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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 11  |  Page : 1624-1632

The effect of continuous supportive care on birth pain, birth fear, midwifery care perception, oxytocin use, and delivery time during the intrapartum period: An experimental study


Department of Midwifery, Health Sciences Faculty of Selcuk University, Konya, Turkey

Date of Submission31-Mar-2020
Date of Acceptance19-Mar-2021
Date of Web Publication15-Nov-2021

Correspondence Address:
Dr. S Cankaya
Department of Midwifery, Health Sciences Faculty of Selcuk University, Konya, 42050
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_147_20

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   Abstract 


Background: Intrapartum professional midwifery support can improve the coping skills with the fear of childbirth and birth pain, increase the perception of the woman, and prevent negative experiences. However, there are relatively few studies supporting this postulation. Aims: To investigate the effects of supportive care given during labor on birth pain, birth fear, perception of midwifery care, oxytocin use, and delivery time. Patients and Methods: This is a quasi-experimental study. We collected the data between January and June 2019 in a province in Central Anatolia, Turkey. Primiparous 102 pregnant women were included in the study. However, we excluded five pregnant women from the intervention group and four pregnant women from the control group as emergency cesarean section developed. In total, 93 pregnant women, 46 in the continuous supportive care intervention group, and 47 in the usual intrapartum care control group were evaluated. The following tools were used to collect data: The Delivery Fear Scale, a Visual Analog Scale for perceived pain, the Scale of Women's Perception for Supportive Care Given During Labor, and labor outcomes information form. Results: The participants in the intervention group receiving continuous intrapartum supportive care had less fear of birth and lower birth pain in the active and transitional stages of labor, their midwifery care perception increased, and the duration of labor was shorter (P < 0.05). However, there was no significant difference in oxytocin use between the two groups at 95% confidence interval (-0.265-0.091) (p > 0.05, Cohen's d = 0.2). Conclusion: Pregnant women who received continuous intrapartum supportive care had less fear of birth and reduced labor pain in active and transitional stages of labor. In addition, with the continuous supportive care provided, the perception of midwifery care of the pregnant women increased and the duration of labor decreased. Therefore, midwifery care support should be provided to women throughout their labor and delivery process.

Keywords: Fear of delivery, intrapartum care, labor, midwifery care, oxytocin, supportive care


How to cite this article:
Cankaya S, Can R. The effect of continuous supportive care on birth pain, birth fear, midwifery care perception, oxytocin use, and delivery time during the intrapartum period: An experimental study. Niger J Clin Pract 2021;24:1624-32

How to cite this URL:
Cankaya S, Can R. The effect of continuous supportive care on birth pain, birth fear, midwifery care perception, oxytocin use, and delivery time during the intrapartum period: An experimental study. Niger J Clin Pract [serial online] 2021 [cited 2021 Nov 27];24:1624-32. Available from: https://www.njcponline.com/text.asp?2021/24/11/1624/330455






   Introduction Top


Birth is a period of biological, physical, emotional, and social changes, all of which are part of the adaptation process to the motherhood. In this period, women try to cope with the process of being in an unknown environment, not being able to protect their privacy, and giving birth. Women in labor experience fear and anxiety because they do not fully know and understand what they are going through.[1],[2] Women need support to cope with labor and have a healthy birth, and they also need to feel that they are cared for. Professional support during labor gives the woman a sense of control, and thus, can help her cope more easily with labor pain, and prevent negative experience.[3],[4]

