The birth plan and the nursing process-a new model.

I've been working on writing up birth plans in a fashion that is more for the client and doula to make sure they include everything that the birthing mother wants/needs.  To do this, I've utilized the nursing process theory.  So, for your enjoyment:)  here is a case study I just finished working on for my course.

Case Study 3

Gestational Diabetes

Occasionally I will be presenting case studies separate from the lesson to help you integrate the information you have learned as well as reinforce concepts taught. This particular case has come from a client I had with the names changed. Her main need did not have to do with gestational diabetes, but this definitely played a role in her choices and her goals. I begin with my notes and assessment during the interview process, then move on to finding out her needs and planning accordingly. At the end of this, a birth plan was made that followed her goals and ideas.

Goals

• To understand how to apply knowledge of a specific medical diagnosis to your role as a doula.
• To provide an example of how to incorporate the assessment and interview into the birth plan and your practice as a doula.
• To provide an example of the all steps in the nursing process.

Reading assignments:

Pages 244-247 in The Birth Partner by Penny Simkin.

Read the medical terminology in the lesson.

Listen to the link below:

http://obgynmorningrounds.com/blog/afternoon-lectures/2-72-medical-problems-in-pregnancy-diabetes/

The Interview,

Assessment, and

Birth Plan

Initial Interview Data

First baby

She had gestational diabetes and took medication for this. She possibly also had pre-eclampsia. At 37 weeks, she went in for a NST and found some problems, she was then induced. She labored for a while and got an epidural. Due to fetal distress, she had an emergency c-section. During this birth she was separated from her first husband, but he was there along with her mother. She had a hard time with him there and didn't want much to do with him.

Second baby

She had a normal pregnancy and had a planned c-section at 39 weeks. I'm unsure if VBAC was even offered to her. She had pre-term labor that was controlled with medications. She had difficulty breastfeeding because she felt like she was not giving her baby enough milk. Baby lost weight in the hospital and was supplemented with formula. This continued at home.

This pregnancy

She possibly may be type 2 diabetes but it is controlled with diet. She has seen a nutritionist for this and wants to avoid taking medications for it. She would like a repeat c-section because she feels more comfortable with this. She already has other complications going on and her husband also feels more comfortable with this. She is also having numerous urinary tract infections.

Other

She has anxiety/panic attacks but is not taking medication for this. During her births she had a few panic attacks and would like help with this. Deep breathing and visualizations help with this, as well as having a support person close by. She does not like the oxygen mask. It makes her anxiety worse. She's okay with it if it is held close by, but not on. She was frustrated with how long her baby was taken away after her last two births and wants to make sure they are with her as soon as possible.

Care provider and place of birth

She will be delivering with Dr. X. Right now she is trying to decide which hospital she wants to go to and would like help choosing.

Client goals or desires

• She would like to have the baby with her unless there is a serious medical reason.
• Would like help with breastfeeding
• Help with anxiety.
• Would like to find a hospital that will support her desires.
• Wants help with shoulder/gas pain after c-section.

Needs Identification, Prioritization and Doula Actions

Physiologic Needs

• Risk for imbalanced nutrition status related to NPO status during c-section and gestational diabetes.
  -Actions implemented: Provide clear liquids or other food according to what is ordered or desired. Plan to have foods that she likes available.
• Risk for dehydration related to NPO status during c-section.
  -Actions implemented: Remind your client to drink. Plan to have drinks available that she likes.
• Risk for fatigue related to anxiety about birth.
  -Actions implemented: Address anxiety the day before as well as the day of her c-section.(See below for actions taken for anxiety).
• Body temperature fluctuations related to c-section.
  -Actions implemented: Provide warm blankets or heating pads immediately afterwards. Provide warm fluids if desired. Request warm iv fluids be hung right after the c-section is finished.
• Impaired mobility related to epidural and c-section.
  Actions implemented: Help control pain to allow movement sooner(see actions addressing pain below).
• Nausea related to c-section.
  Actions implemented: Offer peppermint tea or peppermint oil for nausea. Offer liquids and foods slowly. A fan may also be used.
• Risk for shaking related to epidural use.
  -Actions implemented: Make sure that warm iv fluids are used intraoperatively and immediately afterwards. Request warmed blankets during the operation and afterwards Request warm blankets while being before, during, and after the surgery. Diffuse peppermint in the air afterwards or rub some on the feet.
• Risk for itching related to epidural use.
  -Actions implemented: Find something to distract your client from the itching while it wears off.

