Expectations, Perceptions, and Management of Labor in

Nulliparas Prior to Hospitalization

Kathleen R. Beebe, RNC, PhD, and Janice Humphreys, RN, CS, PhD

This ethnographic qualitative study was designed to explore the phenomenon of prehospitalization labor from
the perspective of nulliparous women. Twenty-three women were interviewed in the early postpartum period
using a semistructured interview guide. The participants recounted their experiences with labor onset
recognition and management before being admitted to the hospital for birthing. Qualitative analyses included
verbatim transcription of audiotaped interviews, line-by-line coding, and categorization of data into codes
and categories. Interpretive analyses were validated with a collaborative research team and the participants
themselves. The central theme that emerged from this study was confronting the relative incongruence
between expectations and actual experiences. Supporting categories included: expectations about the labor
experience, identifying labor onset, managing the physical and emotional responses to labor, supportive
resources, and decision making about hospital admission. Early labor experiences in nulliparas offer insight
into the contributions of both expectations and environment to adaptation in labor. Midwives and perinatal
nurses are in a unique position to design interventions that support and reinforce laboring womens activities
outside of the hospital setting. J Midwifery Womens Health 2006;51:347353 2006 by the American
College of Nurse-Midwives.
keywords: adaptation, decision making, labor onset, life experiences, nulliparity, pregnant women,
sensation, pregnancy, qualitative research, symptom management

INTRODUCTION support the influence of environment on the biopsycho-

social aspects of the childbirth process2,3,1214 and on
Although 99% of births in the United States today occur
birth outcomes. Two recent studies that evaluated the
in a hospital,1 most women who experience spontaneous
benefits of delayed hospital admission on birth outcomes
labor onset do so outside of the hospital setting. Conse-
demonstrated that environment along with personal char-
quently, they spend various intervals of time laboring in
acteristics (such as parity) influences labor variables.2,3
other locales prior to hospital admission. Recent studies
Although these studies support the safety and efficacy of
support the benefits of postponing hospital admission
noninstitutionalized early labor in low-risk women, they
until active labor is established.2,3 However, because
did not explore the mechanisms by which women iden-
active labor is defined by a particular rate of cervical
tify, integrate, and manage this phenomenon.
dilation rather than by subjective behaviors, it is not
Many women plan for and idealize the awaited events
usually assessed in the home environment.4 Thus, labor-
of labor and birth, but they may not be fully prepared for
ing women, particularly those experiencing their first
the various decisions associated with early labor man-
births, must assume the tasks of recognizing the onset of
agement. A number of studies have evaluated the role of
true labor as well as determining the right time to
factors such as experience, expectations, ambivalence,
transfer to the hospital. Uncertainty and frustration can
and support in womens decision-making processes dur-
result when women enter the hospital only to be told that
ing childbirth.1518 Findings from these investigations
they are not really in labor. Other women, who may
confirm that laboring women are faced with a number of
have believed they were not coping well during labor at
decisions about childbearing preferences and that con-
home, learn they are in very advanced labor on hospital
textual factors play a role in the degree and quality of
admission. These experiences highlight the challenges
womens participation in these decisions. However, fur-
women face in interpreting and acting on somatic and
ther investigation is needed of womens experiences as
affective cues that labor has begun.
they enter labor for the first time, particularly the influ-
Published investigations of experiences during labor
ence of environment on such experiences. This qualita-
prior to hospital admission are scarce, particularly those
tive study explored the phenomenon of labor prior to
addressing womens perceptions of the labor environ-
hospital admission from the perspective of nulliparous
ment as a qualitative component of the birthing experi-
women.
ence. Numerous studies have addressed the physical and
psychological components of labor,511 but they have
METHODS
focused on hospitalized women. There is evidence to
This study was an ethnographic qualitative analysis of
data from women experiencing labor for the first time.
Data were largely derived from interviews conducted
Address correspondence to Kathleen R. Beebe, RNC, PhD, Dominican
University of California, 50 Acacia Ave., San Rafael, CA 94901. during a previous study of biopsychosocial influences on
E-mail: kbeebe@dominican.edu prehospitalization labor,19 supplemented by additional

