preparation for parenthood peggy korman ma cnm assistant professor

Preparation for Parenthood

Peggy Korman MA CNMAssistant Professor

Handouts

• Medication to Know Before Going to Maternity Clinical

• Terminology and Abbreviations• Practice Medication Quiz• break into small groups lead by someone who has been to clinical and do

your best!

The Power of Birth

“There comes a turning point in intense physical struggle where one abandons oneself to a profligate usage of strength and bodily resource, ignoring the costs until the struggle is over. Women find this point in childbirth, men in battle.Past that certain point, you lose all fear of pain and injury. Life becomes very simple at that point, you will do what you are trying to do, or die in the attempt, and it does not really matter much which.” -Diana Gabaldon The Outlander

Preparation for Birth

Possibilities

• Women can give birth 85-90% of the time without complication and without unreasonable bravery

Penny Armstrong

• >1200 Births• Meds: Pitocin, methergine, valium,

epinephrine, IBU/Tylenol/Percocet, Abx,• Amnihooks, syringes, IV fluids, ring forcep,

clamps, scissors suture kit, needles, suction, O2, larygoscope, ET tubes, ambu

Primip Birth

Challenging for several reasons:1. Women don’t have any personal experience

of birth. Likely frightened.2. Muscles are tight and baby has to travel

against resistance3. Hormonal systems are inexperienced at

birth and may be slow to blendAll combine to create the major challenge: the

long labor

Goal• Preserve the woman’s energy so that she will have enough

strength at the end to push the baby out

Strategies:• Labor in any position the woman feels

comfortable• Do few vaginal checks• Encourage the woman to walk the halls, inhabit

the shower• Speak kindly• Eat

The Friedman Curve

• Designed to describe the average length of labor, many practitioners and hospital review committees use it the other way around – to prescribe how long a labor might be.

Friedman's

Michael Odent

• French physician-surgeon• Pithivers• Interested in avoiding unnecessary sx with

medical mgmt techniques• Odent’s gifts: boundless curiosity,

excellent creative mind, superb capacity for observation, knowledge of medicine and physiology, an appreciation of women & enthusiasm for life..

Reform at Pithivers

Odent’s conclusions

• Birth goes best if it takes place in a small, dimmed, quiet, well-protected room

• Birth goes best if it is not intruded upon by strange people and strange events

• Birth goes best when a woman feels safe enough & free enough to abandon herself to the process

Physiological Language

• A “fetus ejection reflex”• Spontaneous natural process• At best managed not by our thinking minds,

the neocortex, but by the body brain, the hypothalmus, which directs the interplay of hormones

Hypothalmus

• Makes and stores oxytocin, which is released (the trigger mechanism is not understood) by the pituitary gland.

• Oxytocin causes uterine contractions, which find a rhythm and increase in strength.

Endorphins

• With the pain of the UC come endorphins, which both diminish pain and make us feel good.

• They also flow when breast milk does• The allies of the laboring woman• Fear and stress can inhibit them

The 3 P’s

• The body is malleable and birth is dynamic.• Contractions (powers) like hands kneading

close on the baby (passenger), whose moving mass then pressures the pelvis (passage) causing it to spread; presses on the cervix which gives way.

FNS• Good outcomes from caregivers who defer to

birth.• Since 1955, not one maternal death• Since 1971 their perinatal mortality rate has

averaged 6 per 1,000 or less than half the national average

CPM

c/s hazards for the mother: Maternal mortality rates are 5-10 times

higherc/s disadvantages for the baby: Higher mortality…resp cx

Our History

• Turn of the century one woman died for every 154 births

• If a woman had 5 babies, which was common, her chance of surviving her reproductive life was one in 30.

.

1880’s

• Stethoscope, laryngoscope, opthalmoscope• Organisms responsible for TB, cholera, typhoid

and diptheria were isolated• Later we had x-ray, spirometer, ECG

Dr. Joseph DeLee

• To protect women he recommended reducing birth to predictable patterns by using outlet forceps and episiotomy routinely and prophylactically in normal deliveries

• Women still died in discouraging numbers

1930’s

• NY Academy of Medicine, the Philadelphia County Medical Society and the White House Conference on Child Health and Protection and others got together and went on record: blamed docs & hospitals

• Established regulations to control overuse of drugs, establish minimum delivery standards & got a hold on asepsis

