FEELINGS DURING LABOUR

The feelings looked at in this study were related to stress. Specific questions were asked about incidents that made women angry, their feelings of control over her body, mind and treatment and their perception of physical and psychological stress.

Anger
Women were asked about things that made them angry. The table below shows the various things that made women angry during labour itself.
Table R28: Reasons for anger
at staff treatment at self at waiting* other total incidents
home 6 1 2 – 5 14
GP unit 6 1 – – 5 12
cons unit 4 6 – 4 5 19
totals 16(25%) 8(13%) 2(3%) 4 (6%) 15(24%)
* anger at waiting means waiting for attention during labour and does not include waiting to be admitted to the hospital itself or to the labour ward, which have been dealt with elsewhere.
The largest number of responses in a single category was for anger at staff showing how important it is for staff to be sensitive to women’s needs during childbirth. No statistical analysis was done but it can be seen that consultant unit mothers had more episodes of anger about treatment given or not given and at being kept waiting.

Women talking about anger
Mother who gave birth at home
First the gas and air – dreadful, annoying irritating. The GP took a long time fiddling around and didn’t have it ready in time. Second, my other child if he wanted attention during a contraction. The midwife asked for something old to wrap the baby in and was give an old towel and it was hard [the mother wouldn’t have minded spoiling a new soft towel] Timing of breastfeeding, too soon. There were people all around and I was naked. I should have followed my instincts and not done it. (104).
I had the ‘wrong’ midwife. I would book with a [named] midwife another time. Angry at the system, not at individuals. I felt let down over the gas and air [not available] (111).
The middle midwife burst in when I was on the toilet. She said, “We don’t want to deliver our babies on the toilet.” then, “Sit down, you’ve got to rest”, but it hurt to sit, I wanted to find positions to feel comfortable. The middle midwife was an intruder (113).
Mothers transferred from home in labour
A total sense of failure on being transferred to hospital. I was compliant, I accepted it because I expected it . They put the monitor on, didn’t give me a chance to see what would happen naturally (transferred for failure to progress, 110).
I was too tired to be angry, I was distressed, unhappy and anxious – not while I was with my GP and the community midwife (131).
Consultant unit mothers
My notes were in the consultant’s car despite the fact that I was two weeks overdue. I couldn’t have an epidural because my blood group information was needed and not available . Waiting around being on my own in the progress room. (210).
There was a long wait to start with when my contractions were strong and close (213).
A long internal examination to break the waters. I felt bullied and annoyed at my husband who said ‘Go with what they say”. I felt it should be discussed, I’m also a professional (214).
Lack of communication. The midwife on progress. I had rung, but nothing was ready, the attitude was disgusting (220).
Being examined during contractions. People not being kind really, they should treat people how they’d want to be treated. The placenta was separated from the cord by the midwife yanking, the midwife went home within five minutes of the birth, I had a new midwife to suture (226).
The whole process. They weren’t listening to me at all. A textbook delivery, “You can’t be doing that because it’s not next in the book”. A constant struggle to convince them how I was feeling really . They made me put him down off the breast, I had to ask for him, the baby was not delivered on to my tummy and straight on to the breast (228).
Waiting for the vomit bowl. I had rung the bell. They didn’t come immediately. I was embarrassed, I was sick in the sink in the progress room (230).
“We’ll be with you in a minute”. I seemed to be left in discomfort for a long time not knowing what to do. I sent my husband to fetch the midwives (233).
Postnatally there was a disagreement as to whether to stitch the laceration. It was not stitched on labour ward. I was transferred to the postnatal ward where two midwives examined me and decided I needed a suture. The labour ward midwife was called up to do it. Argument about the stitch. The labour ward midwife insisted upon gas and air. I wanted to be a good patient even though I was a professional (234).
mothers giving birth in the GP unit
The midwife saying, “Push”. “I am pushing,” I said. I wanted to go to sleep but the midwife said, “Come on now” (301).
I wanted to walk around, I was on the bed for examinations (307).
The midwife telling me to hold my leg up (308).
Right at the end. There was only one midwife, my husband was gowned to help her, there was a dish will tools, he passed her some things. I’d wanted him up this end [her head]. He was told he could cut the cord (319).
The midwife talking to my husband quite happily while I was there. I wanted to lie on my side, not on my back. The baby was not happy, different positions, they were not happy that I wanted to move around, they did let me (330).
No brake on the bed, it moved . My husband was sent out of the room for stitching, they took the baby away (341).
After the birth, I wasn’t given Syntometrine, I haemorrhaged, went to the bathroom. I was given a J cloth “There you go, [to clean up the blood herself] (342).
Mothers transferred from the GP unit to the consultant unit
I was annoyed to be in the consultant unit and not seeing my own midwife and doctor but I could understand why (303).
Continual monitor, hurting, uncomfortable for five hours. Midwife holding the pads of the monitor down. I yanked it off. They explained it then again, They didn’t want to worry me, there was a danger to the baby, they didn’t say, they thought it would upset me. They tried to lessen the stress, they explained the drip and the catheter (310).
Comment
The answers to the question on anger seemed to elicit aspects of women’s care that they disliked most. The degree of anger felt seems to have varied with some women reporting irritating incidents. Consultant unit mothers had more episodes of anger. They were often angry at being kept waiting for attention during labour itself (in addition to being kept waiting before admission) and at treatment they were given or not given. One woman who was also a member of staff was angry about being told about a recent obstetric disaster while she was in labour, and was angry about, ‘staff not being kind, really’. One of the transferred home mothers who was transferred was angry about hygiene after the birth and about the indifference of the nurses (sic). “I can’t pretend it’s not an everyday experience for them because it is, but I regretted it personally, I wanted to be the celebrated Queen Bee, not just another one”. Another woman was extremely upset because she gave birth just before a shift change and the midwife tried to speed up the third stage of labour by pulling on the cord so hard that it broke, then she went off duty leaving a new midwife to suture. Another consultant unit mother said: “The whole process [made me angry]. They weren’t listening to me at all, a textbook delivery – ‘you can’t be doing that because it’s not next in the book’ – it was a constant struggle to convince them how I was feeling, really.”
Two of the homebirth mothers were angry at themselves; it is often said that women who have high hopes of birth can become distressed if it fails to live up to expectations, and this is a common criticism of NCT type antenatal care. Both of these mothers were angry in retrospect. The women who were transferred from home during labour did not express much anger, for the most part they accepted the reason for the transfer with resignation.

