ICEA Study Guide 2 – Informed Decision-Making and Evidence-Based Teaching

OBJECTIVES At the completion of Part 2 the learner will:

■ define key questions for informed decision-making using the acronym BRAN.

■ compare and contrast two different models of maternity care.

■ list evidence-based resources for evaluating maternity care options.

■ discuss the pros and cons of evidence-based care.

■ evaluate the strengths of various methods of study used for investigating maternity care.

■ demonstrate several ways to teach decision-making skills.

■ define Mother-Friendly Care, Baby-Friendly Care, and the CIMS Mother-Friendly Nurse recognition.

■ discuss benefits of creating a birth plan or a list of birth preferences.

■ compare and contrast informed consent and informed refusal.

■ explore a personal view of the ‘body in birth’ and how that viewpoint may influence teaching methods.



  1. Informed decision-making requires knowledge of alternatives
  2. Definition

Informed Decision Making: www.childbirthconnectionorg;;;;;;;;;;;;;;

If disagree with caregiver: in U.S and Canada, a pregnant woman has legal right (in most circumstances) to change caregivers, and caregiver has right to discontinue care if there are other options for pregnant woman

BRANBenefits– problem were trying to identify/prevent/fix; how is it done; how likely is it to work, Risks – possible risks/side effects for baby/me. Other tradeoffs/disadvantages such as additional procedures or precautions; cost, Alternatives-other options available; other procedures that may work; delay treatment or choose not to; risks and benefits of alternatives and effectiveness (low risk options sometimes less effective), Next Steps– if it solves problem, what can we do after; if it doesn’t, what after?

Health Care Coverage – licensed midwife may charge as little as $2,500 for uncomplicated home birth. Midwife for prenatal/birth center – $4000-$4500. OB uncomplicated birth $7,500. Cesarean complicated can cost more than $20,000.

Contact insurance company representative to understand coverage. See work sheet on

Some insurance plans cover but don’t pay directly for midwifery care, childbirth prep, birth or postpartum doulas, home birth and breastfeeding assistance, but you pay and they reimburse you. Can also use a FSA (flexible spending account).

~25% of people in U.S. can’t afford health insurance or don’t work for employers who offer it as a benefit. Medicaid coverage can help cover costs although only a limited number of caregivers and birth places. – new mothers to share info about their birth experiences.

Choosing a Birthplace

  • Hospital – most women in North America give birth in hospitals. Don’t allow pregnant women to choose who administers anesthesia – may be a nurse anesthetist, an anesthesiologist or a resident. Can find out credentials and experience of staff. Visit to view questions to ask a hospital; based on Coalition for Improving Maternity Services “Ten Steps of Mother-Friendly Care”. Visit for locations of baby friendly hospitals
    • Questions to Ask – see; ex ratio of patients to nurses during labor, birth plans, floating/traveling nurses, equipment to monitor baby’s heart rate, move around in labor, iv fluids, eat and drink during labor, anesthesia available at all times, non-drug methods of pain relief, bathtubs, doulas, visitors, usual stay, baby immediately after birth, breastfeeding specialist, postpartum/newborn follow-up
    • Hospital Tour
  • Outside hospital
    • Freestanding birth center – unaffiliated with hospital; for those permitting only essential interventions.
    • For low-risk pregnancies, planned out of hospital births are as safe for mothers and babies as planned hospital births – sometimes even safer.
    • Medicaid and many health insurance plans often cover cost
    • If a woman is transferred, insurance plans might not cover some costs
    • 15-25% of first-time mothers and 5-10% of 2nd tie mothers transferred
    • Almost all transfers (96%) are for non emergencies such as prolonged labor, meconium in amniotic fluid, prolonged ruptured membranes or desire for pain medication
    • 3-4% urgent transfers require immediate medical action such as cord prolapse, hemorrhage, or concerns about baby’s heart rate and oxygen supply.
    • After a home birth, just over 1% of mothers and just under 1% of babies require a transfer for reasons such as bleeding in mother, retained placenta and respiratory problems in baby
    • Midwives carry oxygen tanks, IV fluids and suctioning devices as well as medications to stop contractions temporarily, stop bleeding and lower blood pressure
    • Consider how far away your home or birth center is from hospital
    • com for list of questions to ask midwife/yourself for out of hospital birth

Choosing Caregiver

  • Physician
    • (OB-GYN) – a physician who has graduated from medical school or a school of osteopathic medicine and has had 3 or more years of additional training in OB/GYN
    • Perinatologist- an OB/GYN who has received further training and certification in managing very high risk pregnancies and birth
    • Family physician- a physician who has graduated from medical school or a school of osteopathic medicine and has completed 2 or more years of additional training in family medicine, including maternity and pediatric care
  • Midwife
    • Certified nurse-midwife (CNM) – maternity caregiver who has graduated from nursing school, passed an exam to become a registered nurse, and completed 1+ years of additional training in midwifery
      • Spend more time in prenatal visits with clients, individualizing care
    • Licensed midwifed (LM) – a maternity caregiver who has completed up to 3 years of formal midwifery training according to state requirements
      • 21 states recognize LMs; most provide care only for those planning home births or birth centers
    • Certified professional midwife (CPM)- maternity caregiver who has received training from a variety of sources, including apprenticeship, school and self-study and has been the primary attendant at 20+ births. She practices outside hospitals and provides care similar to a licensed midwife.
  • Other
    • Advanced practice nurse practitioner – maternity caregiver who provides prenatal and postpartum care, but doesn’t attend women during labor
    • Naturopathic doctor (ND) – a health care provider who has completed 3-4 years of postgraduate training in natural medicine. May also have taken an additional year of midwifery training to be able to provide prenatal care and attend births
    • Lay midwife – a maternity caregiver who might or might not be legally registered with the state of province, and whose qualifications and standards of care might or might not meet state or provincial standards. Also called empirical midwife

Models of Care – Midwifery vs Medical

A caregiver’s philosophy of care typically follows one or the other.

Midwifery Model of Care – designed to maintain and enhance a woman’s physiological and psychological resources for giving birth

  • Birth is a normal physiological process and an emotionally transformative experience
  • A woman’s state of mind influences the labor process, so individualized care is necessary
  • Because a woman’s participation contributes to a healthy pregnancy, labor and birth, childbirth preparation is necessary
  • Low intervention and cesarean rates are desirable
  • Caregivers monitor the mother’s and baby’s well-being and provide education and support. If problems arise, they start with tools that cause the least intervention to regain a healthy physiological process

Medical Model of Care – designed to replace or alter the body’s own resources with medical and technological interventions

  • The natural childbirth process is unpredictable, unreliable and potentially unsafe. Routine care protocols for all women give the caregiver a sense of control over the birth process
  • Medical interventions improve labor and birth
  • Cesareans are no less safe for the mother or baby than natural labor and vaginal birth; in fact, they may be safe
  • Caregivers use routine interventions before problems arise. If problems arise, they intervene quickly with the tool most likely to have the quickest effect

Interviewing a Potential Caregiver – when scheduling, make it clear it’s only to learn more about the caregiver and his or her practice

Questions to Ask a Potential Caregiver

  • Will I see you or another caregiver at each appointment? Does a nurse sometimes handle visits
  • Do caregivers share same philosophy of care? Chances of attending birth? Good idea do induce labor while you’re on call? Colleagues respect birth plan? Hospital staff?
  • Recommend childbirth prep classes? Doulas? Birth plans?
  • Do you support natural childbirth?   Use non-drug ways to relieve labor pain and avoid routine interventions? How many of clients attempt natural? How many succeed?
  • How often use interventions such as labor induction, IV fluids, AROM, continuous electronic fetal monitoring, episiotomy, forceps, and vacuum extractor?
  • How often perform unplanned cesarean with first time mothers? How many clients have one? What can I do to reduce likelihood?
  • If I develop complications, will you handle care or refer me? Who will you refer me to?
  • When and ho often will I see you for checkups after birth?
  • PCNguide for worksheet to record answers
  • if have concerns about respecting legal right to informed consent and refusal

Changing Caregivers if dissatisfied – it’s essential you feel comfortable

  • Express discomfort by using pronouns I instead of you
  • If doesn’t work, consider change but don’t drop until you’ve found someone who better suits you and who has agreed to be your caregiver
  • If you cant change and can’t discuss freely with caregiver, talk with office nurse, childbirth educator, doula or others

Choosing Childbirth Prep Classes – hospitals, colleges and universities, nonprofit community organizations, groups of caregivers, and independent childbirth educators offer

Hospitals usually have provider oriented about hospital which avoid discussion of reasonable alternatives or controversial topics.

