Articles
Labors of Abused and Non-Abused Women
by Kathie Records, PhD, RN and Michael J. Rice, PhD, ARNP, Associate Professors at Intercollegiate College of Nursing
Contact Information:
Kathie Records, PhD, RN and Michael J. Rice, PhD, ARNP, Associate Professors
Intercollegiate College of Nursing
Washington State University College of Nursing
W. 2917 Ft. Wright Dr.
Spokane, WA 99224-5291
TEL: 509-324-7244 / FAX: 509-324-7341 FAX
Email: recordsk@wsu.edu
Funding
Dean's Research Funds, College of Nursing, Intercollegiate Center for Nursing Education/Washington State University College of Nursing, Spokane, Washington
Abstract
This retrospective pilot study explored the relationship of prior or current physical or sexual abuse to labor progression. Selye's stress response theory guided the study. Subjects were at least 18 years of age and delivered at a low-risk LDR unit. Informed consents were mailed to clients in an obstetrical clinic and resulted in a sample of 30 charts. Abuse prevalence in this sample was 13%. Abuse was significantly related to late entry into prenatal care (r = .489, p<.003), spontaneous abortions (r = .369, p<.022), pre-existing health problems (r = .362, p<.029) and pregnancy related illnesses (r = .460, p<.006). During labor, abused women experienced longer labors (r = .490, p<.003), particularly prolonged first stage, made more requests for pain medications (r = .414, p<.013), and used more pitocin (r = .542, p<.023) than non-abused women. These results offer insight for prenatal and intrapartum health care professionals working with abused women.
Labors of Abused and Non-Abused Women
Stress, anxiety and fear are common for women during labor. For abused women, these reactions are magnified. Women may feel violated by frequent vaginal examinations reminiscent of sexual abuse, and unable to control and protect themselves in this dependent stage of pregnancy, feelings reminiscent of physical abuse.
During the stress response, neural and endocrine changes decrease the availability of glucose for the contracting uterus. Blood flow also decreases, which can result in decreased uterine contractility and prolonged labor.
Psychologically, women experience pain enhancing catecholamine release and increasing physical distress. Increased catecholamine release precipitates the fight or flight response (Perry, 1994), which can lead to decreased perceptual accuracy and inability to participate fully in the labor process, exacerbating physiological difficulties.
Schei, Samuelson and Battekteig (1991) found no significant differences in labor complications between physically abused and non-abused women. Benedict et al. (1999) found no significant difference in the length of labor for childhood survivors of sexual abuse and non-abused women. Jacobs (1992), however, reported that survivors of childhood sexual abuse (n=15) perceived themselves to have longer labors and more use of ultrasounds (p<.05) than a comparison group of women (n=13) without a history of sexual abuse. Also, anecdotal reports from labor and delivery nurses and case studies of abused women in labor suggest that abused women do have longer labors (Tidy, 1996) than other women.
According to the American Medical Association, 23% of all pregnant women are victims of domestic abuse (Shea, Mahoney, & Lacey, 1997). Further, reports suggest that past or current abuse results in significantly poorer fetal and maternal outcomes. The purpose of this pilot investigation was to explore the relationships between prior or current abuse, labor progression, and childbearing outcomes for mother and newborn. The study also examined the medical interventions for both groups.
Methods
This retrospective study was based on chart audits of prenatal and labor/delivery records. Selye’s (1978) stress response theory guided the study.
Subjects and Setting
Subjects were eligible for the study if they were at least 18 years of age, had given birth in the past 18 months, and had no history of incompetent cervix or previous emergency cesarean section. All subjects were delivered at a low-risk labor, delivery, recovery and postpartum (LDRP) unit having approximately 1000 births per year. The unit was located in a Northwestern metropolitan area with a population of approximately 300,000 residents.
Abuse was self-identified by subjects entering prenatal care and/or the labor unit, in response to a question about whether they had either a history or current experience with physical or sexual abuse. Women were assigned to the abused or non-abused group based on the data in their prenatal and hospital records.
