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International Journal of Nursing Practice 2015; 21: 454–461
RESEARCH PAPER
Stress, sleep quality and unplanned Caesarean section in pregnant women Yi-Li Ko EdD RN Associate Professor, Department of Nursing, College of Medicine, Fu Jen Catholic University, Taiwan
Pi-Chu Lin EdD RN Associate Professor, School of Nursing, College of Nursing, Taipei Medical University, Taiwan
Shu-Chuan Chen MSN RN Director, Nursing Department, Shin Kong Wu Ho-Su Memorial Hospital, Taiwan
Accepted for publication August 2013 Ko Y-L, Lin P-C, Chen S-C. International Journal of Nursing Practice 2015; 21: 454–461 Stress, sleep quality and unplanned Caesarean section in pregnant women This study examines the relationship among prenatal maternal stress, sleep quality and unplanned Caesarean delivery. For this research, we adopted a prospective survey design and a sample of 200 women in the early stages of labour. The findings were as follows: (i) 11.5% of the participants underwent unplanned Caesarean sections; (ii) based on a Pittsburg Sleep Quality Index split point of 5, approximately 90.5% of the participants experienced poor sleep quality; and (iii) the odds ratio for primiparas undergoing an unplanned Caesarean section was 4.183 times that for multiparas (95% confidence interval (CI) = 1.177 to 14.864), indicating a statistically significant difference. The results also showed that stress was a significant factor related to unplanned Caesarean sections; a 1-point increase on the Pregnancy Stress Rating Scale was associated with a 1.033-fold higher probability of undergoing an unplanned Caesarean section (95% CI = 1.002 to 1.065). Furthermore, prenatal stress was a significant variable that can be used to predict unplanned Caesarean deliveries. Key words: pregnant women, sleep quality, stress, unplanned Caesarean section.
INTRODUCTION In Taiwan, the rate of Caesarean section delivery is 32.67%,1 considerably higher than the 10–15% recommended by the World Health Organization.2 Caesarean sections pose physical and mental health risks for women, and can also result in negative childbirth experiences, delayed postoperative recovery, and increased occurrence of diseases and additional complications. In addition, previous research has shown that Caesarean sections increase
Correspondence: Shu-Chuan Chen, no. 95, Wen-Chang Road, Taipei City 11101 Taiwan. Email: [email protected] © 2014 Wiley Publishing Asia Pty Ltd
the risks of haemorrhaging, infection, thrombosis, pelvic cavity injury, abdominal organ injury and anaesthesia complications. Furthermore, the risk of stroke for mothers undergoing a Caesarean section delivery is 1.6 times higher than that for mothers who experience a normal spontaneous delivery.3 The incidence of postoperative complications following unplanned Caesarean sections (24.12%) is also higher compared with that for planned Caesarean sections (16.3%).4 In addition, posttraumatic stress symptoms after delivery have been associated with unplanned Caesarean sections.5 Compared with a normal spontaneous delivery, a Caesarean section incurs an additional NT$15 000 in insurance expenses, leading to waste in health-care spending.6 doi:10.1111/ijn.12267
Stress, sleep and Caesarean section
For women, pregnancy is a significant life event and a complex development process. Rubin contended that during the pregnancy period, women’s role identity and interpersonal relationships are reconstructed.7 When transitioning into motherhood, women primarily focus on the following four maternal tasks: (i) seeking safe passage for themselves and their baby; (ii) securing acceptance of the baby from significant others; (iii) learning to give of themselves; and (iv) bonding with the unknown baby. Sources of mental stress for women during the first to third trimesters of pregnancy include: (i) the need to ensure the health and safety of themselves and their fetus; (ii) adopting or identifying with the maternal role; and (iii) changes in body shape and acceptable physical activity. During the early stages of pregnancy, women experience both excitement and anxiety. Despite their excitement regarding the new life they have created and are carrying, they experience concern regarding physiological reactions, such as menolipsis, breast-distension pain, frequent urination, nausea and fatigue resulting from changes in hormonal activity, as well as changes to their body shape or figure.8,9 Women also experience conflicting emotions and mental states when considering the pain of delivery and the likelihood of a successful pregnancy.7 During the third trimester of pregnancy, although women generally have a positive perception of themselves and their unborn child, and have embraced being pregnant, their anxiety tends to increase. At this stage, in addition to a restricted capacity to engage in physical activity and the inconvenience caused by their bodies, pregnant women experience anxiety regarding various issues, including the potential for a successful childbirth and the infant’s health. Additionally, women might perceive that the world and the external environment pose a threat to the well-being of themselves and their child.10 Yang and Chen investigated the mental stress of 247 pregnant women and found that pregnant women typically experience mental stress when they have not coordinated the changes in family relationships nor identified and organized a support network.11 Furthermore, the need to accept or identify with the maternal role, changes in body image, and concerns regarding the health and safety of themselves and their unborn child generated pressure for pregnant women. Feelings of mental stress can vary across cultures, marital status, age and number of pregnancies.12,13 Hsu and Chen found that mental stress during pregnancy is significantly associated with depression and has a considerable influence on the daily life of pregnant women.14
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Stress during pregnancy can also result in infants with a low birth weight.15 Previous research has shown that pregnant women who experience greater stress before childbirth tend to receive additional pain relief during labour, which increases the potential need for a Caesarean section. In addition, the fetuses of mothers who were administered pain relief during labour exhibited a higher incidence of abnormal heartbeat, which is another reason to perform a Caesarean section.16 Sleep disorders or sleep pattern disturbances during pregnancy are common physiological conditions caused by increased progesterone levels, which lead to reduced slow-wave sleep and changes in overall sleep duration.17,18 Furthermore, numerous symptoms experienced during pregnancy have a crucial influence on sleep quality. During the first trimester, 10–15% of women might experience sleep problems or disturbances due to frequent urination, nausea, back and waist pain, and leg cramps. Beginning in the second trimester, fetal movement and heartburn can further disturb sleep. Approximately 66.0% of pregnant women experience frequent urination, shortness of breath, leg cramps and itching. During the third trimester, as the fetus continues to grow, labour anxiety is typically accompanied by poor sleep quality, including reduced slow wave sleep, which manifests as increasingly frequent or longer waking episodes during sleep.19–21 Hertz et al. indicated that during the late stages of pregnancy, wake after sleep onset and inefficient sleep are common.22 Women in this stage frequently report lower back pain, leg cramps, nightmares that impact their sleep quality, and increased daytime sleepiness and fatigue.23,24 Nevertheless, few studies have examined the relationship between sleep quality during pregnancy and childbirth outcomes. For example, Lee and Gay reported that compared with women who slept for more than 7 h a day during the late stages of pregnancy, women who slept for less than 6 h a day experienced a longer delivery period of up to 12 h, and were 4.5 times more likely to undergo a Caesarean section.25 Tsai et al. examined the association between sleep quality and Caesarean sections for 184 women in the third trimester of pregnancy. The results showed that 77.2% of the women experienced poor sleep quality, and 40.7% were dissatisfied with their quality of sleep. Furthermore, poor sleep quality was found to increase the likelihood of a Caesarean section by 1.22 times (95% confidence interval (CI) = 1.01 to 1.48).26 © 2014 Wiley Publishing Asia Pty Ltd
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The purpose of this study was to explore the relationship among prenatal maternal stress, sleep quality and unplanned Caesarean delivery.