Midwives have important responsibilities in reducing women's fears and anxiety about birth, preparing them for labor, and ensuring that they have a positive birth experience. Intrapartum supportive care includes physical support, emotional support, education, informing, and advocacy support.[3],[5],[6] If the midwife provides education, meeting the physical and emotional needs of the woman during the labor, and fulfilling the duty of advocating their rights, she can improve the delivery process and results by lowering birth fear and boosting self-confidence.[2],[3],[5],[7] From admission to the postpartum period, women receiving birth support have been reported to be more likely to have “spontaneous” births, less likely to use pain medication, more satisfied with labor, the duration of labor is slightly shortened, their fear and anxiety about birth are reduced, and there is a higher probability of no side effects.[6],[8] In addition, some studies have reported that intrapartum supportive care reduces the use of oxytocin induction.[9],[10] Although the midwives working in maternity units in Turkey have sufficient knowledge and skills about supportive care, they provide services in a manner that is mostly work-centered and focused on daily routines. Even though midwives have started to work with the patient sharing system in recent years, routine work and medical interventions related to the pregnant women are still at the center of the care. Therefore, it is observed that there are serious deficiencies in the delivery of supportive care, which includes many important independent midwifery interventions.[11],[12],[13] In addition, the incidence of oxytocin infusion uses in maternity hospitals in Turkey, especially in primiparous pregnant women, is reported to be between 37.8% and 69.7%.[14],[15] Another purpose of this study was, with continuous intrapartum support, to reduce the amount of oxytocin use. Therefore, further research is needed to regarding the effect of supportive care during childbirth on delivery outcomes. In this study, we aimed to evaluate the effect of supportive care given during labor on birth pain, fear of birth, perception of maternity nursing care, oxytocin use, and delivery time.

Hypotheses of the study

H1: Pregnant women receiving continues supportive midwifery care during the intrapartum period would have a lower fear of childbirth than that of those receiving no such support.

H2: Pregnant women receiving continues supportive midwifery care during the intrapartum period would have lower perceived birth pain than that of those receiving no such support.

H3: Pregnant women receiving continues supportive midwifery care in the intrapartum period had higher midwifery care perceptions than that of those receiving no support.

H4: Pregnant women receiving continues supportive midwifery care in the intrapartum period had lower use of oxytocin than that of those receiving no such support.

H5: Pregnant women receiving continues supportive midwifery care in the intrapartum period had shorter delivery time than that of those receiving no such support.


   Materials and Methods Top


Type of the study

This is a quasi-experimental study comparing two groups: women receiving intrapartum supportive care intervention and those receiving the usual intrapartum care.

Study participants and setting

We performed this study in a birth clinic of a state hospital located in the province of Konya, Turkey. The study group included primiparous pregnant women admitted to the obstetrics clinic between January 2019 and June 2019. This hospital was selected because the number of pregnant women giving birth at this hospital is quite high (the mean number of births per month: 300-350), and it is the only maternity hospital in this province. In addition, this hospital has the highest number of midwives in the province of Konya. Routine intrapartum care in this hospital is provided by midwives. In case the women needed extra-ordinary care, they were transferred to local hospitals.

Inclusion criteria were being 18 years and over, literate, married, over ≥37-week pregnant, and primiparous, and having singleton pregnancy, experiencing no complications for vaginal delivery, having a 3-cm cervical dilatation, being volunteer, and having sufficient language skills to understand and speak Turkish.

Exclusion criteria included the development of a situation requiring urgent cesarean section during labor, separated or divorced women (as it may affect the results in terms of a psychological aspect).

Sample size

According to the present study data, the effect size of the fear of birth scale and of the scale measuring the perception of woman about the supportive care given at birth could not be obtained. Therefore, sample calculations for these scales could not be performed.[16] For this reason, we calculated that we needed to include 51 pregnant women each group to obtain 85% power, 5% Type I error level with an effect with of 0.6 (medium). A total of 102 pregnant women constituted the sample of the study. However, we included 93 women, therefore, the power analysis was calculated. Based on the calculation, 46 pregnant women were allocated in each group, the study had a Type I error level of 5%, a study power of 90%, and a high effect size of 0.7.[17] We used G*Power (Ver. 3.1.9.2, Franz Faul, Üniversität Kiel, Germany) for this purpose.

