According to the U.S. Department of Health, one in four girls and one in five boys will be sexually abused before they turn 18. One in five women and one in 71 men will be raped at some point in their lives. This is in many ways a silent epidemic. Sometimes victims don’t disclose their abuse to their care providers. The reasons vary, and can range from  ongoing suffering of the traumatic effects of the abuse and  avoiding  reliving it, to a continuing sense of shame that victims  may have never come to grips with.

What are some possible signs of sexual abuse?

According to When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women, having a constellation of these symptoms can indicate a history of abuse. Having one or more of the following should trigger a red flag and considerations for a woman’s  care during childbirth:

• Not able to feel fetal movement. Some women have “numbed” that part of the body
• Hyperemesis gravidarum
• Chronic pelvic pain
• Missed prenatal appointments
• Panic with vaginal exams
• Extreme anxiety with IV starts
• Disassociation that manifests as if she’s going into a trance

Many of these symptoms can understandably occur in women who don’t have a history of sexual abuse, but when a woman has two or more, it’s reasonable to suspect that such a history is possible. These symptoms can stem from PTSD, which is triggered by a woman’s perception of loss-of-control, as well as the physical sensations that occur during pelvic exams, labor, and birth. By rushing through procedures, and not allowing the woman time to process (if possible), understand, and consent to what is happening to her body, we can inadvertently trigger a posttraumatic reaction.

Admittedly, the discussion of sexual abuse is a tough topic for those on either end of the conversation. We often just touch on the subject while reviewing women’s admission histories, and then move on. Fortunately, we don’t need the admission of abuse to employ strategies developed for survivors. It’s actually much more common for caregivers to pick up on non-verbal cues and then tailor their care. A real tragedy is the guilt and shame survivors can feel after giving birth. So, like we would do for any woman,  it’s best to acknowledge the struggle of labor and birth, the strength a woman demonstrated, and the effort and precious reward she  achieved.

What are interventions that nurses and other caregivers can provide?

• Explain as much as you can in advance, for example “If we run into an emergent situation there might be unfamiliar nurses coming in to help. I know this can cause anxiety, but I want to prepare you ahead of time in case it happens.”
• Always start with asking permission. From starting an IV to turning on the overhead lights, make sure to obtain permission before doing any procedures or making changes to the environment
• Go slowly with everything you do–this can be helpful in relation to a woman’s  fear of losing control. Fast movements can be triggers. This is especially important when uncovering a woman or assisting her with positioning.
• Limit vaginal exams. These are especially traumatic and should be minimized. If a woman is having difficulty in relaxing enough to complete an exam, try making an agreement about when and why you can perform one. If a woman understands that the exams are being performed only when necessary, and with her consent, her anxiety is often more controllable during exams.
• Minimize people in her room. She might have issues with nursing students or residents, especially if they are male. Obtain her permission before any new staff come into the room, unless there’s an emergent situation.

What are things not to say?

• Intrusive interest-prying for details or descriptions of the abuse
• Minimizing the abuse: “Well, that’s over now.”
• Exaggerated concern
• Shock or disgust
• Pity

What are good things to say?

• “I can imagine that was very hard to share that with me. It takes a lot of courage to talk about and I respect you for doing that.”
• “Sometimes talking about these episodes can trigger strong feelings. How are you feeling right now?”
• And, it’s always essential to assess the woman’s current well-being “Do you feel unsafe in any aspect of your life?”

Not all survivors of sexual abuse have difficulty with pregnancy or childbirth, for some it can be empowering. For those who do struggle, recognize that we have a powerful opportunity to help them. We can communicate therapeutically to help  change the woman’s focus from feeling out-of-control.  We can employ care practices to avoid the woman feeling re-traumatizatized.  And we can set the stage to promote healing and bonding with the newborn. In many instances it’s our tacit recognition and respectful and supportive care that facilitates healing, more than any words we could utter or medicines we could administer.

Where can I learn more?

• When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women
• Simkin, Penny and Phyllis H. Klaus. Seattle: Classic Day, 2011. Print.

What are resources for my patients?

• National Sexual Abuse Hotline: 1800-656-HOPE
• RAINN: Rape, Abuse, Incest National Network, www.rainn.org

Tasha Poslaniec has been a registered nurse for 17 years. She has been working in obstetrics for over a decade and is currently a Perinatal Quality Review Nurse and Childbirth Educator.

She also writes about nursing and childbirth and has been published in the Huffington Post and the American Journal of Nursing. Pain control in childbirth has long been a topic of study and research for her.

There are many great reasons why hospitals choose to work toward and achieve Baby-Friendly hospital status. There are also plenty of ways to encourage breastfeeding in line with the World Health Organization’s (WHO) guidelines without having that official Baby-Friendly Hospital designation. In fact, research has shown that implementing Baby Friendly practices such as early breastfeeding after birth, skin-to-skin care , and rooming-in,  in hospitals that do not have this designation, resulted in higher rates of breastfeeding initiation and duration.

