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Stress Adaptation
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Stress Adaptation A Theory for Childbirth Education JEANNETTE L. SASMOR, RN, MEd The proliferation of childbirth educatim programs In the past ten years has led to considerable confusion among both the public and professlonrls about the efficacy of any one approach. The methods often rigidly hold to their own principles, dlsclaimlng the general applicability of the others, and this has tended to compound the confusion in the minds of expectant parents seeking the “best” method and to cause professionals to doubt the validity of any approach to prepared Childbirth.
In the past decade public demand for adequate preparation for childbearing has flourished in the United States. In response t o this demand, numerous programs for expectant parents have sprouted throughout the country. European methods are directly applied in some programs which bear the names of the developersRead, Lamaze, Wright. Practitioners of other programs have steadfastly insisted that they do not follow one method and choose to call their courses “Preparation for Childbirth” and “Preparation for Labor and Delivery,” but these are usually based on a modification of one or more of the European methods. The time has come to turn from the study of the tonterzt of childbirth education to a study of the process of childbirth education. For it is in the process that the various methods find common ground. Leon Chertok, in his discourse on the various programs of psychophysiologic preparation for childbearing, stresses the value of preparing the expectant mother and fulfilling her particular psychologic needs.l Yet, even though he recognizes the similarities in the programs, Chertok fails to emphasize the three consistent commonalities in all of the approaches to educated birth: 1) factual information about human reproduction, with detailed descriptions of the processes of labor and delivery; 2) controlled relaxation; and 3 ) specific learned breathing techniques to be used in response to the labor sensations. These three areas of commonality are considered in the theory of childbirth education to be discussed here. This theory is based on an understanding of human behavior and the ability to cope with stress, It is broadly applicable to each method because it explains the overall process of preparation for childbirth. Even though each approach claims a theory to rationalize its particular method, the method-specific theories are usually inadequate to explain more than a part of an approach and often cannot explain the efficacy of other methods. The tenacity with which proponents of a method hold to it and reject all others has divided practitioners and factionalized their efforts. Total immersion in any one method can lead to a loss of professional perspective. A unified theory, describing the commonalities of the various programs within a broader theoretic and scientific framework, could help regain that perspective. T o establish a theoretic framework it is necessary to look at the general needs of expectant mothers during parturition. Crawford demonstrated that anxiety could interfere with the process of labor and should be alleviated.2 Among the studies of anxiety and stress, Hans Selye’s is particularly relevant for understanding stress and adaptation3 Although his clinical experiments have dealt largely with cardiac Novernber/Decernber 1973 ]OGN Nursing
patients, Dr. Selye agrees that his findings and projections might have direct application to childbirth education? According to Selye, man exists simultaneously on three interrelated planes, i.e., the biologic or structural, the physiologic or functional, and the psychologic or mental. An alteration in one plane affects the other two. For example, Crawford reports that when the laboring woman becomes extremely anxious (psychologic plane), the adrenal glands respond by secreting hormones (physiologic plane) which can supress uterine muscle contraction (biologic plane). If each expectant mother is a triplanal unit approaching a stressful situation, the goal of childbirth education is stress adaptation-that is, to provide mechanisms by which the mother can cope with the physical and emotional stresses of parturition, From this point on, I will relate Selye’s theory to the psychoprophylactic method. I believe, however, that the theory is equally applicable to the other approaches, The first step in preparing the expectant mother to cope with labor and delivery is to provide adequate facts. This will help the patient develop a positive attitude toward the processes, Second, it helps the patient understand why the techniques are learned. And third, in terms of stress and adaptation, factual information can help reduce anxiety caused by ignorance and fear of the unknown-an additional stressor during labor. The second step in preparing the expectant mother to cope with the stress of labor is to provide a regular program of exercises. In the psychoprophylactic method there are two kinds of exercises: one to prepare the body, the other to establish the conditioned response t h a t is essential to the success of the method. In terms of stress adaptation, the first set of exercises (called “physical fitness” or “body building”) serves a purpose that has not really been described before. They do prepare the body; however, it is not only the stretching and exercising of muscles to be used in labor t h a t is important. The act of exercising is the real preconditioner. Labor is a process of progressive muscle contractions. Because labor is a prolonged activity, the contractions become stressors eliciting body reactions to cope with the stress. With short daily sessions of mild exercise up to the time of labor, the body develops specific responses to the stressor “muscular activity,” and is better able to cope with uterine contractions during labor. This explanation involves the somaphysiology or body functioning. T h e second set of exercises involves the neurophysiologic systems. Called controlled relaxation, tension relaxation, or neuromuscular control exercises, they are designed to develop an automatic response to selectively relax groups of muscles. This November/Decernber 1973 JOGN Nursing
Hans Selye’s stress theory provides an excellent framework for unifylng the process of childbirth education. By expanding the concept of education beyond the purely cognitive domain, it becomes possible to view chiidbearing and the birth process as it effects the total person, i.e., biologically, physiologically, and psychologically.
