preparation for parenthood peggy korman ma cnm assistant professor
TRANSCRIPT
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