CONTROL
There were three questions relating to control: control over the body, control over the mind and control over treatment. Scores on these variables emerged from the data. For the control over body and control over treatment sections, women saying they had no control scored 0; women saying they had total control scored 2; and those saying they lost control of their body or their treatment only at one specified time scored 1. For the control over the mind section women said that they had it or they didn’t have it, however, one woman was given a score of -1 on this variable; she said that she was hallucinating, drifting out of reality and fantasising about being ‘allowed’ to die.
A total control score was obtained by adding the control over mind, body and treatment scores together and treating it as an ordinal scale ranging from -1 to +5.

Table R29: Control over the body
intended none partly totally n
home 4 4 18 26
GPU 3 4 15 22
CU 4 2 9 15
totals 11 10 42 63

Table R30: Control over the mind
intended hallucinating no yes n
home 0 3 23 26
GPU 1 3 18 22
CU 0 3 12 15
totals 1 9 53 63

Table R31: Control over treatment
intended place no partly yes n
home 1 3 22 26
GPU 8 1 13 22
CU 6 2 7 15
totals 15 6 42 63

Table R32:Total control scores by intended place of labour
-1 0 1 2 3 4 5
home 0 1 1 1 2 4 17 26
GPU 1 1 2 0 4 5 9 22
CU 0 2 1 1 5 0 6 15
total 1 4 4 2 11 9 32 63

