Nurses Urged to Trust Birth!

Journal of Obstetric, Gynecologic, & Neonatal Nursing

Volume 37 Issue 1 Page 85-93, January/February 2008

To cite this article: Elaine Zwelling (2008) The Emergence of High-Tech Birthing
Journal of Obstetric, Gynecologic, & Neonatal Nursing 37 (1), 8593 doi:10.1111/j.1552-6909.2007.00211.x

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In Focus The Emergence of High-Tech Birthing Elaine Zwelling RN, PhD, is a perinatal nurse consultant with the Hill-Rom Company in Sarasota, Florida Elaine Zwelling, RN, PhD, Hill-Rom Company, 8467 Cypress Hollow Dr., Sarasota, FL 34238.

journey from “normal” to high-tech childbirth has taken place gradually over the past century. This article gives a historic review of maternity care and defines normal birth according to care practices adapted from the World Health Organization. The issues facing today’s consumers, care providers, and caregivers that have led to the high-tech approach to birth are discussed. Recommendations for nursing practice are proposed to balance a normal approach to childbirth with a high-tech clinical environment.

“We’re not in Kansas anymore,” Dorothy said to Toto in The Wizard of Oz. Professionals with long-term experience in maternal-newborn care may feel the same today. Where are we? How did we get here? Although change in any area of life is inevitable, the changes in health care in the past century are dramatic, and the specialty of perinatal care is no exception. This article reviews the journey that has taken place from an era when pregnancy and childbirth were viewed as “normal” and managed with little intervention to today’s world in which pregnancy and birth are viewed as high risk and the care of childbearing women has become “high tech.” Recommendations are given for nurses who want to make birth a normal event for parents in a high-tech world.

Our historic past
Because birth was viewed as a normal process prior to the 20th century, it most often took place in the home and was a social and emotional life event shared by the woman with her family and friends. However, maternal mortality rates were high, and birth began to move into the hospital. Semmelweis had discovered the importance of hand washing to decrease the incidence of puerperal fever in 1847, but his theory did not gain widespread acceptance until many years later. As a result, childbirth continued to be associated with maternal and neonatal morbidity and mortality due to infection (Leavitt, 1986; Martell, 2000; McCool & Simeone, 2002; Zwelling & Phillips, 2001).For this reason, medical care was primarily protective in nature, separating mothers from their babies and other family members.
By the early 20th century, as the hospital gradually became the preferred site for birth, childbearing was evolving into a medical event. A medical-surgical model of care delivery separated mothers and babies. Care was provided as if the maternity process was a pathologicdysfunction rather than biologically healthy and normal. Midwives were replaced by physicians and new methods of pain relief evolved (Pitcock & Clark, 1992).The beginning of technology for birth was seen, with the invention of forceps, and the use of twilight sleep and general anesthesia. Breastfeeding declined due to the development of artificial feeding for newborns. The postpartum experience was rigidly controlled by physicians and nurses. Women were treated as if they were ill after birth and confined to bed for 10 to 14 days (Martell, 2000).
Throughout the later decades of the 20th century, changes continued, including childbirth education, a return to breastfeeding as the preferred method of infant feeding, the development of the family-centered model of maternity care and home-like environments in labor/delivery/recovery rooms (LDRs) or labor/delivery/recovery/postpartum rooms (LDRPs),shorter hospital stays, and rooming-in of babies with their mothers. At the same time, there was an increase in routine technologic interventions, new methods for monitoring the status of mothers and babies, and increased options for pain management. Simultaneously, research grew in maternal-newborn care to provide an evidence base for clinical practice (Martell, 2000; McCool & Simeone, 2002; Zwelling & Phillips, 2001).
Now that we have entered the 21st century, the current challenge seems to be a philosophical struggle between the desire to make birth a normal event in the lives of families and the ever-growing perceived need for technology to provide state-of-the-art, safe care (Wagner, 2006).
By the early 20th century, care was provided as if the maternity process was a pathologic dysfunction rather than biologically healthy and normal.

