OBJECTIVES At the completion of Part 3 the learner will:
Women of childbearing age today fit into 2 categories: “Generation X” (born between 1961-1980) and “Millennials” (born between 1981-2000). Tech-savvy, multi-task, want to have fun while learning, think visually and like experiential learning. Expect good communication.
Prep you do before 1st class will largely determine the success of your series. Should receive text, email or written confirmation of their registration. Need time, date, location of classes, clear directions and map, instructions on what to wear/bring. Might be posted on FB page. Some give info form to be filled out before first class. Sample info forms in Appendix
Contact each couple before class to introduce self and to determine special concerns/needs. Knowing about labor partners may keep you sensitive to language you use. Ask gay, lesbian, bi-sexual, transgender how they would prefer that you refer to them.
Physical needs met before social/higher level needs. Provide snacks for first class. Food enhances social atmosphere and may meet needs of students who missed meal to get there on time. Snacks should be healthy. Can do sign up sheet and ask couples to take turns. Should have access to water.
Make classroom comfortable. Ask them to bring pillows. Ask them if temp, lighting, noise etc is okay.
Most comfortable teaching is often your home, but when looking for a classroom: carpeting/mats for practicing comfort measures on the floor, windows and good lighting with dimmer for relaxation time, pictures on walls – multicultural pics of babies, pics of breastfeeding moms/babies, nature pics, photos that can relate to birth (Harriette Hartigan), variety of seating options – comfortable chairs, beanbags, birth balls, back supports for sitting on floor. Arrange seating in circle or U-shape, so students can see each other.
People seem to be busier than ever. Engage them in the first class. Consider a free class early in pregnancy to get them interested, remaining classes can start in mid 2nd trimester. Encourage early start dates to begin building confidence by providing information sooner. Word of mouth spreads benefits of a good program.
More class bonding in series with same group. If comfort measures practiced every class, students will gain more confidence.
Prefer 5-8 weekly classes, but weekend “fast-track” classes are a necessity for some people. Not as much bonding takes place and not as much info retained. Too often these are the ones that have no time to read. If 2 full day classes are held a week apart instead of the same weekend, more time for assimilation of info and practice between sessions is possible. Make these classes highly interactive.
New formats for childbirth classes: Thinking “Outside the Box”
“Flipped classroom” is gaining popularity in some colleges. Lectures heard online and classroom is an interactive experience used for skill development and projects with peers. Could make your own YouTube video for them to watch! Use class time for hands-on skills practice, discussion on the assigned topics and/or their concerns and fears. Small groups can work together on learning tasks, games, and review of their understanding. Drawback would be if students didn’t to independent learning prior to class. Format best for self-motivated learners. Often, 1 person of a couple fits this description and the other doesn’t.
Preconception class helps parents to be learn what they can do to prepare for a healthy pregnancy. Opportunity to learn about choice of providers – midwife, family practice doctor, or OB – as well as choices of birth locations available in their area.
Early pregnancy classes focus on nutrition, exercise and dealing with stress as well as of pregnancy for pregnant woman, her partner and the baby. Communicate with healthcare provider regarding prenatal testing, as well as options for labor and birth.
Prenatal yoga, belly-dancing, movement, and exercise classes can be offered throughout pregnancy to give pregnant women the opportunity for healthy exercise as well as support from other pregnant women and the instructor.
In mid pregnancy, expectant parents are often eager to learn more about breastfeeding, baby equipment and baby care.
Later in pregnancy, they may want to learn about their options for pain relief during labor, and to practice comfort measures.
After the birth, mothers’ support groups, infant massage, breastfeeding and parenting classes, all ease the transition to parenthood.
Single-topic classes on a wide variety of subjects, from nutrition to birth options to baby-wearing are being offered. Participants either pay by the class or as a package plan with unlimited classes. Package might include online information and support form the educator. Online forums for expectant parents having similar due dates may be combined with in-person classes.
Posting some info on the web can be helpful. However, its rare for a woman and her partner to both sit in front of a computer at the same time for a full childbirth class. Use web to hook students and to entice them to attend one or more in person classes, which provide opportunity for birth partners to meet one another and to hear that most pregnant women are experiencing the same emotions.
ICEA Teaching Paper – Curriculum Development and Content for the Childbirth Educator
Curriculum Development – ICEA endorses a learner-centered curriculum development model. Ongoing, sequential and educational process. Steps as follows:
Content of Childbirth Classes – encompasses entire childbearing year and includes prep for pregnancy, labor, birth, postpartum and early parenting, including breastfeeding, sexuality, changing relationships, and family planning. Should include pre-conception, early pregnancy, mid-pregnancy, later pregnancy and parenting classes.
Class content may include:
ICEA also recommends education in following possible subject areas as appropriate:
ICEA does not promote 1 specific method of childbirth prep – there are many approaches that can help a woman cope w labor. Effectiveness based on:
Class format must provide adequate time for demonstration, return demonstration and practice/review of:
Advocacy of following concepts should be evident:
Interactive Lecture – lecture alone does not allow for personal interaction of exploring participants feelings and attitudes. Involve students in discussion, Q&A sessions, small group analysis etc between segments.
