted in "the mechanics" being calExample. This patient recalled with irrita- led in. This increased the hustle-bustle in tion that the monitor was not functioning the room and produced a lack of privacy, properly, and there was much concern so that while they lay uncovered, multiple about and attention to the equipment. She doctors and "mechanics" came into the felt she could give the physicians better room, with the door to the hall often left information than the machine, yet there ajar. were four people standing by it and lookThe fourth problem was that of the ing at it. She then added: "But when I sounds emitted by the monitor (three rereally wanted attention, I got it." sponses). Patients, especially when they felt they were out of control, began to be bothered by the buzzing and clicking of The Fetal Monitor as the machine. Others responded with fear a "Mechanical Monster" to the sounds emitted by the machine. One The patients identified several areas in patient, for example, noted that when a which the use of the monitor created addi- buzzer went off, she wasn't sure if this tional difficulties for them. The first dis- meant something was wrong with the baby advantage was that of increased physical or the machine was about to explode. discomfort (seven responses). The discomfort produced by insertion of the inThe Monitor Producing ternal monitor was described as considerIncreased Anxiety able. Women also mentioned the disagreeableness of wires dangling between their A particularly frequent cause of anxiety legs. was concern about injury to the baby that The second problem was that of en- might result from the attachment of the forced immobility (eight responses). With monitor to its scalp (six responses). the external monitor applied as a belt Women wondered how this could be done around the abdomen, patients were ob- safely since the baby was still high up in liged to remain still while lying on their the pelvis, and they feared that since this back. With the internal monitor they were was a blind procedure the "soft spot" never sure how much they could move might be punctured and produce injury. about, fearing that they might injure either They had fantasies about the type of device themselves or the baby. This was a parti- that would be attached to the baby's head. cular disadvantage, because many women Several women, for example, envisioned it felt that had they been able to change posi- as a long rod that was threaded under the tions and be more motorically active, it baby's scalp. would have helped them to tolerate better As mentioned previously, several the pain of their contractions. women reported relief from anxiety by The third problem was that of mechani- hearing the fetal heart rate output, which cal difficulties with the equipment (four proved to them that the baby was still 274
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alive, particularly if they had experienced a fetal loss in the past. Other women, however, experienced increased anxiety because of the continuous auditory information emanating from the monitor (five responses). Some of these women were very sensitive to slight variations in the fetal heart rate. When they heard the fetal heart rate slow during contractions, they became frightened and wondered whether this was normal or meant something was wrong. Several patients noted that even when true abnormalities occurred, they preferred hearing the heart rate directly themselves despite the increased anxiety this produced. Another source of anxiety for some patients was the feeling of helplessness engendered by the simultaneous use of the monitor and an oxygen mask (two responses). The patient, while being prepared for an emergency cesarean section, was in a situation perceived as frightening and dangerous to herself and her baby. She was restricted in movement by the monitor and unable to speak because of the facial mask. One woman described this as being like a nightmare in which one tries to run and scream and finds that one is both paralyzed and mute. Almost all of the patients with difficulties during their labor were keenly aware of the situation and experienced anxiety. In contrast, the interview with one patient revealed the utilization of suppression. Example. This 24-year-old woman experiencing her first delivery had a history of primary amenorrhea and "injudicious dieting," and was described in the medical chart as moody and anxious, responding to pressure with depression and anorexia. On the way to the delivery room she overheard a comment made to her husband by the physician that the fetal heart rate was de-
TABLE 1. Distribution of Responses Related to Prior Loss of Pregnancy Positive response
Negative response
Prior loss of pregnancy No prior loss of pregnancy
creasing. The patient described her reaction: "I really didn't want to hear it. I sort of ignored it." Initial Overall Spontaneous Response to the Fetal Monitor Of the 25 women interviewed, 14 gave responses rated as positive; of these, four were strongly positive, six were moderately positive, and four were weakly positive. Ten women gave responses rated as negative; of these, four were exclusively negative. One woman denied having any response at all to the monitor, and is therefore not included in the statistical analysis. A striking finding of this study was the relationship of a positive response with prior loss of a pregnancy (p < .01) (see Table 1). In addition, of the four women giving a strongly positive response, three had experienced at least one second or third trimester loss, and the fourth had been infertile for more than 5 years. All of the other variables tested were not statistically significant. DISCUSSION Since this study was done in a university hospital, the sample contained a large percentage of women with difficulties in past or current pregnancies. For this reason, the absolute frequencies of positive and negative responses may not be representative of the general obstetric