What is normal birth?
According to Lamaze Internationals (2003) Institute for Normal Birth, a normal birth is one that takes place with the recognition that a woman’s body is capable of growing a healthy baby during pregnancy, giving birth without routine interventions that can disrupt normal body processes and nurturing the baby after birth by breastfeeding. The World Health Organization Department of Reproductive Health and Research (1999)stated that the goal of care is to have a healthy mother and baby with the least amount of intervention that is compatible with safety. This approach implies that in normal birth, there should be a valid reason to interfere with the natural process.
The following care practices, adapted by Lamaze International from the World Health Organization, are those believed to promote, support, and protect nature’s plan for birth (Lothian, 2004).However, many births in the United States today do not meet this definition of normal. Despite available evidence on appropriate care for healthy childbearing women that favors care practices that support physiological labor (Albers, 2005, 2007; Davis-Floyd, 2003; Wagner, 2006),routine interventions are often implemented. Accompanying the recommendations below is information regarding the current status of care and the technology that has affected each care practice.

Care practice 1: labor begins on its own
In our country, induction of labor has become almost routine in many hospitals, to the point that it is more uncommon to see a woman whose labor began on its own than to see a woman being induced (Davis-Floyd, 2003; Simpson, 2003; Wagner, 2006).In 2004, the National Vital Statistics Report showed the total induction rate to be 21.2%. Of that number, 25% were reported to have no apparent medical indication and were done for the convenience of either the patient or the physician (Martin et al., 2006). This rate represents a 9.5% increase since 1990. An even higher induction rate of 41% was found by the Listening to Mothers II survey (Declercq, Sakala, Corry, Applebaum, & Risher, 2006).
Although both American College of Obstetricians and Gynecologists (ACOG, 1999) and Joint Commission on Accreditation of Healthcare Organization (JCAHO, 2003)recommend that women be informed about the risks and benefits of induction, many women are not given this information and elect to be induced for their convenience or because they have become tired of being pregnant (Lothian, 2006c).Many physicians continue to schedule inductions, despite recommendations to the contrary based on research that has shown the disadvantages of elective induction (Wagner, 2006). Studies have documented a significant increased risk of cesarean delivery after induction of labor, particularly in nulliparous women or women with an unfavorable Bishop score at admission (Johnson, Davis, & Brown, 2003; Vrouenraets et al., 2005), and an increased rate of delivery of near-term infants born between 35 and 37 weeks gestation (Medoff-Cooper, Bakewell-Sachs, Buus-Frank, & Santa-Donato, 2005;
Wang, Dorer, Fleming, & Catlin, 2004).

Care practice 2: freedom of movement throughout labor
The ability to move and change positions during labor has been known for centuries to help facilitate labor progress and decrease pain (Atwood, 1976; Engelmann, 1977; Johnson, Johnson, & Gupta, 1991).Because of routine use of technology, women today are often confined to bed from a very early point in the labor process, thus decreasing the baby’s ability to flex, engage into the pelvis, find the best fit, rotate, and descend.
Fenwick and Simkin (1987)discussed six physiological mechanisms that are important to facilitating labor progress and preventing dystocia, through the use of walking, sitting, kneeling, leaning, and squatting. However, in the Listening to Mothers II survey, 76% of women reported being unable to walk after admission to the hospital (Declercq et al., 2006).
It has been suggested that the maternal immobility that results after epidural administration may contribute to midpelvic arrest and failure to descend, with the resulting need for either forceps, vacuum extraction, or cesarean delivery (Fenwick & Simkin, 1987). However, a Cochrane Collaborative review of 21 studies (Anim-Somuah, Smyth, & Howell, 2007)found that although epidural anesthesia resulted in an increased risk of instrumental delivery, it had no significant impact on the risk of cesarean delivery. Because epidural anesthesia is used for the majority of women today, it is important that movement (in a rocking chair, on a birthing ball, or with ambulation or slow dancing) be encouraged prior to its administration and that the mothers position be changed in the birthing bed at regular intervals after administration (Simkin & Ancheta, 2005).