METHODS Study participants and setting A prospective survey design was adopted for this study. In addition, purposive sampling was employed to recruit 200 women experiencing the early stages of labour during their third trimester of pregnancy. These women were recruited from the delivery rooms of a medical centre located in Taipei City between September 2010 and December 2010. The inclusion criteria were women aged 20 years or older, who were pregnant with a singleton, had no medical or obstetric complications, underwent an unplanned Caesarean section, possessed the ability to communicate in Mandarin or Taiwanese, and expressed willingness to participate in this study. Structured questionnaires including the Pregnancy Stress Rating Scale (PSRS) and the Pittsburgh Sleep Quality Index (PSQI) were used to collect data.
Measurements Demographic data A questionnaire was employed to obtain the participants’ basic information, including their demographic variables (age, weight gain during pregnancy, education level and occupation), obstetrical variables (gravidity, parity and abortion history) and exercise habits during pregnancy. This study also collected relevant birth data, including birth patterns, sex of newborn and infant birthweight after delivery.
PSRS
This study adopted the PSRS developed by Chen et al.27 which comprises 30 items for assessing the mental stress experienced by pregnant women. A 5-point Likert scale was used to score each item, for a total potential score of 150 points (1 = none; 2 = slight; 3 = moderate; 4 = severe; and 5 = extremely severe). Higher scores indicate higher levels of stress during pregnancy. The PSRS contained three subscales, namely, ‘Stress caused by the need to ensure the health and safety of oneself and the fetus’, ‘stress caused by the need to adopt or identify with the maternal role’, and ‘stress caused by changes in body shape and acceptable physical activity.’ The internal consistency Cronbach’s α coefficient for this scale was 0.89. © 2014 Wiley Publishing Asia Pty Ltd
PSQI The PSQI developed by Buysse et al. was employed to measure sleep quality. This scale contains 10 items that comprise the following seven dimensions: subjective sleep quality, sleep latency, sleep hours, sleep disorders or difficulties, sleep efficiency, use of sleeping pills, and daily functions and operations.28 A calculation standard was established for every dimension. The number of points awarded for each dimension ranged between 0 and 3, for a total score ranging between 0 and 21 points. Furthermore, ≥ 85.0% was set as the indicator of good sleep efficiency. According to previous studies, a split or boundary point of 5 for the PSQI score is associated with an 88.5% accuracy rate, 89.6% sensitivity rate and 86.5% specificity rate.28 A total score of 5 or above for the seven dimensions indicates poor sleep quality, and a score of less than 5 indicates good sleep quality. In other words, higher scores imply a poorer sleep quality. Regarding the reliability of the PSQI, previous studies have reported Cronbach’s α values ranging between 0.53 and 0.83; the coefficient obtained in this study was 0.60.4,28
Ethical considerations and data collection We obtained approval from the institutional review board (IRB) of the study hospital before recruiting participants (IRB approval number: C9804). In the hospital delivery room, trained interviewers invited women in the early stages of labour, and who met the inclusion criteria, to participate in the study. The interviewers then explained the research purpose and data collection process. Upon providing written consent, the participating pregnant women were enrolled in the study. The participants in a stable physical condition were instructed to complete the PSRS and PSQI questionnaires, and leave a contact number to facilitate post-partum follow-up visits for collecting maternal delivery and infant information.
Data analysis SPSS for Windows, version 17.0, statistical software (SPSS, Chicago, IL, USA) was employed for data analysis. Descriptive statistics were employed to analyse the stress levels and sleep quality of pregnant women, using percentages, means and standard deviation (SD) to present the information. Bivariable analyses were performed using t-tests. Multivariate logistic regression was adopted to examine the relationships between mental
Stress, sleep and Caesarean section
stress, sleep quality and mode of delivery. A P-value of less than 0.05 was set as the standard for statistical significance.
RESULTS Basic demographics The mean age of the 200 participants was 31.42 years (SD = 4.02) and the mean weight gain during pregnancy was 13.91 kg (SD = 4.20). Approximately 124 (62.0%) participants were employed full-time, and the majority had achieved a college or higher level of education (75%). Regarding the number of pregnancies, 120 (60%) of the participants were primiparas, which represented the majority. In addition, half of the participants (100; 50%) had exercised regularly during their pregnancy, and just over half of all pregnancies gave birth to boys (n = 111, 55.5%). The mean infant birthweight was 3064 g (SD = 413.22). Furthermore, 177 participants (88.5%) experienced a normal spontaneous delivery, with the remaining 23 participants (11.5%) undergoing a Caesarean section. The primary reasons for performing the 23 Caesarean sections were prolonged labour and fetal distress (Table 1). The mean PSRS score for the 200 participants in the early stages of labour was 64.74 ± 15.19 points, indicating moderate to high levels of stress. The mean score for sleep quality during the later stages of pregnancy was 7.33 ± 2.11 points. The study participants achieved an overall sleep efficiency level of 92.81%, with an average of 8.59 ± 1.67 h of sleep per day. Approximately 69% of the participants were dissatisfied with their sleep quality, with ‘sleep disorders or difficulties’ being the most commonly reported reason for poor sleep quality. Based on the poor sleep quality split point of ≥ 5, 90.5% of the participants were considered to have poor sleep quality.
