ICEA Study Guide 3 – Teaching Skills for the Childbirth Educator

OBJECTIVES At the completion of Part 3 the learner will:

  • List various generational groups and their characteristics found in a childbirth class.
  • List ways to establish professional rapport.
  • Explain the acronym ADULTS as it relates to how adults learn.
  • Discuss four learning preferences or styles with appropriate learning activities.
  • List various teaching methods and strategies for the childbirth class.
  • Evaluate visual tools, posters, and music for the childbirth class.
  • Practice using props to support a childbirth class presentation.
  • Recognize issues important to a variety of partners.
  • List predisposing factors and characteristics of vulnerable childbearing populations both globally and in the local community.


  1. Generational groups and their characteristics
    1. Generation X
    2. Millennial generation

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.

  1. Establishing rapport
    1. Professional appearance
    2. Open body language
    3. Encourage client autonomy
    4. Prepare for class
    5. Facilitate relationships and communication


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:

  1. Assess needs of learner – consideration given to learner’s existing knowledge base, previous learning experiences, age, cultural diversity, attitudes about birth, previous birth experiences, learning styles, socioeconomic status, spiritual concerns and info needs
  2. Establish goals and objectives – clearly defined goals for each class. Establish learner based objectives based on goals. Objectives should be SMART: Specific, Measurable, Achievable, Relevant and Time-framed.
  3. Determine content and teaching strategies – focus on needs of learned. Based on current/factual info; teaching strategies varied. Adults learn better and retain more info when given opportunity for immediate discussion, feedback and application.
  4. Implement and evaluate – moving from simple to more complex. Continual and ongoing evaluation important – should measure learner’s ability to perform objectives and degree to which curriculum met learner’s expectations.

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:

  1. Natural physiological and psychological patterns of pregnancy, labor, birth and postpartum
  2. Common abnormal or unexpected variations on urusal patterns of childbearing year
  3. Maternal and infant nutrition, including breastfeeding
  4. Common medical interventions and procedures during labor and birth process as well as:
    1. Obstetrical procedures and technologies
    2. Vaginal, cesarean, and vaginal birth after cesarean
    3. Analgesia and anesthesia
    4. Indications, contraindications and benefits and risks for above
    5. Alternatives to above, whether or not available in community

ICEA also recommends education in following possible subject areas as appropriate:

  1. Anatomy (male and female) and physiology of reproduction and sexuality during childbearing year
  2. Fetal development and newborn characteristics
  3. Emotional changes of father at each phase of pregnancy, birth and postpartum
  4. Benefits of labor support
  5. Impact of pregnancy and parenthood on couple relationship
  6. Family development
  7. Resources for dealing w unexpected outcome
  8. Perinatal screening and diagnostic procedures
  9. Teratogenic and iatrogenic influences in pregnancy
  10. History and philosophy of childbirth education
  11. Philosophy and practice of family-centered maternity care

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:

  1. Appropriate match between participant’s personal beliefs and approach of educator
  2. Competent and supportive childbirth educator
  3. Adequate learning time that includes practice, discussion and feedback
  4. Caring and knowledgeable birth attendants and support person (s)
  5. Supportive and nurturing birth environment

Class format must provide adequate time for demonstration, return demonstration and practice/review of:

  1. Coping methods for labor, including: relaxation skills, breathing (Either in pattern or natural response to forces of labor) and comfort measures)
  2. Body awareness and condition exercises for pregnancy, birth and postpartum

Advocacy of following concepts should be evident:

  1. Pregnant patients rights and responsibilities for making informed choices based on knowledge of alternatives
  2. Legal rights and informed consent
  3. Effective communication and negotiation w other members of circle of care
  4. Breastfeeding as preferred means of promoting infant nutrition and providing immunological protection
  5. Promotion of pregnancy and birth as a significant and life changing event
  6. Parent-infant bonding
  7. Avoidance of routine medical intervention during pregnancy, birth and postpartum ww use of evidence-based medical treatment should complications arise
  8. Women-centered, baby-centered, and family-centered maternity care
  9. Parental participation, sharing and individual satisfaction in vaginal and cesarean births
  10. Consumer participation and advocacy in planning maternal and newborn services at all levels of healthcare system


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

  • Prepare – Develop your objectives. What do you hope to accomplish with your presentation? Do you plan to inform, present facts? Do you plan to persuade, change behavior or attitude? What do you want your students to learn? How will you involve your audience in your presentation?
  • Visualize – imagine yourself in front of your group at your very best. How are you dressed? (be comfortable whether casual or formal). Where are you positioned? (lecture, podium, table, chair, floor?). Will you use a microphone? (if so, do you know how it works?) think about your natural gestures, and good posture. Picture yourself without nervous habits. Imagine a positive audience response.
  • Practice, Practice, Practice – practice in all situations. Anticipate questions and how you will answer them. Practice with your visual aids in a similar room. Record and listen to at least 10 min of your talk (Can be painful, but do it). Have someone video your practice session or an actual class (can be even more painful, but you’ll learn a lot)
  • Focus, concentrate, breathe and relax – use these skills you know well. Play music you like as you set up room and check you’re a-Vs, light etc. get to room early enough to relax and focus before participants arrive. Concentrate on your introduction – the rest will flow if you have prepared. Take a cleansing breath before you speak.
  • Deliver with confidence. Use strength of voice and vocal variety. Teach to all temperaments, using a variety of teaching techniques. Make eye contact with friendly faces first. They will encourage you. Move around the room or away from a lectern. Use notes rather than a script. Enjoy your group. Feel passionate about your subject, if possible. Be knowledgeable about your subject.

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!


  • Overuse of animation, such that it becomes a distraction
  • More than 2 typefaces on one slide
  • More than 3 colors per visual (unless it’s a full-color photo)
  • “Data dump” – too much info per slide and too many slides
  • Too much time with lights low
  • Positioning yourself between visual and audience
  • Turning your back on the audience to look at the screen
  • Waving a pen or pointer in the air
  • Bright light left on screen (insert a blank, colored background slide or turn off projector).


Discussion points:

  • While 2 people may have come to understand one another as their relationship has grown, mood swings, with the heightened emotions often encountered in pregnant, may wreak havoc with that understanding.
  • Though 1 cannot assume that all men prefer to focus on one thing at a time, or that all women describe their complaints or needs ina tediously detailed fashion, many will identify with those stereotypes. Sometimes the roles are reversed, with the woman preferring to “listen” and the man preferring to “talk”
  • A childbirth class discussion of communication differences, as well as the communication styles of different personalities or temperaments, may bring about a new understanding and appreciation of one another that can enhance not only the pregnancy but also the relationships within the new family

4 Temperaments (“Please Understand Me” book:)

  1. The Artisan: talks of things in present, more than past or future. Tells stories/jokes filled w details. Dramatic/impulsive. Little interest in definitions, hypotheses or theories. Speaks with colorful phrases/current slang.
  2. The Guardian: believes in wisdom of past. Learns, remembers, repeats facts. Prefers to discuss facts, not theories. Observes details. Organizes thoughts. Gives warnings and precautions.
  3. The Idealist: speaks more of what can be imagined than of what can be observed. Sensitive to hints or mere suggestions. Moves from a few particulars to sweeping generalizations.
  4. The Rational: speaks on what can be observed/experienced rather than imagined. Logical to the extreme. Does not state obvious or waste words.