Care practice 3: continuous labor support
When childbirth took place in the home, continuous labor support was provided for the laboring woman by her family, female friends, and midwife. Research has shown that labor support (emotional support, information, and comfort measures) enables a woman to be more involved and cooperative with her labor, have higher satisfaction regarding her labor, have less pain medication, and increases her chances for a spontaneous birth (Albers, 2005; Hodnett, Gates, Hofmeyr, & Sakala, 2006).
When birth moved to the hospital, continuous labor support became a rare luxury for several reasons. It is unusual that a nurse can devote all her time to one laboring woman, and today’s nursing shortage has made AWHONNs recommended 1:2 nurse-to-patient ratio in active labor a challenge in some settings (Schofield, 2003; Sleutel, Schultz, & Wyble, 2007).The demands of increased technology, increased documentation, and rising induction and cesarean rates take nurses away from hands-on bedside care. Many nurses today have not learned labor support strategies in school, do not value or are uncomfortable with providing this type of care, or have no role models or support from leadership to implement hands-on labor support (Sleutel et al.). The amount of time nurses spend in giving labor support has been found to range between6.1% and 31.5% of their total nursing activities (Gagnon
& Waghorn, 1996; Gale, Fothergill-Bourbonnais, & Chamberlain,
2001; McNiven, Hodnett, & OBrien-Pallas, 1992; Miltner, 2000).

Care practice 4: no routine interventions
Routine interventions in maternity care, applied for all women rather than selectively used and individualized as needed, have become the norm in many hospitals in the United States. Interventions begin in pregnancy with routine ultrasound screening (Voelker, 2005; Wax & Pinette, 2006) and continue throughout the labor and birth (Davis-Floyd, 2003; Wagner, 2006).Statistical trends have shown a steady increase in past decades for such procedures as medical or elective induction of labor, electronic fetal monitoring (EFM), amniotomy, forceps, vacuum extraction, and cesarean births (Declercq et al., 2006; Kozak & Weeks, 2002; Martin et al., 2006), despite evidence of adverse outcomes of many of these interventions when applied routinely (Lothian, 2004; Wagner, 2006).
Cesarean birth rates in the United States are now 30.2% (Centers for Disease Control and Prevention National Center for Health Statistics [CDC], 2006)and are expected to continue to rise. Some professionals view this trend as being caused by the “cascade of interventions” that begins with induction of labor, leading to the need for intravenous lines, continuous EFM, amniotomy on admission to the hospital, early epidural administration, and immobility due to bed rest required for these interventions (Alexander, Mcintire, & Leveno, 2000).

Care practice 5: nonsupine positions for birth
For centuries in most cultures, women gave birth in upright positions. Many studies have highlighted the benefits of the upright position for both labor and birth. These include: an increase in the uterospinal drive angle to direct the fetus more effectively into the pelvic inlet, the effect of gravity to facilitate fetal descent, increased diameters of both the pelvic inlet and outlet, improved uterine contractility, improved fetal well-being, reduced duration of second-stage labor, reductions in assisted deliveries and episiotomies, and decreased pain (Caldeyro-Barcia,
1979; Collis, Harding, & Morgan, 1999; DeJong et al., 1997; Fenwick
& Simkin, 1987; Gupta & Nikodem, 2000; Johnson et al., 1991;
Keen, DiFranco, Amis, & Albers, 2004; Keirse et al., 2000;
Mendez-Bauer et al., 1975; Simkin, 2003).
Fifty-seven percent of women in the Listening to Mothers II survey reported that they gave birth lying flat on their backs (Declercq et al., 2006).Although some upright positions may not be possible after epidural administration, a multisite survey demonstrated that with the use of lower dose epidurals, many upright positions can still be used (Gilder, Mayberry, Gennaro, Clemmens, 2002; Mayberry, Strange, Suplee, & Gennaro, 2003).The barriers to facilitating upright positioning in today’s high-tech clinical practice can include nurse and physician resistance to upright positioning, reluctance of the laboring woman to change positions to be upright, maternal fatigue, intolerance of the fetus to maternal upright positioning, or a high-dose epidural block with total motor block(Gilder et al.).

