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Factors Associated With Labor Support

Behaviors of Nurses
Samantha J. Barrett, RN, BSN
Mary Ann Stark, RNC, PhD

ABSTRACT
Labor support is known to support progress of normal labor. Nurses are encouraged to provide labor
support yet may encounter barriers to the practice of labor support. The purpose of this secondary
data analysis was to examine individual and institutional factors associated with labor support behav-
iors. Age and experience were individual factors related to labor support. Older and more experienced
nurses reported providing more labor support. Institutional factors associated with labor support
were lower rates of epidural analgesia use and cesarean surgery. These ndings indicate birthing
families should understand that the birth environment may inuence the care that nurses give during
labor. Choosing an environment that supports normal birth may be the best place for receiving labor
supportive nursing care.

The Journal of Perinatal Education, 19(1), 1218, doi: 10.1624/105812410X481528


Keywords: labor support, labor epidural, normal birth

Having labor support from a nurse during labor can REVIEW OF LITERATURE
have benefits for mother and baby. Labor support What Is Labor Support?
does not always occur because nurses tend to have Labor support is a term used to describe the work of
coexisting responsibilities for more than one labor- caring or social support that is provided to women
ing woman, spend large amounts of time managing during labor and birth (Payant, Davies, Graham,
technology or keeping records, and begin or end Peterson, & Clinch, 2008). Birth outcomes improve
shifts in the middle of womens labors (Hodnett, when a trained birth companion (doula), nurse, or
Gates, Hofmeyr, & Sakala, 2007). While providing nurse-midwife provides supportive care (Sleutel,
labor support is an important component of nurs- 2002). When labor support behaviors are imple-
ing care, only 6.1% of nurses time was spent in pro- mented consistently, they have the ability to posi-
viding supportive care in a work sampling study of tively affect birth experiences (Adams & Bianchi,
intrapartum nurses (Gagnon & Waghorn, 1996). 2008).
The purpose of the present study was to examine Hodnett et al. (2007) completed a systematic re-
factors associated with labor support behaviors of view to assess the effect of continuous, one-to-one
nurses. intrapartum support, compared with usual care.