Storytelling – unfortunately students will share far too many frightening or frustrating stories. Ask them “what could you have done differently to have a more positive outcome?” sharing solutions to potential problems or telling encouraging birth stories can increase women’s confidence in their own ability to give birth.
Adapt or create a story to make a point.
Bonding with your class – when you introduce yourself to the class, share your passion with them. Let them know of the importance of birth memories and how you want to help them have the best possible experience to remember. The first impression of a first class is very important to the success of your course. Rehearse your “opening talk”, involving them in your agenda, and sharing your knowledge and skills with them in many and varied ways.
Books on interactive teaching: Using brain science to make training stick; design for how people learn; the accelerated learning handbook; from telling to teaching: a dialogue approach to adult learning; creative training techniques handbook; the art of teaching adults
Talking the Talk
For quiet, organized intellectuals, a speaker should be: organized, timely, knowledgeable, trustworthy, thoughtful, intellectual, logical. They prefer discussion with small groups of intellectuals, lecture, research-based studies, slides, handouts, factual videos, homework, research
For relaxed, easygoing mediators, a speaker should be empathetic, nurturing, responsible, happy, intuitive, trustworthy, non-judgmental. They prefer open discussion, games if everyone wins, demo and return demo, videos with positive outcomes
For fun-loving, outgoing talkers, a speaker should be: emotional, creative, intuitive, imaginative, humorous, entertaining, energetic. They prefer discussion of feelings, role-play, return demonstration, hands-on, videos of people and feelings, games
For outgoing, hard-working leaders, a speaker should be authoritative, in control, competent, efficient, futuristic, open minded, visionary. They prefer discussions, if they can lead, lecture, debates, analysis, meeting goals and objectives.
Using PowerPoint Effectively – Need more than bullet points, charts and graphs to be interactive. Images can be used to show a position or exercise, while the instructor or class member demonstrates the proper movement and all students return the demonstration. Slide is visible to all as student experiments. An anatomical drawing appears larger on a screen than on a poster. Wipe in feature allow students to answer questions about an unlabeled drawing, then answers are reinforced when they appear through animation feature. Video clips or music can be embedded on a slide so that you don’t have to involve another piece of equipment. Music can be timed and used for a stretch break or a relaxation sequence. A video can introduce a subject that will be followed by a discussion or learning task. Use slides as a tool to help you keep track, but don’t let them become your entire presentation that your audience could simply read on their own.
For a more engaging presentation, use mostly graphics on your slides. If you use words, use no more than 5-7 words per line in 5-7 lines. Use words or phrases, not sentences. Add graphics to text to make slides more visually appealing. Use bullets, not numbers. Wipe in one bullet at a time to allow for discussion without your audience’s being distracted by reading ahead. Animation may be used sparingly to gain attention and to emphasize a point. Always have a hard copy of your teaching notes with you in case you must give your presentation without electricity or computer!
4 Temperaments (“Please Understand Me” book:)
Important for students to know and educator to understand how to speak so all temperaments will listen. Meyers Briggs…
“ADULTS” Agenda, Discussion, Understand, Learning preferences, Time, Setting
Greet each student as they come in. handshake or hand or placing biodot on student’s hand provides brief physical contact. Introduce self and share importance of birth memories ~ tell them you want to help them have the best possible experience to remember. First impression of a class is very important to success of course. Encourage them to share questions, answers and concerns.
Class roster. Ask permission before distribute names, email addresses or phone numbers and personal information such as due dates. Form pg VIII-13. Some may locate others via FB. Can follow The Family Way on FB.
Begin each class with opener or icebreaker. Section II gives examples.
Stretch break every hour. Don’t cut it short if short on time – valuable time when students talk to each other. Will enhance group process.
Emphasis today is interactive learning. The more involved students are in their own learning, the more they will remember. 60-70% should be student-driven. Adults can listen for 90 min, but retain only 20 min of info. Repetition aids retention. Present info in lists of 3 for better recall.
Method of presentation should change every 20 min in a 90 min session. Every 20 min add interest with a video clip, a different visual aid, a story, a group activity, skills practice etc. For every 8 min of “teacher talk”, student needs 2 min to process info, so involve students in some way every 8 min. 90/20/8 Rule.
Short YouTube clips ex. 24 Hours in a Newborn’s Life ~ in 3 min the reality of caring for a new baby. Journal of Perinatal Education has article in 2015 about using video clips in Lamaze classes.
Repeat key concepts orally and visually; ask them how they might apply the concepts or skills you presented to them. Involve students in reviewing info for each other. Repeat key concepts after minutes, hours, days, weeks.
Rule of 3s.
Course evaluation forms pgs V-3 to V-6.
Certificate of completion. Can have them pick from pile and give to couple. That couple then becomes the one they are to email or telephone when baby is born. Birth stories then spread throughout class and follow up reunions often result.
ICEA Statement- Curriculum Development and Content for the Childbirth Educator – see above
For quiet, organized intellectuals, educator should: organize self and class; provide an agenda; give facts and theories, use logic; have written resources available; show practical application; allow class time to practice skills. They like to think, will read and study, like to be prepared, are organized people. They enjoy good lectures, may not participate in class discussions, like quiet time.