Birth Doulas – Cochrane Library issued a report about dehumanization of women’s birth experiences. Review found that support was most effective when provided by women who weren’t hospital staff.

Most studies show that continuous support benefits laboring women, especially when the support begins in early labor and is given by someone whose only role is to provide it. Benefits include:

  • Shorter labors, with less need for medication to speed up labor
  • More spontaneous vaginal birth (those that don’t require forceps, vacuum extraction, or cesarean)
  • Fewer requests for pain medications
  • Less dissatisfaction with birth experiences

A few hospitals provide doula services at low cost or no cost to the patient, and some charitable agencies or public health departments cover doula’s fees for women who can’t afford; health insurance plans rarely cover. for lists of questions to ask

Baby’s Health Care – make decisions about baby’s health care before birth. Ex: circumcision and vaccinations

Choose a caregiver before birth

  • Pediatrician
  • Family physicians
  • Pediatric and family nurse practitioners
  • Naturopathic doctors

Health Care Coverage for baby – cost depends on plan. Children’s health clinics usually cost less than private practices, but they may have longer waiting times. If clinic is associated with a medical school, its staff may change frequently. Community health clinics or well-child clinics associated with a public health department offer free or low-cost checkups and vaccinations, but they usually don’t provide care for sick children.

Questions to Ask Potential Caregiver – do you support breastfeeding, formula feeding, work with lactation consultants, thoughts on circumcision, vaccinations, comfortable with home remedies, use of antibiotics, available for phone consultation, do you have hospital privileges, examine baby after birth.;

Schedule an interview w 1 or more caregivers before birth – check with insurance to see if it covers such appointments; if it doesn’t, see if caregiver will charge a fee.

Finding Help After Baby’s Birth – family members and friends help by cooking meals, running errands, doing laundry, housecleaning and watching baby so parents can sleep/relax. Babys nurses or nannies can take care of baby while you do other activities and mother’s helpers cook and clean but don’t help with baby care or give advice.

Postpartum doula – someone (typically a woman) who’s trained and experienced with helping a woman and her family adjust to postpartum life by teaching them about newborns’ needs and abilities, and about infant feeding, sleep and cues, while providing assistant with household tasks; potential costs may seem daunting but help and care are well worth the price. Health insurance plans rarely cover. Put aside money during pregnancy.

Questions to Ask Potential Postpartum Doula (try to hire before birth)–

Training/education/experience; criminal background check; TB test, DTap vacc, CPR cert, philosophy, meet before birth, additional services, call with questions before birth; when do services begin after birth; experience with breastfeeding, fee, refund policy

Returning to Work – see if possible for family to delay returning to work (you or partner), if one can work part-time/job share, work from home, costs of returning to work – child care, more visits to baby’s caregiver (daycare), income exceed total costs making it worthwhile, how will person who works feel about other staying at home? See PCNguide

Finding Child Care for Baby – arrange well before birth; try to wait 3-4 months after birth before returning to work. Allow at least a month to find child care that best suits your needs. Ask coworkers/other working parents about child care. Consider sharing nanny/babysitter. Ask family members/friends. Stagger you and partners work schedule or work part time. Some works have day cares. If outside your home – see and for advice on evaluating. Give appropriate holiday gifts to caregivers.

10 Steps to Improve Your Chances of Having a Safe and Satisfying Birth

  • Exercise in moderation; eat well
  • Choose birth place with low cesarean birth and minimal routine interventions (fewer interventions in out-of-hospital setting
  • Caregiver with low intervention rates
  • Birth plan. See to read rights of childbearing women
  • Birth doula
  • Avoid labor induction for non-medical reasons. Ask about alternatives
  • Use medical interventions only when clearly necessary, not because routine. Avoid routine IV fluids, continuous electronic monitoring, augmentation with Pitocin or AROM.
  • *Learn to differentiate between early labor and active labor so you can delay hospital admission until active labor. Use labor-coping skills at home to manage pain. Eat, drink and rest as needed to keep up energy
  • Use variety of positions and activities during active labor, such as walking, dancing, rocking in a rocking chair or on birth ball, or taking a shower or bath
  • Push in positions that aid descent, unless birth is happening fast; then use positions that slow descent.

Childbirth Education and Advocacy – most childbirth educators are already birth advocates. Some had empowering birth experiences of their own and became childbirth educators in order to tell other women about the life-changing possibilities of childbirth. Some wish that their own childbirth experiences had been handled differently, and became educators to help other women take a more active role in their births. Some are nurses who work in labor and birth who want to share their experiences and knowledge with pregnant women. Whatever brings people to childbirth education, most are passionate about wanting to help pregnant women and their partners experience safe, healthy and empowering births.

Maternity care in the U.S. and in many other countries is under close scrutiny; in the U.S. the overall cesarean rate is almost 33%, more than 2x the rate of 15% recently recommended by UNICEF and the WHO. Low-cost maternity care practices with few, if any, risks such as continuous labor support, freedom to change positions, warm bath and showers, and early skin-to-skin contact between mother and baby are under-used or not available at some hospitals. Other maternity care practices, which have risks for both mothers and babies such as labor induction and cesarean surgery, are overused. Reducing waste, including unnecessary maternity care interventions (targeting unnecessary cesarean sections specifically) has been identified as one of the 6 goals for improving American healthcare by the NPP. The partners represent 28 influential health organizations including National Quality Forum, the Join Commission, Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services, AFL-CIO, National Governors Association, National Partnership for Women & Families and others.

What can you do to advocate for better births? We encourage you to become an active member of the organization that trained you. Many childbirth educators belong to either ICEA and/or to Lamaze International. Both organizations have volunteer opportunities for members. Both also have journals; you can read the journal to keep up with the field of childbirth education and to know what is going on within the organization. Representatives from ICEA, Lamaze International, DONA and many other organizations work together in the CIMS. If you’d like to determine whether your childbirth classes are “mother friendly” according to CIMS standards and use the form on pg III-17. Grassroots organizations called “birth networks” composed of consumers and childbirth educators, have sprung up in many communities. Members of CIMS and local birth networks have collaborated on the Transparency in Maternity Care project. They are encouraging new mothers to complete a comprehensive birth survey, evaluation both their care providers and their place of birth. The results of the survey are published online on the Birth Survey website at The birth survey volunteers also publish info about interventions rates on the website.

It is also important for educators to encourage their students to pay attention to the evidence when surfing the web. Please note the web it! Feature in the workbook. By viewing, they will be directed to excellent websites on each of the topics included in most childbirth education classes. We want to encourage the parents we teach to become birth advocates too.

If you teach childbirth classes for a hospital, you may want to volunteer to serve on the Quality Improvement Committee, as recommended on pg III-11. It can be very effective to work with other health care professionals within the hospital to create change. In past years, Lamaze volunteer Debra Bingham has invited leaders from local hospitals to attend a special session during the Lamaze International annual conference devoted to hospital change projects. The hospital leaders have shared goals for change at their hospitals and brainstormed strategies to create change. Debra has kept up with several of those leaders since the conferences; she has reported success at increasing skin-to-skin contact between mothers and babies immediately after birth at promoting freedom of movement during labor.