Care practice 6: no separation of mother and baby after birth with unlimited opportunity for breastfeeding

Despite the Baby Friendly Hospital Initiative (2004)in the United States to promote successful breastfeeding, separation of mothers and babies remains a common practice in many hospitals today. The Listening to Mothers II survey reported that most babies were not in their mothers arms for the first hour after birth, and 39%of the babies spent the first hour with hospital staff, most for routine care (Declercq et al., 2006).Even in hospitals that advertise family-centered maternity care, the baby may be taken from the mother after an initial 30 to 60 min of “bonding” time to a nursery to receive “transitional care,” including assessment, bathing, and weighing. Mothers are often discouraged from keeping their babies during the night so that they can get their rest (Zwelling & Phillips, 2001). One fourth of women in the Listening to Mothers II survey reported that their baby stayed with them during the day but returned to the nursery at night (Declercq et al.).
These practices continue despite research in the past 30 years that has highlighted the importance of nonseparation to facilitate neonatal physiological adaptation, maternal-infant attachment, and establishment of breastfeeding (Bystrova et al., 2003; Keirse et al., 2000; Kennell & McGrath, 2005; Klaus et al., 1972; Klaus & Kennell, 1982).
The three most influential factors fueling the movement to high-tech birthing may be consumers (childbearing women), physicians and nurse-midwives, and perinatal nurses. When defined according to these six parameters, evidence seems to indicate that a normal birth without routine high-tech interventions may be
difficult to achieve in our country today. The gradual evolution that has brought our clinical practice in maternity care to this point has been complex and multifaceted.

