JOGNN

Martha Rider Sleutel

PRINCIPLES & PRACTICE

Intrapartum Nursing: Integrating Rubin's Framework With Social Support Theory

_ Numerous stud ies and articles on labor support have focused o n the potential for improved labor and birth outcomes from supportive ca re during labor. Despite increased attention to labor sup port research, su rpri sing ly little has been written about the theoretical underpinnings for intrapartum nursing ca re. Thi s article explo res Reva Rubin's framework and socia l support theory as a foundation for intrapa rtum nu rsing care. The most common features of soc ia l support provided the structure into which Rubin's descriptions of nursing care during labor a nd birth could be eva luated. Socia l support theory fit remarkably wel l, both with Rubin's views of the role of the perinatal nurse and with Rubin's observations of mothers' needs and feelings du ring chi ldbirth . Combining these theoretical frameworks provides a perspective of intrapartum nursing practice that has not been previously considered in the published literature. JOGNN, 32, 76-82; 2003. DOl : 10.1 177/08842 17502239803 Keywords: Intrapartum nursing- Lobar support-Reva Rubin - Social support- Theory Accepted: March 2002 Helping moth ers in labo r is th e essence o f intrapartum nursin g ca re. The porentia l role of labo r suppo rt in impro vin g la bor an d birth o utcomes h as received much attention recentl y within both pro fessio nal a nd con sum er-oriented litera ture. In the past several decades, th e un ique subspecialty of intrapartum nursi ng care has had littl e pu blished descr ibing irs th eoretical und erpinnings . Perh aps as a res ul t, practi cin g intrapartum nurses may feel that nursin g theory d oes not have mu ch mea ning to th em or r elevan ce to wh a t they do. Yet, nursing th eo ry sho uld help improve nu rsin g p ractice (Chinn & Kra mer,

1999) . Two di verse sources, the writings of Reva Rubin and socia l s upport theory, p rov ide a remarka b ly so lid theo retical fou ndation for n urses ' care of moth ers in la bo r. Thi s article inregrates con cepts fro m both fram ewo rks and appli es them to labor a nd childbirth care by nurses .

Backgroun d
Neither the soc ial s upport litera ture nor Rubin 's fra mework a re typ ica ll y ap p li ed to intrapartum nursing care. Reva Rubin was a nursing th eo rist w ho w rote of the morher's experience of pregnan cy, child birth, and ma tern a l id enrity. H er innovat ive and now cla ssic writings described w omen 's cognitive work during preg nancy (i.e., ho w mo thers thin k), in additi o n to describing nursin g ca re o f pregna nt women. Rubin 's w orks a re w id ely associa ted with pregnancy a nd ma te rn a l role a tta inm ent, focusing primari ly o n the a ntepartum a nd p ostpa rtum pe riods. By contra st, the social support literature spa ns se vera l d isc ip li nes and ha s clea rl y sho wn that health o utco mes a re influ enced by suppo rt. La bor sup port , as defined by Hodnett (2001 ), is
strikingly si milar to th e co mmon defin iri ons of social

support. Desp ite thi s pa ra ll el, soc ial sup port a lso is not com monly associated with nursing care durin g chil d b irth. Integra tin g both theoretica l frameworks crea tes a link age between th e childbearing mother's cogniti ve and emotion a l p rocesses and specifi c suppo rti ve nursing interventio ns ta il o red to meet her needs and o ptimi ze her birth experi ence. Rubin 's fra mework ex pl a ins th e la borin g moth e r's psyc ho logical mil ieu, g uidin g th e s uppo rt processes that ca n ease th e tria ls of her labor, improve birth o utco mes, enha nce her self-esteem

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and identity, a nd provide a foundatio n for her ro le trans i-

tion to motherhood. In describing the evolution in mothers' emotions, behavior, and se lf-view during and after birth, Rubin also affirmed or implied a great dea l about
the need fo r nurses to provi de s upporti ve care to wo men