Instrument
The Childbearing Health Questionnaire (Table 1) was developed for the study from review of the literature on factors relevant to labor progression and abuse disclosure, as well as from review of existing prenatal and labor and delivery forms. Routine assessments during labor such as length in time of each phase and stage of labor, electronic fetal monitoring (pattern description), and amount and effectiveness of pain medications were recorded. Medical interventions were defined as pitocin administration (duration, dosage), forceps and vacuum extraction, artificial rupture of membranes, and cesarean section. Newborn variables of APGAR and birth weight were also measured during the chart audits.
Prenatal records were reviewed for general childbearing health status and included entry (in weeks gestation) into prenatal care, concomitant and pre-existing diseases/health problems, and sexually transmitted diseases. Data on blood pressure changes, weight gain, gravida and para were also collected.
The data collection form was designed to facilitate data gathering from chart audits by ordering items to match the order of data found in the prenatal and hospital records. The instrument was evaluated by a panel of obstetrical nurses (n=3) and obstetricians (n=5). All items with 90% agreement between experts were included on the final instrument. Testing of the instrument revealed an internal consistency estimate of .82.
Human Subjects
Office staff that reviewed deliveries and mailed information about the study to women who had delivered within 18 months identified potential subjects. A consent letter was mailed to 300 potential subjects, and responses were received from 35 women (response rate = 13%). Medical records for 30 of these women could be retrieved.
Results
Among the 30 women who participated in the study, the mean age was 26.4 (SD = 6.01) years. Entry into care occurred at a mean of 9.9 weeks gestation (SD = 3.66), with a range of 4.0 to 23.0 weeks. Almost two-thirds (70%) of the sample were multiparous; 30% were primiparous. Four women reported a history of/or current abuse (13%).
Spearman's Rho correlations revealed significant relationships between abuse status and entry into care, physical and surgical illnesses, muscular/skeletal problems, and abnormalities during fetal monitoring (EFM)
(Table 2). Although these correlational relationships were significant, a Chi square test of differences between the abused and non-abused groups showed no significant differences for these variables.
The number of spontaneous abortions was significantly related to abuse (r=-.369, p<.022). Abused women had more spontaneous abortions than non-abused women (75% versus 19%) (Chi square = 14.816, p<.01).
Pregnancy-related illnesses (e.g., previous or current pregnancy induced hypertension, gestational diabetes, premature labor) were also significantly related to abuse (r = .460, p<.029). Abused women had significantly more illnesses diagnosed during pregnancy than non-abused women (Chi square = 8.848, p<.031).
Labor was measured in three stages; stage one labor was measured in three phases. The average total length of stage one labor for the entire sample was 8.86 hours (SD = 4.35). The non-abused group experienced stage one labors lasting an average of 7.9 hours (SD = 4.0) while abused women had first stage labor lasting an average of 13.2 hours (SD = 4.25). The difference between groups was statistically significant (Chi square =7.765, p<.006). Primarily, this difference between groups was due to phase one (Chi square = 24.00, p<.06). No significant differences between the groups were found for phases two and three of stage one, stage two, or stage three labor. There were no significant differences in the lengths of labor based on parity.
The use of pitocin was significantly related to abuse (r=.542, p<.023). While the differences between groups was not significant, the descriptive data revealed a trend. Thirteen women (43%) were given pitocin during their labors, in two distinct distribution patterns: low dose pitocin (1-9 mu/min) and high dose pitocin (9-22 mu/min). The non-abused group had lower doses of pitocin (M = 6.09 mu/min, SD = 5.0, range = 1-18) than the abused group (M = 15.0 mu/min., SD = 9.0, range = 5-22).
It was expected that abused women would use more pain medications than non-abused women during labor, and this was supported by the data. The relationship between abuse and narcotics use during the postpartum period was significant (Table 2), but comparison of the groups did not reveal statistically significant differences.