49
t h e common elements in the process of childbirth-correct information, anticipatory guidance., controlled relaxation, and deliberate learned behavior patterns in response to labor contractions-interact with the already intercommunicating planes of structural, functional, and psychologic existence to permit the laboring woman, with the assistance of her labor-coach husband, to confidently and intelligently cooperate with the obstetric staff and reduce the stresses of labor to a manageable level.
A charter member of N A A C O G , the author founded and is president of the American Society of Childbirth Educators, Inc. Her book What Every Husband Should Know about Having a Baby was published b y the Nelson-Hall Company in 1972 (reviewed in JOGN, Volume 2 , Number 2, March/April 1973). She is currently a doctoral candidate in Nursing Education at Teachers College, Colmbia University, and holds the position of Associate Professor of Nursing at the University of South
Florida.
is perhaps the heart of the psychoprophylactic method. Combined with the breathing techniques, the exercises provide a focus for concentration during a contraction. More importantly, they help the laboring woman conserve energy and prevent the physiologicpsychologic irritability that results from structural fatigue. T h e third step in preparing the expectant parent to cope with the stresses of labor and delivery is to provide specific complex patterns of behavior to use in response to the sensations of labor. Parents are usually told that the goal is to reduce the perception of pain associated with labor contractions. T h e theory base for this part of the psychoprophylactic method is found in the neurophysiology of Pavlovian conditioning.6 Within recent years, it has been challenged as an appropriate rationale for human learning behavior, which is thought to be conditioned by operant techniques. Whatever the nomenclature, the process is believed to alter the perception of pain by focusing the attention of the woman on the response she is making to the actual sensation of the contraction. The stronger the contraction, the more complex her response. She is not ignoring the contraction nor is she disassociating her mind as she would with hypnosis. Because she focuses on the response rather than the stimulus, her perception of the pain of the contraction is changed. The responses involve all three planes of existence. By responding automatically to the contraction with a breathing technique, the woman is able to reduce her perception of pain and increase her feelings of selfconfidence and satisfaction. Her controlled relaxation conserves her energy and reduces her oxygen needs. Her husband, acting as labor coach, provides her with physical and emotional comfort. T h e total effect is a more efficient and comfortable contraction. Labor is a stress situation. Through prior preparation, the woman develops the coping mechanisms-relaxation and breathing techniques-so that when labor occurs, her body can react effectively to the stressors, quickly go from the alarm phase into the resistance phase, and maintain itself there rather than progressing into a phase of exhaustion. T h e three planes of the life process are involved in the preparation for childbirth, and the prepared woman can respond positively on each plane during labor. References 1. Chartok, Leon: Motherhood and Personality. Philadelphia, J. B. Lippincott Co.,
1969 2. Crawford, Mary Irene: Physiological and Behavioral Cues to Disturbances in
Childbirth. Doctoral dissertation, Teachers College, Columbia University, 1968 3. Selye, Hans: Stress of Life. New York, McGraw-Hill Book Company, 1956 4. Selye, Hans: Personal interview, University of Montreal, February 18, 1972 5. Lamaze, Fernand: Painless Childbirth. Chicago, Henry Regnery, 1970 This article was taken from a aper delivered at the First Annual Conference
on Psychosomatic Medicine in Jbstetcics and Gynecology, Philadelphia, Pennsylvania, January 1973. Address re rint requests to Jeannette Sasmor, RN, President, The American Society of Cfildbirth Educators, Inc., 1502 Bogie Drive, Tampa, FL 33612. November/December 1973 JOGN Nursing
Stress Adaptation A Theory for Childbirth Education JEANNETTE L. SASMOR, RN, MEd The proliferation of childbirth educatim programs In the past ten years has led to considerable confusion among both the public and professlonrls about the efficacy of any one approach. The methods often rigidly hold to their own principles, dlsclaimlng the general applicability of the others, and this has tended to compound the confusion in the minds of expectant parents seeking the “best” method and to cause professionals to doubt the validity of any approach to prepared Childbirth.
