Prenatal exposure to alcohol can lead to a range of physical, mental, behavioral, learning, and developmental disabilities, with possible lifelong effects for the child exposed in utero. This range is commonly known as fetal alcohol spectrum disorder or FASD. FASDs are 100% preventable when a baby is not  exposed to alcohol during pregnancy.

Healthcare professionals may tell women that it’s OK to drink alcohol on occasion or even in moderation, when they are pregnant. However, evidence shows that there is no known safe type, safe amount, or safe time to consume alcohol while pregnant.

Additionally, it’s important for healthcare professionals to broach the subject of alcohol consumption, not only with their pregnant patients, but with all women of reproductive age. Women who are sexually active and not using effective contraception may be at an increased risk for alcohol exposed pregnancies, as nearly half of all pregnancies within the United States are unplanned.

It is critical that healthcare professionals educate all women of reproductive age about alcohol use and pregnancy. Alcohol screening and brief intervention (alcohol SBI) is one evidence-based approach to assessing patients for at-risk alcohol use. Screening includes use of a validated tool, such as the Alcohol Use Disorders Identification Test (AUDIT). The AUDIT is a clinically reliable and valid instrument (Bohn, Babor & Kranzler, 1995). The AUDIT has been consistently found to screen and detect alcohol use across a spectrum of low, moderate, and high risk consumption (Reinert & Allen, 2007).  The AUDIT has been found to be valid and reliable with diverse populations and in a variety of settings.

When a patient screens positive for at-risk use, a non-judgmental discussion, called a “brief intervention” occurs with the use of motivational interviewing techniques. For example, the patient is provided with the score on the AUDIT during the health care visit. If a patient scores between an 8 and 15, this score is discussed in relation to their current health condition and presented objectively to the patient as moderate alcohol consumption. If the AUDIT score is between 16 and 19, then brief counseling and continued monitoring are suggested. With a score of 20+ a referral for further assessment is indicated (Babor & Higgins-Biddle, 2001). The main goals of the brief intervention are to increase a patient’s awareness of their alcohol consumption patterns, understand the associated risks and options for reducing or eliminating those risks, and to increase their motivation to make healthy choices.

As nurses, it is our obligation to ensure that women are provided with the knowledge needed to make informed choices regarding their health. For example, giving the patient objective feedback about their score on the AUIDT and then asking them “What are your thoughts about this score?” is a way to elicit their thoughts and feelings about their alcohol consumption in relation to their health and wellness. Further, exploring the pros and cons of the patients current level of alcohol consumption is an excellent technique to elicit the patients thoughts and provides an opportunity for the health professional to provide feedback and health education.  Patients have high trust in confiding to their healthcare provider and in particular nurses.

Additional Resources

• AWHONN’s FASD Resources
• AUDIT Website

Dr. Ann M. Mitchell is professor of nursing and psychiatry at the University of Pittsburgh School of Nursing. She is principal investigator on a CDC-funded project for the implementation of alcohol screening and brief intervention with the ultimate goal of preventing FASDs.

Dr. Holly Hagle is Director of Education for the Institute for Research, Education and Training in Addiction (IRETA) and a partner in the CDC-funded FASD project.

Brayden Kameg is a graduate student in the psychiatric-mental health nurse practitioner DNP program at the University Of Pittsburgh School Of Nursing. She is actively participating in grant-related activities on Dr. Mitchell’s projects.

I could feel the excitement in the room as I entered. The couple was receptive to my questions and suggestions; and the woman was more than happy to involve me in her care.  I tried to build rapport even though I was nervous in my role as a nursing student. This was the first time I had assisted a woman in labor and, after her membranes were artificially ruptured, her contractions started to come about two minutes apart.  At one point, I had my hand on her back and her husband smiled at me across the room and signaled for to me to remove my hand!  It was a great moment in which the support person and I connected!  I remained quiet during her contractions and I asked her if she wanted me to breathe with her but she said she had it under control. I kept thinking back to my own labors and what I felt I wanted from support people so I asked her if she would like lower back counter pressure but she refused.  The family had not done a childbirth preparation course so I assumed that their interest or skills with working through labor was limited.  I thought that they would need my help more yet her prenatal yoga practice seemed to have given her the tools she needed to get through her labor. The tools I offered her personally were meditative.  I told her to focus on her favorite place, to discuss her needs and frustrations with us in between contractions and reassured her that I was there for her to breathe with her and regulate her breathing as needed.

