Learning Objectives
By the end of this section, you will be able to:
- Explain the normal psychologic changes of the person during the four stages of labor
- Explain the normal sociologic changes of the person during the four stages of labor
Labor and birth cause some of the most dynamic physical changes a body can endure, and the mind is greatly affected by the work the body is doing. Major changes in the psyche of the laboring and birthing person are often present in overwhelming ways—positive, challenging, or, in many cases, both. Because the mind and body are so affected, the relationships to others around the birthing person are also impacted during this time of transition from pregnancy to labor, birth, and parenthood (Olza et al., 2020). This is also a time when the birthing person gets to know and understand their culture’s traditions, expectations, hopes, and fears specific to the experience of birth.
Nurses are vital to the experience of birthing people during their transition to parenthood. Nurses can impact this experience in a positive way by reducing trauma and providing support for the mental and physical health of the birthing person. Unfortunately, nurses can also contribute to or even cause trauma to the birthing person and their family. Understanding this great responsibility is the first step to practicing trauma-informed nursing care and reducing the risk of birth trauma in birthing people and their families.
Psychologic Changes during the Process of Labor and Birth
Leading up to labor, pregnant people may feel everything from excitement, joy, and anticipation to extreme fear, anxiety, and panic. Some of those extreme levels of emotion can be tempered by taking childbirth classes, preparing the home for the early postpartum period, securing a birth or postpartum doula for support, or discussing birth with friends and family (Olza et al., 2020). While the anticipation is almost always great, the experience of this vast range of emotions can vary from person to person and pregnancy to pregnancy, making it difficult to prepare pregnant people for what they will feel. They often won’t know what they’re feeling until the moment an emotion begins.
As labor begins, emotions can be heightened or may abruptly switch to the opposite of what the pregnant person was experiencing. In early labor, most people can be present and feel those emotions; but as labor progresses, especially if the person is unmedicated, the intensity of labor can become all-consuming, and the laboring person will often internalize emotions and focus on laboring through the contractions and other sensations of active labor (Olza et al., 2020). It is common in labor to have a pause before the second stage begins, where the birthing person has a moment of clarity, feels stronger emotions again, and prepares for the birth.
Birth is a process that many describe as impossible to explain but that others can describe in exquisite detail. Those able to name their feelings often report feeling overwhelming euphoria, peace, and joy; others report relief, numbness, or floating/out of body experiences; and still others recognize fear or anxiety that this part of birth is ending, and new parenthood is beginning (Olza et al., 2020). The most important thing to do as a nurse during this moment is to be there and listen. If reassurance or support is needed, the nurse can offer it while protecting the space for the birthing person to process the moment. In protecting the space, the nurse allows the overwhelming moment to pass slowly. It is okay to just hold the baby and not count toes for that first moment. The nurse allows the birthing person or their support person to confirm (or announce) the newborn’s sex. Protecting the space may involve echoing the words the birthing person uses for reassurance rather than inserting the nurse’s own interpretation or commentary. Nursing staff should try to limit interruptions for assessments for at least that moment unless medically indicated not to do so. Another way to protect the space is to encourage decision making for the third stage to have taken place prior to that moment. Now is not the time to ask about active management with oxytocin unless the risk factors or bleeding have changed since delivery. The nurse should advocate for the patient’s wishes if reminders are needed for delayed cord clamping, delayed newborn measurements/medication administration, physiologic versus active management of the third stage, uninterrupted skin-to-skin contact, breast-feeding or breast crawl plans, and so on. Nurses need to offer a therapeutic presence in this moment and protect the space of this new family unit.
The fourth stage of labor comes with the slow return to a less heightened emotional state for most. The fatigue and exhaustion from the labor can start to overwhelm the feelings that were all-encompassing just moments ago (Olza et al., 2020). Continued transition to the newness of parenthood as well as continued bonding for the family occurs during the necessary fourth stage nursing assessments to monitor maternal and newborn safety. Families may want to notify other family members, take pictures, call or video chat with loved ones, and even update social media in those early hours. The nurse should follow the birthing person’s lead for how fast or slow this process occurs and should normalize private moments of bonding before notifying others if that is the desire of the birthing person. Gentle reminders of moments to capture, experience, or put to memory during this period can be helpful if the family does not have specific or prepared ideas for this time.