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population. It can be predicted on the basis of these data, however, that women with problems in a prior pregnancy, particularly fetal losses, will respond most favorably to the fetal monitor. Their perception of the monitor as a protection against the disaster that they had previously experienced apparently overshadows the perception or recall of actual disadvantages. Women with no previous delivery experience, or prior normal labors and no fetal losses, will tend to recognize the benefits of the monitor but also will respond negatively to its disadvantages. Of primary interest is the effect of the fetal monitor on maternal anxiety during labor. Aside from psychologic distress, the physiologic concomitants of anxiety, such as alterations in blood pressure and blood flow, may have a significant effect on the course of labor and the health of mother and fetus. This study has shown that the monitor can be utilized by the patient in such a way as to relieve anxiety. It can be experienced as an alter-ego of the physician, representing the desired qualities of the doctor such as watchfulness and competence. At times, it can be invested with magical powers and can be seen as an omniscient, omnipotent protector, which can guarantee the survival of the infant. This irrational belief in the monitor's power can prove a powerful defense against anxiety, particularly in those women who have suffered through the traumatic experience of fetal loss in previous pregnancies. The monitor lends itself to incorporation into individual defensive styles of coping with anxiety. Women who feel inadequate or wish decreased responsibility welcome the opportunity to abdicate responsibility to the monitor without experiencing guilt. Women who rely on intellectual understanding and rational mas276
tery find the concrete information provided by the monitor a useful aid. Furthermore, women utilizing the Lamaze technique of childbirth are able to incorporate data provided by the monitor into the Lamaze program, which itself promotes a sense of control over their bodies. The fetal monitor can alleviate anxiety by facilitating the involvement of husbands as active participants in labor, thus diminishing feelings of isolation and enhancing the sense of support and security. Alternatively, the monitor can become a source of anxiety in several ways. The first occurs when there is an incongruity between the patient's expectation of how the monitor is used and the actual utilization of the machine. For example, patients who have been told prepartum that the monitors are used predominantly for problem labors and rarely for normal labors become apprehensive and suspicious if an obstetrician decides to use an available monitor to gain more insight into this new technological development by observing the patterns that occur in a normal labor. Hospital practices that are not consonant with patient expectations can produce lack of trust and anxiety. A second source of anxiety stems from the fact that the very use of the monitor makes overt to the patient the existence of potential problems that otherwise might never be apparent to her. For example, prior to the development of fetal monitoring, when meconium-stained amniotic fluid was observed during labor, the obstetrician would note this and be silently watchful for possible complications. Currently, fetal monitoring will be instituted and the patient told that possible fetal distress makes this necessary. A third source of anxiety arises out of fears and fantasies related to the monitor as a potential danger to the infant. This in
Psychosomatic Medicine Vol. 38, No. 4 (July-August 1976)
PSYCHOLOGICAL RESPONSES TO USE OF FETAL MONITOR
part is related to partial and incomplete information. The information given is sufficient to indicate that some physical invasion of the infant will take place, but not specific enough to deter the fantasies that may far exceed reality. While individual patients have different needs for cognitive input, and there is a danger of overburdening patients with too much technical information, vague explanations of potentially threatening procedures do produce anxiety. Fourthly, the presence of the monitor emitting its continuous inescapable clickings increases anxiety in a small number of women. For those patients needing to utilize denial defensively, the constant sensory barrage signifying a medical situation of danger might well interfere with their ability to utilize this defense mechanism effectively. Finally, the effect of mechanization on the total experience of labor and delivery deserves comment. Childbirth is a peak experience with tremendous potential for the generation of a sense of creativity and mastery. It is not surprising that those
women in this study who were most dissatisfied with the monitor were those who had a prior experience of uncomplicated labors and healthy liveborn infants. These women expressed resentment at the interference the monitor presented to their being able to experience labor "my way." They felt deprived of the opportunity to discover and utilize personalized coping behavior, to freely and fully involve themselves in and master the experience of labor.
