Effects of antepartum electronic fetal monitoring on maternal emotional state
Abstract
Background. To evaluate the emotional state of pregnant women undergoing computerised cardiotocography (cCTG). Methods. A questionnaire including questions about socio-demographic background, personal obstetric history and physician-patient relationship was given to 204 pregnant women about to undergo cCTG. The Edinburgh Post-natal Depression Scale (EPDS) was used to assess patients’ mood state before CTG, while the Spielberger State-Trait Anxiety Inventory (STAI) was used to evaluate anxiety levels before and after this examination. Results. Mean STAI T-anxiety score did not differ before and after CTG (p = 0.38), but higher levels of basal anxiety were found in women who had undergone only occasional prenatal controls (p = 0.04), as well as smokers (p = 0.01), and women preferring a vaginal delivery (p = 0.01). The mean STAI S-anxiety score of 43.6±4.03 before the cardiotographic examination, increased to 45.2±5.4 after this test with a statistically significant difference (p = 0.0001). This increase was found to be correlated with the presence of obstetric complications during the current pregnancy (p = 0.036) and a lower number of fetal active movements (p = 0.029). Based on the EPDS, 22 patients (14.1%) were found to be depressed, but this condition was not correlated with significant increases in anxiety levels. Conclusions. Anxiety levels in pregnant women who undergo routine CTG are increased, and this emotional reaction seems to be influenced by the perception of fetal movement during the examination, and is more evident in pregnancies affected by obstetric complications.
Introduction
Analysis of the fetal heart rate (FHR) by cardiotocography (CTG) is the most widely used method to assess fetal well-being during pregnancy and labour. In a high-risk pregnancy, its initiation depends on the severity of obstetric indications, while in low-risk pregnancies it is usually performed beyond the estimated date of delivery and routinely employed in clinical practice. Although several reports have analysed the benefits of this technique in predicting fetal compromise (1), no report has studied the effects of this routine test on the maternal emotional state. Over the last few decades, growing attention has been paid to the psychological aspects of pregnancy in order to help women in this particular state, and to reduce maternal and fetal risks associated with stress and anxiety in pregnancy (2). It has been reported that gestational anxiety is associated with an increased rate of caesarean section (3), obstetric abnormalities such as premature birth and lower birth weight (4), and fetal neurobehavioural development (5). In light of this, the potential psychological effects of prenatal screening tests have been studied by several authors, but have produced conflicting results. It has been reported that performing certain procedures, such as maternal serum screening (6), ultrasound examination (7), amniocentesis (8) and prenatal screening for group B streptococcus disease (9), is associated with increased levels of anxiety, especially when these procedures test positive. However, these studies focussed mainly on women's reactions to the results of these procedures, while less attention was paid to the effects that these tests have per se on maternal emotional state.
The aim of this study was to evaluate the effects of CTG on the maternal emotional state by assessing pre- and post-anxiety levels in a sample of low-risk pregnant women undergoing fetal heart monitoring at 40 weeks’ gestation.
Material and methods
This study was carried out at the Department of Gynecological, Obstetrical Sciences and Reproductive Medicine in Messina University Hospital between January and July 2006. Some 204 consecutive pregnant women at 40 completed weeks of gestation (≥280 days), who were attending our Department to book their first antepartum computerised CTG (cCTG), were enrolled in this study. All women were thoroughly briefed on the study, and provided written consent to participate. The participants were asked to complete a questionnaire, a self-rating scale for evaluating anxiety (State-Trait Anxiety Inventory; STAI) (10), and a self-rating instrument to assess depression (Edinburgh Post-natal Depression Scale; EPDS) (11). A specialist in psychiatry (GF) explained how to respond to these scales. Two days later, these patients underwent cCTG. Immediately after this procedure, but before knowing the results, the women were asked to complete a second STAI scale in order to evaluate the anxiety levels linked to this examination.
Questionnaire
The questionnaire contained 3 sections. The first part included questions about socio-demographic background: age (<35 years, ≥35 years), marital status (married, unmarried), level of education (high: high school, university; low: compulsory schooling), family income (middle-high: $18,000; low: <$18,000) and occupation (employed, unemployed).