The events that occur during labor may be perceived as traumatic to the birthing person, especially when unplanned or unexpected. These events include (but are not limited to) cesarean birth, use of forceps or vacuum extractor, multiple uncomfortable vaginal exams, inability to receive an epidural for discomfort, episiotomy, perineal lacerations, shoulder dystocia, postpartum hemorrhage, and feelings of lack of control over decisions regarding the birth (ACOG, 2021).
Sociologic Changes during the Process of Labor and Birth
Leading up to labor and birth, the experience of a pregnant person can shift as society begins to recognize them as a parent or a parent of more children. For parents, this can be a new financial expectation or strain. Parents may experience changes in role expectations in work or family life; emotional changes within the family with the addition of their youngest member; or changes in the household caused by reduced space, moving into different homes, or even losing access to homes due to parenthood or additional children (Sæther et al., 2023). Pregnancy, labor, and birth can cause intense emotional changes that can strain or solidify relationships with partners and extend to multiple generations. While each family experiences this differently, it is crucial for nurses to recognize that this role change or relationship shift can be a significant factor in the health of a birthing person and their newborn. Nurses should have an in-depth discussion of social factors during the intake assessment to identify potential needs for support. In addition, nurses should remember to always assess for intimate partner violence during this discussion, as not all sociologic changes in pregnancy are healthy ones (Holmes & Kim, 2019). More discussion of intimate partner violence is found in Chapter 9 Violence Against Women.
During labor, sociologic changes can continue to be positive, neutral, or negative. The intensity of labor and birth can amplify strong bonds or amplify weaknesses of bonds in the social support system of the birthing person (Sæther et al., 2023). The nurse should be prepared for moments of joy, love, and tears from anyone in the room. Also, the nurse must be diligent in preparing for moments of fear or outbursts that can occur when relationships are experiencing hardship. A prudent nurse understands unit policies for unstable or dangerous relationship shifts that can occur in the depths of labor, and never forgets to monitor the safety of the nurse and other staff present in addition to that of the patient. If the nurse is in danger, so are the laboring person and their newborn.
The third stage can be overwhelming because all the postbirth processes take place quickly. The nurse should strive to protect the bonds of the family, individually and as a group, as much as possible while completing the necessary tasks. Many families prepare less for this stage of labor, and it can be foreign to them. The nurse should support the family by explaining all procedures and providing reassurance of normality when indicated as well as any deviation from normal that needs additional intervention or support. Keeping the environment calm and limiting disruptions as much as possible can help this stage feel less clinical and more about family bonding (Bellini et al., 2023). The calm environment can promote physiologic changes in oxytocin levels that may be protective for complications of the third stage, such as retained placenta and postpartum hemorrhage.
The fourth stage is a very vulnerable time for many birthing people as they navigate the handling of this new person, become comfortable with breast-feeding or bottle-feeding, and deal with the realities of postpartum recovery discomforts. Families will often introduce the newborn to other family members as they are ready, either during the fourth stage or in the days and weeks following. Different families and cultures have traditions about what is best or appropriate during this time. The nurse should be sure to assess for any cultural or familial traditions, needs, or wants. For example, many cultures prefer not to have males, even if related, present during newborn diaper changes or breast-feeding for the promotion of modesty; other cultures strongly advocate for public breast-feeding and can be offended by offering coverage of the breast or nipple during feedings (Finlayson et al., 2020). Before additional visitors or support people come to meet the new baby, the nurse should determine any desires for privacy during bleeding assessments or feedings so that the birthing person has the opportunity to voice those preferences privately. Nurses should continue to interrupt as little as possible while the parent-newborn bond forms and sociologic shift occurs.