10.11 Family Adaptations During Childbirth

The birth experience affects bonding and attachment for the family, and the nurse plays an important role in supporting the family during this transition time.

Support During Labor and Delivery

The labor and delivery experience for the client and their partner or support person can be enhanced by participation in prenatal classes. Some partners and support persons feel empowered in their role during labor and delivery and provide excellent labor support, but others may feel disempowered or too overwhelmed to provide support in the manner preferred by the laboring client. Nurses can help guide the partner or support person by reading the birth plan and asking the client regarding their preferences for support. The nurse provides health teaching to the partner or support person to be prepared for the sights and sounds of labor and birth, how to support the client during labor, to know their own limits,  and maintain their own hydration and nutrition throughout the experience so they are able to continue to provide support and to ask questions so they feel prepared.^[1]

Some clients are unable to have their desired partner with them during labor and delivery for a variety of reasons, so the nurse provides emotional and physical support. A doula can also help serve as a support person. Doulas are non-medical professionals who are trained to provide physical and emotional support to clients during labor and birth. Research shows the addition of an experienced support person can improve a family’s birth experiences.^[2]

Clients may request to have additional family members present during labor and delivery. The selection of participating family members is a personal choice that can be impacted by cultural preferences, policies of childbirth settings, health issues and infection control, and relationship dynamics. For example, a client may prefer to have her mother, mother-in-law, sisters, or children present for support. Historically, family involvement during pregnancy included giving advice, helping clients prepare for birth, and attending the labor and delivery. This type of family involvement has been shown to increase emotional security and decrease stress, as well as reduce the incidence of postpartum depression. Nurses support clients’ requests for the presence of additional family members by promoting family member access to the extent the client prefers and agency policy allows, as well as providing health teaching to these additional members about labor and delivery, knowing this support can improve birth outcomes and experiences for clients and families.^[3]

Support Immediately After Childbirth

Nurses promote emotional bonding and secure attachment immediately after vaginal delivery or cesarean delivery by promoting skin-to-skin contact with the parent(s). In some circumstances, the client has chosen to immediately relinquish the newborn as part of gestational surrogacy or adoption, in which case the initial skin-to-skin contact may occur with someone other than the client or her partner.

Gestational Surrogacy

Gestational surrogacy is becoming increasingly common to allow individuals or a couple to become parents despite circumstances in which carrying a pregnancy is medically contraindicated or biologically impossible. Gestational surrogacy is a process where a woman, called a surrogate or gestational carrier, carries and gives birth to a baby for another person or couple, called the intended parents. The process of gestational surrogacy involves in vitro fertilization (IVF) where an embryo is created by fertilizing eggs using sperm from the intended parents or donors and then implanted in the surrogate’s uterus. The surrogate is medically screened to ensure they are healthy and have had at least one previous viable pregnancy, and they meet with a mental health professional to ensure they are emotionally prepared for the surrogacy process. The intended parents are also screened to ensure they are physically, mentally, and legally capable of parenting and can afford potential costs associated with the surrogacy process. A legal agreement is created by attorneys that outlines parental rights and payments. Gestational surrogacy can be expensive, ranging from $75,000–$150,000 to cover medical expenses, attorney fees, counseling costs, agency fees, and the surrogate’s living expenses and compensation. However, using a gestational surrogate is illegal in some states.^[4]

Nurses advocate for the surrogates, infants, and intended parents and provide emotional support and guidance to families during the childbirth process.

Adoption

Adoption is a legal process that transfers a child’s parental rights from their birth parent(s) to adoptive parent(s). The term adoption triad is often used to describe the individuals directly impacted by adoption, including adoptees, birth parents, and adoptive parents. Although adoption is a legal process, it is also a social and emotional process. It can be joyful experience, but individuals involved may also have feelings such as loss, grief, and identity issues.^[5]

