The Effect of Relaxation Therapy on Preterm Labor Outcomes

The Effect of Relaxation Therapy on Preterm Labor Outcomes ]ill]anke, RNC, M N , DNSC

Objective: To examine the effect of relaxation on preterm labor outcome. Design: Quasi-experimental, with women who experienced preterm labor randomly assigned to a control or experimental group. The experimental group was to do a daily relaxation exercise. A third group was added to the study: women who were originally assigned to the relaxation group but were unable to adhere to the daily practice. Final data were analyzed for three groups: control (n = 40),experimental (n = #), and nonadherent (n = 23) participants. Setting: Women were referred to the study from physician offices and a hospital-based obstetric triage clinic in the Northwest. Participants: Total sample was comprised of 107 women with singleton gestations, documented contractions with cervical change, and intact membranes. Interventions: The experimental group was instructed in a progressive relaxation exercise. The participants were given tapes of the exercise and instructed to do it daily. Outcome Measures: Study outcomes included gestational age at birth, rate of pregnancy prolongation, and birth weight. Results: The outcome variables were analyzed using analysis of covariance, with the preterm labor risk score entered as a covariate to compensate statistically for group differences. A positive response to the relaxation intervention was found: The experimental group had significantly longer gestations and larger newborns when compared to the control and nonadherent groups. Conclusions: Relaxation therapy made a difference in preterm labor outcome. Women who practiced relaxation had larger newborns, longer

MaylJune 1999

gestations, and higher rates of pregnancy prolongation. Given the low cost of the intervention, it should be offered to all women at risk for preterm labor. JOGNN, 28, 255-263; 1999. Accepted: December 1998

Preterm labor occurs in 11% of all pregnancies (Ventura, Martin, Curtin, & Mathews, 1995). Complications secondary to preterm birth are the primary cause of perinatal morbidity and mortality in the United States (Sullivan & Morrison, 1995; U.S. Department of Health and Human Services, 1992). Although advances in obstetric and neonatal care have improved the outcomes for preterm birth, there has been no significant decrease in the incidence of early delivery over the past few decades (American College of Obstetricians & Gynecologists, 1995; McLean, Walters, & Smith, 1993; Monga & Creasy 1995). Relaxation training often is used in the treatment of psychologic and physical disorders associated with anxiety or stress (Crist, Rickard, Prentice-Dunn, & Barker, 1989). Although stress plays a significant role in the occurrence of preterm labor, relaxation therapy has received little attention as a cost-effective nursing intervention (Bryce, Stanley, & Garner, 1991; Crandon, 1979; Newton & Hunt, 1984; Omer, Freidlander, & Palti, 1986; Waldron & Aasayama, 1985).

Purpose The purpose of the current study .was to explore the effect of relaxation on prolonging the

JOGNN 255

pregnancies of women diagnosed with preterm labor. The following research hypotheses were tested: Hypothesis 1: Women diagnosed with preterm labor who received relaxation therapy will have longer pregnancies than will women who do not receive relaxation therapy. Hypothesis 2: Women diagnosed with preterm labor who received relaxation therapy will give birth to heavier newborns than will women who do not receive relaxation therapy.