Infants born to women with no history of abuse had an average APGAR score at 1-minute of 8 (range 2-9) and at 5-minutes of 9 (range = 6-10). Infants born to abused women had an average 1-minute APGAR score of 6 (range = 1-9) and a 5-minute average APGAR score of 8 (range = 4-9). These differences were significant (Chi square = 37.667, p<.01; Chi square = 86.800, p<.01, respectively). Birth weights did not significantly differ between the groups. Infants born to women without a history of abuse weighed an average of 7.1 pounds (range = 5.5-8.8); infants born to women with a history of abuse weighed an average of 6.12 pounds (range = 4.99-7.5).
Discussion
Despite the small sample size and reliance on medical records for data, these results are significant for health care professionals caring for abused women during childbearing. Identification of abuse and effective interventions through all phases of childbearing are critical to the health outcomes for this group. The abused women in this study had more pre-existing illnesses and pregnancy-related complications than the non-abused women. Repeat visits for a variety of health care concerns may be a cue signaling abuse (Rice, 1998). Asking about abuse becomes easier over time, and the patient who has repeated contact with the same health care provider may feel more able to disclose if abuse is occurring. Early identification provides increased time for interventions to improve the health of both mother and infant.
Significantly, labor patterns differed between the abused and non-abused women. Abused women had labors that averaged six hours longer than their non-abused peers. Granted, the time period for ‘longer labor’ in this sample is still within acceptable guidelines following Friedman’s (1978) specifications. However, given the increasing cesarean section rate, particularly among women in early labor (Gifford et al., 2000), abuse status may be a significant cue for alternative approaches to care. Interventions to increase relaxation and facilitate contractions may help to decrease both the length of labor, use of pitocin, and subsequent medical interventions for abused women.
Narcotics use for abused women in this study exceeded that for non-abused women. Health care providers caring for women need to be aware that more medications may be requested and efficacy may not be optimal due to the stress response. Use of relaxation and non-pharmacologic pain relief methods may help to alleviate pain for abused women.
Finally, since stage one labor was longer and more medical interventions occurred to the abused women in this study, it is clear that the labors of abused women are more costly to the woman, the family, and the health care provider. Specific interventions to improve the childbearing experience of these women could improve health outcomes and decrease costs to all involved.
References
- Benedict, M.I., Paine, L.L., Paine, L.A., Brandt, D., & Stallings, R. (1999). The association of childhood sexual abuse with depressive symptoms during pregnancy, and selected pregnancy outcomes. Child Abuse & Neglect, 23(7), 659-670.
- Friedman EA. An objective method of evaluating labor. Hospital Practice. 1970;July, 82-87.
- Gifford, D.S., Morton, S.C., Fiske, M., Keesey, J., Keeler, E., & Kahn, K.L. (2000). Lack of progress in labor as a reason for cesarean. Obstetrics and Gynecology, 95(4), 589-595.
- Jacobs, J.L. (1992). Child sexual abuse victimization and later sequelae during pregnancy and childbirth. Journal of Child Sexual Abuse, 1(1), 103-112.
- Perry, B. (1994). Neurobiological sequelae of childhood trauma. In Catecholamine function in post traumatic stress disorder: Emerging concepts, (M. Murburg, Ed.). Washington, D.C.: American Psychiatric Press, 253-276.
- Rice, M.J. (1998). ONE VOICE: Assessment and intervention standards of domestic violence. Santa Clara, CA: Concept Media.
- Schei, B., Samuelsen, S.O., & Bakketeig, L.S. (1991). Does spousal physical abuse affect the outcome of pregnancy? Scandinavian Journal of Social Medicine, 19(1), 26-31.
- Shea, C.A., Mahoney, M., & Lacey, J.M. (1997). Breaking through the barriers to domestic violence intervention. American Journal of Nursing, 97(6), 26-33.
- Tidy, H. (1996). Care for survivors of childhood sexual abuse. Modern Midwife, July, 17-19.
Table 1: Sample Childbearing Health Questionnaire Items
Table 2: Significant relationships to Abuse status