Journal of Midwifery & Womens Health www.jmwh.org 347

2006 by the American College of Nurse-Midwives 1526-9523/06/$32.00 doi:10.1016/j.jmwh.2006.02.013
Issued by Elsevier Inc.
data that were collected after development of this re- Table 1. Demographic Characteristics of the Sample (N 23)
search emphasis. Face-to-face, audiotaped interviews
were used to collect the data. Variable n (%)
Twenty-three women experiencing their first births, Age (y)
who were recruited through convenience sampling at 1825 7 (30.4)
childbirth preparation classes or on inpatient postpartum 2630 6 (26.1)
units. Nulliparas were selected as the population of 3135 7 (30.4)
3640 3 (13.1)
interest because this group has significantly longer labor
Ethnicity
durations than parous women20 22 and because the level Caucasian 20 (87)
of experience with childbirth is assumed to contribute to Hispanic 2 (8.7)
patterns of behavior during labor. Participants had un- Other 1 (4.3)
complicated, singleton, term pregnancies, and began Education
High school 3 (13)
spontaneous labor outside of the hospital. The women
Some college 7 (30.4)
were from two locations on the West Coast: one, a large College 8 (34.8)
city (n 4), and, a suburban/rural setting (n 19). All Some graduate school 2 (8.7)
were partnered, had participated in childbirth preparation Graduate degree 3 (13.1)
classes, and were planning hospital births. Nineteen Annual household income
$25,000 4 (17.4)
women had been interviewed for the original study,19
$25,000$50,000 5 (21.7)
which investigated associations among selected third- $50,000$100,000 11 (47.8)
trimester and early labor variables in nulliparas, and $100,000 1 (4.3)
included an elicited, semistructured narrative of the Unreported 2 (8.7)
prehospitalization labor experience. By using the same
format, four additional women were recruited and inter-
viewed as analysis proceeded to enhance the trustworthi-
included the two authors and two nurse researchers
ness of the findings. The additional participants were also
experienced in qualitative methods and perinatal phe-
used to validate the emerging themes from the initial
nomena. This process culminated in the emergence of a
cohort and to ensure sufficiency of data within the
central theme illuminating the interrelationships among
qualitative analytic process.
categories.
After securing written informed consent (with ap-
Analysis of these data was conducted with consider-
proval from the University of California, San Franciscos
ation for analytical precision and theoretical connected-
Institutional Review Board, Committee on Human Re-
ness.24 Trustworthiness of the findings was enhanced by
search), participants met for a 60- to 90-minute interview
validation with participants, sustained involvement in the
with the first author. A semistructured interview guide
field, and discussion with two nurse researchers experi-
was developed (Appendix A) and used to elicit partici-
enced in qualitative methods.
pants experiences and management strategies during
labor prior to hospital admission. Probes were used when
needed to further explore the processes of navigating RESULTS
prehospitalization labor. All interviews were audiotaped Table 1 lists the demographic characteristics of the entire
and transcribed verbatim. sample. The central theme that emerged during this
Analysis proceeded from an overall read of the inter- exploration of the phenomenon of prehospitalization
views followed by line-by-line coding. Categories labor for nulliparas was confronting the relative incon-
emerged from commonalities among the codes as the gruence between expectations and actual experiences.
analytic process produced higher levels of abstraction. This theme was evident within all of the identified
Key associations among words and clusters of phrases supporting categories, which included expectations,
were scrutinized for related components and used to identifying labor onset, managing the experience, sup-
structure analytic categories.23 These categories were portive resources, and decision making about going to
discussed and agreed on by the research team, which the hospital.

Kathleen R. Beebe, RNC, PhD, is Assistant Professor of Nursing at
Dominican University of California in San Rafael, a former Post-Doctoral
Fellow in the Center for Symptom Management at the University of
California, San Francisco, and a Staff Nurse in the Labor and Delivery Unit
at Santa Rosa Memorial Hospital, Santa Rosa, CA.
Janice Humphreys, RN, PhD, CS, PNP, is Associate Professor of Nursing
and Vice-Chair for Faculty Practice in the Department of Family Health
Care Nursing at the University of California, San Francisco.
Expectations
Because of inexperience with childbirth, many women
sought information about what sensations to anticipate to
construct their idealized labor experience. Their expec-
tations about birthing were derived from a number of
sources, including vicarious experience; childbirth edu-
cation; discussions with others; prior experiences with