Whether or not you’re pursuing Baby-Friendly status, your hospital can effectively support and promote breastfeeding among staff, mothers, and their families. Here are just 5 of many ways to go about it:

1. Start educating women about breastfeeding early.

Setting expectations and goals early in the care process that a mother will achieve desired health objectives. This is true of breastfeeding, as well.

• Educating mothers about the benefits of breastfeeding is most successful when it starts during pregnancy. Indeed, Step 3 of WHO’s 10 Steps to Successful Breastfeeding—the key criteria for formal Baby-Friendly hospital status—requires that hospitals “inform all pregnant women about the benefits and management of breastfeeding.”
• Educating parents proactively, rather than waiting for them to request information, ensures they have the education they need when they need it.
• Educating parents electronically means the information can be shared in small, consistent pieces that don’t feel overwhelming. It’s also a time savings for staff and providers who would otherwise need to use medical appointments for breastfeeding education.

2. Incorporate breastfeeding education into your ongoing staff training.

Keeping your staff updated on supportive breastfeeding practices doesn’t have to be time-consuming or require organized training classes. Consider providing electronic breastfeeding education for staff to access anywhere and at their own convenience. Choose a solution that lets you track their progress, so you know when they’ve read the required information.

3. Stay in touch with women and their families about breastfeeding support opportunities, even after they’ve returned home.

In the U.S., 74% of babies have breastfed at least once, but only 23% are still breastfeeding by 1 year of age, according to the CDC’s Breastfeeding Report Card. Once new mothers are discharged, a strong connection with your hospital can encourage them to take advantage of available support, overcome challenges and stick with breastfeeding.

When following up with women who’ve recently had babies invite them to schedule a session with a lactation consultant or attend a  breastfeeding support group at your hospital. These opportunities not only provide additional revenue sources,  but also nurture relationships with women and their families, who will be more likely to return to your hospital in the future—whether for obstetric or other medical care.

4. Ask new moms for feedback about your hospital’s breastfeeding support practices.

Breastfeeding is an emotional topic for new mothers. With patient experience and satisfaction so important to a hospital’s bottom line these days, you want to know where you stand in patients’ minds.

Surveys are a great way to measure patient satisfaction with your breastfeeding education practice and policy. Send a quick survey by email or text message, asking new moms specifically about how your breastfeeding support has helped them and where you can improve.

5. Collect data on how many women who had their babies at your hospital continue breastfeeding.

Healthy People 2020, the population health measures created by the federal Office of Disease Prevention and Health Promotion, set goals for how many infants are breastfed by the year 2020, including 34% of infants breastfeed at 1 year and 26% breastfed exclusively through 6 months.

If you want to work toward or even surpass this goal, you need to measure how your patients are doing after they leave the hospital. Providing patients education in a digital format, i.e. on their mobile device, combined with data collection technology can help you gain insight.

Baby-Friendly status remains the gold standard for many hospitals encouraging breastfeeding. But if your facility has limited resources, these 5 strategies can help your hospital successfully support and encourage breastfeeding.

For additional information on becoming a Baby-Friendly hospital, visit www.babyfriendlyusa.org

AWHONN Resources

• Breastfeeding Support
• Perinatal Nursing
• Breastfeeding Rates Improve with Support and Education for Mothers
• Increasing Initiation and Exclusivity of Breastfeeding in the Hospitalized, Postpartum Dyad (JOGNN)

Deirdre Wilson, Senior Editor for UbiCare, is an award-winning writer and editor with 30 years’ experience researching and writing on a wide range of health, wellness and education topics for newspapers, magazines and a news wire service.

 “I was at a routine dental office visit a few weeks after my daughter was born. I remember being reclined in the chair, the bright overhead light and the scent of latex.  Images of surgical masks whipped through my mind.  Fear rushed through my body and I shook uncontrollably.  My body felt hollow and numb but also heavy and out of control.  In that moment I truly believed I was having another emergency c-section.”

This quote is from a woman who experienced a traumatic birth.  She is the mother of a beautiful baby and has had many moments of joy and connection, but also times of panic and fear.  “Mini movies” of her daughter’s birth play in her mind throughout the day.  She deleted the photos of her daughter in the NICU and she wants to disappear when her friends talk about pregnancy.  The birth didn’t end when her baby was born; it followed her from the hospital and it has interfered with many aspects of her life.

Research reveals that between 33-45% of women perceive their births to be traumatic. (Beck, 2013).  Birth trauma is defined as “an event occurring during the labor and delivery process that involves actual or threatened serious injury or death to the mother or her infant.  The birthing woman experiences intense fear, helplessness, loss of control and horror.”  (Beck, 2004a, p. 28).