A list of the websites and phone numbers for many childbirth and childbirth-related organizations is included on pgs VII-25-29 in this guide. We encourage you to become as involved as possible in advocating for improved maternity care services. Together, with many voices, we can improve birth for women, babies, and families.

Handouts – The rights of childbearing women – – Publications tab. Guide to a healthy birth

DVDs – the business of being born; more business of being born; pregnant in America; orgasmic birth

Video clips on the web that promote advocacy – onewordbirth: free website w online documentaries from birth experts around the world –


  1. Childbearing families have a right and responsibility to share decision-making

Evidence-Based Maternity Care/Childbirth Education – Evidence-based care is one of the most important tenants in healthcare today. Virtually all practitioners and healthcare organizations aim to provide evidence-based care. The tricky part is in defining the “evidence.”

Maternity care has lagged behind some other specialties in adopting evidence-based care. Even when the evidence is strong, there is often a lag from the time the evidence become apparent until changes in practice are seen. An example is routine episiotomy. At one time, physicians were taught that routine episiotomy reduces complications and healing time after birth. Even after studies appeared in the obstetric literature showing that episiotomy increases rather than decreases the risk of complications, it took many years (until 2000) for the ACOG officially to recommend restricted rather than routine use of episiotomy.

On the other hand, occasionally the publication of 1 study will change practice almost overnight. Such was the case with the “Term Breech Trial” published in 2000. The authors of this multi-center international study concluded that cesarean delivery is safer for breech babies than vaginal delivery. Vaginal breech deliveries almost disappeared completely. In 2004, the researchers published a follow-up study after screen the children in the original study at age 2 for death or neurodevelopmental delays. Researches found no difference between the babies born vaginally and the babies delivered by cesarean. In addition, since the publication of the original study, researchers have identified many methodological problems with the 2000 study, casting the authors’ conclusions in doubt. In July 2006, ACOG published a committee opinion stating that in certain instances, vaginal delivery of a breech baby is a safe alternative. The question now is whether or not vaginal breech delivery will return as an option in appropriate cases, given that for years many medical training programs stopped training new practitioners in how to deliver breech babies safely. Certainly, practice should rarely change based on a single study; however, when the evidence is clear and well-established by several studies or a meta-analysis, practice should reflect best practice.

Learning about best evidence – there is a wonderful story about Penny Simkin, noted childbirth educator, author and speaker. An angry anesthesiologist took Penny to task for presenting information about epidural analgesia in her childbirth classes. “You’re not a doctor. What makes you qualified to discuss labor analgesia?” he asked. She replied – I can read.

You can read, too. You can keep up with what the evidence is saying about maternity care. In fact, you need to keep up so that you can present current, up-to-date information in your childbirth classes.

How does the childbirth educator determine best evidence? The most respected source for info about evidence-based care for the childbearing woman is the Cochrane Library, a collection of databases that contain high-quality, independent evidence to inform healthcare decision-making. The Cochrane Library includes Cochrane Reviews, systematic reviews of the evidence of the effects of healthcare interventions, intended to help healthcare providers and consumers make informed decisions about health care. (A systematic review is a comprehensive survey of a topic in which all the primary studies of the highest level of evidence have been systematically identified, evaluated and then summarized according to rigorous standards.) Cochrane reviewers in over 90 countries keep uo to date with the latest medical research and publish the Cochrane Library every 3 months. The library is published by the Cochrane Collaboration, an international, non profit, independent organization. Current funding is provided by its publisher, John Wiley and Sons Limited. Previous funding has been provided by the WHO, the Rockefeller Foundation, the UK National Health Service Research and Development Programme, and universities in Canada, Australia, England and South Africa. The library is available online at abstracts and summaries of systematic reviews are available at no charge. A subscription is required for access to the full systemic reviews. Some countries have national subscriptions, which hallow everyone in those countries to access it for free. (The U.S.. does not). Many hospitals, universities, and other institutions have subscriptions. One of the membership benefits of joining Lamaze International is access to the full systematic reviews of the Cochrane Library.

Instructions – For abstracts and summaries only (Free access)

  2. Click on browse by topic
  3. From pull down window “Select topic (Review group)” scroll down to “pregnancy and childbirth”
  4. Topics will appear; select one that interests you
  5. Most topics include a “plain language summary” in a blue box
  6. After you read or print your abstract, select back arrow to return to the list of topics
  7. YouTube tutorial:

We strongly recommend that all childbirth educators read Optimal Care in Childbirth: The Case for a Physiologic Approach by Henci Goer and Amy Romano. In this 2012 book, the highly respected author of Obstetric Myths Versus Research Realities and The Thinking Woman’s Guide to a Better Birth, joined with certified nurse-midwife and former editor of the Lamaze research blog, Science and Sensibility, Romano, to provide a comprehensive analysis of the current evidence about maternity care.

In 2008, childbirth connection published an excellent, meticulously researched report, Evidence-Based Maternity Care: What It IS and What It Can Achieve. This too is reading we highly recommend. Its available at no charge on childbirth connection website.

What if I want to research topics on my own? You cant always find the topic that you are interest in listed in the Cochrane Library. The next place that we commend that you visit is PubMed – a free service of the U.S. National Library of Medicine and the National Institutes of Health. Go to type in topic that you are researching in box that you see near the top of the web page. Click on search. A list of research studies will appear. Sometimes there will be hundreds of articles listed. The articles are listed in chronological order. Scroll through the list to find articles that look helpful. When you click on an article, you will get the abstract – summary of the study. Most will tell yu what kind of study is being presented. Abstracts may include background about the topic being studied; the objective; methods; results and the conclusions of the authors.

If you would like to limit your search on PubMed to a type of study known as a meta-analysis or systematic review, find Article types on far left of list of studies, select Review. A list of systematic reviews will appear. When you are viewing a particular abstract, occasionally a logo will pop up on the right that says Free Access. You can click on that button to get access to the full article. We have found that sometimes it is valuable to read the entire article rather than just the abstract. You may get an entirely different slant than you get from reading just the abstract. Many Canadian and British medical journals offer free online access; most U.S. journals will charge you for each article you download.

Where can I find journals? Many hospitals and schools have libraries with journal subscriptions. A hospital librarian may be able to get you an electronic copy of an article that you would like to read. Even if your hospital or school library doesn’t subscribe to the journal you need, librarians can often get copies of article through an inter-library loan program. If you do not have access to a hospital or school library, you may not be entirely out of luck. Many community libraries have subscriptions to the most popular medical journals such as the New England Journal of Medicine and the Journal of the American Medical Association (JAMA). If there is a medical school or nursing school nearby, the libraries at those institutions may offer free access to the public, or memberships for a nominal fee.

If you would like info about the different types of studies, turn to the next page. If you’d rather learn more about other places on the web that summarizes research for you, skip to pg III-8.

The Cascade Effect of Obstetric Interventions: Induction/continuous EFM -> inactivity, confined to bed -> increased anxiety -> false positive monitor readings -> slowed labor -> AROM -> Pitocin -> increased pain -> pain meds/anesthesia -> abnormal FHR patterns -> (failed) forceps or vacuum -> cesarean surgery

Assessment of Effective Coping During Labor

Upon admission, ask the laboring woman about her preferences:

Which of the following best describes your plan for pain management during labor?

  1. I would like to have an unmedicated birth. Please do not offer me any type of pain medication. If I decide that I want medication for pain, I will ask for it
  2. I want to see how it goes. I would like to tray nonpharmacologic (non-drug) pain management strategies, but I may decide to use pain medications too
  3. I would like to have a small dose of pain medication (narcotic) by injection (shot) or put into my IV (if I have an IV)
  4. I would like to have epidural analgesia

During labor, ask the laboring woman how well she feels she is coping with her contractions. Give her a scale of 0 (coping well) to 10 (not coping well).

Coping Rating/Suggested Nonpharmacologic Nursing Comfort Strategies

0-3 /Coping Well

  • Encourage her –tell her how well she is doing
  • Reassure her that labor is going normally; provide reassuring touch to shoulder or hand
  • Offer to stay with the laboring woman if her labor partner needs a short break.
  • Inform her of options available such as a tub and/or shower.