1914 - Enter Scopolamine

• “Twilight Sleep”• An amnesic, used in combination with morphine

seemed to liberate a woman’s animal self• Tauted as best of both worlds. Return to more

physiological birth without return to pain• Effectively sealed off a generation of women from

the experience of power and capability at birth• Replaced with drugs like demerol, epidurals, spinals

Admission

• Seconal 100mg• Demerol 75mg• Phenergan 25mg• 1/150th Scopolamine• Followed by 1/100th of Scop in ½ hour• And followed in 1/2 hour with 1/100th

Williams Obstetrics

“ From the first prenatal visit a conscious effort should be made on the part of all persons involved in the care of the mother and her unborn child to make the point that L & D are normal physiologic processes.”

More Williams

• “Haverkamp and co workers (1976-1979) have demonstrated that an equally satisfactory outcome for the fetus can be achieved without continuous EFM, continuous intrauterine pressure recording and fetal scale measurements, if the mother and fetus are closely attended by appropriately trained labor room personnel.”

Midwifery vs Obstetrical Practice

• Some disagreements subtle, difficult and worthy of debate

• How a practitioner presents the risk factors present in test is a good example

• Meant to show the absence of a certain protein in the mother’s blood. If the protein shows, then the baby could have a spinal defect.

• “Time for your test” vs presentation of a complete picture, one that includes limitations of the tests and the ethical and emotional issues they raise

The Details

• 5/100 women will be told the test reads positive• Only a first screening and those 5 must undergo

further tests• Amniocentesis 3/1000 chance of causing a

miscarriage• Ultrasound-long term risks unknown• Only then is it possible to determine which one or

two are carrying a potentially disabled child

The Details

• 5/100 women will be told the test reads positive• Only a first screening and those 5 must undergo

further tests• Amniocentesis 3/1000 chance of causing a

miscarriage• Ultrasound-long term risks unknown• Only then is it possible to determine which one or

two are carrying a potentially disabled child

Holistic Inquiry

• Human is an organism in relationship to the environment

• Job of the holist to help women clarify her thinking about her inner state

• What is a woman’s relationship to her body? Does she trust it? Does she listen to it? What is her relationship with her partner? What are their attitudes toward birth?

What works is mind and body together

Those “qualified labor room personnel” find that what a woman thinks and feels and how she relates to her environment dramatically affect the course of birth

Culture and Back to the Amish

• In the Amish culture, women avoided medicalization craze and continued to believe in themselves as birthers.

• The legacy of birth was never lost• Young Amish women expect to give birth• For the Amish the rhythms of nature are not

exceptional, but the daily stuff of their lives

Our Bodies Our Selves

• 1969 Boston group of women• Covers large topics of women’s health• Scope, intelligence, disarming style• Educated women’s minds about their bodies,

helped them take back responsibility for making decisions about their bodies.

Grantly Dick-Read

• Childbirth Without Fear• Argued that pain was caused by fear• Proclaimed pain was unnecessary• Educate women about birth, undo

misteachings, relinquish her body to natural laboring state

• Argued that pain was influenced by outward circumstances and other people.

G. D-R

• Pain increased when a person was tired, weary of mind, and depressed.

• Caregiver needs to be patient, quiet, understanding, honest, gentle, peaceful, confident, interested, cheerful, attentive and so communicate to the woman that all was well, then she would be “undisturbed” and “confident”

Lamaze

• Frenchman, admired D-R but thought his neurophysiology was flawed

• Recommended women employ higher intelligence to avoid pain

• Birthplace should grant privacy and low lights• Lamaze’s book Painless Childbirth was not

published in the US until 1970

Lamaze Theory

• Recommended that women employ their higher intelligence to avoid pain

• Learn to barricade some of the nerve corridors by siderailing the painful messages-thought women could avoid not having pain, but perceiving it.