Iy strong. You are doing a great job !" Emotional support yields a sense of co mfort and security a nd a fee ling of being ca red fo r (Cutrona & Ru sse ll, 1990 ). Rubin (1984)
w rote that interest, caring concern, and attention help the

in labor. Most social suppOrt actions by nurses during labor are d irected toward two of the four components of what Rub in (1975a) described as pregnancy work : seeking safe passage a nd giving of oneself. Seeking safe passage refers to the mother's know ledge and ca re-seeking behaviors to ensure that both she and her newborn emerge fro m pregnanc y and chil db irth intact and hea lth y. Thi s task is ma nifested by the mother's characteristi c worries and co nce rns o ver po rcnria l and real ha za rds or risks .

mo ther give birth and make her feel res pected and va lued . Labor pain is ameli orated by th e presence of a wi lling, ca pabl e, empathetic person. According to Rubin, after 4 cm of cervical dilation, labo ring women should teceive
continllou s nursi ng care to reduce th eir a nxi ety and fear. Ca re provi de rs' indifference to pa in causes a sense of abandon ment and rejection, diminishing a woman 's selfwo rth. "Pain under cond itions of iso lat ion has no limits"

Giving of on eself refers to the mother's willingness and ability to make person a l sacrifices (time, discomfort, etc. ) for the child (Rubin, 1975a ),
Socia l support is often described as an interpersona l tran sacti o n that contains emotional support or affec t, information or adv ice, instrlllnental or ph ys ical a id , and

(Rubin, 1984, p. 82 ). r 10Li se (1981 ) cons idered emotional suppOrt to be the most important type of support in buffering stress a nd optim izin g health. In Cutrona a nd Ru ssell 's (1990) theory of optimal matchin g, un controllab le events (s uch as

labor) we re con sidered most responsive to emotional suppOrt. Accord ing to Rubin 's framework, mothers should be
attend ed and helped, nOt left a lone e' to swea t out labor"

appraisal support or affirmation. Othet facets of socia l suppOrt include (a) social ties, relationships, or networks; (b) th e recipi ent's perception of available support; (c) the degree of reci procity with in the support relationshi p; a nd (d ) the personalities of the support-gi ver and rec' p,em (Hupcey, 1998; La ngford , Bows her, Maloney, & Lilis, 1997; Tilden, 1985 ).

(Rubin, 1975a, p. 1683 ). She articu lated the essential nature of emotional support in labor as a strategy to promote mothers' indi vidua l streng th s and capab ilities .

Information

01'

Advice

This category of soc ial su ppOrt fac il itates coping and

problem-solving through adv ice, suggestions, guidance,

Merging Rubin's Writings Into Social Support Theory

The rema inder of this discussion will focus on synthesiz ing th e two th eo ri es to form a bas is for nursin g support

an d information (Cutrp na & Russell, 1990; Va ux, 1988 ). Intra partum n urses commonly provide thi s type of supPOrt by expla in ing wha t is hap pening or suggesting position s that might be more comfortable. Rubin (1984)
wrote that keeping women informed in general , and

of women in la bor. Th e ca tego ties a nd additional facets of

socia l s uppo rt theory provide an organizing framework,

and Rubin's descripti o ns fit easily w ithin those social support components .

ntrapartum nursing skills revolve around

aboLit labor progress specifica ll y, was essential to their self-image. Consistent with soc ia l support th eorists, she fel t that information and advice help mothers cope with labor by providing hope and reducing pain intensity. Nu rses ca n help a woman's coping a bilities by prov iding two specifi c ca tegori es of information : (a) defining the so urce, beginning, and end of contraction pain an d (b) or ientin g her to time, rate of progress, and di stance traveled toward the ultimate goal of delive ry. Rubin believed
that such a time orientation helps to anc hor the moth er to the rea l v,,'orld : "Cogn itive awareness ma rshal s her inne r

facilitating a woman's abi lity to totally surrender her body to a uniquely feminine task, that of giving birth (Rubin , 1967c).

co ntrols" to relieve pain (Rubin , 1984, p. 94 ). The essence of nurturing intra pa rtum C 3re is g iving the moth er contro l during a time w hen s he must surrender all vol i-

Emotional

01'

Affect Support

Empath y, es teem, concern, unconditiona l regard, and reflective li stening a rc emotionall y s usta ining beha viors

tion to th e force s of labor (Rubin , J 967c, 1984 ). Wh en Rubin ( 196 1b) wrote th at nursing is creative in culti va ting women's abilities a nd enhanc in g th ei r potential , s he described information suppOrt as a component of that
care.