Important for students to know and educator to understand how to speak so all temperaments will listen. Meyers Briggs…

  • ADULTS: Agendas, Discussion, Understand my needs, Learning preferences, Time, Setting

“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

  1. Four learning preferences or styles and appropriate activities
    1. Quiet, organized intellectuals
    2. Fun-loving, outgoing talkers
    3. Relaxed, easygoing mediators
    4. Outgoing, hard-working leaders
    5. Knowing the educator’s preference


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.

  1. Teaching methods
  1. Icebreakers
  2. Learning tasks
  3. Return demonstration
  4. Quizzes, games, and role play
  5. Computer program tools
  6. Lecture
  7. Storytelling


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?

  • Create stack of index cards with one adjective on each card such as “Excited, tired, happy, worried, concerned, anxious, exhausted, comfortable, confident, prepared, unprepared, tender, special, sexy etc. have as many positive as negative. Make multiples of words. Spread out in floor. Ask each student to pick up 1 or more cards that describe themselves. Can also do feeling flashcards available at
  • Ask students to take one item from wallet or purse that tells something about them.
  • Divide students into groups by season born, favorite color or any other grouping. Have them come up with something they have in common other than being married or pregnant. Have small groups report to big group.
  • Ask each student to draw a contraction, a picture of a pregnant woman or a pic of what they think birth will look like at their birth location. Have them all hold at same time. If shows woman laboring in bed, say how did this woman know to labor in bed? Birthing from Within has more about birth art.

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

  • Return demonstration – demonstrate a skill and allow students to do it in return
  • Quizzes, games and role plays– can use internet at home or work in small groups. Or for their eyes only. Competition between couples/genders.
  • Interactive lecture – involve students in discussion, Q&A session, small group analysis between segments.
  • Storytelling – discussion follows story. Funny stories provide laughter. Lots of birth stories available.
  • Bonding with class – when introduce yourself, 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. Rehearse. First impression sets class.

Teaching Strategies pg 33


Visuals, props and music

  1. ‘VACCINATE’ PPs, DVDs, posters, and flip charts
  2. Using childbirth class props: the pelvis, knitted uterus and baby model
  3. Respect the baby prop as a parenting teaching tool

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



  • New England Journal of Medicine
  • Birth Survey (Transparency in Maternity Care Project)
  • Nursing for Women’s Health (AWHONN)
  • Obstetrics & Gynecology – The Green Journal
  • Pediatrics – Journal of the American Academy of Pediatrics


Anatomy of Pregnancy

  • Graphics – childbirth graphics – With Child Conception to Birth Set posters (7); or flip chart
  • Models – life-size plastic or vinyl female pelvis, baby doll and knitted uterus.
  • Presentation of Baby
  • DVDs– see Section VII- Resources. Celebrate Birth! Shows an inside look at labor. Stages of labor shows 3D computer animation.
  • Precautions – many babies born with problems that could’ve been prevented. Emphasize potential hazards of drugs, including alcohol and tobacco. Some people are overly cautious. Reassure flying, small amounts of caffeine okay.
  • Grab bag– filled with health and unhealthy items. For each item, discuss risks, benefits and recommended limits. Safe: airplane, Tylenol. Sex, sugar, hair color, small coffee, bath, water- better than soda, paint brush, fish. Not safe: ashtray, alcohol, mega dose vitamins, Nyquil, St johns wart (herbals), white powder (drugs), cat litter, douche
  • Discussion Points: heavy drinking and binge drinking (5+ per sitting) associated with fetal alcohol syndrome. 10-16% continue to smoke during pregnancy; research shows even 5 cigarettes a day are harmful and risk increases with heavier smoking. No drugs should be used unless administered by midwife or pregnancy doctor. Soft cheeses such as brie, feta and blue can carry listeriosis unless pasteurized. Toxoplasmosis spread by feces of outdoor cats.

  • Understanding the needs of various partners
    1. Male partners
    2. Female partners
    3. Parents
    4. ? NOT LISTED


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.

  • Women – 51% of US population. Significant gaps exist in quality of care for women compared to men. Low levels of educational attainment (HS or lower) are also associated with lack of resources and difficulty navigating the health care system. This is particularly true of women of ethnic and racial minorities, whose limited English proficiency may compromise provider access and quality of care.
  • Minority– women in racial/ethnic minorities experience disproportional burden of disease, disability and premature death. Disparities in early prenatal care, an important factor in achieving healthy pregnancy outcomes. Minority women, many who live in poverty, also have higher rates of chronic disease including heart disease, cancer, hepatitis, and AIDS as well as mental health issues. Women with underlying health issues are especially at risk for poor obstetric outcomes. They have high rates of preterm labor and gestational hypertension, often have intrauterine growth restriction, resulting in birth of small infants.
  • Adolescent Girls – generally considered healthy, however they participate in riskier behaviors compromising their health. STIS and HIV have significant implications for perinatal outcomes.
  • Older Women – have greater life expectancy than men, but more likely to have chronic illnesses, less likely to use preventative services and ultimately spend more on health care.
  • Incarcerated Women – # continues to climb, at a rate more than men. High risk for STIs, HIV and AIDS, other chronic and communicable diseases and complicated pregnancies.
  • Immigrant, Refugee and Migrant Women – 40 million or 13% of population foreign born. Not easy access to health care because not U.S. citizens. Don’t seek medical care for fear of deportation. Health care policies restrict Medicaid eligibility for these groups, although a number of states provide some prenatal, birth and postpartum care. Refugees more likely to live in poverty than immigrants. Migrants less likely to receive prenatal care and have greater incidence of inadequate weight gain during pregnancy than other poor women.
  • Rural vs Urban – 15% of populations. Older, less educated and generally in poorer health. Fewer physicians, lack of insurance. Financial and transportation barriers, higher rates of preterm birth, low birth weight and infant mortality.
  • Homeless Women – 636k homeless people; single women make up 13% – often to escape domestic violence. Families with children make up the fastest growing group of homeless. Women at increased risk for illness and injury – many victims of assault, rape etc. Multiple barriers to prenatal care – transportation, distance and wait times; they underutilize available services. High-risk lifestyles often result in adverse perinatal outcomes. Opening Doors – federal strategic plan to prevent and end homelessness in 2010.

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 AdaptationEarly 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.

