MCN Chapter 14-17 Preparing a Family for Childbirth and Parenting PDF

C h a p ter 1 4 Preparing a Family for Childbirth and Parenting KEY TERMS alternative birthing centers (ABCs) effleurage birthing bed gating control theory of pain birthing chair...

C h a p ter 1 4 Preparing a Family for Childbirth and Parenting KEY TERMS alternative birthing centers (ABCs) effleurage birthing bed gating control theory of pain birthing chair perception birthing room labor-birth-recovery-postpartum cleansing breath room (LBRP) conditioned reflexes conscious relaxation Leboyer method psychoprophylactic  lena Garza is a 30-year-old woman consciously controlled breathing vaginal birth after cesarean birth who is pregnant with her second child. During distraction (VBAC) her first pregnancy, she did not attend any doula childbirth classes and received an epidural for the birth. During a prenatal visit for her current pregnancy, Elena tells you she would now like to have a more natural birth in a birthing center. OBJECTIVES She asks you for information on childbirth After mastering the contents of this chapter, you should be able to: education classes. Her partner, Joe, a Navy Seal, 1. Describe common preparations for childbirth and parenting, including wants Elena to go to the hospital and have an common settings for birth. epidural like the last time. He says, “The doctors 2. Identify 2020 National Health Goals related to preparation for know what they’re doing. Just let them do parenthood and how nurses can help the nation achieve these goals. 3. Assess the readiness of a couple for childbirth with regard to choice of their job.” After further speaking with Joe, you birth attendant, preparation for labor, and birth setting. discover he doesn’t want Elena to go through 4. Formulate nursing diagnoses related to preparation for childbirth and parenting. the pain of natural childbirth because he fears 5. Identify expected outcomes for a couple preparing for childbirth and he may be out of town when she’s in labor. parenting while helping them manage seamless transitions across Previous chapters discussed normal differing health care settings. 6. Using the nursing process, plan nursing care that includes the anatomy and physiology, and nursing care six competencies of Quality & Safety Education for Nurses (QSEN): necessary during pregnancy. This chapter adds Patient-Centered Care, Teamwork & Collaboration, Evidence-Based Practice (EBP), Quality Improvement (QI), Safety, and Informatics. information about ways couples can make 7. Implement nursing care to assist a couple in selecting and preparing labor and birth a more satisfying experience. for an alternative birth setting such as a free standing clinic or The information helps protect the mental as their home as well as support a woman during labor by controlled breathing. well as the physical health of both women 8. Evaluate outcome criteria for achievement and effectiveness of care. and children throughout the continuum of 9. Integrate knowledge of prepared childbirth with the interplay of nursing process, the six competencies of QSEN, and Family Nursing pregnancy, birth, and childrearing. to promote quality maternal and child health nursing care. How can you help alleviate some of Joe’s concerns and best advise the Garzas on preparations for childbirth? 328 PILLITTERI_E7_CH14.indd 328 7/8/13 1:40 AM  CHAPTER 14 Preparing a Family for Childbirth and Parenting 329 BOX 14.1 Nursing Care Planning Childbirth education is not just for primiparas because if a woman expecting her second or third child Based on 2020 National Health Goals has waited several years between children, she usually appreciates refresher information as much as a primipara Preparation-for-childbirth classes supply information not hungers for new information. Whether a woman is a only on how to prepare for childbirth but also on how primipara or multipara, ask whether either she or her to parent. A number of 2020 National Health Goals that support person wants to attend childbirth or parenting speak directly to such classes or counseling include: courses. Provide appropriate information on what classes are available and how and when they should enroll. Increase the proportion of pregnant women who attend a series of prepared childbirth classes Nursing Diagnosis (Developmental). Nursing diagnoses tend to cluster around whether the Increase the proportion of pregnant women who woman or couple is sure of their decision about the birth receive early and adequate prenatal care from a setting and childbirth preparation. Examples include: baseline of 70.5% to a target of 77.6%. Increase the proportion of women delivering a live birth Health-seeking behaviors related to learning more who received preconception care services and practiced about childbirth and newborn care. key recommended preconception health behaviors If there is a lack of a support person, the following (Developmental) (U.S. Department of Health and Human diagnoses might apply: Services [DHHS], 2010; see www.healthypeople.gov). Ineffective coping related to lack of a support person Anxiety related to absence of significant other Nurses have a direct role in helping the nation achieve For a couple unable to make a decision about a child- these objectives by participating as instructors in birth setting, an appropriate diagnosis might be preparation for childbirth and parenting classes as well decisional conflict related to lack of information about as teaching and supervising prenatal care. advantages and disadvantages of various childbirth settings. If there are older children in the family, a nursing diag- As active consumers of health care, expectant families can find nosis might be anxiety related to sibling role in pend- themselves faced with a wide array of choices for a childbirth ing birth event and sibling ability to welcome a new experience and preparation for parenting. Three important family member. decisions families need to make before labor include: Outcome Identification and Planning Choice of birth attendant When planning with couples for labor and birth, goals Choice of setting that are set should seem both realistic and flexible. For How much and what type of analgesic they want to use in example, the goal of preparation is to help couples make labor informed choices, rather than to follow a rigid plan. Not all women want to go through labor without For example, a woman may elect to have her family doc- analgesia, so setting a goal to do so would be unrealistic tor, an obstetrician, or a nurse-midwife as her birth attendant. for such a woman. The majority of women, however, She may choose to be supported by her intimate partner, want to participate as fully as possible in their labor and other family members, friends, or a doula (a woman experi- birth experience, so setting a goal for them to do that enced in childbirth who provides continuous emotional and would be very realistic. Some women may be reluctant physical support). She may choose to give birth in a birthing to attend a childbirth preparation course because of fear center or a hospital with specially equipped birthing rooms attending will mean they are committing themselves to a (MacDorman, Mathews, & Declercq, 2012). medication-free birth. You can assure them that learning No matter what setting the woman or couple choose, about medications or other methods to reduce the pain expectant parents are well advised to be as prepared as possible of childbirth does not mean they have to use one or the for the physical and emotional aspects of childbirth (Kemp, other of these methods. In the same way, women who Kingswood, Kibuka, et al., 2013). Box 14.1 shows 2020 National are certain they want medication before having taken a Health Goals related to preparation for childbirth and parenting. class will not be held to this afterward. Helpful Internet referral sources for couples making Nu r s in g Pro c e s s Overview childbirth plans are Childbirth Connection (www.child birthconnection.org), Lamaze International (www.lamaze For Childbirth and Parenting Education.org), International Childbirth Education Association (www.icea.org), La Leche League International (www.llli Assessment.org), and the Coalition for Improving Maternity Assessing each woman’s or couple’s readiness for decision Services (www.motherfriendly.org). making about childbirth, as well as