Intervention

Supportive care for the women in the study group was given by midwives certified in working in delivery room and supportive care and practices at birth. The women in the study group was provided a routine care as well as continuous perinatal supportive care as recommended by Adams and Bianchi[3] and The Royal College of Midwives[18]. We started the support process while they were admitted to the delivery room through the third stage of labor. During the childbirth process, interventions in the supportive care were performed at different times and durations with different frequencies based on the preferences of the pregnant women. For example, some women preferred massage, while others preferred breathing exercises.

Midwives provided a routine care to the women in the control group. These midwives were not certified about working in delivery rooms and supportive care and practices at birth. The routine care given to the women is closely monitored. Childbirths were realized by midwives, and specialists were reached when/if needed. As physical support in the first of phase of the labor, room temperature and odor control, positioning of the patient, hygiene, and urine elimination. Encouragement was the only emotional support offered during labor in this study. Routines and procedures, such as helping them get familiarized with physical conditions and routine procedures in addition to pushing techniques were included in the present study as part of the instructional informational support offered. Midwives also provided conflict resolution as advocacy support during labor. The following parameters were collected from all the women in the first stage of labor when the vaginal examination was performed: labor, pain, and fear in the latent (dilatation of 0-3 cm), active (dilatation of 4-7 cm), and transition (dilatation of 8-10 cm) phases. Data collection using the scale of the perception of the women regarding the supportive care given during labor was carried out in postpartum 4 hours, when the labor outcomes information form was also filled out.

Intrapartum supportive care

Physical support: Environmental control, positioning, touch, hot and cold application, hygiene, urination, nutrition

Emotional support: Distracting, verbal or nonverbal communication, turning negative thoughts into positive ones.

Informative and Educational Support: Routine hospital procedures and breathing exercises, relaxation and pushing techniques, massage, positions

Advocacy Support: Conveying respect, ensuring safety, accepting mothers' birth expectations, resolving conflicts, if any.

Data collection

The study group comprised of 108 voluntary primiparous pregnant women were presented to at the birth clinic of a hospital located in Konya province, Turkey, between January 2019 and June 2019. Signed informed consents were obtained from all pregnant women included in the study. The participants were informed about the purpose of the study and the procedures to be performed. Signed informed consent forms were obtained from all participants. We excluded eight women in the study group and seven women in the control group because of emergency caesarean section during the study period [Figure 1]. A midwife blinded to group assignments was assigned to record all the data. We collected the data using four tools at five different time periods: at the admission to the delivery room, during labor (at latent, active, and transition phases), and in four hours after delivery [Figure 1]. To avoid data collection bias, a midwife who was blinded to group assignments accompanied the researcher to make sure all data were collected and entered correctly. Four forms were used to collect the data and the data were collected in five stages: upon admission to the delivery room, during labor (latent phase, active phase, and transition phase), and within 4 hours after delivery.
Figure 1: The flow chart of the study phase

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Demographic information

We developed a data collection form to collect data on age, education, employment, marital, and income statuses, number of pregnancies, and pregnancy week.

Labor outcomes information

We obtained data on the initiation of labor, the use of oxytocin infusion, and delivery duration (from the time of admission to the clinic to the time of within an hour postpartum.

Visual analog scale (VAS) scores for perceived pain

Price et al.[19] developed this scale, which is used to determine the severity of pain. On a 10 cm straight line, “0” means no pain and “10” describes a very severe pain. The patient indicates a point on the line showing the level of pain she feels. Accordingly, the corresponding location in centimeters is evaluated as the level of pain: “0” no pain, “2” light pain, “4” moderate pain, “6” severe pain, “8” very severe pain, and “10” worst possible pain. Pain level increases as the numerical value increases. VAS was administered during the first admission to the obstetrics clinic and also during the latent, active, and transitional phases of delivery.