4-7/Struggling with her contractions

  • If possible provide continuous support; provide reassuring touch to shoulder or hand
  • Reassure her that what she is feeling is normal; give her info on her progress
  • Encourage her – tell her how well she is doing and try the following to help her more:
  • Modify environment – turn down lights, play music (of her choice)
  • Encourage upright positions
  • Encourage rhythmic movements such as: slow dancing, walking, gently bouncing or swaying on birth ball; rocking in a chair
  • Encourage her to try a warm bath or shower
  • Massage (or show her partner how to) shoulders, back, hands, feet, to help her relax
  • Provide hot packs (shoulders, back) or cold packs (back, cool cloth to forehead, neck)
  • Encourage her to vocalize during contractions (I can do it, I can do it)
  • Add aromatherapy (jasmine or lavender scent in bath water, lotion or essential oil on a cotton ball)
  • Is she is experiencing severe back pain: encourage her to try all fours position or pelvic tilts; encourage her to try lunge; do knee press, counterpressure, double hip squeeze; provide hot or cold packs for lower back; offer intradermal water block

8-10/Overwhelmed, unable to cope effectively with her contractions

  • Between contractions, try strategies listed above
  • Reassure her that you will stay with her to help her
  • Reassure her that what she is feeling is normal; acknowledge her pain
  • Have partner, other support person provide counterpressure to back as needed
  • During contractions, use the “panic routine” – position yourself so that you can heave eye to eye contact wither her; with permission, place hands on shoulders or arms; breathe with her to help her establish a rhythm

Knowledge, evidence and skills for normal birth – evidence based care mainstream over the last 5 years. Yet, concerns remain about politics of evidence: hot it is distilled at a national level, how its enacted at a local level and how individual practitioners interpret and apply it. Gender bias affects both choice of research topics and methods chose to research, analyze and synthesize them as well as guideline development. Evidence paradigm’s epidemiological roots spread in Western health has been remarkable since mid 1990s.

Critiques of the evidence paradigm – critics objections and professional role in exercising clinical judgment w patients that their patient is not typical average patient in research studies. Argue that intuitive judgments and hunches were as much a apart of armory for clinical decision making as research knowledge.

Measuring fixed clinical outcomes is insufficient when studying human beings. Research participant’s subjective experience of intervention or treatment must also be examined, as should its impact on significant others. Cochrane Database full of trials where these elements were omitted, though this is changing. “Sometimes what really counts cannot be counted.” Childbirth experience cannot be reduced to simple statistics.

Another weakness in quantitative research is its assumption that population studies are directly applicable to individuals. Clinical trials are selective of their samples and attempt to control for variables that could introduce bias.

Quantitative research is predicated on the attainment of certainty, the principle of of linearity and simplicity, which is a poor fit w multi-factorial causation and effects.

Tentative evidence may be helpful for novice but constricting of the expert. Make best clinical judgment in partnership w women, even if it means going against normative practice.

Qualitative Research – important role in addressing complexities of practice. Has power to explain multi-layered phenomena.

So far evidence has been sourced to research both quantitative and qualitative, clinical experience, women’s preferences, common sense and personal knowing through thinking about practice. Childbirth has been around a long time and therefore it also may be fruitful to examine anthropological sources for evidence (ex: upright position for birth).

Intuition – argue that cesarean rates might come down if OBS and midwives intuit care scenarios better by connecting and listening to women, rather than standing outside a situation of uncertainty to evaluate it objectively. Intuition covers all these contingencies of knowledge for practice highly regarded by midwives and women, yet undervalued and marginalized within conventional evidence paradigm.

Evidence is not a neutral concept – w various interest groups standing to gain or lose from adoption of particular take on evidence. 2 principles late 1980s when Cochrane Database first published: 1) don’t intervene in physiology unless the intervention is known to be more effective than nature 2) ensure the intervention has no side-effects that outweigh the benefit

Models and underpinning tenets of childbirth care – Hippocrates injunction “First, do no harm” person introducing intervention to prove its superiority over what is happening naturally. Management approach is indicative of the values and beliefs underpinning the biomedical model. Institutional birth settings now humanizing birth space and few would say all OBs fully subscribe to a biomedical ethos or that all midwives embrace a social model of care. 3 C’s (continuity, choice, control) official maternity care policy in many countries. Information is a 4th theme that is implicit in good maternity care policy.

Study – Great Expectations – all groups of women want info. Women who approach labor and birth w an optimistic mindset did better than women who had a more fearful, negative attitude. Midwives have window of opportunity antenatally to challenge negative and anxious dispositions to see if women could adopt a more positive outlook.

Informed choice – choices can be limited by providers or deprivation and others constraints may restrict women’s access to those choices available. Not being offered home or birth centre options.

Control has been deconstructed to show a number of interpretations. For many women, control is understood as control over their body’s response to the awesome power of labour or retaining psychological control during labor while their body feels out of control.

Widespread collapse of confidence among low-risk women in ability to do birth without routine interventions. As little as 17% laboring and birthing physiologically. Rise of tocophobia (morbid fear of labor).

Working w evidence sources in relation to research that are circumscribed by setting in which vast majority of inquiry was carried out. Does all this research tell us about physiological birth or about how women’s bodies behave when observed in hospital setting.

Setting for birth also brings into play organizational factors that impinge on evidence. With trend towards increasingly large institutions for birth, brings pressure to childbirth event. Some temporal (time pressure), institutional (constraints/regulation), bureaucratic (power differentials w/in professional groups and between professionals and women). Small scale as optimum model of organization.

Large Scale vs Small Scale

  • Bureaucratic vs Pragmatic
  • Institutional vs Homely
  • Hierarchical vs Non-hierarchical
  • Impersonal vs Personal
  • Formal vs Informal
  • Rigidity vs Flexibility
  • Standardized vs Individualized
  • Control vs Autonomy
  • Throughput vs Input
  • Risk vs Efficacy
  • Organization vs Community
  • Time-bound vs Going w the flow
  • Doing vs Being

Skills and evidence – application of evidence requires nuanced decision making (diagnosing delay in labour), sometimes practical skills (assisting physiological 3rd stage), sometimes psychological skills (assisting woman through labor pain), sometimes technical skills (interpreting CTG) and sometimes procedural skills (urinary catheterization).

Not a lot of research into midwifery decision making. Web of overlapping factors such as setting, perception of risk, professional paternalism, and bureaucratic and rule-based approaches. In spite of midwifery’s woman-centered ethos, there is little empirical evidence of a shared decision-making model in practice, except in caseload midwifery literature.

Practical skills for supporting normal birth can be as much about unlearning, sitting on one’s hands and literally doing nothing. Upright birth positions, assisting physiological 3rd stage and attending Waterbirth may mean doing less rather than doing more.

Conclusion – evidence-based care has been around long enough now to have passed through a honeymoon period and has matured as a concept. Form its original orthodoxy emphasizing the research base of a variety of interventions, there is a substantial body of evidence around normal birth now available for implementation. Providers beginning to structure care to maximize the utilization of this body of evidence.

Potential to rehabilitate physiological birth not only as possible, but desirable for the vast majority of this generation of women. Evidence that springs from intuitive, experimental and anthropological origins as wells a research has the power to reconnect us to the transformative nature of this ancient rite-of-passage event. And then not only individual women but families, communities and even nations will benefit.

  1. BRAN: Benefits, Risks, Alternatives, Next Steps

BRAN – Benefits– problem were trying to identify/prevent/fix; how is it done; how likely is it to work, Risks – possible risks/side effects for baby/me. Other tradeoffs/disadvantages such as additional procedures or precautions; cost, Alternatives-other options available; other procedures that may work; delay treatment or choose not to; risks and benefits of alternatives and effectiveness (low risk options sometimes less effective), Next Steps– if it solves problem, what can we do after; if it doesn’t, what after?