providing founda- tion information early in the process can help a woman Implementation or couple make plans for childbirth. Some couples have Be certain to provide a woman and her partner with a clear idea of where and how they wish their child’s information on the benefits and drawbacks of birthing birth to occur from the moment they realize they are options without influencing them in a particular direc- pregnant. Others cannot even consider the actual birth tion. To remain objective, examine your own attitudes, until they have adjusted to the idea of pregnancy. cultural influences, and values related to childbirth and PILLITTERI_E7_CH14.indd 329 7/8/13 1:40 AM  330 UNIT 3 The Nursing Role During Normal Pregnancy, Birth, the Postpartum, and Newborn Period explore how these beliefs might differ from those of BOX 14.2 Nursing Care Planning to your clients (Box 14.2). Referring couples to a child- birth preparation course can provide many answers for Respect Cultural Diversity them in a sympathetic group setting, where feelings Whether women want or are able to take a childbirth and and anxieties can be shared. Be familiar with the con- parenting preparation course depends a great deal on tent of courses available in your community so you can cultural and socioeconomic factors and individual choices. be certain the courses you suggest are appropriate for In some cultures, for example, the advice of a friend or individual couples and present adequate and accurate family member carries more weight than the advice of information. a professional health care practitioner. A very old cross- Review the arrangements a woman needs to make for cultural belief is a knife placed under the mattress will “cut labor and birth at the midpoint of pregnancy. No matter the pain” better than a Lamaze program, so you may need how calm a woman seems when discussing these details, to advocate to allow this type of pain relief. Asking each many women experience some fear at the last minute woman separately whether she is interested in a course and and will forget what they need to do when labor begins. being certain women are fully informed about the options Be certain a woman has thought through arrangements available are two ways to be certain all women receive as for transportation to the hospital or birthing center and much advice and knowledge as they wish about childbirth. for child care if she has other children at home. Be cer- Who women choose as a support person or coach tain a woman who anticipates a home birth has orga- in labor also differs depending on one’s cultural back- nized her home and purchased supplies for birth well in ground. Some women would not think of choosing advance of her expected due date. anyone but their male partner; whereas others’ first choice would be a female relative or friend. Assess each Outcome Evaluation couple individually to be certain cultural preferences Evaluate whether expected outcomes for childbirth such as these are respected. education have been achieved during the last few pre- natal visits. By this time, a woman or couple should know where the baby will be born and should have worked out transportation and child care details. En- courage women who will be coached through child- birth by their partners or another support person to BOX 14.3 Nursing Care Planning continue practicing breathing and relaxation tech- Using Assessment niques together up to the time of birth so they do not Assessing a Woman’s Preparation lose these skills. A final evaluation as to whether the for Labor couple was satisfied with their birth setting or prepa- ration choices takes place after the birth. Examples of expected outcomes that would demonstrate the suc- Plan for birth Prepared to attendant and cess of interventions include: setting in mind use imaging or focusing The couple states they feel prepared for childbirth. The client states she feels confident she can use breath- ing exercises for contractions as long as 70 seconds. Breathing The client has made preparations for a doula to sup- exercises to port her during labor. reduce pain The sibling states she is ready to welcome a new in labor brother or sister into the family. The couple states they were well prepared for birth and Flexible lumbar spine from that it was both a satisfying and a growth experience Strengthened pelvic rocking abdominal for them. muscles Strengthened perineal muscles from tailor sitting CHILDBIRTH EDUCATION Although parenting is unarguably an important occupation, it is one of the few occupations that requires no formal edu- cation, no examination to test a person’s ability to take on such a role, and no refresher course to ensure a parent is fol- lowing healthy standards of childrearing. Assessing whether couples need preparation for childbirth or parenting classes or encouraging them to take one can therefore be extremely important to make childbirth a satisfying experience, to help a family bond with its new member, and to help couples become effective parents (Box 14.3). PILLITTERI_E7_CH14.indd 330 7/8/13 1:40 AM  CHAPTER 14 Preparing a Family for Childbirth and Parenting 331 Preparation for childbirth courses that teach this mate- pregnancy, childbirth, and early parenthood as well as present rial should be individualized to meet the parents’ needs. coping skills and labor support techniques. Although child- Classes should be personalized and structured for women birth education is an interdisciplinary field, it has historically with special needs such as adolescents, career women, been associated with nursing, and nurses play major roles in women who are physically challenged, or those experienc- designing and teaching such courses. Most classes are taught ing a high-risk pregnancy. There also are classes available to in a group format, incorporating a variety of teaching tech- help prepare siblings or grandparents learn more about their niques such as DVD or PowerPoint presentations, lectures, role. Women having a vaginal birth after cesarean (VBAC) and demonstrations (especially for content on relaxation and or women who are having a scheduled cesarean birth can breathing techniques). One of the most important aspects attend classes specially designed for them (Horey, Weaver, of these courses, however, is group interaction. Women and & Russell, 2011). their partners enjoy the opportunity to share their fears and Preparation for childbirth courses initially began in the hopes about their pregnancy and upcoming birth with others early 1900s to encourage women to come for prenatal care as they learn together (Box 14.4). (Kiely & Kogan, 2012). Classes continue today because, with all the birth choices available, they fulfill an important need Efficacy of Childbirth Education Courses for education about labor and childbirth. As many as 15% of women express fear or anxiety about what will happen in Many studies have been done to determine just how effec- labor, so counseling can be very important to alleviate this tive childbirth courses are at reducing the pain of child- fear (Alder, Breitinger, Granado, et al., 2011). birth, shortening the length of labor, decreasing the amount The overall goals of childbirth education are to prepare of medication used, and increasing overall enjoyment of the expectant parents emotionally and physically for childbirth experience. Because of the variability in courses offered and while promoting wellness behaviors that can be used by par- the variability in women’s reactions to childbirth, however, ents and families for life. Women usually enjoy such classes it is often difficult to compare results of attending child- because they offer them a sense of “family” if their intimate birth classes versus not attending them. This is also partly partner also attends as well as create a sense of empowerment because people who volunteer to attend classes already have or confidence that they will be knowledgeable enough to par- a high degree of positive motivation, which may skew the ticipate fully in their birth experience. results. Despite these difficulties with measurement, it is generally accepted that preparation courses can increase Childbirth Educators and Methods satisfaction, reduce the amount of reported pain, decrease of Teaching risky behaviors such as smoking, and increase feelings of control during childbirth (Al-Sahab, Saqib, Hauser, et al., Childbirth educators