European Journal of Cardiovascular Medicine

Pregnancy is an incredibly stressful period due to outcome of delivery, anxious about the well-being of the unborn child, added responsibilities once the child is born, financial obligations, adapting to her postpartum body, interpersonal relationships with her spouse and other family members.

A certain degree of anxiety is considered normal in pregnancy but it can become troublesome and have detrimental effects on the mother, the unborn child and the rest of her family.

Pregnancy-specific maternal anxiety (PSA) is a separate and distinct condition which refers to fears and concerns about the pregnancy, birth, child's health, and ability to care for the kid. (1)

Pregnancy-specific anxiety was shown to be most prevalent in the third trimester in a study conducted in Kerala (2). Lack of official birthing instruction, inadequate perceived knowledge about delivery and parenting may be a contributing factor in the high frequency of pregnancy specific anxiety. (2)

An anxious mother during the time of delivery poses substantial risk to herself and her unborn child as anxiety can deter the progress of labour and cause harm to the unborn child. This has been linked to stimulation of hypothalamus causing an increase in the levels of the hormone adrenaline which is a vasoconstrictor hence leading to decreased blood flow to the uterus subsequently causing decreased blood flow to the placenta hence causing low oxygen availability to the fetus.(3)

Adrenaline has been linked to uterine contractions – in high concentrations it has been found to have stimulatory effects and help in inducing contractions but these were highly erratic, irregular and not maintained constantly throughout. On the other hand low levels of adrenaline decreased the uterine tone and was highly inhibitory to uterine activity .(4)

These physiological responses can further lead to maternal stress and exhaustion and prolong the duration of labour leading to complications making this entire process even more stressful and tiresome.

Majority of antenatal maternal anxiety studies has been done in high-income nations. On the other hand, little is known about this in research from low- and middle-income nations. (5). High rates of maternal and infant mortality, poor access to healthcare and the expense of receiving treatment can be considered as variables for increasing maternal anxiety (5).

This study attempts to fill the lacuna in knowledge on maternal mental health, in developing countries where awareness and access to mental health care services is limited. The novelty of this study is it focuses on term patients as this would be the apt time to provide emotional support and guidance which might help in alleviating her concerns and make her journey relatively smooth.

1. To determine whether higher anxiety levels in term patients has significant effects on the duration, progress and complications of labour
2. To assess whether significant maternal anxiety can lead to an increase in caesarean sections or instrumental deliveries.
3. To assess the difference in anxiety levels between term primigravida and term multigravida

The study was a descriptive cross-sectional study conducted in the Department of Obstetrics and Gynecology in IGMC&RI.  Antenatal women in the low-risk group with gestational age more than or equal to 37 weeks, who gave consent for participation were included in the study. Antenatal women who refused to give consent or those with known co-morbidities complicating labour like gestational diabetes mellitus, pregnancy induced hypertension, multiple gestation, breech presentation, placental abnormalities like placenta previa or abruption, previous history of caesarean section and cephalo - pelvic disproportion were excluded.

Before the commencement of the study, detailed information and instructions regarding the questionnaire was explained clearly.

All participants were asked to complete the Perinatal Anxiety Screening Scale (PASS) developed by Susanne Somerville et al. to screen for anxiety (10). It assesses four domains 1) Excessive worry and specific fears 2) Perfectionism, Control and Trauma 3) Social anxiety 4) Acute anxiety and adjustment. The items are on a scale of 0 to 3 (Not at all to almost always). (6) They were asked to rate according to the severity of symptoms if any, experienced during the past month. The final scores were calculated based on the responses obtained and were classified into three groups as Asymptomatic (0-20), having mild to moderate symptoms (21-41) and having severe symptoms (42-93). (11). Additionally, socio demographic details, obstetric score and details for communication of all participants were also obtained.

Details of labour were collected regarding spontaneous or induced, duration of labour, uterine contractions, mode of delivery were also recorded. From the data obtained, asymptomatic group and symptomatic group (mild to moderate or severe symptoms) were compared and the results were analyzed.

Sample size: 

Considering the proportion of pregnant women with anxiety as 22.6% (6), with alpha error as 5%, absolute error of margin as 5%, the minimum required sample size was using the formula given below. 

Sample size was calculated using following formula. N = z 2 (pq) / d 2  Where, n= sample size  p = proportion of pregnant women with anxiety

 q= 1-p 

d= absolute precision of 5

Z = the table value for alpha error corresponding to the standard normal deviation (1.96 for 5% alpha)

So, N = 269

Sampling technique:

Systematic random sampling (As per MRD statistics 720 patients arrived in the previous 2 months considering this number every alternate eligible pregnant woman was taken till the desired sample size).

Data analysis: 

Data was entered in excel and analyzed using SPSS version 20. Descriptive statistics is represented as frequency, percentages and standard deviation. Inferential statistics is done using chi square test / student T test. p < 0.05 will be considered significant.

The demographic details of the participants are shown in Table 1. Out of the 269 participants analysed for the study, Majority of them were housewives, belonged to the age group of 25-30 years (40%). Majority were graduates (49%) and pregnant for the first time (primi) (56.1%)

The PASS questionnaire scoring was as follows,

Among the 269 participants, 164 were classified asymptomatic (60.9%), 86 were classified to have mild to moderate anxiety (31.9%). and 19 were found to have severe anxiety (7%)

Table 1

The labour records of these participants were analysed and it was found that 138 participants had labour pain and delivered through spontaneous vaginal delivery without any forms of induction or augmentation.