12 The Journal of Perinatal Education | Winter 2010, Volume 19, Number 1


The outcomes of their review included labor events, and positions in labor that are known to be bene-
birth events, newborn events, immediate maternal ficial to the progress of labor (Hodnett et al., 2007).
psychological outcomes, and long-term maternal The act of labor support includes three main
outcomes. Overall, 16 trials involving 13,391 ideas: emotional support, physical comfort, and ad-
women met the criteria for inclusion in their review vocacy. First, emotional support is directed toward
and provided usable outcome data. The results activities such as continuous presence, positive re-
revealed that women who had continuous one- assurance, and praise (Miltner, 2000; Payant et al.,
to-one support during labor were less likely to have 2008). According to Adams and Bianchi (2008),
regional analgesia/anesthesia, an instrumental vag- emotional support can encompass several types of
inal birth, or cesarean surgery or to report dissatis- behavior: nursing presence, effective caring attitude,
faction with the childbirth experience. Women with distraction, spirituality, and partner care. Second,
continuous one-to-one labor support were more physical support and comfort measures enhance
likely to have a spontaneous vaginal birth and labor progress and increase satisfaction with the
tended to have slightly shorter labors. Hodnett birth experience (Adams & Bianchi, 2008). To ac-
et al. (2007) also discovered evidence that strong complish this, nurses may use environmental con-
and prolonged continuous support during labor trol, proper positioning, touch, application of cold
may be most effective, and continuous support ap- and heat, and partner care. During labor and birth,
pears to be more effective when it is provided by proper positioning can reduce pain, analgesia use,
caregivers who are not employees of the institution. and perineal trauma and enable more effective uter-
Also, continuous support that begins earlier in labor ine contractions (Adams & Bianchi, 2008). Provid-
appears to be more effective than support that be- ing physical comfort consists of activities such as
gins later in labor. Three meta-analyses provided therapeutic touch, massage, warm baths or showers,
consistent findings that women in labor who had and encouraging fluid intake and output (Payant
continuous support were less likely to have a cesar- et al., 2008). Interventions that encourage comfort
ean or forceps birth and receive oxytocin (Hodnett, during labor may allow the laboring woman to
2002; Scott, P. Klaus, & M. Klaus, 1999; Zhang, be actively involved in her labor, giving her confi-
Bernasko, Lebovich, Fahs, & Hatch, 1996). The re- dence and strength (Schuiling & Sampselle, 1999).
view completed by Hodnett et al. (2007) provides Last, advocacy for the laboring woman consists of
compelling evidence that continuous labor support communicating the womans wishes and offering
is a cost-effective, safe intervention that may be ben- information about the progress of labor, coping
eficial for many women. Their finding suggests that methods, or relaxation techniques (Payant et al.,
continuous one-to-one labor support should be the 2008). When advocating for the laboring woman,
norm for women in labor. the nurse must convey respect, acknowledge the
Although labor support can be provided by a va- mothers expectations, and resolve conflict (Adams
riety of individuals (e.g., a family member or friend, & Bianchi, 2008).
a trained doula, a labor nurse, or a nurse-midwife), In addition to the three main ideas of labor sup-
a labor nurse is always present during hospital la- port, Hodnett (1996) proposed that labor support
bors and birth. Labor support provided by nurses also consists of information/advice and partner
has been examined by many researchers and is support. Instructional/informational labor sup-
the focus of this research. Intrapartum nurses are port behaviors include instruction for relaxation,
present at 99% of births and have a unique oppor- breathing, and pushing and information about pa-
tunity to positively affect a laboring woman (Adams tient care. Providing instruction about breathing
& Bianchi, 2008). Because nurses spend more time awareness and use of different breathing levels
with women in labor than do other health-care can increase a womans confidence and ability to
providers, nurses can have a powerful influence cope with contractions (Adams & Bianchi, 2008).
on the physiologic and psychosocial outcomes of Nurses also can decrease anxiety and provide sup-
the childbirth experience (Payant et al., 2008). port to the partner by offering information about
The theoretical basis for the benefits of labor sup- the womans labor progress (Adams & Bianchi,
port is proposed to be the reduction of stress and
stress responses a woman may experience in labor
Continuous labor support is a cost-effective, safe intervention that
(Corbett & Callister, 2000). In addition, the nurse
providing labor support may encourage activities may be beneficial for many women.

