ICEA Study Guide 4 – Curriculum Development

 

OBJECTIVES At the completion of Part 4 the learner will:

■ discuss how curriculum should reflect the goals of a client and her family with each trimester.

■ list three phases of a partner’s adaptation to pregnancy and birth that should influence curriculum.

■ list five considerations helpful in designing a childbirth class.

■ compare and contrast block and spiral sequencing.

■ list concepts to improve recall.

■ define a learner-centered curriculum.

■ write learner-centered objectives using the SMART format.

■ name three domains of learning and write a learner-centered objective in each domain.

■ recognize the importance of evaluating outcome.

 

OUTLINE

  1. The needs of women change during the childbearing year and should influence class content

Teaching an Early Pregnancy Class

Icebreaker: Hazards of pregnancy (myths and facts), Introductions, Physical Changes of Pregnancy, Discomforts/Comfort Aids:

  • Have them fill out form – “tell me about yourself” when the come in
  • Pass around grab bag of items hazardous or safe for pregnant woman. Ask them to grab and guess.
  • Have each person (woman and partner) mention something positive and negative about pregnancy as introduce selves. Write it down on flip chart.
  • With child conception to birth posters or PowerPoint cd available from childbirth graphics illustrate changes in pregnant body
  • Use discomforts mentioned. Have people share what comfort techniques work for them.

Body Mechanics, Exercise (Benefits, Suggestions, Pelvic Tilt, Kegel, Precautions):

  • “Moving with pregnancy and birth” from celebrate birth! (Injoyvideos.com)
  • Mini lecture, demonstration, return demonstration, practice, pelvic floor muscle chart
    • Music great; ask partners to practice too
  • Kegels – hand out Kegel stickers
  • Handout on warning signs
    • Discuss possible prevention of gestational diabetes, decreased incidence of depression, stress relief, easier labor and birth.

Emotional changes of pregnancy/sexuality:

  • Divide pregnant women and labor partners into separate groups. Have each group list emotional changes in partner since they became pregnant. Discuss. If sex doesn’t come up, be sure to discuss

Unexpected outcomes

  • Before going to break, pass out index cards. Have everyone write their greatest fear/concern about this pregnancy. After break, read cards. Discuss fears briefly, resources for help and stages of grieving. Read and discuss the story “Welcome to Holland” Show first birth “Expect the Unexpected” from Open Minds to Birth; lead discussion after showing YouTube video.
  • Hard topic for most educators but important in early pregnancy when moms might have miscarriage. Not all unexpected outcomes are negative. Open Minds to Birth is available on YouTube (episodes 1&2)

Nutrition/Precautions

  • Have each pair fill out nutrition quiz. Discuss.

Informed Decision making/overview of birth options

  • Ask about questions over choices they are making now regarding pregnancy (prenatal testing). Give them informed decision making cards (IV-101) and discuss.
    • Ask class members advantages/disadvantages of each
  • Lead discussion about how pregnant women can plan for 6 healthy birth practices as recommended by Lamaze – short video clips on each practice available on website
    • Include discussion on risks/benefits of: elective cesarean, elective induction, epidural, natural childbirth

Fetal development

  • Video: Fetal development – a 9 month journey (04 edition; milner-fenwick.com) or edit Miracle of Life, which is less expensive and widely available (amazon). Nice way to end class.

Refresher – 1 day (9am -4:30pm)

  • Icebreaker- 5 min – “I remember wheel” find someone else who had at least 1 similar experience. Rethink birth as class gathers. Share a previous experience with someone in room
  • Overview handbook – 5 min – review contents so they will be aware of reference they have; reinforce outside reading
  • Introductions with agenda setting -10 min – using wheel share most significant memory. Encourage class bonding to increase class discussions
  • Terminology and anatomy – 5 min – illustrations on pages 7,39-42 workbook. See pg IV 8-9.
  • Onset of labor – 5 min – discuss student’s own experiences; pg 38. Emphasize uniqueness of birth
  • Exercises – 10 min – 5 min review to music; pg 100. Learn by doing, feels good
  • Normal labor variations – 20 min – pgs 34-35; discuss in relation to stories of previous births; what might they have done differently? Think how 1 might cope with possible variation
  • Break – 15 min – refreshments
  • Positioning – 15 min – ask students to assume positions on pgs 20-23. Demonstrate and explain comfort measures used in different positions (heat, cold, pressure, vibration). Practicing makes it more likely they will use it. Discussing why it works increases confidence. Plan for things that comfort them
  • Labor support through phases of labor, esp VBAC – 20 min – quick review of flow of labor and what labor support might be, pgs 39-42. Reinforce how partner helps; pain relief strategies
  • Progressive relaxation – 15 min – practice sequence on pg 104. See scripts pgs IV 33-50. Demonstrate sensations of tension, stretch and release
  • Guided imagery – 15 min – instructor recites image with music. See in section IV. Handbook pg 106- concentrating on positive thoughts diminishes pain
  • Fight or flight response – 10 min – story to illustrate; how it pertains to labor. Gives reasons to relax or respond to labor rather than flee/fight
  • Pain pathways – 15 min – demo use of heat, cold, water, vibration etc. “With this birth” pg 108; physiological effects of stimuli which reduce pain perception
  • Breathing – 10 min – introduce strategies of visualizing scenes or colors, use of words or phrases; counting; images, or patterns with paces of breathing on pgs 43 & 107
  • Differences in 1st and 2nd pregnancies – 5 min – discussion of tales heard. Myths vs facts. Reality of life with 2 or more
  • Lunch – 1 hr – directions on where to find food
  • Stroking and massage – 15 min – demo and return pgs 24-26, 105. Scripts pgs IV 39-43; learn to help partners reduce stress
  • 2nd stage pushing – 20 min – show video or slides of birth; VBAC DVD if appropriate. Practice various positions for 2nd stage pg 44-45
  • Medical options and interventions; medications; cesarean birth – 20 min – discussion of options/decisions in previous births; pros and cons- prepare for negotiations and discussions with providers
  • Selective relaxation/release to touch – 20 min – practice session with partners; release to touch pg 26
  • Siblings -15 min- offer ideas for preparing siblings pgs 28-29
  • Break – 15 min
  • Rehearsal – 1 hr – good bag to share contents for practice session, pg 96. Practice breathing, relaxation, position, and labor support with labor stations. Pgs IV 73-76. Helps them decide what they might like in labor
  • Birth plans – Q&A with problem solving – 15 min – couple activity to complete, pg 111. Make plans for upcoming birth
  • Closing slides or video; evaluation

I remember…? Icebreaker: Write down the first thing that pops into your mind about each topic. Go around room and find other students who wrote the same or similar feelings: Natural childbirth, The Baby, Pain, Hospital, Medication, Doctor or Midwife

Teaching Parents of Multiples – increase in multiple births – ideal when they are taught in classes designed especially for them alone. Preparing for multiples – the family way.

Rationale for special classes – statistically, infants are born earlier and smaller than singletons and less likely to survive 1st year of life. Parents of multiples more likely to need detailed info on preterm labor, bedrest, what to expect in NICU, cesarean. Nutritional needs are considerable different. Prenatal tests more prevalent. Discomforts more exaggerated and appear sooner. Build confidence in parents for a positive, normal birth while at same time realistically preparing them w info they may need to know in case of complications.

Classes should be taken early in 2nd trimester to prepare for different needs and in attempt to prevent potential complications.

Specific needs to be addressed for parents of multiples:

  • Terminology that identify whether babies are identical (monozygotic) or fraternal (dizygotic). Further divisions into 3 types of identical. See pgs 4-5.
  • Physical discomforts due to increased size of belly and weight of multiple gestation.
  • Emotions of pregnancy soar and swing in multiple gestation due to impact of having multiple babies, increase hormones and changing body image. Discuss added emotional stress w added babies; suggest journaling/art/visualization; importance of communications (partner, family, caregiver)
  • Prenatal tests increased see pgs 9-10
  • Nutritional needs change with # of babies. Experts john p Elliott and Barbara duke agree diet high in calories and protein (esp meat) significantly increases birth weight of babies and length of gestational age at delivery. Eat 3 meals and 4 hearty snacks each day pgs 11-15
  • Warning signs to be taken seriously because preterm labor is difficult ro recognize due to overextension of uterus and exaggerated discomforts. Possible complications should be addressed as well as measures for preventing problems
  • Birth plans for multiples may involve even more thought and flexibility. Most moms have cesarean but its important that mom who gives birth vaginally and who needs coping skills not be neglected. If she does not prepare for vaginal birth, its even less likely that shell have one. Instill confidence in ability to give birth, encourage to trust instincts, give freedom to move and to labor as she sees fit and provide her with medical team supportive of her efforts.
  • 2nd stage delivery of >1 and postpartum care of 2+ that calls for special instruction.
  • See pgs VI-12 for parents expecting multiples in traditional childbirth class

Topic outline for 6-8 hrs of instruction: for those who combine with a general class for parents of single babies or cesarean class.