Safety Needs

• Desires control related to birthing place.
  Actions implemented: Research the hospitals in the area to see what their protocols are regarding infant care afterward, particularly as it relates to babies born by c-sections and from mothers who have gestational diabetes.
• Desires control related to infant bonding.
  Actions implemented: Make sure staff knows that your client wants the baby with her as much as possible. Encourage skin-to-skin.
• Pain related to should/gas pain after c-section.
  Actions implemented: Hot packs to shoulders. Distraction techniques. Get your client up and moving quickly.
• Pain related to incision after c-section.
  Actions implemented: Ice packs for the first 24 hours, then heat packs.
• Pain related to iv
  Actions implemented: Use heat or ice(whichever feels better). Before the iv is put in, warm the hand where is is going to be placed.
• Information seeking behavior related to breastfeeding as manifested by desire for more knowledge and difficult past experiences.
  Actions implementd: Find the closest LLL group. Make sure your client is able to see a lation consultant. Encouragement. Reassurance. Place a sing on babies crib that says not to give this baby anything else by mouth.
• Anxiety related to c-section.
  Actions implemented: Reflexology. Lavender oil. Music therapy. Encouragment. Make sure spouse is close by. Teach spouse light tough to use during c-section.
• Anxiety related to gestational diabetes.
  Actions implemented: Point out what your client is able to control(i.e. Food choices). Focus on signs of good health. Connect them to a nutritionist if possible. Make sure your clients have any medical questions answered by their chosen care providers and provide information they are unablet to obtain.

Social Needs

• Opportunity for enhanced parent/infant bonding.
  Actions implemented: Provide resources on breastfeeding. Provide resources and information on bonding.
• Risk for impaired parent/infant bonding related to c-section and complications from gestational diabetes.
  Actions implemented: Research hospitals to find one that is committed to mom and baby staying together. Make sure the staff understands that your client wants her baby with her as much as possible.
• Opportunity for enhanced relationships.
  Actions implemented: Discuss plan of care with spouse or significant other. Make sure spouse is doing all that he wants to do. Discuss what your clients spouse can do to be involved.
• Isolation related to c-section policies.
  Actions implemented: Make sure that someone is always with your client afterward. Get the majority of the prep work done before your client goes into the operating room.
• Opportunity to enhanced connection to the birthing process.
  Action implemented: Allow your client to see as much as she desires of the c-section birth. Ask to do skin to skin as soon as possible afterward.

Esteem Needs

• Risk for body image disturbance related to physical changes and c-section.
  Actions implemented: Mirror therapy.
• Opportunities for enhanced feelings of empowerment.
  Actions implemented: Make sure your client understands her choices and is given choices.
• Opportunities for keeping environment focused.
  Actions implemented: Request music that your client would like. Make sure choices made are in accordance with your clients wishes. Speak in soft tones. Dim lights as much as possible. Be aware of your clients privacy needs and ask that those be respected as much as possible.
  
  
  
  

Obviously this is not the short and sweet birth plan that you would give to your care -providers, but rather a working birth plan that can be reassessed and changed and is mainly for the doula and her client to understand what exactly the birthing mothers needs are.

Because of the birthing environment we have in our culture, birth plans are viewed as unuseful and sometimes hostile by some medical personnel. Therefore, I do not always recommend giving one to the medical personnel at the hospital, but leave it up to you and your clients discretion. 

In the absence of hostility, a birth plan can be a good way to let your care providers know what your desires and wishes are, so that they can be prepared to offer you the care that you desire.  The one that you write for your care providers will be a lot shorter and mostly just express the birthing mothers immediate desires for her birth.