There are two major categories of adoption called open adoption and closed adoption, with the main difference being the amount of information shared between the birth parent(s) and adoptive parents. During open adoption, the birth parent(s) and adoptive family know each other’s identities and have regular contact that may include phone calls, emails, video calls, and in-person visits. There are two types of open adoption called fully open adoption, where there is direct contact among the birth parents, adoptive parents, and the child, or semi-open adoption where an agency caseworker, lawyer, or other mediators pass information like photos and letters between the birth parent(s) and the adoptive family. This type of adoption lets birth parents and adoptive parents communicate and share information while also keeping their privacy. During closed adoption, the identity of the birth parents and adoptive parents is not disclosed, and there is little or no contact before or after the adoption. The adoptive family may receive relevant medical records without personal identifying information, but other information remains private and the records are sealed. Based on state law, adoption records may not be viewed until the adopted child becomes an adult.^[6]

There are many types of adoption, including adoption through private child placing agencies, adoption from foster care, and adoption through tribal agencies. Domestic adoption is the process of placing a child born in the United States with an adoptive family who are also citizens of the United States. The birth mother creates an adoption plan and may elect to choose which family adopts her child. The birth father may also be involved in this process. A licensed adoption agency performs an adoption home study and provides training to prospective adoptive parents. The birth mother may provide permission for the adoptive parents to be present during childbirth. After the child is born, they are discharged from the hospital according to the adoption plan with the adoptive parents, foster parents, or their birth parent(s) before the Termination of Parental Rights hearing. Costs associated with private adoption by adoptive parents can vary significantly across adoptive agencies and range from $12,000 to $25,000.33 See Figure 10.74^[7] for an image of adoptive parents.

Nurses provide therapeutic communication to pregnant clients considering adoption while being aware there are many reasons that may underlie their decision, including the following^[8]:

• To handle an unplanned pregnancy: Adoption is an alternative choice for an unplanned pregnancy with many possible rationales. A client might choose adoption if they’re at a point in their life when they are focused on fulfilling personal goals like completing their education or pursuing a career. They may choose adoption if they know their current life circumstances are not conducive to raising a child in a stable home. A mother might choose adoption if she has other children and feels her current family is complete. A client may have personal or cultural beliefs against abortion and worry they will regret a decision to have an abortion. Some clients focus on adoption as a choice to fulfill someone else’s dream of being a parent if they are biologically unable to have children.
• To prioritize the child’s well-being: Adoption can provide a child with stability and opportunities that the client is currently unable to provide due to life circumstances. If the client chooses an open adoption, the child may have a large support system, similar to extended family, that allows a continued relationship with the child.
• To allow more time for a decision: Based on state law, there is a limited timeframe in which to make a decision about having an abortion. Medical abortions are generally performed within the first ten weeks of pregnancy, and most states do not allow aspiration abortions after 24 weeks’ gestation because this is when the fetus is considered viable and able to survive outside the uterus. A mother can choose adoption at any point during the pregnancy, even after abortion is no longer an option.

The nurse plays a vital role in the adoption process, supporting the birth mother and adoptive parents throughout various stages of childbirth. Here are some key aspects of the nurse’s role during the adoption process^[9]:

• Know the adoption policy at your agency.
• Be aware that labor, delivery, and the postpartum stay can be an emotional and stressful time for the birth mother, her partner, the birth father, the adoptive parents, and associated family members. The role of a nurse is to remain nonjudgmental and use therapeutic communication. Keep in mind that although you may not know the backstory or the client’s reasons for considering adoption, the role of the nurse is to support and empower the client to make a decision they feel is best for their circumstances.
• Respect the client’s wishes regarding her adoption plan. The client usually has a social worker who helped create an adoption plan that includes preferences regarding the hospital stay and contact with the adoptive parents.
• Communicate the adoption plan with members of the interprofessional health care team caring for the client to provide sensitive and empathetic care.
• Know that a client considering adoption maintains all the legal rights and responsibilities for the baby until the adoption consent documents are signed. The client’s adoption plan can be changed at any time during their hospital stay until these documents are signed. Nurses support clients by staying flexible and respecting the client’s wishes that may change during the hospitalization.
• Words are powerful. Avoid language like “giving up the baby for adoption” and instead use phrases like “making an adoption plan,” “choosing adoption” or “placing the baby for adoption.” This removes implications that the client is carelessly “giving the baby away” or “giving up” by choosing adoption.