Initial Visit:

  • Prenatal Interview – first prenatal visit longer and more detailed than future visits. Comprehensive health history emphasizing current pregnancy, previous pregnancies, the family, a psychosocial profile, a physical assessment, diagnostic testing and overall risk assessment. Nurse includes those that visit with mother in first interview. Data gathered on woman’s age at menarche, menstrual history, contraceptive history, any infertility or reproduction system conditions, history of STIs, sexual history and detailed history of her pregnancies including present one and their outcomes. Date of last Pap test and result are noted. Date of LMP obtained to calculated EDB.
  • Health History – diabetes, hypertension or epilepsy requires special care. Allergies and reactions, medication use and immunization . if women had uterine surgery of extensive repair of pelvic floor, a cesarean birth may be necessary. Appendectomy rules out appendicitis as cause of right lower quadrant pain. Spinal surgery may contraindicate use of spinal or epidural anesthesia. And injury involving pelvis from a motor vehicle accident or childhood nutritional deficit. Women who have chronic or handicapping conditions often forget to mention during assessment because they’ve become so adapted to them. Special shoes or a limp can indicate existence of pelvic structural defect.
  • Nutritional History – dietary practices, food allergies, eating behaviors, practice of pica (consumption of nonfood substances); obese women should receive counseling about weight gain, physical activity and healthy food choices. Women with a history of bariatric surgery are nutritionally at risk and should be followed throughout pregnancy.
  • History of Drug and Herbal Prep Use – past and present use of drugs (legal, OTC and prescription, vitamin supplements, herbal, caffeine, alcohol, nicotine). Many substances cross placenta and can therefore pose a risk to developing fetus. Immunization record should be reviewed for rubella, varicella, flu, hep B and pertussis that can pose a particular risk to pregnant women or infants during pregnancy and immediately following birth.
  • Social /Occupational– pregnancy wanted, potential parenting problems, depression, lack of family support, inadequate living situations. Attitudes toward unmedicated or medicated labor. Occupation – past and present because some can adversely affect maternal and fetal health – heavy living and exposure to chemicals and radiation. Standing for long periods at retail checkout or in front of a classroom associated with orthostatic hypotension. Long hours working at a desk carpal tunnel or circulatory stasis in legs.
  • History/Risk of Intimate Partner Violence – all women should be assessed fro abuse in all forms – physical, sexual or psychological because likelihood increases during pregnancy. Should be done at first visit and at least once a trimester and postpartum. Adolescents can be trapped in an abusive relationship because of inexperience, dependence on abuser, and separation from family and friend support systems. Victims of human trafficking and victims of IPV can show signs such as scars, bruises, burns, unusual bald patches or tattoos that can be a sign of branding. Likely to be accompanied by someone who never leaves them alone and speaks for them. They may not speak English and may lack ID. If woman is alone, she may have cell phone in speaker mode so person can hear everything. Nurses must get creative to get women in for questioning – send other to front for paperwork, interviewing women in restroom, saying no cellphone. National Human Trafficking Resource Center.
  • Physical Exam– Height of fundus is noted if first exam done after first trimester. Potential threatening condition – supine hypotension – low BP that occurs while woman lying on back, causing feelings of faintness. Particular attention to size of uterus because indicates duration of gestation. 1 vaginal exam during early pregnancy recommended than another late in third trimester.
  • Lab Tests – Urine, cervical and blood samples at initial visit. If woman refuses HIV, should be documented. Screening for HIV (transmission 25% without treatment; 1% with HAAART) syphilis, chlamydia, and gonorrhea repeated in 3rd trimester for those high at risk. Urine tested for protein, glucose and leukocytes. Some may choose to undergo genetic testing. GBS test 35-37 test for infection. 24-28 weeks gestational diabetes. Cardiac evaluation for those with history of hypertension or cardiac disease.

Follow-Up Visits

  • Interview – 3rd trimester – assess current family situations. Test woman’s knowledge of warning signs of emergencies, signs of preterm and term labor, labor process and concerns about labor.
  • Physical Exam – BP measured using same arm at each visit. Woman’s weight and appropriateness of gestational weight gain in relationship to BMI. Urine checked by dipstick and presence and degree of edema are noted.
  • Signs Potential Complications – first trimester: hyperemesis gravidarum (severe vomiting), burning on urination, chills, fever (infection), vaginal bleeding (miscarriage). 2nd: discharge of fluid from vagina before 37 weeks (PPROM), severe backache or flank pain (kidney infection), change in fetal movements, swelling of face/fingers , visual disturbances, headaches, muscular irritability (hypertensive conditions/preeclampsia), epigastric/abdominal pain (preeclampsia, abruption placentae).
  • Fetal Assessment
    • Gestational Age – first uterine evaluation (date, size), fetal heart first heard, date method, date of quickening, current fundal height, current week of gestation by history of LMP/ultrasound. Quickening usually between 16 and 20 weeks. Multiparous often sooner. Ultrasound can detect multiple gestation.
    • Fetal Heart Tones – late in first trimester can be heard with Doppler. As uterus grows and becomes and abdominal organ, fetoscope can hear. Pinard horn used by midwives in Europe. Start in midline 2-3 cm above symphysis publis, moving to left lower quadrant etc. counted for 1 minute and quality/rhythm noted. Once heard, it’s absence should be immediately investigated.
    • Health Status – fetal movement. Absence correlated with fetal death. Count movements daily over 1-2 hour period. 4+ movements in an hour is reassuring. Most important is mother’s perception that they have decreased from previous levels.
    • Fundal Height – 2nd trimester uterus becomes abdominal organ. From weeks 18-30, height of fundus is approximately number of weeks of gestation (+/- 2). 3cm variation if bladder full. Stable or decreased height can indicate intrauterine growth restriction, an excessive increase can indicate presence of multifetal gestation or polyhydraminos. Disposable paper metric tape is preferred – plastic should be cleaned after use and prior to retraction. Same person measures each time – same method and whether uterus was relaxed or contracted. Measurements obtained with woman in various positions differ.
  • Lab Tests – clean catch urine tests for glucose, protein, nitrites and leukocytes at each visit. Sequential integrated screening (SIS) for those who began care before 14 weeks. Identifies: down syndrome (trisomy 21), trisomy 18, neural tube defects (anecephaly and spina bifida), and Smith-Lemli-Opitz syndrome. First blood test 10-13 weeks measure 2 biochemical markers – pregnancy associated placental protein (PAPP-A) and free beta-human chorionic gonadrotropin (B-hCG). 2nd step for SIS is ultrasound between 11 and 14 weeks to assess for nuchal translucency. Final step 15-20 weeks measures levels of 4 substances normally found in a pregnant woman’s blood: alpha-fetoprotein (AFP), human chorionic gonadotropin (HcG), unconjugated estriol, and inhibin-A (group of tests know as quad marker screening). Maternal serum marker levels higher or lower than normal show increased risk for chromosomal abnormalities (Ch 26). Woman who begin care between 14th and 20th week too advanced to be offered first two steps but can be offered quad screening. Glucose Screening -1 hour, 50 g oral glucose tolerance test. If elevated, need to do 3 hour 100 g GTT. Group B streptococcus (GBS)– between 35 and 37 weeks – even for those with schedule cesarean because labor can begin or membranes rupture prior to admin of prophylactic antibiotics.