Control over treatment varied significantly. Women labouring in the consultant unit had significantly less control (mean rank 25) than women labouring at home (mean rank 38). Women labouring in the GP unit came between with a mean rank of 29. These rankings as a whole were significant (Kruskal-Wallis, Chi2 8.67, df 2, p < 0.01). However, the difference between the GP unit and consultant unit was not in itself significant. When analysed by home or hospital by Mann Whitney U test, the level of significance was considerably greater (mean ranks: home 38, hospital 27, U 312.5, p < 0.002 ). Women who were in control of their body had significantly shorter labours than those who did not (Chi2 6.2, df 2, p < 0.05) however, control over the mind and control over treatment were not significantly associated with the length of labour. Summed control score and clinical variables Length of labour A one-way ANOVA showed that there was a significant difference between length of labour and the control score (F = 2.8541, df = 6, p < 0.02). Table R33: Average length of labour by summed control score control score average length (hrs) no of women -1 36 1 0 13.9 4 1 12.6 4 2 17 2 3 8.6 11 4 6.2 9 5 6.7 32 Perineal trauma was ranked and tested against the total control score and showed that the women feeling most in control had the least damage to the perineum: Table R34: Mean rank perineal trauma and summed control score mean rank control no of women (total = 49) 45 -1 1 40 0 6 45 1 3 38 2 1 23 3 8 23 4 7 18 5 23 A Kruskall-Wallis test showed this to be significant at the p < 0.001 level (Chi2 = 21.7, df = 6). The descending ranks with increasing control suggested a linear relationship and thus Spearman’s correlations were used to test for linear relationships of control with other variables. The following variables were found to be related to control score: Correlations: total control score with clinical variables Length of labour The more in control women felt, the shorter their labour. Spearman’s rho = - 0.25 (p < 0.05). Use of pain relief The more in control women felt the lower the level of pain relief they used. Spearman’s rho = - 0.46 (p < 0.001) Blood loss The more in control women felt the less blood they lost. Spearman’s rho = - 0.33 (p < 0.05) Lack of perceived control over body, mind and treatment then is associated with longer labour, more pain relief used and greater blood loss. It is not possible to tell from these data for example whether more pain relief leads to loss of control or whether loss of control leads to a need for more pain relief but the correlations are high enough to encourage more research into the clinical implications of control in labour. A prospective study could perhaps record perception of control at various times in labour and record also the timing of pain relief given to ascertain any causality. Correlations: total control score with psychological variables Painfulness of contractions The less in control women felt, the more painful was their descriptions of contractions. Spearman’s rho = - 0.27 (p < 0.05) It is interesting to note that the correlation between the painfulness of contractions and summed control score is less than that between the use of pain relief and summed control score. This implies that pain relief may be instrumental in losing control. Summed stress score (details to follow) The less in control women felt, the greater the perceived stress of labour. Spearman’s rho = - 0.28 (p < 0.05) Time when baby was first held The more in control women felt the sooner they held their baby. Spearman’s rho = - 0.31 (p < 0.01) Time taken to establish a routine The more in control women felt during labour, they sooner they got into a routine in their daily lives. (this variable measured the number of days to acquire a routine.) Spearman’s rho = - 0.39 (p < 0.01) It is not perhaps surprising to find that women who felt they were not in control did not hold their babies until later but the effect persisted until after they had been discharged from professional care. Maintaining control during labour may ease the transition to motherhood. Control and postnatal depression The mean control score of women having postnatal depression severe enough to be given treatment [n = 5] was 2.4 and the mean of those without postnatal depression [n = 58] was 3.9, this was significant at the 1-tailed p < 0.05 level. Breaking down the component parts of the control score it was seen that control of the mind was the most important factor (mean ranks 33 and 24, 1-tailed p < 0.05) . This establishes tentative support for the hypothesis that postnatal depression may be linked to psychological stress in labour. However, these figures are questionable since only five mothers out of 63 (8%) interviewed required medical treatment for postnatal depression. The low incidence of postnatal depression is of itself of interest since the national rate is said to be between 12 and 15% (Clement, 1996). The sample was not typical of the childbearing population as a whole because of the high incidence of home and GP unit births and because there were few first time mothers. Women talking about control The questions on control were rather blunt but women answered the questions readily and they themselves provided the middle scores (partly, at one particular time etc.). Questions were answered with reference to control well before the researcher asked the specific questions about control. The following women could perhaps be classified as having an internal locus of control; they answered the question of fears about labour thus: Fears of labour Would I be able to cope? If your mind is in control of your body [then] they are in the same gear... people taking over control of yourself (112) . Fear: It’s something you can control, you don’t have to worry because you can change things (102). Not being in control, not knowing what will happen. Fears were justified, I was not in control (226). I lost control once I was admitted to hospital (130) . Control over pain Control over pain was also important, some women were worried that they would not be able to do without drugs: Worried about a major emergency like pain I couldn’t cope with (129). I’d