  1. Two models of maternity care
  2. Physiological model (Social model) 
  • Whole person –physiology, psychosocial, spiritual
  • Respect and empower
  • Relational/subjective
  • Environment central
  • Anticipate normality
  • Technology as servant
  • Celebrate difference
  • Intuition/meaning-making
  • Self-actualization
  1. Medical model (biomedical model) 
- ESNLB Ch 1
  • Reductionism – powers, passages, passenger
  • Control and manage
  • Expertise/objective
  • Environment peripheral
  • Anticipate pathology
  • Technology as partner
  • Homogenization
  • Quantitative research/objective facts
  • Safety

III. Evidence-based care is a broad term that demands evaluation of types of studies and experiences.

Evidence-Based Practice in Perinatal Care – before mid 1970s, OB care was based on authority and/or opinion. In latter part of 20th century, clinicians began questioning this at the same time women demanded a voice in their own maternity care. Principle of evidence-based care is now widely accepted.

Although human lactating mammary glands use more energy (30%) than the brain (23%), there is no medical specialty related to their normal function. Only 1 profession specializes – IBCLC.

Informed Consent – requires that medical providers provide patient w all relevant info about a proposed procedure prior to obtaining consent. 4 items of info must be provided: nature of procedure, risks, benefits, availability of alternatives (including no treatment) and risks/benefits. Complicated because 1 of patients is a fetus who cannot understand/give consent.

What Evidence Really Counts? Major gaps exist in research linking birth practices to breastfeeding outcomes, and much of it often old, flawed or only partly relevant.

Analyzed 362 federally funded research projects on infant nutrition, breastfeeding or lactation awarded ~40MM over 3 years. Only 13.7% (5.6MM) went to research for increasing incidence and duration of breastfeeding. 7.5% funded projects using human milk to improve artificial feeding products (infant formula) and develop new pharmaceuticals. Preventative care often more poorly funded than latest cures. Private funders and few corporations directly benefit in short term when more babies breastfed.

Most credible research on healthcare outcomes derives from randomized, controlled, double-blind clinical trials. In randomized studies, subjects have been chose in a statistically random manner from a defined population, without any bias. Controlled studies use samples of subjects who are studies w a new approach or intervention; they are matched w a sample of similar subjects from same population who we be used in control group.

Studies considered stronger if subjects blinded – don’t know who is receiving info and who is not. Even stronger are double blinded studies when neither subject nor research knows who is getting intervention and who is the control.

Cochrane Pregnancy and Childbirth Database – most significant contribute to evidence-based approach to perinatal care has been a projects started by Iain Chalmers and other colleagues who began to organize a register of controlled clinical trials. Rigorous criteria were utilized for acceptance of research into this register. In addition to published clinical research, in early years or establishing database, more than 40k OBs in 18 countries were polled for unpublished data that might be considered as protocols for care. This effort produced Effective Care in Pregnancy and Childbirth in 1989, in which standards for perinatal care were supported by rigorous research.

Shortly thereafter, other user-friendly sources for similar info became available. A Guide to Effective Care in Pregnancy and Childbirth summarizes the analysis of the clinical trials into a format that readily provides guidance for perinatal care. Its available for free through Childbirth Connection. Cochrane Library is an electronic database established for general reference in 2995 and is regularly updated. Reviews are systematic, up to date summaries that constitute reliable evidence of the benefits and risks of health care and are intended to help policy makers and clinicians make sound practical decisions. Data are often combined statistically (with meta-analysis) to increase the power for the findings of numerous studies that are too small to produce reliable results individually.

WHO Reproductive Health Library – WHO has utilized Cochrane database to provide healthcare planners and clinicians in developing countries with the most current info on reproductive health care. The WHO’s Reproductive Health Library (RHL) is updated regularly with Cochrane reviews and corresponding commentaries. They are grouped by topic and commentary is provided on evidence of provider and user satisfaction and on feasibility and effectiveness of the practice in different settings. Categorizes 6 levels of evidence, based on the rigor of studies:

  1. Beneficial forms of care
  2. Forms of care likely to be beneficial
  3. Forms of care w a trade-off
  4. Forms of care of unknown effectiveness
  5. Forms of care likely to be ineffective
  6. Forms of care likely to be harmful

Box 2-1 Examples of Practices Categorized by Level of Evidence, from WHO RHL No.5 2002

  1. Beneficial forms of care:
    1. External cephalic version at term reduces breech delivery and cesarean section rates
    2. Social support during labor in busy, technology oriented settings reduces need for pain relief and associated w positive labor experience
  2. Forms of care likely to be beneficial:
    1. Social support during labor in busy, technology oriented settings could lower cesarean rates, number of infants w low Apgar scores (<7 at 5 min) and duration of labor
    2. Kangaroo-mother care skin to skin in low birth weight infants associated w reduced likelihood of illness at 6 months and exclusive breastfeeding at discharge from hospital
  3. Forms of care w a trade-off:
    1. When compared to intermittent auscultation of heart rate, routine electron fetal heart rate monitoring during labor associated w fewer neonatal seizures, similar long-term infant outcome but increased cesarean rates
    2. IM prostaglandins are effective in reducing blood loss in 3rd stage of labor but satisfy uncertain and costs prohibitive in under-resourced settings
  4. Forms of care of unknown effectiveness:
    1. Using postural (position) maneuvers to convert breech to vertex presentation unknown
    2. Effectiveness of kangaroo care in reducing neonatal and infant mortality and exclusive breastfeeding at 1 or 6 months unknown
  5. Forms of care likely to be ineffective:
    1. Early amniotomy (breaking of bag of waters) during labor in reducing cesarean rates
    2. Routine EFM during labor for low risk pregnancies
    3. Routine intubation at birth in vigorous term meconium-stained babies to prevent meconium aspiration syndrome
  6. Forms of care likely to be harmful:
    1. Policy of routine episiotomy to prevent perineal/vaginal tears compared to restricted use
    2. Forceps extraction instead of vacuum extraction for assisted vaginal delivery when both applicable is associated w increased incidence of trauma to maternal genital tract

Other Resources for Evidence-Based Maternity Care – A Guide to Effective Care in Pregnancy and Childbirth – 50 chapters and >500 pgs wealth of recommendations on perinatal care.

Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors presents practice standards for facility-based clinicians in resource poor settings and countries.

National Quality Forum (NQF)- non for profit org created to develop and implement national strategy for healthcare quality measurement and reporting. Issued its National Voluntary Consensus Standard for Perinatal Care in Oct 08 – intended to be used to assess and public report on safety and quality of care issues.

Evidence-Based Breastfeeding Practices – 10 Steps to Successful Breastfeeding evolved from research evidence available in 1989 and forms the basis of the UNICEF/WHO Baby-Friendly Hospital Initiative (BFHI). A decade later, Evidence for the Ten Steps to Successful Breastfeeding was published and provided additional and more current evidence for the implementation of the BFHI in maternity facilities. 5 studies noted negative effect on breastfeeding if mom receives labor analgesia, specifically meperidine (Demerol and Pethidine).

Politics of Research – literature searches linking the keywords of birth intervention and breastfeeding reveal scant literature – is gap an oversight or intentional? Dr. Michel Odent comments on 2 types of epidemiological research: circular research and cul-de-sac research. In circular research, studies are repeated and continued beyond the point of reasonable doubt or tendency to test same question again and again. Cul-de-sac research includes research about issues that “Despite the publication of this research in authoritative medical or scientific journals…are shunned by medical community and media.” These studies aren’t replicated.

Odent recognized the importance of protecting the mother from interference during and immediately after childbirth. After retiring, Odent continued writing and speaking about need to humanize birth, most notably in his books The Nature of Birth and Breastfeeding and The Scientification of Love. Although his work is widely read by midwives, natural childbirth activists and family’s seeking nonmedicalized childbirth, it has not been mainstreamed into modern obstetric or pediatric textbooks. Perhaps linking birth and breastfeeding is politically incorrect.