Literature Review and Conceptual Framework Stress exists on many different levels and is found in our environment, our bodies, and our thoughts. When a person feels stressed various chemical changes occur in his or her body. This physiologic reaction is often called the “fight or flight” response. It prepares the body for physical action by increasing cardiac output, shunting blood from the viscera to the major skeletal muscles, mobilizing lipid and glucose energy stores, decreasing blood clotting time, and diminishing the immune response (Seaward, 1994). Physiologic changes that occur when a women is under stress have been linked to adverse pregnancy outcomes, including preterm labor (Lobel, Dunkel-Schetter, & Scrimshaw, 1992; Omer, 1986; Omer, Friedlander, & Palti, 1986; Omer, Friedlander, Palti, & Skekel, 1986). The exact mechanism of action is unclear. One theory is that peaks of epinephrine, secreted under acute stress, precipitate labor contractions (Institute of Medicine, 1985). Another theory is that the sustained levels of corticosteroid found under chronic stress conditions cause varying degrees of immunosuppression. This predisposes a person to infection, which can lead to preterm labor. A final theory is that stress causes secretion of oxytocin. This theory must be viewed cautiously because it is based on animal studies and has yet to be studied in humans (Lang, Jurgen, & Ganten, 1983; Takahashi, Daimone, Bieniarz, Yen, & Burd, 1980). Relaxation training has been used as an effective treatment for stress-related disorders. Whereas the “fight or flight” response prepares the body for action, the relaxation response provides a homeostatic counterbalance. Activation of the relaxation response lowers the heart rate, blood pressure, respiratory rate, oxygen consumption, skeletal muscle tension, and blood lactate levels. It increases peripheral blood flow, production of slow alpha brain waves (associated with relaxed state), carbon dioxide elimination, and activity of natural killer cells (Seaward, 1994). Many relaxation strategies are practiced today. The more common ones include diaphragmatic breath256 JOGNN

ing, meditation, hatha yoga, mental imagery, music therapy, massage therapy, progressive relaxation, hypnosis, autogenic training, and biofeedback. The techniques vary in difficulty, and each has many combinations and variations (Seaward, 1994). Diaphragmatic breathing is one of the easiest and oldest relaxation techniques and in its simplest form entails focused deep breathing. This form of breathing occurs naturally when a person takes a big breath to regroup his or her thoughts, to gain composure, or to direct energies for a challenging task. What makes diaphragmatic breathing different from normal breathing is its emphasis on movement of the lower abdomen rather than the thoracic cavity. Its pacifying effect is theoretically due to a parasympathetic override of the sympathetic nervous system, leading to homeostasis (Seaward, 1994). Progressive relaxation was developed in the 1920s by Edmund Jacobson (Lehrer, 1982). It is often used in combination with diaphragmatic breathing. There are two variations to this technique. One method calls for systematically contracting and relaxing muscle groups; the other involves conscious release of muscle tension without contracting muscles first (Lehrer, 1982). Both methods proceed in a systematic head to toe (or toe to head) fashion. Lucic and colleagues compared the two methods in a well-designed laboratory study and concluded that the conscious release method resulted in greater relaxation, as measured by electromyography (Lucic, Steffen, Harrigan, & Stuebing, 1991). In the literature, only one experimental study was found that examined the effect of relaxation on preterm labor (Omer, Friedlander, & Palti, 1986). The researchers obtained a sample of 109 women who had been hospitalized for preterm labor. The‘ experimental group received hypnotic relaxation training and medication to suppress their preterm labor, while the control group received only the medication. The experimental group had an average rate of pregnancy prolongation of 74.2%, compared to 55.4% in the control group ( t = 3.09; p < .002). The experimental group also gave birth to newborns who weighed, on the average, 200 g more ( t = 1.64, p < .005). Several limitations to the study war-

W o m e n who practiced relaxation had better preterm labor outcomes in terms of infant birth weight, gestational age at delivery, and rate of pregnancy prolongation.

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list of numbers was used to determine group assignment. Verbal and written explanations of the study were given to eligible women, and the voluntary nature of the study and participant confidentiality were emphasized. Data collection occurred over a 3-year period. A university institutional review board for the protection of human subjects approved the study.

ranted attention. The data for the control group were collected in a different year than were the data for the experimental group. It was possible that the better outcome was due to changes in the environment or health care protocols. Another limitation was the lack of objective confirmation that relaxation was occurring. This raised the question as to whether the outcomes were due to some other event, such as the attention of the researcher and the patient's desire to please. The limitations found in the research design of Omer et al. (1986)provided a starting point for the current study. Several methodologic modifications were made: Group membership was determined by random assignment and data were collected concurrently for both groups. All participants received similar attention from the researcher or her assistant. Instead of hypnotic relaxation, a simpler, cost-effective, taped relaxation technique was used. Another major difference was the attempt to quantify activation of the relaxation response through measurement of skin temperature changes and subjective report.