For relaxed, easygoing mediators, educator should: balance pros/cons, risks/benefits, listen to and acknowledge them, if they speak, tell positive stories of pregnancy and birth, come to consensus, make group decisions, play cooperative games and work puzzles, practice skills in class. They do not like conflict, may not often speak up; need time to reflect, are nurturing people who give and desire respect. They do not often show strong emotion, have difficulty making decisions, would rather listen than talk.
For fun-loving, outgoing talkers, educator should: have fun, relate subject to real life experience, change activities often, be spontaneous, do things – role play, games, puzzles, contests, rehearsals, touch things – pelvis, baby doll, partner, show things they enjoy – videos, demonstrations, instructor role plays, share experiences. They prefer to play as they learn, are bored in a traditional classroom, are emotional people. They will tune out of long lectures, may become the “clown” if bored, find verbal and visual work far more appealing than paper and pencil.
For outgoing, hard-working leaders, educator should: state class goals and objectives, hold debates, contests, discussions, provide books, scientific journals, references. They will set goals and plan ahead, ask why, like problem solving, will lead small groups and report back. They may try to take over class, need to understand, explain, predict, experiment, control.
Icebreakers – beginning a class with an icebreaker helps students to make the transition from the activities of the day to the childbirth class. Early in the series, it helps people get to know one another and give people who arrive early something to do. Will reinforce you start on time. In later classes, they can be used to present new information, review material, stimulate discussion or lighten up ground with humor. Can ask “how did your week go?” or involve games with props.
Getting to Know You – can ask people to introduce selves before or after activity. Most people comfortable sharing names, due dates, location of birth, name of doctor/midwife. Can ask student to fill out “information sheet for childbirth educator” prior to class. A “people search” encourages students to discover things they have in common with others. Can ask people “if you could be anywhere else right now, where would it be?” “What is the thing that surprised you most about this pregnancy?” “Tell us the most difficult part, then the best part of being pregnant” “What do you do to relieve stress in your life?
Just for Fun – The Alphabet Game (pg II-10) – quick, humorous icebreaker. Come up with words for each letter about pregnancy. split pregnant woman and partners and have them come up with comfort measures; sometimes men finish first, reassuring woman.
Cartoon Captions– suggest captions for each cartoon
Openers That Teach – for class of 6 couples or less, can create 2 sets of cards. 6 healthy birth practices matching cards: Let labor begin on its own; walk, move around, and change positions throughout labor; bring a loved one, friend, or doula for continuous support; avoid interventions that are not medically necessary; avoid giving birth on your back, and follow your body’s urges to push; keep baby and mother together – it’s best for the mother, baby and breastfeeding. Each student finds the “match” to his or her card. Could add sets of cards such as “back to sleep
Terminology Quiz or Matching Cards – when they arrive or give index cards and have them find their match
20 Questions – similar to “people search” – includes info in earlier sessions
Nutrition Crossword Puzzle – pg 101 in Prepared Childbirth – The Family Way
“Ball” Game – midway through session – have people wear name tags and throw to a person. 1) educator begins toss and students continue until everyone receives 2) faster 3) after first ball is thrown, toss in a second, then a 3rd, then a 4th. Compare game to labor – challenges (extra balls) for transition. Mention nobody quit when it got chaotic – everyone just kept going. If someone drops, you just pick up and keep going.
Topics To Contemplate: Feeling Wheel (pg II-13) – have them fill out and find someone with similar feelings; midway through series. Pain Medications Preference Scale (pg 110 in The Family Way)- couples share with one another can also have people line up at invisible line next to their number and have them share why they picked that number. Show and Tell – bring a focal point or comfort aid to class. Birth Stories- ask to discuss with a mother, sister or friend during the week; if it was not a happy one, ask them what they could’ve done differently to make it more pleasant. Share positive stories. Pain Management Pie (pg II-14) – discuss with partner. Top 10 List (pg II-15) – have each one fill on out and compare. Breastfeeding Grab Bag: ex clock (saves time), thermometer (perfect temp), diaper (smell not as bad), play money (saves $), paper diploma (higher IQ). See pg IV-141 for list. Postpartum Grab Bag- include as man positive as negative – relaxed fit clothes, pic of smiling baby, fast food container, sexy nightgown.
Learning tasks instead of traditional lecture – see Section IV
Teaching Strategies pg 33
Visuals, props and music
Make sure visual aids enhance and not replace. Models, video clips and toys. Don’t read slides. Keep lights on. VACCINE. Visible – slides high on screen. ACCURATE – verify stats. CLEAR – large, easy to read letters. CONCISE – short and simple. INTERESTING AND INFORMATIVE – color, symbols, pictures, graphs, charts. NEAT – visuals and handouts legible and clean. EFFECTIVE – desired image to emphasize point and increase retention.
Tips for flip charts – write on every other page to prevent marker from bleeding through. Leave a blank page between subjects to serve as topic transition. Use tabs or paper clips on side of pages for ease in flipping to topics. Don’t talk and write at same time unless very good at it. Trace lines or images lightly in pencil, then draw over them with marker. Write notes of points to remember lightly on sides of pages. Always have good markets with you. 1-2 inch letters. Colored stickers (dots in various sizes for bullets). Errors may be corrected by cutting out and pasting a correct version on top.