Delivery fear scale (DFS)

Wijma et al.[20] developed this 10-item scale to measure fear during delivery. The participant is asked to score each item between 1 and 10 points. Five items of the scale have a negative meaning (1, 3, 5, 7, and 10) and the other five have a positive meaning (2, 4, 6, 8, and 9). The negative items are scored in a 10-point scale: 1 = completely disagree and 10 = completely agree. The positive items are scored inversely. The lowest and highest scores of the scale are 10 and 100, respectively. The higher the score, the more the fear is. The Cronbach's alpha level of the original scale is 0.88.[20] The Turkish reliability and validity study of the scale was performed by Serçekuş et al.[16] The Cronbach's alpha value of the Turkish version was reported to be 0.90. This scale was used four times: at the first admission to the clinic, and during the latent, active, and transitional phases of delivery. Ten items were selected by item-total analysis. The final list of ten items was tested psychometrically, and semi-structured interviews were conducted to investigate women's definitions regarding the content of each of the ten items. According to the content analysis of the interviews, the dominating connotation of the ten items is “fear” based on the appraisal of being captured.[16] According to the literature, both the sub-dimensions of the scale and the total score are considered valid and reliable since Cronbach's α value is 0.70 ≤α <1.00.[21]

The scale of women's perception for supportive care given during labor

The scale was developed by Uludağ and Mete[22] to measure women's perception of the care offered during labor. Each item in this Likert-type scale is scored between 1 and 4. This 33-item scale has three subdomains, namely, comforting behaviors (0.92), education (0.85), and disturbing behaviors (0.87). The total Cronbach's alpha value of the scale is 0.94. The score range of the scale is 33-132. There is no breakpoint on the scale. Higher scores indicate better perception of the maternity nursing care. We applied this scale before the release of the women from the hospital. In the present study, Cronbach's α values of the subscales, namely, comforting behaviors, education, and disturbing behaviors, and the total score were 0.85, 0.75, 0.80, and 0.89, respectively. The scale was subjected to three exploratory factor analysis, namely comforting behaviors, education, and disturbing behaviors, and the factor load ranged from 0.38 to 0.76. Factor structures were verified by confirmatory factor analysis. Item-total score correlations of the scale vary between 0.42 and 0.77.[22] According to the literature, both the sub-dimensions of the scale and the total score are considered valid and reliable because the Cronbach's α value is 0.70 ≤α <1.00.[21]

Ethical consideration

Research ethics committee approval was obtained prior to the study from the Faculty of Health Sciences of Selçuk University (Ethics permit no: 2018/1974). Institutional approval was obtained from Konya Provincial Health Directorate (Date: 10.12.2018 and # 94723667-806.01.03). Potential participants meeting the study criteria were informed about the research purposes and benefits/risks of intervention and procedures, and written consent was obtained from all participants. They were informed that they could withdraw from the study at any time without stating a reason. They were also informed that their participation is completely on voluntary-basis and their identity will be anonymous.

Statistical analysis

We used SPSS 20.0 (SPSS Inc., Chicago, IL, USA) for data analysis. To test if the data were normally distributed, the Kolmogorov-Smirnov (K-S) normality test was used. Numbers, percentage, mean, standard deviation (SD), and median were used as descriptive statistical values. We used independent samples t tests to analyze demographic and obstetric data (e.g., age and gestational age). We used the Chi-square test to analyze the education level, employment status, family income, the status of the start of the childbirth, and the amount of oxytocin administered. Independent-samples t tests were used to compare the groups in terms of duration of labor and VAS scores for perceived pain, DFS, and the Scale of Women's Perception for Supportive Care Given During Labor during the stages of labor. Any P value less than 0.05 was considered significant. Supportive care was provided to the pregnant women by three certified midwives who were similar in terms of their personal characteristics, namely, age, working year, professional experience at the delivery room, and education level (all university graduates).[21]


