Chapter 14: Preparing a family for Childbirth and Parenting

 3 Important Decisions Families Need to Make before Labor include:

a. Choice of birth attendance
b. Choice of setting
c. How much and what type of analgesic they want to use in labor
 Doula: a woman experienced in childbirth who provides continuous emotional and
physical support
Nursing Process Overview
Assessment
 Assess each woman’s or couple’s readiness for decision making about childbirth as
well as providing foundation information early in the process can help a woman or
couple make plans for childbirth
 Ask whether a either she want her support person to attend the childbirth
Nursing Diagnosis
 Health-seeking behaviors related to learning more about childbirth and newborn care.
 If there is a lack of support person, the following diagnosis may apply:
a. Ineffective coping related to lack of a support person
b. Anxiety related to absence of significant other.
 Decisional conflict related to lack of information about advantages and disadvantages
of various childbirth setting
 Anxiety related to sibling role in pending birth event and sibling ability to welcome a
new family member
Outcome Identification and Planning
 Goals should be both realistic and flexible
 Assure learning about medications or other methods reduce the pain of childbirth does
not mean they have to use one or other of these methods
Implementation
 Be certain to provide a woman and her partner with information on the benefits and
drawbacks of birthing options without influencing them in particular direction.
 Remain objective, examine your own attitudes, cultural influences and values related to
childbirth and explore how theses beliefs might differ from those of your patients.
 Be familiar with the content of courses available in your community
 Review the arrangement a woman needs to make for labor and birth at the midpoint of
pregnancy
 Be certain a woman has thought through arrangement for transportation to hospital or
birthing center and for child care
Outcome Evaluation
 Encourage women who will be coached through childbirth by their partners or another
support person to continue practicing breathing and relaxation techniques
 Couple states they feel prepared for childbirth.
 Client states she feels confident she can use breathing exercises for contractions as
long as 70 seconds.
 Client has made preparations for a doula to support her during labor.
 Sibling states she is ready to welcome a new brother or sister into the family.
 Couple states they were well enough prepared for birth that it was a satisfying and
growth experience for them

A. Childbirth Education
 Assessing whether couples need a preparation for childbirth or parenting class:
help family bond with its new member, and become effective parents
 Vaginal birth after cesarean (VBAC): women who are having scheduled
cesarean birth can attend classes specially designed for them
 Goal of childbirth education: prepare expectant parents emotionally and
physically for childbirth while promoting wellness behaviors that can be used by
parents and families for life
 1. Childbirth Educators and Methods of Teaching
- are health care providers who usually have a professional degree in the helping
professions as well as a certificate from a course specifically about childbirth
education.
- Most classes are taught in a group format; most incorporate a variety of teaching
techniques such as videotapes and slides, lecture, and demonstration (especially
for content on relaxation and breathing techniques).

B. Childbirth Plan
 Include information such as their choice of setting, birth attendant, special needs
such as the extent of family participation they wish during labor, birthing
positions, medication options, plans for the immediate postpartum period and
baby care, and family visitation
 Be certain it includes flexibility as well as is centered on the ultimate goal of
childbirth

C. Preconception Visits
 Are specific visits for couple who plan to get pregnant within a short time and
want to know more about what they can expect pregnancy to be like and what
birth setting and procedure choices exist

D. Expectant Parenting Class

 Are designed for couples who are already pregnant.
 They focus on family health during a pregnancy, covering such topics as the
psychological and physical changes of pregnancy, pregnancy nutrition, routine
health care such as dental checkups, and newborn care.
 A typical course plan for 8 weeks is shown in Box 14.7 in pp.312.

