Relationship Between Fetal Activity and Subsequent Infant Temperament;

THE RELATIONSHIP BETWEEN FETAL ACTIVITY

AND SUBSEQUENT INFANT TEMPERAMENT

Julie G. Ralston

A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of

Master of Science

College of Nursing

University of Utah

March 1988 THE UNIVFRSITY OF UTAH CRAnU.-'.TE SCHOOL

SlTPERVlSORY COlvfwfIT1-'EE APPROVAL

of a r.hesis 5ubrnirrcd by

G. Julie Ralsto�

This thesis has been read by each member of the following su pervisory co:nmittee and by majority to vOle has been found be sa�isfactOry.

/ - &,-B B Chairman: El i abeth J. J?l(l -;r-

� , Carol A. Kirgi

B. Arthur Elster THE UNIVERSITY OF UTAH GRADUATE SCHOOL

FINAL READING APPROVAL

To the Graduate Council of The University of Utah:

Julie G. Ralston I have read (he thesis of in its final form and have found that (I) its format. citations. and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures. tables. and charts are in place; and (3) the final manuscript is satisfactory to the Supervisory Committee and is ready for submission to the Graduate School.

Dat. Elizabeth J. Pugh M�mb;:r. Su�rvisor)'Commitl�

Approved for the Major Department

Li:Ida K. Amos

Approved fur tht: Graduate C,Juncii

A nonexperimental, descriptive correlational design was used to test the relationship between fetal activity and subsequent infant temperament. Thirty-eight primi gravida women, at low risk for adverse obstetrical outcomes, were recruited from childbirth preparation classes. Fetal activity was assessed between 35-39 weeks from both a Nonstress Test (NST) recording and a maternal fetal movement count (FMC) log. Two months after birth, infant temperament was rated by the mother using the

Rothbart Infant Temperament Questionnaire (RITQ). A significant relationship was found between fetal activity

and the rating of infant activity at 2 months of age. The

most consistent correlation was found between the measures of maternal perception of fetal activity and maternal

perception of infant activity. The findings from this

study suggest that maternal perception of fetal activity

and the FMC score do measure common features of fetal

activity and are related to maternal perception of infant

activity at 2 months of age. CONTENTS

ABSTRACT .... .iv

LIST OF TABLES. . vii

Chapter

I. INTRODUCTION . . . . 1

Conceptual Framework 3 Statement of the Problem . . 5 Purpose of the Study . . . 5

II. REVIEW OF LITERATURE . . 7

Fetal Movement . • • . • . . . . . 7 Infant Temperament ...... 17 Research Questions ...... 28 Definitions ...... •.. • 28 Assumptions ...... 31

III. METHODOLOGY • • 32

Design ...... 32 S ampl e ...... • . . . . . 32 Instruments...... •. 34 Procedure...... ••. 38 Data Analysis ....•.•.••..... 40 Human Subjects Considerations. . ... 40

IV. RESULTS ...... 43

Description of the Sample. . . . • 43 Research Question One. . • . • 46 Research Question Two...... • . • . . 50

V. DISCUSSION . 61

Research Question One...... 61 Research Question Two...... • • • • . 64 VI. CONCLUSIONS AND RECOMMENDATIONS • • • 67

Conclusions ...... 69 Limitations of the Study ...... 70 Recommendations for Further Study ..... 70

Appendices

A. CONSENT FORM ...... · 72

B. HIGH RISK SCREENING TOOL . . . 75

C. FETAL MOVEMENT COUNT LOG · 79

D. QUESTIONNAIRES . . . . 81

E. INFANT BEHAVIOR QUESTIONNAIRE · 89

REFERENCES ...... 99

vi LIST OF TABLES

Table Page

1. Maternal Characteristics. . . 45

2. Infant Characteristics . 47

3. Frequency and Distributions of Fetal and Infant Variables ...... • • 48

4. Significant Correlations of Measures of Fetal Movement and Maternal Perception of Fetal and Infant Activity Measures ...... 51

5. Maternal Factors as they Relate to Measures of Fetal Activity ...... 53

6. Situational Factors as they Relate to Measures of Infant Temperament and Activity ...... 54

7. Significant Correlations of Maternal Medication in Labor and Infant Apgar Scores ...... 56

8. Significant Correlations of Prenatal and Situational Factors Relating to Fetal Activity and Infant Temperament ...... 57

9. Maternal Characteristics According to Age Groups. 60 CHAPTER I

INTRODUCTION

Since earliest recorded history, fetal movement has been considered a sign of life. An early reference to

fetal movement appears in the Bible (Genesis 25) when

Rebecca, the wife of Izhak, stated that the "children

struggled within her."

Mothers initially feel fetal movements (quickening)

between the 16th and 20th weeks of gestation. This event

is emotionally reassuring and provides an early perceptual

link with the offspring. Once felt, fetal movement is the

cardinal sign of fetal life.

Expectant mothers often comment that their fetal

activity varies during the day_ They wonder, "does an

active fetus mean an active baby?" Or does the variable

of movement change at the moment of parturition?

The existence of behavioral states in the human fetus

is now well supported in the literature (DeVries, Visser &

Prechtl, 1982, 1985; Nijhuis, Prechtl, Martin & Bots, 1982; Rosen, Dierker, Hertz, Sorokin & Timor-Tritsch;

1979 & Timor-Tritsch, Dierker, Hertz, Deagan & Rosen,

1978). Such behavioral states are more easily assigned to

fetuses in the third trimester using the variability of 2

fetal heart rate, fetal eye movement and gross body movement. The question that then arises is, if patterns of fetal behavior exist prior to birth, do these relate to

later human behavior?

The general concept of temperament goes back to at

least medieval times, when it was used to refer to a person's mental disposition (Rutter, 1982). Today, the

term refers to a preponderant style in the way individuals do things or how they respond to situations and people, rather than to what individuals do (or why they do it) or to the behavioral capacities or abilities they manifest

(Thomas & Chess, 1977).

Various investigators have stressed the importance of

temperament assessment in infants. Rothbart (1981)

thought that by studying temperament in infants and

children, an integrative approach to the development of

individual differences would be provided. Others thought

that temperament should be assessed in infancy so

systematic studies of the nature of a child's specific

pattern of individuality and its pertinence to psychologi

cal development could be established (Chess & Thomas,

1973). Questionnaires or interview protocols have been

devised for such assessment. These include parental

rating instruments which measure the nine New York

Longitudinal study dimensions of temperament (Carey & McDevitt, 1978; Persson-Blennow & McNeil, 1979; Rothbart, 3

1981; Thomas, Chess & Birch, 1968).

More interest is being generated in the period of life before birth and the possible effects it has on future development. If a relationship between fetal movement and infant temperament could be established, earlier predictions of behavioral factors, possibly affecting social and cognitive development, could be made.

The data obtained may provide a basis for future studies regarding the relationship of intrauterine movement to human development.

Conceptual Framework

Buss and Plomin (1975) developed a temperament theory which included a hereditary component, considered to be necessary to distinguish temperament from other personality dispositions. The key feature of their temperament theory was the postulation of five inclusion criteria which were biological or developmental in nature.

These criteria require that valid dimensions of tempera men~ be (a) heritable, (b) stable, (c) predictive of adult personality, (d) adaptive, and (e) perhaps present in other animals. Personality traits commonly observed to develop early in human life have also been found in other primates and even in nonprimate mammals (Buss & Plomin,

1984). Genetic influences on the development of these

individual differences have been documented (Torgersen &

Kringlen, 1978). These results were consistent with the 4 view that such early developing personality traits have a biological origin that stretches back into our evolution ary past (Buss & Plomin, 1984).

Consideration of the evidence relevant to these criteria led Buss and Plomin to postulate four broad dimensions of temperament:

1. Emotionality: intensity of reaction; the degree of arousal.

2. Activity: the total energy output, includes actions and speech.

3. Sociability: affiliativeness; a strong desire to be with others; responsiveness to others.

4. Impulsivity: tendency to respond quickly rather than inhibiting the response. This area consists of two components: resisting versus giving into urges, impulses or motivational states, and responding immediately and

impetuously to a stimulus versus lying back and planning before making a move (Buss & Plomin, 1975).

Buss and Plomin's (1975) temperament model starts

with inborn dispositions. The subsequent course of these

temperament dispositions is determined by a complex

interaction with the environment, but the environment, in

turn, is also affected by the dispositions. The social

environment may be shaped by temperament initially or

through feedback.

Temperament refers more to style than content, more 5 to expressive behavior than to instrumental (coping) behavior, and more to what a person brings to a role or situation than what either of these demand of him.

Temperaments are broad dispositions that are expected to differentiate during development, much like intelligence.

Each infant manifests characteristic attributes of temperament and each has a recognizable behavioral style.

Individual patterns of reactivity can be identified within the first 2 months of life, often within a week or two after birth (Thomas & Chess, 1977). These initial patterns persist through later stages of childhood, despite significant modifications.

When considering the developmental and biological origins of temperament, a question arises regarding the relationship between the early measure of fetal behavioral states (and fetal activity) and later activity levels in infancy. Are active fetuses also active infants and children or does temperament change after birth?

Statement of the Problem

The problem addressed in this study was to determine the relationship between the amount of fetal movement in

utero and subsequent infant temperament.

Purpose of the Study

The purpose of this study included the following:

1. To determine if there was a relationship between 6 fetal movement measured between 35-39 weeks gestation and infant temperament measured at 2 months of age.

2. To provide data to future researchers studying fetal environment and its effect on subsequent infant development.

3. To increase information for nurses engaged in both clinical practice and research in the area of fetal movement and infant temperament. CHAPTER II

REVIEW OF LITERATURE

Fetal Movement

Although fetal movement has been known since Biblical times to confirm fetal life, the structured use of fetal movements to provide clinical information about fetal health is relatively new. One of the first studies to utilize recordings of fetal movement was conducted by

Ahlfeld in 1905 when he recorded human fetal respiratory movements (Timor-Tritsch, Zador, Hertz & Rosen, 1976).

Later, respiration in utero was studied extensively in experimental animals by Snyder and Rosenfeld (1946), Rosen

(1967) and Howatt, Humphreys, Normand and Strang (1965).

Boddy and Dawes (1975) introduced ultrasound monitoring of fetal respiratory movements into antepartum clinical management of high-risk pregnancies in 1975.

In the early 1970s, researchers began to investigate fetal skeletal movements as a sign of fetal well-being.

Sadovsky and Yaffe's (1973) and Sadovsky and Polishuk's

(1977) research created a greater interest in the examina tion and study of fetal movement when they related decreased fetal movements to placental insufficiency.

Fetal movement may be an expression of fetal well-being 8 and a reduction or cessation of fetal motion may signify fetal distress due to anoxia or other factors.

Fetal heart rate accelerations associated with fetal movements were considered to be signs of fetal well-being by several researchers (Lee, DeLoreto & Logrand, 1976; Rochard, Schifrin, Goupil, Legrand, B101tiere & Sureau,

1976). Since their introductory work, determinations of fetal heart rate accelerations associated with fetal movement have gained unprecedented popularity for further research. Timor-Tritsch, Dierker, Zador, Hertz and Rosen

(1978) correlated fetal skeletal movement with fetal heart rate changes. They found that movements lasting 3 seconds or more were associated with a fetal heart rate acceleration 99.8% of the time. Navot, Yaffe and Sadovsky

(1984) found that the ratio of fetal heart rate accelera tions associated with fetal movements per total fetal movements increases with gestational age. Patrick,

Carmichael, Chess and Staples (1984) also measured fetal heart rate and fetal movements for 24 hour observation intervals at 38 to 40 weeks gestation to study the normal structure and pattern of fetal heart rate accelerations.

They found that fetuses made 0 to 130 gross fetal body movements per hour with the longest period of complete absence of gross fetal body movement being 75 minutes. At

38 to 39 weeks' gestational age, fetuses had a peak in activity between 2100 and 0100 hours. 9

Techniques for monitoring fetal movement using

real-time ultrasonography devices, pressure-sensitive

electromechanical devices or maternal recordings of

perceived activity have made it possible to characterize

different patterns of fetal activity and to better

differentiate between normal and abnormal patterns

(Rayburn, 1982). Fetal limb motion and fetal respiratory movement have been studied using two-dimensional ultra

sound imaging (Birnholz, Stephens & Faria, 1978; Patrick,

Natale & Richardson, 1978; Patrick et al., 1980; Patrick & Challis, 1980; Roberts, Griffin, Mooney & Cooper,

1980). Pressure-sensitive electromechanical devices using

strain gauges receive force from the fetal movement and

transduce this mechanical energy into electrical current.

