Effects of ADIET communication and delivery rehearsal on anxiety, labor process, and outcomes in vaginal trial delivery

Abstract

BACKGROUND

In recent years, the obstetrics department has advocated vaginal delivery to reduce the rate of cesarean sections. However, in clinical practice, pregnant women are prone to anxiety before childbirth, making it difficult to perform a vaginal trial delivery smoothly. The combined approach of ADIET communication and delivery rehearsal for vaginal trial delivery can provide a reference for reducing prenatal anxiety, shortening labor duration, facilitating a smooth delivery, and ensuring the safety of both mothers and babies.

AIM

To analyze the effect of AIDET communication combined with labor rehearsal on vaginal trial delivery.

METHODS

A study conducted between January 2023 and December 2023 included 200 vaginal trials. Women were randomly assigned to an observation group (100 women), which received ADIET communication plus delivery intervention, and a control group (100 women), which received routine communication plus delivery intervention. This study aimed to compare antenatal anxiety status as measured using the Maternal Anxiety Scale, labor duration, delivery efficacy as assessed using the simplified Chinese version of the Childbirth Self-Efficacy Inventory, and delivery outcomes.

RESULTS

After the intervention, the observation group had a lower Maternal Anxiety Scale score and higher Childbirth Self-Efficacy Inventory score (P < 0.05) than the control group (P < 0.05), whereas the observation group had higher natural delivery, cesarean delivery, vaginal delivery, and neonatal asphyxia rates (P < 0.05).

CONCLUSION

For women undergoing vaginal trial delivery, a combination of AIDET communication and delivery rehearsal can relieve prenatal anxiety, enhance delivery efficiency, shorten labor duration, and somewhat improve delivery outcomes.

Key Words: Greeting-self-introduction-process-explanation-thanks for communication; Labor rehearsal; Vaginal trial; Prenatal anxiety; Labor; Labor outcome

Core Tip: ADIET communication combined with delivery rehearsal can help reduce prenatal anxiety, enhance delivery efficacy, encourage women to actively cooperate with midwives, shorten labor duration, further improve the rate of natural delivery, and prevent and control the occurrence of neonatal asphyxia and other adverse events, especially for primiparas.

INTRODUCTION

Natural delivery refers to the type of delivery process where the fetus is delivered vaginally. It is considered a normal physiological process of human reproduction, with relatively minimal harm to both the mother and child. The objectives of a vaginal trial delivery are for women with vaginal stenosis, insufficient amniotic fluid, advanced age, and other complications. A vaginal trial delivery is recommended for these women who may not be able to undergo a natural delivery to ensure the health of both the mother and child. If the trial delivery is not successful, a cesarean section is then considered[1,2]. However, in clinical practice, vaginal trials may lead to different degrees of maternal stress response. Maternal factors such as birth and childbirth experience are relatively lacking, making prenatal anxiety easy. Changes in maternal hormone levels may increase uterine contraction, endangering maternal and infant safety. Therefore, effective intervention is essential.

Delivery rehearsal is a new method of health education that can enable puerperas to fully understand and personally experience the delivery process, thereby improving their understanding of delivery and coping methods[3,4]. AIDET communication is a technique used by medical staff to communicate effectively with patients. While focusing on standardized communication processes, giving more attention to patients’ medical experiences can lead to better communication outcomes and improve patient satisfaction, ultimately enhancing the quality of nursing service[5,6]. However, there are few clinical reports on the joint application of these interventions in vaginal trial delivery. Therefore, to further clarify the application effect of the combined intervention of AIDET communication and delivery rehearsal, this study was conducted.

MATERIALS AND METHODS

General information

A total of 200 women who underwent vaginal trial delivery at our hospital between January 2023 to December 2023 were selected as study subjects and grouped according to the random throwing method. The control group consisted of 100 individuals aged 20-45 years (mean 32.57 ± 4.23 years), with a gestational age of 33-41 weeks (mean 37.08 ± 1.31 weeks). Body mass index ranged from 18.5 to 27.9 kg/m² (mean 23.26 ± 1.85 kg/m²). There were 72 primiparous women and 28 multiparous women, with 35 women having a high school education or below and 65 having education above senior high school. The observation group consisted of 100 individuals aged 20-45 years (mean 32.86 ± 4.58 years), with a gestational age of 33-41 weeks (mean 37.15 ± 1.20 weeks). Body mass index ranged from 18.5 to 27.9 kg/m² (mean 23.47 ± 1.63 kg/m²). There were 70 primiparous women and 30 multiparous women, with 33 women having a high school education or below and 67 having education above high school. There were significant differences between the two groups (P > 0.05). The inclusion criteria included the following: (1) Singleton pregnancy with the fetal in the fetal head position; (2) Vaginal delivery conditions and opting for natural delivery; (3) Absence of conditions such as cognitive impairment, audio-visual impairment, speech impairment; and (4) Women and their family provided informed consent. The exclusion criteria were as follows: (1) Presence of heart disease, severe hepatitis, or severe preeclampsia; (2) Presence of mental illness or history of mental illness; (3) Fetus with malformation; and (4) Refused to participate or participating in other studies.