The second section contained questions regarding the patient's obstetric history: parity (nulliparous, multiparous), previous miscarriages (yes/no), alcohol consumption (yes: ≥1.5 drinks per day; no: <1.5 drinks per day), use of tobacco (yes/no), and the presence of obstetric complications in the current pregnancy (yes/no). The question used for the latter item was: ‘Have you had any obstetric complications?’ (The following complications were mentioned: threatened abortion, diet-controlled gestational diabetes mellitus, mild gestational hypertension, preterm labour.)
The third part focussed on the physician–patient relationship: a personal evaluation (sufficient/insufficient) of the quality of information provided by the physician about the course and possible complications of pregnancy and delivery, the frequency of prenatal controls (regular/occasional), and a subjective assessment of relations with the physician (satisfactory/unsatisfactory). Women were also asked about the kind of delivery they preferred (vaginal birth/caesarean section).
Psychiatric tools
Anxiety was assessed using the STAI, which consists of 2 self-report scales for measuring 2 distinct dimensions of anxiety, state-anxiety and trait-anxiety (Cronbach's alpha 0.87 for state-anxiety and 0.85 for trait-anxiety). Both scales contain 20 statements that ask the respondent to describe how she feels at a particular moment in time (state-anxiety) or how she generally feels (trait-anxiety). State anxiety (STAI S-anxiety) is conceptualised as a transitory emotional state, whereas trait-anxiety (STAI T-anxiety) refers to relative static individual differences in proneness to anxiety. The score for each statement is 1–4, with a total ranging from 20 to 80.
Depression levels were assessed using the Italian version of EPDS (Cronbach's alpha 0.79) (12). This self-report scale consists of 10 items assessing common symptoms of depression, such as dysphoric mood, anxiety, feeling of guilt and of not coping well. Scores for each question range from 0 to 3, increasing in severity so that 3 indicates the worst mood, while 0 refers to the absence of depressed mood. The total score may range from 0 to 30. A score ≥13 is considered indicative of a depressive state.
Cardiotocographic examination
The women were instructed to have a normal breakfast on the day of examination, but to abstain from coffee, tea, chocolate and smoking. The same operator (AD) carried out all examinations at the same time of day, between 09:00 and 10:00 h. During the examination, the women rested in a semi-recumbent position in a dimly lit and quiet room. FHR and fetal active movements (FAM) were recorded using a three-channelled cardiotocograph (8002 Sonicaid, Oxford Instruments Medical, Surrey, UK). The cardiotographic parameters considered in the analysis were: fetal movements reported as the ratio between the number of movements and the length of the examination, and expressed as movements per minute; duration of examination reported in minutes; FHR expressed in beats per minute (bpm). The first computerised analysis is performed at 10 min and repeated thereafter every 2 min until the Dawes-Redman criteria for normality are met (13), or otherwise the objective FHR record has a maximum duration of 60 min.
Statistical analysis
Statistical analysis was performed using the SPSS 13 software package (SPSS Inc., Chicago, IL, USA). The total scores of STAI (T-anxiety and S-anxiety) were reported as mean±standard deviation (SD), and differences in T-anxiety between the subgroups of demographic and obstetric variables (dichotomic) were analysed applying the Student's t-test for parametric continuous data, and the Mann–Whitney test for skewed data. The Wilcoxon sum-ranks test was used to compare mean S-anxiety and T-anxiety scores before and after CTG. A general linear model (GLM) for repeated measures was developed to assess the effects of the variables analysed in the questionnaire, as well as the cardiotocographic parameters on S-anxiety variations before and after CTG. The criterion for statistical significance was set at p < 0.05.
Results
Of the 204 patients enrolled, 48 (23.5%) were excluded: 22 women because they did not answer all the questions and 26 patients who delivered before the planned fetal examination. The remaining 156 (76.5%) pregnant women were considered for the analysis. The mean age was 31.3±4.9 years. All the items in the questionnaire given to the 156 pregnant women considered in our study are shown in Table I. As regards the CTG parameters, the mean number of fetal movements per minute was 1.08±0.97, the mean duration of the examination was 17.02±10.1 min, and the mean FHR was 135.9±10.64 bpm. The mean EPDS score was 7.9±4.5. Some 134 women (85.9%) had a score ≤13, while 22 patients (14.1%) had a value above the cut-off and were thus classified as depressed. The analysis of anxiety showed that the mean STAI T-anxiety score did not differ before and after CTG (45.2±4.2 versus 45.5±4.5, p = 0.38). When this type of anxiety was matched with the questionnaire items, higher levels of basal anxiety were found in women who had undergone only occasional prenatal controls (occasional versus regular: 49.5±2.9 versus 45.1±4.2, p = 0.04), who smoked (smokers versus non-smokers: 45.4±4.1 versus 42.0±4.0, p = 0.01) and who preferred a vaginal delivery (vaginal versus caesarean section: 45.6±4.4 versus 43.4±2.7, p = 0.01). No significant differences were found for the other variables considered (Table II). In contrast, the mean STAI S-anxiety score of 43.6±4.03 before the cardiotographic examination increased to 45.2±5.4 after CTG, and this increase was statistically significant (p = 0.0001). The univariate analysis adjustment for the variables analysed in the questionnaire revealed that only the presence–absence of obstetric complications during the current pregnancy was able to account for the significant increase in STAI S-anxiety after CTG (p = 0.03). None of the other variables considered in the questionnaire correlated with this increase.