PowerPoint tips – see above
Anatomy of Pregnancy
Community Care: The Family and Culture
Patient Protection and Affordable Care Act (ACA) signed 2010 make insurance affordable. Among nations most pressing challenges are reducing rate of preterm births and reducing the infant death rate in 46 other countries (Healthy People 2010/2020). Visit state center for health statistics (SCHS website) – live births, physician vs midwife, out of wedlock births, cesarean, low birth weight, maternal smoking and fetal/infant mortality..
Important for nurses to include extended family. Census: 24% of children live only with moms, 4% with dads; 4% with neither. Single parent family is vulnerable economically and socially and can affect health status, school achievement, and high risk behaviors (some families become more stable with absence of drugs, alcohol, family violence).
Same sex households: 594,000 in US raising 115,000 children. Almost 2 millions children raised by LGBT parents.
Ecomap describes social relationships and depicts available support.
Mexican/Arab families typically view birthing as a female affair. Hispanic: Unsatisfied food cravings thought to cause a birthmark; pica observed in eating of ashes/dirt; chamomile tea thought to ensure effective labor, no bathing for 14 days after, 40 day restriction on sex. African American: acceptance of pregnancy depends on economic status, sassafras tea thought to have healing power postpartum. Asian: ginseng root as strength tonic, inactivity/sleeping late may cause difficult birth. Father does not actively participate in labor. Postpartum – protect self from yin (cold forces) for 30 days . Shower/bathing prohibited. European: bonding with “sacred hour after birth”. Native American: herbal teas encouraged, birth may be attended by whole family, birth may occur in squatting position. Herbal teas to stop bleeding.
Primary prevention involves promoting healthy lifestyles through immunizations, encouraging exercise and healthy nutrition. Secondary prevention involves targeting populations at risk for certain diseases. Tertiary preventions focuses on rehabilitation of an individual to health as optimal as is possible in the presence of disease/injury. During pregnancy, primary and secondary preventions are most relevant. Prepared childbirth classes, mass media efforts by March of Dime, Public Health Campaign “Back to Sleep” and AWHONNs 40 reasons to go full 40. WIC offers a variety of healthy education and written information to mothers.
Assessing community of those who developed preterm labor.
Accessibility of care – some live in rural/remote areas. Growing trend in US to have walk in care at grocery stores. CDC and National Health survey describe national health trends. US census by zip helps identify subpopulations or aggregates whose needs may differ from those of larger community. Data reliability and validity are difficult to verify. As you observe community, take note of: physical environment, people in area, stores/services available, social, religious, health services, transportation, education, government, safety, own observations.
Vulnerable populations – minorities have preventable disease compared with non minority. Services are inefficiently and unevenly across populations. Differences in access to care, social determinants, provider biases, poor provider-client communication and poor health literacy. Urgent attention needs to be directed towards diabetes care, maternal and child health care, disparities in cancer care and quality of care.
Nurses – camp volunteers assisting migrant worker camps. Important role in advocating for funding to support health services for homeless and improve access to preventative care for homeless populations.
Specialized maternity home care nursing services began in 1980s. telephonic nursing – internet and Skype to communicate. Newborns in distress in rural hospitals. Telehealth and telemedicine make it possible for clients in home to be interviewed and assessed by a specialist located hundred of miles away.
Home care perinatal services may be supported by hospitals but some innovative programs must be sponsored by an agency with long term funding. There are less expensive than a days hospitalization. 60-90 min visit requires 2.5-3 hours of nursing time including travel and documentation. Limited availability of nurses with expertise in maternity care and concerns about the nurses physical safely in the community. Alternative is contacting via telephone.
High-risk antepartum care can be provided by home care agencies – ex women with hyperemesis gravidarum, cardiac disease, substance abuse, and diabetes.
Client Selection and Referral – health status of mother – is condition serious enough and is stable enough for intermittent observation. Availability of professionals. Family resources. Cost effectiveness.
Nursing Care of the Family During Pregnancy
Pregnancy counted in lunar months, which last 28 days or 4 weeks. Normal pregnancy lasts 10 lunar months, or 40 weeks or 280 days. Trimesters 1: weeks 1-13; 2: 14-26; 3: 27-40. Term at 37 weeks.
Diagnosis of Pregnancy – Presumptive indicators of pregnancy include subjective symptoms (amenorrhea, nausea and vomiting (morning sickness), breast tenderness, urinary frequency and fatigue. Quickening – mother’s first fetal movement between weeks 16 and 20 and objective signs (elevated BBT, breast and abdominal enlargement and changes in uterus and vagina. Others striae gravidarum, deeper pigmentation of areola, melasma (mask of pregnancy), and linea nigra). Probably indicators – physical changes in uterus. Objective signs – uterine enlargement, Braxton Hicks contractions, placental soufflé (sound of blood passing through placenta), ballottement (examiner feels fetus float during vaginal examination), and positive pregnancy test. Positive indicators of pregnancy include presence of fetal heartbeat distinct from mother, fetal movement felt by someone other than mother and ultrasound.
