FAMILY DYNAMICS

From the ScVA 23059CommonweAddress coNursing, VRichmond,© 2012 El1527-3369doi:10.1053

Family-Centered Care and ContinuousLabor Support

Susan L. Lindner, RNC-OB, MSN and Jacqueline M. McGrath, PhD, RN, FNAP, FAAN

Keywords: Continuous labor support; Family-centered care; Doulas; Centering pregnancy

Creating a family-centered approach to prenatal and intrapartumcare has potential to lead to positive maternal and neonataloutcomes. Continuous labor support (CLS) for families isparamount to positive outcomes for mothers and their babies.1,2

Combining family-centered maternity care and CLS duringprenatal care, and labor and delivery has been discussedthroughout the literature, but implementing this model hasbeen challenging. Registered nurses in labor and delivery are oftenthe primary source of support for families; however, the registerednurse has many roles to fulfill during a labor and deliveryadmission, and oftentimes, family-centered care and CLS areeasily relegated to the fringes of his/her responsibilities. Given thesomewhat predictable nature of labor and delivery care, routineintegration of doulas for CLS has the potential to provide thesupport and family-centered care that families need. ProvidingCLS during birth experience has the potential to increaseconfidence and fosters a holistic foundation for the new family.

BackgroundContinuous labor support and family-centered maternity

care are well supported in the literature.1,2 However, theimplementation of CLS, family-centered maternity care, anddoulas as partners in prenatal care and education and birth havenot been fully integrated in many health care facilities in theUnited States. Birth is a natural physiological event for awoman. In 2009, there were 4 130 665 births reported in theUnited States.3 This number represents a 3% decrease in thebirth rate, but a 2% increase in the cesarean delivery (C/S) rate,and a 50% increase in the C/S rate since 1996.3 The current rate

hool of Nursing, Virginia Commonwealth University, Richmond,; and Family and Community Health Department, Virginiaalth University School of Nursing, Richmond, VA 23298.rrespondence to Susan L. Lindner, RNC-OB, MSN, School ofirginia Commonwealth University, 1100 East Leigh St,VA 23059. E-mails: lindnersl@vcu.edu, jmmcgrath@vcu.edu.sevier Inc. All rights reserved./1202-0457$36.00/0/j.nainr.2012.03.004

of C/S is staggering and has implications not only for short- andlong-term outcomes but also for provision of care in labor anddelivery units. Those discussions are somewhat beyond thescope of this column, yet the issues cannot be totally ignoredbecause of the more global implications for how CLS andfamily-centered care are provided. The focus of our discussionrevolves around providing and implementing interventions tomothers and families during prenatal care such that familiesbecome more knowledgeable regarding what to ask for andexpect throughout family-centered maternity care and CLSduring hospitalization for the birth of their baby.

DiscussionPregnancy and birth are a major event in a woman's life.

Adequate prenatal care to identify and assess risk factorscontributes to a low-risk pregnancy. Introduction of family-centered maternity care and CLS during the initiation of prenatalcare is ideal. Providing the information to mothers, partners, andfamily members provides the foundation for embracing thepregnancy as a family and allows the mother to feel that she is notalone during this life-changing time. Lynn and colleagues4

studied low-risk women and concluded that women who wereidentified early in pregnancy to have higher-than-normal stressfactors in their lives need to be promptly referred for counselingand other supportive resources because stress is often associatedwith intrauterine growth restriction, preterm labor, and bonding.Easily, women who are unmarried, homeless, adolescent, or of aminority group are quickly identified as having an increased riskfor stress in their lives with the need for counseling and support.Many of these individuals also havefinancial stress due to job loss,psychosocial crisis, and health-related risk factors requiring theneed to identify additional resources to increase positivepregnancy outcomes. However, the number of women who arebecoming pregnant and having babies between the ages of 30 and44 years is increasing.3 These women often have thriving careersand have purposefully chosen to wait to become pregnant.Although older career women may have adequate resourcesavailable to them for maternity care, they are often jugglingcareers, families, pregnancy, and personal relationships.5 All these

issues coupled together can increase stress leading to pooreroutcomes, even in healthy women without other comorbidities.Many times, this population is overlooked; yet, it is sometimesevenmore important to have support systems in place to allow forpositive birth outcomes for this group of women.5 In essence, allwomen need and should have support during pregnancy todecrease stress.