Approximately 9% of women experience postpartum post-traumatic stress disorder (PTSD) following childbirth. Most often, this illness is caused by a real or perceived trauma during delivery or postpartum. These traumas could include:

• Prolapsed cord
• Unplanned cesarean
• Use of vacuum extractor or forceps to deliver the baby
• Baby going to NICU
• Feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery
• Women who have experienced previous trauma, such as rape or sexual abuse
• Women who have experienced a severe complication or injury related to pregnancy or childbirth, such as severe postpartum hemorrhage, unexpected hysterectomy, severe preeclampsia/eclampsia, perineal trauma (3^rd or 4^th degree tear), or cardiac disease

My therapy work with mothers is typically after a traumatic birth.  The more I learn about the mother’s labor and birth experience, the more I can understand what care and education could have better supported her during  birth.

The “3 E’s” – explain, encourage and empathize – can be a useful framework for obstetrical staff in lessening the risk of a traumatic birth.  

Explain  

When explaining a process, options or a procedure, always include the woman in the discussion of her own care.  There is a distinct difference in hearing a discussion and being a part of one.  If plans change, explain what is happening and what is needed to correct the situation.

Encourage

The connection a mother has with those caring for her during childbirth is deep — you are present during one of the most emotional, unpredictable times in her life.  Encouragement is empowering and can offer the mother a sense of control.  Encourage questions.   If plans change, discuss possible alternatives.   Using “we” in conversations shows alignment and rallying together.

Empathize 

Women in labor yearn for companionship, support and empathy.

Phrases such as “I know,”  “I’m here,” and “Yes” are phrases that connect staff with a woman’s experience when she feels pain, fear, disappointment or frustration.

I’ve heard many birth stories over the years; devastating stories of physical compromise, intense fear and loss of the baby’s life.  How the mother is cared for, is what she remembers.  The tone of your voice.  The gentleness.  The validation of feelings.  One of my clients was unaware she was being rushed for an emergency cesarean.  She said in all of the chaos and in a knee-chest position, she extended her arm and a nurse held her hand.  Beauty within terror.   It was a simple gesture and it has been the most powerful, healing memory for her.   Even in the midst of an emergency, someone saw her need.  Someone saw her.

Obstetric staff has great influence on how a mother remembers her birth experience.  Expressing empathy and explaining and encouraging a laboring and postpartum mom can influence her health and well-being.  New mothers who receive the “3 Es” can better transition to home, experience less anxiety, have more positive feelings about themselves and improved bonding with their babies.

Karin Beschen is a Licensed Mental Health Counselor specializing in reproductive and maternal mental health.  She also serves as a volunteer co-coordinator for Iowa for Postpartum Support International.

Additional Resources

Postpartum Support International 

PaTTCh (Prevention and Treatment of Traumatic Birth)

Improving Birth

References

Beck, C. T. (2004a). Birth trauma: In the eye of the beholder. Nursing Research 53(1), 28-35.

Beck, C. T., Driscoll, J.W., & Watson, S. (2013). Traumatic Childbirth New York, NY: Routledge.

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.

The first time that I cared for a patient who was both recovering from drug addiction while experiencing acute pain, was in Labor and Delivery in 2014. Neither of us was prepared for this. We both exchanged the same shell-shocked, “What do we do now?” look several times that shift. I had a profound realization that day; I needed to come up with a better plan.

My initial idea was a literature search in Pubmed, a free national database of indexed citations and abstracts from thousands of science and healthcare journals. I also hit up Cochrane, a database that provides systematic reviews of evidence based medicine.

While it is difficult to get a good estimate on the prevalence of drug addiction in pregnancy, the National Institute on Drug Abuse published data in 2015 showing that 21,732 infants were born with Neonatal Abstinence Syndrome (NAS) in 2012. That’s equal to one baby being born every 25 minutes with this syndrome. That is a lot of potentially challenging labors to manage.

Ultimately, the most important take away from my research was “treat the pain, not the addiction”. While it’s never ideal to administer narcotics to a recovering addict without a bigger plan, it’s still superior than allowing a patient to suffer.

In an ideal world, the best plan is to have a pre-labor consultation with the patient and anesthesiologist. This can be tricky to make happen as pain control is rarely addressed (especially the kind that recovering addicts need) during the prenatal course. The opportunity for this most often occurs when women are induced, or come in for antepartum testing. I was fortunate enough that my recovering patient was having both of those.  I was able to broach the topic during an NST, and I then requested her when she came in for induction. We were both thankful that the anesthesiologist on that day was open to discussing a plan that she was comfortable with. Just talking together as a team helped her relax.

My patient at that time was taking methadone, which I learned while doing my nursing assessment. Since she had not taken a childbirth class, I gave her homework to research how methadone can both increase the body’s sensitivity to pain (hyperalgesia) as well as limit the options for other pain medications like Stadol, due to the opioid agonist therapy (OAT) she was in. By front loading her understanding of how her pain control was about more than just preventing a relapse, her expectations were set to be more informed as well as more realistic.