Oxytocin, “The Love Hormone”- Some of the most instructive research of childbirth and lactation was done nearly half a century ago, preceding the natural childbirth awakening and the resurgence of breastfeeding. Psychologist Niles Newton and her OB spouse Michael Newton identified and wrote about the psycho-physiologic aspects of lactation, stressing the interrelationship between a mother’s sense of well0being and her subsequent breastfeeding success.

In pioneering research spanning from 1948-1979, the Newtons published widely on the subject, drawing their conclusions first from animal studies documenting that cows will not let down their milk easily when a cat is put on their backs or they are given injections of adrenaline. Then reproduced for human lactation w herself. They showed that noxious stimuli such as immersion of feet in water, painful toe pulling or math calculations with electric shock after wrong answers would inhibit breastmilk ejection. They also linked milk ejection to plasma oxytocin levels.

He continued to examine the reproductive hormone oxytocin and its role in coitus, labor, delivery and lactation, proposing that all reproductive events share at least 3 characteristics: sensitive to environmental stimuli, being easily inhibited in their easily stages and they all trigger caretaking.

He suggestion that inhibition of milk let-down or milk ejection reflex was built into mammalian psychophysiology as a safeguard from milk stealing.   Oxytocin secretion can be inhibited by adrenaline or the fight or flight reaction if danger approaches. He theorized that oxytocin secretion could be protected by a negative feedback system that would 1) block the trancelike state that occurs during deep sexual arousal 2) stop the progress of labor until safer surroundings are found or 3) inhibit milk let-down until mom and baby can safely feed.

Dr. Kerstin Uvnas-Moberg expanded early research in The Oxytocin Factor.

Technology: Overuse and Underuse: although lack of medicines and equipment is a serious situation, privacy, respectful care and family support can be provided cheaply and in most settings. WHO, UNICEF and ILCA and Emergency Nutrition Network has published guidelines for assisting and supporting pregnant and laboring women and breastfeeding moms in emergencies and extraordinary circumstances.

Listening to Mothers Surveys conducted by Harris Interactive in 2002 and 2006 shows that mothers wishes and best practices are still be ing ignored, undermined and/or discounted. 2002 survey reported 40% of newborn in moms arms in 1st hr after birth and by 2006, it decreased to 38%, despite 3 decades of sound research supporting immediate skin to skin after birth.

Figure 2-1 Practice framework for maternity practitioners. In the center of core there is evidence-based practice (where it exists), which should be used. In the next ring is theory-based practice, practices commonly done or w a basis in general understanding of biology, but no corroborating research as yet. 3rd ring contains what is being done w/out any careful analysis, yet continues as practice bc “it works” or someone else says it works. Also in outer ring are new ideas or experiments in process. As more research is developed, any given practice in the outer or middle ring can move toward the center. If it moves to the core, we should incorporate it, and if it is proved ineffective or harmful we should discontinue it.

Breaking Through the Cul-de-Sac – 5 practices of the 2006 revised and expanded BFHI module Mother-Friendly Care are well-supported by solid evidence. Allowing mom to have companions of her choice, eating and drinking ad lib, moving about freely during labor and birth, avoiding nonmedically necessary procedures, and using nondrug pain relief methods in addition to, instead of, or prior to chemical pain relief methods are not costly interventions; in fact, most have been shown to reduce the overall costs of providing maternity care.

Lamaze International has 6 well-referenced “Six Care Practices That Support Normal Birth”:

  1. Labor begins on its own
  2. Freedom of movement throughout labor
  3. Continuous labor support
  4. No routine interventions
  5. Spontaneous pushing in upright or gravity-neutral positions
  6. No separation of mom and baby after birth, with unlimited opportunities for breastfeeding

Interventions Can Cascade – as they attempt to initiate breastfeeding. Inductions for non-compelling reasons triggers harder, closer contractions and usually a less-mature baby. lack of continuous support in labor, esp among young 1st time moms, can create poor coping behavior, exacerbate anxiety and pain and slow labor progress. Slowed labor may necessitate augmentation with IV oxytocin to bring stronger, more regular contractions and may require woman to be confined to bed with decrease in ability to walk or even to change positions. In most settings, oxytocin drip protocols often require continuous EFM, thus further limiting woman’s movements. With strengthened contractions, mother may become more anxious and pain may increase, leading to a need for pain medications. Narcotic analgesia can lead to slowed and/or dysfunctional labor and thus, ironically, the oxytocin dose must be increased to further strengthen labor. Labor medications affects newborns ability to suck, swallow and breathe normally to initiate breastfeeding. Regional/spinal epidural anesthesia for pain relief in labor is linked to higher rates of instrumental and surgical deliveries; some studies associate these interventions with breastfeeding difficulties. Withholding fluids and calorie support to laboring woman “in case” she might need a cesarean contributes to ketoacidosis (Breakdown of mom’s fat stores), which hinders labor progress and stresses baby further.

One intervention usually leads to more. If oxytocin and its related interventions to not move labor along at the prescribed rate (in some settings this is based on the partograph, an international labor guide that mandates a cm dilation per hr), then cesarean may be done. Or, if mother is in 2nd stage of labor, forceps or vacuum extraction devices may be used.

The cascade continues. Long, difficult and/or assisted labors are linked to breastfeeding difficulties in mom and infant. If an assisted or surgical delivery was performed for fetal distress, baby may not be in a condition for early initiation of breastfeeding. If it was an assisted or surgical delivery for obstructed labor (failure to progress), mom may be exhausted, under influence of labor and/or surgical anesthesia, in pain or all 3. Frequently both mom and baby will be separated after birth. Even when both mom and baby are fine, newborn procedures are often performed immediately after delivery, thus interfering with uninterrupted skin-to-skin.

Fig 2-2 The number of Baby-Friendly steps in place predicts risk of breastfeeding cessation. (Steps measured: early bf initiation; exclusive breastfeeding; rooming-in; on-demand feedings; no pacifiers)

Research Gaps Still Exist – To reach WHO/UNICEF Global Strategy recommendation of 6 months of exclusive breastfeeding, one must first achieve 6 days of exclusive breastfeeding. If mother is unwilling/unable to hold baby skin to skin for many hours a day; if breasts do not initiate lactation normally; and/or if baby unable to feed effectively and comfortable, then normal course of breastfeeding undermined.

Summary Points for Evidence-Based Practice In Perinatal Care:

  • Major gaps exist in current research w impact of childbirth practices on breastfeeding
  • Randomized controlled clinical trials are not ethically possible for many childbirth interventions. Other valid measures of evaluating childbirth and breastfeeding outcomes are reasonable and possible
  • Existing evidence-based care practices are not yet uniformly implemented in maternity settings.

MWHC Pg 10-11 (Ch 1) The Future of Nursing – committee developed 4 key messages: 1) nurses practice to full extent of education 2) nurses higher levels of education through improved education system 3) nurses full partners w physicians 4) effective workforce planning with better data collection and info infrastructure

Trends in Nursing Practice – specialized knowledge through experience, advanced degrees and certification programs. Nurses in advanced practice (nurse practitioners and nurse-midwives) may provide primary care throughout woman’s life, including pregnancy.

Nursing Interventions Classification – examples of interventions for childbearing care to assist in preparation for childbirth before, during and after include breastfeeding assistance, childbirth prep, circumcision care, EFM, family planning and kangaroo care

Evidence-Based Practice – providing care based on evidence gained through research and clinical trials – is increasingly emphasized. AWHONN includes evidence based approach to practice.

Evidence Based Practice – literature may reveal up to 3 levels of evidence. First level consists of primary studies. Strongest are randomized controlled trials. Well-designed studies, even small ones, add another piece to the puzzle.

