A Nurse Looks at Childbirth Anxiety

Jean E. Cassidy, CNM, MPH

Since anxiety is a common denominator in childbirth, it is an excellent target for

nursing intervention during labor and delivery. The nurse can apply basic nursing
techniques in the physical and emotional support of the patient to reduce and improve the
character of the patient's labor.
Many studies of the emotional aspects of normal pregnancies reveal a common
denominator: anxiety. Anxiety develops in all pregnant women regardless of their
physical, emotional, or economic status and is expressed in varying degrees throughout
the nine months of pregnancy. When anxiety is at a peak in the third trimester it is
manifested as insomnia, restlessness, depression or uneasiness.

The Bases of Fear

Pregnancy involves an emotional crisis in which the woman may appear far more
neurotic that she is. Labor and delivery remain great mysteries. A new being is growing
within her, and on some preordained day in the future, he will be expelled or pushed
violently from her body. She knows she will have no part in determining when or how this
threatening event will occur. Any past experiences with childbirth only reinforce her
feelings of helplessness. The memories may also reinforce her fears if all she recalls is
being engulfed by periodic, overwhelming waves of pain.
Along with her fears of the pain awaiting her, she may also fear that she might die
during childbirth. After all, even in these modern times, with all the lifesaving treatments
available, some mothers still die. These feelings gradually increase until they become so
clamorous during the last months that she cannot stop thinking about death, and the pain
and blood of physical trauma. She is about to enter the “great unknown,” where she will
be all alone, with no one to help or comfort her.
She may tell her doctor or nurse about these feelings. Their immediate reaction
will be to send her to a childbirth education class. After all, everyone knows that the facts
about childbirth will relieve a mother’s anxiety. The truth is that facts are not the basis of
her fears, so it is inappropriate to present them as a panacea for anxiety. She has other
influences in her life besides her doctor and

the nurse who will instruct the class. What about her mother? She may feel that
her childbirth experiences were horrible, and undoubtedly her daughter has heard all
about them. Also the young mother may have sisters and friends who have had terrible
times giving birth and have been very vocal about their ordeals. Finally, the expression of
this type of anxiety or fear may be caused by a displacement of more basic and
unconscious fears. A short childbirth education program cannot get at such deep-seated
problems.
It is understandable that a pregnant woman fears physical damage during
childbirth. But the fears she may have of the psychic damage of childbirth are neither
understandable nor apparent to anyone, least of all to the woman herself. That these
fears exist at an unconscious level makes them doubly threatening. The process of
childbirth reduces the strength and cohesion of the ego, and while the pregnant woman
may dread the physical damage to her body, she must intuitively sense that this damage
will go deeper. These intuitive fears will reinforce her sense of helplessness for, again,
something will happen to her that she cannot control.

The Nurse’s Role in Managing Anxiety

Anxiety continues throughout labor. Each woman brings to the labor room her past
history and habits of emotional stability. Those who habitually respond to anxiety in a
certain way will repeat this response whenever anxiety occurs. Anxiety will influence the
character of labor although an emotionally unstable woman, with help and support, can
respond well to an easy labor. However, even an emotionally stable woman will become
tense and fearful when labor is difficult or complicated. The degree of anxiety exhibited
by a woman in labor depends on many things: her basic personality organization, her
general adaptation toward this pregnancy, and her attitude toward the conception of her
child.
 It seems that the degree of anxiety and the character of a woman’s labor are
interdependent. Accordingly, nurses must be particularly concerned with the reduction of
anxiety. In Commitment to Nursing,1 Sister Vaillot described nursing as a therapeutic
relationship that should bring about desired changes in patient behavior. Peplau defined
nursing as an educative and maturing process.2 She said that the nurse should help the
patient become aware of her reactions and coping behavior. 3 These two great nurses
believe that nursing is a therapeutic intervention, which enables patients to incorporate
their present experience into the continuum of their total experience. In the labor room it
is the nurse who is charged not only with the physical care but also with the emotional
support of the patient. In light of the above definitions of nursing goals, the nurse is best
qualified to act on the mother’s anxiety and thereby help the mother achieve a good
childbirth experience.
Variables Affecting Anxiety During Childbirth
Therefore, she must know the variables which affect the degree of anxiety
experienced during childbirth. According to Klein,4 childbirth anxiety is affected by: a)
character structure and emotional tone of the woman, b) attitude towards conception, c)
educational preparation for delivery, d) amount of trust in the doctor or clinic, e) effects of
and response to medication, and f) progression of the birth process.
Let us see how these variables can be relatedqo some basic methods of nursing
intervention to reduce anxiety.