Morning or Day 1 of 2 day series (pg in multiples handbook):

  • Icebreaker – getting to know you
  • Orientation and introductions
  • Overview of course
  • Anatomy of multiple pregnancy (3-5)
  • Concerns, discomforts, things to try (6-8)
  • Introduce relaxation as life skill (8)
  • Prenatal care – tests and options (9-10)
  • Multiple nutritional needs (11-16, 128)
  • Exercise, activities, and limits (17-20, 129)
  • Planning ahead (21-26)
  • Expectations (29-30)
  • Positions of babies (30)
  • Vaginal or cesarean birth (31)
  • Multiple birth plans (32, 130-131)
  • Warning signs (33, 61-63)
  • Robyn’s birth from Miracle of Birth 2
  • Tour of labor, delivery and postpartum areas, nursery and NICU

Break for lunch or 2nd day

Afternoon or Day 2 of 2 day series:

  • Newborn characteristics 53-54
  • Gestational age and NICU needs 67-70
  • Options for NICU infants 71-72
  • Coming home from NICU x73-76
  • Massage for preterm babies; postpartum needs, expectations, emotions 79-81
  • Differences in baby blues and postpartum depression 81-82
  • Parenting, organizing and bonding 82-85, 133-135
  • Infant care 86-89
  • Infant safety, care seats, equipment and supplies 90-91, 136
  • Babies cues, activities, development 92-94, 134
  • Feeding multiples 97-109
  • Closing video segment: natural childbirth of twins and triplets youtube.com/watch?v=7E-wULAaD50

Topic Outline for 12-14 hours of instruction – Parents of Multiples. See VI-10-11

Teaching Tips for Multiples in Singleton Classes – emphasize rate of growth that a woman expecting multiples should expect. Her uterus will be the size of a 40 week singleton mom considerable before she is 40 weeks. She may need to be taught comfort measures sooner.

Be sure to emphasize positive aspects of vaginal birth for moms of multiples. When transition is over, she wont have to repeat the whole labor process. Only pushing is repeated.

In most hospitals, mothers of multiples will be moved to a surgical suite for the birth. Provides necessary space for extra staff and support people for the mother and babies, even if it’s a vaginal birth.

Show video of a twin birth. If don’t want to show to whole class, can show to couple during break or at end of class.

Fun to mention someone famous having a multiple or had multiples. www.tamba.org.uk has interesting and positive articles on twins and triplets in recent news.

www.karengromada.com has pictures of multiples breastfeeding simultaneously.

Emphasize need for postpartum support. Encourage parents to seek additional support from family, friends or professionals for severely weeks after babies come. Postpartum doulas DONA and CAPPA.

Provide resources. Promote local mothers of multiples club and provide contact numbers. Keep referral list of others in past who are willing to speak with expectant moms.

YouTube – Natural Birth of Twins and Triplets: www.youtube.com/watch?v=7E-wULAaD50

DVDs – Prepare parents for multiples; Robyn’s birth from Miracle of Birth 2

Web – Womb Mates

Teaching Teens – consider forming a special program for this important population. For the pregnant teenager, the decision to attend classes may involve more than the common considerations of time, cost or desire. It may also involve a teenager’s need for privacy, acceptance, and respect, which she fear she may not have in an adult centered class.

Similarities and differences between pregnant teens and adults:

  • Both able to physically conceive, nourish and give birth to a child
  • Both accept the fact of pregnancy in varying degrees of enthusiasm or reluctance
  • Both able to prepare mentally and emotionally for the birth only after reaching acceptance of pregnancy
  • Both may have fears or concerns of unknown and of ability to cope with their situation
  • Both benefit from childbirth prep and labor support given by caring, accepting individuals
  • Both want to know their options and make informed decisions
  • Both may challenge authority or may feel vulnerable in a medical environment
  • Both deserve respect and education which will build their confidence in their bodies to give birth and their abilities to become a caring mother
  • Pregnant teen has fewer life experiences from which to draw
  • Pregnant teen is still growing herself, while a baby is growing within her
  • Pregnant teen alternates between adult and childlike behavior while learning self-control
  • Pregnant teen more likely not to have chose to become pregnant
  • Pregnant teen is frequently concerned (Sometimes shamed) by her pregnant appearance
  • Pregnant teen is usually single
  • Pregnant teen often does not have all of the resources to provide for a baby
  • Pregnant teen may wish counseling to set up an adoption plan
  • Pregnant teen may not have a wide support system

Teach pregnant teen local resources in community. Some have support systems, and some have little support. May benefit from a social worker to help her establish prenatal care and follow-up and from support groups to help her deal with emotional aspects of pregnancy. The father of baby has paternity rights if he chooses but law does not require him to be responsible. If he is a responsible partner, he should be encouraged to prepare for birth and parenting with her. The labor partner the woman chooses will not necessarily be the father of the baby.

Who, where, when and how:

  • Educator must have compassion for, and be accepting of, pregnant teens
  • Schoolroom or community center may offer better comfort zone than hospital classroom
  • 5 – 2 hr early evening classes allow for shortened attention spans or interest levels, as well as time for school work
  • Break time is important for class bonding and learning from one another
  • Evening meal or healthy snacks can teach and reinforce good nutrition and may even provide the only good food of the day for some teens
  • Most teens prefer activity over lecture. Use participatory sessions, games, videos, posters, models, demonstration and return demonstration

Important Considerations:

  • Listen to teen mother
  • Help her build confidence that her body is functionally designed to give birth and to breastfeed successfully, even at her age
  • Draw out her questions and concerns, and give her info so she can discuss her desires with her healthcare provider
  • Provider her with techniques for communication and values clarification
  • Teach and practice skills that will help her cope with labor. Successful birth experience can build self-confidence that can help her succeed in other aspects in her life
  • Extend support services beyond the prenatal period into labor, birth postpartum and her return to school
  • Encourage her to breastfeed baby
  • Help her to form a plan for making up school work and returning to school. Completing her degree will further her own personal development and feeling of accomplishment
  • Discuss adjustment to parenthood and childcare options
  • Teach newborn cues to those teens who plan to keep their babies, so that they will have a better chance of bonding and accepting the full-time commitment to baby
  • Provide resources and encouragement for those who decide to give their baby for adoption
  • Resources: when children want children; dubious conceptions; reviving Ophelia
  • Pamphlets: noodle soup
  • DVDs: healthy steps for teen parents – 3 volume set from InJoy

Teen Childbirth Class: A School/Community Partnership – Garland (TX) ISD initiated support of New Horizons program to reduce teen dropout rate, which offered:

Basic academic skills, tutoring and educational materials

  • Prenatal education and assistance in securing prenatal care
  • Family life education and personal, family and crisis counseling
  • Parent education
  • Career guidance and counseling services
  • Case management
  • Childbirth classes
  • Maternity leave services and home instruction
  • Prenatal nutrition assistance for children and breastfeeding assistance
  • Student and dependent transportation
  • Tuition assistance for evening and summer school
  • Child care assistance
  • Access to GED classes
  • Immunization assistance for children
  • Language interpretive services
  • Mentoring facilitation
  • Paternity establishment and initiation of child support payments
  • Social service networking
  • Development assessments of infants and children
  • Assistance in securing post-secondary training and education

Funded via federal, state, corporate and private grand funds. Working relationships with department of Human Services, Attorney General’s Office, health clinics, adoption agencies etc.

Teen Childbirth Class– Childbirth is a scary thought to any expectant mother. To a pregnant teenager, it may seem even scarier. Few understand the process and may fear going into labor while at school. Some may even stop attending during last month of pregnancy. Few attend childbirth classes because they feel uncomfortable in the same class with adult expectant parents. Classes are free to any students in the district. Outcomes are sometimes predictable, sometimes unexpected and almost always positive. Unexpected outcomes include changes in some doctors attitudes about pregnant teen’s ability to handle demands of labor, which makes them more willing to accept and respect them as patients. Classes have given teen fathers an opportunity to be involved. They also get a chance to learn and work together. Attendance in last month of pregnancy began to improve. Parents who attend with teen learn how to help pregnant teen, and they feel relief in knowing that help is available.

 

Common Changes and Concerns in Pregnancy

Your Body’s Preparation for Pregnancy – reproduction anatomy includes internal and external structures. Labia, urethra, clitoris and vaginal opening are external genitals. These plus panus are perineum. Pelvic floor muscles. Internal – uterus (womb, shape of a pear), and vagina -stretchy tube-shaped canal. Lower part of uterus, which protrudes into vagina is cervix. Fallopian tubes provide paths for egg (ovum) to travel from ovaries (sex glands) to uterus.   Ovaries produce female sex hormones estrogen and progesterone. During a cycle, egg matures in 1 ovary and causes increased secretion of estrogen, which along with progesterone stimulates growth of uterine lining (endometrium). Usually only 1 egg ripens each cycle and is released into one of your fallopian tubes. Ovulation occurs halfway through cycle. As fine hairs in fallopian tube propel egg slowly toward uterus, ovary produces more progesterone, which stimulates uterine lining to become a rich, nourishing home for a fertilized egg. If fertilization doesn’t occur, estrogen and progesterone levels diminish and your uterus sheds its unneeded lining (menstruation).

Conceiving Your Baby – he ejaculates ~1 tsp of semen, which contains 150-400 million sperm; they can live inside you for up to 3 days, while egg is viable for 12-24 hours after ovulation. Occasionally, woman ovulates more than 1 egg, resulting in fraternal twins, triplets etc or a single fertilized egg divides into 2 and produces identical twins.

Now That You’re Pregnant – breast changes – fullness/tenderness, tingling, darkened aeola; fullness, bloating, ache in lower abdomen; fatigue and drowsiness; feeling lightheaded or faint; nausea, vomiting, frequent urination, increased vaginal secretions

Confirming Pregnancy – hCg – human chorionic gonadotropin, hormone only produced during pregnant. Take 1 test after missed period and another a few days later. Confirm via blood test.

Calculating Due Date – Pregnancy/Gestation lasts average 280 days or 40 weeks after first day of last menstrual period. Difficult to know exactly when ovulation occurred. Simple formula – subtract 3 months from date of last period and add 7 days. Optional ultrasound in early pregnancy to help estimate due date. Babies born healthy and normal any time from 3 weeks before to 2 weeks after; most babies born within 10 days; 5% born on due dates. Due date important to determine best time to do genetic testing, whether results of lab tests within normal range, to diagnose preterm or post-date pregnancy, or see if baby is growing more slowly or rapidly than normal.