Nursing Interventions

  • Expected Maternal and Fetal Changes – Couples can track development of fetus through websites such as or development.
  • Nutrition– based on woman’s BMI, recommended weight gain during pregnancy is discussed. Include foods high in iron, importance of prenatals and recommendations to avoid alcohol/limit caffeine. Avoid food borne illness such as listeriosis. Assess for practice of pica.
  • Personal Hygiene– sebaceous (sweat) glands highly active because of hormonal influences so perspire freely.
  • Prevention of UTIs – physiological change in renal system, infections of lower urinary tract (acute urethritis, acute cystisis), common. E coli most common causative organism for UTI in pregnant woman. Poses risk to mother and fetus. Oral antibiotics prescribed. Bubble bath/bath oils should be avoided. Some women don’t consume enough fluid – at least 2L or 8 glasses of liquid a day – preferably water. Holding urine lengthens time bacteria are in bladder and allows them to multiply. Bacteria can be introduced during intercourse; so pee before and after and then drink a large glass of water to promote additional urination. Cranberry juice to prevent UTI. Daily consumption of 10 oz juice.
  • Kegels – an exercised muscle can then stretch and contract readily at time of birth. Fewer complaints of urinary incontinence in late pregnancy and postpartum. (Ch 4)
  • Breastfeeding Prep– scars on breast can indicate previous breast reduction surgery, which can affect milk production. Breast implants may affect successful breastfeeding. Asymmetry of breast or tubular shaped breasts suggest lack of glandular tissue and potential problems with adequate milk production. Inverted/flat nipples – some recommend prenatal use of breast shells during last trimester, though evidence is lacking. They can be uncomfortable and cause irritation. Breast stimulation is contraindicated in women at risk for preterm labor. No special prep of nipples or breast for breastfeeding.
  • Exercise Tips for Pregnant Women – if a runner, starting at 7th month, may wish to walk instead. Exercise regularly everyday. Exercising sporadically can place undue strain on your muscles. Take pulse ever 10-15 min. fi more than 140 BPM, slow down until it reaches max of 90 BPM. Avoid becoming overheated for extended periods. As body temp rises, heat is transmitted to fetus. Prolonged or repeated elevation of fetal temp can result in birth defects, especially during first 3 months of pregnancy.   After 4th month of pregnancy, shouldn’t perform exercises flat on back. Rest for 10 min after exercising, lying on side – which removes pressure and promotes return circulation from your extremities and muscles of your heart, thereby increasing blood flow to your placenta and fetus. Choose high protein foods such as fish, milk, cheese, eggs and meat.
  • Dental health – important because nausea during pregnancy can lead to poor oral hygiene, allowing dental caries to develop. Fluoride toothpaste should be used daily. Research links periodontal disease with preterm births and LBW and an increased risk for preeclampsia. No scientific evidence to support belief that filling teeth or even dental extraction involving administration of local or nitrous oxide-oxygen anesthesia precipitates miscarriage or preterm labor. Dental x rays, and use of local anesthetic or nitrous oxide considered safe. Best scheduled during 2nd trimester when nausea passed and can sit comfortably in chair.
  • Posture: As pregnancy progresses, women’s center of gravity changes, pelvic joints soften and relax, and stress is placed on abdominal musculature. Poor posture can lead to injury.
  • Rest/Relaxation: Side-lying recommended because promotes uterine perfusion and fetoplacental oxygenation by eliminating pressure on ascending vena cave and descending aorta, which can lead to supine hypotension. Pelvic rocking relieves low backache (good for menstrual cramps as well). Abdominal breathing aids relaxation and lifts abdominal wall off uterus. To prevent/relieve backache – do pelvic tilts. To restrict lumbar curve- for prolonged standing, place one foot on low footstool or box. Sit with knees higher than hips. To stretch/rest back muscles: stand behind a chair, squat 30 sec, stand for 15. Repeat 6x several times a day. sit in chair and lower head to knees for 30 sec. repeat 6x several times a day.
  • Employment – excessive fatigue is usually deciding factor in termination of employment. Women with sedentary jobs need to walk around at intervals to counter sluggish circulation in legs. Avoid crossing legs at knees because can increase risk of varies and thrombophlebitis. Standing for long periods increases risk of preterm labor. Footstool can prevent pressure on veins, relieve strain on varicosities, minimize edema of the feet and prevent backache.
  • Travel- Avoid travel to high altitude regions above 12k feet. Many health insurance carriers do not cover a birth in a foreign setting or even hospitalization for preterm labor. While sitting, woman can practice deep breathing, foot circling and alternately contracting and relaxing different muscle groups. If traveling by automobile, stop to walk every hour. Motor vehicle accidents are a major cause of maternal morbidity and mortality, second only to violence. Steering wheel should be tilted upward, away from abdomen and seat moved back away from steering wheel as much as possible. Air travel up to 36 weeks for domestic and up to 32/35 weeks for international; hydrations should be maintained because of 8% humidity of commercial airlines.
  • Conscious Relaxation Tips – active imagery – imagine self moving or doing some active activity and experience its sensations. Passive imagery – imagine watching a lovely scene such as lovely sunset. Practice regularly – at same hour for 10-15 min each day to feel refreshed, revitalized and invigorated.
  • Fig 14-15 Put legs up on wall while laying down to rest legs and reduce edema and varicosities.
  • Clothing – no tight clothing over perineum – increases risk of vaginitis and miliaria (heat rash) and impaired circulation in legs can cause varicosities. In 3rd trimester, woman’s pelvis tilts forward, and her lumbar curve increases. Resulting leg aches and cramps are aggravated by non-supportive shoes. Exercises to relieve cramps – foot flexed (pull foot towards you with leg stretched; relieves muscle spasm), lunges on chair.
  • Medications and Herbal Prep: greatest danger of drug caused developmental defects in fetus extends from time of fertilization through first trimester.
    • The use of CAM by pregnant women is widespread. There is limited research evidence about the safety of herbal preparations, esp during pregnancy. Although the use os CAM therapies is consistent w the holistic, woman-centered approach to care, caution is warranted in their use because of the lack of evidence related to their safety and efficacy.
    • Although CAM may benefit the woman during pregnancy, some practices should be avoided because they can increase risk for complications. Important to ask woman about OTC products (including herbals and vitamins) she is using.
  • Immunizations – live/attenuated live contraindicated during pregnancy.   Live (measles, rubeola, rubella, varicella, mumps and oral Sabin poliomyelitis. Vaccines safe include combined Tdap (between 27 and 36 weeks), recombinant Hep B and flu. Tdap recommended each pregnancy regardless of prior vaccination. All pregnant during flue season (Nov-March) should receive flue vaccine; nasal contraindicated because contains live virus.
  • Alcohol/Cigarette/Caffeine/Drugs – maternal alcoholism associated with high rates of miscarriage and fetal alcohol spectrum disorders; risk for miscarriage in first trimester is dose related (3+ drinks/day). Cigarette smoking or exposure to secondhand associated with IUGR and increase in perinatal and infant morbidity and mortality. Increased preterm labor, PROM, abruption placentae, placenta previa and fetal death. Coffee high caffeine intake – 200 mg max a day (~2 cups, depends on coffee).
  • Alternative Therapies – massage, acupressure, mind/body healing, imagery, meditation/prayer/reflection, biofeedback, aromatherapy
  • First trimester – woman gains 2.2-5.5 lb; maintain normal hematocrit and hemoglobin
  • Recognizing Preterm Labor – uterine contractions after 20th week but before 37th week, if untreated can cause cervix to open earlier than normal. Warning signs ch 32
  • Sexuality in pregnancy – increases in 2nd No correlation between miscarriage and intercourse. Abstain if experience cramping/bleeding. Abstain if have history of premature dilation. Uterine activity can increase with sex, can be related to breast stimulation, orgasm or prostaglandins in semen. For majority of women, not a problem. History of more than 1 miscarriage, threatened miscarriage in 1st trimester, impending miscarriage in 2nd and PROM, bleeding/abdominal pain during 3rd trimester may warrant caution against coitus and orgasm. No blowing of air into vagina during last few weeks of pregnancy when cervix can be slightly open? During 1st and 3rd trimesters, some women complain of lower abdominal cramping and backache after orgasm. Tonic uterine contraction, often lasting up to a minute, replaces rhythmic contractions of orgasm during 3rd trimester.