are usually health care providers who 2010; Records & Wilson, 2011). It is documented that have a professional degree in the helping professions as well as by attendance in discussions of breastfeeding, the pro- a certificate from a course on childbirth education. They teach portion of new mothers who breastfeed can be increased expectant parents about the physical and emotional aspects of ( Johnson & Strube, 2011). BOX 14.4 Nursing Care Planning Based on Effective Communication You care for Elena at a prenatal clinic visit. She is in the 24th week of an uncomplicated pregnancy. Less Effective Communication More Effective Communication Nurse: Have you signed up for a childbirth preparation Nurse: Have you signed up for a childbirth preparation class yet, Elena? class yet, Elena? Elena: No. Elena: No. Nurse: Don’t wait too much longer. You’re already in Nurse: Don’t wait too much longer. You’re already in your your sixth month. sixth month. Elena: I don’t really need to go to one. Elena: I don’t really need to go to one. Nurse: Okay. You know best. Nurse: Why is that? Elena: Classes are at the wrong time. And cost too much. Nurse: Let’s work together to find a course that’s right for you. We can use the Internet to find out what options are available. Because women should have input into how much preparation they want to do for childbirth, it is easy to take a woman’s answer at face value for not wanting to attend a class. Careful listening often reveals time or money concerns are the real reason why couples choose not to attend a course. Helping to investigate the many options is the beginning of problem solving. PILLITTERI_E7_CH14.indd 331 7/8/13 1:40 AM  332 UNIT 3 The Nursing Role During Normal Pregnancy, Birth, the Postpartum, and Newborn Period THE CHILDBIRTH PLAN BOX 14.5 Birth Plan: Elena Garza Most classes for expectant parents urge couples to make a Birth Attendants: written childbirth plan to include information such as their Alexander Coppin, MD, and nurse-midwife Kaitlin choice of setting, birth attendant, special needs such as the Brandywine, or whoever is on call for the big day. extent of family participation they wish during labor, birthing positions, medication options, plans for the immediate post- Birth Setting partum period, baby care, and family visitation—all measures Room Number 1 at Huntington Alternative Birth Center to give them a better sense of control (Kuo, Lin, Hsu, et al., 2010). Support Persons Urge couples to make these decisions at least 1 month My boyfriend Joe and my sister Adrienne. Adrienne will before the expected day of birth. This way, if an expectant serve as my doula. couple has a strong desire in a certain area, this gives them time to communicate their wish so it can be accommodated Activities During Labor if possible. If plans are left to the last minute, the couple may I want to walk around or rock in the rocking chair or play find decisions determined by agency policy or the circum- Monopoly. stances at the moment rather than by their input. I want to use breathing exercises with contractions. When talking to couples about their birth plan, be certain I want to wear my own nightgown and listen to Lady it includes flexibility as well as is centered on the ultimate Antebellum’s CD Own the Night goal of childbirth: a healthy baby and healthy parents rather I want to wear my glasses, not my contact lenses. than concentration on a limited goal, such as not having fetal I want to eat “anything chocolate” during labor. monitoring or using a particular birthing position. This is I want to drink raspberry-flavored water to stay hydrated because, in the event of a complication that requires an emer- (partner will supply). gency cesarean birth, their preference to have the baby with- I want a walking epidural for pain as soon as I’m far enough out anesthesia will need to be modified. Making a birth plan dilated to have it. in a group setting has the advantage of allowing a couple to sort out their questions and feelings about what they want to Birth consider in their plan as they share information with others. Position for birth: on my side (no stirrups, please). Box 14.5 is a sample birth plan. No episiotomy please. Joe wants to cut the cord. I want my older son to watch if he wants to (my mother PRECONCEPTION CLASSES will babysit). I want to cord bank a sample of my baby’s blood. Preconception classes are held for couples who plan to get I’m okay with circumcision. pregnant within a short time and want to know more about I want the first voice my baby hears to be my voice so no what they can expect pregnancy to be like and what birth set- talking please while he’s born. ting and procedure choices exist. These classes stress that preg- nancy brings with it psychological as well as physical changes Postpartum and include recommended preconception nutrition modifi- I want to breastfeed immediately and exclusively cations such as a good intake of folic acid (e.g., green leafy (will probably need some help). vegetables) and protein (e.g., meat, tofu, beans) and perhaps I want to use skin-to-skin care to keep the baby warm. a prenatal vitamin during the time waiting to get pregnant to I want to room-in constantly. ensure a healthy fetus (Saravelos & Regan, 2011). Box 14.6 Joe wants to sleep over on bedside cot. lists questions a couple might want to discuss about birth. ✔ QSEN Checkpoint Question 14.1 Patient-Centered Care Elena, 30 years of age, shows you the birth plan that she has EXPECTANT PARENTING CLASSES drafted. Which statement by her would help assure you that Expectant parenting classes are designed for couples to attend she has a workable plan? early in pregnancy. They focus on the woman’s health dur- a. “I’ve written down everything I have to have to make labor ing a pregnancy by covering such topics as the psychological a success.” and physical changes of pregnancy, pregnancy nutrition, b. “I didn’t include anything my boyfriend wanted; I’m the routine health care such as dental checkups, and newborn one having the baby.” care. A typical course plan for 8 weeks is shown in Box 14.7. c. “My mother strongly suggested I ask for morphine like Both the woman and her support person are invited to she did, so I’m going to add that.” classes; the curriculum is individualized for the group mem- d. “I’ve tried to keep it flexible because I know circumstances bers and their needs such as women in the military, sibling can change.” preparation, refresher classes for grandparents, classes for Look in Appendix A for the best answer and rationale. expectant adoptive parents, pregnant adolescents, or women with physical disabilities. If all the women in the group PILLITTERI_E7_CH14.indd 332 7/8/13 1:40 AM  CHAPTER 14 Preparing a Family for Childbirth and Parenting 333 BOX 14.6 Nursing Care Planning Based on Family Teaching CHOOSING A BIRTH SETTING Q. Elena and her partner Joe ask you, “There are so many options available for a birth setting. How do we decide which one to choose?” A. Choosing a birth setting is a personal decision. Some questions you might want to ask to help with the decision include: What type of health care provider do I want to supervise my prenatal care and labor and birth? Nurse-midwife? Family doctor? Obstetrician? What settings does a particular childbirth provider let me choose from? A birthing room? An alternative birthing center? My home? Will the same person be present at prenatal visits as for the birth? Does the setting offer preparation for childbirth or childrearing classes? Will I be allowed to choose a birth position? Will I have input into the amount of anesthesia used? Can a doula be with me in labor? Can administration of ophthalmic ointment for the baby’s eyes be delayed so it doesn’t interrupt bonding? Can I begin breastfeeding immediately? Will nurses who are supportive and informed about breastfeeding be available if I have a problem? Will the setting allow my support person to participate? Will he or she be allowed to stay with me throughout labor and birth? Could he or she cut the cord or help with the birth? Can older children participate? Can I record the birth on video or by photographs? Is early discharge available? Will a follow-up home visit be included in care? If I should have a complication during labor or birth, is there adequate equipment and personnel available for emergency care? If our baby should