EDB (Estimated date of birth) – Naegele’s rule – accurate recall of last menstrual period. Assumes 28 days cycle and fertilization on 14th day. Subtract 3 months and add a week. Only 5% give birth; most women 7 days before to 7 days after.
Adaptation to Pregnancy – Much or research on family dynamics in U.S has been done with Caucasian middle class nuclear family.
Maternal Adaptation – Early in pregnancy, woman may spend much time sleeping to increased fatigue. Many women are upset initially when they discover they are pregnant, especially if unintended. Non-acceptance of pregnancy does not equate with rejection of child, because a woman can dislike being pregnant but feel love for the child to be born. Sexual desire usually decreases, especially if experiencing breast tenderness, nausea or fatigue. Most important person to pregnant woman is usually father of her child; woman have 2 needs: to feel loved/valued and having child accepted by partner. Phase 1: “I Am Pregnant” – child as viewed as part of self
With perception of fetal movement in 2nd trimester, woman turns attention inward to her pregnancy and relationship with mother and other women who are pregnant. Increased pelvic congestion increases desire for sexual release. Phase 2 “I am going to have a baby” – fetus as distinct from herself, usually accomplished by 5th month. Ultrasound and quickening confirm reality of fetus. Women becomes more introspective. If other children in family, they can become more demanding in efforts to redirect mother’s attention to themselves.
Third trimester – breathing is difficult and fetal movements become vigorous enough to disturb sleep. Backaches, frequency/urgency of urination, constipation and varicose veins can become troublesome. Physical bulkiness diminishes interest for sex. Awkwardness of body interfere with ability to care for other children. Phase 3 “I am going to be a mother” – speculate about child’s sex, especially if unknown and personality traits based on patterns of fetal activity.
Men – some experience pregnancy symptoms – couvade syndrome. Announcement phase – few hours to a few weeks – act with joy or dismay depending on whether pregnancy is planned, wanted. Some men engage in extramarital affairs for first time during pregnancy. Others batter wives for first time or escalate frequency of episodes (Ch 5 = violence against women). Second phase – moratorium phase – more introspective – philosophy of life, religion, childbearing, relationships with family members, particularly father. Third phase – focusing phase – father’s active involvement – begins to think of himself as a father. Identifying with father role – his memories of fathering he received and perceptions of male/father roles within his social group. Daydreaming about role as father is common in last weeks but men rarely describe their thoughts unless they are reassured that such daydreams are natural. Some men become involved by choosing name and anticipating child’s sex. Women’s increased introspection can cause partner to feel uneasy and her reevaluation of couple’s relationship. Last 2 months fathers experience a surge of creative energy at home and on the job. Become dissatisfied with present living space and tend to alter environment. This behavior earns recognition and compliments from friends, relatives and partners. With exception of childbirth prep classes, man has few opportunities to learn ways to be an involved and active partner in this rite of passage into parenthood.
Sibling Adaptation – can be first major crisis for a child. Factors that influence response: age, parent’s attitudes, role of father, length of separation form mother, facility visitation policy and way child has been prepared for the change. 1 year old largely unaware. 2 year old notices change in mothers appearance and may comment “Mommy’s fat”. Toddlers exhibit more clinging behavior and sometimes regress in toilet training or eating. 3-4 year olds- children like to be told story of own beginning and comparison to that of present pregnancy. Listen to heartbeat and feel baby move. School age more clinical interest – how did baby get in, how will baby get out. Early and middle adolescents can have difficulty accepting evidence of sexual activity of parents. Can assume critical parental role and say how can you let yourself get pregnant. Many pregnant women with teenage children will confess that attitudes of teenagers are most difficult aspect of current pregnancy. Late adolescents do not appear to be unduly disturbed –busy making plans of their own.
Tips: Take child on prenatal visit – let child listen to heartbeat and feel baby move. Move child to a bed at least 2 months before baby Is due. Give child a gift from baby. have someone else carry baby from car so you can hug child first. Arrange for special time for child to be a lone with each parent. Do not exclude child during infant feeding times. Can feed doll or drink juice or sit quietly with a game. Can read to child while feeding infant. Praise child for acting age appropriately (so that being a baby doesn’t seem better than being older).
Grandparent Adaptation – Most delighted. Reawakens feelings of their own youth. The historian who transmit family history.
Care Management – more than 75% of women in U.S receive prenatal care in first trimester. Reasons for delaying include cost, lack of insurance, child care, transportation barriers or inability to take time off work. Immigrant woman may come from cultures in which prenatal care is not emphasized. Birth outcomes less positive for these populations, low birth weight and infant mortality associated with lack of prenatal care.
Group prenatal care is alternative to traditional. Facilitates learning, encourages discussion and develops mutual support. CenteringPregnancy well known model of group prenatal care.
Preconception care – before conception – good nutrition, entering pregnancy with as healthy a weigh as possible, adequate intake of folic acid, avoidance of alcohol and tobacco and prevention of STIs and other health hazards.
Prenatal Visit Schedule (Traditional)- first visit in first trimester. Monthly visits weeks 16-28. 2 weeks; Weeks 29-36. Weekly visits 36 to birth.
Table 14-2 Discomforts related to pregnancy:
Variations in Prenatal Care/Cultural Influences: variations that influence care include culture, maternal age, medical and OB history and # of fetuses.
