- Email: [email protected]
Expanding the Scope of Childbirth Education to Meet the Needs of Hospitalized, High-Risk Clients
principles and practice Expanding the Scope of Childbirth Education to Meet the Needs of Hospitalized, High-Risk Clients PAULETTE AVERY, RN, MSN, AND IRENE McKENZIE OLSON, RN, BSN A need to provide childbirth preparation classes for hospitalized, high-risk pregnant women is identified. A model for these classes is proposed describing the format and specific content areas to be included in the course as well as the potential benefits to high-risk clients. The need for further research to determine the specific benefits of childbirth education in high-risk pregnancy is identified.
The care of hospitalized, highrisk patients during pregnancy is receiving increasing attention in the nursing l i t e r a t ~ r e .A' ~signifi~~~ cant number of high-risk women are being admitted to hospitals for extended periods, particularly in the third trimester, for treatment of conditions such as hypertension, diabetes, or preterm labor. As a result, these women do not have access to childbirth education and frequently experience labor and delivery with little or no preparation. Childbirth education is an accepted component of the health care provided to healthy pregnant women. The benefits of childbirth education are well documented. These benefits include an increased sense of control during labor: a decreased perception of pain,5 decreased anxiety,6 de-
Accepted: April 1987
418
is certified in childbirth education creased use of analgesics,' and inby a national organization such as creased confidence in dealing with ICEA or ASPO. The educatot also labor and delivery? has a knowledge of and.' experiAll of these effects are potenence in high-risk obM&ric care. tially of equal or greater benefit to The use of a trained instructor rechigh-risk women and the need to ognizes the fact that most staff provide childbirth education to nurses do not have the time12 or this group has been identified repeatedly in the l i t e r a t ~ r e . ' ~ Za~ * ~ * ' ~background to provide this service. charias" not only identifies the need, but also demonstrates more COURSE FORMAT positive attitudes toward the childbirth experience in a group of Course format is designed to urban, high-risk pregnant women meet the needs of the hospitalized who participated in a childbirth woman as well as her family education course. However, prepmembers (Figure 1). Because the aration for childbirth is currently patient population of women renot part of the care offered to most quiring long-term hospitalization women with problem pregnancies. during pregnancy is relatively A model for childbirth education stable? the course is offered in a classes taught to hospitalized, series of six classes taught once-ahigh-risk obstetric clients is deweek. Newly admitted patients scribed below. enter the course at any point and ~~~
COURSE EDUCATOR In this model, the course is taught by a registered nurse who
~
continue until patients complete the series, are discharged, or deliver. Women discharged before completing the series are invited
NovemberIDecember1987 JOG"
Classes are taught By a childbirth educator In the hospital Weekly and ongoing In the evening With spouses and family members With group discussions
Figure 1. Course format.
to continue participation as outpatients. Providing the course to a group of women, rather than to individuals, is more cost-effective. Of equal importance, group instruction offers these women the opportunity to share their common experiences of being pregnant and hospitalized. Dore and Davies13 report that discussion groups for high-risk pregnant women were effective in helping these women cope with some of the problems associated with their stressful situations. However, because some high-risk women are on strict bedrest during hospitalization, individualized instruction at the bedside is also available. Classes are held in the evening to encourage participation by husbands or other family members. The presence of family members allows the childbirth educator to prepare support persons to act as coaches during labor and delivery. Family participation also provides an opportunity for the hospitalized woman and her family to ask questions and express concerns about the woman’s condition in a supportive atmosphere. The improved communication between husband and wife that may result is particularly important, since problems in the marital relationship are common in high-risk pregnancie~.’~J~ If possible, the course is held in a class or conference room on the hospital unit. Because many highrisk women have restrictions on
November/December 1987 JOG”
their activity levels, holding the class on the unit allows them to attend in wheelchairs o r with a minimal amount of walking. Activities in the class are limited to discussion and the practice of breathing and relaxation techniques. Flexibility on the part of the educator is important to accommodate fluctuations in class size, continuity of attendance, and the need to provide one-on-one instruction at the bedside. Ideally, the class will be limited to six to eight women and their partners so that each participant can receive individualized attention from the instructor. COURSE CONTENT
Most or all of the content included in standard childbirth classes is relevant to the high-risk population. However, a number of topics are especially important to high-risk women and are expanded to form the basis of the model course (Figure 2). Of primary importance in the content of the course is the teaching of relaxation techniques. In regular childbirth classes, women are taught to relax in order to increase the sense of control and to decrease anxiety during labor and delivery. The benefits to hospitalized, high-risk women are even greater. Relaxation helps not only
0
Anatomy and physiology of reproductive system Normal labor and delivery process Cesarean birth Labor and delivery drugs and effects Relaxation Breathing techniques Prenatal attachment Breastfeeding
Figure 2. Course content.