Labor Support | Barrett & Stark 13


2008). It is also important that the intrapartum cluded on the survey. Both scenarios involved a
nurse assess the partners expectations related to 26-year-old healthy female; however, in the first sce-
the labor and birth process; if the expectations nario, the woman requested a natural childbirth,
are not in conflict with the laboring woman, every while in the second scenario she received a labor
attempt should be made to honor them (Adams & epidural. The intentions to provide continuous
Bianchi, 2008). labor support were higher in the no epidural sce-
nario. This intention is suggestive of a common
The Problem myth that if she is not hurting, the laboring woman
Concerns about lack of labor support have been does not have emotional needs. Payant et al. (2008)
growing since the middle of the 20th century also found that 40% of the nurses who completed
when the majority of women began to give birth the survey were unaware of research evidence that
in a hospital setting as opposed to the home setting supports the benefits of continuous labor support.
(Hodnett et al., 2007). Modern obstetric care in Collectively, nurses had lower intentions, subjective
a hospital setting may interrupt the natural process norms, and attitude scores to providing continuous
of birth by subjecting women to institutional rou- labor support to women with epidural analgesia when
tines, high rates of intervention, unfamiliar personnel, compared to women without (Payant et al., 2008).
and lack of privacy (Romano & Lothian, 2008).
These harsh conditions may have an adverse effect Barriers to Continuous Labor Support
on the progress of labor and may inhibit the laboring While nurses may believe that labor support is ben-
woman from feeling competent and confident in her eficial, they encounter barriers to providing this
ability to give birth naturally (Hodnett et al., 2007). support to their patients. Sleutel, Schultz, and
Another concern regarding labor support lies Wyble (2007) conducted a qualitative study to ex-
within the ability of the professional nurse to pro- amine nurses views of barriers to continuous la-
vide effective labor support considering the modern bor support. Their study included 416 registered
institutional birth environment (Zwelling, 2008). nurses who provided narrative comments. The most
Nurses tend to have coexisting responsibilities for frequent comment was that unnecessary medical in-
more than one laboring woman, spend large terventions prevented nurses from providing opti-
amounts of time managing technology or keeping mal labor support. Factors that hindered nurses
records, and begin or end shifts in the middle of intrapartum care fell into six themes; (1) hastening,
womens labors (Hodnett et al., 2007). In a study controlling, and mechanizing birth; (2) facility cul-
by Barnett (2008), labor and delivery nurses were ture and resources; (3) mothers knowledge and
asked an open-ended question about the factors that medical status; (4) outdated practices; (5) conflict;
interfered with the time they spent with a laboring and (6) ethical/professional decline. Of these six
woman. The majority of nurses reported on the themes, hastening, controlling, and mechanizing
need to care for other laboring patients. The intra- birth was most frequently mentioned (Sleutel
partum nurse is also expected to know what labor et al., 2007). This particular theme was alarming
support is and how to provide it; however, little because research does not support that medical
agreement about its meaning or its nature is appar- management of labor and birth is safer than re-
ent (Sauls, 2006). Collectively, this means one- specting and facilitating normal physiology (Romano
to-one support by a nurse may be the exception, & Lothian, 2008).
not the routine. Many nurses in Sleutel et al.s (2007) study also
reported that medical interventions were a barrier
Intention to Provide Labor Support to optimal nursing care and to professional labor
Why is continuous nursing labor support not the support techniques. On the other hand, it is not just
norm for providing labor care? Payant et al. (2008) health-care professionals who seem to hasten and
examined nurses intentions to provide labor control the labor and birth experience. Many nurses
support. The study included 97 registered nurses in Sleutel et al.s (2007) study wrote that patients
from two birthing units. Nurses views regarding and families had unrealistic expectations to have
continuous labor support were measured with a sur- a scheduled birth on demand with no pain. Nurses
vey that included questions about subjective norms, also reported that patients had their minds made up
perceived behavioral control, intention, attitudes, before labor to get an epidural and often declined try-
and organizational barriers. Two scenarios were in- ing nonpharmacologic methods of pain reduction.