Primary studies may be combined into 2nd level – systematic analyses such as those in Cochrane Database, research uses methodology to identify all studies relevant to a particular question. If data similar enough, can be pooled into metaanalysis. If evidence strong, analyses will form basis for recommendations for practice.

At tertiary level, professional orgs such as AHRQ or NGC may decide to address a broad practice by sorting through all available primary and secondary evidence. Then crafts consensus statement. Carry enormous authority. Ex is AWHONN Late Preterm Initiative. Most orgs make guidelines available free of charge on their websites.

QSEN expert panel identified 6 competencies necessary to enable new nurse to continually improve health care system: client-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety and informatics.

Cochrane Pregnancy and Childbirth Database – first planned in 19176 with small grant from WHO to Dr. Iain Chalmers and colleagues at Oxford. Formed in 1993 and Oxford Database of Perinatal Trials became known as Cochrane Pregnancy and Childbirth Database. It oversees up to date, systematic reviews of randomized controlled trials of health care and disseminates these reviews. These type of studies provide the most reliable evidence about effects of care. Studies ranked in 6 categories:

  1. Beneficial forms of care
  2. Forms of care likely to be beneficial
  3. Forms of care w trade-off between beneficial and adverse effects
  4. Forms of care w unknown effectiveness
  5. Forms of care unlikely to be beneficial
  6. Forms of care likely to be ineffective or harmful

Joanna Briggs Institute – est in 1996 as initiative of Royal Adelaide Hospital and University of Adelaide in Australia, it uses a collaborative approach for evaluating evidence from a range of sources. Uses following grades of recommendation for evidence of feasibility, appropriateness, meaningfulness, and effectiveness: A, strong support that merits application; B – moderate support that warrants consideration of application and C – not supported.

Outcomes-Oriented Practice – measures effectiveness of care against benchmarks or standards. “Did client benefit or not from care provided?. Scale for Breastfeeding Establishment: infant ranges from Not Adequate to Totally Adequate. Indicators include proper alignment and latching, proper areolar grasp and compression, correct suck and tongue placement and audible swallowing. Can determine whether infant met desired outcome of ingesting adequate nutrition.

  1. Types of research studies


Types of Research StudiesStrongest to Weakest

  • Systematic reviews
    • Focus on 1 question or clinical issues; authors find all relevant studies on question/issue, assess each study, synthesize findings and present balanced and impartial summary
  • Meta-analysis
    • Statistical technique for combining results form 2+ independent studies; most often used to assess clinical effectiveness of healthcare info.
  • Randomized controlled trials (RCTs)
    • Patients are allocated by chance alone (randomly to receive one of several clinical interventions. One of these interventions is the standard of comparison, or control. The control is sometimes no intervention at all, or sometimes it is usual care. They compare outcomes after participants receive intervention. Its considered the gold standard of research.
    • A blind RCT means participants do not know which intervention they receive; double blind means researchers documenting outcomes don’t know either until the end of the study.
    • Its not always most appropriate type of study to evaluate maternity care. Would not be ethical to randomize women to a cesarean surgery and women who would agree to be randomized wouldn’t be representative of all childbearing women. Often a great deal of crossover between 2 arms of study which can invalidate results; in most epidural studies, if women in narcotic groups asks for a epidural, it would not be considered ethical to refuse her.
    • Cohort studies better to analyze maternity care, esp when 1 wants to compare physiological labor and birth (not an intervention) with a particular intervention.
    • See ch 2 “Why this book? Failure of Obstetric Research” in Optimal Care in Childbirth
  • Cohort studies
    • Patients who presently have a certain condition and/or receive a particular treatment are followed over time and compared with another group who are not affected by the condition under investigation. Useful for areas in which it would be considered unethical to randomly assign people. Unethical to assign newborns to breastfeeding or formula.
    • May be other differences between groups – over time, researchers usually lose contact with some study participants. Expensive because they take a long time
    • Can be either retrospective (looking back in time) or prospective (looking forward).
    • Data collected in present to establish risk f developing disease/condition if exposed to a particular risk factor.
  • Case-control studies
    • Epidemiological studies used to identify factors that may contribute to a medical condition by comparing patients who have condition with patients who do not.
    • One of most famous was demonstration of link between tobacco smoking and lung cancer. Disadvantage is statistical relationship does not implicate causal relationship. Lung cancer rates higher for those without college degree but doesn’t mean you can go to college to reduce risk.
  • Case series
    • Small group of patients receive a certain treatment or develop a certain condition.
    • Big disadvantage is no control group
  • Case reports
    • Report of a single patient who experiences an unusual reaction or condition. Often fascinating to read and sometimes first step in identifying new risk factor for intervention or condition
  • Expert opinion and consensus
    • No firm medical evidence that addresses issue at hand or authors have chosen to rely on their own knowledge and experience rather than what medical evidence is available

Levels of Evidence in ACOG Practice Bulletins:

  • Level A refers to recommendation based on good and consistent scientific evidence
  • Level B refers to recommendation based on limited or inconsistent scientific evidence
  • Level C based primarily on consensus and expert opinion
  • 23% Level A; 35% Level B and 42% Level C from 98-04

*Terms systematic review and meta-analysis are sometimes used interchangeable. Reliability of conclusion is only as good as the quality of the independent studies that comprise the review or meta-analysis. Cochrane Library is one of the most respected sources for systematic reviews.

National Standards for Evidence-Based Care – Joint Commission – organization which accredits hospitals and other healthcare organizations in the U.S. exerts a powerful influence on hospital policies and protocols. It strongly supports patient’s right to full evidence-based info about her care. Pg III-16 see guidelines published for physicians for Informed Consent and two sample cards.

Ideal time to provide info is childbirth classes. Handout on pg III-19-22.

It relies on organizations such as the National Quality Forum (NQF) to help establish standards, who is among the best known and most respected national organizations seeking to improve American healthcare.

May be helpful for childbirth educators to become familiar with perinatal standards endorsed by NQF. Oct 08 – NQF endorsed 17 perinatal standards to measure and thereby increase care received by mothers and babies during 3rd trimester through hospital discharge. Joint Commission added new set of “Perinatal Care” core measures which became required as of 1/1/14 for hospitals with more than 1100 births/yr. They included elective delivery prior to 39 weeks, cesarean rate for low risk first birth women and exclusive breastfeeding as hospital discharge. Since now will be reporting, they need to develop protocols to improve numbers.

Handouts for students:

Must watch film for all birth advocates – MicroBirth – as incidence of non-communicable diseases has skyrocketed, scientists are looking at consequences of increased birth technology, esp cesarean, as important cause. Shows research about optimal development of baby’s immune system (and genome) through microbial seeding during normal, vaginal birth, skin to skin and breastfeeding.


  1. The Birth
  2. Coalition for Improving Maternity Services (CIMS)
  3. Childbirth
  4. Evidence based Birth
  5. ICEA
  6. Lamaze
  7. One World
  8. Science &


Are birth classes mother friendly questionnaire by CIMS

How Expectant Parents Can Become Savvy Consumers of Health Care Info handout* gives info on important websites, epidurals, cesareans to post to students

  1. Quantitative vs. qualitative research
  2. Weakest to strongest study paradigm
  1. The Cochrane Library

  1. Websites to keep the educator up to date

Key Websites to Keep You Up-to-Date

  • – look for new releases, position statements and professional guidelines
  • -supporting presentation with quotes/recommendations
  • – U.S. gov sponsored website w comprehensive evidence-based reports
  • BMJ- – search topics, receive email alerts or articles
  • Childbirth – important research and publishes critiques of childbirth news
  • Cochrane
  • Google – search for birth; will sometimes get news stories about just-released research
  • Healthy Mothers, Healthy Babies – sign up on home page to receive weekly newsletter – Monday Morning Memo
  • – select ob-gyn & women’s health. Search by topic or scroll to bottom of page to request RSS list of current stories
  • – choose pregnancy & childbirth under health & medicine.
  • Google blog search
  • Robin Weiss, Birth author and web host; blogs about birth and breastfeeding issues and news
  • The Family – authors Debby Amis and Jeanne Green blog about a variety of topics of interest to childbirth educators, indlcuidng research updates, books and media reviews, teaching tips and more
  • – ICEA leaders blog about variety of topics of interest to childbirth educators, including research updates, book and media reviews, teaching tips and more
  • Lamaze International –
  • Science & – Lamaze experts blog about research related to healthy pregnancy, birth and beyond
  • Giving Birth with Confidence – – real women sharing stories, finding answers, and supporting each other
  • Teri Shilling, Passion for – trainer and creator of the Idea Box, she blogs about a variety of topics including book and medida reviews, teaching tips, items in the news and more
  • Twitter – social networking site – ICEA, March of Dimes, Lamaze and Family Way often post links to news stories and other items of interest. Teri Shilling
  • Facebook – The Family Way