SUMMARY Fetal monitoring has the potential for producing both beneficial and detrimental psychological effects. Personality characteristics and life experiences with pregnancy and childbirth are significant factors that shape the manner in which the monitor is experienced. Staff sensitivity to potential sources of anxiety and to individual patient characteristics and needs is a major factor that can enhance the benefits of fetal monitoring.
REFERENCES 1. Hackett TP, Cassem NH, Wishnie HA: The coronary care unit: an appraisal of its psychologic hazards. N Engl J Med 279:1365-1370, 1968 2. Dominian J, Dobson M: Study of patients' psychological attitudes to a coronary care unit. Br Med J 4:795-798, 1969
Psychosomatic Medicine Vol. 38, No. 4 (July-August 1976)
277
MD
Fetal monitoring, a major advance in obstetrical care, transforms the labor room into an intensive care setting. The psychological effects of this new technology were investigated by means of structured interviews with 25 postpartum women. The multiplicity of psychological responses obtained are described. The relationship of demographic, obstetrical, and psychosocial variables to women's overall positive or negative reaction to the monitor was investigated. Personality characteristics and life experiences with pregnancy and childbirth were factors that shaped the manner in which the monitor was experienced. The effect of fetal monitoring on maternal anxiety is discussed. The impact of mechanization on the total experience of childbirth is noted.
INTRODUCTION Fetal monitoring is a major scientific and clinical advance in obstetrical care. Electronic measurement of uterine contractions and fetal heart rates during labor provides the opportunity for early identification of fetal distress and intervention before irremedial brain damage or death has occurred. The use of the fetal monitor, however, transforms the labor room into an intensive care setting. Sensing devices must be positioned, often by the insertion of a catheter into the uterus and the attachment of an electrode to the presenting part of the fetus. These measurement devices are connected by wires to recording equipment, which transcribes the data onto paper and also emits continuous clicks whose frequency corresponds with the fetal heart rate. Hospital staff must attend the machine, scan it for data, and make
Assistant Professor and Chief of the Adult Service Consultation-Liaison Program, Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan 48104. Received for publication November 10,1975; Revision received February 17, 1976.
adjustments when mechanical difficulties occur. Sensors, wires, recording equipment, and continuous mechanical sounds thus become prominent features in the environment and experience of both physician and patient. Cardiac monitors have been utilized in intensive care and coronary care units for many years, and several studies have investigated their psychological impact (1, 2). The use of fetal monitors in the labor room differs from cardiac monitoring in several respects. Childbirth is essentially an anticipated and desired peak experience of life, not an illness. In addition, cardiac monitoring is continuous over a period of time that includes both acute illness and recuperation, whereas fetal monitoring takes place during the relatively brief but tumultuous process of labor. In order to gain insight into the psychological effects of the new obstetrical technology, the author interviewed a group of women in whom the fetal monitor had been used during labor. The study focused on the exploration of the range of responses to the fetal monitor and the elucidation of factors that shape the patient's experience of it. In this report,
Psychosomatic Medicine Vol. 38, No. 4 (July-August 1976) Copyright © 1976 by the American Psychosomatic Society, Inc. Published by American Elsevier Publishing Company, Inc.
269
MONICA N. STARKMAN
particular attention is given to the effect of the monitor on maternal anxiety and on the total experience of childbirth.