14 The Journal of Perinatal Education | Winter 2010, Volume 19, Number 1


Sleutel et al. (2007) found that barriers within who were outdated, unethical, or interventionistic.
the birthing culture included architectural limita- Findings from Sleutel et al.s (2007) study suggest
tions such as not having whirlpools, rocking chairs, that nurses want to provide labor support but en-
birthing balls, or showers. On a more positive note, counter factors that discourage them. Sleutel
the nurses in their study also said that teaching hos- et al.s (2007) study is consistent with facilitators
pital environments influenced the nurses ability to reported by Davies and Hodnett (2002).
provide labor support techniques because more
emphasis was placed on evidence-based care. Poor Mothers Perceptions of Labor Support
staffing and lack of midwives and doulas were also In exploring mothers experiences of labor support,
obstacles. Outdated practices were reported as frus- Bowers (2002) reviewed and synthesized findings
trating and included physicians not allowing from qualitative research of womens perceptions
nurses to use intermittent fetal monitoring or have of professional labor support. The 17 studies in-
mothers labor in chairs. Another frustrating topic, cluded in Bowers (2002) review were dated from
conflict, occurred mainly when physicians or other 1990 to 2001. The findings indicated that women
nurses undermined the respondents attempts to expected to have pain during labor and birth,
use evidence-based care including labor support and they also expected to have culturally appropri-
techniques. Ethical decline was extremely frustrat- ate interventions to help them control and manage
ing to the respondents and consisted of working pain. Pregnant women expected nurses would sup-
with colleagues who preferred monitoring laboring port them during labor by making them as comfort-
patients from the nursing station rather than pro- able as possible, keeping them calm, keeping their
viding bedside labor support. The findings from coaches calm, providing reassurance that everything
Sleutel et al.s (2007) study are consistent with an- would be alright, providing assistance with breath-
other study of intrapartum nurses who reported in- ing and relaxation techniques, and providing com-
adequate staffing, negative attitudes of other staff, fort measures that would assist in relieving pain.
the physical environment, and lack of management Another expectation was that they would have
support as factors preventing labor support (Davies the continuous presence of a nurse during labor.
& Hodnett, 2002). In an earlier study by Bryanton, Fraser-Davey,
and Sullivan (1994), women reported similar nurs-
ing behaviors as supportive, including giving praise,
Facilitators of Labor Support being calm and confident, helping with breathing
Sleutel et al. (2007) found four themes that helped and relaxation, and treating the woman with re-
nurses provide labor support: (1) teamwork/collab- spect. Women in a qualitative study of the meaning
oration; (2) philosophy of birth as a natural process; of nursing presence in labor assumed that nurses
(3) facility culture and resources; and (4) nursing would be available to them and know and under-
impact, experience, and autonomy. Respondents stand them (MacKinnon, McIntyre, & Quance,
highly valued teamwork with physicians and nurse- 2005). Also, a positive perception of childbirth, in-
midwives; nurses reported labor support was en- cluding satisfaction with childbirth and care, may
hanced when physicians respected their judgment be promoted by fewer interventions such as induc-
and professional opinion. Respondents testified to tions, forceps/vacuum extraction, and episiot-
the normality of birth if it is allowed to progress omies, by participation in decision making, and
without harsh, unnecessary medical interventions. by a positive perception of partner, nurse, midwife,
One nurse said, For 90% of women, labor can and doula support (Bryanton, Gagnon, Johnston,
be a natural, normal, beautiful experience (p. & Hatem, 2008). These studies all suggest that
209). Another nurse stated, Time. Let nature take women expect nurses to provide labor support
its course (p. 209). For this philosophy to be prac- to them.
ticed, the facility needs to have beliefs that match the According to findings in the literature, labor sup-
philosophy of labor care. One nurse said, I am for- port provided by a nurse is beneficial to the progress
tunate to work in a facility that provides a lot of nat-
ural childbirth and labor support. It makes this job Teaching hospital environments influenced the nurses' ability to
much more gratifying (p. 209). Some nurses
provide labor support techniques because more emphasis was
reported experiencing dissatisfaction, disillusion-
ment, and distress from working with providers placed on evidence-based care.