1. Breastfeeding Classes
- Designed to help women learn more about breastfeeding over bottle feeding and
continue it at least for 6 months following their child’s birth
- Often taught by a certified La Leche League instructor who is an expert on what
problems new mothers are apt to counter

2. Preparation for Childbirth Class

- Focus mainly on explaining the psychological and physiologic changes that occur
with childbirth and ways to prevent or reduce the pain of childbirth
 Prepare an expectant woman and her support person for the childbirth
experience
 Create clients who are knowledgeable consumers of obstetric care
 Help women reduce and manage pain with both pharmacologic and
nonpharmacologic methods
 Help increase a couple’s overall enjoyment of and satisfaction with the
childbirth experience

3. Exercise during Pregnancy

- Will both increase blood circulation to the fetus and help prevent excessive
weight gain in the mother
- Do not enroll or participate without obstetric provider approval

a. Prenatal Yoga
o aimed at helping a woman relax and manage stress better for all times
in her life, not just pregnancy
 o help a woman stay overall fit by their focus on gentle stretching and
deep breathing
o help a woman experience high self-esteem as she matters difficult
levels at positions
o Yoga breathing techniques: useful in labor to help both relaxation and
pain management
o Caution women, as pregnancy progresses, that it will become difficult
to maintain difficult yoga positions that involve balancing
o Use chair or wall for stabilization
o Avoid twisting exercises late in pregnancy

b. Perineal and Abdominal Exercises

o Reduces discomfort, and helps perineal muscles function more
efficiently after childbirth, which helps reduce the possibility of
urinary incontinence
o Best, however, for woman to set aside a specific time each day for
practicing exercises, otherwise, her participation may be sporadic.

c. Tailor Sitting
o Done in a way that stretches perineal muscles without occluding blood
supply to the lower legs
o Good position to use to watch tv, read, talk to friends on the phone, or
file papers in a lower cabinet at work.

d. Squatting
o Also stretches the perineal muscles and can be useful position for
second-stage labor as well and, like tailor sitting, should be practiced
for about 15 minutes a day.

e. Pelvic Floor Contractions (Kegel Exercises)

o Can be done easily during daily activities
o While sitting at her desk or working around the house, the woman can
tighten the muscles of her perineum by doing Kegel exercises
o Reduce pain and promote perineal healing
o Long term effects of increasing sexual responsiveness
o Prevent stress incontinence

f. Abdominal muscle Contractions

o Help strengthen abdominal muscles during pregnancy
o Prevent constipation
o Help restore abdominal tone after pregnancy
o Can be done in standing or lying positions

g. Pelvic Rocking
o Helps relieve backache during pregnancy and early labor by making
lumber spine more flexible
o Can be done in variety of positions: on hands and knees, lying down,
sitting or standing

h. Birthing Aids
o Discover what activities that could use as distraction
o Use an exercise ball, jacuzzi tub or change of position such as
squatting, swaying with a partner or rocking in a chair
E. Methods to Manage Pain in Childbirth
 Beginning in the late 1950s, many specific methods for nonpharmacologic pain
reduction during labor were developed. These included the Lamaze, Dick-Read,
and Bradley methods, all named after the professionals who developed them.
 Most approaches to reduce discomfort in labor are based on the ff. 3 principles:
a. Woman comes into labor must know what causes labor pain and be prepared
with breathing exercise to minimize pain during contractions
b. Woman experience less pain if abdomen relaxed and uterus is allowed to rise
freely against abdominal wall with contractions
c. Use gating control theory of pin perception as distraction techniques

1. The Bradley (Partner-Coached) Method

- originated by Robert Bradley, is based on the premises that pregnancy and
childbirth are joyful natural processes and that a woman’s partner should play an
important role during pregnancy, labor, and the early newborn period
- a woman performs muscle-toning exercises and limits or omits foods that contain
preservatives, animal fat, or a high salt content.
- she reduces pain in labor by abdominal breathing
- she is encouraged to walk during labor and to use an internal focus point as a
disassociation technique

2. The Psychosexual Method

- developed by Sheila Kitzinger in England during the 1950s.
- the method stresses that pregnancy, labor and birth, and the early newborn period
- it includes a program of conscious relaxation and levels of progressive breathing
that encourage a woman to “flow with” rather than struggle against contractions

3. The Dick-Read Method

- is based on an approach proposed by Grantly Dick-Read, an English physician.
- the premise is that fear leads to tension, which leads to pain