Family-centered care must begin with the initiation of prenatalcare.6 How can this be accomplished? Several strategies must beconsidered and operationalized based on the individual needs ofthe mother and family. First, prenatal care begins for manywomen with an obstetricians or certified midwives (CNM) whohas their offices near or within health care facilities. These healthcare providers provide prenatal care and education and associatethemselves with the facility where the woman will have her baby.Registered nurses, physicians, and CNM have the opportunity toprovide prenatal education related to prenatal classes at healthcare facilities. Prenatal care is a catalyst for many pregnant familiesto discover, learn, and capture beginning health care resources.Many of these women have never been in a hospital or attendedregular health care visits. For positive birth outcomes, womenneed support and the availability of appropriate resources.

During prenatal care, risk assessments are completed with thepregnant mother but typically not with the family.6 Riskassessments include topics such as obstetric history, medicalhistory, current obstetric status, and psychosocial factors.6 Whenrisks are identified during the risk assessment, support for themother and her family can be the basis for intervention strategies.For example, good nutrition is an integral component of prenatalcare. Moreover, obesity is recognized as a risk factor duringpregnancy for negative mother and neonatal outcomes.7 Supportfor the mother, fetus, and her family needs to be addressed by notonly advising the mother with nutritional facts and providingprinted handouts but also incorporating a registered dietitian intoher care. Finding resources in the community, such as theWomenInfant and Children program and exercise programs for pregnantwomen, is also a strategy that can easily be provided to bestsupport pregnancy outcomes for the woman and her child(ren).7

Encouraging and providing educational information relatedto prenatal classes and opportunities available to mothers andfamilies enables them to learn from educated professionals at thehealth care facilities that will provide support during labor anddelivery for the mothers and their baby as well as their family.Prenatal classes provide not only information but also increasedconfidence for mother and her family during the birth process.While attending prenatal classes, the mother is able to becomecomfortable with the hospital environment, positively leadingtoward increased comfort and decreased stress during the birthof her baby. According to Phillips,8 prenatal classes offereducation that prepares families for “active participationthroughout the evolving process of preconception, pregnancy,childbirth and parenting.” Ideally, attending educational classes/courses preconceptionally can create optimal pregnancy out-comes; however, this is often not the case with most families.8

Another concept, which is gaining momentum in prenatalcare related to a supportive presence, is centering pregnancy(CP). According to the statement on their Web page:

NEWBORN & INFANT NURS

Centering Pregnancy is a multifaceted model of groupcare that integrates the three major components of care:health assessment, education, and support, into a unifiedprogram within a group setting. Eight to twelve womenwith similar gestational ages meet together, learning careskills, participating in a facilitated discussion, anddeveloping a support network with other group members.Each Pregnancy group meets for a total of 10 sessionsthroughout pregnancy and early postpartum. The practi-tioner, within the group space, completes standardphysical health assessments.8

Centering pregnancy allows the mother and her partner toattend prenatal care together in a group setting and promotesautonomy for the family.9,10 Education and support are afundamental component of the CP model. Typically, the motherenters the CP model at 20 to 28 weeks' gestation, and each CPvisit is conducted with the same families/mothers and physicianor CNM.9,10 Throughout the CP, prenatal care relationshipsand support are formed as the families share their pregnancyjourney with one another. In addition, during CP, thephilosophy of support is apparent because many CNMsintroduce collaboration with a doula for support during laborand delivery.9,10

Doulas not only offer CLS but also provide postpartum andprenatal support.

