Volume 5, Number 2, MarchlApril 1976

JOGN Nursing

Journal of The Nurses Association of The American College of Obstetricians and Gynecologists

A Conceptual Model for Obstetric Nursing NANCY H. LEVINE, B S N , MA

The author discusses the need for and purpose of a more comprehensive theoretical basis for nursing practice, research, and education. She then presents her own theoretical model of the pregnancy experience, with implications for nursing interuention. Also included (see box) is a discussiop of the definition, development, and use of theory.

As health science develops, the need for theo- retical concepts for health care becomes increas- ingly important. Nursing, with its multidisciplinary approach, is the logical profession to initiate such theoretical concepts and to implement them in practice. Yet, the profession has been satisfied to absorb most of its information base from other disci- plines and has been too slow in formulating its own theoretical frameworks for practice. This has been due in part to an inadequate amount of scientific nursing investigation or research and to the reluc- tance of the profession-to break away from the medical model with its focus on pathology, the episodic nature of sickness, and technologic inter- vention in disease. There has been in recent years, however, a tentative movement away from depen- dence on medical research and the theoretical basis of medical practice.

Nursing can never be fully independent of medi- cine, nor should it be. Both disciplines are based on psychobiosocial theories as well as on pathophysical biologic sciences; both professions do something for or with a patient; both deal with the patient’s re- sponses to pathology or therapy. The two interact

constantly in helping the patient, but the com- parisons have limits, and nursing must further as- sess attributes that differentiate it from medicine, i.e., nursing’s focus on holistic man constantly inter- acting with his environment along the health- illness continuum. Nursing is not defined by the ability to treat pathology or perform activities or processes, but rather by what the patient and family receive from such activities and the short- and long-term effects of the processes.

Nursing and other health professions function by perceiving, defining, protecting, and potentiating strengths in individuals and families, and by per- ceiving, defining, and meeting, to the extent pos- sible, those needs which cannot be adequately dealt with by the individual or family. Nursing has an extensive educational base that allows practitioners, educators, and researchers to perceive, and inter- vene in, the pregnancy experience. Using this col- lective experience and educational resource, I worked out an experiential field concept of preg- nancy. In originating my theory, I limited the focus to obstetrics so that I could fully develop a theory based on psychobiosocial aspects of humans during

March/April 1976 JOCN Nursing 9

one stage of the health-illness continuum. This the- ory, or conceptual model, suggests that a female’s energy field contracts during the eighth and ninth months of pregnancy in response to the psycho- physiologic changes within her body, severely dimi- nishes for expulsion of the fetus during labor and delivery, and reexpands with lactation on the third or fourth postpartal day.

UNDERLYING ASSUMPTIONS The theoretical assumptions on which the expe-

riential field concept of pregnancy is based are as follows: -Energy maintains human and environmental

field boundaries that are coexistent and contin- uously interacting.

-Tension states, e .g . , needs, drives, and conflicts, exist within or without the human field and cause field contraction or expansion in order to accom- modate these states.

-Progress toward releasing the tension state is de- pendent on biologic or genetic potential, contin- uing interaction with the total environment, and motivation.

-Every individual possesses a unique combination of constantly changing strengths, field bound- aries, and needs.

-The family is the basic unit of behavior and so- cialization patterns.

-Health is an active state of physical, emotional, and social’ well-being that contributes to the achievement of human potential. More simply, basic to this model is the concept

that a human is surrounded by a dynamic energy field, the boundary of which encircles the individual and which responds to internal or external needs by contracting or expanding the periphery-con- tracting in response to internal stimuli or needs and expanding to deal with external needs.

Needs, defined as subgrouped tension systems with psychophysiologic, sociocultural, or sociobio- logic sources, produce tension-like states that mobi- lize energies for their satiation or destruction.’ Needs, with their encircling tension states, exist either within the human field boundaries or in the environmental field, and vary in intensity among individuals as well as within the same individual at various points in the time-space continuum. The human and environmental fields are coextensive and in constant interaction.’ Although needs can be created and destroyed, the reservoir of energy which meets these needs, ix., furnishes force for need gratification and maintains field integrity, re- mains constant and particular for each individual.

When a need arises within the human energy field, the boundaries contract to supply energy for

gratification of that specific need. Pain, as an ex- ample, causes a person to focus on the site of its occurrence. The more severe the pain, the harder it becomes to distract the person’s attention from it. The individual may discover that his pain dimin- ishes if he assumes a particular position, or if he alters his rate of breathing, so he will combine these physiologic responses with his already inner-di- rected attention. If this psychophysiologic process releases the tension state, or pain, the person’s field will assume its premorbid integrity. The pain created a sufficiently strong tension state within the human field to mobilize energies for need grat- ification. Since the reservoir of available energy is constant and since the need arose within the human energy field, the boundaries contracted to supply energies for need satisfaction. Once this occurred, the tension was released and the original field integ- rity was restored.