METHODS
The Setting of the Study The setting of the study was a large university medical center. At this hospital, obstetric patients are seen either as private patients of the attending staff or in the clinic by resident physicians under the supervision of the senior staff. Because the hospital is a regional referral center, many patients have a history of prior obstetrical difficulties. When obstetric patients are enrolled at the hospital, they and their husbands are offered a hospital tour, which is usually taken during the third trimester of pregnancy. As part of the tour, a brief description and discussion of the fetal monitor is given. Another source of information about the fetal monitor is at Lamaze childbirth classes, which are available in the city. Patients also learn about the monitor from their reading and reports from friends. In the labor room, several monitors are available. They are used in the following circumstances: in high-risk pregnancies such as with diabetic women; when meconium-stained amniotic fluid is seen; in premature labor; when labor is prolonged with poor progress; when labor is induced; and in normal labors if the monitor is available.
Obtaining the Sample All private and clinic patients in whom the fetal monitor was used were considered as subjects for the study. For each woman so identified, permission of the attending obstetrician was first obtained, and the patient's name was then placed on a list to be interviewed. In one instance, permission was not granted because the infant was critically ill and the obstetrician felt the interview might further upset the patient. In two other instances, the obstetrician deemed the patient too ill to be interviewed. Patients were seen on an unselected basis while they were still in the hospital and interviewed in order of delivery date. Because of the time delay between delivery date and interview (mean: 3 days; range: 1 to 7 days), women who had had cesarean sections and were therefore in the hospital for a longer period of time had a greater probability of being interviewed. 270
Description of the Sample There were 25 women in the sample. Thirteen women were private patients and 12 were clinic patients. The mean age was 26, with a range of 16 to 40 and a median of 26. Twenty-four patients were Caucasian and one was black. There was a spectrum of educational levels, with 11 patients having a high school degree or less, 10 with some college experience or a college degree, and 4 with a postgraduate or professional degree. Three of the 25 women were single. Six of the 25 current pregnancies were unplanned. Two of the women had a history of psychotic illness that had necessitated psychiatric hospitalization. A third patient had a history of depression following life stresses. Three patients were diabetic, and one patient had systemic lupus erytheraatosus. During the current pregnancies, one patient had had severe pre-eclampsia and another had had thrombophlebitis, both necessitating prepartum hospitalizations. Fifteen patients had just experienced their first delivery of a full-term living infant. Of these, two women had had a previous first trimester spontaneous abortion, while two others had a history of a fetal loss in the second or third trimester of pregnancy. Nine patients had just experienced their second delivery of a full-term living infant. Of these nine patients, one had previously delivered a stillborn infant, one had a history of three pregnancies, which all resulted in second trimester fetal losses, and three had had one or more early spontaneous abortions. The remaining patient in the sample had just experienced her fourth delivery of a full-term living infant. Seven of the 25 women had delivered their current pregnancies by cesarean section. All of the newborn infants were alive and well.
Interview After demographic and historical data were obtained, the structured interview began by asking for the patient's overall general reaction to the fetal monitor. The interview continued with questions pertaining to the patient's sources of prepartum information about the monitor and her initial response to this information. The patient was asked about concerns she might have had about labor and delivery before the monitor was introduced into the labor room. Also elicited was the explanation given by the obstetric staff as to why the monitor was being used, and the patient's response to this explanation. She was asked to describe her feelings about the monitor during the course of labor and the effect of the
Psychosomatic Medicine Vol. 38, No. 4 (July-August 1976)
PSYCHOLOGICAL RESPONSES TO USE OF FETAL MONITOR monitor on her interaction with husband and physicians. Finally, patients were invited to offer suggestions concerning the use of fetal monitors. Scoring and Statistical Analysis
A multiplicity of responses to the fetal monitor were given by the women interviewed and are described below. It should be emphasized that this represents the range of responses given by the sample as a whole. Any individual woman gave only a small number of responses.