Participants All women referred to the study agreed to participate. Eligible participants were English-speaking women with a singleton gestation, documented contractions with cervical changes, and intact membranes at time of entry into the study. One hundred and seven women began the study. The average gestational age at entry into the study was 28 weeks (SD = 2.9 weeks). Cervical changes ranged from effacement to 4 cm dilatation (M = 1.2 cm; SD = 1.1cm). Participants tended to be in their 20s (56%),white (86%),low- to middle-income (65.7%), experiencing their first or second pregnancy (81.3%), and married (71%) (see Table 1).

Design

Instruments to Determine Preterm Labor Risk Homogeneity Among Groups Measure of Stress. A multidimensional concept,

In this quasi-experimental study of women diagnosed with preterm labor, participants were referred to the researcher from private physician offices and a hospital-based maternity triage unit. A randomly generated

stress is defined broadly as the interplay between the environment and the person ( Lazarus & Folkman, 1984). Commonly identified components of stress include stimulus, perceptual response, and emotional

Methods

-

TABLE 1

Sample Demographic Characteristics (N= 107) Characteristics

Age Years of education Number of pregnancies Number of living children Marital status Married Unmarried Race/ethnicity White Nonwhite Income $25,000 or less > $25,000 to $55,000 > $55,000 Parity Nullipara Primipara Multipara

Mayl'une 1999

Frequency

Percent

76 31

71 29

92 15

86 14

33 36 36

31.4 34.3 34.3

43 44 20

40.2 41.1 18.7

M

SD

26.5 13.3 2.6 0.9

5.6 2.5 1.7 1.1

JOG"

257

response (Lobel et al., 1992). For the current study, the emotional response component of stress was of primary interest. Because instruments that measure anxiety often are used to quantify emotional response, the State-Trait Anxiety Inventory was selected as a stress measure for this study (Lobel et al., 1992; Reading, 1983; Spielberger, Gorsuch, & Lushene, 1983). This instrument measures state anxiety (a transitory condition) and trait anxiety (a stable condition of anxiety proneness) and consists of 40 statements describing feelings. For the trait anxiety items, participants responded to how they generally feel; for the state anxiety items they responded to how they feel right now, at this moment. The trait items measured frequency of anxiety feelings and were rated on a 4-point scale ranging from (1)almost never to (4) almost always. The state items described intensity of feelings and also were rated on a 4-point scale, with anchors of (1)not a t ull to (4) very much so. Scores for both scales had a range of 20 to 80, with higher scores reflecting more intense state anxiety and greater anxiety proneness in the trait scale. When this instrument was tested with adult populations, the reliability coefficients for the state and trait anxiety items were .93 and .90, respectively (Lobel et al., 1992; Spielberger et al., 1983). Preterm Labor Risk Invent0 y . The Preterm Labor Risk Inventory developed by Creasy was used to obtain risk scores. Data included past and current obstetric and medical history, as well as demographic and social factors known to increase risk for preterm labor. A score of 0-5 indicated low risk; 6-9, medium risk; and 10 or more, high risk (Creasy & Resnick, 1994). Measures to Determine Achievement of the Relaxation Response. Because relaxation involves physical and mental calming, both subjective and physiologic measures were taken to verify activation of the relaxation response. Physiologic Measure of Relaxation. Peripheral skin temperature was measured by attaching a heat-sensitive electrode to the nondominant index finger with a Velcro fastener. A rise in skin temperature after relaxation indicated that the person had activated the relaxation response. The temperature devices, obtained from a firm that specializes in biofeedback equipment, were checked for accuracy using the Temp Model DT-002 (Biofeedback Systems, Boulder, CO) and were rechecked each time one was returned by a study participant. The women using the device were told to report any changes in its functioning. There was only one malfunction during the study, caused by a low battery, which was replaced. Subjective Measure of Relaxation. A subjective measure of relaxation was obtained by having participants indicate how they felt before and after relaxation by placing an X on a 10-cm line. At the start of the line 258 JOG”

was the word relaxed and at the end of the line was the word stressed. The distance from the start of the line to where the X was placed was measured. Scores ranged from 0 to 10, with higher scores indicating greater stress. A score that was lower at the end of the exercise indicated activation of the relaxation response.