Thank-You Dr. Lamaze

• 1959 Marjorie Karmel • ASPO • Awake and Aware • founded with Elizabeth Bing

Shiela Kitzinger

• Theorist who suggested that Lamaze erred in emphasizing control

• Birth is a psychosexual experience and went better if a woman let herself go with it

• Called Lamaze repressive• More in line with Odent, D-R, today’s holists

Robert A. Bradley, MD

• Recommended responsive participatory birth• Techniques involve husbands

Two school of thought on childbirth Preparation

A Vision of a Better Way to Be Born

How to meet the needs of the laboring woman and her partner

Normalcy: treat birth as a natural, healthy process

Empowerment: provide the birthing woman and her family with supportive, sensative and respectful care

Autonomy: enable women to make decisions based on accurate information and provide access to the full range of options for care

Do no harm: provide safe care, avoid routine use of tests, procedures, drugs and restrictions, respect the birth plan

Options

• Pharmacological pain management

• Anesthesia: Epidural• Non-pharmacological

Needs

• Basic comfort needs: nourishment, rest, hygiene, elimination

• Information/Education needs: to make informed choices

• Love and support for family & caregivers: “mother the mother”

How to Help

• Nurse needs to respond to the progress in labor by suggesting position changes, body massage, emesis basin handy, towels, ice, moist hot/cold, hydration

• Informing the woman about expected physical sensations so as not to be caught unaware.

• Ongoing verbal support and reassurance. Give direction and encouragement.

The Olympics of Birthing

• Asking your body to perform under stress for a number of hours

• Needs energy, massage to match the phase and stage

Perception

• How much pain is expected or tolerable is strongly influenced by culture

• Women in the Netherlands and in Japan do not view labor pain as negative or unacceptable, and there is no epidemic of epidurals for normal labor in either country.

The U.S.

• The way women perceive labor pain is strongly influenced by the way her care giver perceives pain

Physiological basis for pain

• Purpose of pain=alerts us that something is not in harmony with our body.

• Typically evokes a response• Labor pain is different, it is purposeful, not

pathologic, alerts us a baby is to be born Joyful• Pain is an essential component of normal labor, it is

necessary for the release of hormones that control the progress of labor, requires no treatment

Disadvantages of invasive methods of pain control

• When an epidural block removes all feeling in a woman’s lower body, the necessary hormones are not released and labor does not progress normally, leading to more intervention.

Alternatives

• Many far safer, less invasive methods of pain control that have been scientifically proven to be effective

• Presence of family is one• The level interest and commitment of fathers

to the birth of their children is high-professional sports star

Childbirth Education

• Knowledge replaces fear• Fear…anxiety….tension…heightens perception

of painful stimuli• Muscular tension…decreases oxygen…

increases pain. Try massage & relaxation techniques

• Behavioral modification. Breathe in purposeful fashion, focal point, massage

Water tubs

Assessment of Needs

• “take a listening breath” before you enter the client’s room

• Nurses do so much multi-tasking that we may be thinking about the next 3 things we need to do and not necessarily about the immediate task

• “Taking a breath means remembering why we’re there”

• RBC

Body language

• Increasing your peripheral awareness when you enter the client’s room will help you understand how your own body language is perceived by the client

• “Read your patient” gauge the emotional climate of the room and audience

Emotional Climate?

A Vision of A Better Way to Be Born

• Humanized birth means putting the woman in the center and in control so that she, not the doctors or anyone else, makes all the decisions about what happens

• Humanized birth means understanding that the focus of maternity services is community-based (out of hospital) primary care, not hospitalized tertiary care

• Humanized birth means midwives, nurses, doctors all working together in harmony as equals

• Humanized birth means maternity services that are based on good scientific evidence, including evidence-based use of technology and drugs

ABCs

• 132 Freestanding birth centers in America today

• In them birth is safer & healthier than in any other setting.

• In them a woman and those who are with her can experience that eruption of power that accompanies the arrival of a new life.

• In them a family can nourish the bonds that will sustain them.

Alternative Childbirth

• http://www.kbdi.org/news/index.php/2009/09/04/video-a-lower-cost-alternative-to-traditional-hospital-childbirth/

A National Health Care System• It is clear that many of our serious maternity care problems

would be immediately & profoundly improved by establishing a NH care system.

• In the US the MM rate of hispanic women is twice as high as that of Caucasian women

• Among AA women the MM is 4x that of C women• Each year AA babies die at twice the rate of C babies.• Not a matter of race, it is a reflection of our

inadequate care for women and families living in poverty.

IssuesInsuranceCare for allMonitor maternity care practicesImprove quality control Save money: a decade ago Taiwan shifted from

a US style health care system to a Canadian style single payer health care system and in 6 years the % of Taiwanese people covered by health insurance rose from 60% to 97%. Expanded coverage cost no more than previous coverage because of savings in bureaucratic costs