For purposes of analysis, the patient's general reaction to the monitor was scored in the following manner. The response was rated as "positive" if positive features only were mentioned. Within this group, some of the responses were strongly positive, in that The Fetal Monitor as a Protector great enthusiasm and gratitude were expressed for the use of the monitor. Other responses were moderThe monitor was often seen as an extenately positive, with the monitor being seen as a benefit in labor. Still others were weakly positive, in sion of the physician. Women spoke of the that the monitor was stated to be all right with little special reassurance they felt in the preselaboration of its value. The remaining responses, ence of the monitor, particularly when the rated as "negative," were those in which physical and /or emotional disadvantages were mentioned. doctor was absent from the room (12 reSome of these responses were entirely negative while sponses). The protective power of the others occurred in combination with some positive machine was also verbalized as its ability comments. to control the doctor, such as "telling" The following demographic variables were him /her it was necessary to reexamine the studied: patient's age (years); patient's educational patient (three responses). level (up to high school diploma or beyond high The monitor sometimes became inschool diploma); husband's occupation (blue collar or white collar). Obstetrical variables studied were vested with magical powers. It became a parity (primiparous or multiparous); problems in protection against disaster, an omniscient, previous pregnancies (problems or no problems); omnipotent agent that guaranteed that the maternal illness during the current pregnancy (present or absent); threatened loss of the current pre- baby would survive (three responses). gnancy (present or absent); obstetrical problems occurring during the current labor (present or absent); Example. The patient was a 34-year-old and the type of monitor used (external or internal). Also studied were the existence of prior psychiatric married nurse who had a tragic obstetrical illness (present or absent); planning made for the history. She had had one ectopic precurrent pregnancy (planned or unplanned); and the gnancy and three fetal deaths at 6 months manner in which the initial prepartum introduction gestation. This was her second full-term to the existence of the monitor was presented and pregnancy and she had one living child at accepted (positive or negative). home. During this pregnancy, the patient's The likelihood of a relationship between a positive or negative reaction to the monitor and each of the father had told her that both he and her above variables (except age) was tested by placing mother were very worried that she might the data into a series of two by two tables and asses- die during delivery. The patient found this sing the resulting cell frequency distributions by such an unusual statement that she found means of a Fisher Exact Probabilities test. Student's herself thinking about it a great deal. t = test was used to assess the difference in mean age During early labor, she was very conbetween positive and negative responders to the cerned about the baby. She heard the monitor. nurses comment that they had listened to the fetal heart tones and they were 80 beats RESULTS per minute. As a nurse, she knew that this The Variety of Psychological Responses was an abnormally low rate. She was also to the Fetal Monitor worried about her father's remark, which Psychosomatic Medicine Vol. 38, No. 4 (July-August 1976)
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kept coming to her mind throughout the communicated for and about them to their labor. doctor, who would "know everything that She had read about the fetal monitor, but was happening to me just by watching the had not known that they had it at the hos- machine" (two responses). pital. Once the monitor was in place and Several women reported having diffioperative, she felt grateful and reassured culty in reaching out to their doctor verwhen she could see for herself that the fetal bally at a time when they very much heart tones recorded by the monitor were wanted and needed a sense of interaction at the normal rate of 120 beats per minute. (two responses). These women comThe patient recalled: "I suddenly felt that mented that the monitor provided a conif my father was right and I was going to crete subject for discussion, which made it die, at least the baby would make it. The easier for them to initiate a conversation monitor was watching it, keeping track of with their doctors. it. I knew that at least the baby would live, In one instance, the monitor was pereven if I didn't." ceived by the patient as an ally in overriding and overruling the ideas of the physiThe Monitor as an Extension cian: of the Patient This patient had had difficulties with Another response of patients was to her only other pregnancy, when the obstetview the machine as an extension of them- rician had initially doubted the existence selves in being the provider