Elsevier

Midwifery

Volume 20, Issue 2, June 2004, Pages 144-156
Midwifery

The range of coping strategies women use to manage pain and anxiety prior to and during first experience of labour

https://doi.org/10.1016/j.midw.2003.11.001Get rights and content

Abstract

Objectives:

to investigate whether nulliparous women, during pregnancy, can identify their own pre-existing coping strategies for managing pain and anxiety and whether the range of coping strategies used in Labour by women who do not attend antenatal classes can be described.

Design:

qualitative semi-structured interviews.

Setting:

two large maternity units in a city in the North of England.

Participants:

twenty-three nulliparous women were interviewed during their third trimester of pregnancy (prior to any antenatal class attendance) regarding strategies used to cope with previous experiences of pain and anxiety. A separate sample of 20 women, who had not attended any form of antenatal education, were interviewed within 72 h of their first experience of labour regarding the coping strategies used to manage pain and anxiety during labour.

Findings:

Template Analysis was used to code data from transcribed interviews. The findings indicate that as women approach their first experience of labour they can identify coping strategies that they have employed to manage pain and anxiety in their past. Equally women who have not attended antenatal classes use a wide range of strategies in labour. The range of identified coping strategies is described and comprises thoughts and behaviours with positive and negative consequences.

Key conclusions and implications for practice:

it is possible to help nulliparous women to identify, in pregnancy, a range of strategies that they have previously employed to manage pain and anxiety. This range reflects the coping strategies that women may potentially use in labour to manage pain and anxiety. Women may benefit from assistance in pregnancy to develop strategies for labour that are based on knowledge of their own coping repertoire, which includes enhancing positive strategies and finding alternatives to negative strategies.

Introduction

Helping women to prepare for managing pain and potential negative emotions during labour are important aspects of antenatal education. Historically, antenatal education can be traced back to two main approaches, that advocated ‘Childbirth without Fear’ and ‘Childbirth without pain’. The concept of ‘Childbirth without Fear’ (Dick-Read, 1933) suggested that the experience of fear was linked with increased muscular tension. This in turn was hypothesised to lead to prolonged labour and increase in pain. A reduction in fear could be achieved through education about labour and a relief of tension could be achieved through training in relaxation and breathing techniques. Psychoprophylaxis (Velvovsky et al., 1960) was introduced to the West by Lamaze and Vellay, as ‘Childbirth without Pain’ (Lamaze, 1958 (1984)). This applied the principles of classical conditioning to uterine contractions, asserting that pain associated with uterine contractions could be inhibited or blocked by the development of new conditioned reflexes, such as, breathing exercises and relaxation techniques applied at the beginning of a uterine contraction.

Many similarities exist between the early classes and the antenatal education offered today. Classes organised within the National Health Service generally provide training in specific coping strategies for labour. These coping strategies include a breathing technique, comfort positions for first stage of labour, relaxation and more recently massage. Use of taught strategies in labour has been found to be associated with reduced experience of pain and emotional distress (Copstick et al., 1985; Byrne-Lynch, 1991; Green, 1993; Slade et al (1993), Slade et al (2000)). However, in general, translation of training in specific coping strategies into actual use is low (Copstick et al., 1985; Slade et al., 2000).

Attempting to cope with difficulties is a natural human response to stressful experience and it is not only taught strategies that, potentially, may be helpful. Niven and Gijsbers (1996) explored the range of coping strategies used during childbirth. From postnatal interviews, it was noted that on average women used four different coping strategies and that the total number used correlated negatively with intensity of labour pain experienced. The strategies differed in nature between formally taught strategies (i.e. those taught in antenatal classes) and more informal strategies, typically acquired from women's previous experiences of coping with pain. For example, formal training may teach progressive muscular relaxation, whereas informal strategies may achieve the same end but through different means e.g. having a bath, ‘putting one's feet up’. Many women were found to make use of distraction. Formal training in distraction is usually of a mental nature whereas informal strategies were found to be of a more physical nature, e.g. keeping busy. Hence, during labour women were found to make use of a range of personal coping strategies.

The general literature around coping with pain is also helpful in elucidating strategies that women may already possess. Attention has been proposed as one mechanism by which individuals can influence pain sensations (Eccleston, 1995). Task-based coping strategies may help to ameliorate acute pain sensations by distracting attention away from the pain stimulus. Although pain coping strategies can be formally taught in studies of clinical pain, again individuals were found to make use of their own spontaneously generated coping strategies. Such strategies often differ in nature from the more formally taught strategies (Chaves and Brown, 1987; Buckelew et al., 1992). However, in the context of preparation for labour through group antenatal education, the relative contribution of spontaneously generated coping strategies has not been explored.

A second issue is control over choice of strategy to be utilised. In an experimental pain study it was found that individuals may hold preferences for different coping strategies (Rokke and Lall, 1992). Participants who could choose which coping strategy to use during a pain stimulus had significantly higher pain tolerance times than those who were assigned a strategy. Interestingly, no differences in pain reports were noted for the strategies of distraction, imagery, relaxation and somatisation.

Thirdly, there is an issue of individual coping styles. In a further study, rather than simply offering a choice of coping strategies to participants, Rokke and al’Absi (1992) investigated whether participants could be assigned to coping strategies based on knowledge of their pre-existing coping strategy preferences. Participants completed the Cognitive Coping Strategy Inventory (CCSI) (Butler et al., 1989) to obtain a measure of their coping strategy preferences. Based on their score, participants were either assigned to a strategy for which they were strongly matched, assigned to a strategy for which they were strongly mismatched or asked to choose which coping strategy to use to manage the experimental pain stimulus. Participants assigned to a strategy for which they were matched showed increased pain threshold and tolerance times compared to those assigned to a strategy for which they were mismatched. However, no differences were found between participants who were strongly matched and those given a choice of coping strategy. Hitherto, approaches where women have been invited to choose from a broad range of coping strategies within preparation for labour have not been subjected to evaluation.