Hormonal Changes During Pregnancy – placenta is the major source of hormones

  • hCG – ensures ovaries produce estrogen and progesterone for first 2-3 months of pregnancy, until your placenta matures and produces appropriate amount
  • Estrogen – promotes growth of uterine muscles and their blood supply, encourages production of vaginal mucus, and stimulates development of the ductal system and blood supply in breasts. Changes in water retention, body fat buildup and skin pigmentation are related to estrogen levels. In late pregnancy, rising estrogen levels increase uterus’s sensitivity to oxytocin and help start labor.
  • Progesterone – relaxes uterus during pregnancy, keeping it from contracting too much. Helps maintain healthy blood pressure, greater absorption of nutrients/sometimes causing constipation. In late pregnancy, it has less effect on your uterus, letting contractions increase and start labor.
  • Relaxin – from ovaries relaxes and softens ligaments, cartilage and cervix, making them more stretchable during pregnancy and letting pelvic joints spread during birth
  • Prostaglandins – produced in amniotic membrane, increase in level during late pregnancy. They soften and ripen cervix in prep for labor and stimulate muscles in uterus and bowels.
  • Corticotropin-releasing hormone (CRG)- comes from baby, placenta, and tissues within your uterus. Increased levels in late pregnancy change ratio of estrogen to progesterone
  • Oxytocin – produced in pituitary gland, stimulates uterine contractions to help trigger onset of labor and promote labor progress. Responsible for urge to push at end of labor and for let-down reflex during breastfeeding.

 

First Trimester Changes for You and Your Baby“Formation” period because by end of it baby’s organ systems are formed and functioning.

First 4 Weeks

  • Changes in Baby – normal human cell 46 chromosomes; blueprint at conception determines baby’s sex, blood type, eye and hair color, nose and ear shape and some personality traits and mental capabilities; also guides baby’s growth and development throughout her life. After conceptions, fertilized egg quickly divides from 1 cell into 2, then 4, 8, 16, and so on until it becomes a multicellular structure called a blastocyst. It makes it way along fallopian tube and implants in uterine lining in upper part of uterus. By 2 weeks, baby is an embryo and another part of the fertilized egg develops into placenta.
  • Changes in You – breast tenderness, slight ache in belly.

Weeks 5-14

  • Changes in Baby – nervous system and circulatory system are forming and heart is beating by 25th Has simple kidneys, a liver, a digestive tract and a developing umbilical cord.   At half the size of a pea, arm and leg buds appear and face begins to form. Male and female embryos appear same until ~9 weeks old. If male, produces androgens, male hormones that signal development of scrotum and penis. By 8 weeks, baby is structurally complete. Mouth has lips, a tongue, and teeth buds in his gums. Arms have hands with fingers and fingerprints. Legs have knees, ankles and toes, arms and legs move at this time, but coordinate movements don’t begin until ~14 weeks. Developing brain begins to send out impulses. Heart is beating strongly and can be seen easily during ultrasound. At 9 weeks old, called a fetus. During first 3 months, baby becomes quite active. Legs kick and arms move. Baby can suck thumb, swallow amniotic fluid and urinate drops of sterile urine into amniotic fluid, which is completely exchanged ~every 3 hours. Baby makes breathing movements – breathing amniotic fluid into lungs appears to help with lung development. 10-12 weeks, baby’s eyelids cover his eyes, which remain closed until 6th month.
  • Development of Placenta and Changes in Uterus – at end of first month, chorionic villi extend into uterine lining, becoming a primitive placenta. Baby’s blood circulates through chorionic villi, while blood circulates into spaces surrounding them (intervillous spaces). Thin membrane separate 2 bloodstreams, which normally don’t mix. Membranes (amnion and chorion) create amniotic sac that surrounds baby. amniotic fluid protects baby by absorbing bumps from outside, maintaining an even temp, and providing a medium for easy movement. By 12 weeks, placenta is completely formed and serves as organ for producing hormones and exchanging nutrients and waste products. Most identical twins share same placenta. Fraternal twins have separate placentas, through placentas sometimes fuse into one large organ. Umbilical cord links placenta to baby’s navel and pass oxygen and nutrients from you to baby. placenta provides barrier against most (but not all) bacteria in bloodstream, most viruses and drugs cross. Placenta also exchanges waste products from baby, which blood then carries to kidneys and lungs for excretion. By 14 weeks, uterus has grown to just above pubic bone. Cervix is ~4cm long and though softer than before pregnancy, still fairly firm. Mucous plug fills cervical opening provides barrier to help protect baby.
  • Changes in You – 5 weeks, pregnancy test shows positive result. Feel unusually tired and need more sleep because of changing metabolic rate and increased energy needs while growing a baby. urinate more often as enlarging uterus presses on bladder. Nausea, vomiting; morning sickness can occur at any time of day. Cause unknown but hormones produced by developing placenta play a role. Milk glands don’t develop fully until pregnancy. As hormone levels increase, breasts change in prep of providing milk for baby. breasts enlarge, veins appear bigger, and nipples may be tender or have tingling sensation. Nipples and areolae enlarge and become darker. Little bumps on areolae (Montgomery glands) enlarge to produce more lubricant in prep for breastfeeding. Metallic taste, increased salivation, weight loss/gain up to 5 pounds. Difficulty seeing baby as real until proof by ultrasound scan or audible heartbeat (partner).

 

2nd Trimester Changes for You and Baby – “Development” period – baby’s organs and structures begin to enlarge and mature.

15th-27th Week

  • Changes in Baby: baby starts to grow hair, eyelashes and eyebrows. Lanugo develops on arms, legs and back. Fingernails and toenails appear. 18 weeks, baby can do all movements you’ll see her do as a newborn. Forming in baby’s intestines is meconium, collection of digestive enzymes and residue from swallowed amniotic fluid; won’t expel til after birth. Skin is wrinkled and covered in vernix caseosa. Feel baby move for first time (quickening). Light tapping/fluttering sensation that reminds you of gas bubbles. Some babies born at end of this trimester (25 weeks) survive. 23 weeks – heartbeat audible via regular stethoscope. 27 weeks eyes are open, begins to hear.
  • Changes in Placenta/Uterus – uterus expands into abdominal cavity to accommodate growing baby. length of pregnancy in weeks approximates distance in centimeters between pubic bone and top of uterus (fundus).   Uterus normally contracts periodically, although wont notice. Braxton hicks contractions make uterus hard for ~1 minute but aren’t painful; don’t cause changes in cervix.
  • Changes in You – milk glands in breasts begin making small amounts of colostrum by mid-pregnancy. Linea nigra may appear between pubic bone and navel. Skin around eyes may darken, especially after sun exposure; mask of pregnancy called chloasma usually disappears within a few weeks after baby’s birth.   Groin pain from round ligament contractions. Leg cramps.
  • Emotions – more sensitivity to kind word, beautiful sunset or touching photo. May affect sleep, recall more of dreams and may become introspective, distracted by need to examine thoughts and feelings. Swelling belly becomes more obvious; feel baby kick or wiggle. Being able to see evidence gets partner more involved.

 

3rd trimester changes for you and baby – “Growth period” – changes for an easy transition to life outside womb improve closer to due date.

  • Changes in Baby – in late pregnancy, baby’s lungs mature, antibodies pass through placenta to her providing short-term immunity to diseases to which you’re immune. Hair on head grows, lanugo disappears, and fat is deposited under her skin. Buds for permanent teeth appear behind her primary teeth. Baby has periods of sleep and awakeness. Becomes familiar with your voice and other sounds such as placental circulation, gurgling stomach, heartbeat and external sounds. After birth, baby will show a preference for familiar voice and sounds that mimic placental sounds – sloshing of water in dishwasher, vacuum, fan, shushing sounds often sooth baby. Less room to move around. Hiccups. Assumes favorite position – usually head down. Caregiver determines position by using Leopold’s maneuvers. Breathing movements present.
  • Fun – sing same song to baby or play favorite music. Read same children’s book/poem. Talk to baby. Press on belly when you feel hand./foot. Try pressing twice and see if baby responds.
  • Changes in Placenta and Uterus – cervix softens, uterus becomes more sensitive to oxytocin and may notice more contractions. Volume of amniotic fluid decreases from 1.5 quarts at 7 months to 1 quart around due date. 31 weeks – uterus is 3 fingerbreadths above navel. 35 weeks – uterus is just below breastbone and ribs.
  • Changes in You – uterus expands causing shortness of breast or sore lower ribs. High levels of progesterone and pressure from uterus may cause indigestion, heartburn, varicose veins in legs, hemorrhoids or swollen ankles. More back pain as pelvic ligaments relax for birth and heavy uterus and growing baby change center of gravity. Small red bumps (vascular spiders) may appear on skin of upper body along with stretch marks (striae gravidarum) on abdomen, thighs, or breasts – reddish during pregnancy and become glistening white after birth; no evidence shows lotions/cream effectively work to reduce. Tingling/numbness in hands. Increased perspiration/feeling warmer. Changes in balance and agility. Swollen ankles. Anemia. Total weight gain 25-35 lbs.
  • ~2 weeks before birth, baby “drops” into pelvic cavity – engagement or lightening. May feel less pressure on diaphragm and find breathing/eating easier. Tradeoff is baby’s head on bladder so need to urinate more frequently. Some women leak colostrum.
  • Emotions – may feel tired most of the time. Get a big body pillow or use many pillows. Talk about fears; it doesn’t make them more likely to happen, instead someone can comfort you and put fears into perspective. Partner may have anxiety over support role in labor. Longing for relationship to return to normal. Frustration about inability to “fix” partner’s discomforts. Fear of harm to baby during sex. Choosing names.

