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Maternal Confidence for Labor and the Use of Epidural

Anesthesia
Background of the problem:
The problem is: use of epidural anesthesia can effect on the maternal confidence for
labor. A woman's ability to manage pain is one of the primary areas of the labor
experience which can positively or negatively influence her perception of childbirth.
Maternal confidence has been identified as an important component in coping with the
pain of labor (Lowe 1989). A woman's expectation of a natural birth can lead to a sense
of personal failure if she eventually accepts anesthesia for pain. Simkin (1991) reports
that the impact of a woman's birth experience, even 15 to 20 years later, is often vivid and
powerful. Positive or negative birth experiences can have lasting effects in a woman's
memory and caregivers during labor and delivery can profoundly influence her
experience.
The problem is clearly explained and concisely stated at the beginning of the article.
We believe that’s epidural anesthesia should not be the first choice in relieving the labor
pain of labor, because epidural anesthesia has many risks not only for the woman, but
also for the baby. Moreover, women in Israel have various alternatives to reduce pain,
like reflexology and reiki, which have no side effects. Nurses also can give and teach
partners how to support women, ways to comfort them, nurse can tell to the partners
about the benefits and disadvantages of epidural anesthesia and after this woman and her
partner will have objective decision about anasthesia.
The purpose of this study was to investigate, from the woman's perspective, the
relationship between maternal confidence for labor and the use of epidural anesthesia for
pain management during labor in nulliparous women. Specifically, this research explored
perceived self-efficacy and coping abilities of pregnant women preparing for their first
childbirth and the strengths and outcomes of their pre-labor decisions regarding epidural
anesthesia.
This study describes some emotional challenges frequently encountered by women,
even when an epidural has relieved the pain, along with the ways to support and comfort
them.
Review of the literature:

We think that the present study is relevant to the healthcare domain and answers all the
questions that have been asked. It was published in 1997. A review of the literature
revealed recent studies concerning maternal confidence and expectancy outcomes in
coping with labor, and a wealth of studies on the effects of epidural anesthesia for labor.
However, a possible relationship between maternal confidence had not yet been
investigated. Gibbs, Krischer, Peckham, Sharp, and Kirschbaum (1986) reported a
national average of 16%, increasing to 22% of the use of epidural anasthesia in labor.
Hueston et al. 1994 reported: use of epidural anesthesia has been positively associated
with nulliparous women, higher socioeconomic status, women who are privately insured
and patients under the care of a private physician, all of whom also have higher rates of
cesarean section. Walker, Farine, Roibin and Richie( 1991) reported 77% of the
primiparous patients, as compared to 54% of the multiparous patients, received epidural
anesthesia in a total sample of 8,994 patients. When a woman's labor is actively managed
(membranes ruptured by the obstetrician and/or oxytocin initiated to increase uterine
activity), epidural anesthesia is often requested by the patient to manage pain. Oxytocin
often causes uterine contractions to be more intense and painful. Epidural anesthesia
relieves the pain, but it may also indirectly contribute to a prolonged labor. A 1994 meta-
analysis reported an association between the use of oxytocin and the use of epidural
anesthesia (Morton et al. 1994). Of women who received oxytocin to augment labor, 64%
received an epidural to manage pain; of those who did not receive oxytocin, 23%
received an epidural. The prevailing norm in obstetric practice is that the elimination of
pain is the primary factor in providing a positive childbirth experience. However,
effective pain relief does not ensure a satisfactory birth experience for women. In one
study, mothers reported that attention, sympathy, reassurance and support were superior
to epidural anesthesia for a rewarding outcome (Lurie and Priscu 1993).

Humerick 1991- Fear, fatigue, sense of helplessness, loss of dignity and concern for the
safety of the mother and baby can also influence a woman's self-esteem and perceptions
about the birth experience. Mastery of the birth experience can be enhanced by potential
supports such as knowledge of the birth process, skills for active coping, influence in
decisions, and support from others.

THEORETICAL FRAMEWORK:

The theoretical framework for this study is based on self-efficacy, which is a primary
concept in social learning theory (Bandura 1977). Self-efficacy is described most simply
as an individual's confidence in his or her ability to do something. It is not concerned
with actual skills, but with judgments and perceptions of what the individual can do with
the skills he or she possesses (Bandura 1977; Lorig 1992). In our opinion the theoretical
framework is quite clear and explicit. The authors state clearly the theory that underlies
their research; the theory is based on frequency of use of epidural anasthesia and its
relationship to the maternal confidence.
FORMULATION OF QUESTIONS, HYPOTHESES:
The research question asked was: "Is there any relationship between use of epidural
anasthesia and maternal confidence among american women?” What are the factors
that’s affect on the woman’s decision to take epidural anasthesia? The research question
is defined at the beginning of the article and the authors try to answer it. The authors did
not state any hypothesis to be confirmed or rejected.
The dependent variable: maternal confidence at the labor, caused by many factors.
The demographic variables: nulliparous women, socioeconomic status, private
insurance,nationality, confidence about experiencing labor and background information
such as age and marital status
Extraneous variables: advising of the girl-friends, previous experience at the labor,
knowledge about the effects of using epidural anesthesia for labor pain

Identification of assumptions:
Methods and procedures:

Design: The authors used descriptive study of quantitative research explored the
relationship between maternal confidence and the use of epidural anesthesia for pain
management during labor. The research of Nancy K. Lowe, CNM, Ph.D., in the area of
maternal confidence (Lowe 1989, 1991, 1993) served as a base for this study in defining
and exploring this relationship. This descriptive study explored the relationship between
maternal confidence and the use of epidural anesthesia for pain management during
labor. Women who volunteered for this study were given a packet containing
instructions, questionnaires, self-addressed envelopes, a postcard to request study results
and a small gift for their participation. No pilot study was done in this research.