The plan that we all agreed upon involved several key areas:

• Set the expectation. While this falls under “patient education” it’s such a powerful tool that it bears having its own bullet point. Having a realistic and frank discussion about the realities of labor is important for any patient, and it should begin with prenatal care. As any L&D nurse can tell you, there is nothing more disheartening than a woman in labor demanding “the shot that takes all of the pain away”.
• Utilize non-pharmacological modalities as much as possible. I created a folder with childbirth information for her in which Penny Simkin figured prominently. Her free guide with illustrations of positions and easy to read mantras were the perfect shorthand for the situation. While we started her induction, we discussed the handouts together.
• Consult with anesthesia ASAP. Again, this can be difficult since you really need a doctor who is on board and .The plan that we came up with was for a labor epidural as soon as she wanted one. Thankfully, ACOG supports labor epidurals at any dilatation, and the evidence supports that receiving one “early” does not adversely affect labor outcomes. The other nuance was to administer the epidural without any opioids. No fentanyl mixed in, just Lidocaine and Bupivacaine. While the likelihood of the opioids placed in the epidural space crossing over into her circulation were pretty minimal, it was a very real concern for her, and we needed to respect that.
• Have a plan B. Should things not go according to plan go sideways, we needed to have a course of action nailed down. This included contacting the obstetrician and enlisting their support while also reminding them that a patient in OAT can require as much as 70% more opiates to manage pain (which she was willing to take should she need surgery) post-operatively. We also discussed a social services referral in this event to help provide services to prevent relapse.
• Provide continuous support. I have to say, this simple intervention was the most effective thing that I did. It helped that our census was low, and I had an understanding charge nurse.

In the end, a lot of stars aligned that day, as my patient was able to cope with the pain, receive an epidural, and ultimately give birth to a healthy baby girl.

Educating the patient, creating a team, and formulating a plan with the patient’s input, as well as providing continuous support, has guided me with the increasing number of patients that arrive in similar situations. This experience has also led me into many different discussions with other nurses and doctors.

The consensus has been that this growing population of patients is compelling enough to establish a pathway for care during labor.  Something we are working on and will hopefully provide a road paved with evidence based best practices in the near future. And while these patients are by no means representative of every person struggling with addiction (recovering or not) they allowed me to recognize a growing need, as well as to learn new ways of helping patients to cope with the dignity and compassion we all strive to provide for the patients we are caring for.

Search for these resources available in the AWHONN Online Learning Center 

• Opioid Use in Pregnancy: Detection and Support Webinar
• Breastfeeding Implications for Women Receiving Medication Assisted Treatment for Opioid Use Disorders Webinar

Tasha Poslaniec has been a registered nurse for 17 years. She has been working in obstetrics for over a decade and is currently a Perinatal Quality Review Nurse and Childbirth Educator.

She also writes about nursing and childbirth and has been published in the Huffington Post and the American Journal of Nursing. Pain control in childbirth has long been a topic of study and research for her.

“We may have different religions, different languages, different colored skin, but we all belong to one human race”. –Kofi Annan (Ghanian Diplomat, 7th UN Secretary-General, 2001 Nobel Peace Prize winner)

What is exactly childbirth? Some people compare it to a miracle, a heroic act, or a surge of love accompanied by strenuous and intense hours of labor. It’s absolutely one the most unique experiences that can happen to a woman’s body. The time when she is particularly vulnerable and in need of much support and care.

For me, a nurse practitioner student on labor and delivery floor at Massachusetts General Hospital, witnessing childbirth was something that I would never forget. Thrown into the action on a first clinical day, I had mixed feelings of joy, excitement and a slight nervousness. I felt extremely privileged and grateful to witness a natural delivery and I was hoping to help a future-to-be mom during the process.

From the morning report I found out that the woman I was assigned to follow was a recent immigrant from Guatemala who belongs to the indigenous Mayan population. Mayan was the patient’s native language but she was also able to understand Spanish. Her husband had been residing in the United States for 5 years. She moved here a year ago and the family has finally reunited.

My patient was accompanied by a traditional nurse midwife known as comadrona. Comadronas are trusted women leaders in their communities who accepted a spiritual calling. They usually don’t receive any formal training but have years of experience delivering babies. Comadronas regard birth as a natural process and rely heavily on God and prayers. The nurses established a plan of care recognizing my patient’s spirituality and personal support system. The Mayan midwife was present during labor and helped with comfort measures. The nurses also invited a qualified interpreter.

When I entered the room, a nurse and a midwife, along with the comadrona, surrounded the tiny woman. One of the nurses was checking her vital signs and the nurse-midwife was encouraging the woman to take slow deep breaths and relax. The comadrona, wearing a traditional colorful embroidered dress, was gently massaging her back. The room was dimly lit and the scent of fresh lavender floated in the air. My patient’s contractions were increasing steadily and were becoming more regular. This was active labor –she was ready to give birth.