39th/40th Weeks of Pregnancy

  • Changes in Baby – baby’s organs continue to mature in preparation for life outside uterus. Adds fat and gains 1 pound. Newborn avg 20 in (range 18-22 normal). Weighs ~7/7.5 lb (range 5.5-10); from time baby was a fertilized egg; weight has increased 6 billion times!
  • Changes in Placenta/Uterus – size of placenta varies on size/weight of baby. after birth, placenta appear round, flat and 1 inch . Moist, white umbilical cord has 2 arteries and 1 vein; measures 12-39 inches when pulled straight. At birth when baby begins to breath, her circulation pattern begins to change; blood flow through her umbilical cord shuts down and more blood flows to her lungs. Contractions become more obvious and frequent and enhance circulation in uterus, press baby against cervix and work with prostaglandins to soften and thin cervix.

41st Week of Pregnancy and Beyond – Post-Dates

  • Average length is 40 weeks but many last longer and are consider post-date. Caregiver determines whether baby/placenta are healthy by performing specific diagnostic tests. If all is well, labor can begin on its own.
  • Changes in Baby – baby might not be post-mature (doesn’t have symptoms such as an absence of lanugo; scant vernix caseosa; long fingernails and toenails; dry, peeling, or cracked skin; and unusual alertness at birth. True post-maturity is rare even in babies born 2 weeks after due dates.
  • Changes in Placenta: continues to support the growth and well0beging of baby. in rare cases when baby is truly post-mature, tests reveal that the placenta isn’t functioning as well, that the volume of amniotic fluid is dropping and that baby is showing signs of distress. Under these circumstances, baby’s health can’t wait for labor to begin on it’s own and caregiver either induces labor or performs a cesarean.
  • Changes in You – consider self-induction methods

 

Common Concerns and Considerations in Pregnancy

  • Age of Mother – in general, women between 18 and 35 have few problems
    • Teenage Pregnancy – teenager’s body usually fit. Young uterus probably strong and tissues are stretchy. Labor will likely progress normally and won’t need medical interventions. Go to prenatal appointments so that don’t birth too early and deliver baby with low birth weight – the main problem for teen pregnancies. Challenges: dealing with parents’ reactions, working with baby’s father, attending school with peers who can’t relate, deciding whether to keep baby or give up for adoption, decisions about health care
      • Books: Life Interrupted – juggling school and single parenthood; Your Pregnancy & Newborn – Guide for Teens; Unplanned Pregnancy Book for Teens and College Students
    • After 35: birth rate for moms in 30s increased 2x, 3x for women >34, 4x for women >40. Delayed pregnancy due to career, education priorities, financial considerations, infertility, lack of partner. Risks of high blood pressure, gestational diabetes, growth problems or inherited disorders in baby, preterm labor, problems with placenta, fibroids, labor complications and cesarean. Longer a woman lives, more likely poor health practices, accidents, illness or environmental hazards have affected body. High blood pressure and diabetes (2 most common) increase with age. As age, infertility becomes a problem. First time mothers who were older had increased risks of preterm labor, excessive bleeding, or cesarean. Pregnancy mothers who had birth before had increased risks of diabetes and chronic or gestational hypertension. Older women more likely to have baby with genetic disorder such as Down syndrome. Fathers age also risk – increases for fathers >35. Fathers >40 increased risk of certain rare congenital disorders such as dwarfism. Caregivers use age 35 as age to start recommend testing. At this age, potential benefits from invasive tests, such as amniocentesis and chorionic villus sampling (CVS) begin to outweigh risks. Now more noninvasive screening tests are available so younger women being offered. If 35+ what to do – unless have preexisting health problem such as high blood pressure or diabetes, do same as any other pregnancy women. Most women >35 give birth to healthy, full term babies.
  • Multiples: see PCN pgs 53-54 above

 

Note to Expectant Fathers – may never felt so important yet so ignored, so committed yet so abandoned and so deeply in love and sexual yet afraid of sex. Share with other expectant fathers casually or in group.

  • Reality of Baby – first trimester its difficult to see many physical changes so might not think of baby as real. 16-20 weeks, changes in body become obvious and may begin to feel baby move. Many fathers comprehend baby’s existence when you see baby during ultrasound scan and hear baby’s heartbeat. Many men don’t begin to attach to babies until after birth.
  • Excitement, Stress and Worries of Becoming a Father – may begin to reflect on own mortality. Decide to buy more life insurance and write or update will. Some men experience empathy 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. Instead of you, sher turns to friends and relatives for emotional support. May feel you’re expected to care more for her and your relationship but that she’s less available to you emotionally, physically and sexually.
  • Role during labor and birth – take a childbirth prep class, watch DVDs or read books and discuss and worries with other fathers and partner. Consider having a friend, relative or doula at birth.
  • Role as Father – hormone levels in expectant fathers change during pregnancy – lower levels of testosterone and cortisol and higher levels of estradiol.
    • May help to adjust to new role: read books, attend well-baby checkups, talk to other fathers about what to realistically expect during first few weeks after birth; consider priorities and those of family; maintain relationship with partner; find time for yourself; determine how you can get help that you and partner need after birth; how you can care for new baby – holding, rocking, diapering, comforting, playing and learn more about those skills
    • Books: The Birth Partner, The Expectant Father, Father’s First Steps, The New Dad’s Survival Guide
    • Classes: For dads to be, conscious father classes, boot camp for new dads

 

Nontraditional Families

  • If Partner Isn’t Baby’s Biological Parent – he/she may feel like pregnancy is “yours” not “ours”. Partner may questions role in making decisions and providing financial support for your growing family. If baby’s biological father involved, partner may feel even less sure about his/her role. Does partner want to adopt baby? what role will biological father play? If in heterosexual relationship with someone new since becoming pregnant, have to decide who will accompany you to prenatal appointments and who will be with you during labor and birth.
  • If Pregnant and Single – although common today, society often offers single parents little support. Not everyone reacts positively to your pregnancy. Usually take on role of 2 people. At times you may be relieved you don’t have to deal with added burden of an incompatible partner. May be times when you doubt whether you can – or want to – parent alone and wish for companionship and support of a reliable partner.

 

Special Challenges in Pregnancy – past traumatic experiences can present additional challenges

  • History of Childhood Trauma – early childhood trauma sometimes causes unexpected reactions during pregnancy, birth or afterward. Women physically, sexually or emotionally abused as adults can also experience these reactions. Many abused women have difficulty trusting others, especially those in authority (such as physicians or midwives).
    • Estimated that 25-40% of women were sexually, physically or emotionally abused in childhood.
    • Survivor may find vaginal exams, nakedness or prospect of a baby coming through her vagina extremely disturbing or even intolerable
    • May respond to inevitable loss of control over body that occurs in labor in same way she had as a child, when she was helpless to stop her abuser from hurting her
    • May equate though of giving another person total access to her breast, even for breastfeeding, to her inability to prevent her abuser’s violation of her body
    • Extent of these problems vary and may factors influence including nature of abuse, age at which it occurred, how long it lasted, presence or absence of other loving and trustworthy adults in her life. Psychotherapy and emotional support groups promote healing. Appendix C for list of resources for survivors of childhood abuse.
  • Pregnancy After Miscarriage or Stillbirth – knowing why a previous pregnancy ended may help you and caregiver plan. Offer more prenatal testing. Closely watch baby’s health by counting movements. Talk with family members, friends, grief counselors and medical professionals.
    • Books: Pregnancy after a Loss; Trying Again: A guide to pregnancy after miscarriage, still birth and infant loss
  • Disability – consult with physical or occupational therapist or with women you’re your disability who have managed a pregnancy and parenting. Search for online discussion forums

Key Points: 1st trimester – formation period; 2nd trimester – development period; 3rd trimester is growth period

 

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 babycenter.com/fetal-development or parents.com/pregnancy/stages/fetal 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 2ndhand 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.

 

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 http://minorityhealth.hhs.gov 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 (nashvilleparent.com/directories/parents-of-twins-and-triplets-organization-potato), Mothers of Twins (www.nomotoc.org) 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?
  • http://www.motherfriendly.org/resources/documents/having_a_baby-english-8_5x11.pdf

 

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.

 

Exercise Tips for Pregnant Woman- Decrease weight bearing such as jogging and running and increase non-weight bearing such as swimming, cycling, or stretching. if you are a runner, starting in 7th month, can walk instead. Exercise regularly every day. Exercising sporadically can place undue strain on muscles. Take pulse every 10-15 min. if more than 140 BPM, slow down until it returns to 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, not exercises flat on your back. Rest for 10 min after exercising, lying on side, which removes pressure and promotes return circulation from extremities and muscles to your heart, thereby increasing blood flow to placenta and fetus. Choose high protein foods such as fish, milk, cheese, eggs and meat.

 

Discomforts Related to Pregnancy:

2nd trimester

  • Heartburn – sip milk for temp relief; drink 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
  • Round ligament pain (tenderness) – caused by enlarging uterus – not preventable. Use good body mechanics. Relieve cramping by squatting or bringing knees to chest
  • Backache – get back rubs

3rd trimester

  • Leg cramps (gastrocnemium spasm), esp when reclining – stand on cold surface, oral supplement wit calcium carbonate or calcium lactate; aluminum hydroxide gel with each meal removes phosphorous by absorbing it
  • Ankle edema – ample fluid intake for natural diuretic effect

Medications and Herbal Preps – possible teratogenicity still unknown, especially for new medications and combinations. Greatest danger of drug-caused developmental defects in fetus extends from time of fertilization through first trimester.