Perinatal Care Choices:
Creating a Birth Plan:
Questions to Ask When Seeking a Maternity Care Provider – CIMS (group of>50 nursing and maternity care-oriented orgs produced).
Birth Setting Choices: natural/family/woman centered maternity care can be implemented in any setting. 3 primary options: hospital, free-standing birth center and home. Consider preference, characteristics and reimbursement by insurance. Majority occurs in hospitals, increase in out of hospital births from .87% in 04 to 1.36% in 12. 66% were at home, 29% in free-standing birth centers and remaining 5% in physician’s office, clinic or other.
The Adolescent Mother Egocentricity and concrete thinking interfere with ability to parent effectively. More likely to give birth preterm and/or LBW. Mortality rates higher. Often poorer, less educated and receive less prenatal care. In some families/communities, it’s considered a normal or positive life event. Increased risk for postpartum depression; associated with lack of social support and poor relations with partner. Increased risk of child abuse and neglect, risk increases if mother experienced abuse as a child. Can feel “different” from peers, excluded from “fun” activities, and prematurely forced to enter an adult social role. Maintaining a relationship with baby’s father often beneficial for teen and infant, although young father often departs. Mother provides warm and attentive physical care; however, use less verbal interaction than older parents, tend to be less responsive and interact less positively with infants than older mothers. Also have limited knowledge of child development. Nurses should determine support people close to mother are able and prepared to give, as well as community assistance available. Relationships between adolescent parents less stable and often deteriorate or dissolve soon after birth. Involvement of father with infant dependent on relationship with mother, who also controls his access to infant.
Maternal Age 35+ – those who postponed due to career or those who finally become pregnant with aid of reproductive technology. Women of advanced age can experience social isolation. may have less family and social support than younger mothers. Less likely to live near family, and own parents may be unable to provide assistance/support because of age/health issues. “Sandwich generation” – caring for parents while parenting young children. Busy with careers and limited time to help. Friends have older children and less in common. Difficult to find time and energy for romantic rendezvous. Decreasing libido with getting older. Child care major factor in causing stress about work. Work and career issues sources of conflict – being disinterested, not giving enough attention. Loss of control comes as a surprise to many older women. New mothers who are perimenopausal can experience difficulty distinguishing fatigue, loss of sleep and decreased libido as causes of change of sex life.
Paternal Age 35+ – many older fathers describe parenting as wonderful, they see drawback. Positive – increased love and commitment, experiencing child again, more financial stability, more freedom on parenting than career. Drawback is change in relationship with partner.
Same Sex Couples – issues such as lack of family acceptance and support, public ignorance, social and legal invisibility influence ability to adapt as new parents
Grandparent Adaptation – Asian grandparents may come to U.S for new parents to care for baby and mother after birth and to care for children once parents return to work. In U.S. paternal grandparents frequently considered secondary to maternal. Increasing number of grandparents providing permanent care for grandchildren as result of divorce, substance abuse, child abuse/neglect, abandonment, teenage pregnancy, death, HIV and disease, unemployment, incarceration and mental health problems.
Transition to Extrauterine Life – neonatal period includes time from birth through day 28 of life. Term infant usually makes these adjustments with little or no difficulty. Major adaptation occurs during first 6-8 hours after birth. Mediated by sympathetic nervous systems and result in changes in HR, respiration, temp and gastrointestinal function.
3 stages of newborn transition: 1st lasts up to 30 minutes after birth and is called the first period of reactivity. HR increases rapidly to 160-180 BPM but gradually falls after 30 min or so to baseline rate of 100-120 bpm. Respirations irregular- 60-80 bpm. Bowel sounds are audible, meconium may be passed. After this period, newborn either sleeps or has marked decrease in motor activity. Period of decreased responsiveness lasts from 60-100 minutes. 2nd period of reactivity occurs between 2-8 hours after birth and lasts 10 min to several hours. Brief peiods of tachycardia/tachypnea, increased muscle tone, changes in skin color and mucus production. Meconium commonly passed. Extremely and very preterm infants do not experience because of physiologic immaturity.
Physiologic Adjustments – Respiratory System
Most newborns breathe spontaneously after birth and are able to maintain adequate oxygenation. Preterm infants often encounter respiratory difficulties related to immature lungs.
Initiation of Breathing/ Chemical Factors – Clamping umbilical cord causes a rise in BP, which increases circulation and lung perfusion. Activation of chemoreceptors in carotid arteries and aorta result form relative state of hypoxia associated with labor. With each labor contraction, there is a temporary decrease in uterine blood flow and transplacental gas exchange, resulting in transient fetal hypoxia and hypercarbia. Fetus is able to recover between contractions, but appears to be a cumulative effect that results in progressive decline inPO2, increased PCO2 and lowered blood pH. Decreased levels of oxygen and increased carbon dioxide have cumulative effect involved in initiating neonatal breathing by stimulating respiratory system in medulla. As result of clamping cord, there is a drop in levels of prostaglandin which can inhibit respiration.
Mechanical Factors – compression of chest during vaginal birth can stimulate respiration. With birth , pressure on chest is released, and negative intrathoracic pressure helps draw air into lungs. Crying increases distribution of air in the lungs and promotes expansion of alveoli. Positive pressure created by crying helps keep alveoli open.