In the past decade public demand for adequate preparation for childbearing has flourished in the United States. In response t o this demand, numerous programs for expectant parents have sprouted throughout the country. European methods are directly applied in some programs which bear the names of the developersRead, Lamaze, Wright. Practitioners of other programs have steadfastly insisted that they do not follow one method and choose to call their courses “Preparation for Childbirth” and “Preparation for Labor and Delivery,” but these are usually based on a modification of one or more of the European methods. The time has come to turn from the study of the tonterzt of childbirth education to a study of the process of childbirth education. For it is in the process that the various methods find common ground. Leon Chertok, in his discourse on the various programs of psychophysiologic preparation for childbearing, stresses the value of preparing the expectant mother and fulfilling her particular psychologic needs.l Yet, even though he recognizes the similarities in the programs, Chertok fails to emphasize the three consistent commonalities in all of the approaches to educated birth: 1) factual information about human reproduction, with detailed descriptions of the processes of labor and delivery; 2) controlled relaxation; and 3 ) specific learned breathing techniques to be used in response to the labor sensations. These three areas of commonality are considered in the theory of childbirth education to be discussed here. This theory is based on an understanding of human behavior and the ability to cope with stress, It is broadly applicable to each method because it explains the overall process of preparation for childbirth. Even though each approach claims a theory to rationalize its particular method, the method-specific theories are usually inadequate to explain more than a part of an approach and often cannot explain the efficacy of other methods. The tenacity with which proponents of a method hold to it and reject all others has divided practitioners and factionalized their efforts. Total immersion in any one method can lead to a loss of professional perspective. A unified theory, describing the commonalities of the various programs within a broader theoretic and scientific framework, could help regain that perspective. T o establish a theoretic framework it is necessary to look at the general needs of expectant mothers during parturition. Crawford demonstrated that anxiety could interfere with the process of labor and should be alleviated.2 Among the studies of anxiety and stress, Hans Selye’s is particularly relevant for understanding stress and adaptation3 Although his clinical experiments have dealt largely with cardiac Novernber/Decernber 1973 ]OGN Nursing
patients, Dr. Selye agrees that his findings and projections might have direct application to childbirth education? According to Selye, man exists simultaneously on three interrelated planes, i.e., the biologic or structural, the physiologic or functional, and the psychologic or mental. An alteration in one plane affects the other two. For example, Crawford reports that when the laboring woman becomes extremely anxious (psychologic plane), the adrenal glands respond by secreting hormones (physiologic plane) which can supress uterine muscle contraction (biologic plane). If each expectant mother is a triplanal unit approaching a stressful situation, the goal of childbirth education is stress adaptation-that is, to provide mechanisms by which the mother can cope with the physical and emotional stresses of parturition, From this point on, I will relate Selye’s theory to the psychoprophylactic method. I believe, however, that the theory is equally applicable to the other approaches, The first step in preparing the expectant mother to cope with labor and delivery is to provide adequate facts. This will help the patient develop a positive attitude toward the processes, Second, it helps the patient understand why the techniques are learned. And third, in terms of stress and adaptation, factual information can help reduce anxiety caused by ignorance and fear of the unknown-an additional stressor during labor. The second step in preparing the expectant mother to cope with the stress of labor is to provide a regular program of exercises. In the psychoprophylactic method there are two kinds of exercises: one to prepare the body, the other to establish the conditioned response t h a t is essential to the success of the method. In terms of stress adaptation, the first set of exercises (called “physical fitness” or “body building”) serves a purpose that has not really been described before. They do prepare the body; however, it is not only the stretching and exercising of muscles to be used in labor t h a t is important. The act of exercising is the real preconditioner. Labor is a process of progressive muscle contractions. Because labor is a prolonged activity, the contractions become stressors eliciting body reactions to cope with the stress. With short daily sessions of mild exercise up to the time of labor, the body develops specific responses to the stressor “muscular activity,” and is better able to cope with uterine contractions during labor. This explanation involves the somaphysiology or body functioning. T h e second set of exercises involves the neurophysiologic systems. Called controlled relaxation, tension relaxation, or neuromuscular control exercises, they are designed to develop an automatic response to selectively relax groups of muscles. This November/Decernber 1973 JOGN Nursing
Hans Selye’s stress theory provides an excellent framework for unifylng the process of childbirth education. By expanding the concept of education beyond the purely cognitive domain, it becomes possible to view chiidbearing and the birth process as it effects the total person, i.e., biologically, physiologically, and psychologically.