Factors associated with Caesarean sections A comparison of basic data for the women who experienced a normal spontaneous delivery and those who underwent unplanned Caesarean sections indicated that only gravidity was correlated to the mode of delivery (χ2 = 7.87, P = 0.005). The results also showed that primiparas were more likely to experience an unplanned Caesarean section (87%). Regarding the relationship between mental stress, sleep quality and mode of delivery, mental stress during pregnancy was found to be significantly associated with
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Table 1 Basic information of participants (N = 200) Characteristic
M ± SD
Mean age (years) < 34 35–44 Weight gain (kg) < 11 11–13 > 13 Educational level High school College and university > University Occupation status No Yes Regular exercise during pregnancy No Yes Sex of baby Boy Girl Mode of delivery NSD C/S
31.42 ± 4.02
n
%
160 40
80 20
58 40 102
29 20 51
50 128 22
25 64 11
76 124
38 62
100 100
50 50
111 89
55.5 44.5
177 23
88.5 11.5
31.91 ± 4.20
C/S, Caesarean section; NSD, normal spontaneous delivery.
Caesarean sections (χ2 = 7.45, P = 0.006). Furthermore, 78% of unplanned Caesarean sections were performed on women with a PSRS score of ≥ 65 points, and only 21.7% of unplanned Caesarean sections were performed on women with a PSRS score of ≤ 65 points. This finding indicates that greater stress during pregnancy increases the probability of an unplanned Caesarean delivery. The participants were further divided into a high and a low sleep quality group, based on a split point of 9.4, for comparison. The results showed no significant difference in the mode of delivery between the participants who experienced a high and low sleep quality during the later stages of pregnancy (χ2 = 1.158, P = 0.282) (Table 2). The logistic regression analysis results indicated that a 1-point increase in stress during pregnancy increased the likelihood of an unplanned Caesarean section by 1.033fold (95% CI = 1.002 to 1.065), which was statistically significant (P = 0.038). Compared with multiparas, the © 2014 Wiley Publishing Asia Pty Ltd
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Table 2 Relationship between basic information and unplanned Caesarean section (N = 200) Characteristics
Unplanned C/S
Mean age (years) < 34 35–44 Weight gain (kg) < 11 11–13 > 13 Educational level High school College and university > University Occupation status No Yes Regular exercise during pregnancy No Yes Parity Primipara Multipara PSRS score < 65 ≧ 65 PSQI score < 9.4 ≧ 9.4
NSD
16 7
69.6 30.4
143 33
81.1 18.9
6 1 16
26.1 4.3 69.6
47 44 83
27 25.3 47.7
8 14 1
34.8 60.9 4.3
42 114 21
23.7 64.4 11.9
7 16
30.4 69.6
69 108
39.0 61.0
11 12
47.8 52.2
89 86
50.9 49.1
20 3
87.0 13.0
100 77
56.5 43.5
5 18
21.7 78.3
92 85
52.0 48.0
10 13
43.5 56.5
79 98
44.6 55.4
χ2
P value
1.71
0.188
5.84
0.054
2.08
0.353
0.63
0.427
0.08
0.785
7.87
0.005
7.45
0.006
1.158
0.282
C/S, Caesarean section; NSD, normal spontaneous delivery; PSRS, Pregnancy Stress Rating Scale; PSQI, Pittsburgh Sleep Quality Index.
odds ratio for primiparas experiencing an unplanned Caesarean section was 4.183 times higher (95% CI = 1.177 to 14.864), achieving a level of statistical significance (P = 0.027).
DISCUSSION For the participants examined in this study, we observed an unplanned Caesarean section occurrence rate of 11.5%, which exceeds the 8.7% reported by Tsai et al.26 The average amount of sleep reported by the participants was 8.59 ± 1.66 h per day, although their overall subjective sleep quality was poor. Approximately 90.5% of participants were considered to have poor sleep quality (PSQI ≥ 5), and their mean PSQI score was 7.33. This finding is consistent with the 6.87 points reported by Tsai et al. regarding the sleep quality of pregnant women © 2014 Wiley Publishing Asia Pty Ltd
during their third trimester.26 However, the mean PSQI score for the participants in this study was less than that for college students in Taiwan (PSQI = 4.3 points).29 The poor sleep quality experienced by pregnant women might result from increasing levels of hormones reducing the amount of slow-wave sleep.21 Furthermore, during the later stages of pregnancy, as the fetus grows and begins compressing the chest, pregnant women could experience difficulty sleeping comfortably. However, the sleep quality experienced by these women over a 1 month period exceed that of primiparas, as indicated by a mean PSQI score of 9.68 points for post-partum primiparas.4 The potential reasons for the reduced sleep duration and inferior sleep quality women experience in the early postpartum period compared with during pregnancy include pain from uterine contractions, pain from episiotomies or
Stress, sleep and Caesarean section
Caesarean section wounds, and breast distension. Furthermore, post-partum women assuming their maternal role are required to breastfeed and care for the newborn during the night. Although the results of logistic regression analysis did not show a significant causal relationship between unplanned Caesarean sections and poor sleep quality during the later stages of pregnancy, the statistical findings indicate that a 1-point rise in stress during pregnancy increases the probability of an unplanned Caesarean section by 1.33 times (95% CI = 1.002 to 1.065), which implies that mental stress has a significant influence on the mode of delivery. This is consistent with the findings of previous studies, where pregnant women who experienced mental stress and related symptoms, in addition to feeling less confident about becoming a mother, were more likely to undergo a Caesarean section.30 Other related studies have indicated that pregnant