(Gottlieb, 1992; House, 198 1). Samples of ho w intrapartum nurses pro vid e emotional support include sta yin g with th e laboring moth er, mak in g eye contact, tou ching

Affirmation or Appraisal Support

Thi s ca tegor y of socia l support invol ves feedback and socia l comparison (H o use, 1981 ) and ma y o verlap some-

her hand , or telling her that "Those contractions are real -

January/February 2003

JOGNN 77

what with in formation support and with emotiona l support. Intrapartum nurses who offer the mother encouragement and va lidation of he r effofts a re providing affirmation support (e.g., "Excellent pushing! Yo u rea ll y moved the baby a lot that time!" ). Affitmation suppo rt bo lsters a person's sense of self-competence or self-esteem (C utrona & Russell, 1990). Swann a nd Brown (1990) noted that peop le seek self-con fitmatory feedback to verify their se lf-co nceptions and that negative self-views can ca use identity d isruption. Rubin (1984) described the sa me phenomenon, where the laboring mother compares her ideal self against her self- im age (actual ) a nd judges her performan ce and abil ities, someti mes harshl y. During labol; the loss of he r abilities ca uses fee lings of he lp lessness, entrapment, and victimiza tio n. She dreads sllch loss of control in labor and works hard not to cry or scream. She feels s hame in her own self-esteem and in ho w she believes othe rs view her. "Shame is the personal pri vate judgement of fa ilure, passed on to self by self.... It is a merc il ess judgement" (Rubi n, 1968a, p . 23) . Accord ing to H oball, Lilly, and Jack son ('1992), social suppOrt enhances self-esteem and a sense of master y, enabli ng the rec ipi ent to protect and mainta in hi s or her identi ty. Although Rubin (1984) did not label it ap praisa l s up port or affirmation, she imp lied that the intrapartum nurse can relie ve the mother's fee lings of anxiety and shame by (a) expla ining what is norm a l, (b) offeting reassurance, and (c) contexrua lizing the functiona l losses as progress in her journey towa rd delivery an d ultimate resolution and restoration of contro l. Nursing suppo rt invo lves enabling the mother to achieve control of function appropriately in t ime and place (R ubin, 1968a). Facilitating or ena bling control alleviates or even p revents the woma n from experiencing the frustration, fear, and despa ir of feeling t hat she ca nnOt control her destin y or even her body. Rubin ('I968a ) depicted this process of enablin g another to achieve or maintain control as a process of lendi11g ego. Rubin saw the primary goa l of nursing as ego main tenance and support du ring stressful dependenc y situations (Rubin, 1968b). Lending ego and aiding the mother in maintaining control encompass the suppOrt catego ry of appraisal or affirmation support.

Comfort Care . Rubin w rote a great deal about the pain of labor and the nurses' role in providing comfort. She exp lai ned that during labor, the mother's attention is concentrated on an inner co re of pa in that spreads and immo bilizes: "Time super imposed on layers of tension, discomfort, and pain . . . makes labor burdensomcly painful" (R ub in , '1984, p. 93) . She described interventions such as cool, intermittent contact that wou ld renew the mother's awareness of body bo unda ries . A ca lm vo ice; a gentle, firm touch wi th an open palm; and sacral counterpressu re

others with a recent experience of

appropriate and meaningful bodily touch from a ministering person , like the intrapartum nurse, are more likely to use nurturing touch with their babies (Rubin , 1984).