Setting: Research was performed in the Kaiser Permanente Medical Center, Santa Clara
and Santa Teresa facilities. In our hospital use of epidural anasthesia has become
increasingly common for managing labor pain.

Data were collected from the women before delivery using the Childbirth Self-Efficacy
Inventory (CBSEI) (Lowe 1993) with an additional questionnaire, developed by the
researcher, to measure variables such as knowledge about the effects of using epidural
anesthesia for labor pain, confidence about experiencing labor and background
information such as age and marital status. A second questionnaire, also developed by the
researcher, completed approximately two weeks after delivery, measured selected
outcomes including decisions concerning and use of epidural anesthesia.

Subjects: Fifty-nine women completed the questionnaires before delivery and 46 women
were included in the final sample after delivery. The authors didn’t exclude anyone of the
women in this research.

Ethical considerations:
There is no reference in the study to ethical aspects. The authors do not mention that
patients included in the research needed to express their personal feelings,this research
also was confident and anyone didn’t heart from this like happened in many cases before.
Women didn’t write their names in the questionnaires- it’s save a confidence.
Selection of measurement methods:
Data from pre and post delivery questionnaires were analyzed using Epi-Info, Version 6,
statistical program for epidemiology on microcomputers. Both questionnaires provided
an opportunity for the women to comment on areas such as concerns about upcoming
labor or advice they would want to give other women about labor and delivery.
Intervention:
No additional intervention was observed during the research.

Data collection:
This article didn’t describe how many times this research was, it’s not mentioned.
It was performed in the Kaiser Permanente Medical Center, Santa Clara and Santa Teresa
facilities. Data were collected from the women before delivery using the Childbirth Self-
Efficacy Inventory (CBSEI) (Lowe 1993) with an additional questionnaire, developed by
the researcher. The research is Nancy K. Lowe, CNM, Ph.D. The benefits of epidurals are
that it usually relieves labor pain effectively and also allows the woman to relax and rest.
In some cases , these effects result in enhanced labor progress, especially in exhausted,
frightened or tense women. The epidural does not, however, relieve all distress. We think
that practicing nurses can and should be involve in research. The nurses have practical
knowledge and easy accessibility to potential subjects (women). They can help to women
and their families to relieve the labor pain, to teach them how to support women, to use
alternative medicine to reduce pain, like reflexology, reiki and others, to talk with them
about their feelings and fears. Participation in research work can contribute to their self-
esteem, professional knowledge, professional performance, sense of belonging, etc.
Data analysis:
As mentioned above, data analysis was performed by Childbirth Self-Efficacy Inventory
(CBSEI) (Lowe 1993) with an additional questionnaire, developed by the researcher, to
measure variables such as knowledge about the effects of using epidural anesthesia for
labor pain, confidence about experiencing labor and background information such as age
and marital status. A second questionnaire, also developed by the researcher, completed
approximately two weeks after delivery, measured selected outcomes including decisions
concerning and use of epidural anesthesia. The statistical analysis was performed by
using Epi-Info, Version 6, statistical program for epidemiology on microcomputers.
The authors did not use any codes (or they did not mention it); data were presented in
tables (in numbers and percentage)
Results / discussion of results:
Many women said about the importance of social support on avoiding epidural
anesthesia as well as satisfaction of the childbirth experience. Confidence for labor, as
measured by the CBSEI questionnaire, may not be as important as social support
during labor or confidence in one's social support network. In fact, women
reported avoiding epidural anesthesia because alternate methods of pain relief and
social support worked.
No statistical significance (p = .10) was found between the predictor (maternal
confidence) and outcome (epidural use) variables. This may be due to several
factors. First, of the 46 women who returned the post-delivery questionnaire, only
16 used epidural anesthesia. This may not be a large enough sample to achieve
statistical significance. Second, it is possible that the CBSEI questionnaire may not
be the best measurement when looking for medication use outcomes. Third,
maternal confidence before labor may have less to do with medication use than
social support during labor.
The authors give detailed information about their findings, and accompany their
explanations by data presentation in tables and they are informative and
understandable. In our opinion, the findings can not be directly applied to practice,
because each organizational change requires time, money and support of various
elements, and every woman can choose different decisions about herself and for her
body and we need to respect her choose. The risk of applying this research directly to
practice is injury to the freedom to choose what is the best for us, for our body - this is a
basic principle .
Limitations:
Differences in the confidence levels of women approaching childbirth can possibly be
found within different childbirth preparation approaches.
Using a convenience sample, the bias of subjective, self administered post-childbirth data
collection, which may be subject to memory changes or recall inaccuracies and low
return rates due to the busy schedule of a new mother. The small epidural use sample
presented a particular issue with linking statistical significance relationship with maternal
confidence.
Time table:
The research lasted in the 1993, and it had no mention about exact times of doing this
research.
Level of evidence:
Therapeutic level II. It was a descriptive study, not a randomized controlled trial

References:
Stern, D (Sep, 30, 1997). Maternal Confidence for Labor and the Use of Epidural
Anesthesia. International Journal of Childbirth Education . Vol.12, Iss. 3; pg. 34-38