convinced myself I could do without drugs, fear of failure if drugs were needed (228). Choice of place of intended delivery Control played a large part in the choice of place of labour: So I could go with what I feel (103). I wanted to do what I felt like doing. Out of control in hospital, no bargaining power (111). I was told I was not in labour after the waters had broken and I had pains. I felt more in control at home (112). They wouldn’t be able to tell me what to do (113). If I do things my own way then it’s not so bad (124) . I’d have the next one in the GP unit or at home. It’s more relaxed, you feel more confident; not tied down to the bed by monitors and what have you. Answers to questions specifically relating to control Control over the body You’re not in control of your body, your body’s in control of you. As long as you know what your body needs then you’re alright (115). In as much as you can control your uterus (129). You’re not in control of your body. Labour is what you make of it if you’re mentally prepared (209). Not really, are you? It’s just going on. Let it do it, painful but carry on (210). I don’t think you are in control of your body, there’s a sense of inevitability and so much pain you can’t control what’s happening to you (220). Not the pushing time, something was happening I couldn’t stop. My body was doing something quite separate (303). No control of my body. Pains. I just want it to go away, I was completely out of control as far as pain was concerned (330). Control over mind I lost it all in my mind. I started to float, to lose it. The peak of contractions brought me back to earth. I was floating, going away, I felt so close to death it frightened me (310). I was not in control of my mind, they were doing something to me and I wasn’t there.. go to sleep, cut it all out, a muffled effect like coming out of an anaesthetic I should think (326). As far as you can be being drugged up. At the time I thought I was in control (330). Control over treatment For some women control over treatment meant being able to say no: I was not in control of internals only, that was all, the midwife would have stopped if I had asked (102). The midwives would have stopped if asked (107). They never did anything I didn’t want. If I’d said no they wouldn’t (327). They asked [before doing anything] (123). Conversely lack of control means not being asked: I was just told ,‘On with the monitor’. They left it on far too long, they had said just an hour. In the second stage they said ,‘We’re going to have to cut you’. My husband went out (210). They don’t tell you what they’re going to do until they’ve done it. They tried to give pethidine half an hour before I needed it (319). Consent thus emerges as a component of control. So also is information: They explained everything (120). For mothers unable to give birth at home the transfer to hospital led to loss of control: Not at the end; I was completely taken over by other people. I had nothing to do with that baby coming out of me at that stage (110). Not after I went to hospital; after that I was hysterical. I lost control in the ambulance, it was helpful of them to come [she was accompanied by her GP and the midwife] (130). Largely, except when I was strapped to the bed and monitored [after transfer to hospital] I’d given over control (131). Between 9.15 pm and an hour later. I didn’t think the baby had died, not the worst, semi shock (131). Control and hospital I lost control the minute I walked into hospital, I put myself in their hands, I wanted them to take over (216). I lost control when I walked through the hospital doors. Other people take over. They have their rules and their plans that they have to follow (226). They were in charge, the third midwife was in control (331). They didn’t do anything, the midwife was there to sort the cord out, that was all (108). That was the difference between my first and second labours, I let them control the first (115). Yes, I was in control for this birth, for M’s they gave me pethidine ‘For pain and to help you sleep’ - not maternal request (304). Some women were willing to give up control, particularly when something was going wrong: The midwife was concerned; I was happy to hand over control, for someone to step in and do something (235). Stress There was no significant difference between women intending to deliver at home, in the GP unit or on the consultant unit regarding physical stress, psychological stress or the total stress score in labour. Physical stress Apart from three women who replied ‘not particularly’, women replied either ‘yes’ or ‘no’ when asked if they found labour physically stressful. Thirty women found labour physically stressful and thirty three women did not. Physical stress was measured against interval variables were tested using t tests and the following statistically significant differences were found: Length of labour Women who reported labour to be physically stressful had longer labours than those who did not. physically stressful: mean 11.5 hours; not physically stressful mean 6 hours (p < 0.001). Length of second stage Women who reported labour to be physically stressful had a longer second stage of labour. (physically stressful mean 34 mins; not physically stressful mean 15 minutes ( p < 0.01). Blood loss Women reporting labour to be physically stressful lost more blood (means: physically stressful [n = 22] 270ml; not physically stressful [ n = 20] 145ml, p < 0.01). Interview variables Physical stress was tested against ranked interview variables using the Mann-Whitney U test and the following significant associations were found: Painfulness of contractions Women reporting labour to be physically stressful reported more pain (mean ranks: physically stressful, 38; not physically stressful 27, p < 0.01). Total control score Women reporting labour to be physically stressful felt less in control (mean ranks: physically stressful 27; physically stressful 36 (p < 0.05). Psychological stress Table R35: Psychological stress by intended place of delivery (not significant) no at a particular point yes home 18 7 1 GP unit 15 4 3 C unit 10 1 4 totals 43 12 8 Eight women found labour psychologically