Psychological Factors Relating to the Incidence and Outcome of Primary Cesarean Delivery.

Abstract

Although the rate of cesarean delivery has tripled during the past decade, little research has been completed on women undergoing cesarean delivery. The purposes of the present study were to: (1)compare the cesarean with the vaginal birth experience and (2)explore possible psychological factors relative to the incidence and outcome of cesarean childbirth. The subjects were 56 primiparas on a postpartum unit of a large maternity service in a university-affiliated community hospital. Fifty-three subjects were married. All the women were healthy. Infant Apgar scores ranged from 7-9 with four exceptions which were equally distributed among delivery groups. All but two infants were discharged from the hospital with their mothers. Women who had cesarean deliveries due to medical emergency, fetal malposition or documented cephalopelvic disproportion were separated into one analysis group (n = 13). The remaining women (n = 21) had cesarean deliveries for ineffective labor with the presumptive clinical diagnosis of cephalopelvic disproportion. The two cesarean delivery groups were compared to women who delivered vaginally (n = 22). No subject knew at the time of hospital admission whether labor would terminate with a vaginal or cesarean delivery. All women were interviewed in their rooms at 2 to 3 days postpartum. The structured interview was comprised of questions with fixed response choices as well as questions which provided patients with the opportunity for spontaneous descriptions of and reactions to their labor and delivery experiences. The following content areas were covered: (1a)patient's response to the events of labor; (1b)specific labor processes; (2)patient's response to the delivery; (3)patient's response to baby; (4)expectation of and preparation for childbirth; (5)coping style and concurrent stresses during pregnancy; and (6)anticipated adjustment to motherhood. Variables which lacked preselected response categories were coded by two raters, one of whom was unfamiliar with they hypotheses of the study and the delivery mode of the interviewees. Agreement between raters was 83 percent. When the original codes were collapsed for statistical analysis, agreement was 91 percent. The findings of this study replicated those of earlier research which reported that primary cesarean deliveries were less positive experiences than primary vaginal deliveries. However, most women interviewed for the present study did not find the experience to be as unpleasant as previously reported, nor did they show evidence of negative feelings toward themselves or their infants. Women who had cesarean deliveries because of medical emergency, however, were likely to have described the experience as unpleasant. This study supports the thesis that psychological factors are related to the outcome and probably to the incidence of primary cesarean delivery. Specific psychological factors which were related to cesarean delivery included anxiety, prior expectation of labor and delivery, reported symptoms of emotional conflict and external sources of stress. Women scoring high on a labor index of tension/anxiety were significantly more likely to have a lengthy duration of labor and to have cesarean delivery for ineffective labor or unproven etiology. Women in this latter delivery group, compared to the vaginal delivery group, had either significantly more negative expectations of cesarean delivery than of vaginal delivery or equivalent expectations of the two delivery modes. They also reported more symptoms of emotional conflict and external sources of stress during pregnancy. Overall, the present data indicate a need for continued research on prenatal expectations of labor and delivery and on pre-delivery stress and conflict so that support systems might be designed to ameliorate the intense anxiety specific to the childbirth process.