have a complication, is there provision for immediate emergency care or transport to a high-risk facility? Will my partner be able to go with the baby? already have children, for example, they may not need a tour Sibling Education Classes of a maternity unit as part of the program; instead, they may want to learn what is new in baby food or child care. If all Sibling classes are organized to acquaint older brothers and the women in the class work at least part time, discussion of sisters with what happens during birth and what they can “brown bag nutrition” and how to include rest periods during expect a newborn to look and act like. The classes review how work hours might be most useful. If all the women are teen- babies grow and things children can do to help their mother agers, they may be most interested in what is going to happen during a pregnancy, such as eating healthy foods with her and to their bodies during pregnancy, or what sports are safe to not leaving toys on the floor that need to be picked up. continue. They may also need extended information on how If the classes are held at a hospital, a tour of a newborn to care for a newborn. They probably will also want a tour of nursery is included so children can see how small their new the maternity unit (Fig. 14.1). sibling will be (otherwise they may envision the new baby as BOX 14.7 Sample Outline for Weekly Expectant Parents Classes Lesson 1: Review of Physiologic Changes of Pregnancy and Fetal Growth Lesson 2: Personal Care During Pregnancy Nutrition, hygiene such as bathing, dental care, exercise, and rest Lesson 3: Emotional Changes During Pregnancy Lesson 4: Labor and Birth The process of birth, exercises, and breathing techniques, and medication in labor Lesson 5: Plans for Birth Birth settings available, supplies to take to birth settings, tour or film of a typical birth Lesson 6: The Postpartum Period Lesson 7: Infant Care FIGURE 14.1 An enjoyable part of a preparation-for- Nutrition and hygiene parenthood class is touring a maternity service. Here, although Lesson 8: Reproductive Life Planning they will be rooming-in with their newborn, parents-to-be view a newborn nursery. PILLITTERI_E7_CH14.indd 333 7/8/13 1:40 AM  334 UNIT 3 The Nursing Role During Normal Pregnancy, Birth, the Postpartum, and Newborn Period big enough to play with them). A hospital room like the one Explaining the role of both pharmacologic and nonphar- their mother will occupy may also be visited. macologic methods of pain control that are useful for labor To be certain sibling classes are successful, be certain Helping increase the couple’s overall enjoyment of and the information presented is age appropriate. Chapters 29 satisfaction with the childbirth experience through 33 discuss growth and development expectations by In addition to teaching about normal labor and pain relief, age group and when children are ready for formal instruction. classes also include a number of exercises to ready the body Younger children in a group may need assurance their parents for labor. will continue to love them after the new baby arrives. Older children may be interested in learning about newborn care Exercise During Pregnancy and receiving assurance their life will not be totally changed after the arrival of the new family member (Gabriel, 2011). Encourage women to maintain an active exercise program during pregnancy overall because such a program will both Breastfeeding Classes increase blood circulation to the fetus and help prevent exces- sive weight gain in the mother (Szymanski & Satin, 2012). Breastfeeding classes are designed to help women learn more Women should not, however, enroll or participate in a about breastfeeding so they not only choose breastfeeding over formal exercise program without their primary health care bottle feeding but also so they continue with breastfeeding for provider’s approval. They should also not attempt to exercise at least 6 months following their child’s birth. Such classes if any of the danger signs of pregnancy are present and should cover the physiology of breastfeeding as well as the psycho- never exercise to a point of fatigue (Box 14.8). logical aspects. Classes are often taught by a certified La Leche League instructor who is an expert on what problems new Prenatal Yoga mothers are apt to encounter (see Chapter 19 for breastfeeding techniques) (Monica & du Plessis, 2011). Prenatal yoga classes are aimed at helping a woman relax and manage stress better for all times in her life, not just preg- nancy. Yoga exercises help a woman stay overall fit by their What if...14.1 Elena tells you her partner focus on gentle stretching and deep breathing. They can also won’t be coming to childbirth classes with her help a woman experience high self-esteem as she masters dif- because, as a Navy Seal, he may be out of town when ficult levels or positions. Yoga breathing techniques are also she’s in labor. She asks you if it is really important to have useful in labor to help both relaxation and pain management someone with her. How would you advise her? (Smith, Levett, Collins, et al., 2011). Caution women that, as pregnancy progresses, it will Preparation for Childbirth Classes become difficult to maintain yoga positions that involve balan- cing. Urge women to use a chair or a wall for stabilization and Preparation for childbirth classes focus mainly on explain- to avoid twisting exercises late in pregnancy because, when ing the psychological and physiologic changes that occur joints soften in preparation for labor, muscle or joint strain with childbirth and ways to prevent or reduce the pain of could occur. childbirth. Common areas taught include: Perineal and Abdominal Exercises Preparing the expectant woman and her support person for Women can practice specific exercises to strengthen pelvic the childbirth experience and abdominal muscles to make these muscles stronger and Helping women become more informed about the options more supple for labor. If perineal muscles are supple, this available for childbirth allows for stretching during birth, reduces discomfort, and BOX 14.8 Nursing Care Planning to Empower a Family EXERCISE GUIDELINES FOR LABOR PREPARATION Q. Elena asks you, “How can I be sure the exercises I’m doing to be ready for birth won’t hurt me or my baby?” A. Good rules to follow include: Always rise from the floor slowly to prevent feeling dizzy Do not hold your breath while exercising, because from orthostatic hypotension. this increases intra-abdominal and intrauterine To rise from the floor, roll over to the side first and then pressure. push up to avoid strain on the abdominal muscles or Do not continue with exercises if any danger signal of round ligaments because this can cause intense pain. pregnancy occurs. To prevent leg cramps when doing leg exercises, never Never exercise to a point of fatigue. point the toes (extend the heel instead). Never practice second-stage pushing. Pushing To prevent back pain, do not attempt exercises that increases intrauterine pressure and could rupture hyperextend the lower back. membranes. PILLITTERI_E7_CH14.indd 334 7/8/13 1:40 AM  CHAPTER 14 Preparing a Family for Childbirth and Parenting 335 helps perineal muscles function more efficiently after child- birth, which helps reduce the possibility of urinary incon- tinence (Hay-Smith, Herderschee, Dumoulin, et al., 2011). A woman may begin exercises as early in pregnancy as she likes. Many exercises can be incorporated into daily activities so they take little time from a busy day. It is best, however, for a woman to set aside a specific time each day for practicing exercises; otherwise, her participation may be sporadic. Ini- tially, women should do each exercise only a few times, and gradually increase the number with each session. Tailor Sitting Although many women may be familiar with tailor sitting, they may have to be retaught the position so it is done in a way that stretches perineal muscles without occluding blood supply to the lower legs. A woman should put one leg in front of the other, not put one ankle on top of the other to avoid interfering with leg circulation (Fig. 14.2). As she sits in this position, she should then gently push on her knees toward the floor until she feels her perineum stretch. This is a good FIGURE 14.3 Squatting helps to stretch the muscles of position to use to watch television, read, talk