Note that it is rare, if ever, that a need will arise from an isolated source, i e . , that a need will be purely physical, since need sources are fluid and unified. The human energy field is a dynamic unity.

If the need and encircling tension state exist within the environmental field, the individual field must expand to satisfy that need. For example, a baby’s hunger creates a tension state in the environ- mental field of its mother. If this tension is to be resolved, the maternal energies must not only be directed to the tension site (the baby), but also focus on a tension-releasing process (feeding the infant). If or when the need is satisfied, the maternal and infant fields will resume their premorbid conditions. Human and environmental field boundaries are coextensive’ with human field integrity, fluctuating in response to need location and intensity.

CONCEPTUAL MODEL OF LATE PREGNANCY, CHILDBIRTH, AND THE

POSTPARTUM

Late Pregnancy How this field phenomena occurs in pregnancy

can be seen when one examines various stages of the cycle. During the last half-month, changes oc- cur in the pregnant woman’s field that cause her to become inner-directed. The uterus “lightens” and becomes a pelvic organ as the fetal head moves into the pelvic inlet, whereas prior to this the uterus was an abdominal organ that displaced the diaphragm and impeded respiration. Greater ease of respira- tion, however, is combined with more difficult loco- motion, frequent urination, and increased cramping in the lower extremities since the gravid uterus exerts pressure in the pelvic area.’ Increased venous pressure in the lower extremities predisposes the

10 March/April 1976 JOCN Nursing

As we face health crises in hospitals, in- stitutions, and communities, and as health- care consumers increase demands for com- petent, comprehensive care, nursing has to identify and utilize the theories that underlie the practice. Nursing theory development and utilization is the only way the profession can differentiate from medicine, realize opti- mum potential for service to people, and maintain equality among health profes- sionals.

Scientific investigation for nursing theory implies research relevant to helping individ- uals cope with health problems when their own resources, strengths, or information are insufficient. Nursing science theory should enlighten us about the person, what happens to the individual in the health-illness contin- uum, and how we can effectively intervene and validate our actions. However, these the- ories do not happen a priori, intuitively; they must be developed from research into the practice of nursing.

Definition

Dickoff and James, in Nursing Research, have operationalized the concept of theory into workable, understandable terms. They propose the following points:’

-Theory is a conceptual framework or sys- tem invented to some purpose.

-Professional purpose requires a com- mitment beyond mere understanding or describing .

-Significant theory, at the highest level, must be situation producing.

-A profession or practice discipline has built-in advantages that facilitate theory development.

Discussion

Theory must be communicable if it is to structure purpose as a guide, control, or shaper of reality; it is not reality itself. Con- cepts, laws, and propositions are the basic elements of theories, and they provide con-

THEORY: DEFINITION, DEVELOPMENT, USE

ceptualization intended to shape reality to the d isci pli ne’s professional purpose. Nu rsi ng ’s professional purpose reflects the desire to help individuals cope with health problems; therefore, any improvement of practice that achieves this function is the appropriate goal of nursing theory development. The goal de- fines the need for theory development, and determines what theory is significant.2

Significant theory must have scope in cov- ering and relating a smaller number of concepts, and providing a framework for ordering observations about a variety of phenomena. The broader the scope, in terms of the number and variety of facts or con- cepts related, the greater the significance of the theory. For nursing, the scope should be judged in terms of the generalizations and phenomena pertinent to an individual along the health-illness continuum. Theories should be complex in that they take into account multiple variables or relationships and they should be amenable to experimentation. Test- ability of the theory at the general levels is not requisite for use or significance, even though it is desired; testability can be sacri- ficed in favor of scope, complexity, and clini- cal usefulness.2

Theories must be useful as a framework in clinical practice; conversely, clinical practice must test theory by determining significance and relevance. The framework must allow for constant repatterning, reorganization, and change if it is to be pertinent in practice. The- ory and practice must be interrelated, coexis- tent, and must constantly shape each other in order for nursing care innovations and new information to occur. A theory that generates many new hypotheses, with or without high probability, will contribute to understanding and enable situation predictability in future interactions.-N.H.L.

