Preparation for Parenthood

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Preparation for Parenthood

• Peggy Korman MA CNM
• Assistant Professor

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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!

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The Power of Birth
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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
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Preparation for Birth
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Possibilities

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

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Penny Armstrong

• gt1200 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

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Primip Birth

• Challenging for several reasons
• Women dont have any personal experience of
  birth. Likely frightened.
• Muscles are tight and baby has to travel against
  resistance
• Hormonal systems are inexperienced at birth and
  may be slow to blend
• All combine to create the major challenge the
  long labor

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Goal

• Preserve the womans 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

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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
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Michael Odent

• French physician-surgeon
• Pithivers
• Interested in avoiding unnecessary sx with
  medical mgmt techniques
• Odents gifts boundless curiosity, excellent
  creative mind, superb capacity for observation,
  knowledge of medicine and physiology, an
  appreciation of women enthusiasm for life..

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Reform at Pithivers
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Odents 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

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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

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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.

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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

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The 3 Ps

• 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.

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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

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CPM

• c/s hazards for the mother
• Maternal mortality rates are 5-10 times
  higher
• c/s disadvantages for the baby
• Higher mortalityresp cx

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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.
• .

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1880s

• Stethoscope, laryngoscope, opthalmoscope
• Organisms responsible for TB, cholera, typhoid
  and diptheria were isolated
• Later we had x-ray, spirometer, ECG

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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

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1930s

• 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

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1914 - Enter Scopolamine

• Twilight Sleep
• An amnesic, used in combination with morphine
  seemed to liberate a womans 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

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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

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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.

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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.

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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

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• Meant to show the absence of a certain protein in
  the mothers 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

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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

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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

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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 womans 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?

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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

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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

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Our Bodies Our Selves

• 1969 Boston group of women
• Covers large topics of womens health
• Scope, intelligence, disarming style
• Educated womens minds about their bodies, helped
  them take back responsibility for making
  decisions about their bodies.

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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.

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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

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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
• Lamazes book Painless Childbirth was not
  published in the US until 1970

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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.

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Thank-You Dr. Lamaze

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

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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, todays holists

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Robert A. Bradley, MD

• Recommended responsive participatory birth
• Techniques involve husbands

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Two school of thought on childbirth Preparation
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A Vision of a Better Way to Be Born
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How to meet the needs of the laboring woman and
her partner
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Normalcy treat birth as a natural, healthy
process
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Empowerment provide the birthing woman and her
family with supportive, sensative and respectful
care
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Autonomy enable women to make decisions based on
accurate information and provide access to the
full range of options for care
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Do no harm provide safe care, avoid routine use
of tests, procedures, drugs and restrictions,
respect the birth plan
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Options

• Pharmacological pain management
• Anesthesia Epidural
• Non-pharmacological

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Needs

• Basic comfort needs nourishment, rest, hygiene,
  elimination
• Information/Education needs to make informed
  choices
• Love and support for family caregivers
• mother the mother

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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.

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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

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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.

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The U.S.

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

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Physiological basis for pain

• Purpose of painalerts 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

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Disadvantages of invasive methods of pain control

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

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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

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Childbirth Education

• Knowledge replaces fear
• Fearanxiety.tensionheightens perception of
  painful stimuli
• Muscular tensiondecreases oxygenincreases pain.
  Try massage relaxation techniques
• Behavioral modification. Breathe in purposeful
  fashion, focal point, massage

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Water tubs
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Assessment of Needs

• take a listening breath before you enter the
  clients 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 were
  there
• RBC

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Body language

• Increasing your peripheral awareness when you
  enter the clients 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

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Emotional Climate?
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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

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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.

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Alternative Childbirth

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

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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.

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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