A simple strain gauge instrument, the tocodynamometer, has

been reported by several researchers to be useful for

monitoring fetal motion (Sorokin, Pillary, Dierker, Hertz

& Rosen, 1981; Timor-Tritsch, Dierker, Zador, Hertz &

Rosen, 1976; 1978). The tocodynamometer fetal monitor

records a nonstress test (NST) which has been shown to be

useful as an initial antepartum fetal heart rate test for

fetal assessment. This is a noninvasive monitoring of the

fetal heart rate and uterine activity. A fetal monitor

with an ultrasound transducer and external tocodynamometer

is placed on the maternal abdomen and fetal heart rate and

uterine activity are obtained (Evertson & Paul, 1978; Hon, 10 1958). Accelerations of the fetal heart rate in response to sustained fetal movement are reassuring, while lack of sufficient fetal heart rate accelerations suggest fetal compromise.

Perception of fetal activity is the oldest and least expensive technique used to monitor fetal movement.

Descriptions based on maternal report of fetal movement or on external uterine palpation have formed the basis of measuring fetal activity in many clinical investigations

(Leader, Baillie & Van Schalkwyk, 1981; Liston, Cohen, Mennuti & Gabbe, 1982; Neldam, 1980; Rayburn & McKean,

1980). Researchers studying the correlation of maternal assessment and electromagnetic recording of fetal movement found correlations between the two methods of 85-90%

(Sadovsky, Mahler, POlishuk & Malkin, 1973; Rayburn,

1980; Ehrstrom, 1979).

With the availability of external monitoring tech niques to record fetal movements, several researchers have investigated and attempted to classify types of fetal movements (Aladjem, Feria, Rest & Stojanovic, 1977;

Timor-Tritsch et al., 1976; Patrick, Campbell, Car michael, Natale & Richardson, 1982). One classification described four movements, three of which can be considered skeletal movements that were well-perceived by an observer or the mother. It was noted that these three movements: the rolling or total body motion, simple or extremity 11 motion, and the high-frequency or short kicki?g motion, usually caused tocodynamometer spikes on the fetal heart rate tracing (Timor-Tritsch et al., 1979). The fourth motion was described as a fetal respiratory movement which may be superimposed on the maternal respiratory wave and mayor may not be perceived by the mother or observer.

Patrick et al. (1982) described three general types of active movement occurring in the fetus as: stretching, rolling and isolated movements of fetal extremities.

Fetal movement has been studied by various re searchers and found to be influenced by extrinsic and intrinsic factors. Edwards and Edwards (1970) reported no apparent relationship between the mother's activity and changes in the daily rates of fetal motion. Studies differ on the relationship of maternal meals to gross fetal body motion. Several authors reported an increase in fetal activity during a rapid rise in maternal glucose levels (Aladjem et al., 1977; Gelman, Spellacy & Wood,

1980; Miller, Skiba & Klapholz, 1978), whereas, other authors indicated no significant alteration in gross fetal body motion after a recent meal (Birkenfeld, Laufer & Sadovsky, 1980; Rayburn, Motley & Zuspan, 1982). Extrinsic stimulation, such as "shaking" the fetus in utero, can result in an increase in movement. Loud sounds, bells, bright light and touch have been shown to elicit an increase in fetal activity and associated 12 increase in fetal heart rate (Grimwade, Walker & Bartlett,

1971; Scibetta & Rosen, 1971). Drugs such as alcohol or sedating medications and maternal use of cigarettes can reduce fetal activity and the fetal respiratory-like movements (Manning & Feyerabend, 1976; Rayburn et al.,

1982). Hertz, Timor-Tritsch, Dierker, Cjik and Rosen

(1979) studied the effect of ultrasound on fetal movement and concluded that it does not affect the movements of the fetus. Luterkort and Marsal (1985) studied fetal activity in breech presentations and concluded that there were no quantitative differences in motor activity between fetuses born in breech presentation and those born in vertex presentation. VanVliet, Martin, Nijhuis and Prechtl

(1985) investigated whether the development of behavioral states in first born fetuses differed from that observed in the fetuses of multiparous women studied by Nijhuis et ale (1982). Their findings indicated that the development of behavioral states was generally not affected by parity.

Fetal movement is not a random occurrence, but in addition to environmental stimuli, can also be associated with cyclic changes in the fetus. Each fetus has its own rhythm and rate of daily activity_ Cycles in fetal activity have been determined to last 40-80 minutes with a mean of 45 minutes (Granat, Lavie, Adar & Sharf, 1979).

Ehrstrom (1984) monitored fetal movements by maternal 13 subjective recordings in gestational weeks 31-40, and found that the frequency of fetal movements followed a pattern of a circadian rhythm with maximum activity between 9 and 10 p.m. and minimum activity between 1 and 5 a.m. Other investigators have also reported finding an increased fetal movement in the evening, whether recorded by maternal assessment or by ultrasound scanning (Edwards

& Edwards, 1970; Minors & Waterhouse,1979; Patrick et al., 1982; Roberts, Little, Cooper & Campbell, 1979).

The presence of quiet, active and transitional behavioral states in the human fetus have been identified by Timor-Tritsch, Dierker, Hertz, Deagan and Rosen (1978).

In this study, the investigators utilized earlier research based on observations of fetal behavioral states in lambs

(Dawes, Fox, Leduc, Liggins & Richards, 1970), as well as studies on neonatal behavioral states (Hutt, Lenard &

Prechtl, 1969; Parmelee, Wenner, Akiyama, Schulz & Stern,

1967; Prechtl, 1974; Wolff, 1959). A "quiet" or rest period included no fetal movement greater than 1.0 second in duration, decreased long-term fetal heart rate variability, and a low baseline heart rate. An "active" period contained fetal movement longer than 1.0 second in duration, increased long-term fetal heart rate variability and a high baseline heart rate (Timor-Tritsch, Dierker,

Zador, Hertz & Rosen, 1978).

Junge (1979) conducted a comparative study on 14 behavioral states and state-related heart rate and motor activity patterns in the newborn infant and the fetus during the antepartum. He found that newborn infant state-related heart rate pattern changes do occur and that identical heart rate patterns and their changes can be seen in the fetus. His work was based on the informa tion by Prechtl (1974) who defined five behavioral states in the newborn, either directly observed or assessed from polygraphic recordings. These included: state 1: eyes closed, regular respiration, no movement; state 2: eyes closed, irregular respiration, small movement; state 3: eyes open, no movement; State 4: eyes open, gross movements; state 5: crying (vocalization). A study designed to determine the type and degree of relationship between multiple fetal heart rate factors and dimensions of neonatal behavior scored with the Brazelton Newborn

Behavior Assessment Scale was conducted by Emory, Walker and Cruz (1982). Their findings suggest that there is a relationship between intrapartum fetal heart rate and measures of neonatal behavior obtained during the first few days of life.

Rosen, Dierker, Hertz, Sorokin and Timor-Tritsch

(1979) studied fetal behavioral states using the variables of fetal heart rate, fetal movement and respiratory movement and concluded that specific states develop prior to birth and are evident immediately after birth. The 15 qualitative aspects of the emergence of fetal behavior were studied longitudinally by DeVries et al. (1982) during the first 20 weeks of gestation, using real-time ultrasound. Sixteen distinct movement patterns, closely resembling those observed in preterm and full term newborn infants, could be distinguished and described. Dierker,

Pillary, Sorokin and Rosen (1982) used heart rate variability and fetal movement as a means to classify active and quiet fetal periods at 28 to 30 weeks gestation and again at 38 to 40 weeks. The results demonstrated significant differences in the number of active-quiet cycles and the length of active periods.

Nijhuis et al. (1982) proposed the existence of four distinct behavioral states in human fetuses, most easily assigned at 36 to 40 weeks gestation. These four behavioral states were categorized as follows:

State IF: Quiescence, which can be regularly interrupted by brief gross body movements, mostly start

les; eye movement absent, heart rate stable with isolated accelerations strictly related to movements.

State 2F: Frequent and periodic body movements, mainly stretching and movements of the extremeties; eye movements present, heart rate with frequent accelerations during movement.

State 3F: Gross body movements absent; eye move ments continually present, heart rate stable with no 16 accelerations.

state 4F: Vigorous, continual activity including trunk rotations; eye movements continually present, heart rate unstable with large and long-lasting accelerations frequently fused into a sustained tachycardia.

These categories were based on the variability of fetal heart rate, fetal eye movements and fetal body movements visualized by means of real-time ultrasonic imaging. Differences in behavior were determined by measuring the degree of coincidence, simultaneity of change and durations of these parameters. The association of particular combinations of the variables was so consistent after 36 weeks gestational age that Nijhuis et ala (1982) concluded that behavioral states were present after this age.

DeVries et ala (1985), continuing their earlier work

(1982), studied the rate of occurrence of various cate gories of fetal movements to determine if these were generated at regular intervals, or if movement patterns showed a developmental trend. They found .that in most movements, a developmental trend was displayed by the fetus. This involved either a gradual increase in incidence of movement as the fetus grew older, or an increase in incidence until a plateau was reached. Fetal movement and fetal rate of habituation were examined in relation to behavior and development in early infancy by 17

Madison, Madison, and Adubato (1986). The results of their study suggest an association between prenatal behavior and infant behavior soon after birth.

Infant Temperament

Temperament was first used in medieval times to refer to a person's mental disposition, as determined by the combination of four cardinal humors (Rutter, 1982). Its usage today retains much of that emphasis, usually implying reference to the basic elements of behavioral functioning.

Until recently, systematic studies of the nature of a child's specific pattern of individuality and its per tinence and contribution to psychological development have been given little attention. In 1937, Freud asserted that "each individual ego is endowed from the beginning with its own peculiar disposition and tendencies" (Freud,

1950, p. 226). In 1937, Gesse11 and Shirley in 1931 also reported significant individual differences in behavioral characteristics of infants (Goldsmith & Campos, 1982).

Gesse11 and Ames' (1937) analysis of film records of children to assess characteristics such as activity level or energy output, adaptability, and liveliness of emotional expression, constituted one of the earliest studies of infant temperament. Their findings suggested the presence of certain fundamental traits of individu ality which exist early in life, persist late and assert 18 themselves under varying environmental conditions.

In the 1950s, a number of researchers were viewing psychological development as a result of interactions between the child having specific characteristics of individuality and significant features of the environment

(Alpert, Nenbauer & Weil, 1956; Fries & Woolf, 1953;

Murphy, 1962; Ritvo & Solnit, 1958). This view led to studies which sought to determine the relation between neurological functioning and behavioral styles. Walter and Gray (1953) postulated that patterns of electroen cephalographic activity might be correlated with various types of personality. Mirsky (1953) and Williams (1956)

looked for indications of biochemical individuality that might offer clues to initial sources of individuality in children.

Other investigators, who approached the question of

innate differences within a psychoanalytic framework,

looked for answers in terms of the child's intensity and mode of expression of presumed drive states (Murphy,

1957). The study by Fries and Woolf (1953) focused on

certain explicit characteristics of the child, such as

feeding and sleep patterns, responses to sensory stimula

tion, and congenital activity type. Most of the studies

around this time focused on only a few aspects of in

dividuality and were based upon a limited number of

children. 19

The constitutional origins of personality were emphasized by Diamond (1957), when he empirically described four temperaments: fearfulness, aggressiveness, affiliativeness and impulsiveness, which he thought were shared by all primates and by social mammals. In general, however, the 1950s were marked by a deep and pervasive environmentalism which rejected the possibility of built-in tendencies and the relevance of animal behavior for the understanding of human personality (Buss & Plomin,

1984).

From a different perspective, other researchers were rebelling against the psychoanalytic approach and the environmentalism that dominated child development. A most important stimulus to research on temperament came from the New York Longitudinal Study (NYLS) by Chess, Thomas, and Birch in the late-1950s (in Rutter, 1982). They conceptualized temperament as an early-appearing behavioral style. One of their early papers (Chess,

Thomas & Birch, 1959) included the statement:

we believe that the data indicate that the individual specific reaction pattern appears in the first few months of life, persists in a stable form thereafter, and significantly influences the nature of the child's response to all environ mental events, including child care practices (p. 793).