Labor Support | Barrett & Stark 15


of normal labor and valued by laboring women. nurses and had worked for a mean of 14.3 (SD
There are factors, however, that may interfere with 9.3) years with laboring women. The highest degree
the provision of labor support by nurses. The pur- in nursing among the participants was a masters
pose of this secondary data analysis was to examine degree in nursing (n 6, 9.4%), with more than
factors associated with labor support behaviors of one third (n 23, 35.9%) holding a bachelors
nurses who provide labor and birth care. Two re- degree in nursing; most of the participants had a
search questions guided this study. First, is there diploma or associates degree (n 35, 54.7%).
a relationship between nurses demographic charac- The facilities where they worked had mean epidural
teristics and labor support? And second, is there a rates of 53.2 (SD 21.2) percent; most births were
relationship between labor support behaviors of attended by either obstetricians (n 28, 43.8%) or
nurses and characteristics of the birthing units in certified nurse-midwives (n 30, 46.9%).
which they provide care?
RESULTS
METHODS To address the first research question for our study,
The current study was a secondary analysis of data we examined relationships between the nurses LSS
reported by Stark and Miller (in press). In the orig- scores, which measured the level of their labor sup-
inal study (completed in December 2006), intrapar- port behaviors, and demographic characteristics. A
tum nurses who had provided care to laboring positive relationship existed between labor support
women in the previous 24 months were recruited behaviors and age (r .39, p .004) and experience
from three hospitals. The institutional review giving care to birthing women (r .31, p .022).
boards of the three hospitals and a university ap- Age and experience were the only two individual
proved the study. Nurses were recruited via hospital characteristics of the nurses that were associated
e-mail distribution lists. Members of a local chapter with labor support behaviors, as measured by the
of the Association of Womens Health, Obstetric, LSS. No difference was found in the LSS scores when
and Neonatal Nurses were also recruited via e-mail. examined by education (less than a bachelors de-
Nurses who chose to participate in the study com- gree and bachelors degree in nursing or higher)
pleted an online survey generated by the 2006 ver- (t .92, df 53, p ns).
sion of SurveyMonkey.com. A total of 65 nurses To address the second research question, we ex-
completed the survey. Data from one subject were amined relationships between characteristics of the
excluded because she indicated she had not pro- nurses birthing units where they worked and their
vided labor care in the previous 24 months. LSS scores. A negative relationship existed between
To measure the concept of labor support, Stark labor support and use of epidural analgesia (r
and Miller (in press) used the Labor Support Scale .47, p .000) and cesarean surgery (r .38,
(LSS). Developed by Sleutel (2002), the LSS is p .005). Nurses who worked in birthing units with
a 28-item instrument in which higher scores indi- higher epidural rates or higher cesarean surgery
cate greater labor support behaviors. Sleutel rates reported fewer labor support behaviors. A pos-
(2002) tested the scale for validity and reliability itive relationship was found between the use of hy-
(Cronbachs a .90). For Stark and Millers (in drotherapy and labor support (r .46, p .000).
press) study, the internal consistency (Cronbachs No difference was found in LSS scores when pri-
a) of the LSS was .94. In addition to the LSS, Stark mary care providers (physicians or nurse-midwives)
and Miller (in press) used a demographics question- were considered (t .36, df 52, p ns). No
naire, which they developed for their study. The associations existed between labor support behav-
questionnaire included queries about the partici- iors, as measured by the LSS, and other hospital
pating nurses and the hospitals where they worked. attributes.
In the current study, data collected from the LSS
and the demographics questionnaire in Stark and DISCUSSION AND IMPLICATIONS
Millers (in press) investigation were analyzed to In the current study, the nurses demographic vari-
examine factors associated with labor support be- ables of age and experience caring for laboring
haviors of nurses. women were related to their providing labor sup-
Of the 64 nurses who completed the online sur- port. Older and more experienced nurses were more
vey, all were females with a mean age of 43.5 (SD likely to have developed labor support skills. This
10.6) years. Most (n 54, 84.4%) worked as staff finding has been reported previously. Sleutel et al.