The whole atmosphere struck me. There was no other language present in the room but the language of trust, respect and compassion between these women. I immediately wanted to become connected with what was happening- just by holding this woman’s hand and talking to her.

Reflecting back on this experience, I understood that nurses not only created the environment that made this woman feel comfortable and that was respectful of her spirituality but that the environment also had a significant impact on the labor and birth process. Although childbirth is unique and at the same time a unifying biological event for any woman; providing therapeutic communication, physical, emotional, spiritual care and comfort during the labor process is crucial.

The comadrona shared her knowledge and experience with the American nurses. It was important for my patient to have a traditional midwife near the bedside who comforted and prayed with her. There was interplay between modern and traditional medicine that contributed to the positive outcome. Nurses in this particular case were not only culturally sensitive and able to understand cultural values, beliefs and attitudes of clinicians and patients, but also culturally competent and had knowledge, capacity and skills to provide high-quality care (Jernigan et al, 2016).

It’s essential for any nurse in such a unique, heterogeneous country like the United States to be cognizant and open-minded of cultural diversity and the patient’s cultural perspectives. I will take this amazing experience to my future nursing practice and strive to always treat my patients with dignity, respect and compassion. I also hope to continue to integrate a holistic model and culturally sensitive care into our modern childbirth practices.

This woman gave birth to a beautiful baby daughter whom she named after a nurse taking care of her during her labor and birth.

Additional Resources & References
http://prontointernational.org/
https://he-he.org/en/
http://www.mayamidwifery.org/
http://midwivesformidwives.org/guatemala/
http://www.birth-institute.com/study-abroad-guatemala/
http://www.acog.org/
Jernigan, V. B. B., Hearod, J. B., Tran, K., Norris, K. C., & Buchwald, D. (2016). An Examination of Cultural Competence Training in US Medical Education Guided by the Tool for Assessing Cultural Competence Training.Journal of Health Disparities Research and Practice, 9(3), 150–167.

Evgeniya Larionova received her Bachelors of Science in Nursing from MGH Institute of Health Professions. She is a founder and an Artistic Director of AMGITS Drama&Poetry Club at the Boston Living Center. She is a member of the student Leadership Committee of the Harvard Medical School Center for Primary Care. Evgeniya is passionate about infectious diseases, community health and integrating holistic care in modern practices.  In her spare time she plays in the Russian theater, enjoy reading, playing the guitar and hiking.

“But we had this for dinner LAST night” the five year old says.  My joke with the nine year old falls flat because he’s too busy sighing over his lack of clean socks.  “That’s IT!” I tell my husband with a wink, “I’m running away from home and going to work where I’m appreciated!”

I’m one of the luckiest nursing students in the world.  By day I drown in books and deadlines and elementary school paperwork and laundry, but by night I work as a CNA at the birth center of my local hospital.  I know, while the little efforts at home might go unnoticed, no small kindness is missed by our patients. 

We tuck those small kindnesses into our hearts and carry them around, forever grateful.

As a young first time mom I was lying in a military hospital room staring at a pepto bismal pink wall and a broken television.  I was waiting for what I was pretty sure was The Best Baby Ever to be Born after The Most Painful Delivery Any Human had Ever Withstood to come back from the nursery, where a tech had taken him for his 2am vitals.  The door finally creaked open, and the young tech pushed my sweet baby back to me.  He began to leave, and then turned back.  He looked at the bassinet.  “He really is a cute little dude,” he said before closing the door.

Nine years later I can’t quite remember the exquisite pain of unmedicated childbirth or the sound of that baby’s perfect first cry...but I remember the tech—An Expert in Newborns, mind you–telling me that my baby was cute.  It affirmed every suspicion I had that my baby was the best baby ever.  And in those days of rollercoaster hormones and constant feedings and sleep deprivation, I held that gem of praise and encouragement tight.  It’s been nine years and I haven’t dropped it.

My story is one of so very many.

Jenn Osario never thinks of breastmilk without thinking of the nurse whose words encouraged her through the long days of pumping for her twins in the NICU. “When your milk comes in and you refrigerate it, you’ll see the cream settle at the top,” the nurse told Jenn.

I was totally ready to give up on pumping and I remember opening the fridge to bring what milk I had pumped that night to the NICU for the girls and there it was, the cream on the top.  It’s silly, but it really helped encourage me to keep pumping.

Allison Morgan secretly wanted an unmedicated birth, but when she arrived at the hospital she wasn’t sure she could handle the pain if the contractions got worse.

The nurse was very calming and said “You seem to be doing great and you really aren’t feeling any pain, why don’t you just wait and I will check in on you.”  She told me if I felt like pushing or my water broke to call her.  I was like, “Yeah, okay… that isn’t going to happen.”  Two minutes later my water broke and I was desperate to push.  She rushed in and checked me and I was 9.5 cm. I was totally freaking out (exactly what I was trying to avoid) and she was very good with helping me breathe and wait the few minutes for the doctor to arrive and fully dilate. Two rounds of contractions and two pushes and Dallon was born.  