348 Volume 51, No. 5, September/October 2006

physically challenging or painful events, attitudes, and
desires; and body cues. The expectations about labor
centered on two main components: what it would be like
and how it would be managed.
I really did think that I was not in labor. I
thought this is just one of those things, maybe its
a precursor. But, you know, being your first time,
you think labors gonna be this incredibly, all of
a sudden, intense thing that you cant handle, and
when it comes on a little slower, you just, nah,
its not labor, I have something else.
Although there was variation in womens expectations
about what labor would be like and how it would be
managed, there were commonalities in the articulation of
each distinct component. Expectations for managing
labor were well defined and sometimes elaborate, indi-
cating an emphasis on the performance aspects of birth-
ing. However, the expectations about what labor would
feel like were more uncertain. Consequently, with actual
labor onset, both sets of expectations required reap-
praisal, and often, modification.
Identifying LaborThe Real Thing
Retrospectively, participants could describe with ease the
details about the beginning of labor. However, most
participants recalled an uncertainty about labor onset as it
was happening. The phrase the real thing was used so
frequently in womens descriptions of querying labor
onset that it became a category unto itself. The frequency
of the use of the words real thing, really it?, and and duration of physical symptoms, interpersonal inter-
real demonstrates the immense importance assigned to
the task of properly diagnosing labor.
Womens expectations about what labor would feel
like influenced their abilities to recognize labor onset.
Other factors linked to labor onset recognition included:
inexperience, ambivalence, concerns about bothering
others, the desire to complete the pregnancy, concerns
about hospitalization, and other third-trimester symp-
toms. The actual physical sensations associated with
labor onset were overlooked, downplayed, or attributed
to other causes when they did not match pre-existing
expectations about severity or location. In this group, for
example, labor was mistaken for a bladder infection,
constipation, overdoing it, or food poisoning.
Its interesting because the contractions (that)
were described to me in class, or the way I
interpreted them, didnt feel the way I felt when
I. . .it just felt more like cramps. I dont know, the
two just didnt go together for me. They didnt feel
the way I was expecting them to.
Strategies to facilitate reconciliation between expecta-
tions and the actual event of labor onset included
telephone calls to providers, family members and friends,
Journal of Midwifery & Womens Health www.jmwh.org
discussions with partners, inner dialogues, waiting, and
monitoring signs and symptoms. Reappraising expecta-
tions about labor onset and modifying them accordingly
was part of the process of labor recognition.
I thought it was just a bladder infection. On the
way to the doctor, everything hurts. . .and Im
starting to go either Im in labor or Im not
. . .well, Im in labor but its not making any
progress. I almost cried when he said I was six
centimeters dilated I was so happy. I was thinking
theyd tell me to get ready for a really long part of
labor.
So I kind of told myself that, you know, this
probably isnt it. . .I didnt really tell myself that
thats probably what it was until later at night. . .I
kind of suspected by the time I went to bed. . .I
was thinking, OK, this is probably it.
Managing Symptoms and Emotional Responses
Participants described a host of physical sensations as
part of the prehospitalization labor experience (Table 2).
These sensations and an evaluation of their significance
produced individual patterns of responses designed to
manage them.
Women experienced numerous emotions during this
time (Table 3). These were mercurial and sometimes
contradictory (simultaneously happy and sad) but not
without contextual meaning and rationale. Affective
responses were dynamic and influenced by the degree
actions, and the surrounding environment.