Factors that influenced the change from normal to high-tech birth
Among the factors that have fueled the movement to a high-tech birthing environment, the three most influential have probably been the “players” in the birthing scene: the consumers (childbearing women), the health care providers (physicians and nurse-midwives), and the caregivers (perinatal nurses).
The consumers Today’s childbearing women are very different from their mothers and grandmothers in regard to their views of childbirth, the options available to them, and the decisions they must make (Davis-Floyd, 2003).From a sociocultural perspective, the women born in the late 1970s or1980s are known as generation Y (the successors to generation X) or as Echo Boomers (because their 80 million in number rivals the number of baby boomers). They have also been called the iGeneration because they were born into an era of technology and have known nothing else (Huntly, 2006).
In recent years, the author has observed a negative influence of the media in the view of pregnancy and childbirth for today’s childbearing women.
Very seldom are labor and birth depicted in a positive manner on television, whether being discussed on syndicated talk shows, portrayed in soap operas or sitcoms, or in the new reality programs about childbirth. Books written for pregnant women regarding pregnancy and birth are far more likely to portray a negative attitude than a positive approach that encourages women and gives them confidence in their bodies ability to grow a healthy baby and to labor and give birth. When movie stars brag about their epidurals and elective cesarean births, it is difficult for today’s expectant women to have the self-confidence to counter this attitude.
The iGeneration is used to and comfortable with technology. They have known nothing other than fast-food restaurants, microwave cooking, drive-through banking and pharmacies, and fast easy access to communication and information. A technologically managed labor and birth that can be fast and efficient is not a negative concept and is not likely to be challenged. For example, when today’s pregnant women become impatient with the natural length of pregnancy, elective induction seems like an easy solution, particularly for White, well-educated, insured, married women who have had early prenatal care (Simpson & Atterbury, 2003).Anecdotal reports suggest that when a physician suggests induction of labor, the woman may be told that the baby is “ready” and if she waits for labor to begun spontaneously, the baby will be “too large” or will not tolerate labor. Most women do not have enough information to be able to critically evaluate what they are told, so they acquiesce (Lothian, 2006c).Parity, educational level, and financial status may also influence childbirth decisions. Women who had previous births and had the most education and income indicated the greatest preference for epidural analgesia (Stark, 2003).
Another trend is electing cesarean birth with no medical indication. This consumer demand, if it grows, will take us further into a routinely high-tech model of maternity care. Cesarean birth on maternal request(CDMR) may be the result of a number of factors: the impatience with being pregnant, fear of labor and the belief that a cesarean birth will be easier and less painful, the ability to plan and schedule the day of delivery, a lax attitude regarding surgery and a lack of awareness about the risks of cesarean birth, belief that vaginal birth is harmful due to the possibility of future pelvic floor problems, desire for personal control (Lothian, 2006b),or economic considerations such as being able to receive 8 weeks paid maternity leave from a job for a surgical procedure rather than 6 weeks for a vaginal delivery. Concern about this trend prompted the National Institute of Health to convene a State of the Science Conference in March 2006 to assess the current
research related to CDMR. The actual incidence of CDMR is not clear at this time, with reports ranging from2.5% to 18% (Mayberry, 2006; Young, 2006).
Pregnant women are placed in a difficult position if their care providers give information that is frightening. It is easy for them to be convinced to agree to interventions if they perceive that failure to do so will harm their babies, particularly if they have not had an opportunity to evaluate the information given to them. The author was informed of a situation in which a woman was told by her female obstetrician that “labor is barbaric.” The physician herself had had a primary elective cesarean delivery. This kind of negative influence is difficult for the patient to overcome. Women trust their caregivers and fear that if they do not comply or are “disobedient,” they will not receive good care(Davis-Floyd, 2003; Kitzinger et al., 2006; Wagner, 2006).
Decisions are therefore often made as a result of fear. Many expectant women today do not attend childbirth classes, so the benefit of being given pros and cons of various childbirth options, with time to think about and discuss the implications of their choices, may not be available. Some fears may be misplaced, however. For example, childbearing women agree to be induced because of harm to the baby if the due date is passed, but they do not fear the potential risks of the induction; they fear the pain of labor, but not the pain and potential medical complications from major abdominal surgery (Boyd, 2006).The author has observed that today’s women have very little confidence in their bodies ability to give birth or their ability to cope with the labor and birth process. For this reason, one of the stated goals of Lamaze International is to increase women’s confidence through education (Lamaze International, 2003).

The providers No doubt the primary influence on physicians and nurse-midwives that has affected the change to high-tech birth is legal liability. Care providers believe that they must practice defensive medicine to avoid potential litigation. Despite the fact that pregnancy outcomes for both mothers and infants are better than they have ever been in our history, litigation has increased. Consumers zero tolerance for any bad occurrence has become the rule, not the exception (Hankins, Maclennan, Speer, Strunk, & Nelson, 2006; Wagner, 2006).
According to the ACOG, obstetricians have an average of 2.6 claims filed against them during their career; 61% of these are obstetrics related (Cherouny, Federico, Haraden, Leavitt, & Resar, 2005) and the majority for allegedly birth-related cerebral palsy (Hankins et al., 2006).The National Practitioner Data Bank reported that in 2003, there were1,255 obstetric-related legal cases, which generated 8.1% of all physician malpractice payment reports and had the highest median($290,000) and mean ($475,880) payment amounts. For the period from1997 to 2003, the median malpractice award for a childbirth-related claim involving obstetricians and hospitals was $2.5 million (Horsham, 2005).Because of these statistics, liability insurance premiums for obstetricians and hospitals with large obstetrics services have risen dramatically, up to $299,420 per year in some states. This has forced some care providers to relocate to other states, to drop their obstetrics services and provide gynecology care only (1 of 11 have done so), or to leave medical practice (Hankins et al., 2006).
The clinical interventions that have been most fueled by liability concerns are elective induction of labor and cesarean birth. Care providers may believe that if they can obtain some control of the labor and birth process, they can control negative outcomes as well. These two clinical practices also enable physicians to gain control of their personal and professional schedules. There seems to be an attempt to fit childbirth into an 8:00 a.m. to 5:00 p.m. workday, so controlling the labor process with oxytocin or delivering a baby by a scheduled cesarean is very enticing (Wagner, 2006).
And yet, there is a philosophical schism within the medical community on cesarean birth versus vaginal birth. Some physicians practice in a manner to promote normal birth and decrease the cesarean rate, and others believe that cesarean delivery decreases litigation risk. This clash has been observed from one region of the country to another, between hospitals within the same community, and even among physicians within the same hospital system (Moore, 2005).
When surveyed, obstetricians from Maine expressed the belief that women have a right to select their mode of birth. Eighty-four percent stated that they would perform elective cesarean birth upon maternal request, but only 21% stated that they would elect a cesarean birth for themselves or their partners (Wax et al., 2005). This trend was found to be consistent in other areas of the United States and in other countries as well (Klein, 2005).Fears expressed about vaginal birth among obstetricians, whether in regard to their patients outcomes or in regard to their own births, are related to pelvic floor consequences (urinary or rectal incontinence and sexual problems). Some care providers seem to have lost regard for the normal physiology of birth and instead fear the process of childbirth in their clinical practices and in their personal lives (Klein).
The ACOG published a statement that it is ethically permissible to accede to a request for an elective cesarean birth from an informed woman, but also acceptable to refuse if the surgeon thinks that it is not in her interest (ACOG, 2003).When the providers professional organization supports consumer choice of surgical birth as ethically permissible, future escalation of this technology seems likely.
The best approach is to strive to balance both aspects of care, providing high-touch components along with technology as needed.