Outcome Measures Gestational Age and Birth Weight. Gestational age was based on the participant’s due date and the date of the birth. Birth weights were obtained from the neonatal record. Rate of Pregnancy Prolongation. The Rate of Pregnancy Prolongation (RPP) provided a continuous criterion of success that took into consideration the wide range of possible outcomes. The RPP was calculated using a formula developed by Omer et al. (1986). It determined the proportion (percent) of pregnancy prolongation achieved relative to the total time remaining until the due date. For example, any woman giving birth on the day she started the study would get 0%; any woman giving birth midway between entry into the study and her due date would get 50%; and any woman delivering at term (40 weeks gestation) would get an RPP of 100%. To calculate the RPP, the number of days a woman was in the study (start date to date of birth) was divided by the number of days remaining until her due date (start date to due date). This quotient was then multiplied by 100 to obtain the RPP.

Procedure The researcher or her assistant met with each woman in the participant’s home and conducted an interview to obtain information about preterm labor risk. Participants filled out a brief demographic questionnaire and the State-Trait Anxiety Inventory. Subsequent contact was by telephone every week until the birth. The primary purpose of the telephone contact was to see how the women in the experimental group were doing with the relaxation exercises. To minimize the possibility that this contact contributed to the treatment effect, women in the control group also were called on a weekly basis to see how they were doing with their preterm labor. The calls to both groups lasted an average of 5 minutes. After a woman gave birth the medical record was reviewed for outcome data.

Experimental Group In addition to the above procedure, the experimental group received verbal, written, and taped instructions on the benefits of relaxation, the relaxation strategy, and use of the temperature device. When necessary, the researcher provided a cassette player and headphones.

Volume 28, Number 3

Instructions on how to relax were kept simple. Diaphragmatic breathing was taught by having the women lightly place their hands on their abdomens and take in slow, deep, easy breathes, allowing their abdomens to expand and lift their hands. The key words to this were “slow and easy.” It usually took a few minutes to master. Women were then asked to assume a comfortable position, well-supported by pillows. A taped relaxation exercise that combined the diaphragmatic breathing with the conscious release of tension was played. The taped instructions focused on head-to-toe release (see Table 2). Several tapes were left with each participant. The taped exercises varied in length from 5 to 20 minutes and had different musical backgrounds, but the breathing and conscious release instructions were similar. All tapes were recorded by the researcher. Participants were encouraged to listen to all the tapes and select those they liked best. It did not matter which of the tapes they listened to as long as they found one or several that helped them to relax (Benson, 1975, 1984; Carrington, 1984). General instructions were to

listen to a relaxation tape once a day and record the temperatures and subjective feelings of relaxation in a log provided by the researcher. Women were assured that doing the exercise should be helpful. In the event the women felt the tapes were not helpful, they were told to stop using them and to contact the researcher.

Results Nonadherent Group Twenty-three women in the experimental group stopped doing the relaxation exercise after 1-2 weeks in the study. It was not a matter of skipping a few sessions, but rather their perceived inability to relax. The reasons these women gave for their inability to relax were interesting, especially since they were all on activity restrictions. The most common explanations were “too busy” ( n = 15), or “it was just one more thing to do” ( n = 6). Two women quit because their pastor told them it was dangerous. The danger supposedly occurred when relaxation allowed a person to enter an altered state of consciousness where the devil could “take over.” It was