I was so grateful that she was in tune with what was needed rather than just going with whatever I wanted to make her job easy.  I attribute that entire birth experience to her and every time I talk or think about his birth, she is in the forefront of my mind and I say a little thank you to her each and every time.

After a long labor Melissa Scholten-Gutierrez gave birth to a baby with low blood sugar who was more interested in sleeping than eating.  The doctor wanted to give the newborn formula, but Melissa wanted to establish breastfeeding.  The doctor threatened a NICU admission and IV feedings.  Melissa’s nurse proposed a compromise between physician and patient—allow the baby to breastfeed first and then top that off with a formula feeding.

She told me that she would try to help me find a way to do it that would really foster our breastfeeding relationship.  She spent a lot of time with us over my son’s next few feedings helping us find a way to get him to wake up enough to nurse, and then a way to get him to take the formula. At shift change, she made sure that we had another nurse that would be supportive.

Ultimately, this nurse helped me make it through a very stressful first three days, and allowed me to have confidence in my ability to breastfeed. (Of note, my son was a great nursling and still loves it at 16 months. And, I wound up having an oversupply and was able to donate to four other babies!)

Earlier this summer my sister-in-law, pediatrician Dr. Heather Henne, delivered two of the most perfect baby girls ever to be born. (I might be a tiny bit biased.  Except that they really are.)  Early in the day Heather confessed to her labor nurse at the University of Washington Medical Center that she was nervous about pushing.  The nurse had recently given birth, and shared her own experience with what effective pushing felt like.

Listening to her story made it possible for me to visualize my own experience and gave me so much confidence.  In fact, when the obstetrician asked if I wanted to try a couple of practice pushes I agreed, but felt like it wasn’t even necessary.  I felt like I’d already worked through it with the nurse by hearing her experience.  It was incredibly generous of her to share her own personal story instead of just saying “some patients find that this works” or “many patients feel this way”—making it personal made it real to me.

Heather’s positive experiences continued into the postpartum unit where her nurse’s proactive approach made her more comfortable and confident in her first days as a new mom.

My nurse knew what I needed before I needed it.  And I don’t just mean the Q6 Motrin, but things that I wasn’t even thinking about showering. She asked me if I wanted to take a shower and it hadn’t occurred to me to take one so soon after delivery, but it was amazing.  It was the best shower of my life.  It made me feel so much better.  It was incredible to have someone there who was not only with you, but two steps ahead of you.  She knew what I needed before I knew what I needed, and she was so right about it all.  I had been nursing the girls individually, but she suggested and helped me to do a tandem feed.  Never in my imagination did I think I would be tandem nursing on day one in the hospital.  That suggestion meant that when I went home I felt so much more successful and confident because I had tried tandem feeding in the hospital and wasn’t just doing it on my own.”

So as I walk into work every night, I do so with a smile.  I’ll never know what it is that sticks with a new mom, but each shift is an opportunity to pass on a kindness that will glow bright through many sleepless nights.

While pregnant with her first child and serving in the Air Force as an aircraft maintenance officer, Traci dreamed of returning to school and eventually becoming a Certified Nurse Midwife. A decade later, Traci is finally in nursing school and is delighted to be working as a CNA at the Birth Center of Penrose St Francis Hospital in Colorado Springs.

The use of nitrous oxide as a labor analgesic has taken hold in the US in the past three years. It has been used widely in Europe for decades, with favorable results, along with comes educational information but all the perpetuation of myths.

10. Using nitrous oxide in labor is “just like” when you use it at the dental office. It’s not. In dental offices, the concentration of nitrous oxide to oxygen is variable, so the dentist can increase or decrease the concentration based on the patient’s needs. Dentists may use concentrations of nitrous oxide of up to 70%. The dentist also places a small mask over the patient’s nose, through which a continuous stream of nitrous oxide is delivered.

During labor nitrous oxide is only used at concentrations of 50% nitrous oxide to oxygen – no higher. And the stream of nitrous oxide is intermittently administered by the woman herself using either a mouthpiece or mask with a demand valve. The demand valve opens only when the woman inhales (breathes in) – which is when the gas is released. When the woman exhales (breathes out), the valve closes and the gas stream is stopped.

9. You will be confined to bed while using nitrous oxide. You will still be able to move around while using nitrous oxide during labor. About 10% of nitrous users may experience some dizziness, so your care providers will want to see you stand or move about without difficulty before they let you up on your own, but many women use nitrous oxide while standing, squatting, sitting in a rocking chair, or on a birth ball.

8. Continuous fetal monitoring will be required with nitrous oxide use. Whether you have continuous or intermittent fetal monitoring should be dictated by your obstetrical status, not because you are using nitrous oxide. In other words, if you are a candidate for intermittent monitoring, that does not have to change to continuous monitoring just because you begin using nitrous oxide.