1. Dickoff, D., and P. James: “Theoretical Con- structs.” Nursing Res. 17:197-203, May-June 1968

2. Ellis, R.: “Theory for Nursing.” 17:217-222, May-June 1968

March/April 1976 JOGN Nursing 11

female to dependent edema of the ankles and legs and further hampers locomotion. Decreased phys- ical activity, along with descent of the fetus and consequent relaxation of smooth muscle throughout the body can and very often does lead to constipa- tion and partial bowel obstruction.' Heartburn, due to refluxing gastric contents into the lower esopha- gus, is quite common during this period because of uterine compression of the stomach and decreased gastrointestinal mobility.'

Body image during this late third-trimester pe- riod is discontinuous with the usual physical state, and many women complain of feeling sloppy and clumsy. Coitus at this time is not contraindicated, but it may be impossible because of an insur- mountable belly.' There is an increased likelihood of slipping and falling during this period since the size of the late pregnancy uterus creates balance disturbances. This is also the time women quit their jobs. (The time to discontinue routine jobs has been regulated by law in some areas, and the limits, although arbitrary, are generally from 6 to 8 weeks prior to the predicted date of delivery.')

False labor pains, exagge'rations of the painless, intermittent uterine contractions that occurred throughout gestation, now become noticeable and uncomfortable.' Many women experience anxiety with these false labor contractions since they may be perceived as the onset of actual labor. With each contraction the immediacy of the impending labor and delivery is brought to attention.

Decreasing locomotive abilities, increasing dis- comfort, a discontinuous and possibly disturbing body image, plus changes in daily routines provide not only time but direction for field contraction. Manifestations of this field contraction can be seen when the female rarely strays from conversation concerning her physical changes, labor, delivery, or her new role as mother. The complaint of insomnia, the most common symptom of late p regnan~y ,~ in- dicates a rather high tension state as well as a very intense inner-directed focus. Field contraction, a necessary behavior at this point, mobilizes energy for the reduction of these internal tension states. The female must confront the pressing realities of labor and delivery if she is to accept differentiation and final separation from the fetus. Not only will she soon terminate her exclusive protective, nurtur- ing relationship with her fetus, she will forcefully expel it from her body. As severely as the mourner contracts his field during the grieving process, so too must the female contract hers in labor and delivery. Similarly, she must grieve the death of the fetus before she reexpands her field in acceptance of the neonate.

Since her future relationships with her neonate

and husband require thoughtful preparation, the woman's contracted field amasses energy for these tasks. While the female experiences this contracted field state, she is less responsive and aware of envi- ronmental needs. This is not to say she is oblivious, but most of her energies, flowing toward the tension states within her field, are not readily available for environmental need gratification. It is important for the husband to not only understand but also to support and reassure her during this period so she can meet these needs. It may be necessary for him to assume household responsibilities, make important decisions for the family, and express his love and concern more often. Nurses can intervene by ex- plaining the normalcy of these psychophysiologic changes and by supporting the female as she meets these realities.

Should environmental needs become excessive during this stage, severe energy maldistributions in the female's field may occur and so jeopardize the fetus. Acute, severe infections, notably pneumonia, typhoid, and pyelonephritis, occasionally lead to abortion but are more likely to bring about pre- mature labor.' This is an environmental stress that requires tremendous energies from the human field. Since the pregnant female's energies are bound in her psychophysiologic changes, she may be forced to remobilize energies against the infection thereby jeopardizing the life of her fetus. Physioemotional environmental trauma, such as the death of a relative or a car accident, may produce the same severe effects. The female's jesponse to this stress may interfere with uterine circulation and lead to pre- mature placental separation and fetal death.s Post- mature onset of labor can represent redistribution of energies for satisfaction of an environmental need that was not so severe as to jeopardize the fetus, yet great enough to prevent field contraction prior to labor.

Labor and Delivery As the gestation reaches termination, the female's

field is greatly contracted. Her energies, mobilized for the thrusting, propulsive forces that occur in labor and delivery, are intensely inner-directed, and it is important that the husband and health profes- sionals understand this phenomenon. They must be aware that environmental needs will not be met by the female in labor and delivery, but they may distract her to such an extent that the process is prolonged. For example, when environmental stim- uli are so strong as to prevent the female from resting between contractions, she will not be able to regroup her energies for further demands. Pro- longed labor, and hypotonic uterine dysfunction and inertia represent situations where environmen-

12 MarchIApril 1976 JOCN Nursing

tal stimuli prevent energy reorganization.' Marga- ret Mead writes of a Tchambuli female in full labor who, over a period of 12 hours, rises from her squatting position to reprimand her husband for his distracting laughter. Following each episode, the woman would fall asleep until the laughter ceased whereupon she would resume her squatting posi- tion and labor.'