According to the Doulas of North America:

The word “doula” comes from the ancient Greek meaning“a woman who serves” and is now used to refer to atrained and experienced professional who providescontinuous physical, emotional and informational sup-port to the mother before, during and just after birth; orwho provides emotional and practical support during thepostpartum period. Studies have shown that when doulasattend birth, labors are shorter with fewer complications,babies are healthier and they breastfeed more easily.11

Doulas have been recognized as a missing link in theprovision of excellent care in labor and delivery rooms, and theyare often fundamental to providing CLS for families. These areprofessional women who provide CLS through training,practice, and desire to care for families.11 Doulas are trainedthrough Doulas of North America or The Association of LaborAssistants and Childbirth Educators or the many other doulatraining organizations that offer lay support. Continuous laborsupport with a doula or support person contributes to decreasecesarean deliveries, decrease anxiety in labor, increase theresponse and continuation of breastfeeding, and decreasepostpartum depression.11,12

Many health care facilities have volunteer doula programswhere a mother can obtain the services of a doula during theprenatal period, labor, and delivery. At Johns HopkinsUniversity School of Nursing, “student nurse doulas providephysical, emotional and educational support and attend births

71ING REVIEWS, JUNE 2012

at the hospital of the mother's choosing in the Baltimoremetropolitan area.”13 The service provides the underserved inthe Baltimore area and has provided positive birth outcomes forfamilies and their babies. Embracing the underserved popula-tion is paramount to decreasing infant mortality and morbidity.

Nursing care during labor and delivery is imperative for themother and her family. Often, the labor and delivery nurse isunable to provide CLS due to caring for one or more laboringpatients on the intrapartum unit.8-10 Incorporating CLS withthe father, family, and doula can allow the mother to labor anddeliver in a family-centered environment where they are activelyinvolved and supporting the mother.

ConclusionPreconception and prenatal care coupled with CLS are

significant to providing confidence, education, and a lessstressful pregnancy. Registered nurses and doulas play asignificant role in the provision of family-centered maternitycare in health care facilities. During labor and delivery, themother, father, and family must be embraced as a unit; in doingso, the cohesiveness of the family is reinforced.

References1. Campbell DA, Lake MF, Falk M, Backstrand JR. A

randomized control trial of continuous support in laborby a lay doula. JOGNN. 2006;4:456-464.

2. Scott KD, Klaus PH, Klaus MK. The obstetrical andpostpartum benefits of continuous support during child-birth. J Women's Health Gender-Based Med. 1999;10:1257-1264.

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3. National Vital Statistics Reports. November 2011: 60.Retrieve from: http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_01.pdf on September 1, 2011.

4. Lynn FA, Alderdice AA, Crealey GE, McElnay JC.Associations between maternal characteristics and pregnan-cy-related stress among low-risk mothers: an observationalcross-sectional study. Int J Nurs Studies. 2011;5:620-627.

5. Phillips C. Family centered maternity care: the businesscase. Retrieved from: http://www.pandf.com/resources/WhitePaperPandf.pdf on September 1, 2011.

6. Simpson KR, Creehan PA. Perinatal nursing. 3rd ed.Philadelphia, PA: Lippincott; 2008.

7. Keely A, Gunning M, Denison F. Maternal obesity inpregnancy: women's understanding of risks. Br J Midwifery.2011;19:364-369.

8. Centering in Pregnancy (2011). Retrieved September 29,2011. https://www.centeringhealthcare.org/pages/centering-model/pregnancy-overview.php.

9. Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C.Continuous emotional support during labor in a U.S.hospital: a randomized controlled trial. JAMA.1991;265:2197-2201.

10. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J.Continuous support for women during childbirth.Cochrane. 2011:2 Wiley & Sons, Ltd.

11. Doulas of North America (2011). Retrieved September 29,2011. http://www.dona.org/.

12. The Association of Labor Assistants and ChildbirthEducators. Retrieved September 29, 2011. http://www.alace.org/.

13. Jordan ET, Van Zandt SE, Oseroff MS. Educatingundergraduate nursing students as birth companions.Nurs Health Care Perspect. 2001;22:89-91.

2, www.nainr.com