7. If you choose to use nitrous oxide, you cannot use any other pain medications. A fair number of women who start out using nitrous go on to have an epidural placed at some later point in their labor. Using nitrous oxide earlier on allows you to maintain your mobility and stay upright, allowing the baby to move down well in your pelvis before being confined to bed with epidural anesthesia.

6. Nitrous oxide will stall your labor, or slow contractions. There has not been any research showing that nitrous slows down labor or causes contractions to be less strong or happen less often.

5. Nitrous oxide will harm the baby. Nitrous oxide is metabolized (processed) in your lung tissue, but because some of the gas passes into your blood stream, some can also pass through the placenta and go to your baby. However, studies have not shown adverse effects on babies of mothers who have used nitrous oxide in labor.

4. There is a point in labor when it is too late to use nitrous oxide. Actually, some women don’t begin using nitrous oxide until they are in the pushing stage. Other women don’t use it at all during labor, but find it very helpful if they need repair of any tears in their birth canal.

3. My family members can assist me with holding the nitrous oxide mask or mouthpiece if I get tired of holding it. As well-meaning as family members are, this is one area where they can’t help. A safety precaution for nitrous oxide use is that the laboring woman holds her own mask or mouthpiece. When she has had sufficient nitrous oxide, she won’t be able to bring her hand holding the device to her face. Allowing someone else to hold the mask/mouthpiece overrides this safety feature of nitrous oxide.

2. Nitrous oxide is offered at many hospitals and birth centers. Until 2011, there was really only one hospital in the US offering this option. Since that time, use of nitrous oxide has dramatically increased and there are currently over 100 hospitals and 50 birth centers offering nitrous oxide. Though it has come a long way, there is a long way to go to ensure that every woman who desires to use nitrous oxide in childbirth, has the opportunity.

1. Nitrous oxide makes you laugh (hence the nickname “laughing gas”). Despite the nickname, inhaling nitrous oxide doesn’t leave women laughing like hyenas! Because nitrous oxide decreases anxiety, it puts women more at ease and they may be more talkative and relaxed… but don’t count on side splitting laughter!

Michelle Collins is currently Professor of Nursing and Director of the Nurse-Midwifery education program at Vanderbilt University School of Nursing. In addition to the teaching and administrative aspects of her job, she maintains an active clinical practice as part of the Vanderbilt School of Nursing faculty nurse-midwifery practice.  Currently she is a blogger for Nashville Public Television for the popular series Call the Midwife.

Resource on Nitrous Oxide For Nurses

AWHONN has a Nurses Leading Implementation of Nitrous Oxide Use in Obstetrics webinar to describe the history of nitrous oxide use to present day and the necessary steps nurses need to take to initiate nitrous services at their institutions.

Nitrous Oxide as Labor Analgesia, Nursing for Women’s Health, Volume 16, Issue 5, pages 398–409, October / November 2012.

When I think back to the birth of my second child earlier this year, tears almost instantly begin to fill my eyes.

Unlike the birth of my first child three years prior, this isn’t because I am overjoyed by thoughts of holding my baby against my chest for the first time while I stare in awe at the life my husband and I created, a life that I grew in my own body and delivered into the world after many, many hours of hard labor. Instead my eyes fill with tears because I think of my labor and delivery nurse and how I believe her actions on that day affected the trajectory of my life, my son’s life, and the future of our family.

I am not a nurse, I don’t even work in the medical industry, but for the past nine years come June my work has brought me to the annual AWHONN convention, where I support the online system used by those submitting proposals and assist presenters’ presentations. Through this work I have read hundreds of abstracts and watched dozens of presentations on standard topics such as home births and skin to skin care for newborns, to more memorable subject matters like how to care for a vaginal piercing during a delivery.

My work with AWHONN does by no means make me an expert in the field of labor and delivery, but on January 30th of this year, I had gained enough knowledge from working with AWHONN to know what the possible outcomes could be when something suddenly went wrong during the birth of my son.

After 13 hours of laboring in the hospital, the time had finally come to begin pushing. Not yet knowing the gender of my child, I felt extra encouragement to push as hard so I could finally meet my baby. It took only 21 minutes of pushing to hear the words, “only one more push, Jessica, and you will be able to hold your baby!”, however, that was quickly followed by a sudden shout to stop pushing.

Stop pushing, but why? I looked down and between my legs I could see the head of my baby, turned toward my inner right thigh; he was silent and lifeless. Right away I knew that it was shoulder dystocia, and like any mother, my mind went to straight to thinking about the worst case scenarios. Was my baby getting oxygen, would he have brain damage? Is his shoulder going to be broken? I don’t care if he has broken bones, bones heal, just make sure he can breathe! Just last June at AWHONN a presenter and I had a conversation about shoulder dystocia, what was it that she said the other outcomes could be?