| Marital status | Smoking habits | ||
| Married | 130 (83.3%) | Yes | 10 (6.4%) |
| Unmarried | 26 (16.7%) | No | 146 (93.6%) |
| Financial income | Alcohol consumption | ||
| Low | 74 (47.4%) | Yes | 20 (12.8%) |
| Middle-high | 82 (52.6%) | No | 136 (87.2%) |
| Educational level | Obstetric complications | ||
| Low | 38 (24.4%) | Yes | 32 (20.5%) |
| Middle-high | 118 (75.6%) | No | 124 (79.5%) |
| Occupation | Prenatal controls | ||
| Employed | 81 (51.9%) | Regular | 152 (97.4%) |
| Unemployed | 75 (48.1%) | Occasional | 4 (2.6%) |
| Parity | Quality of information | ||
| Nulliparas | 76 (48.7%) | Sufficient | 140 (89.7%) |
| Multiparas | 80 (51.3%) | Insufficient | 16 (10.3%) |
| Previous miscarriage | Preferred kind of delivery | ||
| Yes | 36 (23.1%) | Vaginal delivery | 130 (83.3%) |
| No | 120 (76.9%) | Caesarean section | 26 (16.7%) |
| Current pregnancy | Relations with physician | ||
| Planned | 142 (91%) | Unsatisfactory | 14 (9%) |
| Unplanned | 14 (9%) | Satisfactory | 142 (91%) |
| Variables | T-anxiety scores* | p-Value | Variables | T-anxiety scores* | p-Value |
|---|---|---|---|---|---|
| Marital status | Smoking habits | ||||
| Married | 45.3±4.2 | 0.6 | Yes | 42.0±4.0 | 0.01 |
| Unmarried | 46.1±4.2 | No | 45.4±4.1 | ||
| Financial income | Alcohol consumption | ||||
| Low | 44.6±3.9 | 0.07 | Yes | 46.7±4.7 | 0.09 |
| Middle-high | 45.8±4.3 | No | 45.0±4.1 | ||
| Educational level | Obstetric complications | ||||
| Low | 45.3±4.2 | 0.6 | Yes | 45.2±4.4 | 0.9 |
| Middle-high | 44.9±4.4 | No | 45.2±4.2 | ||
| Occupation | Prenatal controls | ||||
| Employed | 45.2±4.7 | 0.6 | Regular | 45.1±4.2 | 0.04 |
| Unemployed | 45.3±3.6 | Occasional | 49.5±2.9 | ||
| Parity | Quality of information | ||||
| Nulliparas | 45.6±3.8 | 0.26 | Sufficient | 45.3±4.2 | 0.4 |
| Multiparas | 44.8±4.6 | Insufficient | 44.4±4.7 | ||
| Previous miscarriage | Relations with physician | ||||
| Yes | 44.2±3.6 | 0.09 | Unsatisfactory | 44.7±3.9 | 0.6 |
| No | 45.5±4.3 | Satisfactory | 45.3±4.2 | ||
| Current pregnancy | Preferred kind of delivery | ||||
| Planned | 45.4±4.1 | 0.09 | Vaginal delivery | 45.6±4.4 | 0.01 |
| Unplanned | 43.4±5.1 | Caesarean section | 43.4±2.7 |
- *Mean±SD.
The same analysis was applied to the variables linked to CTG parameters, and showed a significant increase in STAI S-anxiety only when adjusting for FAM (p = 0.027). Therefore, the duration of the examination and FHR were not associated with the state anxiety increase (p = 0.4 and p = 0.31, respectively).