Methods

Delivery rehearsal was performed in both groups: The delivery preview was conducted in stages based on the gestational week of pregnant women. The first stage involved theoretical study at 32 weeks of pregnancy. The obstetrician should use video, graphic data, and micro-animation to explain the delivery process, differences, and characteristics of vaginal delivery and cesarean section to the mothers and their families. They should also guide the mothers in learning the respiratory delivery method. A WeChat communication group was created to invite women participating in the theoretical study. The group shared theoretical knowledge of childbirth in the form of PPT and offered 24-hour consultation services to encourage communication among mothers and enjoy the experience. Phase 2 was a realistic scene simulation at 34 weeks of gestation. It involved building a delivery room model, guiding puerperas and their families on a visit, and introducing them to the delivery room environment, as well as characteristic delivery methods (such as doula delivery, painless delivery, delivery ball-assisted delivery). The simulation included experiencing abdominal pain or vaginal bleeding at home, along with combining the video, pelvis, and placenta to demonstrate the delivery position, techniques for pushing, breathing methods, or allowing the puerpera to have a real experience. Phase 3 was planned at 36 weeks of gestation. The patient and her family discussed the delivery plan with the midwifery nurse and obstetrician to clarify possible problems and solutions during delivery. Accordingly, the control group adopted routine communication practices, which included accompanying the puerpera to complete examinations, instructing her to maintain a positive psychological state, and following the instructions of the midwifery nurse or delivery doctor during delivery.

The observation group will also provide AIDET communication: (1) A, Greeting: Understand the basic information of the puerpera in advance, including name, age, and gestational age, and contact with the puerpera; (2) I, Introduction: Take the initiative to introduce their details such as name, work title, and professional expertise, as well as the hospital environment, infrastructure, delivery room environment, and other puerperal aspects; (3) D, Process: Explain the discomfort and interventions during delivery. In the first stage of labor, the mother can experience contractions, cervical dilation, and rupture, which lasts approximately 8-10 hours. At this stage, improve communication with the puerpera, listen to their demands, and adopt methods such as attention shift method and music therapy to relieve negative emotions. During the second stage of labor, the puerpera may experience the natural rupture of fetal membranes and bowel feeling, lasting approximately 1-2 hours. In this stage, it is important to guide the puerpera in pushing and breathing techniques, provide maternal speech support, such as “you are good” and “do well”, to help the puerpera eat properly for strength, and offer an explanation of the fetal condition to the puerpera after successful delivery. During the third stage of labor, the fetus and placenta last approximately 5-15 minutes; in this stage, the mother and newborn are guided in establishing contact and teaching correct breastfeeding techniques; (4) E, Explanation: Patiently answer questions raised by the puerpera and explain any possible abnormal feelings and pain relief methods during childbirth; and (5) T, Thank you: After delivery, we should first express gratitude to puerpera for their cooperation, support, and understanding and then inquire patiently if she has any other needs.

Observational indicators

Prenatal anxiety status: The Maternal Anxiety Scale (PAS)[7] was used for evaluation and consisted of 4 factors and 27 items with values ranging from 1 to 5 points. These factors include labor anxiety, self-anxiety, fetal anxiety, and general anxiety, with 8, 7, 6, and 6 items, respectively. A higher score indicates more severe maternal prenatal anxiety. Evaluation was conducted both before and after intervention (reliability = 0.68, validity = 0.93).

Stage of labor: The time spent in the first, second, and third stages of labor, as well as the total labor was recorded and compared between the two groups.

Delivery efficacy: It was evaluated using the simplified Childbirth Self-Efficacy Inventory (CBSEI-C32)[8]. This scale mainly includes two parallel scales: Outcome expectation and self-efficacy expectation, with each item rated on a scale of 1-10 points. Maternal delivery efficacy can improve based on the score received. The evaluation time points were pre- and post-intervention (reliability = 0.88, validity = 0.96).

Delivery outcomes: The natural delivery, cesarean delivery, vaginal midwifery, and neonatal asphyxia rates were counted and compared between the groups.