16 The Journal of Perinatal Education | Winter 2010, Volume 19, Number 1


(2007) suggested nurses experience and autonomy Birthing units may benefit from having experienced nurses who can
are critical to their effectiveness and use of labor
mentor and support younger nurses developing labor support
support behaviors. In Sleutel et al.s (2007) qualita-
tive study, one nurse said, Lots of experience en- behaviors.
ables me to provide great alternatives to patients
and influence care providers (p. 210). The rela-
tionships between age/experience and increased previous studies and the current investigation, the
labor support are reasonable. Nurses who have birthing environment in which labor and birth care
more experience giving labor care have had the op- is provided can positively or negatively influence
portunity to become more confident and competent labor support behaviors of nurses.
in giving care than younger, less experienced nurses. The current studys findings present several im-
Birthing units may benefit from having experienced plications for perinatal educators and for birthing
nurses who can mentor and support younger nurses women and their families. Perinatal educators
developing labor support behaviors. Because some who are nurses are valuable role models and poten-
nursing curricula have decreased obstetrical nursing tial mentors to other nurses who are less experi-
content in recent years, new graduates may have less enced and confident in providing labor support.
formal education in providing labor support. Al- In addition, perinatal educators can work with hos-
though the younger generation of nurses may be pitals to host labor support workshops for nurses
comfortable with technology, they may lack skills who provide birth care. All nurses, especially those
in providing labor support. who work in environments with high rates of med-
In our study, nurses who worked in facilities with ical interventions, may benefit from labor support
high rates of epidural use and cesarean surgery were workshops. Some nurses may lack knowledge of
less likely to use labor support behaviors than nurses the evidence supporting labor care, as reported by
who worked in facilities with low rates of medical Payant et al. (2008). Encouraging nurses to read
intervention. This finding not only demonstrates the literature and attend workshops on the topic
that the birthing environment can positively or neg- of labor care would be beneficial.
atively influence individual nursing care, but also Perinatal educators can maintain contact with
suggests that medical interventions may negatively birthing units to track changes in rates of medical
influence labor support behaviors of nurses. Our procedures. Rising rates of medical procedures such
studys finding is consistent with similar results as epidurals and cesarean surgery may also indicate
from previous research. In Sleutel et al.s (2007) that labor support may decrease, even for patients
study, nurses reported the most frequent barrier who do not receive the interventions. Educators
to providing labor support was unnecessary medical can inform couples selecting birthing care providers
interventions. According to Hodnett et al. (2007), and environments that facilities with higher rates of
when there are high rates of medical interventions, medical interventions may also provide less labor
nurses may be caught up in attending to technology, supportive care. Finally, perinatal educators can en-
keeping records, and monitoring the laboring courage women and their partners who want a nor-
women in order to safely carry out the procedure mal labor and birth to have a doula present to
rather than giving comfort and providing labor sup- provide labor support. Although women may expect
port. In addition, laboring women who receive nurses to provide continuous labor support (Bowers,
medical interventions (e.g. an epidural or labor in- 2002), this may not be a realistic expectation.
duction) have more limitations (e.g. limited move- Limitations to the present study must be ac-
ment, confined to bed, limited oral intake). The knowledged. The study was a secondary analysis
interventions and subsequent limitations may give of data. Consequently, the variables and measures
the nurse the perception that less labor support can were limited by the original study. The sample
be provided. In a study by Payant et al. (2008), was small and homogenous. Future research is rec-
nurses reported lower intentions to provide contin- ommended on a larger more diverse sample.
uous labor support to women with epidural analge- In conclusion, evidence shows that continuous
sia than to women without epidural analgesia. labor support and the facilitation of normal birth
Payant et al. (2008) suggested nurses may perceive is the best option for laboring women (Romano
that labor support is not needed when pain is re- & Lothian, 2008); however, continuous labor sup-
lieved by epidural analgesia. Thus, as indicated in port by nurses is not routinely provided. Perinatal

Labor Support | Barrett & Stark 17


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SAMANTHA J. BARRETT is a graduate of the Bronson School of
(2007). Continuous support for women during
childbirth. Cochrane Database of Systematic Reviews Nursing and the Lee Honors College at Western Michigan Uni-
(Online : Update Software), (Issue 3), CD003766 10. versity in Kalamazoo. She currently works as a critical care nurse
1002/14651858.CD003766.pub2. at Munson Medical Center in Traverse City, Michigan. MARY
MacKinnon, K., McIntyre, M., & Quance, M. (2005). The ANN STARK is an associate professor in the Bronson School
meaning of the nurses presence during childbirth. of Nursing at Western Michigan University.

18 The Journal of Perinatal Education | Winter 2010, Volume 19, Number 1


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