When adjusting for EPDS values, as a continuous or dichotomised variable, to evaluate the influence of mood on state anxiety changes, no significant correlation with the increase of this emotional component was found (continuous: p = 0.35, dichotomised data: p = 0.31).
The multiple regression analysis, which was applied to the statistically significant variables at univariate analysis, showed that both the variables analysed (FAM and presence–absence of complications) were independently correlated with the increase in state anxiety levels (p = 0.029 and p = 0.036, respectively).
Discussion
Today many prenatal screening tests are offered to pregnant women as part of routine prenatal care. As a result, in general, attention to the psychological aspects of such testing is increasing. Some reports have mostly focussed on women's reaction to antenatal screening, such as first trimester ultrasound nuchal translucency (7, 14), maternal serum screening test (15), amniocentesis (8), and group B streptococcus screening (9). Although increased levels of anxiety were found in all these reports, in some studies the focus was on the performance of these procedures, while others analysed the anxiety levels in relation to the results of screening. Our study, which focussed on the psychological aspects of CTG, a routine and non-invasive test, is consistent with the literature relating to other screening tests in that it also found increased anxiety (8, 16). The analysis of anxiety, performed by the STAI, highlighted that Electronic Fetal Monitoring (EFM) has an important effect only on S-anxiety, which increases in response to physical danger and psychological stress, but not on T-anxiety, which evaluates personal feelings in general. This indicates that the increased levels of anxiety after CTG are linked to a reactive rather than an intrinsic emotional state. However, our results also highlight that T-anxiety is not uniform in the pregnant women population, and is influenced by some individual characteristics. Higher levels of T-anxiety were found in non-smokers, probably because smokers attenuate their anxiety by nicotine, in women who had only occasional prenatal controls, probably because they had taken less care during their pregnancy, and in women who preferred a vaginal delivery. A possible explanation for the latter finding could be that a less painful mode of delivery, such as CS, considered safer for the newborn and themselves, removes the fears surrounding an unpredictable event, namely natural delivery. This choice of the ‘safer’ option thus modifies the psychological approach of women to pregnancy and decreases levels of basal anxiety (3).
The increase in S-anxiety levels that emerged in our report was not found to be significantly influenced by any of the background characteristics with the exception of the presence of complications in the current pregnancy. Since pregnant women know that CTG is an instrumental examination that is able to evaluate fetal well-being, this procedure can lead to heightened anxiety in patients with a complicated pregnancy. In contrast, a previous obstetric history complicated by spontaneous abortion does not seem to influence the emotional state in the current pregnancy. However, it has been reported that the rate of psychological disorders following previous adverse events, such as miscarriage, tends to fall to community levels within 1 year (17). Therefore, it is likely that pregnant women near to childbirth have already resolved their internal conflicts and are focussing their attention on the current experience.
Concerning the analysis of mood in pregnancy, our results did not show higher levels of T-anxiety in women with an EPDS score ≥13. Moreover, depression was not found to be correlated with an increase in S-anxiety. However, it is worth mentioning that a fairly highly percentage of pregnant women in our sample (14.1%) reported feeling depressed during pregnancy (EPDS ≥13), and this finding is in line with the literature (18).
As regards the CTG parameters considered in our report, only FAM were found to be linked with a significant increase in S-anxiety, while FHR and the duration of the examination did not modify the S-anxiety profile. Since pregnant women know that FAM are an important indicator of fetal well-being and that a decrease in FAM could be a signal of fetal suffering, the maternal perception of few fetal movements during CTG generates greater levels of anxiety. Moreover, FAM is the only one of these parameters that can be perceived by women; it is more difficult for them to detect changes in FHR and for this reason does not influence maternal anxiety. Increased levels of anxiety were also not associated with CTG duration, probably because women on their first examination were not informed about the normal duration of this procedure or that the length of examination was similar through the whole sample.
In conclusion, our study showed that women who undergo CTG have an increase in anxiety levels, as reported for other prenatal screening tests. This emotional reaction seems to be influenced by the perception of fetal movement during the examination and is more evident in pregnancies affected by obstetric complications. Given these results, it is desirable that women undergoing even a routine test, such as CTG, be supported in this by healthcare workers, such as psychologists, midwives and nurses, in order to facilitate pregnant women in their internal emotional working process. However, further studies are needed to corroborate our results.