of information of the pregnancy despite the patient's necessary to the doctor. Several women adamant insistence that she was pregnant. commented that the machine could give After the pregnancy was documented, the doctors information about their con- bleeding ensued with continuing uncertractions that they could no longer do be- tainty about the death or survival of the cause of the administration of regional fetus until it was finally passed at 5 months gestation. Describing the current delivery, anesthesia (two responses). Some patients felt relieved of the re- the patient remarked: "I was sure I was in sponsibility of reporting contractions ac- labor, but the doctors didn't think so becurately to their physicians (two re- cause I was only two centimeters dilated sponses). This was related to the fear that after 8 hours of contractions. I was glad the misinformation would mislead the doctor monitor was there to prove that I was really and have an adverse effect on the doctor's in labor." decisions. Example. This patient had undergone an induction of labor. She commented: "It was good to see that the contractions were real and not psychological or my own impression. That way the doctor could get real information." The Monitor as an Aid in Communication Patients noted that they felt the monitor 272
The Monitor as an Extension of the Baby Patients commented that the clicks of the monitor confirmed to them constantly that the baby was alive (five responses). This aspect was particularly meaningful to those women who had lost a baby in the second or third trimester of pregnancy. Some patients pointed out that when they had experienced a moment of concern and asked the doctor how the baby was doing,
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the doctor would look at the monitor and be able to reassure them that the baby was doing well (three responses). Several women noted that they could confirm to themselves by direct observation of the output of the monitor that the infant was doing well (three responses). Although never mentioned overtly, it seemed that some women wondered whether the reassurance given by the physician was not the truth but merely an attempt to calm them. Their own direct perception and interpretation of the monitoring data became for them a more trustworthy source of reassurance. The Monitor Affecting Interactions with Husbands A frequent comment concerned the positive role of the monitor in facilitating the participation of husbands in the experience of labor (nine responses). These women noted that their husbands worked together with them by watching the tracing and alerting them that contractions were coming. Some pointed out that they really did not need to be told when a contraction was beginning, since they could sense this themselves. What they welcomed was the feeling of increased involvement of their husbands and the sharing of the experience. In one instance, the presence of the monitor contributed to the flight of the patient's husband from the labor room: The patient noted that her physician husband was very anxious because serious problems had arisen in previous labors. One full-term infant died in utero, and then fetal distress during the next labor necessitated an emergency cesarean section with a successful outcome. With this pregnancy, labor began prematurely and an alcohol drip was instituted in a fruitless
attempt to inhibit contractions. The patient recalled: "Then, the monitor began to show the fetal heart rate go down. It was so hard for my husband to see and hear it that he had to leave the room." The Monitor as a Distraction Patients commented that they could pass the time by watching the monitor. Women found it interesting to observe the recordings of the uterine and fetal heart rates. During early labor it was a diversion; during contractions later in labor it was a distraction (six responses). The Monitor as an Aid in Mastery Patients, particularly those utilizing the Lamaze method, frequently pointed out the usefulness of the cognitive information provided by the monitor (seven responses). Since they could be alerted that contractions were coming, they could get ready for their impact. Particularly useful was information that an individual contraction was passing its peak. The women felt that they could tolerate pain better knowing that the worst of each contraction had already been experienced. Similarly helpful was concrete evidence that the entire labor was almost over as indicated by the increased intensity and frequency of contractions. Competitive Feelings Toward the Monitor Although many women felt that the presence of the monitor facilitated a positive interaction with their husbands and physicians, several patients expressed feelings of resentment toward and jealousy of the monitor (three responses). They pointed out that physicians would hover
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about the monitor or that a husband might leave the bedside during a contraction in order to look at a distantly placed monitor, just when the patient wanted her husband with her.