stressful; 12 women found it distressing at a particular point ; and 43 did not find it psychologically stressful. Psychological stress was measured against interval variables using one way ANOVA and the following variables were found to be significant: Length of labour Women finding labour psychologically stressful had significantly longer labours (stressful, mean length 15 hours; at a particular point, mean length 13 hours; not stressful, mean length = 6 hours, p < 0.005). Length of second stage Women finding labour psychologically stressful only at a particular point had significantly longer second stages (stressful 2, mean length 20 mins; stressful at a particular point, mean length = 50 mins; not stressful, mean length = 17 mins (p < 0.001). It seems that for most of the women reporting stress at a particular point, that point was the second stage. Psychological stress was measured against ranked variables using Kruskal-Wallis test and the following variables were found to be significant: Helpfulness of midwives not stressful, mean rank helpfulness of midwives 31; stressful at a particular point, mean rank helpfulness of midwives, 42; stressful, mean rank helpfulness of midwives 21. (p <0.05). The women who were distressed only at a particular time tended to use a superlative to describe their midwife and those rated the midwife least helpful were most distressed. Control of body not stressful, mean rank control of body = 36; stressful at a particular point, mean rank control of body = 23; stressful, mean rank control of body = 25 (p < 0.05). The women with most perceived control over their body were least distressed. Control of mind not stressful, mean rank control of mind = 36; stressful at a particular point, mean rank control of mind = 22; stressful, mean rank control of mind = 29 (p < 0.001). Women reporting that they found labour distressing at a particular time felt least in control of their minds. Control of treatment not stressful, mean rank control of treatment = 35; stressful at a particular point, mean rank control of treatment = 27; stressful, mean rank control of treatment = 22 (p < 0.05). Women’s reports of psychological stress during labour was related to their feelings of control over their treatment. The above rankings confirm the suspicion that interactions between place of delivery, known midwife and helpfulness of midwives probably accounted for the out of sequence middle rankings for control of body and mind and add weight to the theory that good support during labour reduces psychological stress. Despite the odd middle rankings of the psychological stress variables, it was decided not to dispense with the middle stress score since it had discriminated between the three groups of women on length of labour, second stage and control of treatment. Total stress score Scores on physical and psychological stress were added to give a total stress score. The table below shows the number of women in each place. The differences were not significant. Table R36: Number of women with each stress score intending to deliver in each place total stress score 0 1 2 3 home 11 9 5 1 GP unit 8 9 4 1 Con unit 7 3 2 3 totals 26 21 11 5 The total stress score showed that perceived stress is associated with clinical variables. Length of labour, length of second stage and blood loss were all significant when tested by a one way ANOVA. Table R37: mean length of labour and second stage, and blood loss by total stress score total mean length mean 2nd stage mean blood stress score (hrs) (mins) loss (mls) 0 5.3 12 170 1 7.2 21 150 2 14.5 51 300 3 18.3 16 400 sig p < 0.0005 p < 0.001 p < 0.01 Stress and control of body and mind The less stress women felt, the more in control of their mind they were (Kruskal-Wallis Chi2 = 15, df 3, p < 0.002) and the less stress they felt the more in control of their body (Kruskal-Wallis Chi2 = 12.4, df 3, p < 0.01). Spearman’s rank correlations were used to test the strengths of other associations: Correlations between total stress scores and clinical variables Length of labour Longer labours were more stressful than shorter labours (Rho = 0.4561, p < 0.001). Length of second stage A long second stage was indicative of stress in labour. (Rho = 0.4746, p < 0.01). Blood loss Blood loss was significantly related to stress score (Rho = 0.3362, p < 0.05). Correlations between total stress scores and ranked clinical variables Perineal trauma More stress was associated with more perineal trauma (Rho = 0.2668, p < 0.05). Level of pain relief Higher stress scores were associated with a higher level of pain relief (Rho = 0.274, p < 0.05) Correlations between total stress scores and ranked psychological variables Painfulness of contractions Stressed women reported more pain (Rho = 0.367, p < 0.01) Control Stressed women reported less control (Rho = - 0.3859, p < 0.01) Time taken to establish a routine Women reporting a less stressful labour took less time to establish a routine (Rho = 0.4087, p < 0.01). Other variables Predictably, women transferred in labour found labour more stressful (p < 0.01). All six women needing oxytocin found labour more stressful, both physically and psychologically. This was to be expected since the need for oxytocin indicated that something was going wrong, which is stressful in itself. Twenty-one women found labour psychologically stressful and a further two replied that it was a positive psychological stress. Reports of psychological stress involved mainly people but also the place and worries for the baby and themselves. Losing control was seen as psychological stressful: Psychologically I lost control, the losing control element, worried and know you can’t do anything about it but bear the pain. You fear for the baby and yourself, you think ‘is there ever going to be an end?’ (216). Being where I didn’t want to be, I had to fight that off, you have to block people out you don’t want to interfere with you (228). When people who are taking care of you are in a rush, wanting to go home, haven’t got time to take care of you. If the staff are tapping [with impatience], you think ‘I don’t want to be part of this’. (226).[/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section]