during the birth process, but also assists these women in dealing with the high levels of anxiety and fear that are common during highrisk p r e g n a n ~ y . ~ *The ~ * ’teaching ~*’~ and practice of relaxation during class are augmented by relaxation tapes at the bedside and women are encouraged to use these techniques during diagnostic tests and other stressful situations. A second content area is the teaching or reviewing of basic anatomy and physiology to provide a foundation for discussion of the normal labor and delivery process. As in standard classes, content on the phases and stages of labor and women’s normal behavioral responses during the birth process provides class members with knowledge of what to expect. As a result, anxiety levels are decreased. Discussion of the signs and symptoms of early labor has special value by preparing those patients hospitalized for preterm labor to recognize the onset of preterm labor and to notify the health team promptly. Because of the hjgher rate of cesarean deliveries hmong high-risk women,16 discussion of this method of delivery is imperative. In addition to presenting factual information about cesarean sections, the educator provides time for class participants to discuss their feelings and ask questions about surgical birth. Teaching specific breathing techniques is another vital topic in the course. Using breathing methods during labor provides women with a tool to help control the pain of contractions. This benefit applies to -healthy pregnant women, but is potentially more significant to high-risk patients who may be restricted from the use of analgesics because of risks to the fetus. Additionally, these women can expand the use of breathing techniques to help relax
419
during uncomfortable diagnostic procedures such as amniocentesis and contraction stress tests. Discussion of analgesics and anesthetics used during labor and delivery provides high-risk expectant mothers with the information needed to make informed choices regarding the option of using drugs for pain relief. For those who are restricted from using analgesics, the educator explains how drugs may jeopardize the fetus. The content on drugs is expanded in this course to include information about medications such as terbutaline and ritodrine that are frequently used to control preterm labor. Uncomfortable side effects often accompany the use of these drugs. Class discussion allows women to understand how the drugs work and to explore ways of dealing with the side effects. The presentation of material on bonding and attachment is part of many childbirth classes and is especially significant for high-risk clients. Because of the uncertain outcome of high-risk pregnancy, attachment to the fetus during pregnancy is often decreased, and the incidence of parenting problems i s i n ~ r e a s e d . ’Class ~ members learn techniques to enhance prenatal attachment, such as the use of effleurage. This light, fingertip massage of the abdomen is a relaxation technique, but can also be used to help women become aware of fetal outline and movement. The increased awareness of the fetus that can result from the practice of effleurage serves to enhance the attachtime is also ment p r o ~ e s s . ’Class ~ spent encouraging the expectant mothers to express their feelings about the fetus and reassuring mothers that reluctance to become attached because of potential loss is normal. Breastfeeding is another impor-
420
tant area of course content. A s with all pregnant women, knowledge of the advantages and disadvantages of breastfeeding and techniques for success allows class members to make informed decisions about which method of feeding is best. In this special class, emphasis is given to the enhancement of bonding and attachment that may result from breastfeeding. Because women hospitalized for preterm labor are more likely to deliver premature infants, some class time is devoted to discussion of breast pumping techniques and storage of milk for neonates in the intensive care nursery. Augmentation of the course content that has been described can be achieved through the use of audio and video tapes at the bedside. This teaching strategy reinforces class content and allows for more time to be spent answering questions and discussing the thoughts and feelings of class members. Additionally, the tapes can be used to enhance the instruction provided to women who are restricted to bedrest. SUMMARY
ducted to document the effects of the classes on the mother, the newborn, parenting behaviors, and the couple relationship. If positive effects can be demonstrated, the likelihood that childbirth education will become a standard of care for the high-risk, pregnant client will increase. ~-
REFERENCES 1. Kemp, V.H., and C.K. Page. 1986.