Immunizations – live or attenuated live viruses contraindicated in pregnancy. Live virus include measles (rubeola and rubella), varicella (chickenpox( and mumps as well as Sabin oral poliomyelitis vaccine (no longer used in US). Vaccines that can be administered include Tdap, recombinant Hep B and influenza (inactivated). Tdap should be administered between 27 and 36 weeks during each pregnancy regardless of prior vaccinations. All women pregnant during flue season should be offered. Intranasal contraindicated because contains live virus.

Alcohol, Cigarette Smoke, Caffeine, and Drugs – maternal alcoholism associated with high rates of miscarriage and fetal alcohol spectrum disorders (FASDs); the risk of miscarriage in first trimester is dose related (3+ drinks per day). Cigarette smoking or continued exposure to secondhand smoke associated with IUGR and increase in perinatal and infant morbidity and mortality. Smoking associated with increased frequency of preterm labor, PROM, abruptio placentae, placenta previa and fetal death. Coffee – 200 mg max daily intake

 

Medications and Herbal Preparations – although much has been learned in recent years about fetal drug toxicity, the possible teratogenicity of many medications, both prescription and OTC, is still unknown. This is esp true for new medications and combinations of drugs. Moreover, certain subclinical errors or deficiencies in intermediate metabolism in the fetus may cause an otherwise harmless drug to be converted into a hazardous one. The greatest danger of drug-caused developmental defects in the fetus extends from the time of fertilization through the 1st trimester, a time when the woman may not realize she is pregnant. Self-treatment must be discouraged. The use of all drugs, including OTC medications, herbs and vitamins, should be limited and a careful record kept of all therapeutic and nontherapeutic agents used.

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.

 

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

Cultural Influences – standards of care at http://minorityhealth.hhs.gov 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.

 

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 (www.nashvilleparent.com/directories/parents-of-twins-and-triplets-organization-potato), Mothers of Twins (www.nomotoc.org) and LLL.

 

Special classes

  1. First trimester, Phase 1 — physical and emotional changes
  2. Second trimester, Phase 2 — developing fetus and infants
  3. Third trimester, Phase 3 — labor, birth, and parenting
  4. Refresher Childbirth Class

 

  1. Three phases of a partner’s adaptation to pregnancy and birth
  1. The announcement phase
  2. The moratorium phase
  3. The focusing phase

 

III. Five considerations for class design

Behavioral Objective/Topic/Teachers Strategies/Learners Activities/Min/Teaching Aids Needed/Evaluation Chart for each class

Using a mind map to design your course – a thinking tool that uses free-form, flowing pictures of ideas using colors, words, images and imagination. Aka graphic organizer. Idea is to brainstorm on paper, either alone or in a group. Ideal way to gather your ideas for teaching strategies, evidence-based facts, and comfort skills on a particular topic.

Make a mind map for each of the topics you want to cover:

  • Write a word or short phrase, or draw a symbol to cover
  • Draw a circle around it
  • Think about what you want to teach and how
  • Write in points you want students to learn about that topic by branching off main circle or image with smaller ones
  • Use lines to connect these thoughts
  • Branch off again with your teaching methods or other details

Using mind maps, make a plan for each of your classes. Divide your topics into chunks of time you have in each class. Can use sticky notes or note cards for easy shifting around. Write what you will spiral into other classes. Figure out how you want to tie it all together. Use colors, various sized circles, curved or dotted lines etc. write as your brain thinks! Gather colored pencils or markers, eraser, colored sticky notes and a marker board or a big piece of paper.

Write class number in center and add or delete rectangles as needed to plan a class.

Topic Outline for 6 Week Series: pgs I28-29 have suggestions for spiraling

Class 1:

  • Icebreaker “Getting to know you”
  • Orientation and introductions
  • Overview of course
  • Discomforts of pregnancy 4-5
  • Body mechanics and birth fitness exercises 14-19, 100
    • Aerobic exercise 19
    • Pelvic tilt 16
    • Kegel 18
    • Wall squat 17
  • Pain management thought: Fear-Tension-Pain cycle
  • Breathing awareness 43
  • Positioning and movement for pregnancy, labor and birth 20-23, 47
  • Relaxation 24
    • Progressive relaxation 25, 104
    • Slow paced breathing 43, 105
  • Simple story of birth; birth hormones
  • Overview of labor (with pregnant anatomy) 6-7, 39-42
  • Labor support – doulas and or partner roles 33
  • DVD/Video Clip/PowerPoint slide capturing joy of birth

Class 2:

  • Icebreaker “Nutrition Crossword Puzzle” (homework from class 1) 9-13, 101
  • Discussion about childbirth experiences of mother, siblings etc
  • Labor pain discussion 36-37
  • Pain management thought: fight or flight/relaxation responses
  • Signs of labor 38
  • Stage 1 labor 39-41
  • Variations of labor and strategies to enhance progress and coping 34-35
  • Relaxation
    • Conditioned relaxation (progressive without tensing first)
    • House of colors IV-50
    • Checking for relaxation
    • Selective relaxation 25
    • Review slow paced breathing 43, 107
    • Foot and hand massage IV 48-49
  • DVD/Video Clip/PowerPoint slide segment capturing joy of birth

Class 3:

  • Students bring focal point
  • Icebreaker: breastfeeding grab bag, or other opening activity to stimulate discussion of reasons to breastfeed 63
  • Pain management thoughts: gate control
    • Sensory stimulation techniques 108
  • Relaxation
    • Touch relaxation 26
    • Massage 26
    • Review slow paced breathing 43, 107
    • Modified paced and patterned breathing 43, 107
  • Challenges of labor 46-48
  • Review stage 1 with practice labor situations (incorporate relaxation skills)
  • DVD/Video Clip/PowerPoint slide segment capturing joy of birth

Class 4:

  • Icebreaker: feeling wheel, pain management pie, or top 10 list
  • Stage 2: 42, 44-45
  • Practice positions for stage 2 45
  • Stage 3: 42
  • Birth video
  • Newborn appearance, capabilities, needs 77-84
  • Relaxation:
    • Visual imagery: your special place 105-106
  • DVD- Delivery Self-attachment or Breastfeeding: Baby’s Choice

Class 5:

  • Icebreaker: pain medications preference scale 110
  • Anesthesia and analgesia risks and benefits 51-53
  • Tour or slides of labor and delivery area
  • Childbirth choices and birth plan 49-51, 111
  • Unexpected outcomes 60
  • Cesarean birth 55-59
  • Communication skills
  • Relaxation
    • Visual imagery: Birth 25, 106
  • DVD/Video Clip/PowerPoint slide segment capturing joy of birth

Class 6:

  • Students bring packed goody bag 96
  • Icebreaker: “time sharing” 112
  • Early breastfeeding and brief postpartum 63-84
    • DVD – Amazing Talents of the Newborn or other newborn/breastfeeding
  • Labor rehearsal with labor stations
  • Closing DVD/Video Clip/PowerPoint slide segment emphasizing joy of birth
  • Wrap up and evaluations

Class 1 Review Sheet (to give to students)

Tonight we covered:

  • Body mechanics 14-15
  • Birth fitness exercises 16-19, 100
  • Positions for pregnancy, labor and birth 20-23
  • Terminology and anatomy 6-7
  • Progressive relaxation 25, 104
  • Slow breathing 42, 107
  • Overview of labor 39-42

Over the next week I hope you both will:

  • Read your handbook
  • Remember challenging situations you have faced. What helped you to cope? Think about who you would like to support you during labor and birth. Discuss whether a professional labor support person or doula might be helpful
  • Do the nutritional crossword puzzle on pg 101 and fill out diet evaluation on pg 103. If desired, begin fetal movement counting chart on pg 98
  • Use good body mechanics and include birth fitness exercises into your daily routine
  • Choose a form of aerobic exercises that is right for you, and plan how you will include it in your daily schedule. Read over ACOG guidelines for exercise on pg 19
  • Do extended Kegel (hold 20 sec) several times a day.   Easy way to remember is to do one each time you go to the bathroom, after you have emptied bladder
  • Tune in to your body to try to become aware of tension. Release tension away. Practice progressive relaxation. Consider adding music to your practice session to reduce stress
  • Practice slow, deep breathing. Try using it during periods of stress
  • Arrange to take breastfeeding and baby care classes (phone number to call)

Bring to class next week:

  • Handbook
  • Pillows for comfort
  • Snack

Instructor:

Phone:

Email:

 

Topic Outline for Weekend Classes pg 20-21

ICEA Statement – Curriculum Development and Content for the Childbirth Educator

http://icea.org/wp-content/uploads/2016/01/Curriculum_Development_Content_CBE.pdf

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

 

  1. Needs assessment
  2. Goals and objectives
  3. Developing and sequencing content
  4. Teaching strategies
  5. Evaluation

 

  1. Two ways to organize class content

ICEA Statement – Curriculum Development and Content for the Childbirth Educator see above

  1. Blocks
  2. Spirals

 

  1. Improving recall

Teachers and Learners: 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.

Learning Preferences:

  • 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.

Reach out to all learners: some come to have fun/hear happy stories about birth; some come eager to ask questions, hear about latest technology and research or seemingly to challenge you. Others want to learn to relax and breathe and be encouraged about giving birth.