The nursing caregivers

in the curricula of many nursing education programs over the past decade have resulted in very little time allocated for the maternal-newborn nursing course. In some schools, it is not even a required clinical experience but can be selected as an elective. In the time that is allocated for this specialty content, the focus has
shifted from that of normal birth and nursing care to support it to a high-risk focus with all the accompanying high-tech interventions. Depending on where students have their clinical experiences, it is possible that they will never see a normal birth. Nurses have learned to manage labor from a distance with the use of monitors and other technology. The move to high-tech childbirth has therefore been a comfortable one for many new nurses.
In addition, a high-tech model of care has been accepted and even embraced in many hospitals, as a result of the nursing shortage or hospital fiscal constraints, or both, that inhibit increasing staffing. Many hospitals cannot meet AWHONNs staffing guidelines of a 2:1 patient-to-nurse ratio for care during active labor (Schofield, 2003).It is easier to “macromanage” more patients if they all have epidural pain relief early in labor, if their labor pattern is being controlled by oxytocin, and if they are monitored so that contraction patterns and fetal status can be continually assessed from a distance (Simpson, 2000). This model of care requires fewer nurses.
The nursing shortage is not expected to improve in the near future. By2015, it is expected that our country will have a 22% shortfall of nurses (Roberts, 2002; Sinclair, 2003).In 2004, the average age of nurses was 46.8 years, more than a year older than it was in 2000; the largest number of nurses working today are in the age group of 45 to 49 year, thus many of the nurse providing care today will be retiring in the next two decades (Health Resources and Services Administration [HRSA, 2004]).The resultant staffing situation is thus likely to play a part in the model of care that will be possible for childbearing women in the future.
As the primary caregivers for women during labor, nurses often find themselves walking a fine line between the wishes of the consumers and the preferences of the women’s medical care providers. Many perinatal nurses describe their feeling as though they are caught in a philosophical dilemma between the technology that has become a standard component of care and the belief that childbirth is normal and may not always require routine interventions. Although nursing caregivers and providers share the same goal of a healthy outcome for mother and baby, communication between them is sometimes a source of frustration, as they do not always agree on the model of care to achieve this goal (Simpson, James, & Knox, 2006).There is also a dichotomy among nurses, for some struggle with the current “medicalization” of childbirth, while others accept it without question.