Table 14-2 Discomforts related to pregnancy:

  • 1st trimester:
    • Nausea/Vomiting – eat dry carbohydrate upon wakening; avoid fried, odorous, spicy, greasy or gas forming foods; wear acupressure bands to treat motion sickness; ginger or acupuncture may be helpful; vitamin B6 + doxylamine (Diclegis) may be ordered if weight loss occurs
  • 2nd trimester:
    • Faintness: vigorous leg movement, keep environment cool. Food cravings influenced by culture or geographic region.
    • Varicose veins – avoid lengthy standing/sitting, rest with legs and hips elevated, warm sitz baths, local application of astringent compresses.
    • Heartburn – sip milk for temporarily relieve, hot herbal tea
    • Varicose veins (Varicosities) can be associated with aching legs and tenderness. Avoid lengthily standing or sitting. Rest with legs and hips elevated, warm sitz baths, local app of astringent compresses
    • Carpal tunnel – elevate affected arms
    • Round ligament pain (tenderness) – caused by enlarging uterus – not preventable. Use good body mechanics. Relieve cramping by squatting or bringing knees to chest
    • Joint pain, backache, pelvic pressure – get back rubs
  • 3rd trimester:
    • Leg cramps (gastrocnemium spasm), esp when reclining: stand on cold surface, calcium carbonate or calcium lactate tablets, aluminum hydroxide gel w each meal removes phosphorus by absorbing it
    • Ankle edema – ample fluid intake for natural diuretic effect

Variations in Prenatal Care/Cultural Influences: variations that influence care include culture, maternal age, medical and OB history and # of fetuses.

  • Cultural Influences – standards of care at early prenatal care in not only unfamiliar but also seems strange to women of other cultures. Lack of $, transportation and language barriers, women from diverse cultures may not see care until late in pregnancy or may not participate at al. concern for modesty can be deterrent. For some, exposing body parts, esp to male, considered serious violation of modesty. Invasive procedures such as vaginal exam so threatening they cant discuss it, even w own husbands. Many women prefer females. Many cultural groups regard care to be necessary only in times of illness. Not considered appropriate during pregnancy. Cultural prescriptions tell women what to do and cultural proscriptions establish taboos. Purpose of theses practices are to prevent maternal illness resulting from pregnancy-induced imbalanced state and to protect vulnerable fetus. They regulate woman’s emotional response, clothing, activity, rest, sexual activity and dietary practices.
  • Emotional Response – some cultural proscriptions involve forms of magic. Some Mexicans believe pregnant women should not be allowed to witness an eclipse of the moon because it can cause a cleft palate. Exposure to earthquake can precipitate preterm birth, miscarriage or breech. In some cultures, pregnant women must not ridicule someone with an affliction for fear her child might be born with same handicap.   Mother should not hate a person lest her child resemble that person. Dental work shouldn’t be performed because may cause baby to have cleft lip. Folk belief widely held is that woman should refrain from raising arms above head and from tying knots because they tie knots in umbilical cord and can cause it to wrap around baby’s neck. Placing knife under bed of laboring woman will “cut” her pain.
  • Physical Activity and Rest – norms that regulate physical activity of pregnancy vary tremendously. Some encourage women to be active, to walk and to engage in normal, not strenuous activities to ensure baby is healthy and not too large. Some believe any activity is dangerous and family members willingly take over work of pregnant woman, believing inactivity protects mom and child. Mother encouraged imply to produce succeeding generation. If health care professionals unaware, they may misinterpret as laziness or nonadherence with desired regimen. Important to find out views on activity and rest.
  • Clothing – modesty an expectation of many. Amulets, medals and beads women by women from some cultures to promote health or protect woman and fetus from danger. Some Mexican women of U.S. SW and Central America wear cord beneath breasts and knotted over umbilicus. Called a muneco, thought to prevent morning sickness and ensure safe birth.
  • Sexual Activity – most cultures do not prohibit until end of pregnancy. Some view it as necessary to keep birth canal lubricated.

Age Differences:

  • Adolescents – U.S. has one of highest teen birth rates among industrialized nations. Much likely to receive adequate care, often receiving none at all. More likely to smoke and less likely to gain adequate weight. Babies increased risk of LBW, serious and long term disability and of dying during first year.
  • Women 35+ – increased risk of miscarriage, stillbirth, diabetes, hypertension, placenta previa, placental abruption and cesarean birth. Chromosomal abnormalities, LBW, preterm birth and multiple gestation.
  • Multifetal Pregnancy – With increased use of assistive reproductive technology and ovulation induction agents, incidence of multifetal pregnancy has risen. In US. Twin birth rate has stabilized at 33.1 / 1000 births. Triplets and higher is 124.4 /10000; a drop from 153.5 in 2009.
    • Multifetal pregnancy places mother and fetuses at increased risk for adverse outcomes. Maternal blood volume is increased, resulting in an increased strain on maternal cardiovascular system. Anemia often develops because of greater demand for iron by fetuses. Marked uterine distention, increased pressure on adjacent viscera and pelvic vasculature, and diastasis of rectus abdominis muscles can occur. Women at increased risk for gestational diabetes, hypertension and preeclampsia. Placenta previa develops more commonly because of large size or placement of placentas. Premature separation of the placenta can occur before the 2nd and any subsequent fetuses are born.
    • Multifetal pregnancies often end prematurely. Risk of preterm labor and birth increase w number of fetuses. Spontaneous rupture of membranes common. Fetuses likely to experience growth restriction or discordant growth. There can be local shunting of blood between placentas (twin-to-twin transfusion); this causes recipient twin to be larger and donor twin to be small, pallid, dehydrated, malnourished and hypovolemic. However, larger twin can develop congenital heart failure during first 24 hrs after birth. The risk of death of 1 or more fetuses increases significantly w higher order multiples.
    • If presence of >3 diagnosed, parents may receive counseling regarding selective reduction to reduce incidence of premature birth and improve opportunities for remaining fetuses to grow to term. Poses ethical dilemma for many couples, esp those who have worked hard to overcome problems w infertility and have strong values regarding right to life. Nurses can help them identify resources (priests, ministers, mental health counselor) to aid in decision making.
    • Likelihood of multifetal pregnancy increased if 1 or combination of following factors is noted:
      • History of dizygotic twins in female lineage
      • Use of fertility drugs
      • More rapid uterine growth for # of weeks of gestation
      • Polyhydramnios
      • Palpation of more than the expected # of small or large fetal parts
      • Asynchronous fetal heartbeats or more than 1 fetal electrocardiographic tracing
      • Ultrasound evidence of more than 1 fetus
    • Diagnosis of multifetal pregnancy a shock to many parents.
    • Prenatal care includes changes in pattern of care and modifications in other aspects. Prenatal visits scheduled more frequently. Frequent ultrasounds, nonstress tests, and FHR monitoring will be performed. Mother needs info related to self-management because guidelines differ. Specific instruction regarding nutrition. other about risk of preterm labor and warning signs. Uterine distention associated w multifetal pregnancy can cause backache commonly experienced by pregnant women to be even worse. Maternal support hose may be worn to control leg varicosities. If risk factors such as premature dilation of cervix or bleeding are present, abstinence from orgasm and nipple stimulation during last trimester is recommended to avert preterm labor. Some recommend bed rest at 20 weeks to prevent preterm labor; others question value of prolonged bed rest. If bed rest recommended, mothers assumes lateral position to promote increased placental perfusion. If birth is delayed until after 36th week, risk of morbidity and mortality decreases for neonates.
    • Multiple newborns can place strain on finances, space, workload and woman and family’s coping capabilities.   Lifestyle changes can be necessary. Parents should be referred to national orgs such as Parents of Twin and Triplets (, Mothers of Twins ( and LLL.

Perinatal Education:

  • Classes for Expectant Parents– early pregnancy: early fetal development, physiologic/emotional changes, nutritional needs. Mid-pregnancy: breastfeeding/formula feeding, infant care. L ate pregnancy: Lamaze, Bradley, dick read – see ch 17. Classes for adolescents, first time mothers older than 35, single woman, adoptive parents, parents of multiples, or women with special needs such as visual/hearing impairments. Cesarean birth.

Perinatal Care Choices:

  • Physicians – 92% of hospital births and 5% of home births. Midwives – 7.6% hospital births and 30.4% out of hospital births. 2.5% birth centers and 2.5% homes. Fewer epidurals and episiotomies and instruments. Increased likelihood of spontaneous vaginal birth. In US. CNM, CMs and CPMs. Home birth – 2 to 3 fold risk for neonatal death compared with planned hospital birth. Large scale studies have documented safety of planned births for low risk woman by CN<s and when plan for transfers in place.
  • Midwives – 6% increase in CNM/CM attended births 05-12, accounting for 7.6% of all hospital births and 30.4% of out of hospital births. Out of hospital births attended by CNMs and CMs occurred in freestanding birth centers (2.5%) and homes (2.5%). Benefits for moms/babies including reduced use of epidurals and fewer episiotomies and instrument assisted births. Increased likelihood of spontaneous vaginal birth. In U.S., 3 types credentialed professional midwives: CNM, CM and CPM. CMs and CPMs known as direct-entry midwives. CNMs legally approved to practice in all 50 states. Fewer states allow the others to practice.
  • CNMs – registered nurses w education in 2 disciplines of nursing/midwifery. Graduate level. Trained to provide women’s health care through lifespan. Practice collaboratively w physicians or independently w arrangement for physician backup. Usually see low risk women. Care often noninterventionalist. Refer women w complications to physicians.
  • DirectEntry Midwives – CMs trained in midwifery schools, colleges or universities. Nursing degree not required, although bachelor’s degree and specific health and science courses required. Graduate degree required for entry into practice. CPMs educated in midwifery programs in colleges, universities, or midwifery schools or through self-study and apprenticeship.
  • Traditional/Lay Midwives – independent aka community-based midwives. Not certified. Trained through self-study and apprenticeship. Up to woman seeking care to assess level of experience. Can legally practice and are licensed in some states, although specific requirements and guidelines must be followed. Usually not covered by 3rd party payers.
  • Doula – provides physical, emotional and information support to women and partners during labor and birth. Shown to decrease use of pain meds, increase satisfaction and increase likelihood of spontaneous vaginal birth. No known risks. Meets w couple before labor and doula focuses her efforts on assisting woman to achieve her goals. Can be found through community contacts, health care providers, or childbirth educators. DONA certifies doulas. Also postpartum doulas.
    • Questions to Ask When Choosing a Doula:
      • What training have you had?
      • Tell me about your experience w birth, both personally and as a doula
      • What is your philosophy about childbirth and supporting women and their partners through labor
      • May we meet to discuss our birth plans and the role you will play in supporting me through childbirth?
      • May we call you w questions or concerns before and after birth?
      • When do you try to join women in labor? Do you come to home or meet at hospital?
      • Do you meet w us after birth to review labor and answer questions?
      • Do you work w 1 or more backup doulas for times when you are not available? May we meet them?
      • What is your fee?
    • Birth Plans- tool which parents can explore childbirth options and choose those most important to them.


Creating a Birth Plan:

  • Partner’s participation: attend prenatal visits? Childbirth and education classes? Present during labor? During birth? During cesarean?
  • Birth setting: hospital delivery room or birthing room? Birthing center? Home?
  • Labor management: walk around during labor? Use a rocking chair? Shower? Jacuzzi? Intermittent vs continuous use of EFM? Music/dimmed lighting? Older children or other people present? Telemetry monitoring available? Stimulation of labor? Medication?
  • Birth: positions – side lying? Hands and knees, kneeling, squatting? Birthing bed or delivery table? Photographing, videotaping or recording any of labor or birth? Who present – partner, older siblings, other family members, friends? Forceps? Episiotomy? Partner cut cord? Emergency considerations – cesarean?
  • Immediately after birth – skin to skin immediately? Breastfeed immediately?
  • Postpartum care: how long does insurance company provide coverage for you to stay? Attend self-management classes?


Questions to Ask When Seeking a Maternity Care Provider – CIMS (group of>50 nursing and maternity care-oriented orgs produced).