   Results Top


Demographic characteristics of the participants are presented in [Table 1]. All the pregnant women participated in the study were married and gave birth at an average age of 25.8 (SD 4.4) years and 38.7 (SD 1.8) weeks of gestation. We did not observe any statistical difference between groups in terms of education, employment, family income level, the status of the start of childbirth (P > 0.05).
Table 1: A comparison of the sociodemographic and obstetric characteristics of the women

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[Table 2] presents the results of the comparison between groups after intervention regarding DFS, pain perceived, the perception level of the women regarding the care provided during delivery, and the status of the use of oxytocin use. There were no significant differences between the two groups in terms of age, gestational week of delivery, VAS scores for pain perceived before intervention, DFS scores before intervention (p > 0.05).
Table 2: A comparison between groups in terms of delivery fear scale, vas scores for pain perceived and scale of women's perception for supportive care given during labor and oxytocin infusion

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While the DFS scores of the pregnant women in the latent phase, the first phase of delivery, were similar between the groups (P = 0.944), they were lower in the pregnant women who received intrapartum birth support in active and transition stages than those of the control group (P < 0.001, P < 0.001, respectively). This evidence verifies the first hypothesis of the study for the active and transitive phases (H1).

While the perceived pain scores in the latent phase were similar in both groups (P = 0.701), it was lower in women who received intrapartum support during the active and transition phases compared to controls (P < 0.001, P < 0.001, respectively). This outcome verifies the second hypothesis of the study for the active and transitive phases (H2). The perception of the care provided during delivery was quite higher in those who received intrapartum support compared to controls (P < 0.001). This outcome verifies the third hypothesis of the study (H3). Furthermore, we did not observe any difference between groups regarding oxytocin use during delivery (Table 1, P = 0.358). This evidence fails to verify the fourth hypothesis of the study (H4).

Childbirth duration was lower in the intervention group (9.67 SD: 3.7) compared to the control group (12.9 SD: 5.5) with a difference of 3.2 hours (P < 0.001, [Figure 2]). This evidence verifies the fifth hypothesis of the study (H5).
Figure 2: A comparison of the groups in terms of the duration of labor (hours)

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   Discussion Top


Intrapartum period is stressful for the woman in labor. Relaxing them during this stressful period can support their coping with the fear of childbirth and labor pain, and increase their perception of midwifery care and the probability of a positive delivery experience. There is insufficient study in the literature to support this assumption. We presented that in women who received intrapartum support from midwives, lower fear of delivery and perceived pain during the active and transition phases of delivery, increased perception, and shorter duration of labor were experienced compared to controls.

In the present study, it was found that the continuous intrapartum support decreased the fear of delivery during the active and transition phases of delivery. Delivery fear has been reported to arise because women are left alone during labor and they do not receive sufficient support and care from midwives.[1],[23] Furthermore, we observed that the participants in the study group had more perception of intrapartum support. As the frequency, severity, and duration of contractions increase, the administration of relaxing methods during the active and transition phases of delivery may have a positive effect on the decrease in fear of delivery, which may eventually positively affect their attitudes towards intrapartum supportive care. In a similar study, it was claimed that as the affirmative perceptions of the women who received intrapartum support provided by maternity midwives increased, their control of perception about childbirth increases and their anxiety and negative feelings decreased.[5],[22] This outcome verifies the first hypothesis of the present study during the active and transition periods of delivery that continuous intrapartum care would decrease fear of birth.

Care is needed most by pregnant women during the intrapartum period. Ongoing support during the childbirth by midwives/maternity nurses is a critical part of labor management.[24] In the present study, the perception of care provided by midwives in the study group was found to be high. Similarly, in women who received intrapartum supportive care, there was less fear and stress, they were relaxed, their satisfaction increased, and delivery outcomes were positively affected.[25],[26],[27] In a qualitive study conducted in Ghana, in women who received intrapartum nursing/midwifery care, pain management improved, and they were satisfied with the behaviors of (respect, acceptance, being informative, etc.) and the care provided by midwives.[28] It can be concluded that supportive care provided by midwives improves women's pain-coping skills, exhibit the behavior expected of delivery, access medical information, and boost self-competence and emotional state. This outcome verifies the third hypothesis of the study that intrapartum supportive care would increase the women's perception of midwifery care.