women who experience greater mental stress tend to receive more analgesics during labour, which increases the probability of undergoing a Caesarean section. In addition, consuming a high amount of analgesics can cause an abnormal heartbeat in fetus, which presents yet another reason to undergo a Caesarean section.16 The American Congress of Obstetricians and Gynaecologists recommends assessing prenatal stress during each trimester of pregnancy. However, prenatal examinations in Taiwan only evaluate maternal and infant physical health. Therefore, we suggest that mental stress evaluations be included in prenatal examinations. Previous domestic research comparing the psychosocial influencing factors for 194 primiparas who experienced a natural or vaginal birth, and 81 women who underwent a Caesarean section, found that older women, women with a higher level of education and women pregnant with a male child were more likely to undergo a Caesarean section.31 The results of this study show that primiparas are significantly more likely to undergo an unplanned Caesarean section. This might be attributed to primiparas’ fear of labour pain, and erroneous mass media reports that Caesarean sections result in less pain and do not affect recovery from childbirth. Pregnant women’s readiness for pregnancy and childbirth, fear of childbirth, risk assessments, anxiety, and self-efficacy regarding a smooth delivery, as well as family members’ opinions of the various delivery modes, are all crucial factors that influence the choice of an elective Caesarean section. Chen also found
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that compared with hospital and physician factors, the individual factors of pregnant women play a more significant role in decisions to undergo a Caesarean section.32
Study limitations and recommendations The study sample comprised pregnant women in the early stages of labour recruited from delivery rooms. Because the participants were only asked to recall their perceptions of maternal stress for the previous month, this study could not measure the changes in levels of mental stress throughout pregnancy. Furthermore, because the participants experienced normal pregnancies without medical complications, and their mean age was 31.43 years, the results cannot be generalized to high-risk or teen pregnancies. This study shows that primiparas are more likely to experience an unplanned Caesarean section. Therefore, we recommend enhancing the health education provided by clinics or prenatal education courses for primiparas by including accurate information regarding the childbirth process, specifically, the advantages and disadvantages of a normal spontaneous delivery and a Caesarean section, to enable primiparas to make appropriate decisions. In addition, the mental stress levels of pregnant women should be evaluated in prenatal clinics to identify and support women experiencing high levels of stress during the early stages of pregnancy. This can also facilitate the identification of mental stress sources, provision of support and early intervention for labour preparation, and execution of referrals to alleviate pregnant women’s fears and anxieties regarding labour, thereby ensuring they maintain positive expectations of labour.
Conclusion In this study, the participants exhibited an unplanned Caesarean section rate of 11.5%. Additionally, 90.5% of the participants were considered to have poor sleep quality, and primiparas were more likely to experience a Caesarean section. Furthermore, pregnant women with high levels of mental stress tended to undergo unplanned Caesarean sections. These findings can assist nurses in designing appropriate risk-specific interventions for preventing unplanned Caesarean sections.
Conflicts of Interest The authors declare that they have no conflicts of interest. © 2014 Wiley Publishing Asia Pty Ltd
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ACKNOWLEDGEMENTS This research study is funded by a grant from Shin Kong Wu Ho-Su Memorial Hospital (No. 99-SKH-FJU-19). The author thanks the nurses in Shin Kong Wu Ho-Su Memorial Hospital, Taipei, for assisting in the enrolment of the study participants.
REFERENCES 1. Department of Health, Executive Yuan, Taiwan. Taiwan hospital average daily amount of medical services and caesarean section rate. Statistics Annual Report 2003. Available from URL: http://www.doh.gov.tw/statistic/ data/Health. Accessed 23 May 2004. 2. Wang HH, Chung UL. An alternative in childbirth education: Vaginal delivery following earlier caesarean delivery. The Journal of Nursing 2004; 51: 66–69. 3. Lin SY, Hu CJ, Lin HC. Increased risk of stroke in patients who undergo caesarean section delivery: A nationwide population-based study. American Journal of Obstetrics Gynaecology 2008; 198: 391–393. 4. Huang CM, Carter PA, Guo JL. A comparison of sleep and daytime sleepiness in depressed and non-depressed mothers during early postpartum period. The Journal of Nursing Research 2004; 12: 287–296. 5. Stramrood CA, Paarlberg KM, Huis In’t Veld EM et al. Posttraumatic stress following childbirth in homelike-and hospital settings. Journal of Psychosomatic Obstetrics & Gynaecology 2011; 32: 88–97. 6. Bureau of National Health Insurance. Payment standard. 2004. Available from URL: http://www.nhi.gov.tw/ 02hospital/hospital_4.htm. Accessed 23 May 2004. 7. Rubin R. Maternal Identity and the Maternal Experience. New York: Springer, 1984. 8. Chen HC, Chen HM, Huang TH. Stressors associated with pregnancy as perceived by pregnant women during three trimesters. The Kaohsiung Journal of Medical Sciences 1989; 5: 505–509. 9. Davis DC. The discomfort of pregnancy. Journal of Obstetric, Gynaecologic, and Neonatal Nursing 1996; 25: 73–81. 10. Chen HM, Chen CH. Compare stress and social support between adolescent and adult pregnant women during third trimester. The Kaohsiung Journal of Medical Sciences 1996; 12: 183–192. 11. Yang QY, Chen CH. A comparative study of psychological stress and social support between Taiwan-born and Chinaborn pregnant women in the Kaohsiung area. Psychological Stress and Social Support 2009; 5: 312–320. 12. Huang HC, Lin SL. The views of adolescent on values and costs of having children. Research in Applied Psychology 2005; 28: 197–222. 13. Dipietro JA, Ghera MM, Costigan K, Hawkins M. Measuring the ups and downs of pregnancy stress. Journal