  • Have an agenda on board or as a handout. If need to deviate from it, tell students your plans and invite their input
  • Have material you plan to teach organized in your mind. Have teaching aids and references arranged for easy access
  • Make class learner-centered. Encourage participation, questions, additions to agenda, group leadership etc
  • Listen to stories and experiences of students
  • Be able to back up statements and theories with research, providing studies if asked
  • Encourage use of comfort techniques throughout class – pillows, water, balls, prop up feet. Adjust lights and temp for comfort
  • Present both sides of controversial subjects. Offer pros and cons, risks, harm and benefits
  • Share positive birth stories
  • Show images of birth that build confidence
  • Include games, role plays, and rehearsal as as well as lectures and discussions
  • Manipulate models, demonstrate comfort tools, show DVDs and graphics. Practice skills; vary your presentation and have fun
  • Provide a safe environment for discussion of thoughts and sharing of feelings by being open and accepting of each students birth-day wishes
  • Provide a method of feedback, so you know that students are leaning and having needs met. Weekly reaction sheets are helpful
  • Preview at beginning and review at end of class
  • Sequence: icebreaker, work phase, application phase
  • Give clear instructions (verbal or handout) of how you wish them to prepare for following class
  • Show sense of humor

Spirals or blocks? Beneficial to teach small doses and repeat frequently rather than to teach all about anatomy, exercises in one, labor support in another etc. spiral curriculum so those who miss a class don’t miss whole subject. Progress from general to specific and each week build on info taught in previous week.

Spiraling by topics

Stages and phases of labor: cover labor onset to birth each week

  1. Overview physical and emotional aspects of textbook labor from onset to birth
  2. Present variety of normal labor patterns with physical and emotional challenges of each variation
  3. Discuss baby’s trip through pelvis and birth canal related to coping skills and labor support
  4. Show DVDs/video clips (any or every week) that show realistic appearance of laboring women – their emotions, coping skills and support throughout labor
  5. Describe various scenarios of labor in a rehearsal
  6. Relax with a birth visualization of flow of labor

Relaxation: teach new techniques, building on previous skills, each week

  1. Progressive relaxation, relaxing words and images
  2. Release to touch; massage
  3. Selective relaxation (neuromuscular control); autogenic phrases
  4. Visual imagery
  5. Combining it all and designing your own teamwork
  6. Hear what worked for others and practice it all

Breathing: teach, review and build on breathing strategies each week

  1. awareness of own breathing – nose, mouth; chest, abdomen, depth, rate
  2. slow breathing with various techniques – counting, colors, images
  3. practice various rates and strategies – counting, colors, images, patterns
  4. second stage breathing: discuss spontaneous and directed pushing
  5. put it all together in labor rehearsal
  6. see what other couples used and brainstorm own “creations”

Exercises: just pick a few favs and repeat variations of them each week

  1. Kegel, calf stretch, pelvic tilt, wall squat
  2. Passive pelvic tuck, extended Kegel, position for rotating breech
  3. Wall stretch – contracting and isolating abdominals, pelvic floor, thighs, buttocks, to prepare for pushing awareness
  4. Kegel, pelvic tilt, squat, as they relate to pushing
  5. Pelvic rock on hands and knees for comfort both during pregnancy and labor
  6. How all above should be done postpartum

Support: teach labor partner to build on skills taught in previous class

  1. Hawthorne effect; observing tension and how she relaxes; emotions to expect in various phases of labor
  2. Support techniques for very long to very short labor pattern; tune into environment; learn effective touch for pregnant woman. Discuss role of doula
  3. Sensory stimulation (goody bag supplies); pressure and touch in relation to baby’s positioning in pelvis
  4. What to do if she panics; partners role in pushing – adapting positions, modeling quiet encouragement
  5. Relaxing visualization, to include partner
  6. Listen to suggestions from returning couples; partner’s support role in postpartum, with new baby, breastfeeding etc

Baby: keep focus on baby throughout entire course

  1. Presentations, movements felt/counted
  2. Discuss 4 Ps = passenger, passageway, power, psyche; integrate with labor pattern variations; emphasizing baby’s labor
  3. Baby’s role in labor onset; baby’s trip through pelvis
  4. Baby’s reaction to birth environment in DVDs
  5. Happenings at birth – cord, circulation change, color, Apgar, appearance; normal newborn characteristics, the new family
  6. Reality check: seeing real babies at reunion or on a tour

Positioning: see pg IV 20 for spiraling suggestions (Study Guide 3)

Breastfeeding see pg IV 136 for … (Study Guide 3)

Postpartum see pg IV 144… (Study Guide 3)

Interactive Teaching Strategies

  • 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.
  1. Use groups of three
  2. Keep lecture at or under 20 minutes
  3. Repetition
  4. Allow for student-directed learning

 

  1. Learner-centered curriculum

ICEA Statement: Curriculum Development and Content for the Childbirth Educator see above

ICEA YouTube Channel – Members Minute: Developing Curriculum https://www.youtube.com/watch?v=mledXUnr7eU

All I could find was: Curriculum Design Tutorial (6:36)

Definition of Curriculum – lists of subjects comprising course of study and methodology of teaching those subjects

Parts of a Curriculum: Objectives, Outline, Timing and Teaching Strategies

Objectives must be SMART: Specific, Measureable, Achievable, Realistic and Time-Bound

Use verbs to begin objectives – Bloom’s taxonomy

People generally remember: 10% of what they read, 20% of what they hear, 30% of what they see, 50% of what they see & hear, 70% of what they say & write, 90% of what they do

Types of Teaching Strategies – Childbirth Education Practice Research and Theory: brainstorming, buzz groups, demo/return demo, group centered discussion, panel discussion, case discussion, labor rehearsal, problem solving discussion, experience sharing discussion, guided discussion, exhibits, field trip, games, interview, lecture, TV, debate, nonverbal exercises, peer instruction, question/answer, cartoons/illustrations, diagrams, questionnaire, storytelling, call and response, roleplaying, simulation, values clarifications, imagery/visualization, grab bag, goal setting, worksheets, workbooks, books, journals, handouts, drawing/art, slides, videos, charts, models, photographs, audio recordings, graphs

Calculate timing to teach objective/class

What makes a great curriculum? Focus on learner, in logical order, balanced, up to date/unbiased, and relevant

Questions? info@icea.org

VII. SMART formatted objectives Specific, Measurable, Achievable, Relevant, Time frame

Posting 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.

Designing Your Course

  • Needs assessment – should be tailored to needs of all students. Can communicate via email, IM, text or phone before class. Learn about them and needs/expectations. If not appropriate beforehand, do at first class. Or ask them to write questions or hopes on a sticky note. Provide white board or easel with words “this class will meet my needs if…” so people can write while gathering. Provide ample time for discussion, questions, and answers and also asking for feedback at end of every class will help you assess if needs met
  • Goals and objectives: increasing confidence for birth and promoting informed decision-making. Need to think about why including each topic in course design. May choose to identify purpose of teaching that topic as in purpose-process-payoff method or can identify objective you have in mind. Behavioral objectives indicate specific behaviors students must demonstrate to indicate learning has occurred
  • Developing and sequencing content – fun part is deciding what to teach. Begin with simple concepts (birth is normal/natural) and build content to more complicated concepts (informed decision making). Most believe its important to present normal process before introducing complications. Rather than teaching in blocks, spiral info
  • Teaching strategies – students learn best if actively involved. Use wide variety of (mostly interactive) strategies. Use mini lecture and class discussion to teach common interventions, then later play a game such as jeopardy to review
  • Evaluation: observe them do pelvic tilt or listen to them discuss birth plans with one another.

Using Chart/Outline- Once you have: considered big picture, set goals for classes, thought about content, and how to teach it so learners will learn and answered question of who, when, where, how often, and how long to teach your classes…then you need a specific course design! Charts and outlines specifically used for this purpose. Chart includes:

  • Objective – what is purpose? What do you want learner to know or be able to do?
  • Topic – 1 topic may meet several objectives or 1 objective may cover several topics
  • Teaching strategies – how will you teach this? What will you be doing?
  • Learners activities – what will student be doing to learn what you are teaching?
  • Time frame – how many min will you spend to teach it
  • Evaluation – how can you tell objective was met. Do they like it? Get it? Can they do it? Do they use it?

Look over topic outlines in this guide. Modify to make them your own or start from scratch with an outline you devise. Think about what it is you want student to know, understand, or be able to do after completing your classes. What teaching activities will it take to accomplish your purpose? How will you construct a learner-centered course? How will you know if students learned what you taught?

  1. Write down topics you plan to cover
  2. For each, consider: need to know, nice to know
  3. How are you going to teach? List teaching strategies; list teaching aids
  4. List ways you can evaluate learning

If charts/outlines aren’t your style, read further to learn about mind-mapping on page I-13

http://en.wikipedia.org/wiki/SMART_criteria

Ideally speaking, each corporate, department, and section objective should be:

  • Specific – target a specific area for improvement.
  • Measurable – quantify or at least suggest an indicator of progress.
  • Assignable – specify who will do it.
  • Realistic – state what results can realistically be achieved, given available resources
  • Time-related – specify when the result(s) can be achieved.

 

VIII. Domains of learning

http://en.Wikipedia.org/wiki/Bloom’s_Taxonomy (link wrong)

Bloom’s taxonomy is a set of three hierarchical models used to classify educational learning objectives into levels of complexity and specificity. The three lists cover the learning objectives in cognitive, affective and sensory domains.

The cognitive domain involves exhibiting memory of learned materials by recalling facts, terms, basic concepts, and answers. Its characteristics include:

  • Knowledge of specifics – terminology, specific facts
  • Knowledge of ways and means of dealing with specifics – conventions, trends and sequences, classifications and categories, criteria, methodology
  • Applying (using acquired knowledge), Analyzing (examining and breaking info into component parts; analysis of elements, relationships, organizational principles), Synthesizing (building structure or pattern from diverse elements – production of plan), Evaluating (making judgments about info, validity of ideas or quality of work based on set of criteria).