to friends on the the pelvic floor. Notice the feet are flat on the floor for optimal phone, or file papers in a lower cabinet at work. If a woman perineal stretching. sits in this position for at least 15 minutes every day, by the end of pregnancy, her perineum should be so supple when she tailor sits, her knees will almost touch the floor if pushed. Pelvic Floor Contractions (Kegel Exercises) Pelvic floor contractions can be done easily during daily activi- Squatting ties. While sitting at her desk or working around the house, a Squatting (Fig. 14.3) also stretches the perineal muscles and can woman can tighten the muscles of her perineum by doing Kegel be a useful position for second-stage labor as well, and, like tailor exercises (see Chapter 12, Box 12.7). Such perineal muscle- sitting, should be practiced for about 15 minutes a day. For pel- strengthening exercises are helpful in the postpartum period to vic muscles to stretch, a woman should keep her feet flat on the reduce pain and promote perineal healing. They also have long- floor and not raise on her tiptoes. Incorporating squatting into term effects of increasing sexual responsiveness and helping daily activities such as picking up toys from the floor reduces the prevent stress incontinence (Allahdin & Kambhampati, 2012). amount of time a woman must devote to daily exercises. Abdominal Muscle Contractions Abdominal muscle contractions may help strengthen abdomi- nal muscles during pregnancy, help prevent constipation, and help restore abdominal tone after pregnancy. Strong abdominal muscles can also contribute to effective second-stage pushing during labor. Abdominal contractions can be done in a stand- ing or lying position. A woman merely tightens her abdominal muscles, then relaxes them. She can repeat the exercise as often as she wishes during the day. Another way to do the same thing is to practice “blowing out a candle.” A woman takes a fairly deep inspiration, then exhales normally. Holding her finger about 6 in. in front of herself, as if it were a candle, she then exhales forcibly, push- ing out residual air from her lungs as if her finger were a lit candle. She can feel her abdominal muscles contract as she reaches the end of a forcible exhalation. Pelvic Rocking Pelvic rocking (Fig. 14.4) helps relieve backache during preg- nancy and early labor by making the lumbar spine more flex- ible. It can be done in a variety of positions: on hands and knees, lying down, sitting, or standing. A woman arches her FIGURE 14.2 Tailor sitting stretches perineal muscles to back, trying to lengthen or stretch her spine. She holds the make them more supple. Notice that the legs are parallel so position for 1 minute, then hollows her back. If a woman one does not compress the other. A woman could use this does this at the end of the day about five times, it not only position for television watching, telephone conversations, or increases her flexibility but also helps relieve back pain and playing with an older child. make her more comfortable during the night. PILLITTERI_E7_CH14.indd 335 7/8/13 1:40 AM  336 UNIT 3 The Nursing Role During Normal Pregnancy, Birth, the Postpartum, and Newborn Period In order to help fetal descent and help relieve pain, women can use an exercise ball, a Jacuzzi tub, or change of position such as squatting, swaying with a partner, or rocking in a chair. These alternative pain and descent methods are dis- cussed in Chapter 16 with other measures that are useful in labor but don’t involve practice during pregnancy. METHODS TO MANAGE PAIN IN CHILDBIRTH Beginning in the late 1950s, many specific methods for non- FIGURE 14.4 Pelvic rocking is helpful for relieving backache pharmacologic pain reduction during labor were developed. during pregnancy and labor. To do this, the woman first hollows These included the Lamaze, Dick-Read, Kitzinger, and Brad- her back and then arches it. ley methods, all named after the professionals who developed them. More recently, childbirth education has moved away from a strict method approach like these to more eclectic ✔ QSEN Checkpoint Question 14.2 ones. Many educators teach a variety of approaches, includ- ing the use of complementary or herbal therapies. Safety Most approaches to reducing discomfort in labor are based Elena asks you which type of exercise is best to strengthen on the following three principles: her perineal muscles in anticipation of birth. Which of the 1. A woman needs to come into labor informed about what following recommendations is safest and most effective? causes labor pain and prepared with breathing exercises to a. Walk or jog 20 minutes daily at a fairly rapid pace. use to minimize pain during contractions. b. Squat or tailor sit for 15 minutes out of every day. 2. A woman experiences less pain if her abdomen is relaxed c. Periodically bear down as hard as possible while holding and the uterus is allowed to rise freely against the abdomi- her breath. nal wall with contractions. d. Lift both of her legs into the air while she lies on her back. 3. Using the gating control theory of pain perception, Look in Appendix A for the best answer and rationale. distraction techniques can be employed to alter how pain is received (Box 14.9). Birthing Slings What if...14.2 Elena tells you she does not A birthing sling is a rectangular piece of material often called a intend to take a preparation for labor class because rebozo (Mexico), a manta (Peru), a kanga (Africa), or a selendang she wants to have epidural anesthesia as soon as she is (Indonesia) that is slipped under a woman’s back as she lies admitted to the hospital in labor. Would you advise her to supine, then held by one or two assistants who gently sway the attend a class? woman’s body back and forth sideways, causing the fetus to rock in the amniotic fluid. The rocking technique is advocated The Bradley (Partner-Coached) Method by doulas to relieve uterine ligament tension during pregnancy; this technique as well as “dangling” from a sling can be used to The Bradley method of childbirth, originated by Robert facilitate fetal rotation and descent during labor as this enlarges Bradley, is based on the premise that pregnancy and child- the pelvic outlet (Simkin, Bolding, Keppler, et al., 2010). birth are joyful, natural processes and that a woman’s part- It is difficult to find evidence-based documentation for the ner should play an active role during pregnancy, labor, and use of birthing slings during pregnancy so, although you will the early newborn period. During pregnancy, a woman per- see them in use, women should check with their primary care forms muscle-toning exercises and limits or omits foods that provider before using them during pregnancy and labor to be contain preservatives, animal fat, or a high salt content. She certain they are safe for them. reduces pain in labor by abdominal breathing. In addition, she is encouraged to walk during labor and to use an inter- Birthing Aids nal focal point as a disassociation technique. The method is During early labor, a woman needs to discover what activities used at specific centers in the United States and is used widely she could use for distraction that would be unique for her in Europe, so it may be a favorite method of an immigrant such as playing cards or listening to specific music; further woman. It is taught by certified Bradley instructors (Bradley, into labor, she should plan what she could use as a greater Hathaway, Hathaway, et al., 2008). distraction for even stronger contractions such as singing out The Psychosexual Method loud, having her partner massage her back, or center intently on breathing exercises. Caution her partner that by mid- The psychosexual method of childbirth was developed by labor, women become so intent on the process of birthing Sheila Kitzinger in England during the 1950s. The method that they no longer want to talk or joke. Remind women that stresses pregnancy, labor and birth, and the early newborn they probably can’t use cell phones because these interfere period are some of the most important points in a woman’s with monitoring equipment. life. It includes a program of conscious relaxation and levels of PILLITTERI_E7_CH14.indd 336 7/8/13 1:40 AM  CHAPTER 14 Preparing a Family for Childbirth and Parenting 337 BOX 14.9 Gating Control Mechanisms to Reduce Pain The Lamaze Philosophy The Lamaze method of