TABLE 2

Abbreviated Example of Taped Relaxation hstmdms w Get comfortable; make sure all limbs are supported and slightly bent. Start to focus on your breathing, slowing it down and relaxing more on each exhalation. Continue to breathe in and out slowly; listening to the music and allowing yourself to become more and more relaxed. Starting at the top of your head, allow your scalp and forehead to relax, smoothing away the wrinkles and tension. Let your eyes softly close and feel the gentle flow of release soothe your eyes. Relax your mouth, allowing it to open slightly. Relax your jaw and allow remaining tension in your face to flow away with your next exhalation. Continue breathing slowly and rhythmically. Relax the muscles in your neck and allow the warmth to radiate down to your shoulders. Feel the soothing sensations as you let the muscles release and go soft. Let the relaxation flow down your upper arms, elbows, forearms, wrists, and hands. Take a moment to relax each finger. As you relax your hands and arms, enjoy the warm and soothing sensations that are your body’s way of showing relaxation. Continue breathing slowly and rhythmically. Let the feeling of warmth and release extend down the front and back of your chest. Soften and release your abdominal muscles.

May/’une 1999

Feel the soothing warmth extend down to your buttocks, thighs, calves, ankles, feet, and toes. Remember to breathe slowly and rhythmically, enjoying the feeling of release, letting go a little more each time you breathe out. It is time to see if any tension, worries, or discomforts remain. Do a mental check from head to toe. If any part of your body or mind isn’t fully relaxed and comfortable, simply take a breath in, and send healing, nourishing air to that area to release the tension and allow it to melt away. As you breathe out, imagine a flow of tension, tiredness, troubles, fears, anxieties, and aches leaving your body as you loosen and soften all your muscles and sink into the blissful feeling of complete relaxation. Take five more relaxation breaths and with each one, allow yourself to become twice as relaxed as you were before; when done, take time to enjoy the good feeling, experiencing warmth and well-being throughout your body. Tell yourself “I can reach a deep state of relaxation whenever I wish, simply by taking the relaxation breath.” Continue listening to the soothing music. Whenever you are ready, take a final relaxation breath and as you exhale, stretch your limbs, open your eyes, and feel energized with a powerful sense of well-being and comfort.

JOGNN 259

decided to include these 23 women in the data analysis as a third "nonadherent" group; they all agreed to continue with the weekly phone calls until they delivered. Three noted they enjoyed the calls: "It means someone cares," they said.

ent (n = 23) groups in terms of age, marital status, income, ethnicity, parity, state anxiety, trait anxiety, or treatment with tocolytics (see Table 3 ) . The one variable on which the groups differed was their preterm labor risk score (F = 4.37, df = 2, 106, = .OM). The nonadherent group had significantly higher scores (M = 19.5,

Presence of the Relaxation Response Paired t tests provided evidence that the experimental group was successful at eliciting the relaxation response. Significant differences ( p < .01) were found in the before (M = 91.9"F, SD = 4.4"F) and after (M = 93.7"F, SD = 3.6"F) skin temperature readings, as well as the before (M = 4.4, SD = 1.6) and after (M = 1.6, SD = 1.3) subjective reports of feeling relaxed.

AII

of the women who

commented on how much it helped them.

As one woman said, "It's a time of peace, it's my time."

Group Comparisons The data were examined for differences between groups that might bias outcomes of the study. No significant differences ( p > .05) were found between the experimental (n = 44), control (n = 40), and nonadher-

-

did the relaxation

SD = 7.4) than either the control (M = 15.2, SD = 5.5) or experimental group (M = 15.9, SD = 5.5).

TABU 3

Differences Between Groups VCIriables

Experimeri tal (n = 44)

Control (n = 40)

Norradlterent (n = 2.3)

M

M

M

26.7 13.3 2.6 0.8 44.1 38.5 15.9

26.1 13.6 2.2 0.9 41.3 34.8 15.2

27.0 12.8 2.5 1.1 43.1 36.3 19.5

%

%

%

Age Years of school Gravidity Parity State inventory Trait inventory Preterm labor risk index

ANOVA F = 0.21, df = 2, 104, p F = 0.75, df = 2, 104, p F = 0.86, df = 2, 104, p F = 0.55, d f = 2, 104, p F = 0.85, df = 2, 104, p F = 1.80, df = 2, 104, p F = 4.37, d f = 2, 104, p Chi square ~~~~