T ltstrumelttal or Physical Aid

T hi s catego ry of soc ial suppOrt involves action to alter the environment or provide a id, mone y, time, or labor (Gottlieb, 1992; Vaux, J 988). Examp les of instrumental or physica l support in labor a re providing sips of water, playing music, offe ring a warm shower, or helping moth ers into different positi ons. Instrumental support yields resources that a person needs to cope w ith a stressful event or situation (C utrona & Russell, 1990). In strumental or physica l sup port in the context of labor can be di vided into two components : (a) co mfort care and (b) clin ica l skill s and expertise.

help conserve body boundaries, relieve tension, and aid the mother in co ncentrating. Rubi n (1984 ) described specific positioning techniques to a lleviate the pain and pressure of labor after the baby had entered the inlet of the pelvi s. Other interv.cn tions included co unterp ressure on sacral press ure point, cool ing washes, cooling compresses to eyes, an ice bag to the head, back massage, ice chips, and sips of cool water. R ubin (J984 ) noted that unrelieved pain is subjectively experienced as a socia l rejection of the self, leadin g to antipath y toward herself, her ch ild, and life. By contrast, mothers with a recent expe ri ence of appropriate and meaningful bodily touch from a ministering person, like the intrapartum nurse, are more likel y to use nurturing touch w ith their infants. In situations of "i ntense personal srress, situ ations in which one feels isolated and vulnerable, there seems to be no other modality compa rable to touch in the immediacy of effective response" (Rubin, 1963, p. 828) . Rubin (1963 ) elabora ted further on the n ursing skills needed to provide adeq uate comfort to laboring mothers. She notcd that individualized touch is interpersona l communication that is significant in a way that verbal language is nor. Intrapartum nursing skills revolve around faci litating a woma n's ability to totally surrender her body to a un iquely feminine task, that of giv in g birth (R ubin, 1967c). Nurses who are knowledgeable and sk illed can augme nt mothers' coping a bili ties by being supportive and responsive to the mother. Nurses shou ld communicate by eye-to-eye contact, verba l confirmation, reassuring touch, and restfu l massage . T he knowledge and skills of the help ing n urse enhance the mother's abilit y to cope with labor and prevent an immob ili zi ng spread

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of pain (Rubin, 1984). In the context of labor, instrumen tal support co nn otes the nu rse as an instrument to a ll ev i-

ate pain and suffering through thera peutic use of self. Clinical Skills and Expertise. Rubin (1975b) spo ke of nurses as skilled professionals and, within the hospital, as a collection of specialized expertise working in the patient's behalf. Rubin (1975b) described si lent miracles that occurred when normal labors "go bad, very bad
w ithi n minutes" and nurses who were an indispensa ble

modeled upon significa nt othets. T he mother assesses and ex plores her relationsh ips throug h interpersonal exchanges that provide data about childbirth and m otherhood. Additiona lly, the moth er's tasks in childbearing
are "to conserve the intactness of th e se lf and of the fa m -

ily as ongoing, open systems and to orchestrate the assimilation and accommodation of this ch ild into the self and family systems" (Rubin, 1984, p. 53). Knowledge of these
processes can aid the nurse in eva luatin g the mothe r's

pa rt of mirac ul ous o utcomes (R ubin, 1975b, p. 1683). Such acrivi ti es as "ready ing the gases," scr ubbing, draping, and getting blood chemistries, and weaning preterm
infants r0111 oxygen are instrumenta l or tangible aid.

attendants and assisting them to validate her efforts and bolster her self- identity.

Recipient's Perception of Support

Perceived support has been shown to be more strongly
associa ted w ith impro ved outcomes than are other meas-

Rubin (1968 b, 1984) wrote that nurses develop skill s of

in formation-gather in g th rough touch using th ese sk ills to

make diagnoses and as a ve hicle for personall y meaningful communication. Instrumental support consists of clin-

ures of social network support, such as the number of

fa mil y membe rs or frien ds, and even actua l s upport

ica l sk ill s and expertise, th e tools by which nurses assume vigil ance for the mother's safe passage through childbirth. It should be noted that whereas Rubin briefl y mentioned technical skills, she extensively emphasized the crucia l
role of nurses in provid ing comfort through th eir presence

received . Perceived support is theorized to be influenced

by cu lture, deve lopment, personality, soc ia l settings, and

life tasks (Procidano & Smith, 1997). Accord ing to Cohen (1992), perception of support reflects a id provided from the social environment, wh ic h, durin g labor,

includes the intrapartum nurse. Rubin (1967c) wrote that

nurses must understand the mother's pe rception of he r

and sk illful, nurturing care.