prepared childbirth, a philosophy Pain flows through pathways because: based on the gating control theory of pain relief, is the one 1. The endings of small peripheral nerve fibers detect a most often taught in the United States today (Amis, 2010). stimulus. The method is based on the theory that through stimulus- 2. Small nerve fibers transmit the sensation of pain to cells in response conditioning, women can learn to use controlled the dorsal horn of the spinal cord. breathing to reduce pain during labor. It was originally 3. Impulses pass through a dense, interfacing network of termed the psychoprophylactic method because it focuses cells in the spinal cord (the substantia gelatinosa). on preventing pain in labor (prophylaxis) by use of the mind 4. Immediately, a synapse occurs in a motor nerve that (psyche). The method was developed in Russia based on initiates a response at the peripheral site. For example, Pavlov’s conditioning studies but was popularized by a French a woman touches a hot stove, the impulse travels to the physician, Ferdinand Lamaze. Formal classes are organized by spinal cord, immediately returns to her fingers, and the Lamaze International and the International Childbirth Edu- woman jerks her hand away from the stove burner. cation Association. 5. After this short-circuit synapse, the impulse then Lamaze preparation is not so much a method to help a continues in the spinal cord to reach the hypothalamus woman cope with labor as it is a total philosophy of how to and cortex of the brain. enjoy a safe and satisfying childbirth experience. Information 6. The impulse is interpreted (e.g., the burner is hot) and is to guide a woman and her coach through pregnancy such perceived as pain. as prenatal nutrition, exercises, and common discomforts of pregnancy are discussed in classes along with information to Gating Theory of Pain Control prepare couples for unexpected circumstances of birth, such The gating theory of pain perception refers to gate control mech- as malpresentation, cesarean birth, or the need for analgesia anisms in the substantia gelatinosa that are capable of halting or anesthesia. Suggestions for supplies a woman or couple an impulse at the level of the spinal cord so the impulse is never might want to pack in advance and bring to the hospital for perceived at the brain level as pain—a process similar to closing a labor and birth are shown in Table 14.1. gate. Techniques that can assist gating mechanisms include: Cutaneous stimulation. If large peripheral nerves next to an injury site are stimulated, the ability of the small nerve TABLE 14.1 Supplies to Use During Labor fibers at the injury site to transmit pain impulses appears to decrease. Therefore, rubbing an injured part or applying Item Purpose transcutaneous electrical nerve stimulation (TENS) or heat or cold to the site (cutaneous stimulation) are effective ma- Lip balm To prevent dry lips neuvers to suppress pain. Effleurage, or light massage used Mouthwash For rinsing dry mouth in the Lamaze method, also accomplishes this. Distraction. If the cells in the brain cortex that will register Toothbrush and toothpaste To prevent dry mouth an impulse as pain are preoccupied with other stimuli, a pain impulse cannot register. Different childbirth classes Warm socks Comfort use different breathing, vocalization, or focusing tech- niques such as imaging to accomplish this. Breathing Small rolling pin covered Back massage techniques not only furnish distraction but can increase with soft cloth oxygenation to the mother and fetus. Tennis ball Back massage Reduction of anxiety. Pain impulses are perceived more quickly if a woman is anxious. The third technique of Focal point To increase concentration gating, therefore, is to reduce patient anxiety as much as possible. Teaching a woman what to expect during labor is Busy work such as knitting To pass time a means of achieving this. or magazines Paper bag To correct hyperventilation progressive breathing that encourage a woman to “flow with” Extra pillow For semi-Fowler’s position in labor rather than struggle against contractions (Kitzinger, 2011). Wristwatch For timing contractions The Dick-Read Method Scented oil For reducing friction of effleurage The Dick-Read method is based on an approach proposed by Grantly Dick-Read, an English physician. The premise is that Lollipops or hard candy For energy and dry mouth fear leads to tension, which leads to pain. If a woman can pre- vent fear from occurring or can break the chain between fear Bottled water To keep well hydrated and tension or tension and pain, then she can reduce the pain Music and music player To increase relaxation of labor contractions. A woman achieves lack of fear through education about childbirth, and she achieves reduced pain Snacks such as apples or For coach’s comfort by focusing on abdominal breathing during contractions potato chips (Dick-Read & Gaskin, 2013). PILLITTERI_E7_CH14.indd 337 7/8/13 1:40 AM  338 UNIT 3 The Nursing Role During Normal Pregnancy, Birth, the Postpartum, and Newborn Period Throughout the program, the following six major concepts Conscious Relaxation. This is learning to relax body parts are stressed: so, unknowingly, a woman does not remain tense and cause 1. Labor should begin on its own, not be induced. unnecessary muscle strain and fatigue during labor. She prac- 2. Women should walk, move around, and change positions tices conscious relaxation by deliberately relaxing one set of throughout labor. muscles, then another, and another until her body is com- 3. Women should bring a loved one, friend, or doula for pletely relaxed. Her support person concentrates on noticing continuous support. symptoms of tension such as a wrinkled brow, clenched fists, 4. Interventions that are not medically necessary should be or a stiffly held arm. By either placing a comforting hand on avoided. the tense body area or telling a woman to relax that area, the 5. Women should be allowed to give birth in other positions support person can help her to achieve complete relaxation. than on their back and should follow their body’s urges to The Cleansing Breath. To begin all breathing exercises, a push. woman breathes in deeply and then exhales deeply (cleansing 6. Mother and baby should be kept together after birth; it breath). To end each exercise, she repeats this step. It is an im- is best for the mother, baby, and for breastfeeding (Amis, portant step to take because it limits the possibility of either 2010). hyperventilation (blowing off too much carbon dioxide) or In addition, the following three main principles are taught hypoventilation (not exhaling enough carbon dioxide), both in the prenatal period related to the gating control method of which could happen with rapid breathing patterns and of pain relief: can interfere with an adequate fetal oxygen supply. If women do become light-headed during labor from hyperventilation 1. If a couple understands the process of labor and birth, they (i.e., develop respiratory alkalosis), breathing into a paper bag can enter labor with decreased tension. can help because it causes rebreathing of exhaled carbon diox- 2. Concentrating on breathing patterns or imagery or focus- ide. The cleansing breath also signals to the woman’s partner ing can block incoming pain sensations. a contraction is about to begin or has ended. 