As with the recognition of labor onset, the planned
activities to manage prehospitalization labor were de-
rived from expectations regarding perceived resources
and capabilities. These expectations were generated from
the information received during childbirth preparation
classes or other experienced and trusted sources.
Women developed individualized plans of action us-
ing specific activities and props (items that supported
the activities) that fit with their preconceived or learned
notions of what would be helpful to do during labor.
Somebody told me that when youre in labor,
stomp. A couple of people told me that. . .try to get
that head engaged.
After labor onset, however, women very often found
themselves rethinking the plan of action based on how
they were feeling at the time.
Subject: We had the aromatherapy, we had
CDs, we had tennis balls for massage. . .
Husband: But, like, she was so tired from the
first two days, that I think if we brought it out it
woulda just irritated her.
Subject: Yeah.
349
 Table 2. Analytic Taxonomy and Descriptive Words Used for the 5) attend to nutritional, hydration, or hygienic needs;
Physical Sensations Experienced During Prehospitalization 6) garner support and reassurance; 7) stimulate or
Labor retard uterine contractions; and 8) determine the cor-
rect time to relocate to the hospital. In some cases,
Category Descriptors specific activities differed in intended purpose. For
Pain Uterine contractions example, one woman might perform a housecleaning
Menstrual-like cramping chore to distract herself from contractions, whereas
Backache another might do the same activity to prepare the home
Stabbed in the back
for the new baby.
Body aches
Stomach cramps
Fatigue Lethargy
Weakness Supportive Resources
Low energy
Tiredness Women called on a number of supportive resources to
Not myself assist them in managing prehospitalization labor. The
Lazy central theme of incongruence between expectations and
Struggling to walk actual events again emerged as participants reflected on
Pressure Heaviness
Pelvic pressure
the significance of their available support systems. The
Restlessness Sleep loss most important and frequently cited sources of support
Up all night were husbands/domestic partners. As one woman put it,
Have to keep moving around I couldnt have done it without him. Some men were
Discomfort Uncomfortable actually able to diagnose labor or ruptured membranes
Dont feel good
Achy
for their partners. Their objectivity, in concert with
Dyspnea Cant breathe
Hunger Hungry
Wanted to eat
Gastrointestinal/Genitourinary Distress Diarrhea Table 3. Emotional Classifications and Constituents of
Constipation Prehospitalization Labor
Nausea/vomiting
Taste alteration Category Descriptors
Urinary frequency/urgency Anxiety Worried
Have to go all the time Scared
Ruptured membranes Gush of fluid Impatient
Well-being Tolerable contractions Eager
Liked the discomfort Uncertain
Resting/napping Stressed
Not that bad Dissociation Out of my body
Strange
Weird
In a haze
To accommodate to the realities of the labor experi- Not feeling myself
ence, women called on their repertoire of learned strat- Detached from others
egies, suggestions from others, and improvisational Ambivalence Uncertain
Trying to ignore it
skills. Bored
It was quite calm actually. . .it was just the Positive affect (general) Happy
Excited
mundane things; going through and cleaning the Relaxed
bathroom and putting the laundry in the washing Calm
machine and making sure it got to the dryer. . .it Mentally prepared
was just the everyday chores that took your mind In control
off things. Eager
Not worried or scared
Some ideas for managing labor had no identifiable Relief
genesis. As one participant stated, my body was just Negative affect (general) Miserable
Terrible
moving me around. Frustrated
A wide variety of management strategies were used Irritable
during this period. These strategies were intended to 1) Dying
promote physical and/or emotional comfort; 2) prepare Tearful/emotional
for hospitalization, birth, and the new infant; 3) pass Sad
End of my rope
the time; 4) ignore or distract oneself from sensations;