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of Psychosomatic Obstetrics & Gynaecology 2004; 25: 189– 201. Hsu CM, Chen CH. The prevalence and predictors of prenatal depression. Journal of Evidence-Based Nursing 2008; 42: 149–156. Torche F. The effect of maternal stress on birth outcomes: Exploiting a natural experiment. Demography 2011; 48: 1473–1491. Saunders TA, Lobel M, Veloso C, Meyer BA. Prenatal maternal stress is associated with delivery analgesia and unplanned caesareans. Journal of Psychosomatic Obstetrics & Gynaecology 2006; 27: 141–146. Bei B, Milgrom J, Ericksen J, Trinder J. Subjective perception of sleep, but not its objective quality, is associated with immediate postpartum mood disturbances in healthy women. Sleep 2010; 33: 531–538. Driver HS, Shapiro CM. A longitudinal study of sleep stages in young women during pregnancy and postpartum. Sleep 1992; 15: 449–453. Baratte-Beebe KR, Lee K. Sources of midsleep awakenings in childbearing women. Clinical Nursing Research 1999; 8: 386–397. Pien GW, Schwab RJ. Sleep disorders during pregnancy. Sleep 2004; 27: 1405–1417. Wolfson AR, Crowley SJ, Anwer U, Bassett JL. Changes in sleep patterns and depressive symptoms in first-time mothers: Last trimester to one-year postpartum. Behavioural Sleep Medicine 2003; 1: 54–67. Hertz G, Fast A, Feinsilver SH, Albertario CL, Schulman H, Fein AM. Sleep in normal late pregnancy. Sleep 1992; 15: 246–251. Lee KA, Zaffe ME, McEnany G. Parity and sleep patterns during and after pregnancy. Obstetrics & Gynaecology 2000; 95: 14–18. Mindell JA, Jacobson BJ. Sleep disturbances during pregnancy. Journal of Obstetric, Gynaecologic, and Neonatal Nursing 2000; 29: 590–597. Lee KA, Gay CL. Sleep in late pregnancy predicts length of labour and type of delivery. American Journal of Obstetrics and Gynaecology 2004; 191: 2041–2046. Tsai MS, Huang CM, Kuo WM, Wu HM, Lee MY. Physical activity, sleep quality, and unplanned caesarean section in pregnant woman. Journal of Nursing and Healthcare Research 2010; 6: 13–23. Chen HC, Chao Yu YM, Hwang KK. Factors that constitute the prenatal maternal stress of the third trimester pregnant women. Public Health 1983; 10: 88–89. Buysse DJ, Reynolds IIICF, Monk TH, Berman SU, Kupfer DJ. The Pittsburgh sleep quality index: A new instrument for psychiatric practice and research. Psychiatric Research 1989; 28: 193–213. Huang PH, Maa SH, Hsu SH. Relationship between sleep quality and illness and biomarkers of disease in
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university freshmen. Chang Gung Nursing 2008; 19: 439– 449. 30. Durik AM, Hyde JS, Clark R. Sequelae of caesarean and vaginal deliveries: Psychosocial outcomes for mothers and infants. Developmental Psychology 2000; 36: 251–260. 31. Chen CH, Wang SY. Psychosocial outcomes of vaginal and caesarean births in Taiwanese primiparas. Research in Nursing& Health 2002; 25: 452–458.
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32. Chen CM. An Exploration of the appropriate use of healthcare resources and related factors in primary caesarean section in Taiwan—National Health Insurance Research Database 2003. Unpublished thesis, Kaohsiung Medical University, 2006.
© 2014 Wiley Publishing Asia Pty Ltd
International Journal of Nursing Practice 2015; 21: 454–461
RESEARCH PAPER
Stress, sleep quality and unplanned Caesarean section in pregnant women Yi-Li Ko EdD RN Associate Professor, Department of Nursing, College of Medicine, Fu Jen Catholic University, Taiwan
Pi-Chu Lin EdD RN Associate Professor, School of Nursing, College of Nursing, Taipei Medical University, Taiwan
Shu-Chuan Chen MSN RN Director, Nursing Department, Shin Kong Wu Ho-Su Memorial Hospital, Taiwan
Accepted for publication August 2013 Ko Y-L, Lin P-C, Chen S-C. International Journal of Nursing Practice 2015; 21: 454–461 Stress, sleep quality and unplanned Caesarean section in pregnant women This study examines the relationship among prenatal maternal stress, sleep quality and unplanned Caesarean delivery. For this research, we adopted a prospective survey design and a sample of 200 women in the early stages of labour. The findings were as follows: (i) 11.5% of the participants underwent unplanned Caesarean sections; (ii) based on a Pittsburg Sleep Quality Index split point of 5, approximately 90.5% of the participants experienced poor sleep quality; and (iii) the odds ratio for primiparas undergoing an unplanned Caesarean section was 4.183 times that for multiparas (95% confidence interval (CI) = 1.177 to 14.864), indicating a statistically significant difference. The results also showed that stress was a significant factor related to unplanned Caesarean sections; a 1-point increase on the Pregnancy Stress Rating Scale was associated with a 1.033-fold higher probability of undergoing an unplanned Caesarean section (95% CI = 1.002 to 1.065). Furthermore, prenatal stress was a significant variable that can be used to predict unplanned Caesarean deliveries. Key words: pregnant women, sleep quality, stress, unplanned Caesarean section.