responses). Women found it particularly frustrating when the monitor did not function accurately after they had suffered the disadvantages of discomfort and immobility. In addition, malfunctioning machinery resulted in "the mechanics" being calExample. This patient recalled with irrita- led in. This increased the hustle-bustle in tion that the monitor was not functioning the room and produced a lack of privacy, properly, and there was much concern so that while they lay uncovered, multiple about and attention to the equipment. She doctors and "mechanics" came into the felt she could give the physicians better room, with the door to the hall often left information than the machine, yet there ajar. were four people standing by it and lookThe fourth problem was that of the ing at it. She then added: "But when I sounds emitted by the monitor (three rereally wanted attention, I got it." sponses). Patients, especially when they felt they were out of control, began to be bothered by the buzzing and clicking of The Fetal Monitor as the machine. Others responded with fear a "Mechanical Monster" to the sounds emitted by the machine. One The patients identified several areas in patient, for example, noted that when a which the use of the monitor created addi- buzzer went off, she wasn't sure if this tional difficulties for them. The first dis- meant something was wrong with the baby advantage was that of increased physical or the machine was about to explode. discomfort (seven responses). The discomfort produced by insertion of the inThe Monitor Producing ternal monitor was described as considerIncreased Anxiety able. Women also mentioned the disagreeableness of wires dangling between their A particularly frequent cause of anxiety legs. was concern about injury to the baby that The second problem was that of en- might result from the attachment of the forced immobility (eight responses). With monitor to its scalp (six responses). the external monitor applied as a belt Women wondered how this could be done around the abdomen, patients were ob- safely since the baby was still high up in liged to remain still while lying on their the pelvis, and they feared that since this back. With the internal monitor they were was a blind procedure the "soft spot" never sure how much they could move might be punctured and produce injury. about, fearing that they might injure either They had fantasies about the type of device themselves or the baby. This was a parti- that would be attached to the baby's head. cular disadvantage, because many women Several women, for example, envisioned it felt that had they been able to change posi- as a long rod that was threaded under the tions and be more motorically active, it baby's scalp. would have helped them to tolerate better As mentioned previously, several the pain of their contractions. women reported relief from anxiety by The third problem was that of mechani- hearing the fetal heart rate output, which cal difficulties with the equipment (four proved to them that the baby was still 274
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alive, particularly if they had experienced a fetal loss in the past. Other women, however, experienced increased anxiety because of the continuous auditory information emanating from the monitor (five responses). Some of these women were very sensitive to slight variations in the fetal heart rate. When they heard the fetal heart rate slow during contractions, they became frightened and wondered whether this was normal or meant something was wrong. Several patients noted that even when true abnormalities occurred, they preferred hearing the heart rate directly themselves despite the increased anxiety this produced. Another source of anxiety for some patients was the feeling of helplessness engendered by the simultaneous use of the monitor and an oxygen mask (two responses). The patient, while being prepared for an emergency cesarean section, was in a situation perceived as frightening and dangerous to herself and her baby. She was restricted in movement by the monitor and unable to speak because of the facial mask. One woman described this as being like a nightmare in which one tries to run and scream and finds that one is both paralyzed and mute. Almost all of the patients with difficulties during their labor were keenly aware of the situation and experienced anxiety. In contrast, the interview with one patient revealed the utilization of suppression. Example. This 24-year-old woman experiencing her first delivery had a history of primary amenorrhea and "injudicious dieting," and was described in the medical chart as moody and anxious, responding to pressure with depression and anorexia. On the way to the delivery room she overheard a comment made to her husband by the physician that the fetal heart rate was de-
TABLE 1. Distribution of Responses Related to Prior Loss of Pregnancy Positive response
Negative response
Prior loss of pregnancy No prior loss of pregnancy
creasing. The patient described her reaction: "I really didn't want to hear it. I sort of ignored it." Initial Overall Spontaneous Response to the Fetal Monitor Of the 25 women interviewed, 14 gave responses rated as positive; of these, four were strongly positive, six were moderately positive, and four were weakly positive. Ten women gave responses rated as negative; of these, four were exclusively negative. One woman denied having any response at all to the monitor, and is therefore not included in the statistical analysis. A striking finding of this study was the relationship of a positive response with prior loss of a pregnancy (p < .01) (see Table 1). In addition, of the four women giving a strongly positive response, three had experienced at least one second or third trimester loss, and the fourth had been infertile for more than 5 years. All of the other variables tested were not statistically significant. DISCUSSION Since this study was done in a university hospital, the sample contained a large percentage of women with difficulties in past or current pregnancies. For this reason, the absolute frequencies of positive and negative responses may not be representative of the general obstetric