Reflecting on the Nursing Care Women and Babies Deserve virtues I used during this experience, I believe they were humility and engagement. Humility in that I had to understand I did not know what was best for this family. I assumed they would want and need what I needed during childbirth or skills I learned from the comfort measures video I used to prepare for this clinical experience. The woman decided what she needed and I was there to support her. In respecting their wishes I could engage with the family. Before I left them for the day they commented, “We felt like we had our own doula”.  It was easy and a pleasure to engage with this couple and follow their commands and offer suggestions. I told them I had never wanted to stay at clinical so much as I did with them. I will always remember this family.

Additional Resources

AWHONN’s Nursing Care and Women Babies Deserve Poster –  AWHONN’s statement on ethical nursing practice, Nursing Care Women and Babies Deserve, is rooted in the American Nurses Association’s Code of Ethics for Nurses, and provides nurses with core elements of ethical nursing practice for our specialty and corresponding examples of the virtues of ethical practice in action.

Read a commentary about Nursing Care Women and Babies Deserve in AWHONN’s journal Nursing for Women’s Health. Consider submitting your own story of how you or your colleagues practice nursing care that women and babies deserve at https://www.awhonn.org/?NursingCare

Amy is an ABSN student at MGH Institute of Health Professions, Boston.  She was a stay at home mother for 12 years,  a community coordinator for a non profit kids running program and a volunteer at Dana Farber Cancer Institute in Boston before deciding to enter the nursing field.  With extensive volunteer experience from a camp for blind & visually impaired adults and children, to co-president of an elementary school PTO, she enjoys working with diverse groups of all ages.  Amy aims to work in labor and delivery after graduation in August 2017 but is also interested in global health and epidemiology.  She has intentions to keep making a difference in the lives of those she may never meet again.

I am the mother of four children, each one unique. The same can be said of their births. Because of the variety of births I have experienced, I’ve learned that for me, nitrous oxide is by far the best form of pain relief during childbirth .

My first delivery was long and painful. I labored at home for 5 hours before my water broke. I stayed at home for another 5 hours hoping for labor to smoothly progress, but upon arrival at the hospital, I was only dilated barely 1 cm. The long night in the hospital was exhausting and not beneficial to the progression of labor. Around 6 the next morning, I was drained and unable to manage pain. After discussing options with my midwife, I decided to get an epidural so my body could relax and allow me to sleep in preparation for later stages of labor and ultimately delivery. The epidural helped with the pain but I felt I didn’t have control of pushing, breathing, feeling and navigating giving birth. After 3 hours of pushing, my beautiful face-up baby girl was born. Recovery was difficult and painful. I felt sore, because I had not been able to successfully gauge how hard or soft I was pushing, and, at times, I was overdoing it. I also found out that I don’t like bladder catheters.

Ten months later, I found out I was pregnant with baby No. 2. I was anxious and focused on having an unmedicated birth. I was envisioning a much easier birth and the opportunity to see how labor and giving birth can be different without so many pokes and interventions. Luckily, my dreams came true with baby No. 2! After laboring all day at home, I decided to go to the hospital around midnight. After laboring for a few more hours with the help of my husband, midwife and sister-in-law, my water broke at 3 a.m. At 3:30 a.m. I felt like I needed to get into position. Before my husband and midwife were fully prepared, my busy baby girl pushed herself into this world without any effort on my part. My recovery was so much easier and our little girl was alert and quick to nurse.

At my 20-week ultrasound for baby No. 3, I found out I was having a boy. I had heard my mother talk about how her big boys and their collarbones were difficult to deliver. From then on, I started to imagine a huge baby boy making delivery difficult. I am naturally an over-optimistic person, so I tried to suppress negative thoughts. All this played a part in my delivery. Once again, I labored all day but this time I did not stay home. I was at my midwife’s office for monitoring since I was 4 days late. (All of my babies have been late, so no surprise here.) Since I was not at home, I was not as comfortable as I could have been. I was tired and really needed a good nap. At one point, I did fall asleep in a recliner and was awakened by a sudden gush of water. My water had broken naturally with the other two deliveries, but never this much! It gushed and gushed and gushed!