The Character Structure and Emotional Tone of the Woman

What are her habits of reaction and how secure is she in the face of anxiety? How
has she handled her basic anxiety throughout pregnancy and at what level is it now
operating? Because childbirth is an end in itself, to be experienced as a positive moment
in the woman’s life, the activity that she herself puts into it will constitute its main value
for her. She should not be allowed to feel that she is losing control of the situation but
should be kept aware of what is happening, why it is happening, and what the outcome
will be. The nurse must convey to the patient the facts about the inherent nature bf
childbirth—that it is a predictable, orderly sequence of events in which one event leads
directly into another. The nurse can help the mother have a total experience by allowing
her as much control over, and knowledge of, her labor process as possible.

The Woman’s Attitude Toward the Conception

If she resents this pregnancy, she will also resent the inevitable outcome of the
pregnancy, i.e., delivery. The nurse can help the woman become aware of her own
attitudes and of why she feels as she does. This learning of meaning should be integrated
into the patient’s total life experience in such a way that it can be channeled to facilitate
labor. Chertok5 states that some women need to express deep-seated tendencies of
rejection and aggression during labor. If the patient is stifled when she attempts to express
such feelings, her efforts of expulsion during the second stage of labor may be futile. The
woman must have total freedom to express any feelings she may have, even if her
feelings are negative. The nurse should help the woman understand the connection
between immediate events and the feelings they elicit. She should also help the patient
realize that negative feelings do not represent rejection of the child.
When a patient expresses negative or aggressive feelings, the nurse’s first instinct
may be to stop her, rationalizing that the patient will be ashamed or

embarrassed when she remembers what she has said. Too often, the true reason
the nurse stops her is because the nurse herself is uncomfortable with such feelings. It is
unfair to the patient for a nurse to allow her own attitudes to interfere with her therapeutic
function.

Educational Preparation for Delivery

As stated above, childbirth education alone cannot totally eliminate anxiety, but
certainly these classes can help the patient cope with it. Many patients have attended
such classes, and the hospital nurse should be prepared to reinforce the patients’ prior
learning. She should be familiar with the different methods taught and be able to assist
the patient with the various techniques of relaxation. The nurse in the labor room should
find out from the patient what type of class she attended, the extent of the knowledge
acquired there, and what aid the patient needs to carry out the techniques she has
learned. The nurse should also be prepared to teach relaxation techniques to the patient
who has not attended any class. All patients should be kept informed of their progress
and constantly encouraged, for the woman who has gone through childbirth education
has often replaced her fear of death in childbirth with fear of “not doing well.” Every woman
wants to have pride in her conduct during labor.

The Amount of Trust in the Doctor or Clinic

Trust in the nurse is implied here as she is the representative of the doctor or clinic
throughout labor. This may be the patient’s first hospital experience, or it may be her
twentieth, but each childbirth is unique, calling forth fresh worries or fears. The woman
may be fearful because she is modest and repulsed by the idea of the intimate things that
will be done to her during labor and delivery. The nurse should help the patient understand
hospital routines, why they are necessary, and how they facilitate a better labor
experience.

The Effects of and Individual Response to Medication

Because individual responses are unique, they cannot be predicted. Accurate
observation of these responses by the nurse is invaluable to the comfort and well-being
of the woman. Basic nursing covers the action and purpose of drugs. During labor, the
nurse should convey her knowledge about drugs to her patient so the patient retains a
feeling of control. The patient should take part in the decisions on timing and type of
medication she receives, and it is up to the nurse to assure that the patient has adequate
knowledge on which to base these decisions.

The Physical Progression of the Childbirth Process

The patient’s physical progress depends somewhat on her emotional state. Some
physical problems can be prevented by nursing intervention in the emotional area of
childbirth. Any true physical complications must be handled competently and efficiently.
In order that the patient’s fears do not hinder treatment of her physical problems, the
nurse should keep the patient fully informed as to what is happening and why certain
things are being done.
Physical care of the laboring mother is extremely important for her comfort and
safety and may determine the caliber of her emotional response. Routine procedures
should be so well incorporated into the nurse’s role that they may be performed efficiently
with the least amount of discomfort to the patient—only then will the nurse be free to
concentrate on the patient’s emotional state. The nurse can prevent physical discomfort
by such simple means as positioning the patient and anticipating the need for analgesia.
Touching the patient can be valuable in reducing physical discomfort and giving emotional
support.
To alleviate the anxiety aroused by physical separation of the mother from her
child, the nurse can let the mother listen to the baby’s heartbeat. During routine
examinations, the nurse can talk about the position of the child and the progress it is
making through the birth canal. Lengthy separation of mother and child following delivery
should not be allowed if the child is in no danger. Immediate breastfeeding can reduce
separation anxiety.

Summary
Reduction of anxiety is one of the primary goals in the nursing care of the laboring
woman. The obstetric nurse should be aware that this anxiety exists and of the measures
which reduce the tensions anxiety causes during labor and delivery. Successful nursing
intervention can reduce anxiety so the mother can have a better experience with
childbirth.