Income S $25,000 $25-50,000 > $50,000 Ethnicity White Nonwhite Marital status Married Not married Tocolytics N o tocolytics Terbutaline

~~

x2 = 2.40 (41, p 23.3 39.5 37.2

35.9 30.8 33.3

39.1 30.4 30.4

81.8 18.2

90.0 10.0

87.0 13.0

72.7 27.3

72.5 27.5

65.2 34.8

= ns = ns = ns = ns = ns = ns = .015

x2

= ns

= 1.19 (2),p = ns

x2 = 0.48 (21, p = ns x2

43.2 56.8

47.5 52.5

= 0.21 (21, p = ns

47.8 52.2

Note. ANOVA = analysis of variance.

260 JOGNN

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TABLE 4

ANCOVA Results Between Gmups and RPP, Birth Weight, and Gestational Age With Pretem Labor Risk S a m as the Cwariate B Variablas

RPP (Yo) Gestation (weeks) Weight (g)

fkperirnerital (n = 44)

(n = 40)

Control

Norradherent (n = 23)

M (SO)

M (SD)

M (SD)

ANCOVA

85.9 (20.2) 38.6 (1.6) 3,379 (360)

69.4 (22.9) 37.5 (1.6) 3,182 (427)

52.8 (23.7) 36.1 (2.3) 2,783 (595)

F = 16.6, d f = 2, 101, p = .001 F = 12.7, d f = 2, 101, p = .001 F = 12.0, df = 2, 101, p = .001

Note. ANCOVA = analysis of covariance; RPP = rate of pregnancy prolongation.

Outcome Variables The outcome variables were analyzed using analysis of covariance, with the preterm labor risk score entered as a covariate. This statistical method adjusts the means of the outcome variables to what they would be if all participants had scored equally on the risk inventory. Results of the analysis of covariance indicated that the experimental group had the best outcomes (see Figures 1-3 and Table 4). The experimental group had significantly longer gestations (M = 38.5, SD = 1.6) than

Relaxation is a cost-effective nursing intervention and could easily be incorporated into the care of preterm labor patients.

either the control (M = 37.5, SD = 1.6) or nonadherent (M = 36.2, SD = 2.3) groups ( F = 112.7, d f = 2, 101, p = .001). A significant difference in RPP also was found ( F = 16.57, df = 2, 101, p = .001): The experimental group was most successful at prolonging their pregnancies (M = 85.8%, SD = 20.2%) compared to the control group (M = 69.4%, SD = 22.9%) and the nonadherent group (M = 52.8%, SD = 23.7%). Birth weight was also greater ( F = 12.03, d f = 2, 101, p = .001) in the experimental group (M = 3,377 g, SD = 360 g), when compared to the control (M = 3,178 g, SD = 427 g) and the nonadherent group (M = 2,794 g, SD = 595 g).

All of the women who participated in the intervention made verbal and/or written comments about how much it helped. As one woman said, “It’s a time of peace, it’s my time.’’ Several made the relaxation therapy into a daily ritual. One creative thinker timed her relaxation “break” with her children’s favorite television show, while she retired to the bathroom with her tape, a candle, and bubble bath. Even though she left the door unlocked the children learned to respect her need for time alone and not to interrupt. Other women reported using the relaxation under unplanned circumstances. One woman said she noticed that she was doing “the breathing” when she got angry or upset, instead of yelling. “I didn’t even know I was doing it!’’ she exclaimed. Other examples included using it in traffic, in labor, and after receiving bad news. Given the low cost of the intervention, it could be easily incorporated into the care of preterm labor patients. The nonadherent group was self-selected and a puzzle to the researcher. These women had the highest risk factor scores, the shortest pregnancies, and the smallest newborns. Although the intervention tested in this study showed positive results for a portion of the 3,500 3,400 3,300 3,200

m

s-

2 3,000 ._ P

2 Discussion and Conclusions

3,100

2.900

U 4-

m z

2,800

L

Relaxation therapy made a difference in preterm labor outcomes in the sample studied. After adjusting for risk score differences, the experimental group had significantly larger newborns and longer pregnancies. MaylJune 1999

2,700 Experimental

Contiol

Non-adherent

FIGURE 1

Mean newborn birth weight (8).