The viewpoint of Thomas and Chess and their colleagues has formulated the dominant approach to temperament. Four books present the results of this 30-year study (Thomas & 20

Chess, 1977, 1980; Thomas et a1., 1968; Thomas, Chess,

Birch, Hertzig & Korn, 1963). From their work, various researchers developed instruments for measuring tempera ment in infants and children.

Paralleling other developments, behavioral genetics emerged as a strong trend in the 1960s. Buss and Plomin

(1975) published their theory of temperament which was a return to the personality approach to temperament with an emphasis on tendencies that have an evolutionary heritage.

Theories of Infant Temperament

Temperament has a long history and a short scientific past. For centuries, most scholars believed in the humoral theory of personality (Buss & Plomin,1975). This theory linked four bodily fluids to distinctive per sonality attributes. For example, an excess of bile would cause a person to be chronically angry, hence the word

"choleric" (angry), which literally means bile. This theory was forgotten along with other medieval, pre scientific notions.

Recent theories of temperament have been more compatible with modern science. Sheldon's theory (1942) postulated that there were three basic body types, each with its own corresponding temperament. These body types were fit, muscular, and lean, and the associated per sonality types are viscerotoma, somatotonia, and cere brotonia. 21

The development of personality is the focus of the temperament theory of Thomas et ala (1968) and Thomas,

Chess and Birch (1970). They suggest that there are nine inborn characteristics, present at birth, that are the building blocks and origins of personality. In the New

York Longitudinal study, Thomas and Chess conceptualized temperament as early-appearing behavioral style.

The key feature of Buss and Plomin's (1975) tempera ment theory is the postulation of five inclusion criteria which are biological or developmental in nature. They developed four broad dimensions of temperament: emotion ality, activity, sociability and impulsiveness (EASI), as temperament measurement instruments.

A wide-range, multilevel theory of temperament was presented by Rothbart and Derryberry (1981). The key concepts in their theory are reactivity of the nervous system and self-regulation of reactivity. They stressed the importance of temperament for understanding social development.

An approach to investigating temperament-related behaviors within the neonate was theorized with the development of the Neonatal Behavior Assessment Scale

(NBAS) (Brazelton, 1973). The main objective of the NBAS is the identification of individual differences in the quality of the neonate's adaptation to its physical and social extrauterine environment. 22

Temperament Definitions

The surge of interest in the temperament of young children can be readily documented, but the definition of the term remains more elusive. A traditional definition of temperament is that of Allport (1937):

Temperament refers to the characteristic phenomena of an individual's emotional nature, including his susceptibility to emotional stimulation, his customary strength and speed of response, the quality of his prevailing mood, and all peculiari ties of fluctuation and intensity in mood; these phenomena being regarded as dependent upon constitutional make-up and therefore largely hereditary in nature. (p. 54).

Buss and Plomin (1975) refined this definition by defining temperament as "inherited personality traits present in early childhood" (p. 9).

Thomas et ale (1968) and Thomas and Chess (1977) focused on stylistic differences in behavior that appear early in life. Their definition stated that:

Temperament is the behavioral style of the individual child, the how rather than the what or why of behavior. Temperament is a phenomenologic term used to describe the characteristic tempo, rhythmicity, adaptability, energy expenditure, mood and focus of attention of a child, inde pendently of the content of any specific behavior. (Thomas et al., 1968, p. 4).

Similarly, McDevitt and Carey (1978) described temperament as the behavioral style of the child in interaction with the environment.

A psychobiological approach to defining temperament was taken by Rothbart (1981). She defined temperament as 23

individual differences in reactivity and self-reg ulation assumed to have a constitutional basis. Constitutional refers to the enduring biological makeup of the individual, influenced over time by the interaction of heredity, life experience and maturation (p. 569).

stevenson and Graham (1982) suggested that the biological processes were not understood sufficiently to discuss the concept of temperament in physiological terms or in terms of the action of particular genes. Therefore, he thought temperament was the part of the phenotype of the individual which is a general attribute of behavior, influenced by cumulative environmental effects.

A behaviorally-based definition of temperament was pursued by Goldsmith and Campos (1982). They defined infant temperament as

the set of characteristic individual differences in the intensive and temporal parameters of behavioral expression of affect-related states (p. 177).

A critical implication of their definition was that there were no behaviors which were unique to a given dimension of temperament.

Despite the lack of agreement as to the definition of temperament, it is likely that temperament will be operationally defined in terms of the measures used to assess it. Research on temperament has largely followed from the NYLS (Thomas & Chess, 1977; Thomas et al., 1963,

1968; 1970) which began with nine dimensions of temperaments derived from parental interview data. These nine 24 categories of primary reactivity in which temperamental attributes are included are:

1. Activity level: the motor component of a child's functioning.

2. Rhythmicity: the regularity and predictability of such functions as hunger, feeding pattern, elimination and sleep-wake cycles.

3. Approach or withdrawal: response to a new food, object or person.

4. Adaptability: speed and ease current behavior can be modified in response to altered environmental structuring.

5. Intensity of reaction: energy level of response.

6. Threshold of responsiveness: intensity level of stimulation required to evoke a discernible response to sensory stimuli, environmental objects and social contacts.

7. Quality of mood: amount of pleasant, joyful or friendly behavior, contrasted with unpleasant, unfriendly behavior or crying.

8. Distractibility: effectiveness of extraneous environmental stimuli in interfering with or altering the direction of ongoing behavior. 9. Attention span and persistence: length of time a particular activity is pursued, and the continuation of an activity in face of obstacles to maintaining the activity 25 direction (Thomas & Chess, 1977).

structured interviews assessing these dimensions have been developed (Garside et al., 1975; Graham, Rutter &

George, 1973). More recently, parental rating instruments have been constructed to measure the nine NYLS dimensions of temperament (Carey, 1970; McDevitt & Carey, 1978;

Pearson-Blennow & McNeil, 1979; Rowe & Plomin, 1977;

Thomas & Chess, 1977).

Other parental-report scales have also been devel oped, such as a questionnaire to operationalize the four broad dimensions of temperament: emotionality, activity, sociability and impulsiveness (EASI) (Buss & Plomin,

1975), and an instrument developed to measure aspects of reactivity and self-regulation in six categories of infant

temperament (Rothbart, 1981).

The most comprehensive attempt to investigate

temperament-related behaviors in neonates has utilized the

framework of the Brazelton Neonatal Behavioral Assessment

Scale (NBAS) (Brazelton, 1973). The scale includes

behavioral and reflex items and assesses response to

stress, habituation, orienting behaviors to environmental

stimuli and irritability.

Hubert, Wachs, Peters-Martin and Gandour (1982)

reviewed 26 temperament instruments developed to assess

temperament at the infant, preschool, and school-age

levels, giving particular attention to content, stan- 26 dardization, sample, reliability, and validity. They con cluded that no single psychometrically-adequate instrument is available, but that specific instruments may be useful for certain situations.

Parental Assessment of Temperament

Both with physical ailments and with developmental and behavioral problems in children, a large part of a clinician's diagnosis depends on the reports of parents regarding what has been happening with the child.

Recently, some critics have maintained that parents are quite unreliable in their descriptions of their children's development and behavior and that they are more likely to report their fantasies or distortions than reality

(Vaughn, Deinard & Egeland, 1980). In the opinion of these critics, parental reports of infant temperament were thought to measure the perceptual qualities, attitudes and behaviors of the parents as much or more than they measure actual infant character (Jones & Parks, 1983). This idea was also supported by other investigators (Bates, Freeland

& Lounsbury, 1979; Vaughn, Taraldson, Crichton & Egeland,

1981). Evidence for this view, however, is contradictory to finding that parents do not project their own per sonality onto their infant when assessing temperament

(Lyon & Plomin, 1981). Rothbart (1981) reported sig nificant correlations between parents' or parents and

babysitter on all infant temperament dimensions. Zeanah, 27

Keener, stewart and Anders (1985) investigated prenatal perception of infant personality and found that both mothers and fathers develop stable perceptions of their infant's personality in late pregnancy, which are nearly as stable as early postnatal perceptions.

There is growing evidence that when parents are asked the right questions in an appropriate way, they offer data of moderate or high validity (Carey & McDevitt, 1980). A recent review of studies of parental ratings of tempera ment found 16 that demonstrated some validity of parental ratings (Carey, 1982). Dunn and Kendrick (1980) found

81%-90% validity for six of their seven temperament dimensions. At present, the validity of parental assess ments of temperament is an important and yet unresolved question (Bates, 1980; Bates et aI, 1979; Carey &

McDevitt, 1980; Rutter, 1982; Sameroff, Seifer & Elias,

1982). Nevertheless, for clinical purposes, parental perceptions of temperament are vital developmental considerations.

Clinical Use of Temperament Data

Temperament data can aid the clinician in fostering parent-child relationships. Carey (1982) thought this could be done on three levels which would provide parents

information, increased awareness, and methods of dealing with individual temperament styles in their children.

Little (1985) suggested providing parents with infant 28 temperament questionnaires at the 6-month well child visit. The results would present parents with a clearer idea of their infant's temperament and how it applies to family life. If parents are aware of their child's individuality, they should be able to adapt their handling to the child's own tendencies, instead of working against them (Chess, 1969).

Research Questions

The following research questions were examined in this study:

1. What is the relation between fetal activity in utero and infant temperament at 2 months of age as measured by the Rothbart Infant Temperament Questionnaire?

2. What prenatal/perinatal factors (i.e., fetal presentation, maternal food intake, smoking and alcohol intake) and situational factors (i.e., socioeconomic status, marital status, age, and race) relate to fetal activity and infant temperament?

Definitions

Fetus

flAfter the embryonic period; from the ninth week after conception to birth the developing human is called a fetus fl (Moore, 1982, p. 6). 29

Fetal Movement

General fetal skeletal activity, such as kicks, squirming, general agitation, or turning are defined as fetal movement. These movements can be felt by the mother, or observed as generalized movements of the maternal abdomen. In addition, these movements cause characteristic changes in the fetal heart rate tracing during fetal monitoring (Timor-Tritsch et al., 1976).

Fetal Heart Rate Accelerations

Fetal heart rate accelerations are exhibited by a transient increase in the fetal heart rate, caused by fetal movement. These increases are typically 15-25 beats per minute above the baseline of 120-160 beats per minute, and last 10-30 seconds or longer. These transient increases are believed to be caused by stimulation of the sympathetic division of the autonomic nervous system

(Weingold, Yonekura & O'Kieffe, 1980).

Nonstress Fetal Monitoring

Nonstress fetal monitoring is noninvasive monitoring of the fetal heart rate and uterine activity using a fetal monitor. With this type of monitoring, the fetal heart

rate is measured using an ultrasound transducer. This

transducer utilizes the mechanical energy of the fetal

heartbeat to transmit an audible, as well as a visual,

representation of the fetal heart rate. The uterine 30 activity is measured using an external tocodynamometer.

This is a pressure-sensitive mechanism which measures the displacement of the fundus during a uterine contraction.

In addition, the tocodynamometer also responds to other activity of the uterus, such as fetal movement, which causes a displacement of the uterine wall and movement observed on the maternal abdomen (Weingold et al., 1980).

Maternal Fetal Movement Counts

A maternal fetal movement count is defined as a chart upon which the mother-to-be records her own fetus's movements (Beach, Duff & Everett, 1983).

Infant

An infant is a child from birth to 1 year of age.

Infant Temperament

An infant's behavior style characterized by the tempo, energy expenditure, focus, mood, and rhythmicity that typify the behavior of an individual infant (Chess,

1969).

Temperament Categories

The nine categories of reactivity in which tempera mental attributes are subsumed include: activity level, rhythmicity, approach-withdrawal, adaptability, intensity of reaction, threshold of responsiveness, quality of mood, distractibility and attention span and persistence (Chess, 31

1969).

Assumptions

This study was based upon the following assumptions:

1. All pregnant women are aware of some fetal activity in utero.

2. All fetuses are active in utero, to varying degrees.

3. Each infant displays a unique behavioral style both before and after birth.

4. All infants are active after birth, to varying degrees.

5. All pregnant women will be able to read and will answer the questionnaire truthfully. CHAPTER III

METHODOLOGY

Design

This study was designed, using a descriptive correla tional design (Polit & Hungler, 1983), to examine the relationship of fetal activity to infant temperament and was conducted in two phases. The first phase between gestational weeks 35-39 included the monitoring of fetal activity with a Nonstress test (NST) and assessment of fetal movement with a maternal fetal movement count (FMC) log. The second phase occurred after the birth of the infant at 2 months of age, at which time the Rothbart

Infant Temperament Questionnaire (RITQ) was completed by the infant's mother.