Contraction duration, frequency, and severity gradually increase in the active and transition phases of delivery, and these phases are the times when women experience the difficulty most.[29] The study group's pain scores were meaningfully lower during the active and transition phases of delivery. In a similar study, pain scores of the women who received intrapartum support during the transition phase of delivery were lower compared to controls.[30] The decreased fear of delivery and increased perception of intrapartum support as a result of intrapartum supportive care, the acceptance of and respect for the women, the information provided to the women, behaviors of the midwives, administration of the methods reducing pain during contractions may have reduced the perception of pain. This finding verifies the second hypothesis of the present study that continuous intrapartum supportive care would decrease the perceived pain during the active and transition phases of delivery.

Another finding of the present study was that while the use of oxytocin was similar between groups, in the study group, delivery duration was approximately 3.2 hours lower compared to controls. Similarly, intrapartum supportive care has decreased the duration of delivery by 0.58 hour and 4.2 hours.[26],[30] This substantial difference between these two studies may be due to the differences between the quality of the intrapartum supportive care and/or because the fear of delivery was contained (as the fear of delivery may cause a delay in delivery).[31] In the literature, supportive care has been reported to reduce the duration of delivery and the need for oxytocin, and increase the satisfaction of childbirth. [6,8-10,32] Based on the findings of the present study, it can be considered that intrapartum supportive care may decrease the fear of delivery, perceived pain, and duration of delivery, and increase the perception of the midwifery care provided, and thereby, increase the women's childbirth satisfaction, all of which may have a positive effect on delivery outcomes.


   Conclusion Top


In this quasi-experimental study, the intervention group, who received continuous intrapartum supportive care, experienced less fear of labor and less labor pain in the active and transitional stages of labor compared to the control group. In addition, pregnant women's perception of midwife/nurse care in the intervention group increased and their duration of labor was shorter. However, there was no difference in oxytocin use between the two groups. The continuous intrapartum midwife support is recommended for all women because it provides both intra- and post-partum clinical benefits. Double-blind randomized controlled studies are needed to investigate the effects of intrapartum supportive care on self-efficacy, fear of birth, labor pain, birth satisfaction, midwife/nursing care satisfaction, maternal fetal complications, oxytocin use, and delivery time. Supportive care given in the intrapartum period reduces the fear of childbirth and the perceived pain in labor, shortens the delivery period, and increases the perception of midwifery care; therefore, it may increase the preference of these hospitals by pregnant women. In addition, intrapartum support may contribute positively to the hospital economy and, accordingly, to the health budget of the country, as it reduces the use of pharmacological drugs (such as painkillers).

Strengths and limitations

Neither the women nor the midwives were blinded to the intervention because the labor rooms were shared with other women. Therefore, the second researcher accompanied the first researcher during data collection. For this reason, the study was designed as quasi-experimental. All these factors constitute the limitations of the present study. In order to study the effects of intrapartum supportive care on self-efficacy, fear of delivery, delivery pain, childbirth satisfaction, satisfaction from the midwifery care, maternal fetal complications, oxytocin use, and the duration of delivery, further multi-center studies involving multiparous women are warranted.

Ethical approval

An approval was obtained from both the local ethical board (Registration number: 2018/1974) and the hospital (Institution approval number: 94723667-806.01.03).

Acknowledgements

We would like to thank the participants of the study. Furthermore, we would like to thank the nurses/midwives for providing supportive care to the women in the intervention group, for respecting the study, and for their helps to the researchers.

Financial support and sponsorship

No specific grant was received from funding agencies in the public, commercial or non-profit sectors.

Conflict of interest

The authors declare no conflicts of interest.



 
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    Figures

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