Once in the American delivery room, the female may actively participate by contracting her abdomi- nal muscles against her uterus. All her energies are bound in expulsion and her attention must be di- rected to this process. Note that the physical struc- ture of the American delivery room centers atten- tion on the female's perineum, the site of expulsion. Doctors and nurses stand within the perineal field to guide the baby's exit with hardly anyone, except possibly the anesthesiologist or husband, if hospital policy permits, standing at the mother's head. This arrangement indirectly focuses on the perineum and directs attention toward the expulsive forces.

During delivery, the female is experiencing the most severe contraction of her field, which permits the psychobiologic separation of her fetus. The fetus, once incorporated within her field, is now differentiating and separating into an individual field, which is coextensive with hers yet unique (See Figure 1). Incomplete field separation may lead to indulgent or domineering maternal overprotection, which can be seen in infantilization, the perform- ance of activities in child care beyond the time when such activities usually occur, prevention of social maturity, and excessive contact.6

Immediate Postpartum (Days 1-4) The female's field remains inner-directed and

contracted during the postpartal period similar to the field state during the last part of the third tri- mester, Psychophysiologic changes within her field demand energy for satiation before field expansion occurs with the onset of lactation, usually on the fourth day of the puerperium. The first 4 postpartal

March/April 1976 JOGN Nursing '3

days, representing an energy-gathering, reorgani- zational period, are critical because the female will not adequately expand her field in caring for her baby and husband if her taking-in needs are ne- glected.

During delivery, the female loses up to 13 to 14 pounds after the evacuation of her uterine con- t e n t ~ . ~ This may be a positive step toward reidenti- fication with her prepregnant body image, but she usually experiences some discomfort with uterine involution and after-pains, due to a tonically con- tracted puerperal uterus8 Profuse sweating, heavy diuresis, and increased thirst usually characterize the early puerperium and signal a further weight loss of 5 pounds.’ The fluctuations in the circulatory system are manifested in varying blood cell counts, marked leukocytosis during and after labor, de- creased cardiac output, decreased pulse, and vary- ing blood v01ume.~ The female with discomfort of edema of the urinary tract, temperature increase, hypotonic broad and round ligaments, and lochia discharge requires reassurance and support from her husband, baby, and staff. Many females relive the labor and delivery process verbally as though these puerperal body changes represented the be- ginning of a second labor. Since the labor and deliv- ery process is rapid in relation to the gestation, one may ask if this conversation is in fact reality testing. By focusing on labor and delivery, is the female seeking verification that these events actually oc- curred? It becomes necessary for the husband and staff to recognize the female’s needs and not only allow but support this behavior. They must also recognize that the female’s inner-directed field sig- nificantly lowers her capacity to deal with environ- mental needs, and therefore, they must handle im- portant questions or issues either for her or with her assistance. During rest periods, environmental stim- uli should be minimized so that the female can rest completely.

The female requires reassurance from her neo- nate during this stage of field contraction. The sight, feel, and sound of her baby reassure the mother not only of her baby’s well-being but also of its existence as an individual with a unique field who is in need of her care.’ Although little has been written from the maternal viewpoint concerning the effects of maternal-neonate separation, all available sources stress that the - degree of maternal-infant interaction during the immediate postpartum pe- riod influences later maternal attachment and in- fant d e v e l ~ p m e n t . ~ * ~ The mother who is separated from her infant at this time is not able to develop a close bond with her infant as fast as the mother and infant who are not separated; examples of the emo- tionally retarded premature infant, who may exist 3

to 12 weeks without being touched or caressed by its mother, illustrate that affectional ties between mother and infant develop at a slower rate than between mothers and normal newborns. lo During this critical period, most hospitals allow mothers and babies to be together only at feeding time, which severely curtails their contact and delays bond formation. Similarly, husbands and wives must abide by specific visiting hours. In many hos- pitals husbands still handle their infants only briefly, if at all, during hospitalization. The reas- surance of the infant and husband not only support the female during this time but help her realize her new roles and responsibilities. Should these internal needs go unsatisfied, the female will remain in a contracted field state and become unable to expand in order to feed and care for her family. Contracted field situations lingering after the third or fourth day can lead to postpartum depression and can interfere with milk production.

Normal field expansion will begin on the third or fourth postpartal day if these internal tension states are released. The postpartal discomforts have usu- ally diminished and the reality of the infant is fairly well established by this time so that outer-directed behavior and lactation can proceed with greater comfort and success. A mother’s inability to handle herself or her baby comfortably during feedings, especially breastfeedings, may be a response to im- portant unresolved needs requiring the nurse to support, reassure, and possibly suggest alternative plans for maternal-infant feeding periods until these needs are satisfied.