3. Conditioned reflexes, or reflexes that automatically occur in response to a stimulus, can also be used to displace pain during labor. For example, a woman is conditioned to ✔ QSEN Checkpoint Question 14.3 relax automatically on hearing a command (“contraction Evidence-Based Practice beginning”) or at the feel of a contraction beginning. The responses to contractions must be recently conditioned One of the most controversial aspects of childbirth addresses to be effective (because conditioned responses fade if the question of the best birth position for women to use. not reinforced). This is the reason it is generally recom- To evaluate the impact of birth position on maternal and mended that women attend Lamaze classes in the last tri- newborn well-being, researchers reviewed 40 studies on birth mester of pregnancy. A disadvantage of enrolling so late is position published over the past 15 years. that it limits the total amount of time directed to perineal The results showed both physical and psychological benefits exercises. If labor begins early, a woman may have had for women when they are able to adopt positions other than little or no practice with this type of exercise. on their back for labor. Women allowed to birth in an upright Lamaze classes are kept small so there is time for individual position had a shorter duration of the first and second stages instruction and attention to each couple (Fig. 14.5). Advise of labor, experienced less medical intervention, and reported a woman to bring the support person who will serve as her less severe pain; they also had an increased rate of satisfac- coach in labor to class with her to practice breathing exercises. tion with their childbirth experience than women who gave Exercises taught vary from teacher to teacher, especially in birth in a semi-recumbent or supine/lithotomy position. The terms of complexity, but have common features, which are only disadvantage identified of an upright position was in- discussed as follows. creased blood loss during the third stage of labor, which may be due to increased perineal edema caused by the upright position (Priddis, Dahlen, & Schmied, 2011). Based on the previous study, what would you like to see included in Elena’s birth plan? a. “I don’t want any medical interventions in labor, like an IV.” b. “I want to labor the same way that you see women do it on TV and in movies.” c. “I’m willing to try anything safe that will make my labor shorter.” d. “I’m afraid I’ll get dizzy if I try to sit up or stand during labor.” Look in Appendix A for the best answer and rationale. Consciously Controlled Breathing. Using consciously con- trolled breathing, or set breathing patterns at specific rates, provides distraction as well as prevents the diaphragm from FIGURE 14.5 Every woman needs to be well prepared for descending fully and putting pressure on the expanding birth. Here, a partner practices a position for pushing. Caution uterus. To practice, after a cleansing breath, a woman inhales women not to actually push to avoid rupturing membranes. comfortably but fully, then exhales, with her exhalation a PILLITTERI_E7_CH14.indd 338 7/8/13 1:40 AM  CHAPTER 14 Preparing a Family for Childbirth and Parenting 339 little stronger than her inhalation (to help prevent hypoventi- contractions or during the second stage of labor to prevent lation). She practices breathing in this manner at a controlled a woman from pushing before full dilatation. pace, depending on the intensity of contractions through the Some courses stop teaching at the point a woman has mas- following various levels of breathing: tered these levels of breathing; others have her learn to shift Level 1. Slow deep chest breathing of comfortable but full from one level to the other on command or at the point she respirations at a rate of 6 to 12 breaths/min. This level is feels a need for more pain relief. used for early contractions in labor when the cervical dila- Figure 14.6 illustrates the use of levels of breathing. At the tion is between 0 and 3 cm. beginning of a mild, early labor contraction, a woman’s coach Level 2. Lighter and more rapid breathing than level 1. The says, “Contraction beginning.” A woman takes a cleansing rib cage should expand but be so light that the diaphragm breath, then breathes at level 1; she feels no bite from the con- barely moves. The rate of respirations is up to 40 breaths/ traction and so does not need to change to a more involved min. This is a good level of breathing for contractions breathing pattern. Later in labor, contractions are stronger when cervical dilation is between 4 and 6 cm. and longer. Now, at the sound of “Contraction beginning,” a Level 3. Even more shallow and more rapid breathing. The woman takes a cleansing breath, then begins level 1 breathing rate is 50 to 70 breaths/min. As the respirations become faster, (3 breaths), shifts to level 2 (4 to 6 breaths), and then shifts the exhalation must be a little stronger than the inhalation to to level 3 (10 breaths). The contraction is lessening. She shifts allow good air exchange and to prevent hypoventilation. If a down to level 2 (4 to 6 breaths), then to level 1 (3 or 4 breaths). woman practices saying “out” with each exhalation, she almost The contraction is gone. She takes a final cleansing breath. inevitably will make exhalation stronger than inhalation. A During actual labor, her coach can tell the strength of woman uses this level for transition contractions when cervi- contractions by resting a hand on her abdomen or observ- cal dilation is between 7 and 10 cm. Keeping the tip of her ing a uterine contraction monitor. A coach can tell a woman tongue against the roof of her mouth helps prevent her oral when to shift breathing levels depending on the coach’s esti- mucosa from drying out during such rapid breathing. mation of the strength of the contraction with words such as, Level 4. Another pattern effective for transition contrac- “contraction beginning, getting stronger, now getting weaker, tions is a “pant-blow” pattern, or taking three or four quick gone.” In the time before transition to the second stage of breaths (in and out), then a forceful exhalation. Because labor, when contractions are longest and strongest, a woman this type of breathing sounds like a train (breath-breath- may need to use her level 4 breathing or continuous light breath-huff ), it is sometimes referred to as “choo-choo” or panting as well. A woman who can perform all five levels of “hee-hee-hee-hoo” breathing. breathing and maintain relaxation can be assured she is pre- Level 5. Quiet, continuous, very shallow panting at pared to handle all labor contractions up to the second stage about 60 breaths/min. This can be used during strong of labor (Lothian, 2011). FIGURE 14.6 An example of differing breathing patterns during a single contraction. 1, 2, and 3 are levels of breathing. A cleansing breath is taken at the beginning and end of the contraction. PILLITTERI_E7_CH14.indd 339 7/8/13 1:40 AM  340 UNIT 3 The Nursing Role During Normal Pregnancy, Birth, the Postpartum, and Newborn Period Effleurage. One additional technique to encourage relax- ation and displace pain in the Lamaze method is effleurage, which is French for “light abdominal massage”; it is done with just enough pressure to avoid tickling. To do this, a woman traces a pattern on her abdomen with her fingertips (Fig. 14.7). The rate of effleurage should remain constant even though breathing rates change. Effleurage serves as a distraction technique and decreases sensory stimuli trans- mission from the abdominal wall, helping limit local dis- comfort. If an external electronic monitor is in place on the abdomen, effleurage can be done superior or inferior to it or even on the thighs. Effleurage can also be done by the sup- port person. Focusing or Imagery. Focusing intently on an object (sometimes called “sensate focus”) is another method of FIGURE 14.8 A woman chooses what object she wishes to keeping sensory input from reaching the cortex of the focus on during labor. Here, a woman and nurse listen to the brain (Marc, Toureche, Ernst, et al., 2011). For example, music the woman will focus on during contractions. (© Barbara a woman brings into labor a photograph of her partner or Proud.) children, a graphic design, or just something that appeals to her like an ocean scene she can concentrate on dur- Second-Stage Breathing. During the second stage of labor, ing contractions (Fig. 14.8). Other women use imagery when the baby is pushed down the birth canal, the type of by imagining they are in a calm place such as on a beach breathing that is best to use is controversial. In the past, watching waves rolling in to them or relaxing on a porch women were told to hold their breath while they pushed. Now swing. Be careful not to step into a woman’s line of vi- it is believed holding the breath for a prolonged time impairs sion during a contraction to break her concentration on blood return from the vena cava (a Valsalva maneuver), so this an object; also, don’t ask questions or try to talk to women practice is now discouraged. Based on this, suggest women while they are focused and breathing or you will break breathe any way that is natural for them, except holding their their concentration. breath during this stage of labor. Women should not practice pushing during pregnancy or if in labor before the end of the first stage