Thermal Factors – temp is significantly lower outside womb. Stimulates receptors in skin, resulting in stimulation of respiratory center in medulla.
Sensory Factors – in days preceding labor, there is reduced production of fetal lung fluid and concomitant decreased alveolar fluid volume. Shortly before onset of labor there is a catecholamines surge that seems to promote fluid clearance from lungs, which continues during labor. Infants born by cesarean in which labor didn’t occur before birth can experience some lung fluid retention, although it typically clears without harmful effects on infant; these infants more likely to develop transient tachypnea of newborn (TTNB) caused by lower level of catecholamines. With absent or decreased surfactant on lungs, more pressure must be generated for inspiration, which can soon tire or exhaust preterm or sick term infants. Once respirations are established, breaths are shallow and irregular, ranging form 30-60 bpm, with periods of breathing that include pauses in respirations lasting less than 20 sec. these occur most often during active rapid eye movement sleep cycle and decrease in frequency and duration with age. Apneic periods longer than 20 second indicate pathologic process and should be evaluated. Newborn infants nose breathers by preferences. Reflex to nasal obstruction is to open mouth; response not presence in most infants until 3 weeks after birth; therefore cyanosis or asphyxia can occur with nasal blockage.
Signs of Respiratory Distress – nasal flaring, intercostal or subcostal retractions (in drawing of tissues between ribs/below rib cage) or grunting with respirations. Seesaw or paradoxical respirations are abnormal and should be reported. Respiratory rate of less than 30 or greater than 20 BPM with infant at rest must be evaluation. It can be slowed as result of effects of analgesics or anesthetics. Tachypnea can be first sign of respiratory, cardiac, metabolic or infectious illness. Changes in infants color can indicate distress. Acrocyanosis, bluish discoloration of hands and feet, is normal finding in first 24 hours after birth. Central cyanosis is abnormal and signifies hypoxemia – lips and mucous membranes are bluish; it is a late sign of distress so newborns usually have significant hypoxemia when cyanosis appears. TTNB usually resolves in 24-48 hours. Common complications include RDS, meconium aspiration, pneumonia, and persistent pulmonary hypertension of newborn.
Cardiovascular System – changes drastically after birth. During first few days of life, crying can temporarily reverse flow of blood through formaen ovale and lead to mild cyanosis. Soon after birth cardiac output nearly doubles and blood flow increase to lungs, heart, kindness and gastrointestinal tract. In utero fetal PO2 is 20-30 mm HG. After birth it is 50 mm Hg due to increased oxygenation. Prostaglandin also has important role in closing ductus arteriosus. In term infants, it functionally closes within first 24 hours after birth; permanent closure usually occurs within 3-4 weeks and ductus arteriosus becomes a ligament. It can open in response to low oxygen levels in association with hypoxia, asphyxia or prematurity. With auscultation of chest a patent ductus arteriosus can be detected as a heart murmur. When cord is clamped/severed, umbilical arteries, umbilical vein and ductus venosus are functionally closed and converted into ligaments within 2-3 months. HR for term newborn ranges from 110-160 bpm.
Lesbian Couple – determine couples’ preference about how they wish to be identified. Birth mother has greater desire to experience pregnancy and birth and to be genetically related to child. Non-childbearing partner can stimulate milk production through induced lactation using medications and regular pumping. Birth mother tends to be one most responsible for child care.
Gay Couples– parents by adoption or assisted preproduction in which gestational carrier is impregnated by artificial insemination or in vitro fertilization. Female to male transgender can become pregnant. Nurses can help men by locating support groups. Data on gay parenting limited and focus more on developmental outcomes of children than on parenting styles or parental caregiving.
Social Support – strong related to positive adaptation by new parents during transition to parenthood. Number of members in person’s social network. Partner support has a positive influence on adaptation in postpartum period. Grandparents or in-laws most appreciated when they assist with household responsibilities and do not intrude into parent’s privacy or judge them critically.
Culture – Asian families, children are source of family strength and stability and perceived as wealth and are objects of parental love and affection. Infants given an affectionate “cradle” name. Algerian mothers may not unwrap and explore infants because babies are swaddled to protect there. Vietnamese woman may give minimal care to infant but refuse to cuddle or further interact with baby to ward off evil spirits, which actually reflects intense love and concern for baby. Asian mother might be criticized for immediately relinquishing care to grandmother and not even attempt to hold baby when brought to room. Mix of breastfeeding and bottle feeding standard practice for Japanese women – rest for first 2-3 months and doesn’t usually lead to problems; breastfeeding widespread and successful in Japan.
Socioeconomic Conditions – mothers who are single, separated, divorced or without a partner, family or friends can view birth of child with dread. Serious financial problems can negatively affect mothering behaviors. Fathers overwhelmed with financial stresses may lack effective parenting skills and behaviors.
Postpartum Risk Assessment – those not screened prenatally, ask first 6 questions from PrePregnancy and Pregnancy Risk Assessment as well
Warning Signs in Mom:
Warning Signs in Baby
Questions to Ask:
Psychotherapists, Psychologists or Social Workers – critical element and being a part of her preconception planning and perinatal safety net. Be familiar w risk factors and most current info on how to reduce risk factors. Be familiar w research regarding relapse and current medication recommendations. Help monitor symptoms. Have info in resources section available.