The future: a need for balance
As the view and management of pregnancy and birth became increasingly high risk, the need for an increase in technology to manage the delivery of care was not surprising. In contrast, the management of birth viewed as normal was more likely to be associated with a hands-on, high-touch approach to care. These two approaches seem to be opposing and nurses tend to select one over the other.
The better approach is to strive to balance both aspects of care, providing the high-touch components along with the technology as needed. In Megatrends (1982) and High Tech/High Touch (2001),Naisbitt discussed the need to balance the ever-increasing technology in our society with a high-touch human response. He theorized that as the amount of technology increases in our personal or professional lives and we realize we cannot stop it, we cope by finding ways to accommodate it, respond to it, and adapt to it. For example, as the technology in obstetric care increased, we have seen the advent of homebirth, freestanding birthing centers, hospital family-centered birthing units, and a resurgence of interest in labor support strategies, all in an attempt to humanize the childbirth experience.

What can nurses do? creating normal birth in a high-tech world
It sometimes seems overwhelming. What influence can nurses have? Where does one begin? How can nurses maintain a balance in their clinical practice? First steps might include the following:
1. Become aware of evidence-based practice related to nursing care to promote normal birth for childbearing women (Albers, 2005, 2007). Read professional journals and attend conferences to learn about current recommended practices based on research.
2. Evaluate your personal philosophy. What do you believe about childbirth? If you believe it is a normal physiological process with the occasional need
for intervention, and a major event in the life of a woman, how can you manifest that belief in your nursing practice? What changes could you implement in the care you provide to your patients?
3. Become a vocal advocate for normal birth in your community. Share positive messages about childbirth with the young women in your life before they become pregnant. Begin these discussions with your daughters, your granddaughters, and any other young women in your life. Nurses have the power to begin a campaign of “social marketing” in their communities to counter the negative impressions given to women by the media. Social marketing has worked to promote change in other areas of perinatal care(importance of prenatal care, prevention of preterm labor, and breastfeeding), so a campaign to promote normal birth also could work (Boyd, 2006).
4. Work to reinstate prenatal patient education opportunities at your hospital and to develop creative ways to attract expectant women and their families to attend. An unfortunate result of the epidural era is the belief of parents that they do not need childbirth education now that anesthesia is readily available. Classes are still equated with “natural childbirth” and therefore avoided. Women need prenatal education more than ever to receive the information they need to make the big decisions they face. They need to know their options to plan the type of birth experience they desire (Lothian, 2006a).They need to be given accurate information, including pros and cons, about all medical interventions so that decisions they make are truly informed.
5. Increase your labor support skills along with your technical skills. If you are not familiar or comfortable with hands-on interventions to assist women during labor, attend a labor support seminar, and review the many professional journal articles or books on the topic (Hodnett et al., 2006; Perez, 2002; Simkin & Ancheta, 2005; Zwelling, Johnson, & Allen, 2006).
6. Welcome doulas as part of your team for care of women during labor if they are available in your community and are being used by your patients. Many
hospitals have even started a doula service to provide labor support to patients and to extend the care that staff nurses are able to provide.
7. Advocate for changes in the birth environment in your hospital. The design of modern LDR or LDRP rooms helps families give birth in a home-like setting and helps the event to feel more normal. The design of the rooms alone is not enough, however. The physical environment needs tobe accompanied by implementing a family-centered model of care (Phillips, 2003).
8. Establish interdisciplinary committees to develop and implement standardized unit policies related to all aspects of clinical practice (e.g., policies
for induction, anesthesia administration, alternative labor support modalities, and cesarean birth). These committees should have membership representation from obstetrics, anesthesia, and nursing. Our beliefs, attitudes, and care practices swing back and forth over time, very much like a pendulum on a grandfather clock. It is difficult to predict how childbirth will be managed 50 years from now. Some aspects of our current model of care may not change. In contrast, societal
influences, fiscal support, and continued research may cause moderation in some of the high-tech approaches we see today. Nurses can have influence in promoting normal birth in a high-tech world if they are willing to strive for balance.

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