The psychosocial impact of a high-risk pregnancy on the family. JOGNN 15:232-36. 2. Williams, M.L. 1986. Long-term hospitalization of women with high-risk pregnancies. JOGNN 15:17-21. 3. Merkatz,
R. 1978. Prolonged hospitalization of pregnant women: The effects on the family. Birth and the Family Journal 5:204-06. 4. Willmuth, L.R. 1975. Prepared childbirth and the concept of control. JOGN Nurs. 4:38-41. 5. Beck, N.C., and D. Hall. 1978. After office hours: Natural childbirth, a review, and analysis. Obstet GyneC O ~ 52:37 . 1-79. 6. Standley, K., B. Soule, and S.A. Copans. 1979. Dimensions of pre-
natal anxiety and their lnfluence on pregnancy outcow. Am. J. Obstet. Gynecol. 135:22-26. 7 . Timrn, M.M. 1979. Prenatal education evaluation. Nurs. Res, 2833842.
The need clearly exists to provide childbirth education to hospitalized, high-risk women, and a model for such a course is proposed. Components of the model are incorporating childbirth educators into the health-care team; using a format appropriate for classes taught to hospitalized clients; and expanding content areas to meet the specific needs of high-risk pregnant women. Potential benefits of the course include decreased anxiety, enhancement of attachment to the fetus, and improvement in the couple relationship. Once these classes become available, research must be con-
8. Walker, B., and A. Erdman. 1984.
Childbirth education programs: The relationship between confidence and knowledge. Birth 11:103-08. 9. Ascher, B.H. 1978. Maternal anxi-
ety in pregnancy and fetal homeostasis. JOGN Nurs.7:18-21. 10. Weil, S.G. 1981. The unspoken needs of families during high-risk pregnancies. Am. J. Nurs. 81:204649. 11. Zacharias, J.F. 1981. Childbirth ed-
ucation classes: Effects on attitudes toward childbirth in highrisk indigent women. JOGN Nun. . 10:265-67. 12. Brown, B. 1982. Maternity-patient
teaching: A nursing priority. JOGN Nu~s.11~11-13. 13. Dore, S.L., and B.L. Davies. 1979. Catharsis for high-risk antenatal inpatients. MCN 4:96-97.
November/December 1987 JOG”
14. Gyves, M.T. 1985. The psychosocia1 impact of high-risk pregnancy. Adv. Psychosom. Med. 12:71-80. 15. Galloway, K.G. 1976. The uncertainty and stress of high-risk pregnancy. MCN 1294-99. 16. Neeson, J., and K. May. 1986. Comprehensive maternity nursing. Philadelphia: J.B. Lippincott. 17. Carter-Jessop, L. 1981. Promoting
maternal attachment through prenatal attachment. MCN 6:107-12. Address for correspondence: Paulette Avevi RNi MSNp3636 Victor Avenue* Oakland, CA 94619. Paulette Avery teaches maternity nursing at Samuel Merritt College of Nursing in Oak-
land, California. Mrs. Avery is a member of NAACOG and is an ASPO certified childbirth educator.
Irene McKenzie Olson is a childbirth educator at Aka Bates Hospital and at an Alameda County Public Health prenatal clinic in Berkeley, California. Ms. Olson is a member of ASPO.
UPDATED STANDARDS FOR OGN NURSES N O W AVAILABLE The third edition (1986) of Standards for Obstetric, Gynecologic, and Neonatal Nursing reflects the dynamic changes occurring in obstetric, gynecologic, and neonatal (OGN) nursing practice today. Designed to be used by OGN nurses in all areas of practice, the standards may be the basis for writing and reviewing policy and procedures and for developing educational programs for nurses, patients, and their families. Also, the standards may be used for long- and short-range planning and for quality assurance programs. One section is devoted to defining standards in each specialty area of OGN nursing: Obstetric nursing-antepartum, intrapartum, and postpartum care Neonatal nursing-normal/low-risk neonate and high-risk neonate care Gynecologic nursing-ambulatory and inpatient care Also included in the 1986 standards is a statement on electronic fetal monitoring jointly prepared by the American College of Obstetricians and Gynecologists (ACOG) and NAACOG. To order, enclose $20.00 for each copy of standards plus $2.00 for postage and shipping (if your order totals more than $20.00, please enclose $3.00 for postage and shipping). Orders must be prepaid. Make check or money order payable to NAACOG. Allow eight weeks for delivery. Mail to NAACOG Publications, 600 Maryland Ave., SW, Suite 200 E, Washington, DC 20024.