Sample

A convenience sample of 40 subjects was selected from the population of primigravida, low-risk women attending prenatal classes at the Family Health Program

(FHP) birthing center in a large intermountain city. The following criteria were utilized to select subjects for the sample:

1. Primigravidas between 35-39 weeks gestation. 33

2. Scores of "low" on the Hobel Prenatal High-Risk

Screening Tool.

3. Not taking any medications, other than vitamins and iron, on a regular or daily basis.

4. Nonsmokers, or smoke less than one pack of cigarettes per day.

5. Reported intake of alcohol less than 3 oz. per day.

6. Not in labor.

7. Able to read and speak the English language.

8. Between 18 and 36 years of age.

9. Remaining in the Salt Lake Valley for at least 2 months after delivery.

Inclusion of infant subjects was based on the following criteria:

1. Healthy, term, between 37-42 weeks gestation, appropriate for gestational age, and delivered without complications with Apgar scores greater than 4 at 1 minute and greater than 7 at 5 minutes.

2. Receiving no medication, other than vitamins, on a routine or daily basis, or receiving no unusual treatments at 2 months of age. 34

Instruments

Hobel Prenatal and Intrapartum High-Risk Screening (HPIHRS)

The HPIHRS (see Appendix A) is a high-risk screening system composed of three parts (Hobel, Hyvarinen, Okada,

& Oh, 1973). The first part focuses on problems detected in the antepartal period, the second part on intrapartal problems, and the third on neonatal problems. The screening system was based on a prospective analysis of

738 pregnancies. Factors were assigned weighted values according to assumed risk: low-risk = scores less than 9; high-risk is scores greater than 9. According to a stepwise multiple regression analysis, actual intrapartum scores are most predictive of neonatal risk, followed by the prenatal scores.

Nonstress Test

The NST measures the response of the fetal heart rate to fetal movement. An external fetal heart rate monitor is attached to the mother's abdomen. The woman reports any fetal movement while fetal heart sounds are recorded on a rhythm strip; she can do this by pressing a button to enter a notation on the rhythm strip. When the fetus moves, the fetal heart rate should increase, then decrease again as the fetus quiets. Numerous investigators have reported the nonstress test to be a noninvasive, low-risk, and accurate procedure which 35 provides reliable, predictive information about the fetal condition (Evertson, Gauthier, Schefrin & Paul, 1979;

Keegan & Paul, 1980; Rochard et al., 1976).

A Fetasound external fetal monitor was used for each subject to measure fetal activity. The machine was standardized with a paper speed of 3mm/second. The NST was scored by counting the total number of movements obtained during the testing period. This score was then divided by the number of minutes tested to a standardized rate for each subject.

Maternal Fetal Movement Count Log

Maternal perception of fetal movement is the oldest and least expensive technique for monitoring fetal well-being. Maternal perception of fetal movement correlates well with other fetal monitoring techniques

(Rayburn & McKean, 1980; Sadavsky et al., 1973). Several studies have suggested a positive relationship between fetal movement perceived by the mother and that recorded by sophisticated instrumentation. Schmidt, Cseh, Hara and

Kubli (1984) showed that with a high degree of confidence fetal movements could be assessed by the mothers them selves, rather than on the basis of routine cardio tocographic tracings. Various studies have shown that the gravid woman can measure with significant reliability the movements of her unborn child by means of the simple, noninvasive subjective method of daily fetal movement 36 counts (FMC) (Pearson & Weaver, 1976). To obtain the FMC log, each mother selected one convenient hour a day for 7 days to count the number of times the fetus moved. It was suggested that the mothers vary the time of day the fetal movement counting was done. The score was obtained by averaging the movements per hour and then breaking it down further to obtain movements per minute. The FMC log can be reviewed in Appendix B.

Rothbart Infant Behavior Questionnaire

Rothbart (1981) developed a six scale, 94-item parental report infant temperament questionnaire (RITQ)

(Appendix C) to measure not only the Thomas et al. (1963,

1968) dimensions, but also to tap other aspects of reactivity and self-regulation that had been identified as involving individual differences with a possible constitu tional basis. Parents rate the frequency of six infant behaviors in the past week on a 7-point rating, from 1 to

7. A description of the scales, along with their reported alpha coefficients follows:

1. Activity level: 17 items with a reliability alpha of .73. The child's gross motor activity, including movement of arms and legs, squirming, and locomotor activity are measured.

2. Smiling and laughter: 15 items with a relia bility alpha of .85. Smiling or laughter from the child in any situation are assessed. 37

3. Fear: 17 items with a reliability alpha of .80.

The child's distress and/or extended latency to approach an intense or novel stimulus are measured.

4. Distress to limitations: 20 items with a reliability alpha of .84. These items include the child's fussing, crying, or showing distress while (a) waiting for food, (b) refusing a food, (c) being in a confining place or position, (d) being dressed or undressed, (e) being prevented access to an object toward which the child is directing her/his attention.

5. Soothability: 11 items with a reliability alpha of .84 including the child's reduction of fussing, crying, or distress when soothing techniques are used by the caretaker or child.

6. Duration of orienting: 11 items with a relia bility alpha of .72. The child's vocalization, looking at and/or interaction with a single object for extended periods of time when there has been no sudden change in stimulation are assessed.

These six different scales were scored individually and each score used in data analysis.

Prenatal Maternal-Fetal Questionnaire

The Prenatal Maternal-Fetal Questionnaire is a

20-item questionnaire (Appendix D) including demographic data and maternal and fetal prenatal information. This included information on maternal perception of fetal 38 activity, diagnostic tests during pregnancy, time of greatest fetal activity and relation of maternal meals to

fetal activity. The questions were scored individually

and pertinent data were used in the final analysis.

Maternal-Infant Postnatal Questionnaire

The Maternal-Infant Postnatal Questionnaire is a

23-item questionnaire (Appendix E) describing the mother's

type of labor and delivery, and the infant's activity

patterns. Questions included type of infant feeding,

maternal perception of infant temperament and activity,

and time of greatest infant activity. Relevant questions

were used in the final data analysis.

Procedure

Prenatal classes at the Family Health Program (FHP)

center were contacted and permission obtained to present

an introduction of the project. Interested primiparous,

English-speaking women, aged 18 to 36 years were then

interviewed, using the Hobel Prenatal Risk Score, to

determine if they met the criteria for inclusion in the

study. When the sample of 40 subjects was selected, the

study was explained and an informed written consent

obtained from those wishing to participate. Arrangements

were made with each subject to do a nonstress fetal

monitoring test at the FHP center, either before or after

the subject's evening prenatal class. The nonstress test 39 took approximately 30 minutes to complete and provided a printout of fetal activity. Explanations about the fetal monitor, what it was recording, and the results were given to each subject. The procedure involved attaching the fetal monitor to the maternal abdomen and adjusting it to provide a clear recording of the fetal heart rate.

During the 20-minute monitoring period, the mother was instructed to record fetal movements by pressing a button on the machine which produced a mark on the paper. The same instructions were given to each subject and repeated or clarified as needed. If a monitor strip indicated fetal distress, the subject's health care provider was contacted.

The maternal fetal movement count log was explained to each subject at this time also. Mothers were asked to record each of the baby's movements for one convenient hour each day for 1 week, varying the time of day the movements were recorded. The Prenatal Maternal-Fetal questionnaire was given to the subject to complete which took approximately 5 minutes.

All mothers were contacted within 2 weeks after the expected delivery date to determine their infant's inclusion in the study. If the previously described inclusion criteria were met, the mother-infant dyad was continued in the study.

When the infant was 2 months of age, each mother was 40 contacted and an appointment made to deliver the

Maternal-Infant Postnatal Questionnaire and the Rothbart

Infant Temperament Questionnaire to her home. The questionnaires took approximately 25-30 minutes to fill out; the researcher waited for the mother to complete them. After the questionnaires were completed, the mother's questions regarding infant temperament and behavior were answered.

Data Analysis

The data obtained from the study were analyzed using the Macintosh Statistical System by StatSoft, Inc., 1987.

In addition to the descriptive statistics, relationships between fetal activity and infant temperament, and maternal prenatal/perinatal and situational factors possibly affecting fetal activity were determined.

Pearson product-moment correlations were used for ratio and interval level data, Spearman Rho for ordinal level data, t-tests for differences between means, and chi-square for nominal level data.

Human Subjects Considerations

Potential Subjects

The study sample consisted of primiparous women of childbearing age (18-36 years) in gestational weeks 35-39 of their pregnancy, and after delivery of their infant, at

2 months of age. All mothers were English speaking and 41 capable of signing an informed consent. A total of 38 (of an anticipated 40) low-risk, healthy, mother-infant dyads were included in the final data analysis. Subjects were free of existing medical conditions and obtained a low score on the Hobel Prenatal and Intrapartum High-Risk

Scale (Hobe1 et al., 1973). The study population came from the Family Health Program (FHP) prenatal classes.

Two mother-infant dyads were eliminated from the original

40 subjects, 1 delivered a high-risk infant and 1 other mother delivered before completing the FMC log.

Recruitment Procedures

Permission was obtained from the Family Health

Program to present an introduction of the study to the prenatal classes, until such a time"as sufficient number of subjects volunteered. Subjects who volunteered were interviewed to determine if they met the criteria for inclusion in the study. After inclusion criteria were met, the study was explained and an informed written consent was signed by those agreeing to participate.

Potential Risks

There were minimal risks to the pregnant woman, her fetus and infant child since there were no invasive procedures. There have been no documented side effects of either nonstress testing or fetal movement counts to either the mother or fetus. There were minimal risks to

ECCLES HEALTH SCIENCES LIBRARV 42 the infant at 2 months of age when the Infant Temperament

Questionnaire was completed.

Confidentiality Safeguards

Names of the women and infants participating in the study are not revealed or reported, in order to maintain confidentiality. Following the collection of maternal and infant outcome data, the data sheets were coded by number and the individual sets of information gathered are not identified.

Potential Benefits

Potential benefits to the mother and infant include increased awareness and knowledge of the activity patterns of her fetus and infant and shared information at the conclusion of the study. Other possible benefits might

include a better understanding of infant temperament for

the parents and how they can best interact with their

infant to meet his/her style of temperament.

Risk in Relationship to Anticipated Benefits

The risk of the nonstress test in relation to the

anticipated benefits of the study is minimal. There are

no data to suggest that there are risks to the mother or

fetus from having a nonstress test during pregnancy. CHAPTER IV

RESULTS

Data were analyzed using the MacSS Macintosh Statis tical System program, by Statsoft, Inc., 1987. Demo graphic data were examined to describe the character and homogeneity of the sample. Each research question was analyzed using correlational statistics appropriate for the level of measurement of the variables used. The level of statistical significance was set at 0.05.

Description of the Sample

The subjects consisted of 38 low risk, English speaking, primigravida women and their 2-month old infants. The sample population was fairly homogeneous for age, race, religion, education, and income. Ages at entry ranged from 18 to 34 years, at 35-39 weeks gestational age. Thirty-seven subjects were Caucasian and one was

Mexican-American. Responses of this subject did not differ significantly from the group as a whole and were, thus, included in the sample. The number of years of education ranged from 11 to 20 years. All but 1 subject was married. This subject did not differ significantly on any outcome variables. Twenty-seven subjects (71%) 44 reported the pregnancy was planned. Annual family incomes ranged from $5,000 to over $25,000. Table 1 outlines the maternal descriptive characteristics of the sample.

Of the 38 women, only two knew the sex of their infant before delivery. One mother knew the information from an amniocentesis and another one from an ultrasound during pregnancy_ Nineteen mothers had undergone an ultrasound during the pregnancy and of those, 16 saw the fetus move. Only one mother smoked cigarettes during the pregnancy and one other mother drank fewer than 3 ounces of alcoholic beverages per week during the pregnancy.

All of the deliveries were vertex presentation, except one breech presentation delivered by cesarean section. A total of 5 cesarean sections (13%) were performed, 5 vaginal deliveries assisted with forceps

(13%), and 28 normal spontaneous vaginal deliveries (74%).

The mean length of the mother's labor was 802 minutes with a range of 50-4320 minutes_ Pain medication was adminis tered to 12 women during labor (32%), and the remaining 26 received no medications during labor (68%). At delivery,

4 mothers had no medication (11%), 20 had only a local anesthesia for the episiotomy repair (53%), 13 had epidural anesthesia (34%) and 1 had general anesthesia for a cesarean section delivery (2%).