  • Who can be w me during labor/birth?
  • What happens during a normal labor and birth in your setting?
  • How do you allow for differences in culture and beliefs?
  • May I walk and move around during labor? What position do you suggest for birth?
  • How do you make sure everything goes smoothly when my nurse, dr, midwife or agency works w one another?
  • What things do you normally do to a woman in labor?
  • How do you help mothers stay as comfortable as they can be? Besides drugs, how do you help mothers relieve the pain of labor?
  • What if my baby is born early or has special problems?
  • Do you circumcise babies?
  • How do you help mothers who want to breastfeed?

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.

  • Hospital: types of services vary greatly from traditional LDR w separate postpartum and newborn units to in-hospital birthing centers where all care takes place in single unit. Stay for 6-48 hrs after birth. Unites furnished to provide homelike atmosphere and some have accommodations for family members to stay overnight. Fetal monitors, emergency resuscitation equipment and heated cribs/warming units; often in cabinets when not being used.
  • Birth Centers: located near hospitals so quick transfer can occur when needed. Staffed by CNMs or physicians who also have privileges at local hospital. Only low risk women. Homelike accommodations including double bed for couple and crib for newborn. Emergency equipment and drugs in cabinets. May be living room, small kitchen. There until discharge, often within 6 hrs after birth. Lending library w books, DVDs and reference materials for childbirth educators. Community resources for early parenting, support groups, genetic counseling. Fees typically less than or equal to those charged by hospitals. Some have a reduced fee sliding scale. Several 3rd party payers, as well as Medicaid and Civilian Health and Medical Programs of Uniformed Services recognize and reimburse these centers.
  • Home Birth: popular in certain countries such as Netherlands. Also in developing countries. Less than 1% of births in U.S. ACOG agrees safest place is hospital or birthing center. ACOG notes that absolute risk may be low, but cite a 2-3fold increased risk for neonatal death. Research findings based on cohort and observational studies do not support this stance. Large-scale studies documented the safety of planned home birth for healthy, low risk women attended by CNMs when system in place for transfer to hospital. National groups supporting home birth are Home Oriented Maternity Experience (HOME) and National Association of Parents for Safe Alternatives in Childbirth (NAPSAC). Advantages – mother may be more relaxed. Less interventions. Contact w newborn immediate and sustained. Less expensive. Serious infection less likely because people generally relatively immune to own home bacteria.


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:

  • Missed appointments
  • Excessive worrying (often about moms own health or health of baby)
  • Looking unusually tired
  • Requiring a support person to accompany her to appointments
  • Significant weight gain or loss
  • Physical complaints w no apparent cause
  • Poor milk production or breastfeeding problems (could indicate thyroid dysfunction)
  • Evading questions about her own well-being
  • Crying
  • Not willing to hold the baby or unusual discomfort handling or responding to baby
  • Not willing to allow others to care for baby
  • Excessive concern about baby despite reassurance (ex: eating sufficiently, development, weight gain)
  • Rigidity or obsessiveness (ex: regarding baby’s feeding/sleeping schedules)
  • Excessive concern about appearance of herself or baby
  • Expressing that baby doesn’t like her or that she’s not a good mom
  • Expressing lack of partner support

Warning Signs in Baby

  • Excessive weight gain or loss
  • Delayed cognitive or language development
  • Decreased responsiveness to mom

Questions to Ask:

  • How are you doing? Have good eye contact w her while you ask
  • How are you feeling about being a mom? Women who feel like they’re doing a bad job or who generally don’t like the job may be depressed
  • Do you have any particular concerns?
  • How are you sleeping (quality and quantity)? 6 hrs of uninterrupted sleep per night required for clear thinking/functioning
  • Can you fall asleep and stay asleep at night when everyone else is asleep? (Sleep problems common in every mood and anxiety disorder)
  • How is baby sleeping? Poor infant sleep is associated with maternal depression and anxiety
  • Who gets up at night w baby?
  • Have you had any unusual or scary thoughts? If yes, refer to perinatal psychotherapist or psychiatrist for immediate evaluation. Some thoughts may be normal; however, others may indicate obsessive-compulsive disorder (less urgent) or psychosis (emergency)
  • Are you receiving adequate physical and emotional help? A good support system of family and friends can make a significant difference
  • Do you generally feel like yourself? Women w perinatal mood disorders often report not feeling like their usual selves, or having a different personality
  • How is your appetite? A significant change in appetite is a warning sign. Check for rapid weight loss or gain
  • What and how often are you eating and drinking?
  • If breastfeeding or pumping, how is it going? Poor milk production may indicate a thyroid dysfunction or be a result of anxiety
  • If using formula, when and how quickly did you wean the baby? Abrupt weaning can precipitate a mood disorder or anxiety disorder
  • When was your last period? Fist menses after delivery can be a precipitating factor
  • Are you taking any medications or herbs on a regular basis? Women who are self-treating for insomnia, anxiety, sadness, fatigue or other symptoms that may indicate a mood or anxiety disorder should be evaluated by a perinatal psychotherapist
  • Are you feeling moodier than normal (tearful, irritable or worried)? This is common in mood disorders.
  • Have there been any healthy problems for your or the baby? These factors increase the risk for mood and anxiety disorders
  • How are you feeling toward your baby? Ambivalence and anger are 2 examples of feelings that may indicate postpartum depression. Discomfort around the baby may indicate anxiety or OCD.

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.

  • Parents w babies in intensive care at high risk for depression/anxiety; they need extra support and screening. Have referrals to local professionals available.
  • Use standardized postpartum screening tool; women should be assessed throughout 1st
  • Women already on meds or those who you assess who need medical evaluation should be referred to psychiatrist specializing in mood and anxiety disorders.

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.

  • Woman taking psychotropic medication who is pregnant or planning pregnancy should be encouraged to consult perinatal psychiatrist to determine whether to continue/change meds. Women on mediation for bipolar or psychosis should develop medication plan; they need careful monitoring throughout pregnancy and postpartum.
  • Use standardized postpartum screening tool.
  • Women already on meds should be referred to psychiatrist specializing in perinatal mood.

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.

  • Women taking psychotropic meds who is pregnant or planning pregnancy should consult w psychiatrist specializing in PMADs to determine whether to continue. Women on meds for bipolar or psychosis should be referred to psychiatrist to develop medication plan. Need careful monitoring throughout pregnancy and postpartum.
  • If interviewed before employment, can ask about particular concerns about birthing or postpartum. Let woman know that one of your strengths is sensitivity to various emotions that can occur during birth or postpartum.
  • If continue to see women postpartum, use Postpartum Risk Assessment. Info can be gathered informally, simply through chatting.

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.

  • Help to create healing/supportive environment, such as opening curtains to give more light, checking to see if she has healthful food and eliminating unnecessary noise to make her home calmer and more soothing.
  • Use standardized postpartum screening tool such as EPDS or PDSS.

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.