Among these 49 participants (35.5%) were screened positive for anxiety

It was observed that none of these participants had any interventions including instrumental delivery, emergency LSCS or any factors complicating labour including slow progress of labour, inadequate uterine contractions leading to prolonged labour, foetal distress, manual removal of placenta or post-partum bleeding.

30 participants who were screened positive for anxiety had to be induced with either mechanical induction using Foleys catheter or using PGE2 gel (Dinoprost) following which they delivered through vaginal delivery and complications of labour mentioned above were notably absent among these participants also.

P value = 0.660

The difference in trend is not statistically significant

Duration of labour was assessed and the overall duration was not found to be prolonged among the participants screened for anxiety. P value could not be assessed as the duration of labour was not prolonged and remained a constant.

None of the following criteria were met

Latent phase more than 20 hours in primi and more than 4 hours in multigravida

Active phase – No cervical dilation after 4 hours of adequate uterine contractions Awith ruptured membranes in primi and after 6 hours of adequate uterine contractions in multigravida despite oxytocin administration.

Second stage duration of more than 3 hours without an epidural or 4 hours with an epidural in primi and more than 2 hours without an epidural or 3 hours with an epidural in multigravida.

Uterine contractions were assessed to assess if there was none progression of labour among the participants screened for anxiety and it was observed that uterine contractions were inadequate among 42 participants positive for anxiety and required augmentation (42.9%)

P value = 0.366

The difference in trend is not statistically significant

Complications of labour were observed in 45 participants who were screened positive for anxiety among which foetal distress was observed to be the leading complication followed by post-partum hemorrhage. Meconium-stained liquor was also observed in 5 cases and there was an observation of 2 cases of shoulder dystocia, 1 case of eclampsia and 1 case of stillbirth. 3 cases were observed to have perineal tear and manual removal of placenta was also observed in few cases.

P value = 0.271

The difference in trend is not statistically significant

Comparing to see if there was an increase in interventions among participants screened for anxiety, it was observed that 43.1% among those positive for anxiety were taken up for emergency LSCS and 33.3 % were taken up for instrumental delivery ( forceps).

P value  = 0.660

The difference in trend is not statistically significant

Comparing the anxiety levels among primigravida and multigravida , an increase in the number of primigravidas were observed to have screened positive for anxiety(42.4%) while only (34.7%) of the multigravidas screened positive for anxiety.

P value = 0.203

The association between the number of pregnancies and anxiety is not statistically significant

According to a study carried out in the primary centres in Tabriz by Mahini et al. to evaluate factors related to maternal anxiety, it was found that out of the 533 pregnant women screened, 37.5 % was found to have anxiety (7). This study aimed to evaluate the effect of maternal anxiety focusing on term patients and its impact on childhbirth – the need for increased interventions like instrumental delivery or caesarian sections. According to the results 105 participants have found to be screened positive for anxiety among whom 86 were classified to have mild to moderate anxiety (31.9%). and 19 were found to have severe anxiety (7%).

The scorings in both studies were done using PASS scale (Perinatal anxiety screening scale )

A cross-sectional study carried out by Nurul Komariah and Sari Wahyuni – anxiety was assessed using Hamilton Anxiety Rating Scale (HRAS) and pain by the comparative pain scale – 22 people experienced severe anxiety (68.8%). The p value was found to be significant 0.028 in assessing maternal anxiety and labour pain (14)

A prospective exploratory study with prospective cohort approach in Kerala by Girija Kalayil Madhavanprabhakaran et al among which 500 low-risk Indian pregnant women of age 18–35 years were screened and State Trait Anxiety Inventory and Pregnancy Specific Anxiety Inventory were used to collect data. Highest prevalence of PSA was found to be during the third trimester and Nulliparous women reported higher levels of PSA than parous pregnant women. (2)

This study also aimed at finding the difference in anxiety levels between term primigravida and multigravida

This study showed an increase in primigravidas screening positive for anxiety but p value was not significant

The higher number of the above-mentioned result could also be due to overall more number of primigravidas - 151 screened than multi gravidas - 118

Anxiety levels were measured during the third trimester and at the start of labor using the Spielberg State Trait Anxiety Inventory in a prospective cohort, case-controlled study conducted by Aral et al at a hospital in Malatya with 50 nulliparous and 35 multiparous patients. Higher anxiety levels by were observed to have a significant negative effect on the total duration of the labour phases. (8)

This hypothesis was considered in this study but an overall increase in the duration of labour and non-progression of labour due to inadequate uterine contractions were not observed among these participants. Maybe with a bigger sample size these could be rectified and a proper and detailed observation could be made out.

The significance of this study is that maternal anxiety was found positive in about 105 patients, among which 19 participants had severe anxiety. These anxiety scores if known during the antenatal chechups can help in interventions for the betterment of maternal health including guidance and counselling.

Further proper evaluation with a large sample size could yield further insight into this research topic as assessment of mental health of mothers should be made mandatory and given equal if not more importance when compared to the importance given to physical health.

Careful monitoring and plotting of partograph during each phase of labour can give us very much insight into the duration and progress of labour  .

Summary:

This study was a descriptional cross sectional study aimed at screening of term patients for anxiety symptoms using the Perinatal Anxiety Screening Scale. 269 participants were then classified into asymptomatic and symptomatic groups based on their scoring. Their labour records were analysed and observations of whether there was an increase in the duration of progress of labour or an increase in interventions in participants with higher anxiety levels were noted . It was noted that maternal anxiety is still relevantly high in the third trimester of pregnancy especially in term patients nearing labour but regarding the variables and anxiety, were not statistically significant in our setting. Further research and evaluation with an increased sample size might yield prominent results.

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