Sixteen boys and 22 girls were delivered between 37 45

Table 1

Maternal Characteristics

(li = 38)

Mean SD Range

Maternal Age (years) 25.2 3.5 18-34 Education (years) 13.7 1.8 11-22 Weeks Gestation at NST 36.4 1.2 35-39

Race

Caucasian 37 97 Hispanic 1 3

Income

<$10,000 1 3 $10,000-24,999 20 52 )$25,000 17 45

Religion

Latter Day Saint 26 68 Protestant 5 13 Catholic 1 3 No Preference 6 16 46 and 42 weeks gestation with birthweights ranging from

1701 grams to 4082 grams. All infants were healthy at delivery with no 5-minute apgar score less than 7. The 1 infant with an apgar score of 4 at 1 minute, was a precipitous delivery and had as-minute apgar of 8 without further problems. By 2 months of age 50% of the infants' mothers had returned to work, 84% on a full-time basis. Table 2 outlines the infant descriptive characteristics of the sample.

Research Question One

Research question one stated:

What is the relationship between fetal activity in utero and infant temperament at two months of age as measured by the Rothbart Infant Temperament Questionnaire (RITQ)?

Frequency distributions were obtained for the fetal variables of maternal perception of fetal activity, FMC log score, and NST score, and infant variables of maternal perception of infant activity, maternal perception of infant temperament and the RITQ scores (Table 3).

Significant correlations were found between the fetal movement count (FMC) score and two Rothbart subscores, activity level score (Q=.0018), and distress to limitations score (Q=.0339). The objective measure of fetal movement, the nonstress test (NST) movement count, showed significant correlation with the RITQ soothability score

(Q=.0311), and with maternal perception of fetal activity 47

Table 2

Infant Characteristics

(li = 38)

Mean SD Range

Infant Birthweight (grams) 3357.0 463.0 1701-4082

Infant Apgar Score (I-minute) 7.7 1.1 4-9

Infant Apgar Score (5-minute) 8.9 .3 8-9

Infant Weight at 2 months (grams) 5230.0 473.0 4479-6492

Infant Corrected Age at RITQ (weeks) 9.5 1.8 6-15

Sex

Boys 16 42 Girls 22 58

Infant Feeding at 2 Months

Breast 14 37.0 Breast and Solids 4 10.5 Breast and Bottle 4 10.5 Bottle 10 26.0 Bottle and Solids 6 16.0 48

Table 3

Frequency and Distributions of Fetal and Infant

Variables (N = 38)

Mean SD Range

Fetal Variables

Maternal Perception Fetal Activity 2.15 .789 1-3 FMC Score .776 .629 .09-2.82 NST Score 1.20 .539 .28-2.95

Infant Variables

Maternal Perception Infant Activity 1.52 .506 1-3 Maternal Perception Infant Temperament 1.60 .916 1-5 RITQ Activity Level Score 3.65 .974 2.05-5.71 RITQ Limitations Score 3.55 .814 2.10-5.06 RITQ Latency Score 2.26 .604 1.18-3.80 RITQ Orientation Score 3.57 1.310 .00-7.00 RITQ Smiling Score 4.03 .864 1.63-5.80 RITQ Soothability Score 4.76 .841 2.20-6.25 49

.0263). Significant correlations were also found between maternal qualitative perception of fetal activity

and maternal perception of infant activity (2=.0315), as well as for the RITQ activity level score ( .0255).

An attempt was then made to determine if sex differences affected fetal activity and infant tempera ment. For females (n=22), there was no statistical significance for any of the variables measuring fetal movement or infant temperament. Males (n=16) did display significant correlations between maternal perception of

fetal activity and the RITQ activity level score

(2=.0369), as well as the FMC score (2=.0314). Maternal perception of infant activity and the RITQ activity level score ( .0224), and the FMC score and the RITQ activity

level score (2=.0049) also demonstrated significant correlations.

Some factors which might conceivably affect fetal or

infant activity (or perception of them) were examined.

Significant correlations were found between the fetal movement count score and infant birthweight (2=.0329),

maternal perception of fetal activity and the FMC score

(2=.0437), maternal perception of infant activity level

and the RITQ activity level score .0400) and maternal

perception of infant temperament and the RITQ distress to

limitations score (2=.0027). An interesting correlation

was found between the nonstress test score and infant sex 50

.003i) and also the fetal heart rate score and infant sex (2=.0241), with girls showing increased fetal heart rate and increased NST activity. Table 4 outlines the significant correlations from research question one.

The strongest measure of fetal activity was maternal perception from the Prenatal Maternal-Fetal Questionnaire.

This demonstrated significant relations with the RITQ activity level score and maternal perception of infant activity from the Maternal-Infant Postnatal Questionnaire.

The objective measure of fetal activity, the NST, did not demonstrate a significant relation to the subjective FMC

log.

Research Question Two

Research question two stated:

What prenatal/perinatal factors, i.e. fetal presentation, maternal food intake, smoking and alcohol intake, and situational factors, (i.e. socioeconomic status, marital status, age, and race, relate to fetal activity and infant tempera ment?)

Many of the variables addressed in research question one could not be examined because of a lack of variation.

These included: fetal presentation (37 vertex, 1 breech), smoking (1 smoker), and alcohol intake (only 1 drinker), race (1 Mexican-American), marital status (1 single) and religion (26 Latter Day Saint, 12 other). A positive

trend, (2=.0650) did exist, however, in the relation

between time of last food intake before the NST and the 51

Table 4

Significant Correlations of Measures of Fetal Movement

and Maternal Perception of Fetal and Infant Activity

Measures (~ = 38)

asures r

Fetal Movement Count Log

Maternal Perception of Fetal Activity .327** .043 Infant Birthweight .343* .032 RITQ Activity Score .499* .001 RITQ Distress to Limitations Score .341* .033

Nonstress Test Scores

Maternal Perception of Fetal Activity .356** .026 RITQ Soothability Score -.346* .031 Infant Sex (1 == ) -3.213*** .003 Maternal PerceQtion of Fetal Activity

Fetal Movement Count Score .327** .043 Non-Stress Test Score .356** .026 RITQ Activity Level Score .363** .. 025 Maternal Perception of Infant Activity -.349** .031 Ultrasound (1 == ) 2.154*** .035 Maternal PerceQtion of Infant Activity

RITQ Activity Score -.331** .040 Maternal Perception of Fetal Activity -.349** .031

Maternal PerceQtion of Infant TemQerament

RITQ Distress to Limitations Score .500** .002 Note. * Pearson Product-Moment Correlation ** Spearman-rho Coefficient Correlation *** t-test. 52

NST movement score.

No statistical significance could be identified between the analyzed situational factors (maternal age, education, and income) and the measurements of fetal activity (Table 5). This also was true when situational factors were related to infant temperament and activity measures. Additionally, no significant correlations were observed when infant temperament was correlated with: length of labor, working or not working, infant's apgar score at 1 and 5 minutes, type of infant feeding, sex of infant, birthweight, or weight at 2 months (Table 6).

The infant's age at the time of the RITQ, as well as the age corrected for variation from a 40-week gestation, were not related to any measures or the RITQ. A positive correlation was found between those mothers who had an ultrasound during pregnancy (~=19) and maternal perception of fetal activity (2=.0359). This relationship was further explained by comparing within group relationships for those who had had ultrasound to those who had not.

Those having ultrasounds demonstrated significant correla tions between maternal perception of fetal activity and the FMC score (2=.0211), maternal perception of fetal activity and the NST score (2=.0321), and the FMC score and the RITQ activity level score (2=.0130). For mothers who did not have an ultrasound ( 19), only correlations between perceived fetal activity and the RITQ activity 53

Table 5

Maternal Factors as they Relate to Measures

of Fetal Activity (~ = 38)

e r

Maternal Age

Maternal Perception Fetal Activity -.030** .8690 FMC Score -.199* .228 NST Score .056* .735

Maternal Education

Maternal Perception Fetal Activity .046** .772 FMC Score .042* .787 NST Score .241* .141

Maternal Income

Maternal Perception Fetal Activity -.188** .249 FMC Score .082* .626 NST Score .036* .810

Note. * Pearson-Product Moment Correlation ** Spearman-rho Coefficient Correlation Level of Statistical Significance 2=0.05. 54

Table 6

Situational Factors as they Relate to Measures of Infant

Temperament and Activity (~ = 38)

e r

Infant Temperament Maternal Age .075 .655 Maternal Income -.592 .722 Maternal Education .117 .487 Maternal Length of Labor -.008 .913 Infant Sex (! =) -1.586*** .117 Infant Birthweight .022 .861 Infant Apgar Score I-Minute -.033 .821 5-Minute -.183 .263 Infant Age at Assessment -.092 .579 Infant Weight at 2 months .020 .867 Type of Infant Feeding -.183 .262 Mother Working or Not .237 .145

Infant Activity Maternal Age .140 .404 Maternal Income .050 .758 Maternal Education .119 .479 Maternal Length of Labor -.274 .091 Infant Sex (! =) -.270*** .778 Infant Birthweight -.240 .139 Infant Apgar Score I-Minute -.078 .639 5-Minute .0181 .877 Infant Age at Assessment .296 .067 Infant Weight at 2 Months .002 .936 Type of Infant Feeding -.047 .765 Mother Working of Not -.105 .528

Note. Level of Statistical Significance E=0.05; Spear man-rho Coefficient Correlations; ***t-test. 55 level score (2=.0246) and the FMC score and the RITQ activity level score (2=.0455) were significant.

Maternal age, a potentially important variable, was analyzed against maternal perception of fetal and infant activity level, birthweight, NST scores, fetal movement count scores, the RITQ scores, and type of infant feeding.

Of those, the only significant correlation found was between maternal age and type of infant feeding (2=.0003).

Several additional correlations of interest were demonstrated during the analyses. A significant relation ship was found between medication during labor and infant apgar scores at 1 and 5 minutes (Table 7). This correla tion was analyzed two different ways. The original variable included the type of medication the mother received in labor, such as none, pain, or sleep. This showed significant correlations with the I-minute apgar score (2=.0145), and the 5-minute apgar score (2=.0356).

A second analysis was done which, using yes or no, asked if the mother had any medication during labor. This also demonstrated significant correlations with I-minute apgar scores (2=.0214) and 5-minute apgar scores (2=.0472). A correlation between the mothers who received medication in labor and the length of labor was also significant

(2=.0173). Table 8 describes significant correlations for research question two. The group of 38 mothers was split at the mean age to 56

Table 7

Significant Correlations of Maternal Medication

in Labor and Infant Apgar Scores (N = 38)

e r

Specific Type of Medication

Apgar Score at 1 Minute -.399** .014 Apgar Score at 5 Minutes -.341** .035 Yes/No for Medication Apgar Score at 1 Minute (t=) 2.381*** .0214 Apgar Score at 5 Minutes (!=) 2.029*** .0472

Note. ** Spearman-rho Coefficient Correlation *** t-test Level of Statistical Significance 2=0.05. 57

Table 8

Significant Correlations of Prenatal and Situational

Factors Relating to Fetal Activity and Infant

Temperament (N = 38)

e r

Maternal Food Intake Before NST

NST -.299** .065

Ultrasound

Maternal Perception of Fetal Activity Ct.=) 2.154*** .035 FMC .538** .021 NST .499** .032 FMC to RITQ Activity Level Score .555* .013

No Ultrasound

RITQ Activity Level Score FMC .459* .045 Maternal Perception of Fetal Activity .523** .024

Maternal Age

Infant Feeding at 2 Months of Age -.629** .0003

Older Mothers (>24 years) (n = 21) RITQ Distress to Limitations Score Maternal Age .481** .044 Maternal Perception of Infant Temperament .604** .012 58

Table 8 continued

e r

RITQ Activity Level Score FMC .667* .004 Maternal Perception of Fetal Activity .532** .036 Maternal Perception of Infant Activity -.583** .022

Maternal Perception of Fetal Activity FMC .548** .031

Note. * Pearson-Product Moment Correlation ** Spearman-rho Coefficient Correlation *** t-test. 59 evaluate age group differences. Group 1 was less than 24 years of age (Q=17) (average age 21 years), and Group 2 was greater than 24 years of age (n=21) (average age 29 years). For the older group, statistically significant correlations were found between the RITQ distress to limitations score and both maternal age (2=.0445) and maternal perception of infant temperament (2=.0122). The older mothers perceived their fetus to be quieter and their NST and FMC scores were also lower than the younger mothers. Yet, the older group perceived their infants' temperament as more difficult than the younger mothers.