JOGNN 261

90.0

39.0,

38 5

80.0 38.0

70.0

*c

37 5

-

370

'

u)

z6

.-Lz

365

I U

2

36.0

w"

35.5

.-c !

Experimental

Control

FIGURE 2 Mean gestational age.

preterm labor population, more research is needed on the nonadherent group. A better understanding of why they found it difficult to relax may help in developing alternative strategies for this high stress group. One contributing factor may have been the added bother of taking skin temperature readings and recording feelings; while such record keeping was necessary for the study, participants might have enjoyed the relaxation more if all it entailed was listening to a tape. The treatment effect could be strengthened by helping women to better integrate the exercise into daily activities. One of the women who quit had three young children at home. She maintained bed rest on the living room couch while directing the activities of the household. She said there was never quiet time to do the exercises until the children were in bed, and by then all she wanted to do was sleep. The gravidity and parity of all three groups were similar, but the mothers who were able to relax may have had better support systems for child care. However, that would not explain why women without children were also in the nonadherent group. A possible explanation may be that there were some basic personality differences between groups that were not identified in this study. Other researchers might want to explore personality types or locus of control predictors for preterm labor. Tocolysis may have played a role in group membership. Even though data were gathered on patient tocolysis and no differences were found between groups, this study looked at only the presence/absence of tocolysis, not dosage. It may be that women in the nonadherent group received higher doses and the side effects from the drug contributed to their inability to relax. It also is possible that women who reported they were "too busy" to relax were also nonadherent in other aspects of their treatment, such as bed rest. As a whole, the nonadherent women seemed to have a hard time slowing down. Attempts to quantify 262 JOG"

Experimental

Non-adherent

Control

Non-adherent

FIGURE 3

Mean percent of pregnancy prolongation.

adherencehonadherence may provide additional insight into this population's behavior. Preterm labor is a complex phenomenon that requires a multifaceted approach to treatment. Relaxation therapy is a nursing intervention that easily can be incorporated into patient care. Not only does it help women experiencing preterm labor, but it also has lifelong health benefits when practiced regularly. Future research should focus on large diverse populations as well as on attempting to identify relaxation strategies that would help nonadherent women. REFERENCES American College of Obstetricians and Gynecologists. (1995). Preterm labor ( A C O G Technical Bulletin No. 206). Washington, DC: Author. Benson, H. (1975). The relaxation response. New York: Avon Books. Benson, H. (1984).The relaxation response and stress. In J.D. Mataraszzo, S.M. Weiss, & J. Herd (Eds.), Behavioral health: Health promotion and disease prevention (pp. 326-338). New York: John Wiley & Sons. Bryce, R., Stanley, F., & Garner, J. (1991). Randomized controlled trial of antenatal social support to prevent preterm birth. British Journal of Obstetric and Gynaecology, 98, 1001-1008. Carrington, P. (1984). Modern forms of meditation. In R.L. Woolfolk & P.M. Lehrer (Eds.), Principles and practice of stress management (pp. 108-141). New York: The Guilford Press. Crandon, A.J. (1979).Maternal anxiety and obstetric complications. Psychosomatic Medicine, 23 (2), 109-111. Creasy, R., & Resnick, R. (1994).Maternal-fetal medicine: Principles and practice ( 3rd ed). Philadelphia: W.B. Saunders. Crist, D., Rickard, H., Prentice-Dunn, S., & Barker, H. (1989). The relaxation inventory: Self-report scales of relaxation training effects. Journal of Personality Assessment, 53(4), 716-726.

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Jill Janke is a professor of nursing at the University of Alaska Anchorage. Address for cowespondence: Jill Janke, RNC, MN, DNSc, University of Alaska Anchorage, 321 1 Providence Drive, Anchorage, AK 99508.

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