4. The Lamaze Philosophy

- a philosophy based on the gating control theory of pain relief, is the one most
often taught in the United States today
- the method is based on the theory that through stimulus-response conditioning,
women can learn to use controlled breathing to reduce pain during labor.
- it was originally termed the psychoprophylactic method, as it focuses on
preventing pain in labor (prophylaxis) by use of the mind (psyche).
- the method was developed in Russia based on Pavlov’s conditioning studies but
was popularized by a French physician, Ferdinand Lamaze. Formal classes are
organized by Lamaze International or the International Childbirth Education
Association
- Throughout the program, six major concepts are stressed:
1) Labor should begin on its own, nit be induced
2) Women should walk, move around, and change positions throughout labor
3) Women should bring a loved one, friend, or doula for continuous support
4) Interventions are not medically necessary should be avoided
5) Women should be allowed to give birth in other positions than on their back
and should follow their body’s urges to push
6) Mother and baby should be kept together after birth, best for mother, baby and
breastfeeding
- 3 main principles taught in prenatal period related to the gating control method of
pain relief
1) Couple understand process of labor or birth can enter labor with decreased
tension
 2) Concentrate on breathing patterns or imagery can block pain sensation
3) Conditioned reflexes, reflexes automatically occur in response to stimulus,
used to displace pain during labor

a. Conscious Relaxation
o learning to relax body parts
o by deliberately relaxing one set of muscles, then another and another until
her body is completely relaxed.
o her support person concentrates on noticing symptoms of tension such as a
wrinkled brow, clenched fists, or a stiffly held arm
o place comforting hand on tense body area or tell to relax

b. The Cleansing Breath

o woman breathes in deeply and then exhales deeply
o limits the possibility of either hyperventilation (blowing off too much
carbon dioxide) or hypoventilation (not exhaling enough carbon dioxide)
o helps ensure an adequate fetal oxygen supply
o if woman become light-headed from hyperventilation, breathe into paper
bag

c. Consciously Controlled Breathing

o set breathing patterns at specific rates, provides distraction as well as
prevents the diaphragm from descending fully and putting pressure on the
expanding uterus.
o Various levels of breathing:
1) Level 1. Slow deep chest breathing of comfortable but full respirations
at a rate of 6 to 12 breaths/min
2) Level2. Lighter and more rapid breathing than level 1
3) Level3. Even more shallow and more rapid breathing
4) Level 4. Another pattern effective for transition contractions is a
“pant-blow” pattern or taking 3 or 4 quick breathes then forceful
exhalation
5) Level 5. Quiet, continuous, very shallow panting at about 60 breaths
per minute.
o During actual labor, her coach can tell the strength of contractions by
resting a hand on her abdomen or observing a uterine contraction monitor.

d. Effleurage
o French for “light abdominal massage,” done with just enough pressure to
avoid tickling
o Serves as a distraction technique and decrease a sensory stimuli
transmission from abdominal wall, helping limit local comfort

e. Focusing or Imagery
o Focusing intently on an object (sometimes called “sensate focus”) is
another method of keeping sensory input from reaching the cortex of the
brain.
o Other women use imagery by imagining they are in a calm place such as
on a beach watching waves rolling in to them or relaxing on a porch swing

f. Second-Stage Breathing
 o Now it is believed that holding the breath for a prolonged time impairs
blood return from the vena cava (a Valsalva maneuver), so this is now
discouraged. Based on this, most classes suggest that women breathe any
way that is natural for them, except holding their breath during this stage
of labor.

5. Preparation for Cesarean Birth

- to ensure a safe birth and what a couple can expect if this happens is covered in
most childbirth classes, although as vaginal birth is encouraged, this may be done
to varying degrees

F. The Birth Setting

 Analgesia or anesthesia for childbirth was unpopular until Queen Victoria
delivered Prince Leopold under chloroform in 1853.
 Chloroform relieved pain, but also complicated birth Women were not only asleep
for one of the most memorable moments of their life, but under anesthesia, they
were no longer able to push effectively during the second stage of labor
 As a result, women were allowed to labor without any pain medication and then
were given anesthesia or analgesia right before the baby was born.

1. Choosing a Birth Attendant and Support Person

o Most births are supervised by an obstetric, a physician specializing in
labor and birth; a family practitioner or a nurse mid-wife
o Many women choose a doula, or a person specially prepared to assist with
birth. Doulas can be helpful as fathers may find it hard to provide doula-
type support during labor when they are so emotionally involved
themselves in the birth.