Those in the younger group showed more of a tendency to have introduced solid feeding to their infants and to be bottle feeding; whereas the older group was mainly breastfeeding exclusively. Table 9 outlines the descrip tive statistics for the two groups of mothers.

Numerous prenatal and situational factors thought to affect "fetal activity and infant temperament were ana lyzed. Of those, only ultrasound during pregnancy, infant birthweight and maternal age demonstrated significant relationships. The use of medications during labor was found to correlate with infant apgar scores at 1 and 5 minutes, and significant correlations were found among the older group of mothers and their perception of infant temperament. 60

Table 9

Maternal Characteristics According to Age Groups

Mean

Age (yrs) 21.20 1.40 26.70 2.60 Education (yrs) 12.60 1.10 14.60 1.90 NST score 1.20 .48 1.10 .59 FMC Score .84 .79 .72 .46 Maternal Perception of Fetal Activity 2.20 .75 2.00 .83 Labor Length (mins) 884.00 603.00 736.00 862.00 RITQ Activity Level Score 3.50 1.00 3.70 .96 Income (median) $10,000-14,999 >$25,000

s- -n 0 n %

Cesarean Section 2.0 22.0 3.0 14.0

Infant Feeding at 2 Months Breast 2.0 11.7 12.0 57.1 Breast and Bottle 0.0 0.0 4.0 19.1 Bottle 5.0 29.4 5.0 23.8 Breast and Solids 4.0 23.5 0.0 0.0 Bottle and Solids 6.0 35.2 0.0 0.0 CHAPTER V

DISCUSSION

Previous studies have identified distinct behavioral states in the human fetus by observing fetal movement, heart rate and respiratory movement, and by using real-time ultrasound (Timor-Tritsch et al., 1978; Prechtl,

1974; Nijhuis et al., 1982). Others have demonstrated a link between fetal heart rate patterns and newborn infant heart rate patterns soon after birth (Rosen et al., 1979).

More recently, studies have emerged focusing on infant development in relation to fetal movement (Emory et al.,

1982; Junge, 1979; Madison et al., 1986). These studies have suggested an association between prenatal behavior and infant behavior soon after birth.

Research Question One

The results of the present study also suggest an association between fetal activity and infant activity assessed at 2 months of age. The most consistent correlations were found between the measures of maternal perception of fetal activity and maternal perception of infant activity, both on the maternal prenatal and postnatal questionnaires and the RITQ activity level 62 score. Mothers who perceived greater fetal activity during pregnancy reported more active infants at 2 months of age. This relationship was true for their global perceptions of fetal activity, as well as in the more quantitative, though still subjective, fetal movement counts. There were significant correlations between the maternal subjective measure of perceived fetal activity and the FMC score. Infants with more reported fetal activity on the FMC, also had higher distress to limita tions scores on the RITQ. Also, mothers who perceived their infant's temperament as more difficult had higher distress to limitation scores on the RITQ. This score assesses infants' fussing, crying or showing distress while waiting for food or refusing food, being dressed or undressed, or confined to one position for a brief period.

There was significant correlation between the subjective measures of perceived fetal activity and FMC score.

Although the only objective measure of fetal activity in this study, the NST score, showed a relation to maternal perception of fetal activity, it was not correlated with the FMC score. Mothers who perceived their infants less active also showed lower NST activity.

The NST score also correlated with the RITQ soothability score, showing more active infants to be less soothable or harder to pacify.

Another factor that affected fetal activity was 63 birthweight. Larger babies at birth demonstrated higher scores on the FMC logs. This relationship may be due to the mothers' being able to perceive the movement of larger babies more easily than that of smaller babies. Birth weight did not relate to NST scores or later infant activity.

The infant's sex correlated to the amount of fetal activity on the NST, but not to the FMC score or perceived fetal activity. There was an increased fetal activity level in females over the males' NST scores. Interesting ly, mothers perceived their male fetuses to be more active in utero, although the sex was not known at the time of the questionnaire. Correlations between maternal perception of fetal activity and the variables of FMC score and the RITQ activity level score were stronger in male than female babies. The FMC score and the RITQ activity level score were also statistically significant.

After birth, mothers perceived males to be more active.

This was demonstrated in the correlation between maternal perception of infant activity and the RITQ activity level score which was higher in males and not in females. This finding demonstrates that mothers perceive males to be more active in utero and after birth, whereas the NST

(perhaps a more objective measure) showed girls to be more active. An interesting finding was the significant difference of FHR score between boys and girls. Fetal 64 heart rate is used by some when trying to guess the sex of the baby before birth. In this study, males had a mean fetal heart rate of 128 and females 135 on the NST.

Two

There was insufficient variation in cases to adequately test for statistical significance of some of the prenatal factors suspected to affect fetal activity.

However, various studies have shown that the maternal use of alcohol and cigarettes during pregnancy can reduce fetal activity and fetal respiratory movements (Manning &

Feyerabend, 1976; Rayburn et al., 1982). There was only one breech presentation in this study; therefore, no conclusions could be drawn as to the effect of presenta tion on fetal activity. Luterkort & Marsal (1985) found there were no differences in fetal motor activity between breech and vertex presentations. Results of studies on the effect of maternal meals to fetal activity differ.

Some researchers show an increase in fetal activity after a meal (Aladjem et al., 1979; Gelman et al., 1980; Miller et al, 1978), while others show no alteration in fetal activity (Birkenfeld et al., 1980; Rayburn et al., 1982).

The present study suggests a trend toward decreased fetal movement on the NST with increased length of time since the mother's last meal before the NST. This might indicate that the lower the maternal blood glucose level, the less active the fetus. 65

Very few situational factors were found to have any relationship to fetal activity or infant temperament. No consistent effect was seen with marital status, income, or infant feeding. Those that did show a relation were ultrasound during pregnancy and maternal age.

Some support was found for the premise that mothers who have an ultrasound during pregnancy may have a dif ferent perception of fetal activity than those who do not. The group of mothers (~=19) who had an ultrasound during pregnancy perceived fetal activity to be higher than those mothers who did not have an ultrasound. This is supported in the literature by Sadovsky et al. (1973),

Rayburn et al. (1980), and Ehrstrom (1979) who studied the relationship of maternal assessment of fetal motion and ultrasound and found correlations of 82-90% for the two methods. The group of mothers who had an ultrasound also showed stronger relationships between maternal perception of fetal activity and FMC scores; perception of fetal activity and NST scores, and FMC scores and RITQ activity level score. The ultrasounds had been done on the mothers before they completed the NST, FMC log and the maternal perception questionnaire. The present study also showed that mothers who did not have an ultrasound reported significant relations between the RITQ activity level score and both maternal perception of fetal activity and the FMC score. In that there was a stronger relation in 66 the group having an ultrasound, this might suggest that the ultrasound increases maternal awareness of fetal activity and, thus, greater perception of movement is exprienced.

Maternal age is a factor thought to affect fetal activity and infant temperament. However, the only positive correlation found in this sample was with maternal age and the type of infant feeding. With an increase in maternal age, there was more breastfeeding without solids at 2 months of age. Older mothers perceived their infants' temperament at 2 months of age to be more difficult than the younger mothers. However, they did not report them to be more active on the RITQ or maternal perception questionnaire. CHAPTER VI

CONCLUSIONS AND RECOMMENDATIONS

This study was conducted to examine the relationship between fetal activity and infant temperament at 2 months of age. Literature had defined both patterns of fetal behavior and patterns of infant temperament; if a relationship between them could be established, earlier predictions of behavioral factors possibly affecting social and cognitive development could be made. Such observations might also be useful in allowing an earlier, smoother adjustment by parents to the infant's behavioral style. Relationships between measures of fetal activity and infant temperament were analyzed. Physical and situational factors which may relate to fetal activity and infant temperament were also measured.

The majority of research conducted on fetal activity or behavioral states and infant activity or temperament has measured the infant within the first week of life. It was thought that by assessing infant temperament at two months of age a broader scope of temperament characteris tics could be measured.

The first research question examined the relationship between fetal activity and infant temperament. The 68 strongest measure of fetal activity was maternal percep tion which demonstrated several relationships with measures of infant temperament. The data support the idea that there is a relationship between perception of fetal activity and infant temperament. The mothers who perceived their fetus to be active also showed higher infant activity level scores. It was less clear that the brief objective fetal movement measurement, the NST, predicted infant behavior. It is possible that the length of time of the NST was too short to provide an adequate sampling or that a better time for administering the test might be found.

The second research question examined the prenatal and situational factors relating to fetal activity and infant temperament. The sample was too homogeneous to allow examination of the relationships between the prenatal factors and fetal activity. The only situational factors that significantly related were ultrasound during pregnancy, birthweight, and maternal age: Maternal perception of fetal'activity and the FMC scores were higher in the group of mothers having an ultrasound; mothers with larger babies at birth demonstrated higher scores on the FMC log: and older mothers perceived their infant's temperament to be more difficult than the younger mothers did. This research question could be answered better with a larger, more diverse population and also by 69 analyzing more perinatal/prenatal factors which may affect fetal activity and infant temperament.

Conclusions

From the data, it is concluded that maternal percep tion of fetal activity and the FMC score do measure common features of fetal activity and are related to maternal perception of infant activity and the RITQ activity level score 2 months later. The continuity was between maternal perception of fetal activity and maternal perception of infant activity. The objective measure of fetal activity, the NST, was not related to fetal or infant activity scores. The NST was not a predictor of infant activity and did not relate to fetal movement.

Since most of the significant results were of relationships between maternal perception of fetal activity and maternal perception of infant activity, it might be suggested that the continuity might be in maternal perception and not infant activity. This researcher was unable to determine which of the pos sibilities is most important.

The fact remains that there was a relationship between perceived fetal activity and infant temperament.

This continuity may be useful to clinicians, especially if preventive interventions could improve mothers' rating skills or if an accurate, objective measure could be found. 70

Limitations of the study

Limitations to this study include:

1. Two months may not be an ideal time to assess infant temperament and activity_ Most infants do not demonstrate varied levels of activity or temperament at this age.

2. Maternal report may not be the best way to measure infant temperament and activity. The answers may measure perceptual qualities, attitudes, and behaviors of the mother as much or more than actual infant character.

3. The I-week recall of the Rothbart Infant

Temperament Questionnaire may make answering the questions more difficult for the mothers.

Recommendations for Further Study

Recommendations for additional studies based upon the data and findings of this investigation are:

1. A similar study should be conducted which would include mothers with wider variation in demographic data and a larger sample size.

2. A similar study design should be employed with a random sample which includes both primiparous and multiparous women for comparison.

3. A similar study design should be utilized with the addition of an objective measure of infant tempera ment.

4. Replication of the study is recommended using 71 longer NST fetal monitoring periods. The fetus should be monitored for approximately 90 minutes, based on the findings of Granat et al. (1979).

5. A long-term study should be conducted which involves follow-up of the infants using the RITQ later in the first year to determine individual temperament and its relationship to fetal activity.

6. Replication of the study is recommended, including a high-risk population of pregnant women for comparison.

The relationship between fetal activity and infant temperament was examined in this study. Findings indicated the presence of a positive relationship between the two variables. This research provides baseline information for future research, as well as information that can be used by the nurse in the clinical setting.

Further research is indicated since little systematic study has been done examining the relationship between fetal activity and subsequent infant temperament. APPENDIX A

CONSENT FORM 73

Title of study: The Relationship Between Fetal Movement and Subsequent Infant Temperament.

Information:

A study is being conducted to see if there is a relationship between fetal activity in utero and infant temperament. The study is being conducted by a Registered Nurse who is a perinatal graduate student in the College of Nursing at the University of Utah. Her name is Julie Ralston; she may be reached at 484-0349.

There is no compensation for participation in this study. This study involves no known risk to you, your unborn child, or to your infant. There is the possible inconvenience to you of time (30 minutes) taken for the nonstress test--which will be done at no cost to you- and in your home for the questionnaire and infant assess ment. Participation in this study will add to your knowledge of your unborn infant' s temperament style and how he/she may be after birth. This increased knowledge may benefit you and future expectant women. A short summary of the findings will be sent to the subjects who request this summary. Alternatives are seeking informa tion on your own or not participating in the study.

Records will be held in the strictest confidence. Any release of information derived from these records to scientific organizations, nursing journals, etc. will be done only without identification of the subjects.