350 Volume 51, No. 5, September/October 2006

their familiarity with her pregnancy, allowed them to
translate her sensations more accurately.
I got out of bed, and then we realized I had
water, and I couldnt figure out what that was
either. Of course, my husband put two and two
together and realized it was my water. . .I was
clueless, you know? I went into the bathroom and
Im like, theres this water leaking out of me, I to make such a transition. The perceived benefits of
wonder what this is? Hes like, HELLO! You hospitalization reported by participants included access
know? How many books have I read for the last 9
months and its just so overwhelming what youre
about to go through.
Other supportive individuals included mothers, fa-
thers, sisters, in-laws, friends, and doulas. They played
an integral role in aiding women in labor to determine
labor onset, manage labor as it evolved, and decide about
going to the hospital. Health care providers served as
remote sources of support, offering advice and direction
about labor progress and hospital admission planning.
Three quarters of the participants entered labor during
the night. In these cases, expectations about the role of
support persons sometimes conflicted with actual levels
of participation.
He was in the room but he was sleeping. [He
was] waking up every 10 or 15 minutes to [hear
me] me moaning and groaning. But. . .its funny
now when I tell people, they crack up, yeah, he
was sleeping the whole time. But, like I said, he
didnt know if it was gonna be the real thing and
if it was he wanted to get his rest [before going to
the hospital]. So that wasnt very helpful at all.
When more than one support person was involved
with the participant, the relative dominance of each was
the result of a complex fabric of negotiation, collabora-
tion, interaction, and assigned agency. The social rela-
tionship aspect of managing labor at home became an
important part of womens labor experiences. The par-
ticipants did not fully appreciate the potential conflicts
among support people or between support people and
themselves until they were manifest during labor.
There was a time my husband kept asking me,
well, dont you want to go to the hospital? My
sister was here, so I felt safe with her here too,
and then my mother-in-law kept telling them she
will know when its time to go to the hospital.
They were all supportive of me being here. I think
that helped me relax being here and knowing I
was doing the right thing. . .but (my husband)
being nervous made me kind of questionI
wonder if I should go?
Journal of Midwifery & Womens Health www.jmwh.org
Decision Making About HospitalizationGoing In
The decision about when and why to go into the hospital
during labor was an important one for the women in this
study. Participants expressed some ambivalence about
their ultimate birthing environment, with some clearly
more comfortable about the hospital setting and others
uncomfortable. Others accepted the hospital transition as
a necessary activity but were not sure about the best time
to professional personnel to take care of them, monitor-
ing equipment, immediate assistance for unanticipated
complications, additional labor support and company,
medical advice and resources, information about labor
progress, and pain-relieving medications. Perceived dis-
advantages to the hospital setting were focused on the
lack of self-directed and lower-tech labor management,
which included being stuck in bed or jailed (immo-
bilized), being hooked up (to monitors), having IVs,
and requiring drugs to stimulate labor. The stated benefit
of the home setting was that it was a familiar and
comfortable environment where women felt more in
control of their activities. One subject stated, I think as
long as Im home, Im in control. For some reason, I felt
like I had less control when I was in the hospital. The
concerns about the home setting included the inability to
get an adequate assessment of labor progress, leading to
concerns about having the baby at home or going in too
late to receive planned analgesia or anesthesia.
Decision making about going to the hospital involved
a number of factors and usually other people. Some
women followed a set of criteria (usually related to
contraction frequency or duration) given to them by their
providers. Frequently, the decision was made after a
telephone consultation with their providers.
An often-cited reason for delaying hospital admission
was the fear of going in too soon. This was a particular
concern for women because, as stated:
The only thing I worried about was going to the
hospital maybe too soon. You have that fear of
getting there and. . .then having the doctor tell me
that I could come in tomorrow, and kind of going
over him and making that decision [to go in
sooner], and worrying about it being wrong. . .I
just thought it would be bad if we get there only to
be told to go back home. It would be
discouraging.
For the few women who did go in for a labor
evaluation and returned home undelivered, the thought of
repeating that pattern was even more distressing.
Hes [husband] the one that said, We need to
call the doctor. Im not calling her; she thinks
Im a wimp. I dont want to go back. . . I dont
351
 want to call her. I dont even want to bring my
bag. Its like shes going to send me home again.
The women who did have a formal labor evaluation
sometime before hospital admission entered the hospital
for delivery, on average, much later in their labors than
the rest of the sample. Many participants offered that if
they had known what their progress in labor had been in
terms of cervical dilation and fetal well-being, they
would have stayed home longer before entering the
hospital. Women who planned to stay out of the hospital
as long as possible before admission also found them-
selves in need of feedback about labor progress.
So when I did hear that I was 7 centimeters, I
was very relieved. . .if Id known that at home, I
probably wouldve. . .I mean, thats why I was
getting scared. Cuz it was like if theyre not
timing these and theyre gonna make me stay at
home because I said I want this natural childbirth