A further consideration in relation to coping strategy use concerns the individual's thinking style. Catastrophising involves individuals engaging in progressively more negative thoughts. Heyneman et al. (1990) found that individuals with a tendency to catastrophise about pain respond better to training in self-instructional coping strategies (which attempt to modify negative self-statements about painful stimuli) than attention-diversion strategies, but non-catastrophisers responded better to training in attention-diversion strategies. Further, in a clinical population, Baron et al. (1993) found that providing information on the pain stimulus was only helpful if it matched the pre-existing coping strategies of individuals. Participants whose tendency was to cope by distraction were more likely to find being provided with information about the pain stimulus as unhelpful. These studies emphasise the importance of identifying pre-existing coping strategies and thinking styles.

Alongside managing pain in labour, studies indicate that managing anxiety in labour is also an important part of coping with childbirth. Lederman et al. (1985) demonstrated a negative association between level of emotional distress in the mother during labour and fetal well-being. The thoughts that women experience both before and during labour are important especially in relation to negative appraisals. Wuitchik et al. (1990b) found an association between women's antenatal cognitions relating to fear of pain, feelings of helplessness and loss of control with experiencing higher levels of pain and distress-related thought in labour. Hence women's negative cognitions prior to labour may influence feelings of anxiety in labour. With respect to distress-related thought during labour, Wuitchik et al. (1990a) demonstrated that women's negative cognitions during labour became less associated with their experience of pain as labour progressed as women who were now ‘pain-free’ in labour (due to epidural analgesia) continued to display distress-related thinking.

Individual's experience of pain is a function of culture, as well as previous exposure. Being aware of the range of culturally dependent responses to childbirth pain is important for the providers of care and support to women in labour. Such cultural aspects of pain have been discussed within the midwifery literature (Moore, 1997; Mander, 1998). The idea that a person's coping history, cultural background, race or religious belief can influence their responses to coping with pain and anxiety is important knowledge in helping to prepare women appropriately for labour. Such an individualised model would provide greater opportunity for women to understand their own personal coping requirements, and for midwives to provide appropriate support. Moore (1997) suggests steps that may help to achieve equitable care during labour for women from different cultures. Thus, helping women to identify their own coping strategies for labour would fit a midwifery model which advocates care based on individual needs in terms of personal preference, cultural, religious and racial backgrounds. It would also broaden the experience of providing support in labour from the midwife's perspective.

In summary, managing pain and anxiety is important to women's experiences of labour and use of coping strategies can assist in this process. A wide range of coping strategies exist and it has been demonstrated in settings other than antenatal education, that individuals hold preferences for use of coping strategies that may be associated with prior coping experience or thinking style. Coping also includes managing thoughts and behaviours that may potentially lead to negative consequences, such as catastrophising. Given that studies suggest that many women do not use the methods they have been taught in standard antenatal classes, a more individualised approach to preparing to manage a painful and potentially anxiety-provoking situation may be beneficial. Women may therefore benefit from having a greater choice of coping strategies from which they can select. This could be achieved through assistance in the antenatal period to explore a wider range of strategies beyond those currently taught in antenatal education. In addition, helping women to develop coping strategies for a future event with knowledge of their own coping style may highlight potentially unhelpful strategies that could then be avoided. However, prior to such an approach it is important to determine whether women approaching their first experience of labour can identify their own patterns of coping. During pregnancy women acquire knowledge about coping with labour from a variety of formal (antenatal classes) and informal sources (friends, media). In an attempt to separate out the influences of taught coping strategies in antenatal education, women who had not attended antenatal education would be asked for their participation.

The aim of the present study was to understand the feasibility of helping pregnant women to identify their pre-existing coping strategies for managing pain and anxiety. If feasible then the range, nature and effectiveness of those strategies would be described. Further, the range, nature and effectiveness of coping strategies used in labour would also be investigated in a second group of women who had not attended antenatal classes and who had not been formally taught coping strategies. No references in the literature regarding the employment of coping strategies to manage pain and anxiety during labour by women who have not attended antenatal classes were identified.

Section snippets

Design

This study took place in the maternity units of two university hospitals in a city in the North of England. Individual semi-structured interviews were carried out with two different groups of women who, through personal choice, had no experience of antenatal education: referred to as the antenatal and postnatal interviews. The antenatal interviews were concerned with identifying and describing the range, nature and perceived helpfulness of women's pre-existing coping strategies as they approach

Findings

The characteristics of the participants are shown in Table 1. The range of coping strategies identified by women in the antenatal group as used to manage their previous experiences of pain and anxiety is summarised in Table 2. The range of coping strategies identified by women in the postnatal group as used to manage pain and anxiety experienced during first stage of labour is presented in Table 3. A brief summary of the nature and perceived helpfulness of each coping strategy is included in

Discussion

Exploratory research of this nature is, of necessity, conducted with relatively small sample sizes but this does not invalidate the findings, gathered from women's perspectives. The use of unstructured interviews allowed issues to be explored in a way that women could respond to. The fact that data obtained relied on women's memory for past events is not a limitation of the postnatal interviews as women's recall of the events of childbirth has been demonstrated to be accurate many years after

Acknowledgements

A Grant from the NHS Executive Trent funded this research. Our sincere thanks go to all the women who kindly agreed to participate in this research.

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