In the event you sustain physical injury from the research project in which you are participating, the University of Utah will provide you, without charge, emergency and temporary medical treatment not otherwise covered by insurance. Furthermore, if your injuries are caused by negligent acts or omissions of University employees acting in the course and scope of their employ ment, the University may be liable, subject to limitations prescribed by law, for additional medical costs and other damages you sustain. If you have any questions regarding this research project or research subject's rights, please contact the IRB Office University of Utah, 581-3655. 74

Participation in the study involves the following:

1. A 20-minute nonstress test at the FHP clinic to measure fetal activity and 5 minutes to complete a short questionnaire.

2. A fetal movement log which consists of counting fetal movements for one convenient hour each day for 1 week in your home.

3. Approximately 45 minutes in your home when your infant is 2 months of age for you to complete an Infant Temperament Questionnaire.

Consent

I understand that participation in this study is voluntary and that my refusal to participate will involve no penalty or loss of benefits to which I would otherwise be entitled. My care at FHP will not be different whether or not I part

I understand that I am free to withdraw myself or my infant from the study at any time for any reason of my choosing without prejudice to my future care.

I have read the foregoing, my questions have been answered, and I desire to participate in this study. A copy of the consent document and any related materials has been given to me.

I give permission for information gathered in this study to be released to Julie Ralston, RN.

Date Signature of Participant

ss APPENDIX B

HIGH RISK SCREENING TOOL I

lAdapted from Habel et al., 1973. 76

1 Factors

I. Cardiovascular and Renal

1. Toxemia, moderate to severe. 2. Hypertension, chronic. 3. Renal disease, moderate to severe. 4. Heart disease, severe (Class II-IV). 5. Eclampsia, history of. 6. Pyelitis, history of. 7. Heart disease (Class I). 8. Toxemia, mild. 9. Pyelonephritis, acute. 10. Cystitis, history of. 11. Toxemia, history of.

II. Metabolic

1. Diabetes (~ Class A-II). 2. Endocrine ablation, previous. 3. Thyroid disease. 4. Prediabetes (A-I). 5. Diabetes, family history of.

III. Previous Histories

1. Fetal exchange transfusion for Rh, previous. 2. Stillbirth, previous. 3. > 42 weeks postterm. 4. Premature infant, previous. 5. Neonatal death, previous. 6. Cesarean section, previous. 7. Abortion, previous habitual. 8. Birth of previous infant(s) > 10 lbs. 9. Multiparity> 5. 10. Epilepsy, previous. 11. Pelvis, small.

IV. Anatomic Abnormalities

1. Uterine malformation. 2. Incompetent cervix. 3. Abnormal fetal position. 4. Polyhydramnios. 5. Pelvis, small.

V. MISCELLANEOUS

1. Cervical cytology, abnormal. 2. Pregnancy, multiple. 3. Sickle cell disease present. 77 4. > 35 years of age or younger than 15 years of age. 5. Viral disease. 6. Rh sensitization only. 7. Serology test positive. 8. Anemia, severe « 9 gm Hgb). 9. Drug use, excessive. 10. TB or PPD > 10 mm, history of. 11. Underweight « 100 lbs) or overweight (> 200 lbs). 12. Pulmonary disease. 13. Severe flu syndrome. 14. Spotting, vaginal. 15. Anemia, mild (9-10.9 gm Hgb). 16. Smoking (> 1 pack per day) 17. Alcohol use (moderate). 18. Emotional problems.

Intrapartum Factors

Maternal

1. Toxemia, moderate to severe. 2. Hydramnios or oligohydramnios. 3. Amnionitis. 4. Uterine rupture. 5. Toxemia, mild. 6. Premature rupture of membranes (> 12 hrs). 7. Dysfunctional labor, primary. 8. Arrest of dilation, secondary. 9. Administration of DemerolR (> 300 mg). 10. MgS04 values > 25 gm. 11. Long labor (> 20 hrs). 12. Long second-stage (> 2.5 hrs). 13. Small pelvis, clinical. 14. Induction, medical. 15. Precipitous labor « 3 hrs). 16. Cesarean section, primary. 17. Cesarean section, repeat. 18. Induction, elective. 19. Latent phase prolongation. 20. Tetany, uterine. 21. Augmentation, pitocin.

Placental

1. Placenta previa. 2. Abruptio placentae. 3. > 42 weeks Postterm. 4. Amniotic fluid meconium stained (dark). 5. Amniotic fluid meconium stained (light). 78

6. Separation, marginal.

Fetal

1. Presentation, abnormal. 2. Multiple pregnancy. 3. Bradycardia (fetal) ) 30 mins. 4. Total extraction, breech delivery. 5. Cord prolapsed. 6. Low birthweight « 2500 gms). 7. Fetal acidosis (pH < 7.25 gms) 8. Tachycardia (fetal)-) 30 mins. 9. Vacuum extraction or operative forceps. 10. Delivery, breech (spontaneous or assisted). 11. Anesthesia, general. 12. Forceps, outlet. 13. Dystocia, shoulder.

Scoring

Low risk = < 9; High risk = > 10. APPENDIX C

FETAL MOVEMENT COUNT LOG 80

I.D. Subj

FOR OFFICE USE ONLY

Instructions

A daily diary of your baby's movements provides useful information. Please mark down any time your baby moves during at least one convenient hour each day for 7 days. Try to count while lying on your left side, so you get enough rest and the circulation to the baby is improved. Try to vary the times of day you count the baby's movement.

DAY HOUR COUNTINGS TOTAL

1 APPENDIX D

QUESTIONNAIRES 82

I.D.# Subject--~~------# FOR OFFIC-E--U~S-E~O~N-L-Y-----

Prenatal Maternal-Fetal Questionnaire

Information in this questionnaire will aid in the study on fetal activity and infant temperament. The questions asked pertain to your prenatal care and to your unborn baby's activity. Please circle the number cor responding to the questions as appropriate. Feel free to make any comments on the answers.

1. Who is your primary care provider for this pregnancy?

Obstetrician ...... 1 Family practice physician ...... 2 Certified nurse midwife ...... 3 Other (please specify) ...... 4

2. Where will your baby be born?

Hospital delivery room ...... 1 Hospital birthing room ...... 2 Birth center ...... 3 Home ...... 4 Other (Please specify) ...... 5

3. Was an ultrasound done during your pregnancy?

Yes ...... 1 No ..... (skip to question 5) ...... 2

4. Did you see your baby moving?

Yes ...... 1 No ...... 2

5. Was an amniocentesis done during your pregnancy?

Yes ...... 1 No (skip to question 7) ...... 2

6. Do you know the sex of the baby?

Yes ...... 1 No ...... 2 83

7. Was this pregnancy planned?

Ye s ...•....•.•.•...... ••.....•••••••••••• 1 No ...... 2

8. What is your due date? (please specify)

9. How do you describe your unborn baby's activity?

More quiet periods than active ...... 1 Equal quiet and active periods ...... 2 More active periods than quiet ...... 3 other (please specify) ...... 4

10. At what time of day is your unborn baby most active?

Morning ...... 1 Afternoon ...... 2 Evening ...... 3 Late night ...... 4 Other (please specify) ...... 5

11. Is your unborn baby more active before or after a meal?

Before ...... 1 After ...... 2 No difference in activity with meals ...... 3

12. What do most of your unborn baby's movements feel like?

Rolling or turning ...... 1 Kicking ...... 2 Stretching ...... 3 Hiccuping ...... 4 Other (please specify) ...... 5

13. Do you feel your unborn baby move every day?

Yes •••••.••••••...•..•.••••.••.•.•••.•••••• 1 No ...... 2 Not sure ...... 3 84

The following questions deal with some background information about you and your household. This informa tion is needed in order to group your responses with those of persons with a similar background when the results of this study are analyzed.

14. What is your age in years? ...... ------15. What is your ethnic group?

White/Caucasian ...... •••...... 1 Mexican or Latin American/Puerto Rican ...... 2 Black/Negro/African-American ...... •...... 3 Polynesian/Tongan .•...... 4 Asian-American/Oriental ..•..••...... •... 5 American Indian ...•...... •.. 6 other (please specify) •••...... •...... 7

17. In what range was your family's income from all sources last year?

Under $5,000 ...... ••.•...... ••...... 1 $ 5, 000 - 9 , 999 ..•••••••..••••••••••••••••••••.•• 2 $10, 000 -14, 999 •...... ••...... 3 $15, 000 -19 , 999 ...... •...... 4 $20 ,000-24,999 • •••.••••••••••••••••••••.•••••• 5 $25,000 or over ...... •...... ••...... 6

18. What is your religious preference?

Latter Day Saint (LDS) ...•...... •...... l Protestant .•..•...... •...•....•..•.•...... 2 Catholic ...... •...... •...... •....•.•... 3 Jewish ...•...... •.•...... 4 No preference .•..••...•.•...... ••..•....••.... 5 Other (please specify) .••••..•••••...... 6

19. What is your highest grade or year of school you have completed (Circle the highest grade or year)?

None ••••••••••••••••••••••••••••••••••••••••• 00 Elementary ...... •••.....• 01 02 03 04 05 06 Junior high/high school .. 07 08 09 10 11 12 College ....•...... • 13 14 15 16 Postgraduate •••...... 17 18 19 20 21 or more

20. What is your primary occupation (please specify)? ___

Thank you for your participation. Please return the completed questionnaire to Julie Ralston. 85 I.D.# --~~------Subject # ------FOR OFFICE USE ONLY

Maternal-Infant Postnatal Questionnaire

The following questions pertain to your labor and delivery and your infant. Please circle the number corresponding to the answers to the questions as ap propriate. You are welcome to make any comments in the answers that you feel would be helpful for the study.

1. Did you have a cesarean delivery?

Yes (skip to question 2) ...... 1 No (skip to question 3) ...... 2

2. Was the cesarean section an ...

Emergency ...... 1 Elective/scheduled ...... 2

3. What type of delivery did you have?

Normal spontaneous vaginal ...... l Forceps delivery ...... 2 Other (please specify) ...... •..... 3

4. Was your labor started initially with medication (Pitocin)?

Yes ...... •..... 1 No ...... 2

5. Was your labor assisted with medication (Pitocin) once it had started?

Yes ...... •...... 1 No ...... 2

6. What was the length of your labor?

Hours------Minutes------7. Was your labor and delivery as you had anticipated?

Yes (skip to question 6) ...... 1 No ...... 2 If no, expl 86

8. What type or types of medication did you have during your labor (Circle as many as apply)?

No medication ...... I Pain medication during labor ...... 2 Sedating/sleeping medication during labor ...... 3 Other (pI ease speci fy ) ...... 4

9. What type or types of anesthesia did you have for labor and delivery (Circle as many as apply)?

Local anesthesia for delivery ...... l Epidural or caudal anesthesia ...... 2 General anesthesia ...... 3 Paracervical or pudendal anesthesia ...... 4 Other (please specify) ...... 5

The following questions pertain to your infant and his/her daily activity patterns. This information will be important when the results of the study are analyzed.

10. What method of feeding are you currently using for your infant (Circle as many as apply)?

Breastfeeding ...... 1 Bott 1 e feeding ...... 2 Solid foods ...... 3 Other (please specify) ...... 4

11. Are you working outside the home since the birth of your infant?

Yes ...... 1 No (skip to question 14) ...... 2

12. What amount of time do you work?

Full-time ...... 1 Part-time ...... •..... 2 Other (please specify) ...... 3 87

13. If you do work, what type of child-care arrangements are you currently using?

Take infant to babysitter at his/her home ...... 1 Have babysitter come to my home ...... 2 Take to day care center ...... 3 Husband watches infant at home ...... 4 Live-in child care/nanny ...... 5 Child care at work facilities ...... 6 Other (please specify) ...... 7

14. Compared with other infants of the same age, how would you describe your infant's temperament?

Easier than average ...... 1 More difficult than average ...... 2 About average ...... 3

15. How would you rate your baby's activity level? By this is meant the amount of physical activity during sleep, feeding, play, dressing, etc.

High ...... 1 Medi urn ...... •...... •••..• 2 Low ...... 3

16. At what time of day is your infant the most awake or active?

Morning ...... 1 Afternoon ...... 2 Evening ...... 3 Late night ...... 4 Other (please specify) ...... 5

17. What were your infant's apgar scores at birth?

at 1 minute at 5 minutes------18. What is your infant's sex?