Primary Care Providers – evaluate pre-pregnancy risk. Have info from resources available as well as referrals to local professionals trained in perinatal mood and anxiety disorders. Woman taking psychotropic medications who are pregnant/planning a pregnancy should be encouraged to consult psychiatrist specializing in perinatal disorders in order to determine whether to continue meds. Women on medication for bipolar disorder or psychosis should be referred to perinatal psychiatrist to develop medication plan. Need careful monitoring throughout pregnancy and postpartum.
Pediatricians and Neonatologists – well documented that mental health of parents has tremendous impact on development of children in home. If mom has been on meds during pregnancy, reassure parents that baby is fine and not experiencing any withdrawal or neonatal complications. Support mom if she wishes to feed her baby breast milk while taking antidepressant. Mothers w depression or anxiety nurse or pump for shorter durations; they give up. Moms on medications feed their babies breast milk for longer duration then those untreated.
OB/GYNs, Midwives and Other Women’s Healthcare Providers – many women will not be forthcoming w negative feelings or concerns unless specifically asked. Women w history of neonatal loss need monitoring and extra support.
Psychiatrists – research findings and recommendations about medications in pregnancy and lactation constantly changing. Make sure give patients name of psychotherapist trained in PMADs. Essential to have list of local resources and referrals.
Birth Doulas – studies show use of doula contributes to reduction of postpartum depression. Can screen prenatally/watch for early warning signs of emotional problems. If when doing prepregnancy and pregnancy risk assessment, you discover woman has suffered previous traumatic delivery or childhood sexual abuse, she may experience flashbacks during birth.
Postpartum Doulas and Visiting Nurses – can observe home and social environments of mom, which can given crucial info about her well-being and that of family unit. If notice lack of partner support or signs of marital conflict, she’s at greater risk for PMAD. If house unusually neat/clean, want to find out who is doing housework; if she’s obsessively cleaning or awake in middle of night vacuuming, this is not normal.
Lactation Consultants – may be first professional to see the mom/baby during initial postpartum weeks. Can observe/listen for potential emotional problems. Postpartum moms listen carefully to what you advise and are quite trusting of you.
Childbirth Educators – so often heard “why didn’t we learn about this during pregnancy?” have a responsibility and opportunity to educate couples about perinatal mental illness.
New Parent Group Leaders – statistically 1-2/10 will have PMAD. Rarely will woman disclose since she most likely will be experiencing guilt and shame. Will be aching for someone to open door and give her permission to express how she’s really feeling. If partners present, ask them how they themselves are doing. Dads/partners may have preexisting mood or anxiety disorders. Stress of pregnancy can also worsen symptoms. Dads and partners need and deserve support too.
Adjunct Professionals – many others who touch lives of pregnant and postpartum women. Physical therapists, instructors in prenatal and postpartum exercise should mention possibility.
Sex life changes for each trimester: 1st) increased blood flow to pelvic organs/hormonal changes/ not worrying about getting pregnant increase; those with nausea/vomiting/fatigue/breast tenderness decrease. 2nd) Stronger libido and more pleasure than other trimesters. 3rd) Decreased desire bigger bellies/fatigue. Air embolus– air bubble in in blood, potentially fatal condition.
Sex safe, but avoid if high risk: at risk for preterm labor, partner has STI, placenta previa, incompetent cervix, vaginal bleeding, painful cramps after, membranes have ruptured. Uterine contractions are a normal part of having an orgasm. Try positions that don’t put partner’s weight on belly (side-lying, hands and knees, woman on top)
Expectant Fathers: have never felt so important yet so ignored, so committed yet so abandoned. Talk with others expectant fathers casually or in discussion group. During 1st trimester, will not see physical changes in partner and might not think of baby as real. ~16-20 weeks, see changes in body and may feel baby move inside. Baby’s existence when see during ultrasound/hear heartbeat. Many men don’t attach to babies until birth. May reflect on own mortality – buy more life insurance and write/update will. Pregnancy symptoms: weight gain, food cravings, abdominal cramps or bloating, nausea, vomiting, backaches, toothaches, loss of appetite and insomnia. Changes in relationship – may feel left out at times. She turns to friends/relatives instead of you for emotional support. You are expected to care more for her/your relationship, but she’s less available to you emotionally, physically and sexually. Role during labor: attend childbirth class, watch DVDs, read books discuss worries with other fathers or consider having support at labor.
No inappropriate place except one that limits freedom of choice and knowledge of alternatives. Restrictions prevent fully informed decision making and may contribute to increasing medicalization of childbirth and a dehumanization of birth for woman and family.
Need to be aware of impact on setting on views of classes as related to professionalism, privacy, comfort, continuity, convenience and credibility.
Pelvic Model Can Be Used:
~23MM Americans may not be able to comprehend what professionals are discussing w them.
Posters and Visual Aids:
National Perinatal Task Forces exists bc too many babies being born too soon. Perinatal safe spot – where woman can find support for herself, where its possible to carry baby to term.