Statistical analysis

All data collected in the study were analyzed using SPSS27.0. The measurements were conducted on data as (mean ± SD). Data with normal distribution were analyzed using self-sample t-test and t-test, and count data were analyzed using χ² test and are expressed as percentage (%). P values of < 0.05 were considered statistically significant.

RESULTS

Comparison of the prenatal anxiety status

Before intervention, the four PAS factors were statistically balanced (t = 0.204, 0.170, 0.107, and 0.0.064, respectively; P = 0.839, 0.865, 0.915, and 0.949, respectively; all P values > 0.05 and t = 2.842, 2.466, 2.538, and 2.559, respectively; P = 0.014, 0.015, 0.012, and 0.011, respectively; all P values < 0.05; Table 1).

Table 1 Comparison of prenatal anxiety status between the two groups (mean ± SD, score).

Group	n	Childbirth anxiety		Self-anxiety		Fetal anxiety		General anxiety
		Before	After	Before	After	Before	After	Before	After
Control	100	29.18 ± 5.36	22.39 ± 5.24a	23.29 ± 5.45	19.05 ± 5.28a	21.57 ± 5.32	17.15 ± 5.21a	22.08 ± 5.47	18.02 ± 5.23a
Observation	100	29.30 ± 2.42	20.57 ± 5.13a	23.16 ± 5.34	17.24 ± 5.10a	21.49 ± 5.26	15.31 ± 5.04a	22.13 ± 5.51	16.14 ± 5.16a
t		0.204	2.482	0.170	2.466	0.107	2.538	0.064	2.559
P value		0.839	0.014	0.865	0.015	0.915	0.012	0.949	0.011

^aP < 0.05, compare with specific values before intervention in the same group.

Comparison of labor time

Regarding labor and total labor times, the observation group had significantly shorter labor and total labor times (t = 2.695, 3.135, 2.774, and 2.956, respectively; P = 0.008, 0.002, 0.006, and 0.003, respectively; all P values < 0.05; Table 2).

Table 2 Comparison of labor times between the two groups (mean ± SD, hour).

Group	n	First stage of labor	Second stage of labor	Third stage of labor	Total stage of labor
Control	100	8.09 ± 1.12	1.14 ± 0.32	0.18 ± 0.03	9.38 ± 1.24
Observation	100	7.68 ± 1.03	0.95 ± 0.21	0.17 ± 0.02	8.89 ± 1.10
t		2.695	3.135	2.774	2.956
P value		0.008	0.002	0.006	0.003

Comparison of delivery efficacy

Before intervention, the CBSEI-C32 scores were well balanced between the groups and showed no significant difference (t = 0.174 and 0.187, respectively; P = 0.862 and 0.852, respectively; all P values > 0.05), and the differences between the scores were statistically significant (t = 2.398 and 2.531, respectively; P = 0.017 and 0.012, respectively; all P values < 0.05; Table 3).

Table 3 Comparison of delivery efficacy between the two groups (mean ± SD, score).

Group	n	OE-16		EE-16
		Before	After	Before	After
Control	100	84.12 ± 5.27	105.05 ± 5.39	82.25 ± 5.32	102.13 ± 5.34
Observation	100	84.25 ± 5.30	106.89 ± 5.46	82.39 ± 5.26	104.07 ± 5.50
t		0.174	2.398	0.187	2.531
P value		0.862	0.017	0.852	0.012

OE-16: Outcome expectation; EE-16: Self-efficacy expectation.

Comparison of delivery outcomes

The rate of spontaneous delivery was higher, and the rates of cesarean section, vaginal delivery, and neonatal asphyxia were significantly lower (52.00% vs 77.00%, 34.00% vs 21.00%, 8.00% vs 1.00%, and 6.00% vs 0.00%, respectively; χ² = 13.647, 4.238, 4.188, and 4.295, respectively; P = 0.000, 0.039, 0.040, and 0.038, respectively; all P values < 0.05; Table 4).

Table 4 Comparison of delivery outcomes between the two groups, n (%).

Group	n	Natural birth rate	Cesarean section rate	Vaginal midwifery rate	Neonatal asphyxia rate
Control	100	52 (52.00)	34 (34.00)	8 (8.00)	6 (6.00)
Observation	100	77 (77.00)	21 (21.00)	1 (1.00)	0 (0.00)
χ2		13.647	4.238	4.188	4.295
P value		< 0.001	0.039	0.040	0.038

DISCUSSION

With the adjustment of China’s family planning policy, the impact of high cesarean section rates has become prominent. Multiple cesarean sections may increase the risk of adverse events such as postpartum bleeding and even hysterectomy, resulting in a serious economic burden on both society and families. Vaginal trial delivery is of great significance in reducing the rate of cesarean sections, reducing near-term and long-term complications in mothers and children, and rationally allocating medical resources. However, maternal concerns and fear of childbirth pain, limited understanding of childbirth, and lack of childbirth experience can not only contribute to higher rates of cesarean section but also hinder the progress of vaginal trial delivery. Therefore, in clinical settings, strengthening health education and communication with expecting mothers regarding vaginal delivery is recommended.