and I gotta stay at home for another 3 to 4 hours
like this?. . .Im not gonna make it.
Although some participants considered homebirth,
none chose this option, primarily related to apprehension
about unavailability of neonatal services. Most did not
comment on the trip to the hospital, but a few reported an
uncomfortable ride, feeling the lurching and bumping of
the vehicle on top of the labor contractions.
DISCUSSION
These findings, presented in a linear fashion, should
not be construed as occurring chronologically, but
rather, as interwoven processes. It was not unusual for
participants to recount their use of management tech-
niques for labor while still questioning whether labor
had actually started. The identified categories repre-
sent an interpretive evaluation of the experience of
labor in nulliparas prior to hospital admission within a
particular demographic composition. Study limitations
include the possibility of recall bias and a sample that
was fairly homogenous and not necessarily represen-
tative of all nulliparous women. Future studies might
focus on women with different demographic charac-
teristics.
The notion that early labor is a light-hearted precur-
sor to the real work of active labor and delivery
negates the complexities of the mind-body recognition
of and adaptation to the birthing process. The fact that
this crucial undertaking begins outside of the hospital
setting should not minimize its significance within the
continuum of childbirth. Environment is recognized as
an important domain of influence on human perception
and interaction. It is precisely because labor onset
occurs away from the hospital and is experienced by
women in unique contexts that environmental influ-
ences must be appreciated. The current study provides
352
a richer description of the experiences and activities
during labor prior to hospital admission than has
previously been reported. Women experiencing labor
onset for the first time place a great deal of emphasis
on their performance. This is evidenced by the need to
prepare for and engage in the birthing process pro-
ceeding from a preconceived, albeit sometimes unre-
alistic, set of expectations. The relative fit between
these expectations and the actual sensations, behav-
iors, and events women encounter contributes to the
work of labor. Reappraisal and modifications of ex-
pectations and planned activities are additional tasks
in the early labor experience of first-time mothers.
Confronting and then realigning incongruences in
these areas have been unrecognized factors that affect
adaptation and decision making within the labor pro-
cess. The central theme of this study suggests that
opportunities exist to assist nulliparous patients, be-
fore and during labor, to narrow the gaps between
expectations about labor experiences and actual occur-
rences.
A recent finding from the literature on decision
making indicates that people wait to make important
decisions until they have acquired all of the relevant
information needed to proceed.25 Participants in this
study reported that, at times, they were unable to make
a decision about whether labor had begun or when the
best time to transfer to the hospital should be. In such
cases, confusion about their status resulted in difficulty
recognizing labor onset or progress and a perception
that they may have been admitted to the hospital too
soon. Such perceptions can undermine confidence and
satisfaction with decision-making abilities. Midwives
and perinatal nurses are well-positioned to provide
information about progress in labor, reassurance about
fetal well-being, and confirmation of the normalcy of
the birthing process as it is unfolding. These interven-
tions, along with supportive reassurance and reinforce-
ment of coping strategies and symptom management
activities in the early stages of labor are resources that
can be safely and beneficially provided outside of the
hospital setting.2 Possible models of care might in-
clude home visitation or centralized outpatient facili-
ties for noninvasive early labor assessment and sup-
port. Such approaches can assist women by facilitating
reconciliation of incongruences among expectations
about labor and its realities. Further benefits may
include reduced anxiety and uncertainty, along with
improved confidence in decision-making abilities. Ul-
timately, better support for laboring women at home
can contribute to overall improved labor progress and
outcomes. The next step in this effort involves assess-
ing the feasibility of establishing effective programs to
provide such services, with the goal of promoting
labor care in an appropriate and comfortable environ-
ment.
Volume 51, No. 5, September/October 2006
This research was supported by the Nursing Research Training Program in
Symptom Management; awarded to the School of Nursing at the University
of California, San Francisco, from the National Institute of Nursing
Research (T32 NR07088).
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Appendix A. Interview Guide
This interview guide provided general guidelines for all
interviews. Further questioning built upon the subjects
responses.
Environmental and Temporal Conditions
1. When did your labor begin? Where were you and how
did you decide labor had started? Tell me about that.
2. How long were you in labor before you went into the
hospital?
Thoughts, Feelings, Activities, and Experiences
1. What did you do during the time you were in labor
before you went to the hospital?
2. What did you think about during the time you were in
labor before you went into the hospital?
3. How did you feel during this time?
4. Of the things you mentioned doing and thinking, what
was most helpful for you? Least helpful?
5. Do you recall where you learned to do these things?
Transition to the Hospital
1. What made you decide to go to the hospital when you
did? Were there any other deciding factors?
2. Was it different being at home compared to being at
the hospital during labor? If so, how?
Probes for the interviewer
Is there anything else you think is important for me to
know?
Tell me more about that.
Encourage examples/illustrations
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