The next few minutes were all a blur me screaming at the doctor to help my baby, my husband kissing my head and doing the best he could to stay strong for the two of us, the student midwife attending her first delivery still holding onto my left leg waiting for someone to give her instructions and then there was a voice that I will never forget. Then the firm voice of my labor and delivery nurse as she turned to the doctor and said, “Doctor. Would you like me to call for another set of hands?” I got the sense that she wasn’t asking for permission, but rather she was politely informing the doctor of her intent to ask for assistance because she knew it was needed.

The doctor nodded as my nurse instantly took one side step closer to my head, she looked me straight in the eyes and smiled as she pushed the call button for the nurse’s station and requested another attending physician join us in my delivery room. A moment later the door swung open and the already crowded room began to fill with more people. In an instant, my nurse and another doctor were in the delivery bed with me, pushing on my low abdomen , doing all they could to change the position of my baby.

In this chaotic scene I once again heard that firm voice calmly say, “Doctor. Would you like me to call in a NICU team?”. The doctor nodded yes and soon a NICU team stormed into the room to wait for my son to be born to take over his care.

At the end of this ordeal, I was blessed with a perfectly healthy child; not one bruise on his body, no torn muscles, no broken bones, and no lack of oxygen to his brain. He did stay in the NICU for two days to be supervised for a potential infection, but otherwise all 10lbs, 5ozs of him was unscathed during his traumatic birth .

It may have been my doctor’s hands that brought my son into the world, but it was my nurse’s voice that I credit for my son’s health and our future without the need for further medical treatment.

Would my son have been fine if he were stuck during the birthing process for another couple of minutes? I don’t know. Fortunately because my labor and delivery nurse spoke up during a time of crisis, I don’t have to find out.

Jessica L. Grenon is the Director of Continuing Education Services at The Conference Exchange, where she has worked with AWHONN since 2007. She, her husband, and their two young children enjoy traveling and spending time with their extended family, especially with her twelve nieces and nephews.

Resources on Shoulder Dystocia

Definition: Shoulder Dystocia is the impaction of the fetal anterior or posterior shoulder behind the material pubic symphysis resulting in delay in a cephalic vaginal delivery. This creates a high-risk intrapartum complication affecting both mother and baby.

For Parents: Health providers can’t always predict or prevent shoulder dystocia, but there are some risk factors you can learn about.

For Nurses: AWHONN has a Shoulder Dystocia online product to help prepare clinicians for this level of critical care event.

My husband and I always wanted a family. The summer before I turned 29, we decided to start trying. Little did we know there would be a roller coaster of a journey ahead.

I got my first positive pregnancy test in September. I knew my life was about to change. I quit smoking, which was a huge deal for me. My husband and I were thrilled. At my first ultrasound, there was silence. The verdict was devastating: I was miscarrying due to a blighted ovum.

My doctor advised me to wait two full cycles before trying to conceive again. I didn’t track anything; I just guessed at when I was going to be ovulating. In February, I got my second positive test. Though nervous, I had a better feeling, thinking the odds were low I would have a second miscarriage.

We picked out names, I looked at birth plans, and at 8 weeks I started building a baby registry. We were cautious to share the news, waiting to tell even our parents. On March 20, one week after announcing our new addition, I went to the restroom and noticed blood. I immediately fell on the floor crying. In that split second, my dreams of our family were crushed.

When they did the ultrasound in the emergency room, they wouldn’t let me see the screen, saying only that they couldn’t detect a heartbeat. I felt like I died inside. My doctor ordered a D&C (dilation and curettage) and told us to wait two cycles.

This time, I took ovulation and trying to conceive (TTC) seriously. I continued taking prenatal vitamins, educated myself, and tracked my ovulation with digital ovulation predictor. The moment I saw the little smiley face letting me know I was ovulating, I told my husband it was go-time! The two-week waiting period after that felt even longer than the two cycles we had to wait to start trying again.

On July 11, I got my big fat positive! I called my husband, and then I called my mom, who was so supportive. I had a form of PTSD after dealing with two miscarriages, and I didn’t want to tell anyone I was pregnant, so as to avoid the embarrassment.

At 6 weeks, I had my first ultrasound. When we saw that tiny little heartbeat, I cried. My doctor put me on progesterone. We had our next ultrasound at 11 weeks, and there was our baby, active and wiggling around. It was amazing! I wasn’t used to seeing my ultrasounds. Every time I saw my baby felt like a miracle. We learned my due date was March 20—the date of my second miscarriage. Everything was coming full circle. Even more exciting, it was a boy!

As badly as I wanted to meet my son, he was even more anxious: At 34 weeks and 4 days, Charles David Poe made his appearance. His birthday is February 9, the same date I had my second positive pregnancy test the year before. Tiny but strong, Charlie came into our lives so fast and has made it indescribably beautiful. It was beyond worth it to have gone through all the turmoil of TTC to get to this amazing part of my life.

Aimee Poe is an experience specialist at Verizon. She loves playing video games, watching movies, hanging out with her family, and flexing her creative muscle with various projects.