Social Network
Perhaps reflective of the era , R ubin mentioned significant others during labor only wi thin the context of avoiding isolation of the mother within a labor room. Rubin

(1984) noted that th e presence of fami ly members is usefu l but not sufficient to the mothe r's ca re an d that fam ily members feel helpless and angry when they are isolated with help all around, ye t not present or available to the
mother. Howeve r, in her explanation of basic materna l

si tua tion a nd have empath y in order to rendet care. The mother perceives la bor and birth as a threat to her well being. She fears being damaged, losing bodil y functions a nd body intactness, and not su rviving. She regards th e hospital as a site of ~ompete n t and knowledgeable personnel and feels secure when she believes the staff is qualified and knows her situ ation or condition (Rubi n, 1984). Understanding the mother's fears and building on her
con fidence in mod ern hea lth care, nurses can tailor labor sup port to allay those universa l fears and to maximi ze the mother's sense of security and control.

behavior ('1961 a) and attainment of the maternal role (1967b), Rubin desctibed how throughout pregnanc y, the
mother uses cultural comparisons and role mode ls wit hin

Reciprocity Within the Suppo11 Relationship

Social sup port researchers have exam in ed various

her circle of acq uaintances to form a basis for her behavior and evolving maternal identit y. Childbitth classes as well as pregnant fr iend s and relati ves provide opportunities for mothe rs to id e ntify and compare themselves to other pregnant wom e n. This process entails th e rea li g nin g

qualities of the social exchan ge of support, such as (a) the degree of equity between the support giver and the support receiver and (b) the immed iacy of the benefit (Anton ucci & Jackso n, 1990) . Rubin (1984) expressed an
inte racti ve view of support, notin g that when a mother accepts ass istance , it is "an act of giving and nOt JUSt pas-

of kinship and frien dship bonds, tightening some and loosen ing others. The net result is a shift from one social sphere to another, to use selected models and referents to ptocess her assimilation to another identity (Rubin , 1970).
Soc ial network s provide soc ial id e ntities, soc ial esteem ,

sive acceptance" (p. 66) . Thus, by accepting the intrapartum nurse's care, th e laboring mother g ives the nurse her trust at a tim e when she is most vulnera ble . Another interactive perspective, that of a "suppo rt bank," is that in tim es of need, indiv idu a ls ca n draw strength from pre-

social norm s, a nd a sense of belonging (Vaux, 1988). Accord ing to Swa nn and Brown (1990), social relationsh ips offer self-con firm atory feedback to veri fy indi viduals' identity a nd self-conception s, a process ca ll ed identi ty support. This sounds remarkably similar to the
maternal role attainment process, in w hich the mothe r's

vioLis SLi ppOrt deposits (i. e., previo us episodes of being valued and nurtured). Rubin (1984) mirrored this social
suppo rt p erspec tive when she descr ibed "gifts" to th e mother of nurturing assistance, personali zed care, enco uragement, and kindness by famil y, friends , and careg ive rs: "The attendance of another, particula rl y in tim es

fam il y and friends pla ya key rol e (Rubin , 19673, 1967b) . Throughout pregnancy, the mother's reflection of sel f is January/February 2003

JOGNN 79

o f uncerta inty and stress, is perceived as a gift " (1' . 68) .