Novernber/Decernber 1987 JOCNN
42 1
The care of hospitalized, highrisk patients during pregnancy is receiving increasing attention in the nursing l i t e r a t ~ r e .A' ~signifi~~~ cant number of high-risk women are being admitted to hospitals for extended periods, particularly in the third trimester, for treatment of conditions such as hypertension, diabetes, or preterm labor. As a result, these women do not have access to childbirth education and frequently experience labor and delivery with little or no preparation. Childbirth education is an accepted component of the health care provided to healthy pregnant women. The benefits of childbirth education are well documented. These benefits include an increased sense of control during labor: a decreased perception of pain,5 decreased anxiety,6 de-
Accepted: April 1987
418
is certified in childbirth education creased use of analgesics,' and inby a national organization such as creased confidence in dealing with ICEA or ASPO. The educatot also labor and delivery? has a knowledge of and.' experiAll of these effects are potenence in high-risk obM&ric care. tially of equal or greater benefit to The use of a trained instructor rechigh-risk women and the need to ognizes the fact that most staff provide childbirth education to nurses do not have the time12 or this group has been identified repeatedly in the l i t e r a t ~ r e . ' ~ Za~ * ~ * ' ~background to provide this service. charias" not only identifies the need, but also demonstrates more COURSE FORMAT positive attitudes toward the childbirth experience in a group of Course format is designed to urban, high-risk pregnant women meet the needs of the hospitalized who participated in a childbirth woman as well as her family education course. However, prepmembers (Figure 1). Because the aration for childbirth is currently patient population of women renot part of the care offered to most quiring long-term hospitalization women with problem pregnancies. during pregnancy is relatively A model for childbirth education stable? the course is offered in a classes taught to hospitalized, series of six classes taught once-ahigh-risk obstetric clients is deweek. Newly admitted patients scribed below. enter the course at any point and ~~~
COURSE EDUCATOR In this model, the course is taught by a registered nurse who
~
continue until patients complete the series, are discharged, or deliver. Women discharged before completing the series are invited
NovemberIDecember1987 JOG"
Classes are taught By a childbirth educator In the hospital Weekly and ongoing In the evening With spouses and family members With group discussions
Figure 1. Course format.
to continue participation as outpatients. Providing the course to a group of women, rather than to individuals, is more cost-effective. Of equal importance, group instruction offers these women the opportunity to share their common experiences of being pregnant and hospitalized. Dore and Davies13 report that discussion groups for high-risk pregnant women were effective in helping these women cope with some of the problems associated with their stressful situations. However, because some high-risk women are on strict bedrest during hospitalization, individualized instruction at the bedside is also available. Classes are held in the evening to encourage participation by husbands or other family members. The presence of family members allows the childbirth educator to prepare support persons to act as coaches during labor and delivery. Family participation also provides an opportunity for the hospitalized woman and her family to ask questions and express concerns about the woman’s condition in a supportive atmosphere. The improved communication between husband and wife that may result is particularly important, since problems in the marital relationship are common in high-risk pregnancie~.’~J~ If possible, the course is held in a class or conference room on the hospital unit. Because many highrisk women have restrictions on
November/December 1987 JOG”
their activity levels, holding the class on the unit allows them to attend in wheelchairs o r with a minimal amount of walking. Activities in the class are limited to discussion and the practice of breathing and relaxation techniques. Flexibility on the part of the educator is important to accommodate fluctuations in class size, continuity of attendance, and the need to provide one-on-one instruction at the bedside. Ideally, the class will be limited to six to eight women and their partners so that each participant can receive individualized attention from the instructor. COURSE CONTENT
Most or all of the content included in standard childbirth classes is relevant to the high-risk population. However, a number of topics are especially important to high-risk women and are expanded to form the basis of the model course (Figure 2). Of primary importance in the content of the course is the teaching of relaxation techniques. In regular childbirth classes, women are taught to relax in order to increase the sense of control and to decrease anxiety during labor and delivery. The benefits to hospitalized, high-risk women are even greater. Relaxation helps not only
0
Anatomy and physiology of reproductive system Normal labor and delivery process Cesarean birth Labor and delivery drugs and effects Relaxation Breathing techniques Prenatal attachment Breastfeeding
Figure 2. Course content.