49
t h e common elements in the process of childbirth-correct information, anticipatory guidance., controlled relaxation, and deliberate learned behavior patterns in response to labor contractions-interact with the already intercommunicating planes of structural, functional, and psychologic existence to permit the laboring woman, with the assistance of her labor-coach husband, to confidently and intelligently cooperate with the obstetric staff and reduce the stresses of labor to a manageable level.
A charter member of N A A C O G , the author founded and is president of the American Society of Childbirth Educators, Inc. Her book What Every Husband Should Know about Having a Baby was published b y the Nelson-Hall Company in 1972 (reviewed in JOGN, Volume 2 , Number 2, March/April 1973). She is currently a doctoral candidate in Nursing Education at Teachers College, Colmbia University, and holds the position of Associate Professor of Nursing at the University of South
Florida.
is perhaps the heart of the psychoprophylactic method. Combined with the breathing techniques, the exercises provide a focus for concentration during a contraction. More importantly, they help the laboring woman conserve energy and prevent the physiologicpsychologic irritability that results from structural fatigue. T h e third step in preparing the expectant parent to cope with the stresses of labor and delivery is to provide specific complex patterns of behavior to use in response to the sensations of labor. Parents are usually told that the goal is to reduce the perception of pain associated with labor contractions. T h e theory base for this part of the psychoprophylactic method is found in the neurophysiology of Pavlovian conditioning.6 Within recent years, it has been challenged as an appropriate rationale for human learning behavior, which is thought to be conditioned by operant techniques. Whatever the nomenclature, the process is believed to alter the perception of pain by focusing the attention of the woman on the response she is making to the actual sensation of the contraction. The stronger the contraction, the more complex her response. She is not ignoring the contraction nor is she disassociating her mind as she would with hypnosis. Because she focuses on the response rather than the stimulus, her perception of the pain of the contraction is changed. The responses involve all three planes of existence. By responding automatically to the contraction with a breathing technique, the woman is able to reduce her perception of pain and increase her feelings of selfconfidence and satisfaction. Her controlled relaxation conserves her energy and reduces her oxygen needs. Her husband, acting as labor coach, provides her with physical and emotional comfort. T h e total effect is a more efficient and comfortable contraction. Labor is a stress situation. Through prior preparation, the woman develops the coping mechanisms-relaxation and breathing techniques-so that when labor occurs, her body can react effectively to the stressors, quickly go from the alarm phase into the resistance phase, and maintain itself there rather than progressing into a phase of exhaustion. T h e three planes of the life process are involved in the preparation for childbirth, and the prepared woman can respond positively on each plane during labor. References 1. Chartok, Leon: Motherhood and Personality. Philadelphia, J. B. Lippincott Co.,
1969 2. Crawford, Mary Irene: Physiological and Behavioral Cues to Disturbances in
Childbirth. Doctoral dissertation, Teachers College, Columbia University, 1968 3. Selye, Hans: Stress of Life. New York, McGraw-Hill Book Company, 1956 4. Selye, Hans: Personal interview, University of Montreal, February 18, 1972 5. Lamaze, Fernand: Painless Childbirth. Chicago, Henry Regnery, 1970 This article was taken from a aper delivered at the First Annual Conference
on Psychosomatic Medicine in Jbstetcics and Gynecology, Philadelphia, Pennsylvania, January 1973. Address re rint requests to Jeannette Sasmor, RN, President, The American Society of Cfildbirth Educators, Inc., 1502 Bogie Drive, Tampa, FL 33612. November/December 1973 JOGN Nursing