Furthermore, "G ifts serve as na rcissistic suppli es, charg-

her recepti ve ness a nd respon se to suppOrt provided by the

intrapar tum nurse. The social support literature suggests that e ffects of support are contingent on the character of

ing th e batteries of self-res pect throu gh the symbo lic

ex press ion o f ano th e r's obj ec tive respect for and es teem of

the relationship between the pro vider and recip ient a nd

th e manne r in whi c h th e suppo rt is con ve yed (Go ttli eb,

oneself" (Rub in, 1984, Pl'. 66-67) . When ca re provid ers

ex press interes t, make tim e fo r he r, li ste n, and arc c on cern ed fo r he r we lfa re, it shows th e mother th a t she is

1988) . The impact of any pa rticular suppo rti ve efforr depends

011 th e mo ti va tion s and expecta tio ns of both prov ider and rec ip ient, the nature of rhe re la ti onship in w hich th e suppo rr ive exchange occurs, and the proble ma tic si tu a ti o n to whic h rhe sup porti ve e fforts are di rected.

valued a nd res pected. Th ese gifts of suppo rt compensate fo r the difficulties of childbearin g and build up a reserve of giving to be extended by the mother to th e bab y a fter birth (Rubin , 1984 ).

Role of Personality
T he cogniti ve and emotion a l reno v;1rioll s that occur during preg nan cy represe nt qua litati ve pe rson a lit y c hanges, al tering mo th e rs' rece pti ve ness to rece ivin g a id (Rubin , 1984 ). This is consistent with current theo ries, w hic h state th a t th e persona li ties of those rece ivin g sup-

(Sarason, Sarason, & Pierce, 1992, p. 145 )

The effec ti ve ness of th e support de pe nds upon th e cogn iti ve a ppra isa ls of th e pa rticipants in that inte ra ction

(Sarason et a I. , 1992 ). Recent resea rch suggests that perce ive d sup pO rt is a meas ure o f th e recip ie nt'S sense of

parr influence their perception of the avai labi lity and usefulness of a id (Dunkel-Schetter & Benn ett, 1990). Factors slich as personal effi cacy, gender, social competence, coping sty le, cog ni tive perfo rm ance, and se lf-conce pt have been found to influe nce perce pti o ns o f suppo rt (Sa ra son,

accepta nce and feeling o f being valued (Sarason et aI. , 1 990). Th e interacti ve view of social support suggests that the persona lity of the labor nu rse and her style o f provid ing care w ill ha ve a g rea t impa ct o n th e mo th e r's pe rce p-

ti on of her ca re (Saraso n et a I. , 1990).

Pi erce, & Sa rason , 1990) . In add ition to affecting support

pe rce ptio n, pe rso na lity varia bles a lso influ e nce problem perceptio n, he lp -seeking behavio rs, and mo ti va ti on to

ntegrating Rubin's framework with social nurses' labor support strategies more

seek help (Va ux, 1988) . Gottli eb (1988) suggested tha t

th e re is a mut ua l interplay am o ng suppo rt prov id ers, rec ipi e nts, and t ypes o f support. Fo r exampl e, th e express in g o f distress e li c it s support in prov id e rs, yet rec ipie nts are more likel y to in d ica te di stress to pro vi ders

support theory can help guide intrapartum effectively toward the goal of improvin g labor and birth outcomes.

w ho a ppea r ca rin g (Collin s & D iPaula, 1997) .

Highl y re levant to nursing is earl y resea rch suggest in g that pe rsonalit y fa ctor s of th e s upport prov id er contribute to th e support re nd ered and to ~the recipi ent'S pe rcep tion of s uppo rt. Two suc h pe rsona lity charac te ri st ics a re d isposi ti o na l e m pa th y (e mot iona l ca pac ity) an d causa l a ttri-

Di scuss ion
To some degree, Rubin 's \riting may reflect an e ra in w hich hands-on ca re \..vas morc valu ed and there w as no t ye t an ove rwhelm in g emphasis on tec hnolog y and procedures slic h as cont in uo us fetal heart rare monitOring or 011 time-consu ming docume ntati o n. M any w ould arg ue that th ese newe r Ilursin g res ponsib iliti es ex pand ed w hil e dimi nishing rhe n urse's role in prov iding comfort and supporr to mo thers in lab o r. T hree w ork sampli ng studi es of intr a partum nursing ca re fo und that nurses spent onl y 60/0 to 120/0 o f th ei r rim e providing supporti ve ca re and o nly 11 0 /0 to 390/0 o f th eir tim e prov iding direct ca re