during the birth process, but also assists these women in dealing with the high levels of anxiety and fear that are common during highrisk p r e g n a n ~ y . ~ *The ~ * ’teaching ~*’~ and practice of relaxation during class are augmented by relaxation tapes at the bedside and women are encouraged to use these techniques during diagnostic tests and other stressful situations. A second content area is the teaching or reviewing of basic anatomy and physiology to provide a foundation for discussion of the normal labor and delivery process. As in standard classes, content on the phases and stages of labor and women’s normal behavioral responses during the birth process provides class members with knowledge of what to expect. As a result, anxiety levels are decreased. Discussion of the signs and symptoms of early labor has special value by preparing those patients hospitalized for preterm labor to recognize the onset of preterm labor and to notify the health team promptly. Because of the hjgher rate of cesarean deliveries hmong high-risk women,16 discussion of this method of delivery is imperative. In addition to presenting factual information about cesarean sections, the educator provides time for class participants to discuss their feelings and ask questions about surgical birth. Teaching specific breathing techniques is another vital topic in the course. Using breathing methods during labor provides women with a tool to help control the pain of contractions. This benefit applies to -healthy pregnant women, but is potentially more significant to high-risk patients who may be restricted from the use of analgesics because of risks to the fetus. Additionally, these women can expand the use of breathing techniques to help relax
419
during uncomfortable diagnostic procedures such as amniocentesis and contraction stress tests. Discussion of analgesics and anesthetics used during labor and delivery provides high-risk expectant mothers with the information needed to make informed choices regarding the option of using drugs for pain relief. For those who are restricted from using analgesics, the educator explains how drugs may jeopardize the fetus. The content on drugs is expanded in this course to include information about medications such as terbutaline and ritodrine that are frequently used to control preterm labor. Uncomfortable side effects often accompany the use of these drugs. Class discussion allows women to understand how the drugs work and to explore ways of dealing with the side effects. The presentation of material on bonding and attachment is part of many childbirth classes and is especially significant for high-risk clients. Because of the uncertain outcome of high-risk pregnancy, attachment to the fetus during pregnancy is often decreased, and the incidence of parenting problems i s i n ~ r e a s e d . ’Class ~ members learn techniques to enhance prenatal attachment, such as the use of effleurage. This light, fingertip massage of the abdomen is a relaxation technique, but can also be used to help women become aware of fetal outline and movement. The increased awareness of the fetus that can result from the practice of effleurage serves to enhance the attachtime is also ment p r o ~ e s s . ’Class ~ spent encouraging the expectant mothers to express their feelings about the fetus and reassuring mothers that reluctance to become attached because of potential loss is normal. Breastfeeding is another impor-
420
tant area of course content. A s with all pregnant women, knowledge of the advantages and disadvantages of breastfeeding and techniques for success allows class members to make informed decisions about which method of feeding is best. In this special class, emphasis is given to the enhancement of bonding and attachment that may result from breastfeeding. Because women hospitalized for preterm labor are more likely to deliver premature infants, some class time is devoted to discussion of breast pumping techniques and storage of milk for neonates in the intensive care nursery. Augmentation of the course content that has been described can be achieved through the use of audio and video tapes at the bedside. This teaching strategy reinforces class content and allows for more time to be spent answering questions and discussing the thoughts and feelings of class members. Additionally, the tapes can be used to enhance the instruction provided to women who are restricted to bedrest. SUMMARY
ducted to document the effects of the classes on the mother, the newborn, parenting behaviors, and the couple relationship. If positive effects can be demonstrated, the likelihood that childbirth education will become a standard of care for the high-risk, pregnant client will increase. ~-
REFERENCES 1. Kemp, V.H., and C.K. Page. 1986.