2. Choosing the Birth Setting

o Women having uncomplicated pregnancies may choose hospitals, birthing
centers, or their homes as settings for birth.

a. Hospital Birth
 whether they are mother friendly based on, through its
practices, if the hospital respects that birth is a normal, natural,
and healthy process and a woman has the opportunity to:
• Experience a healthy and joyous birth experience, regardless
of her age or circumstances
• Give birth as she wishes in an environment in which she feels
nurtured and secure
• Have access to the full range of options for pregnancy, birth,
and nurturing her baby
• Receive accurate and up-to-date information about the
benefits and risks of all procedures, drugs, and tests suggested
for use during pregnancy, birth, and the postpartum period,
with the rights to informed consent and informed refusal
• Receive support for making informed choices about what is
best for her and her baby based on her individual values and
beliefs
 To qualify a mother-friendly hospital, a hospital should not
have routine policies that include practices such as perineal
shaving, admission enemas, withholding food or fluid during
labor, rupturing membranes to hurry labor or the use of
continuous lines or constant fetal monitoring
  If she has preregistered at the hospital, she is admitted to a
birthing room without any separation time from her support
person. Birthing rooms are also called labor-delivery-recovery
rooms (LDRs) or labor-delivery-recovery-postpartum rooms
(LDRPs)
 bed can be used as a labor bed until birth, when it converts into
a birthing bed or a lithotomy position bed
 Birthing chairs (Fig. 14.10) are comfortable reclining chairs
with a slide-away seat that allows a woman to assume a
comfortable position during labor and also furnishes perineal
exposure so a birth attendant can assist with the birth

b. Postpartum care
 Women giving birth in LDRPs remain in the room with their
families for the rest of their hospital stay.
 Both LDRPs and postpartum units serve as “rooming-in” units
in which the infant remains in the mother’s room for most of
the day, whichever is her choice.
 There should be no restrictions on visiting for the primary
support person
 Mother can breastfeed the infant if it is hungry, not according
to any schedule
c. Alternative Birthing centers (ABSs)
 are wellness-oriented childbirth facilities designed to remove
childbirth from the acute care hospital setting while still
providing enough medical resources for emergency care should
a complication of labor or birth arise.
 Such a setting is established within, or at least within an easy
distance of a hospital.
 Nurse- midwives, primary birth attendants

d. Home Birth
 is the usual mode of birth in developing countries
 may be supervised by a physician, but nurse-midwives are the
more likely choice as birth attendants in this setting
 to be candidate for a home birth, a woman:
 Should be in good overall health
 Must be able to adjust changing circumstances
 Must have adequate support people to sustain her
during labor and to assist her for the first few days after
birth
 Be certain women planning home birth know the ff:
 Adequate equipment
 Abrupt change of goal
 Couple can be exhausted because of responsibility
 Prepared independently
 Interference with the “taking-in phase”

3. Children Attending Birth

o Good advice to suggest family attend class designed to prepare children to
witness birth beforehand to keep the event from becoming overwhelming
o Child will remember as exciting, happy experience
o Another way is to expose them to dog or cat giving birth
G. Alternative Methods of Birth
1. Leboyer Method
- Frederick Leboyer was a French obstetrician who postulated that moving from a
warm, fluid-filled intrauterine environment to a noisy, air-filled, brightly lit birth
room creates a major shock for a newborn
- Leboyer method, the birthing room is darkened so there is no sudden contrast in
light; it is kept pleasantly warm, not chilled. Soft music is played, or at least harsh
noises are kept to a minimum. The infant is handled gently; the cord is cut late;
and the infant is placed immediately after birth into a warm-water bath.
- reduce spontaneous respirations and allow a high level of acidosis to occur.
- Late cutting of a cord can lead to excess blood viscosity in a newborn

2. Hydrotherapy and Water Birth

- Reclining or sitting in warm water during labor can be soothing; the feeling of
weightlessness that occurs under water as well as the relaxation from the warm
water both can contribute to reducing discomfort in labor

3. Unassisted Birthing
- Refers to women giving birth without healthcare provider supervision
- A woman learns pregnancy care from reading books or articles found on the
Internet and then arranges to have her childbirth at home, perhaps accompanied
by her family or friends but without healthcare supervision
- Believe birth is such a natural process that no medical supervision is necessary
- No health insurance and so can’t afford
- Potentially dangerous