Boy ...... 1 Girl ...... 2

19. What was your infant's birthdate?

20. What is your infant's age?

21. What was your infant's birthweight?

ounces ------lbs 88

22. What is your infant's present weight?

------lbs ounces 23. Who is your primary care provider for your infant?

Pediatrician ...... 1 Family practice physician ...... 2 Nurse practitioner ...... 3 other (please specify) ...... 4

Thank you for your participation in the study.

Please return the completed questionnaire to Julie Ralston. APPENDIX E

INFANT BEHAVIOR QUESTIONNAIRE1

Subject No. --- Date of Baby's Birth month day year

Today's Date month day year

Age of Child months weeks

Sex of Child

Instructions (please read carefully before starting)

As you read each description of the baby's behavior below, please indicate how often the baby did this during the last week (the past 7 days) by circling one of the numbers in the left column. These numbers indicate how often you observed the behavior described during the last week.

( 1 ) (2 ) (3 ) ( 4 ) ( 5 ) ( 6 ) (7 ) (X) Never Very Less About More Almost Always Does Rarely than half than always not half the half apply the time the time time

The "Does Not Applyll (X) column is used when you did not see the baby in the situation described during the last week. For example, if the situation mentions the baby having to wait for food or liquids and there was no time during the last week when the baby had to wait, circle the (X) column. "Does not apply" is different from "never" (1). "Never" is used when you saw the baby in the situation but the baby never engaged in the behavior listed during the last week. For example, if the baby did have to wait for food or liquids at least once but never cried loudly while waiting, circle the (1) column.

Please be sure to circle a number for every item.

When having to wait for food or liquids during the last week, how often did the baby:

1 2 3 4 5 6 7 X · ..... ( 1 ) seem not bothered? 1 2 3 4 5 6 7 X · ...•. ( 2 ) show mild fussing? 1 2 3 4 5 6 7 X · ..... ( 3 ) cry loudly? db

(I) (2) (3 ) ( 4 ) (5) (6) ( 7 ) (X) Never Very Less About More Almost Always Does Rarely than half than always not half the half apply the time the time time

During feeding, how often did the baby:

1 2 3 4 5 6 7 X ...... ( 4) 1 ie or sit quietly? 1 2 3 4 5 6 7 X ...... (5} squirm or kick? 1 2 3 4 5 6 7 X ...... (6) wave arms? 1 2 3 4 5 6 7 X ...... (7) fuss or cry when she/he had enough to eat? 1 2 3 4 5 6 7 X ...... (8} fuss or cry when given a disliked food?

When given a new food or liquid, how often did the baby?

1 2 3 4 5 6 7 X ...... ( 9) accept it immediately? 1 2 3 4 5 6 7 X ..... (10) reject it by spitting out, closing mouth, etc.? 1 2 3 4 5 6 7 X ..... (11) not accept it no matter how many times offered?

Sleeping

Before falling asleep at night during the last week, how often did the baby:

1 2 3 4 5 6 7 X ..... (12) show no fussing or crying?

During sleep, how often-did the baby:

1 2 3 4 5 6 7 X ..... (13) toss about in the crib? 1 2 3 4 5 6 7 X ..... (14) move from the middle to the end of the crib? 1 2 3 4 5 6 7 X ..... (15) sleep in one position only? 92

(1) (2) (3 ) (4 ) ( 5 ) ( 6 ) (7 ) (X) Never Very Less About More Almost Always Does Rarely than half than always not half the half apply the time the time time

After sleeping, how often did the baby?

1 2 3 4 5 6 7 X .... (16) fuss or cry immediately? 1 2 3 4 5 6 7 X ..... (17) play quietly in crib? 1 2 3 4 5 6 7 X ..... (18) coo and vocalize for periods of 5 minutes or longer? 1 2 3 4 5 6 7 X ..... (19) cry if someone did not come within a few minutes?

How often did the baby?

1 2 3 4 5 6 7 X ..... (20) seem angry (crying and fussing) when you left her/him in crib? 1 2 3 4 5 6 7 X ...•. (21) seem contented when left in the crib? 1 2 3 4 5 6 7 X ..... (22) cry or fuss before going to sleep for naps?

Bathing and Dressing

When being dressed or undressed during the last week, how often did the baby?

1 2 3 4 5 6 7 X ..... (23) wave his/her arms and kick? 1 2 3 4 5 6 7 X ..... (24) squirm and/or try to roll away? 1 2 3 4 5 6 7 X ..... (25) smile or laugh? 93

( 1 ) (2 ) ( 3 ) (4 ) ( 5 ) ( 6 ) ( 7 ) (X) Never Very Less About More Almost Always Does Rarely than half than always not half the half apply the time the time time

When put into the bath water, how often did the baby?

1 2 3 4 5 6 7 X · .... ( 26 ) startle (gasp, throw out arms; stiffen body, etc. )? 1 2 3 4 5 6 7 X · .... ( 27 ) smile? 1 2 3 4 5 6 7 X · .... ( 28 ) laugh? 1 2 3 4 5 6 7 X · .... ( 29 ) have a surprised expression? 1 2 3 4 5 6 7 X · .... ( 30 ) splash or kick? 1 2 3 4 5 6 7 X · .... ( 31 ) turn body and/or squirm?

When face was washed, how often did the baby?

1 2 3 4 5 6 7 X · .... ( 32) smile or laugh? 1 2 3 4 5 6 7 X · .... ( 33 ) fuss or cry? When hair was washed, how often did the baby?

1 2 3 4 5 6 7 X · .... ( 34 ) smile or laugh? 1 2 3 4 5 6 7 X · .... ( 35 ) fuss or cry? Play

How often during the last week did the baby?

1 2 3 4 5 6 7 X · .... ( 36 ) look at pictures in books and/or magazines for 2-5 minutes at a time? 1 2 3 4 5 6 7 X · .... ( 37 ) look at pictures in books and/or magazines for 5 minutes or longer at a time? 1 2 3 4 5 6 7 X · .... ( 38 ) stare at a mobile, crib bumper or picture for 5 minutes or longer? 1 2 3 4 5 6 7 X · .... ( 39 ) play with one toy or object for 5-10 minutes? 94

(1) (2) ( 3 ) ( 4 ) (5) (6) ( 7 ) (X) Never Very Less About More Almost Always Does Rarely than half than always not half the half apply the time the time time

1 2 3 4 5 6 7 X ..... (40) play with one toy or object for 10 minutes or longer? 1 2 3 4 5 6 7 X ..... (41) spend time just looking at playthings? 1 2 3 4 5 6 7 X ..... (42) repeat the same sounds over and over again? 1 2 3 4 5 6 7 X ..... (43) laugh aloud in play? 1 2 3 4 5 6 7 X ..... (44) smile or laugh when tickled? 1 2 3 4 5 6 7 X ..... (45) cry or show distress when tickled? 1 2 3 4 5 6 7 X ..... (46) repeat the same movement with an object for 2 minutes or longer (e.g., putting a block in a cup, kicking or hitting a mobile)?

When something the baby was playing with had to be removed, how often did she/he?

1 2 3 4 5 6 7 X ..... (47) cry or show distress for a time? 1 2 3 4 5 6 7 X ..... (48) cry or show distress for several minutes or longer? 1 2 3 4 5 6 7 X ..... (49~) seem not bothered?

When tossed around playfully, how often did the baby?

1 2 3 4 5 6 7 X ..... (50) smile? 1 2 3 4 5 6 7 X ..... ( 51) laugh? 95

(1) (2) ( 3 ) ( 4 ) ( 5 ) ( 6 ) ( 7 ) (X) Never Very Less About More Almost Always Does Rarely than half than always not half the half apply the time the time time

During a peekaboo game, how often did the baby?

1 2 3 4 5 6 7 X ... .. ( 52) smi 1 e? 1 2 3 4 5 6 7 X ..... (53) laugh?

Daily Activities

How often during the last week did the baby:

1 2 3 4 5 6 7 X ..... (54) cry or show distress at a loud sound (blender, vacuum cleaner, etc. )? 1 2 3 4 5 6 7 X ..... (55) cry or show distress at a change in parents' appearance (glasses off, shower cap on, etc. )? 1 2 3 4 5 6 7 X ..... (56) when in a position to see the television set, look at it for 2-5 minutes at a time? 1 2 3 4 5 6 7 X ..... (57) when in a position to see the television set, look at it for 5 minutes or longer? 1 2 3 4 5 6 7 X ..... (58) protest being put in a confining place (infant seat, play pen, car seat, etc.)? 1 2 3 4 5 6 7 X ..... (59) startle at a sudden change in body position (for example, when moved suddenly? 96

( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 ) ( 6 ) ( 7 ) (X) Never Very Less About More Almost Always Does Rarely than half than always not half the half apply the time the time time

1 2 3 4 5 6 7 X · .... ( 60 ) startle to a loud or sudden noise? 1 2 3 4 5 6 7 X · .... ( 61 ) cry after startling?

When being held, how often did the baby?

1 2 3 4 5 6 7 X ..... (62) squirm, pull away or kick?

When placed on his/her back, how often did the baby?

1 2 3 4 5 6 7 X · .... ( 63 ) fuss or protest? 1 2 3 4 5 6 7 X · .... ( 64 ) smile or laugh? 1 2 3 4 5 6 7 X · .... ( 65 ) lie quietly? 1 2 3 4 5 6 7 X · .... ( 66 ) wave arms and kick? 1 2 3 4 5 6 7 X · .... ( 67 ) squirm and/or turn body?

When the baby wanted something, how often did she/he?

1 2 3 4 5 6 7 X · .... ( 68 ) become upset when she/he could not get what she/he wanted? 1 2 3 4 5 6 7 X · .... ( 69 ) have tantrums (crying, scream- ing, red face, etc. ) when he/she did not get what she/he wanted?

When placed in an infant seat or car seat, how often did the baby?

1 2 3 4 5 6 7 X · .... ( 70 ) wave arms and kick? 1 2 3 4 5 6 7 X · .... ( 71 ) squirm and turn body? 1 2 3 4 5 6 7 X · .... ( 72 ) lie or sit quietly? 1 2 3 4 5 6 7 X · .... ( 73 ) show distress at first; then quiet down? 97

(1) (2) (3 ) (4 ) ( 5 ) ( 6 ) ( 7 ) (X) Never Very Less About More Almost Always Does Rarely than half than always not half the half apply the time the time time

When you returned from having been away and the baby was awake, how often did she/he?

1 2 3 4 5 6 7 X ..... (74) smile or laugh?

When introduced to a strange person, how often did the baby?

1 2 3 4 5 6 7 X ..... (75) cling to a parent? 1 2 3 4 5 6 7 X ..... (76) refuse to go to the stranger? 1 2 3 4 5 6 7 X ..... (77) hang back from the stranger? 1 2 3 4 5 6 7 X ..... (78) never "warm up" to the stranger? 1 2 3 4 5 6 7 X ..... (79) approach the stranger at once? 1 2 3 4 5 6 7 X ..... (80) smile or laugh?

When introduced to a dog or cat, how often did the baby?

1 2 3 4 5 6 7 X ..... (81) cry or show distress? 1 2 3 4 5 6 7 X ..... (82) smile or laugh? 1 2 3 4 5 6 7 X ..... (83) approach at once?

Soothing Techniques

Have you tried any of the following soothing techniques in the last 2 weeks? If so, how often did the method soothe the baby? Circle (X) if you did not try the technique during the last two weeks.

1 2 3 4 5 6 7 X ..... (84) rocking. 1 2 3 4 5 6 7 X ..... (85) holding. 1 2 3 4 5 6 7 X ..... (86) singing or talking. 1 2 3 4 5 6 7 X ..... (87) walking with the baby. 1 2 3 4 5 6 7 X ..... (88) giving the baby a toy. 98

( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 ) ( 6 ) ( 7 ) (X) Never Very Less About More Almost Always Does Rarely than half than always not half the half apply the time the time time

1 2 3 4 5 6 7 X • •••• ( 89 ) showing the baby something to look at. 1 2 3 4 5 6 7 X • _ • _ • ( 90 ) patting or gently rubbing some part of the baby's body_ 1 2 3 4 5 6 7 X • •••• ( 91 ) offering food or liquid. 1 2 3 4 5 6 7 X • •••• ( 92) offering baby his/her security object. 1 2 3 4 5 6 7 X • .••• ( 93 ) changing baby's position. 1 2 3 4 5 6 7 X · •••• ( 94 ) other (please specify) REFERENCES 100

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