  • If physical/emotional health declining, it’s not good for baby. Support person will need to feed baby during half of night if not getting enough sleep (6 hrs a night at least a few nights a week).
  • Breastfeeding difficulties may be associated w sexual abuse, childbirth trauma, OCD, depression and anxiety. Women suffering w depression and anxiety give up breastfeeding more quickly. When mental health improves, often lengthens duration of breastfeeding. Sudden weaning can precipitate mood or anxiety disorder, esp when woman is predisposed. If she’s suffering, abrupt weaning can greatly exacerbate symptoms. Esp if woman is depressed and not feeling good about herself, there can be great amount of guild if at any point she cannot or should not continue breastfeeding.   What you say or do not say at the time can make a big difference regarding how she feels about herself as a mom.
  • Many professionals unaware of current research regarding psychotropic meds in breast milk – important to be informed so you can advocate for women who want to continue taking meds. Have referral to psychiatrist w experience prescribing medication during lactation. Use standardized postpartum screening tool.

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.

  • Can invite expert in field to speak to class.
  • Rate of depression in pregnancy 15-23%. Some of women already suffering in class and at risk for postpartum disorders. No danger in giving info and great danger in omitting it. Partner might soak up info if mother to be doesn’t. often spouse who recognizes symptoms and encourages wife to seek help.
  • Hand out info from resources section and name and number of professional trained in perinatal mood disorders. If follow up w participants, ask about feelings regarding challenges as well as joys of parenthood. Be sure to call participants who didn’t attend reunion. May not be doing well and could be trying to avoid an uncomfortable situation. PSI DVD (Resources) will be helpful.

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.

  • Encourage discussion about normal feelings accompanying adjustment to parenting and relationship to oneself, partner, baby, friends and family.
  • Can invite professional.

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.

  • Research shows certain hormone levels in expectant fathers change during pregnant. Lower testosterone and cortisol and higher levels of estradiol than men who aren’t expecting babies.
  • Attend well baby checks ups, talk to new fathers about what to expect weeks after birth, maintain your relationship with your partner, think about how you can care for your new baby.
  • If partner isn’t baby’s biological father, he may feel pregnancy is “yours”, not “ours”. May question his role in making decisions and providing financial support for growing family. If baby’s biological father is involved, partner may feel even less sure about role. Lesbian couples: Does partner want to adopt baby? what role will biological father plan? If in a heterosexual relationship with someone new, who will accompany to prenatal appointments, be there at birth.
  • If pregnant and single: society often offers single parents little support. But may be relieved you don’t have to deal with added burden of an incompetent partner. Times when you doubt you can – or want to – parent alone. May wish for companionship/support of a reliable person.
  • Books: The Birth Partner, The Expectant Father, Father’s First Steps, The New Dad’s Survival Guide.
  • Classes for dads: Conscious Fathering classes, Boot Camp for New Dads


  1. Additional Reading: Practice Settings for the Childbirth Educator
    1. ICEA Statement – Practice Settings for the Childbirth Educator


  • Teach variety of options include alternatives to care at hospital such as home birth
  • Promote freedom to choose where, how, with who care should take place
  • Continue to grow/expand as childbirth educator
  • Class size limited to 6-10 people and their support person
  • Woman has option labor partner of choice
  • Adequate physical surroundings
  • Adequate teaching materials – handouts, text, visual aid

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.

  1. ICEA Teaching Idea Sheet #1: Using a Pelvic Model

Pelvic Model Can Be Used:

  1. Female anatomical structure and function – important parts of pelvis, such as inlet, outlet, ischial spines, coccyx etc. Effects of hormone relaxin on joints, as well as increased size of pelvic outlet can be illustrated by loosening screws on plastic model. Station, descent, cardinal movements, process of birth, fetal positions and presentation can be demonstrated by using w a fetal doll or fist
  2. Positions for pushing – use flexible clothes dryer (part which leads from dryer to outside vent; right angle – can purchase ad hardware store) elbow to show advantages and disadvantages of various positions. Insert elbow directly into pelvis to demonstrate “down-up-and-out” dynamics of pushing. Gives visual explanation of value of upright position.
    1. Available in 2 forms: metal and plastic (recommended). Discussion of elasticity of vagina important.
  3. Posterior position and back labor – point out coccyx and sacrum. Physiological reasons for back massage, counter measure and effleurage.
  4. Good posture and body mechanics – place pelvis in carious positions. Teach pelvic rocking by tilting pelvis forward and backward.
  5. Causes of common discomforts of pregnancy – swelling, sciatic pain, decreased circulation in extremities, pelvic distention and hemorrhoids can be illustrated by using pieces of ribbon, rope or yarn to portray abdominal sorta (1 red piece), sciatic nerves (2 green pieces), and pelvic veins (2 blue movies). Place them in pelvis as they appear anatomically. Ribbons may be taped. Inflate medium sized balloon until shaped like uterus. Place neck down into pelvis to show effect of weight of gravid uterus on arteries, veins and nerves. Shows graphic of supine position on laboring woman. Use neutral colored balloon and under-inflate.
  6. Relationship of fetus, uterus and pelvis during childbirth – place fetal doll in knitted uterus and place in pelvic model.
  7. Location and function of pelvic floor muscles – stretch 2 wide rubber bands around screws of pelvic model, 1 on right, 1 on left. Will illustrate sling effect of perineal floor. Discuss importance of pelvic floor. When teaching Kegels, press rubber bands down and up to demonstrate strength, function and muscle tone of perineal floor. Contrast between good and slack pelvic musculature can be demonstrated by using smaller, tighter rubber bands and then larger ones.
  8. Hold pelvis forward, not up and down. It tips quite far forward in normal woman
  9. Using a Knitted Uterus
  10. Instructions for Knitting a Uterus and Vagina
  • The Body as a Teaching Tool
  1. Using a Teaching T-shirt
  • Factors and predispositions of vulnerable populations
    1. MWHC Pgs 31-33 (Ch 2) – see above
    2. ICEA Teaching Idea Sheet #13 – Working with Families W Low Literacy Skills

~23MM Americans may not be able to comprehend what professionals are discussing w them.

Written Material:

  • Consider readability, clarity and amount of text presented
  • Will people be able to identify w photographs?
  • ICEA Bookmarks has great selection of posters and books
  • March of Dimes has many prenatal pamphlets written for low literacy families

Verbal Material:

  • Simple, non condescending language
  • Present only a few ideas at a time, allowing time for questions
  • Don’t assume anything. Start w basic and build on teaching
  • Connect new ideas w familiar experiences (contractions may feel like baby balling up inside)
  • Terminology – present commonly known term w proper term

Posters and Visual Aids:

  • Simple, uncluttered, present 1-2 ideas at a time
  • Careful of cartoon illustrations. Simple drawings best
  • Whole bodies instead of parts
  • Changing anatomy better in black and white w organs colored rather than different colors that all blend together
  • Video clips w people with which families identify.
  • Preface videos w intro about what’s going to be seen and what to look for. Can stop video if discussion is helpful
    1. ICEA YouTube Channel – Video presentation: National Perinatal Task Force (Jenny Joseph, 1 min 16 sec)

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.

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