INTRODUCTION In Taiwan, the rate of Caesarean section delivery is 32.67%,1 considerably higher than the 10–15% recommended by the World Health Organization.2 Caesarean sections pose physical and mental health risks for women, and can also result in negative childbirth experiences, delayed postoperative recovery, and increased occurrence of diseases and additional complications. In addition, previous research has shown that Caesarean sections increase
Correspondence: Shu-Chuan Chen, no. 95, Wen-Chang Road, Taipei City 11101 Taiwan. Email: [email protected] © 2014 Wiley Publishing Asia Pty Ltd
the risks of haemorrhaging, infection, thrombosis, pelvic cavity injury, abdominal organ injury and anaesthesia complications. Furthermore, the risk of stroke for mothers undergoing a Caesarean section delivery is 1.6 times higher than that for mothers who experience a normal spontaneous delivery.3 The incidence of postoperative complications following unplanned Caesarean sections (24.12%) is also higher compared with that for planned Caesarean sections (16.3%).4 In addition, posttraumatic stress symptoms after delivery have been associated with unplanned Caesarean sections.5 Compared with a normal spontaneous delivery, a Caesarean section incurs an additional NT$15 000 in insurance expenses, leading to waste in health-care spending.6 doi:10.1111/ijn.12267
Stress, sleep and Caesarean section
For women, pregnancy is a significant life event and a complex development process. Rubin contended that during the pregnancy period, women’s role identity and interpersonal relationships are reconstructed.7 When transitioning into motherhood, women primarily focus on the following four maternal tasks: (i) seeking safe passage for themselves and their baby; (ii) securing acceptance of the baby from significant others; (iii) learning to give of themselves; and (iv) bonding with the unknown baby. Sources of mental stress for women during the first to third trimesters of pregnancy include: (i) the need to ensure the health and safety of themselves and their fetus; (ii) adopting or identifying with the maternal role; and (iii) changes in body shape and acceptable physical activity. During the early stages of pregnancy, women experience both excitement and anxiety. Despite their excitement regarding the new life they have created and are carrying, they experience concern regarding physiological reactions, such as menolipsis, breast-distension pain, frequent urination, nausea and fatigue resulting from changes in hormonal activity, as well as changes to their body shape or figure.8,9 Women also experience conflicting emotions and mental states when considering the pain of delivery and the likelihood of a successful pregnancy.7 During the third trimester of pregnancy, although women generally have a positive perception of themselves and their unborn child, and have embraced being pregnant, their anxiety tends to increase. At this stage, in addition to a restricted capacity to engage in physical activity and the inconvenience caused by their bodies, pregnant women experience anxiety regarding various issues, including the potential for a successful childbirth and the infant’s health. Additionally, women might perceive that the world and the external environment pose a threat to the well-being of themselves and their child.10 Yang and Chen investigated the mental stress of 247 pregnant women and found that pregnant women typically experience mental stress when they have not coordinated the changes in family relationships nor identified and organized a support network.11 Furthermore, the need to accept or identify with the maternal role, changes in body image, and concerns regarding the health and safety of themselves and their unborn child generated pressure for pregnant women. Feelings of mental stress can vary across cultures, marital status, age and number of pregnancies.12,13 Hsu and Chen found that mental stress during pregnancy is significantly associated with depression and has a considerable influence on the daily life of pregnant women.14
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Stress during pregnancy can also result in infants with a low birth weight.15 Previous research has shown that pregnant women who experience greater stress before childbirth tend to receive additional pain relief during labour, which increases the potential need for a Caesarean section. In addition, the fetuses of mothers who were administered pain relief during labour exhibited a higher incidence of abnormal heartbeat, which is another reason to perform a Caesarean section.16 Sleep disorders or sleep pattern disturbances during pregnancy are common physiological conditions caused by increased progesterone levels, which lead to reduced slow-wave sleep and changes in overall sleep duration.17,18 Furthermore, numerous symptoms experienced during pregnancy have a crucial influence on sleep quality. During the first trimester, 10–15% of women might experience sleep problems or disturbances due to frequent urination, nausea, back and waist pain, and leg cramps. Beginning in the second trimester, fetal movement and heartburn can further disturb sleep. Approximately 66.0% of pregnant women experience frequent urination, shortness of breath, leg cramps and itching. During the third trimester, as the fetus continues to grow, labour anxiety is typically accompanied by poor sleep quality, including reduced slow wave sleep, which manifests as increasingly frequent or longer waking episodes during sleep.19–21 Hertz et al. indicated that during the late stages of pregnancy, wake after sleep onset and inefficient sleep are common.22 Women in this stage frequently report lower back pain, leg cramps, nightmares that impact their sleep quality, and increased daytime sleepiness and fatigue.23,24 Nevertheless, few studies have examined the relationship between sleep quality during pregnancy and childbirth outcomes. For example, Lee and Gay reported that compared with women who slept for more than 7 h a day during the late stages of pregnancy, women who slept for less than 6 h a day experienced a longer delivery period of up to 12 h, and were 4.5 times more likely to undergo a Caesarean section.25 Tsai et al. examined the association between sleep quality and Caesarean sections for 184 women in the third trimester of pregnancy. The results showed that 77.2% of the women experienced poor sleep quality, and 40.7% were dissatisfied with their quality of sleep. Furthermore, poor sleep quality was found to increase the likelihood of a Caesarean section by 1.22 times (95% confidence interval (CI) = 1.01 to 1.48).26 © 2014 Wiley Publishing Asia Pty Ltd
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The purpose of this study was to explore the relationship among prenatal maternal stress, sleep quality and unplanned Caesarean delivery.
METHODS Study participants and setting A prospective survey design was adopted for this study. In addition, purposive sampling was employed to recruit 200 women experiencing the early stages of labour during their third trimester of pregnancy. These women were recruited from the delivery rooms of a medical centre located in Taipei City between September 2010 and December 2010. The inclusion criteria were women aged 20 years or older, who were pregnant with a singleton, had no medical or obstetric complications, underwent an unplanned Caesarean section, possessed the ability to communicate in Mandarin or Taiwanese, and expressed willingness to participate in this study. Structured questionnaires including the Pregnancy Stress Rating Scale (PSRS) and the Pittsburgh Sleep Quality Index (PSQI) were used to collect data.
Measurements Demographic data A questionnaire was employed to obtain the participants’ basic information, including their demographic variables (age, weight gain during pregnancy, education level and occupation), obstetrical variables (gravidity, parity and abortion history) and exercise habits during pregnancy. This study also collected relevant birth data, including birth patterns, sex of newborn and infant birthweight after delivery.