The psychosocial impact of a high-risk pregnancy on the family. JOGNN 15:232-36. 2. Williams, M.L. 1986. Long-term hospitalization of women with high-risk pregnancies. JOGNN 15:17-21. 3. Merkatz,
R. 1978. Prolonged hospitalization of pregnant women: The effects on the family. Birth and the Family Journal 5:204-06. 4. Willmuth, L.R. 1975. Prepared childbirth and the concept of control. JOGN Nurs. 4:38-41. 5. Beck, N.C., and D. Hall. 1978. After office hours: Natural childbirth, a review, and analysis. Obstet GyneC O ~ 52:37 . 1-79. 6. Standley, K., B. Soule, and S.A. Copans. 1979. Dimensions of pre-
natal anxiety and their lnfluence on pregnancy outcow. Am. J. Obstet. Gynecol. 135:22-26. 7 . Timrn, M.M. 1979. Prenatal education evaluation. Nurs. Res, 2833842.
The need clearly exists to provide childbirth education to hospitalized, high-risk women, and a model for such a course is proposed. Components of the model are incorporating childbirth educators into the health-care team; using a format appropriate for classes taught to hospitalized clients; and expanding content areas to meet the specific needs of high-risk pregnant women. Potential benefits of the course include decreased anxiety, enhancement of attachment to the fetus, and improvement in the couple relationship. Once these classes become available, research must be con-
8. Walker, B., and A. Erdman. 1984.
Childbirth education programs: The relationship between confidence and knowledge. Birth 11:103-08. 9. Ascher, B.H. 1978. Maternal anxi-
ety in pregnancy and fetal homeostasis. JOGN Nurs.7:18-21. 10. Weil, S.G. 1981. The unspoken needs of families during high-risk pregnancies. Am. J. Nurs. 81:204649. 11. Zacharias, J.F. 1981. Childbirth ed-
ucation classes: Effects on attitudes toward childbirth in highrisk indigent women. JOGN Nun. . 10:265-67. 12. Brown, B. 1982. Maternity-patient
teaching: A nursing priority. JOGN Nu~s.11~11-13. 13. Dore, S.L., and B.L. Davies. 1979. Catharsis for high-risk antenatal inpatients. MCN 4:96-97.
November/December 1987 JOG”
14. Gyves, M.T. 1985. The psychosocia1 impact of high-risk pregnancy. Adv. Psychosom. Med. 12:71-80. 15. Galloway, K.G. 1976. The uncertainty and stress of high-risk pregnancy. MCN 1294-99. 16. Neeson, J., and K. May. 1986. Comprehensive maternity nursing. Philadelphia: J.B. Lippincott. 17. Carter-Jessop, L. 1981. Promoting
maternal attachment through prenatal attachment. MCN 6:107-12. Address for correspondence: Paulette Avevi RNi MSNp3636 Victor Avenue* Oakland, CA 94619. Paulette Avery teaches maternity nursing at Samuel Merritt College of Nursing in Oak-
land, California. Mrs. Avery is a member of NAACOG and is an ASPO certified childbirth educator.
Irene McKenzie Olson is a childbirth educator at Aka Bates Hospital and at an Alameda County Public Health prenatal clinic in Berkeley, California. Ms. Olson is a member of ASPO.
UPDATED STANDARDS FOR OGN NURSES N O W AVAILABLE The third edition (1986) of Standards for Obstetric, Gynecologic, and Neonatal Nursing reflects the dynamic changes occurring in obstetric, gynecologic, and neonatal (OGN) nursing practice today. Designed to be used by OGN nurses in all areas of practice, the standards may be the basis for writing and reviewing policy and procedures and for developing educational programs for nurses, patients, and their families. Also, the standards may be used for long- and short-range planning and for quality assurance programs. One section is devoted to defining standards in each specialty area of OGN nursing: Obstetric nursing-antepartum, intrapartum, and postpartum care Neonatal nursing-normal/low-risk neonate and high-risk neonate care Gynecologic nursing-ambulatory and inpatient care Also included in the 1986 standards is a statement on electronic fetal monitoring jointly prepared by the American College of Obstetricians and Gynecologists (ACOG) and NAACOG. To order, enclose $20.00 for each copy of standards plus $2.00 for postage and shipping (if your order totals more than $20.00, please enclose $3.00 for postage and shipping). Orders must be prepaid. Make check or money order payable to NAACOG. Allow eight weeks for delivery. Mail to NAACOG Publications, 600 Maryland Ave., SW, Suite 200 E, Washington, DC 20024.
Novernber/Decernber 1987 JOCNN
42 1