Preparation for Parenthood

Peggy Korman MA CNM

Assistant 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 resistance
3. Hormonal systems are inexperienced at
birth and may be slow to blend
All 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.
 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
higher
c/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/2009/0
9/04/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.
 Issues
Insurance
Care for all
Monitor maternity care practices
Improve 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