Since my last baby came 30 minutes after my water broke, my husband, midwife and I rushed to the hospital thinking the baby would come flying out any minute. Upon arrival at the hospital, I was dilated to 5 cm. I continued to labor on my own for a few hours. At that point I had not progressed, and, in fact, my contractions had started to slow down. We discussed Pitocin, which scared me because I knew that would make contractions stronger and more painful . I asked if we could try anything else. My midwife said nitrous oxide was available at the hospital, and I should give it a try. I agreed to try it, but I was not really excited about it. The anesthesiologist came to explain how nitrous is administered. It was easy to understand, and I was willing to try the mask on and take a few deep breathes. I took my first deep breath and instantly relaxed so much that I fell into a very deep sleep for a few moments.

My body was exhausted but I had not allowed it to rest up to that point. I rested, and immediately, labor picked back up. I began talking about all of my fears and deep-rooted worries about how big my little man was going to be. This talk was new to my husband and midwife who had no idea that I was nervous or even afraid about my baby’s size. I had not expressed any of this until after using nitrous and feeling completely free to be myself . I stopped fighting labor, and instead embraced the contractions and allowed them to push labor along. Within 20 minutes, I had dilated from 5 cm to 10 cm and was ready to push. With each push I could feel the pain and his little body descending, but because of the nitrous oxide, I was able to separate myself from the pain. After 5 minutes of pushing, we met our first boy and biggest baby. He was 8 pounds 6 ounces. My fear of having a bigger baby was legitimate.

Seven months ago, I gave birth to another baby girl. Her birth was fast and furious! I tried to labor at home like I always do, but these contractions went from easy early labor to hard late stages of labor very quickly. I was very nervous and afraid that I would have the baby in the car. We arrived at the hospital, and I was in so much pain. This pain was unbearable. I wanted relief, and I wanted it fast. I was already dilated to 8 cm and fully effaced. I expressed my desire to have help managing the pain and the nurse was quick to let me know that nitrous would be the easiest to administer and quickest to provide relief. She was so right! I started the nitrous and instantly received the help I needed to distance myself from the unbearable pain that normally accompanies quick labors. Just like my first child, baby No. 4 was “sunny-side up”, but I was determined to push my hardest and get her out. She was born 50 minutes after arriving at the hospital. She was by far my fastest and most painful delivery.

From my experiences with nitrous oxide, I would strongly recommend it to help provide relief and pain management. I am not the best at keeping my mind focused and distracted from the pain. Nitrous oxide gave me exactly what I needed to distance myself from the hard pains of labor while still allowing me to navigate through contractions and pushing without feeling like I was driving blindly.

Not all hospitals in the United States are offering nitrous as a form of pain management in labor, but hopefully, more will begin to see its advantages.

There are few things more memorable in life than the birth of a baby. No matter where in the world, what socioeconomic background she comes from, or how many times she has given birth, a woman can probably tell you every single detail surrounding her birth and the early days thereafter. She can tell you the exact moment each baby was born, how long it was and how much it weighed. I have been honored and privileged through the years of working with moms, dads, and babies to hear their birth stories and bear witness to the one of the most important moments in their lives.

Living abroad over the last five years has given me a unique perspective of birth culture. I live in the second largest city in Sweden, Gothenburg. It is an international city that welcomes students and workers from all over the world. Gothenburg boasts international universities and large companies such as Volvo and Ericsson. It offers refuge to asylum-seeking immigrants from war-torn regions past and present including most recently Syria. I have met and cared for babies whose parents come from all parts of Europe, Africa, and The Middle East. One of the first questions I have always asked goes something like, “where are you from, what is your baby’s name, and what is something unique to your culture around the birth of your baby?” The answers are interesting and varied.

Join me on my journey of birth traditions around the world as I compare birth models and customs. Bear in mind is that most of the highlighted countries use a midwife model of care during pregnancy and birth. We will end our tour in the U.S. where we find that what may be the norm for us, may not be the norm everywhere else in the world.

Iran

Toktam, an engineer at Volvo, in Gothenburg, comes from Mashad, Iran. She recently gave birth to a baby girl, Hannah. She gave birth naturally and is the first in her generation of women to do so. Most women give birth by cesarean in Iran, but Toktam delivered her baby in Sweden where cesareans are reserved for emergencies and when medically indicated. When I asked her about birth traditions in Iran, she began talking about a shower. I immediately pictured the American baby shower with a group of women playing games and eating the latest Pinterest-inspired edibles. I was way off. A shower in Iran traditionally happens around 10 days after the baby is born or when the umbilical cord has fallen off. The mother’s sister, mother or aunt showers the mother. She is then massaged with special oils, given a facial, and painted with henna. It is reward for all her hard work and the pain she had to endure in labor. After the mom is showered, baby is bathed. Following the shower, friends and family are invited for a special lunch, called Valimeh (traditionally lamb). Guests bring gifts such as clothes and blankets while close relatives often bring something made of gold.