PSRS
This study adopted the PSRS developed by Chen et al.27 which comprises 30 items for assessing the mental stress experienced by pregnant women. A 5-point Likert scale was used to score each item, for a total potential score of 150 points (1 = none; 2 = slight; 3 = moderate; 4 = severe; and 5 = extremely severe). Higher scores indicate higher levels of stress during pregnancy. The PSRS contained three subscales, namely, ‘Stress caused by the need to ensure the health and safety of oneself and the fetus’, ‘stress caused by the need to adopt or identify with the maternal role’, and ‘stress caused by changes in body shape and acceptable physical activity.’ The internal consistency Cronbach’s α coefficient for this scale was 0.89. © 2014 Wiley Publishing Asia Pty Ltd
PSQI The PSQI developed by Buysse et al. was employed to measure sleep quality. This scale contains 10 items that comprise the following seven dimensions: subjective sleep quality, sleep latency, sleep hours, sleep disorders or difficulties, sleep efficiency, use of sleeping pills, and daily functions and operations.28 A calculation standard was established for every dimension. The number of points awarded for each dimension ranged between 0 and 3, for a total score ranging between 0 and 21 points. Furthermore, ≥ 85.0% was set as the indicator of good sleep efficiency. According to previous studies, a split or boundary point of 5 for the PSQI score is associated with an 88.5% accuracy rate, 89.6% sensitivity rate and 86.5% specificity rate.28 A total score of 5 or above for the seven dimensions indicates poor sleep quality, and a score of less than 5 indicates good sleep quality. In other words, higher scores imply a poorer sleep quality. Regarding the reliability of the PSQI, previous studies have reported Cronbach’s α values ranging between 0.53 and 0.83; the coefficient obtained in this study was 0.60.4,28
Ethical considerations and data collection We obtained approval from the institutional review board (IRB) of the study hospital before recruiting participants (IRB approval number: C9804). In the hospital delivery room, trained interviewers invited women in the early stages of labour, and who met the inclusion criteria, to participate in the study. The interviewers then explained the research purpose and data collection process. Upon providing written consent, the participating pregnant women were enrolled in the study. The participants in a stable physical condition were instructed to complete the PSRS and PSQI questionnaires, and leave a contact number to facilitate post-partum follow-up visits for collecting maternal delivery and infant information.
Data analysis SPSS for Windows, version 17.0, statistical software (SPSS, Chicago, IL, USA) was employed for data analysis. Descriptive statistics were employed to analyse the stress levels and sleep quality of pregnant women, using percentages, means and standard deviation (SD) to present the information. Bivariable analyses were performed using t-tests. Multivariate logistic regression was adopted to examine the relationships between mental
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stress, sleep quality and mode of delivery. A P-value of less than 0.05 was set as the standard for statistical significance.
RESULTS Basic demographics The mean age of the 200 participants was 31.42 years (SD = 4.02) and the mean weight gain during pregnancy was 13.91 kg (SD = 4.20). Approximately 124 (62.0%) participants were employed full-time, and the majority had achieved a college or higher level of education (75%). Regarding the number of pregnancies, 120 (60%) of the participants were primiparas, which represented the majority. In addition, half of the participants (100; 50%) had exercised regularly during their pregnancy, and just over half of all pregnancies gave birth to boys (n = 111, 55.5%). The mean infant birthweight was 3064 g (SD = 413.22). Furthermore, 177 participants (88.5%) experienced a normal spontaneous delivery, with the remaining 23 participants (11.5%) undergoing a Caesarean section. The primary reasons for performing the 23 Caesarean sections were prolonged labour and fetal distress (Table 1). The mean PSRS score for the 200 participants in the early stages of labour was 64.74 ± 15.19 points, indicating moderate to high levels of stress. The mean score for sleep quality during the later stages of pregnancy was 7.33 ± 2.11 points. The study participants achieved an overall sleep efficiency level of 92.81%, with an average of 8.59 ± 1.67 h of sleep per day. Approximately 69% of the participants were dissatisfied with their sleep quality, with ‘sleep disorders or difficulties’ being the most commonly reported reason for poor sleep quality. Based on the poor sleep quality split point of ≥ 5, 90.5% of the participants were considered to have poor sleep quality.
Factors associated with Caesarean sections A comparison of basic data for the women who experienced a normal spontaneous delivery and those who underwent unplanned Caesarean sections indicated that only gravidity was correlated to the mode of delivery (χ2 = 7.87, P = 0.005). The results also showed that primiparas were more likely to experience an unplanned Caesarean section (87%). Regarding the relationship between mental stress, sleep quality and mode of delivery, mental stress during pregnancy was found to be significantly associated with
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Table 1 Basic information of participants (N = 200) Characteristic
M ± SD
Mean age (years) < 34 35–44 Weight gain (kg) < 11 11–13 > 13 Educational level High school College and university > University Occupation status No Yes Regular exercise during pregnancy No Yes Sex of baby Boy Girl Mode of delivery NSD C/S
31.42 ± 4.02
n
%
160 40
80 20
58 40 102
29 20 51
50 128 22
25 64 11
76 124
38 62
100 100
50 50
111 89
55.5 44.5
177 23
88.5 11.5
31.91 ± 4.20
C/S, Caesarean section; NSD, normal spontaneous delivery.
Caesarean sections (χ2 = 7.45, P = 0.006). Furthermore, 78% of unplanned Caesarean sections were performed on women with a PSRS score of ≥ 65 points, and only 21.7% of unplanned Caesarean sections were performed on women with a PSRS score of ≤ 65 points. This finding indicates that greater stress during pregnancy increases the probability of an unplanned Caesarean delivery. The participants were further divided into a high and a low sleep quality group, based on a split point of 9.4, for comparison. The results showed no significant difference in the mode of delivery between the participants who experienced a high and low sleep quality during the later stages of pregnancy (χ2 = 1.158, P = 0.282) (Table 2). The logistic regression analysis results indicated that a 1-point increase in stress during pregnancy increased the likelihood of an unplanned Caesarean section by 1.033fold (95% CI = 1.002 to 1.065), which was statistically significant (P = 0.038). Compared with multiparas, the © 2014 Wiley Publishing Asia Pty Ltd
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Table 2 Relationship between basic information and unplanned Caesarean section (N = 200) Characteristics
Unplanned C/S
Mean age (years) < 34 35–44 Weight gain (kg) < 11 11–13 > 13 Educational level High school College and university > University Occupation status No Yes Regular exercise during pregnancy No Yes Parity Primipara Multipara PSRS score < 65 ≧ 65 PSQI score < 9.4 ≧ 9.4
NSD
16 7
69.6 30.4
143 33
81.1 18.9
6 1 16
26.1 4.3 69.6
47 44 83
27 25.3 47.7
8 14 1
34.8 60.9 4.3
42 114 21
23.7 64.4 11.9
7 16
30.4 69.6
69 108
39.0 61.0
11 12
47.8 52.2
89 86
50.9 49.1
20 3
87.0 13.0
100 77
56.5 43.5
5 18
21.7 78.3
92 85
52.0 48.0
10 13
43.5 56.5
79 98
44.6 55.4
χ2
P value
1.71
0.188
5.84
0.054
2.08
0.353
0.63
0.427
0.08
0.785
7.87
0.005
7.45
0.006
1.158
0.282
C/S, Caesarean section; NSD, normal spontaneous delivery; PSRS, Pregnancy Stress Rating Scale; PSQI, Pittsburgh Sleep Quality Index.
odds ratio for primiparas experiencing an unplanned Caesarean section was 4.183 times higher (95% CI = 1.177 to 14.864), achieving a level of statistical significance (P = 0.027).