Lactation and breastfeeding are responses pri- marily to environmental needs in that the baby, existing outside the mother’s field, requires atten- tion if his needs are to be satisfied. Breastfeeding, unfortunately, is sometimes influenced as much and possibly more by prevailing hospital or sociocultural attitudes than by the newborn’s needs. A recent study illustrated that mothers from an English col- ony in Africa, who normally breastfeed for 18 to 24 months in their country, breastfeed 3 months, if at all, when they deliver in England or Australia.” Lack of knowledge among the health personnel of the psychophysiology of lactation coupled with ill- considered, ill-informed maternity unit regimens become sufficient environmental forces in discour- aging breastfeeding. A mother’s choice of feeding is personal; while she should receive information concerning all methods, she should be encouraged to choose the method most comfortable to her and her husband. Should her chosen feeding procedure be uncomfortable psychophysiologically, it will in- crease her internal tensions and contract her field, preventing her from meeting other environmental

‘4 March/April 1976 JOCN Nursing

needs. Although breastfeeding signals field expan- sion for the female, the same effect holds for women who select artificial feeding; however, the field ex- pands a bit slower in the latter case, because arti- ficial feedings do not provide the same intimate psychobiologic interaction between mothers and in- fants that breastfeedings do and thereby require more time for field expansion.

CONCLUSION The human is surrounded by a dynamic energy field which is coextensive with the environmental energy field. Responding to needs and their sur- rounding tension states, the human field integrity will contract to release internal tension states or expand to satisfy environmental needs. Pregnancy illustrates how needs arising within the female’s field cause an inner-directed, contracted field expe- rience that persists and intensifies throughout the 9 months, diminishes severely during labor and deliv- ery, and reexpands around lactation. Implications for family and health personnel during these stages are knowledge, acceptance, and support of the fe- male. The female who otherwise may be quite inde- pendent and capable, may be withdrawn, appre- hensive, and unable to make decisions during field contraction, thus requiring trusted support or inter- vention from family or health professionals. It be- comes important to minimize environmental factors that could prevent or arrest the female’s field con- traction and expansion at the various states of preg- nancy. Failure to do so could result in sudden or prolonged labor and delivery, inability of the fe- male to recognize field separation from the new- born, difficulties in feeding, and problems with postpartum roles and responsibilities.

REFERENCES 1. Lewin, K . : “On the Structure of the Mind,” in A

Dynamic Theory of Personality. New York, McGraw-Hill Book Company, 1935, p. 47

2. Rogers, M . E.: “Man: An Open System,” in Theo- retical Basis of Nursing. Philadelphia, Davis Com- pany, 1970, pp. 53, 54

3. Eastman, N. , and L. Hellman: “Clinical Course of Labor,” in Obstetrics. Thirteenth edition. New York, Meredith Publishing, 1966, pp. 329-336, 396,

4. Coleman, A. , and L. Coleman: Pregnancy: The Psy- chological Experience. New York, Herder & Herder, 1971, pp. 23, 25

5. Mead, M . : Sex and Temperament in Three Primitive Societies. New York, Dell Publishing Company, 1935, p. 254

6. Levy, D. M.: Maternal Ouerprotection. New York, Norton Company, 1966, p. 71

7. Montagu, A. : “Breastfeeding,” in Touching. New York, Columbia University Press, 1971, p . 75

8. Barnett, C., et al.: “Neonatal Separation: The Ma- ternal Side of Interactional Deprivation.” Pediatrics 45(2):197, Feb 1970

9. Klaus, M. , et al,: “Maternal Attachment.” N EnglJ Med 286(9):460, Mar 1972

10. Klaus, M . , et al.: “Human Maternal Behavior at the First Contact with Her Infant.” Pediatrics 46(2):187, Aug 1970

11. “Lactation, Conception, and the Nutrition of the Nursing Mother and Child.” J Pediatr 81(4):829, Oct 1972

482-484, 530, 824

Nancy Levine is a clinical instructor of parent-child nursing at Jewish Hospi- tal of the S t . Louis School of Nursing, S t . Louis, Missouri. She is a mem- ber of ANA, serving on that organization’s Ma- ternal-Child Interest Group, Legislative Action Committee, and National Council for Family Rela- tions. Her BSN is from

the University of Miami; her MA, from New York University in New york City.

March/April 1976 JOGN Nursing