Australia

Rebecca is a nurse from Australia who has two little ones. Her first was delivered by emergency cesarean and the second by VBAC (vaginal birth after caesarean). Yay for VBAC options! Rebecca shared that in Australia it is common for family and friends to fill the new parents’ freezer with pre-made meals such as soups, casseroles, and lasagna. It gives the new sleep-deprived parents the precious time needed to rest between feedings and allows for more bonding time. She also shared a tradition new fathers share with their friends after the baby arrives. “Wetting the baby’s head,” means having a drink in honor of the new member of the family. It is a common tradition in England as well.

Italy

Amina, a postdoctoral researcher, comes from Parma, Italy. Yes, Parma where they make the most delicious cheese on the planet! She delivered her baby girl naturally. Amina shared the tradition known as “camicino della fortuna” in Italy. It is a jacket for the baby given to the mother to be after her third month of pregnancy. It is made of either silk or cotton and most commonly is white. It is worn right after birth as it is thought to bring good luck. It is usually passed on by a friend of family member whose baby wore it. Once worn, it is put away unwashed until it is time to pass it on to the next lucky mom.

Spain

One more stop in Southern Europe. We meet Astrid from Spain, mother of Sebastian. Astrid is a researcher at Ericsson, Sweden. She delivered Sebastian naturally. In Spain, it is traditional to pierce a newborn baby girl’s ears soon after birth, thus distinguishing that she is, in fact, a girl. It is very common for random strangers to approach new moms and babies in the streets to exclaim over the sweet little baby. It shouldn’t come as a surprise that these complete strangers will move in and give your baby a little peck.

Germany

Emma, a consultant, delivered her baby boy, Finn, naturally. She shared a common birth tradition after the baby arrives called Babypinkeln, which literally translates to baby pee, but is actually a party to welcome the baby. Historically, the naked baby was passed around and it was considered eternal luck to be the person that the baby peed on. It eventually became a party that occurred while mom and baby were still in the hospital to allow the mother to recover after birth. The father would get together with friends, family, and neighbors to eat, drink, and celebrate the new baby. Sometimes even cigars were passed around. These days, the party is usually planned when the mom and baby come home to join in the celebration.

Sweden

We move onward to Northern Europe to Sweden. Saga, a doula, preschool teacher, and artist, was part of a reemerging birth model in Sweden and the world for that matter, when she gave birth to both her children at home. While most Swedes give birth in the hospital with assistance of a midwife, a growing number opt to birth at home. Saga shared that it is frowned upon to bring flowers received in the hospital home after a baby is born because it is thought to be bad luck. A tradition I find most interesting and have witnessed in the years since moving to Sweden is the culture of leaving babies outside to nap. Even in the dead of winter, as far north as the Arctic Circle here in Sweden, and in minus degree temperatures, babies are bundled (Swedes know how to bundle) and their stroller is pushed outside for a nap. It is not unusual on any given day to be strolling downtown and see a line of strollers with sleeping babies outside a cafe while their moms have lunch or coffee (fika) together inside. It is thought the fresh air keeps the babies healthy and it seems to work.

U.S.

We end our tour in the U.S., my home country. Mandy (massage therapist and mother of two) recently gave birth to her baby girl, Mollie via repeat cesarean. Two traditions come to mind when it comes to having a baby in the U.S. including preparing a nursery (the baby’s room) and having a baby shower. American baby shower culture gained popularity towards the end of World War II. Women are “showered” with gifts and essentials needed in preparation for their baby. The host is usually a sister or best friend and the shower traditionally invites women only though more and more women are opting for a coed shower.

As we sum up our tour of birth models and culture, we can see that traditions vary widely. It is fascinating to hear about and share these women’s stories and learn a little about their country’s birth customs. Thank you to all who shared their special ways of celebrating mothers and babies.!! Merci! Cheers! Grazie! Gracias! Danke! Tack så mycket! Thank you!

Lori is a NICU Staff Nurse  at Sahlgrenska University Hospital in Gothenburg, Sweden. After becoming a nurse, Lori traveled across the country to work a three-month travel contract in San Francisco, California.  Nearly five years later her journey continued to Gothenburg, Sweden, where she now lives and works