DISCUSSION For the participants examined in this study, we observed an unplanned Caesarean section occurrence rate of 11.5%, which exceeds the 8.7% reported by Tsai et al.26 The average amount of sleep reported by the participants was 8.59 ± 1.66 h per day, although their overall subjective sleep quality was poor. Approximately 90.5% of participants were considered to have poor sleep quality (PSQI ≥ 5), and their mean PSQI score was 7.33. This finding is consistent with the 6.87 points reported by Tsai et al. regarding the sleep quality of pregnant women © 2014 Wiley Publishing Asia Pty Ltd
during their third trimester.26 However, the mean PSQI score for the participants in this study was less than that for college students in Taiwan (PSQI = 4.3 points).29 The poor sleep quality experienced by pregnant women might result from increasing levels of hormones reducing the amount of slow-wave sleep.21 Furthermore, during the later stages of pregnancy, as the fetus grows and begins compressing the chest, pregnant women could experience difficulty sleeping comfortably. However, the sleep quality experienced by these women over a 1 month period exceed that of primiparas, as indicated by a mean PSQI score of 9.68 points for post-partum primiparas.4 The potential reasons for the reduced sleep duration and inferior sleep quality women experience in the early postpartum period compared with during pregnancy include pain from uterine contractions, pain from episiotomies or
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Caesarean section wounds, and breast distension. Furthermore, post-partum women assuming their maternal role are required to breastfeed and care for the newborn during the night. Although the results of logistic regression analysis did not show a significant causal relationship between unplanned Caesarean sections and poor sleep quality during the later stages of pregnancy, the statistical findings indicate that a 1-point rise in stress during pregnancy increases the probability of an unplanned Caesarean section by 1.33 times (95% CI = 1.002 to 1.065), which implies that mental stress has a significant influence on the mode of delivery. This is consistent with the findings of previous studies, where pregnant women who experienced mental stress and related symptoms, in addition to feeling less confident about becoming a mother, were more likely to undergo a Caesarean section.30 Other related studies have indicated that pregnant women who experience greater mental stress tend to receive more analgesics during labour, which increases the probability of undergoing a Caesarean section. In addition, consuming a high amount of analgesics can cause an abnormal heartbeat in fetus, which presents yet another reason to undergo a Caesarean section.16 The American Congress of Obstetricians and Gynaecologists recommends assessing prenatal stress during each trimester of pregnancy. However, prenatal examinations in Taiwan only evaluate maternal and infant physical health. Therefore, we suggest that mental stress evaluations be included in prenatal examinations. Previous domestic research comparing the psychosocial influencing factors for 194 primiparas who experienced a natural or vaginal birth, and 81 women who underwent a Caesarean section, found that older women, women with a higher level of education and women pregnant with a male child were more likely to undergo a Caesarean section.31 The results of this study show that primiparas are significantly more likely to undergo an unplanned Caesarean section. This might be attributed to primiparas’ fear of labour pain, and erroneous mass media reports that Caesarean sections result in less pain and do not affect recovery from childbirth. Pregnant women’s readiness for pregnancy and childbirth, fear of childbirth, risk assessments, anxiety, and self-efficacy regarding a smooth delivery, as well as family members’ opinions of the various delivery modes, are all crucial factors that influence the choice of an elective Caesarean section. Chen also found
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that compared with hospital and physician factors, the individual factors of pregnant women play a more significant role in decisions to undergo a Caesarean section.32
Study limitations and recommendations The study sample comprised pregnant women in the early stages of labour recruited from delivery rooms. Because the participants were only asked to recall their perceptions of maternal stress for the previous month, this study could not measure the changes in levels of mental stress throughout pregnancy. Furthermore, because the participants experienced normal pregnancies without medical complications, and their mean age was 31.43 years, the results cannot be generalized to high-risk or teen pregnancies. This study shows that primiparas are more likely to experience an unplanned Caesarean section. Therefore, we recommend enhancing the health education provided by clinics or prenatal education courses for primiparas by including accurate information regarding the childbirth process, specifically, the advantages and disadvantages of a normal spontaneous delivery and a Caesarean section, to enable primiparas to make appropriate decisions. In addition, the mental stress levels of pregnant women should be evaluated in prenatal clinics to identify and support women experiencing high levels of stress during the early stages of pregnancy. This can also facilitate the identification of mental stress sources, provision of support and early intervention for labour preparation, and execution of referrals to alleviate pregnant women’s fears and anxieties regarding labour, thereby ensuring they maintain positive expectations of labour.
Conclusion In this study, the participants exhibited an unplanned Caesarean section rate of 11.5%. Additionally, 90.5% of the participants were considered to have poor sleep quality, and primiparas were more likely to experience a Caesarean section. Furthermore, pregnant women with high levels of mental stress tended to undergo unplanned Caesarean sections. These findings can assist nurses in designing appropriate risk-specific interventions for preventing unplanned Caesarean sections.
Conflicts of Interest The authors declare that they have no conflicts of interest. © 2014 Wiley Publishing Asia Pty Ltd
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ACKNOWLEDGEMENTS This research study is funded by a grant from Shin Kong Wu Ho-Su Memorial Hospital (No. 99-SKH-FJU-19). The author thanks the nurses in Shin Kong Wu Ho-Su Memorial Hospital, Taipei, for assisting in the enrolment of the study participants.
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