 

The affective domain (emotive-based)[edit]

Skills in the affective domain describe the way people react emotionally and their ability to feel other living things’ pain or joy. Affective objectives typically target the awareness and growth in attitudes, emotion, and feelings.

There are five levels in the affective domain moving through the lowest-order processes to the highest:

  • Receiving –The lowest level; the student passively pays attention. Without this level no learning can occur. Receiving is about the student’s memory and recognition as well.
  • Responding- The student actively participates in the learning process, not only attends to a stimulus; the student also reacts in some way.
  • Valuing- The student attaches a value to an object, phenomenon, or piece of information. The student associates a value or some values to the knowledge they acquired.
  • Organizing – The student can put together different values, information, and ideas and accommodate them within his/her own schema; comparing, relating and elaborating on what has been learned.
  • Characterizing – The student at this level tries to build abstract knowledge.

 

The psychomotor domain (action-based)[edit]

Skills in the psychomotor domain describe the ability to physically manipulate a tool or instrument like a hand or a hammer. Psychomotor objectives usually focus on change and/or development in behavior and/or skills. Bloom and his colleagues never created subcategories for skills in the psychomotor domain, but since then other educators have created their own psychomotor taxonomies

  • Perception – ability to use sensory cues to guide motor activity
  • Set – readiness to act: includes mental, physical and emotional sets
  • Guided response – early stages in learning complex skill
  • Mechanism – intermediate stage in learning complex skill
  • Complex overt response – skillful performance of motor acts
  • Adaptation – skills well developed and individual can modify
  • Origination – creating new moment patterns to fit particular situation

 

  1. Three Objective domains:
Cognitive – What information should the learner acquire?
  2. Affective – What attitudes may the learner have about the subject?
  3. Psychomotor – What physical skill will the learner be able to demonstrate?

 

  1. Evaluation

Educator’s Self-Evaluation

Evaluate yourself:

  • I have a basic teaching plan with clear objectives for each session I teach
  • I analyze the needs, constraints and preferences of my students/audience
  • I include a preview and review of important topics
  • My introduction will attract attention and provide background info
  • The visual aids I choose to use are simple, easy to see/read and serve a purpose
  • I use an appropriate number of different types of visual aids
  • My presentation is logical and evidenced based (but not boring)
  • I communicate with enthusiasm
  • I focus on my class/audience, not on my notes
  • I rehearse using my visual aids and timer
  • I practice responding to anticipated questions
  • I arrange seating and check A-V equipment before my presentation
  • I maintain eye contact with participants
  • I use vocal variety and physical movements to hold attention
  • I listen to my recorded presentation to hear my annoying or overused sounds and phrases (umm, ahh, ok, right, you know)
  • I included learning activities that build confidence in students’ abilities

What are my greatest strengths as a teacher/presenter?

What weaknesses am I trying to overcome?

What would I like to hear said about me after my presentation?

Ask a peer to evaluate you:

What are my greatest strengths as a teacher/presenter?

What weaknesses should I try to overcome?

What is your perception of how I came across to the class?

PCEG Section V: Evaluation (pgs 1-12)

Book – “Evaluating Training Programs: The 4 Levels”; thorough evaluation looks at 4 outcomes:

  • Reaction: do they like it?
  • Learning: do they get it?
  • Behavior: do they do it?
  • Results: do they use it?

Classes who get together for a reunion often decide to continue meeting for postpartum support. At the very least, encourage students to include you on their text/email list when they send out birth stories.

Labor and birth questionnaire on pg 117-120 workbook.

Weekly Reaction Form – Tonight I liked; Next week I hope we; 3 things I learned in class are; I wish more time had been spent on; I didn’t like spending so much time on

Course reaction form – 3 things I learned in this course are; what I liked best about this course; I wish more time had been spent on; I didn’t like spending so much time on. On scale of 1-10, how likely would you recommend this course to a friend?

Mid course evaluation form

  • Time spent on (review/lecture/comfort techniques/audiovisuals/questions) – circle too much/too little/just right
  • What do you like best about course so far?
  • Any suggestions for improving the course?
  • List any topics/techniques you feel confused about or are having difficulty with
  • My greatest fear or concern about labor or birth is
  • Since taking this course, my attitude toward childbirth is: more positive/less positive/ no change – still positive/still negative

Course Evaluation Form:

  • Please check: I learned more in these classes than I thought I would/I learned about what I expected in these classes/ I had expected to learn more than I did
  • What did you enjoy most about the classes?
  • Do you have any suggestions for improvement?
  • Would you prefer class size (larger, smaller, same size)
  • Would you prefer method of teaching: lecture (same/more/less), discussion (same/more/less), practice (same/more/less), charts (same/more/less), videos (same, more, less).
  • Would you prefer practice sessions: role of labor partner (same/more/less), positioning & movement (Same/more/less), relaxation and breathing (same/more/less), massage (same/more/less), other comfort measures (same, more, less)
  • Are there any subjects to which you wish more time had been devoted?
  • Are they any subjects to which you wish less time had been devoted?
  • Indicate your feelings concerning the following questions with a check in appropriate column: always/usually/sometimes/never/comments
    • Did you feel instructor was well informed about material
    • Did instructor organize and present material so that it was easy to follow?
    • Were positioning, relaxation, and comfort measures taught so that you could easily learn them?
    • Did you feel free to ask questions and/or contribute to discussion?
    • Did you feel that your individual needs were met?
    • Did you enjoy the classes?
  • What are your plans regarding the use of medication for labor/birth?
  • On scale of 1-20, how likely would you recommend this course to a friend?

Summary of Course Evaluation Forms: summarizing the forms you received

Labor and birth survey (for birthing experience)

Maternity services evaluation form – for labor/birth

Childbirth educator peer evaluation form

  1. Formative – on-going
  2. Summative – after series and after birth

 

  1. Other Part 4 References
  2. ICEA Statement Curriculum Development and Content for the Childbirth Educator – see above (www.ICEA.org: Position Papers and Other Statements)
  3. PCEG Section-I Getting Started 
(pgs 1-40) Your Philosophy of Childbirth – will influence the content of your class series and the amount of time you spend on various topics. Will you spend more time showing images of natural birth or possible complications? How will you divide time between lecture, small group activities and practicing skills? Will you present normal birth before interventions or will you weave them into a chronological description of labor and birth?

Society/Media tends to portray birth as potentially dangerous and regard epidural as “the only way to go.” Some feel they should contradict this view by encouraging natural birth. These educators spend little time on medical technology and medications. Others believe they should present comprehensive, evidence-based information regarding the use of medical technology and pain medication in an unbiased way, so that consumers can make their own decisions regarding these issues. Still others present medical interventions in only a positive manner in order to prepare women for the high-tech birth they will most likely have in some locations.

Reality is that most will probably do a little of all 3 above. They want to encourage women that natural childbirth is a possibility, they want women to make truly informed decisions regarding use of interventions and medications and want all women to have positive birth memories, regardless of the use or non-use of interventions and medications.

Think about what it is you want to accomplish in your classes. Answer the following questions, then design your curriculum accordingly: what is the most important goal you have in teaching childbirth education classes? What do you think is the most important goal of students attending your classes? If there is a difference between your goal as a childbirth educator and the goal of your students, how will you address this?

In considering your own philosophy of childbirth, may wish to incorporate elements developed by authoritative organizations, which are active in the field. The following info from Coalition for Improving Maternity Services addresses many of the issues associated with contemporary childbirth. Position papers form DONA, ICEA and Lamaze are included in Appendix.

The CIMS Philosophy of Childbirth – the Coalition for Improving Maternity Services (CIMS) is a national alliance of 27 childbirth organizations and many prominent individuals who came together in 1996 to create the “Mother-Friendly Childbirth Initiative” national childbirth organizations which have ratified this document include Lamaze International, ICEA, the Bradley method, AWHONN, ACNM, DONA, LLL and many more. These prominent organizations believe the philosophical cornerstones of mother-friendly care to be:

Normalcy of the Birthing Process

  • Birth is a normal, natural and healthy process
  • Women and babies have the inherent wisdom necessary for birth
  • Babies are aware, sensitive human beings at the time of birth, and should be acknowledged and treated as such
  • Breastfeeding provides the optimum nourishment for newborns and infants
  • Births can safely take place in hospitals, birth centers and homes
  • The midwifery model of care, which supports and protects the normal birth process, is the most appropriate for the majority of women during pregnancy and birth

Empowerment

  • A woman’s confidence and ability to give birth and to care for her baby are enhanced or diminished by every person who gives her care, and by the environment in which she gives birth
  • A mother and baby are distinct yet interdependent during pregnancy, birth and infancy. Their interconnectedness is vital and must be respected.
  • Pregnancy, birth and the postpartum period are milestone events in the continuum of life. These experiences profoundly affect women, babies, and families and have important and long-lasting effects on society

Autonomy– Every woman should have the opportunity to:

  • Have a healthy and joyous birth experience for herself and her family, regardless of her age or circumstances;
  • Give birth as she wishes in an environment in which she feels nurtured and secure, and her emotional well being, privacy and personal preferences are respected
  • Have access to the full range of options for pregnancy, birth and nurturing her baby and to accurate information on all available birthing sites, caregivers and practices
  • Receive accurate and up to date info about benefits and risks of all procedures, drugs and tests suggested for use during pregnancy, birth and postpartum, with rights to informed consent and informed refusal
  • Receive support for making informed choices about what is best for her and her baby based on her individual values and beliefs

Do No Harm

  • Interventions should not be applied routinely during pregnancy, birth or the postpartum period. Many standard medical tests, procedures, technologies and drugs carry risks to both mom and baby, and should be avoided in the absence of specific scientific indications for their use
  • If complications arise during pregnancy, birth or postpartum, medical treatments should be evidence based

Responsibility

  • Each caregiver is responsible for the quality of care she/he provides
  • Maternity care practice should be based, not on needs of caregiver or provider, but solely on needs of mother and her child
  • Each hospital and birth center is responsible for the periodic review and evaluation, according to current scientific evidence of the effectiveness, risks, and rates of use of its medical procedures for moms and babies
  • Society, through both its government and the public health establishment, is responsible for ensuring access to maternity services for all women, and for monitoring quality of those services
  • Individuals are ultimately responsible for making informed choices about the health care they and their babies receive

See CIMS website at www.motherfriendly.org

 

History of Childbirth Education – When birth took place in homes, the birthing woman was surrounded by women who provided advice, encouragement and support. When birth moved into the hospital in the 20th century, women lost the wisdom gained from being present at births throughout their lifetimes.