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population. It can be predicted on the basis of these data, however, that women with problems in a prior pregnancy, particularly fetal losses, will respond most favorably to the fetal monitor. Their perception of the monitor as a protection against the disaster that they had previously experienced apparently overshadows the perception or recall of actual disadvantages. Women with no previous delivery experience, or prior normal labors and no fetal losses, will tend to recognize the benefits of the monitor but also will respond negatively to its disadvantages. Of primary interest is the effect of the fetal monitor on maternal anxiety during labor. Aside from psychologic distress, the physiologic concomitants of anxiety, such as alterations in blood pressure and blood flow, may have a significant effect on the course of labor and the health of mother and fetus. This study has shown that the monitor can be utilized by the patient in such a way as to relieve anxiety. It can be experienced as an alter-ego of the physician, representing the desired qualities of the doctor such as watchfulness and competence. At times, it can be invested with magical powers and can be seen as an omniscient, omnipotent protector, which can guarantee the survival of the infant. This irrational belief in the monitor's power can prove a powerful defense against anxiety, particularly in those women who have suffered through the traumatic experience of fetal loss in previous pregnancies. The monitor lends itself to incorporation into individual defensive styles of coping with anxiety. Women who feel inadequate or wish decreased responsibility welcome the opportunity to abdicate responsibility to the monitor without experiencing guilt. Women who rely on intellectual understanding and rational mas276
tery find the concrete information provided by the monitor a useful aid. Furthermore, women utilizing the Lamaze technique of childbirth are able to incorporate data provided by the monitor into the Lamaze program, which itself promotes a sense of control over their bodies. The fetal monitor can alleviate anxiety by facilitating the involvement of husbands as active participants in labor, thus diminishing feelings of isolation and enhancing the sense of support and security. Alternatively, the monitor can become a source of anxiety in several ways. The first occurs when there is an incongruity between the patient's expectation of how the monitor is used and the actual utilization of the machine. For example, patients who have been told prepartum that the monitors are used predominantly for problem labors and rarely for normal labors become apprehensive and suspicious if an obstetrician decides to use an available monitor to gain more insight into this new technological development by observing the patterns that occur in a normal labor. Hospital practices that are not consonant with patient expectations can produce lack of trust and anxiety. A second source of anxiety stems from the fact that the very use of the monitor makes overt to the patient the existence of potential problems that otherwise might never be apparent to her. For example, prior to the development of fetal monitoring, when meconium-stained amniotic fluid was observed during labor, the obstetrician would note this and be silently watchful for possible complications. Currently, fetal monitoring will be instituted and the patient told that possible fetal distress makes this necessary. A third source of anxiety arises out of fears and fantasies related to the monitor as a potential danger to the infant. This in
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part is related to partial and incomplete information. The information given is sufficient to indicate that some physical invasion of the infant will take place, but not specific enough to deter the fantasies that may far exceed reality. While individual patients have different needs for cognitive input, and there is a danger of overburdening patients with too much technical information, vague explanations of potentially threatening procedures do produce anxiety. Fourthly, the presence of the monitor emitting its continuous inescapable clickings increases anxiety in a small number of women. For those patients needing to utilize denial defensively, the constant sensory barrage signifying a medical situation of danger might well interfere with their ability to utilize this defense mechanism effectively. Finally, the effect of mechanization on the total experience of labor and delivery deserves comment. Childbirth is a peak experience with tremendous potential for the generation of a sense of creativity and mastery. It is not surprising that those
women in this study who were most dissatisfied with the monitor were those who had a prior experience of uncomplicated labors and healthy liveborn infants. These women expressed resentment at the interference the monitor presented to their being able to experience labor "my way." They felt deprived of the opportunity to discover and utilize personalized coping behavior, to freely and fully involve themselves in and master the experience of labor.
SUMMARY Fetal monitoring has the potential for producing both beneficial and detrimental psychological effects. Personality characteristics and life experiences with pregnancy and childbirth are significant factors that shape the manner in which the monitor is experienced. Staff sensitivity to potential sources of anxiety and to individual patient characteristics and needs is a major factor that can enhance the benefits of fetal monitoring.
REFERENCES 1. Hackett TP, Cassem NH, Wishnie HA: The coronary care unit: an appraisal of its psychologic hazards. N Engl J Med 279:1365-1370, 1968 2. Dominian J, Dobson M: Study of patients' psychological attitudes to a coronary care unit. Br Med J 4:795-798, 1969
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