because the pos- sibility they could rupture membranes by doing this is too great. They can practice assuming a good position for push- ing (e.g., squatting, sitting upright, leaning on partner) but should always be cautioned not to actually bear down and push. ✔ QSEN Checkpoint Question 14.4 Informatics A Elena’s sister-in-law has referred her to a Web site that outlines the Lamaze method for labor and birth. What is the guiding principle of Lamaze childbirth? a. Pain can be interrupted before it registers in the brain as pain. b. Labor contractions are rooted in psychology, not physiology. c. “Brown pain” like labor contractions, is unlike other forms of pain. d. Labor contractions can be eliminated by learned mind control techniques. Look in Appendix A for the best answer and rationale. B Preparation for Cesarean Birth Some women chose to have a cesarean birth to help pre- vent uterine prolapse or urinary incontinence in later years (Dursun, Yanik, Zeyneloglu, et al., 2011). To ensure a safe FIGURE 14.7 Effleurage patterns. (A) During uterine birth, a cesarean birth may become necessary during labor. contractions, a woman traces a pattern on her bare abdomen The specific preparations needed for a cesarean birth as with her fingers. (B) If electronic fetal monitoring is being used, well as a vaginal birth after cesarean (VBAC) is discussed in effleurage may be performed on the thigh. Chapter 24. PILLITTERI_E7_CH14.indd 340 7/8/13 1:40 AM  CHAPTER 14 Preparing a Family for Childbirth and Parenting 341 THE BIRTH SETTING birth at birthing centers or hospitals. Women with high-risk pregnancies are advised to give birth in hospitals where more Besides how to best prepare for labor, choosing a birth setting immediate emergency care is available. is another important decision that a couple needs to make dur- ing pregnancy (Hodnett, Downe, Walsh, et al., 2010). This The Hospital Birth decision depends on a woman’s health and that of her fetus, The maternity services of hospitals have changed a great deal the couple’s preferences, and on how much and what kind of in recent years, having been influenced by the Coalition for supervision they want for the birth. Although hospitals are Improving Maternity Services (CIMS). This organization the usual site for birth today in the United States, that has not rates hospitals as to whether they are mother friendly or always been true. Up until the late 1800s, childbirth was con- not based on if a woman has the opportunity for any of the ducted in the home setting with little pain relief. Analgesia or following: anesthesia for childbirth first became popular when Queen Victoria birthed Prince Leopold under chloroform in 1853. Experience a healthy and joyous birth experience, regard- Although chloroform relieved pain, it also complicated birth less of her age or circumstances because not only were women asleep for one of the most mem- Give birth as she wishes in an environment in which she orable moments of their life but it also caused them to not be feels nurtured and secure able to push effectively during the second stage of labor, thus Have access to the full range of options for pregnancy, making it necessary to use a lithotomy position, an episiotomy, birth, and nurturing her baby and forceps for birth. Receive accurate and up-to-date information about the ben- Part of the reason for giving so much anesthesia during efits and risks of all procedures, drugs, and tests suggested birth can be attributed to health care providers misinterpret- for use during pregnancy, birth, and the postpartum period, ing the moment of birth as the time that produces the great- with the right to informed consent and informed refusal est degree of discomfort. As a result, women were allowed Receive support for making informed choices about what to labor without pain medication and then were given anes- is best for her and her baby based on her individual values thesia or analgesia right before the baby was born. Although and beliefs (CIMS, 2012) the pain felt at birth is intense, it is also only a hot flash and To qualify as a mother-friendly hospital, a hospital should over quickly, unlike the hours of labor that precede it, making not have routine policies that include practices for such women not as uncomfortable during the actual birth as they things as perineal shaving, admission enemas, withholding are during labor. Birth is also such an exhilarating time that food or fluid during labor, rupturing membranes to hurry the excitement of the moment and natural perineal anesthesia labor, or the use of continuous intravenous lines or constant can mask pain. fetal monitoring. It also should have low rates of episioto- Fortunately, based on women’s descriptions of the pain mies, induction for labor, and cesarean births. In contrast, of childbirth, birthing practices have changed to better meet it should also have a high VBAC rate (60% or more [CIMS, women’s needs (Gabriel, 2011). Nurses are in a strong posi- 2012]). Urge women to ask their primary care provider if the tion to advocate for making childbirth as “natural” a process hospital they recommend is rated as mother friendly because as possible and conducted in the least restrictive setting pos- this should influence both a couple’s choice of a hospital and sible. At the same time, nurses have a strong responsibility to their birth attendant. encourage parents to respect any restriction that will allow the The major advantage of a hospital birth is that equipment birth to remain safe. and expert personnel are readily available if the mother, fetus, or newborn should have a complication. When hospital birth Choosing a Birth Attendant and is compared to births at alternative settings as to how many Support Person complications occur, women who give birth in hospitals in- In the United States, most births are supervised by an obste- variably have more complications. Remember, though, that trician, a physician specializing in labor and birth; a family women at high risk for complications choose to give birth at practitioner; or a nurse-midwife (Hodnett, Gates, Hofmeyr, hospitals so, of course, more complication will occur there. et al., 2011). In addition to selecting who will medically su- A woman usually comes to the hospital when her contrac- pervise her baby’s birth, many women choose a doula, or a tions are approximately 5 minutes apart and regular in pat- person specially prepared to assist with birth. Doulas can be tern. If she has preregistered at the hospital, she is admitted especially helpful as support people because having such a to a birthing room without any separation time from her person present frees the father to enjoy the birth rather than support person. Birthing rooms are also called labor-birth- feel occupied with coaching instructions. Although research recovery rooms (LBRs) or labor-birth-recovery-postpartum in the subject is not extensive, there are suggestions that rates rooms (LBRPs). Such rooms are decorated in a homelike of oxytocin augmentation, epidural anesthesia, and cesarean way, and couples can bring favorite music or reading materi- birth can all be reduced by doula support (Gilliland, 2011). als with them to use during labor (Fig. 14.9). With specific education, many nurses are participating as Women are expected to use a prepared method of child- either a doula or special support nurse to women in labor. birth with a minimum of analgesia and anesthesia (al- though an advantage of a hospital birth is that anesthesia such Choosing a Birth Setting as an epidural is readily available if needed). The woman’s partner or other family members can stay with her through- Women who are low risk for complications may choose hos- out labor and birth, allowing a couple and their families to pitals, birthing centers, or their homes as settings for birth. feel they have control over and can share in the birth experi- Women who might have a complication are advised to give ence. The bed is used as a labor bed until birth, when it is PILLITTERI_E7_CH14.indd 341 7/8/13 1:40 AM  342 UNIT 3 The Nursing Role During Normal Pregnancy, Birth, the Postpartum, and Newborn Period a birth attendant can assist with the birth, could also be used (Fig. 14.10). The chair has the advantage of maintaining a woman in a semi-Fowler’s position, a position that acts with gravity and so may speed the second stage of labor.