Vaginal trial delivery for expectant mothers are often hindered by insufficient knowledge of childbirth, lack of childbirth experience, and difficulty adapting to factors such as role changes emotional stress, anxiety, depression, and psychological stress before labor, if not timely, can prolong labor, increase the risk of adverse pregnancy outcomes, and lead to increased possibility of neonatal asphyxia; these make ensuring maternal and infant safety is challenging. The study results showed that after intervention, PAS and CBSEI-C32 scores of the observation group were lower than those of the control group. The duration of labor was shorter in the observation group than in the control group (P < 0.05; Table 2).

Regarding labor rehearsal, theoretical study can enhance understanding of natural delivery and cesarean section, enabling individuals to select the most suitable delivery method according to their specific circumstances. Practical simulation can not only ease delivery discomfort but also improve cooperation between the puerpera and midwife, leading to faster delivery and ensuring maximum safety for both mother and infant. Simultaneously, it can also improve maternal psychological resilience to a certain extent, consistent with previous findings[9]. In ADIET communication, greetings, introduction, process, explanation, thanks to five processes throughout the prenatal, labor, postpartum three delivery stage, can give maternal physiological and psychological support, and progressive, can meet the demand of maternal delivery, eliminate or reduce maternal anxiety, help maternal confidence, improve its compliance behavior, build a harmonious relationship between nurses and patients, and shorten the labor, improve the delivery outcome[10]; this is consistent with the findings reported by Li et al[10]. The combination of both interventions, from the perspective of the puerpera, can not only mitigate the negative effects of psychological stress but also enhance the accurate perception of childbirth. This can reduce symptoms of prenatal anxiety and assist the puerpera in achieving a positive delivery outcome. In addition, the results of this study showed that the rates of spontaneous delivery, cesarean delivery, vaginal delivery, and neonatal asphyxia in the observation group were 77.00%, 21.00%, 1.00%, and 0.00%, respectively. The primary reason is that the combined approach of ADIET communication and delivery rehearsal can help rebuild the correct understanding of childbirth and establish a positive attitude toward delivery. This can help maintain the physical and mental well-being of the mother, leading to a significant increase in natural delivery rates and effectively ensuring the safety of the mother and baby.

The greeting and self-introduction phases establish a trusting relationship between doctors and patients, providing a safe and supportive environment for pregnant women. This relationship is crucial for alleviating anxiety as it makes patients feel at ease and in good spirits[11]. The process explanation phase helps pregnant women in understanding childbirth by explaining the labor process, reducing the fear of unknown factors. It also reduces anxiety by addressing questions and concerns. The gratitude phase shows respect for pregnant women and encourages a positive childbirth experience, enhancing their positive emotions. Second, childbirth rehearsal enhances pregnant women’s coping abilities by simulating the actual childbirth process. This simulated experience gives pregnant women a practical sense of the labor process, thereby reducing fear and tension during childbirth[12]. Additionally, rehearsal helps pregnant women learn breathing techniques and relaxation methods, which can effectively shorten the duration of labor and reduce pain during childbirth.

From a physiological perspective, reducing anxiety and enhancing coping abilities can lower the levels of stress hormones such as cortisol in pregnant women. This can help reduce the irregularity and intensity of contractions, potentially shortening the duration of labor. Simultaneously, a lower stress level can reduce the risk of fetal distress, consistent with the lower rate of neonatal asphyxia observed in our study. Furthermore, we believe that the combined intervention of ADIET communication and childbirth rehearsal may enhance labor efficiency by boosting pregnant women’s self-efficacy[13]. Self-efficacy refers to an individual’s belief in their ability to complete specific tasks. During childbirth, pregnant women with high self-efficacy are more likely to actively participate in labor, cooperate with midwives, increase the rate of natural childbirth, and reduce the rate of cesarean section.

CONCLUSION

Through the combined approach of ADIET communication and labor rehearsal for vaginal trial delivery, a satisfactory intervention effect can be obtained. On the one hand, it can effectively relieve prenatal anxiety, reduce psychological burden, improve delivery efficacy, accelerate the work of the midwifery, obtain a good foundation, meet the needs of the puerpera in different stages of labor, and strive to provide a good delivery experience, thereby improving the rate of natural deliveries. Therefore, this intervention is worth promoting and applying in clinical practice.