buti ons (th e tende ncy to beli eve mi sfortun e is dese rved) (Co llin s & DiPaula, '1997) . Fo r instance , a ca reg iver who
is nOt elTIpa th et ic and w ho blames hardships o n th e vic-

tim wo uld be less likely to re nder a id a nd the recipient wo uld be less likely to fee l supported. Expanding this pe rspective to peri nata l care, Ru bin (1975b) w ro te that the
most significa nt contributi o n of intrapa rtum nursin g w as

the foc us o n the mother. Additi o na ll y, she o bserved that

th e nurse must be e mpath eti c a nd ta ilor he r ca re to the pa rti cu lar psychosocial situa ti o n and the se lf-es teem of

each mother (Rub in, 1984) .

The so c ia l suppOrt lite rature re fl ec ts an intrica te inte rac ti o n amon g many vari a bles, including persona li ty, lea ding to impro ved hea lth o utco mes (Pie rce, La key, Sarason, & Sa raso n, J 997) . This is co nsistent w ith Rubin 's w ri t-

(Gagnon & Wagho rn , 1996; Ga le, Fothergill -Boutbonna is, & Cha mberla in, 2001; M cNlven, Hodnett, & O ' BrienPallas, 1992 ). There were no work-sa mpling studi es in th e time fra me of 1960 to 1978, bur Rubin's descriptions impl y th at direct and supportive ca re was (or sho uld be)
nurses' primary focll s. Sc ientific ev id e nce suggests that providin g comfort and support to mo th e rs in labor has a far g rea te r impact on birth outcomes than does app lying

ings of the changin g la nd sca pe of the mo ther's persona lity, so c ial c ircle, and rece pti ve ness to g ivin g of care by oth e rs. The mothe r's cog niti ve an d e moti o na l c hanges affec t

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tec hn o logy to no rm a l c hildbirth (H o dn ett, 2001 ; Ka rdo ng-Ed gren, 20 01 ; Thac ker & Stroupe, 2000) . Th e integ ra ti o n of Rubin 's fra mewo rk wi th social supp o rt theo ry can help g uid e in tra pa rtu m nu rses' la bo r sup po rt strateg ies m ore effecti vely towa rd th e goal of improvi ng la bor a nd birth o utcomes .

Conclusion
Both th e socia l su pport li rcra w re a nd Rubin 's w rit ings p rovide a th eo retica l fo und atio n fo r in trap ar tulll nu rs ing ca re. Rub in (1968 b) desc ribed nursing as a n in te ra ctive helping process a nd suggested tha t inrraparrul1l nurses s ho uld c rea te in t he la boring woma n feelings of acce ptan ce a nd of be ing va lued. Regard in g th e nurse as a su ppo rt provider, Rub in clea rl y esta bli shed bo th the p riv ilege and comm itment th a t nurses have w hen th ey help wo m en "thr o ug h t he va ll ey of the shadow tha t a ll wo men wa lk to have a child " (Ru bi n, 1975b, p . 1685) . To prov ide nu rwr ing a nd empatheti c carc, nurses need a se nse of res pect a nd awe fo r the t ria ls a nd endeavors o f la bo rin g women . A fina l qu o te ca ptures the e mbedd edness of soc ia l su p port theory wit hin Rubin 's fra mewo rk : Nu rses perfo rm ed miracl es of heali ng . . . . T here is som eth ing ve ry specia l a bo ur th e la ying o n of ha nds rig ht w here th e h urt is . .. . Mo the rs lefr th e hos p ita l fo r ho me fee ling ca red fo r, res pected , and wa n te d in thi s wo rl d. (Rub in, '19 75a, p. 1682)

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Ma rtha Rider Sleutel, PhD, RN, eNS, is a n assistal1 t professor of Ilu rsing, A ngelo State Unive,-sity, San Angelo, TX . Address for co rrespondence: Mmtha Rider Sletf tel, Ph D, RN, eNS, Department of Nursing, A llgelo State University, 2601 West Avenue N, San A ngelo, TX. E- mail: martha.sleutel@angeIO.edll .

slI pport

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