Dr. Grantly Dick-Read is credited with the birth of modern childbirth education. He offered a woman chloroform and she said no thank you, it doesn’t hurt and that changed his life. His book Childbirth Without Fear was published in 1942. He sought to reduce fear by educating women about what to expect during birth, and to reduce tension by teaching relaxation techniques. He helped countless women break the “Fear-Tension-Pain” cycle.

In 1950s, French Dr. Fernand Lamaze adapted Russian techniques of physchoprophylaxis. Early Lamaze strategies included focused breathing, relaxation techniques, and continuous support by a special nurse known as a monitrice. American women who gave birth with him returned to U.S. and wrote book Thank You, Dr. Lamaze which helped to spark natural childbirth in the U.S. in 1960, Lamaze and ICEA were formed. Both have continued to inform birthing women since that time. ICEA mission is to support educators and other health care providers who believe in freedom of choice based on knowledge of alternatives. Lamaze International works to promote, support and protect natural, safe and healthy birth through education and advocacy through the dedicated efforts of professional educators, providers and parents.

For more info see: Birth – The Surprising history of how we are born by T. Cassidy, Lying in- a history of childbirth in America by Wertz or Deliver me from pain – anesthesia & birth in America by Wolf. Also The timeless way video clips.

Significant Events in U.S. Childbirth History:

  • 1800s – physicians started attending normal births in mid 1800s. most babies born at home. 1847- Semmelweis instituted hand-washing in Vienna; Simpson introduced ether into obstetric practice in Scotland
  • 1900s- 50% of births attended by midwives; 50% by physicians
  • 1910s – American women marched in streets for right to have “twilight sleep”; 1915- low cervical cesarean significantly decreased infection/rupture (maternal mortality 600/100,000; infant mortality 124/1000)
  • 1920s – 1920 – DeLee published The Prophylactic Forceps Operation; 1925 – Frontier Nursing Service, staffed by nurse-midwives founded
  • 1930s – only 15% of births attended by midwives; births split 50/50 home/hospital. NY Academy of Medicine campaigned against unnecessary instrument and drug intervention. Sulfa drugs discovered; blood banks established (maternal mortality 620/100,000; infant mortality 65/1000; cesarean rate 2.5%)
  • 1940s – 1942 – Childbirth Without Fear by Dr. Grantly Dick-Read publishes; penicillin became widely available (maternal mortality 355/100,000; infant mortality 47/1000)
  • 1950s – 95% of all births in hospital; 1956 – La Leche League held 1st meeting; 1959 – Thank You, Dr Lamaze published (maternal mortality 83.3/100,000; infant mortality 29.2/1000)
  • 1960s- natural childbirth movement underway, with formation of both ASPO/Lamaze and ICEA in 1960; fathers fought to enter delivery room (maternal mortality 32.1/100,000; infant mortality 26/1000; cesarean rate 4.9%)
  • 1970s- electronic fetal heart monitors introduced without randomized, controlled trials; EFM led to wider use of epidural anesthesia (maternal mortality 21.5/100,000; infant mortality 20/1000; cesarean rate 5.5%)
  • 1980s- first large scale, random studies of continuous EFM: showed no benefit (maternal mortality 9.4/100,000; infant mortality 12.6/1000; cesarean rate 16.5%)
  • 1990s- 1992 – DONA International formed (originally Doulas of North America); Lamaze Philosophy of Birth adopted; Childbirth Summit (Birth of CIMS); VBAC increased from 12.6% in 1988 to peak of 28.3% in 1996 (maternal mortality 8.2/100,000; infant mortality 9.2/1000; cesarean rate 22.7%)
  • 2000s – ‘00- WHO Code adopted by Lamaze International; ‘01- VBAC safety questioned, rate plummeted to 9.2% in ‘04; ‘03- ACOG states its ethical to do elective primary cesareans (maternal mortality 8.9/100,000; infant mortality 6.89/1000; cesarean rate 22.9%)
  • 2010s – ’10- NIH Consensus Development Conference on VBAC; ’10- Lamaze and ICEA celebrate 50th anniversaries with joint conference; ’14- Joint Commission Perinatal Quality Measures on elective births before 39 weeks; low-risk cesarean rates; and exclusive breastfeeding at discharge become mandatory for hospitals with >1100 births. ’14- ACOG recommends generally no inductions except for medical reasons and inductions for post-dates after 42 weeks (maternal mortality 21/100,000; infant mortality 6.5/1000; cesarean rate 32.7%)
  • 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 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.

 

Teaching Strategies

Complete chart to help you determine your priorities and preferred teaching strategies

Rate each 1- 4 from not important to very important; indicate strategies you think would be most effective. Make sure you have selected a variety for all learners:

Possible Strategies: lecture (with or without PowerPoint, storytelling, learning task, large group discussion, small group discussion, brainstorming, problem-solving, values-clarification, games/role play, audiovisuals, demonstration/return demonstration, practice, rehearsal, handouts, homework, other)

Important of Topics/Teaching Strategies

  • Normal labor, birth and postpartum
  • Positioning and movement to facilitate progress and comfort
  • Massage techniques
  • Comfort measures (tub or shower, use of heat, cold, pressure etc)
  • Relaxation skills, including breathing
  • Labor support
  • Communication skills
  • Problems which could occur
  • Analgesia and anesthesia
  • Routine procedures/interventions
  • Cesarean birth
  • Breastfeeding and postpartum
  • Healthy lifestyles
  • Other

Talking the Talk – speaking skills important. Educators frequently asked to speak to peers & other professionals.

  • 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 involved your audience in your presentation?
  • Visualize – imagine yourself in front of your group at your very best
    • How are you dressed? (Be comfortable whether causal or formal)
    • Where are you positioned (lectern, 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 – 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 even be more painful, but you will learn a lot)
  • Focus, concentrate, breathe and relax– use these skills you know well
    • Play music you like as you set up the room and check your A-Vs, lights etc
    • Get to your 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 breathe 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, and visionary. They prefer discussions, if they can lead, lecture, debates, analysis, meeting goals and objectives.

Showing the Talk – 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.

 

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!

Avoid:

  • 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).

Polishing Your Presentation

  • Start on time- greet them as they arrive; begin with icebreaker
  • Convey your presence and confidence with alert, erect posture
  • Tell them what you plan to teach – agenda on board or handout
  • Teach them – interactive participation; involved students in content every 8-10 min. Adults listen with understanding for 60-90 min, but with retention for 20 min or less. Use a variety of teaching techniques
  • Tell them what you taught them – review, summarize, feedback, reaction sheets, evaluation
  • Speaking techniques – if use notes, talk, don’t read; speak loudly for all to hear; vary voice level, pitch and pace to maintain interest; keep pace that will allow most to follow and understand; become aware of speech distractors such as um and ahh – silence is preferable while you think or reflect; enunciate clearly. Don’t mumble. Don’t speak too fast. Use pauses to emphasize points, and help listeners contemplate and reflect message. Be sensitive to audience – read them constantly
  • Use humor – but try to keep it spontaneous and related to content
  • Vary format – whiteboard, slides, models, demonstrations, and discussions. Don’t just talk at group
  • Maintain eye contact w audience – speak to group, not wall, paper or screen. Move eyes from person to person. Do not favor 1 person or location. Avoid looking exasperated, disgusted, or bored, esp when responding to students
  • Maintain interest by moving around with certainty, rather than standing in 1 place
  • Have fun and enjoy yourself!

Educator’s Self-Evaluation

Evaluate yourself:

  • I have a basic teaching plan with clear objectives for each session I teach
  • I analyze the needs, constraints and preferences of my students/audience
  • I include a preview and review of important topics
  • My introduction will attract attention and provide background info
  • The visual aids I choose to use are simple, easy to see/read and serve a purpose
  • I use an appropriate number of different types of visual aids
  • My presentation is logical and evidenced based (but not boring)
  • I communicate with enthusiasm
  • I focus on my class/audience, not on my notes
  • I rehearse using my visual aids and timer
  • I practice responding to anticipated questions
  • I arrange seating and check A-V equipment before my presentation
  • I maintain eye contact with participants
  • I use vocal variety and physical movements to hold attention
  • I listen to my recorded presentation to hear my annoying or overused sounds and phrases (umm, ahh, ok, right, you know)
  • I included learning activities that build confidence in students’ abilities

What are my greatest strengths as a teacher/presenter?

What weaknesses am I trying to overcome?

What would I like to hear said about me after my presentation?

Ask a peer to evaluate you:

What are my greatest strengths as a teacher/presenter?

What weaknesses should I try to overcome?

What is your perception of how I came across to the class?

 

  1. ICEA Mentor Program (found at www.ICEA.org)

http://icea.org/educators-and-doulas/icea-membership-program/

 

About The Author

Jessica