Childbirth Websites

  1. Academy of Certified Birth Educators
  2. American Academy of Husband-Coached Childbirth
  3. Birth Survey (Transparency in Maternity Care Project)
  4. Birthing From Within
  5. Birthworks
  6. Childbirth Connection
  7. Childbirth and Postpartum Professional Organization (CAPPA)
  8. Coalition for Improving Maternity Services (CIMS)
  9. Waterbirth International
  10. International Childbirth Education Association (ICEA)
  11. Lamaze International ( for consumers;
  12. National Childbirth Trust –
  13. DONA International
  14. BirthEssential –
  15. Birth & Life Bookstore –
  16. Childbirth Graphics
  17. Cutting Edge Press
  18. Family Way Production
  19. Mama Goddess Birth Shop
  20. Noodle Soup
  21. International Board of Lactation Consultant Examiners
  22. International Lactation Consultants Association (ILCA)
  23. La Leche League
  24. United Nations Children’s Fund (UNICEF for WHO Code)
  25. S. Breastfeeding Committee
  26. American Academy of Pediatrics
  27. American College of Nurse Midwives
  28. American Congress of Obstetricians & Gynecologists
  29. American Nurses Association
  30. Association for Pre and Perinatal Psychology and Health
  31. Association of Women’s Health, Obstetric & Neonatal Nurses
  32. Midwives Alliance of North America (MANA)
  33. The Cochrane Library (subscription)
  34. Evidence Based Birth
  35. Journal Watch – Women’s Health (subscription)
  36. Medline (free)
  37. Medcape- Women’s Health (free)-
  38. National Center for Health Statistics
  39. PubMed (free)
  40. Science and Sensibility-
  41. American Journal of Obstetrics & Gynecology
  42. American Journal of Public Health
  43. Birth: Issue in Perinatal Care
  44. Journal of Midwifery & Women’s Health
  45. Journal of Perinatal & Neonatal Nursing
  46. Journal of Obstetric, Gynecologic and Neonatal Nursing
  47. Journal of Perinatal Education
  48. Journal of Prenatal and Perinatal Psychology and Health
  49. Journal of Psychosomatic Obstetrics & Gynecology
  50. Journal of The American Medical Association (JAMA)
  51. International Journal of Childbirth Education
  52. MCN- The American Journal of Maternal/Child Nursing
  • New England Journal of Medicine
  • Birth Survey (Transparency in Maternity Care Project)
  • Nursing for Women’s Health (AWHONN)
  • Obstetrics & Gynecology – The Green Journal
  • Pediatrics – Journal of the American Academy of Pediatrics
  1. International and national guidelines regarding care in normal birth

International and National Guidelines for normal, low risk pregnant women

  • Cochrane Library Most Recent Reviews or A Guide to Effective Care in Pregnancy & Childbirth (00)
  • William’s Obstetrics 2010 (Policies at Parkland Memorial Hospital)
  • Baby-Friendly Hospital Initiative 2009
  • CIMS
  • ACOG
  • Canadian Professional Birth Related Organizations

Position & Movement:

  • “… clean and important evidence that walking and upright positions in the 1st stage of labor reduces the duration of labour, the risk of cesarean the need for epidural…”
  • “We give women without complications the option of electing either recumbency or supervised ambulation during labor”
  • “offers all birthing mothers: freedom to walk, move about, and assume the positions of her choice during labor and birth…”
  • “provides the birthing woman with the freedom to walk, move around, and assume the positions of her choice”
  • “if you feel like it and your health care provider says its OK, walk the halls”
  • “The SOGC and its partners providing maternity health care recommend freedom of movement throughout labor”

Elective Induction:

  • “the decision to bring pregnancy to an end before the spontaneous onset of labor is one of the most drastic ways of intervening in the natural process of pregnancy and childbirth. There has been very little methodologically sound research on the indication for elective delivery…”
  • No elective inductions – “we consider 41 week pregnancies without other complications to be normal. Thus, no interventions are practiced solely on fetal age until 42 completed weeks”
  • “…has an induction rate of 10% or less”
  • “has rate of 10% or less for induction and augmentation (presently under review)
  • “in cases in which continuing the pregnancy is more risky than delivering the baby, the health care provider might induce labor. The risks depend on method chosen and include change in fetal heart rate, increased risk of infection in the woman and her baby, umbilical cord problems, overstimulation of the uterus and uterine rupture (rarely)
  • ‘ The SOGC and its partners providing maternity health care recommend spontaneous onset of labor”

Fetal Monitoring:

  • “regular auscultation by a personal attendant, as used in the randomized trials, therefore seems to be the policy of choice for these (low-risk, without induction or augmentation) labors”
  • “intermittent auscultation or continuous electronic monitoring is considered an acceptable method of intrapartum surveillance in both low and high risk pregnancies”
  • “does not employ practices and procedures that are unsupported by scientific evidence, including but not limited to the following…EFM”
  • ‘ does not employ practices and procedures that are unsupported by scientific evidence, including but not limited to the following: ECM”
  • according to ACOG practice bulletin #106 “given that the available date do not show a clear benefit for the use of EFM over intermittent auscultation, either option is acceptable in a patient without complications”
  • recommend use of fetal surveillance by intermittent auscultation

Foods & Fluids:

  • “since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labor for women at low risk of complications”
  • “food should be withheld during active labor and delivery…according to AAP and ACOG, sips of clear liquids, occasional ice chips and lip moisturizers are permitted”
  • “does not employ practices and procedures that are unsupported by scientific evidence, including…withholding nourishment”
  • “does not employ practices and procedures that are unsupported by scientific evidence including withholding nourishment
  • “according to ACOG committee opinion, modest amounts of clear liquids may be allowed for patients with uncomplicated labor. Women scheduled for a cesarean may drink clear liquids up to 2 hrs before anesthesia
  • “no routine interventions”

Labor Support

  • “continuous support during labor has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labor and birth”
  • “parkland policy: 2 support persons allowed
  • “”offers all birthing mothers: unrestricted access to the birth companions of her choice ,including fathers, partners, children, family members, and friends AND support from a doula”
  • “unrestricted access to the birth companions of her choice, including fathers, partners, children, family members and friends AND support from a skilled woman, for example, a doula
  • “another issue to think about is whom you’d like at your side during labor and delivery. It’s a good idea to choose someone who may be best at helping you stay relaxed and calm. A childbirth partner can be a spouse, partner, relative, or close friend. A growing trend is the sue of a doula, a layperson who has received special training in labor support and childbirth
  • recommend continuous labor support

Pain Management

  • “there is some evidence to suggest that immersion in water, relaxation, acupuncture, massage and local anesthetic nerve blocks or non-opioid drugs may improve management of labor pain, with few adverse effects” epidural analgesia provides effective pain relief but at the cost of increased instrumental vaginal birth
  • parkland policy: nurse-midwives utilize a variety of physical comfort measures as well as emotional support in addition to narcotics and epidural anesthesia. No showers or baths available.
  • “educates staff in non drug methods of pain relief and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication”
  • “educates staff in non-drug methods of pain relief and do not promote the use of analgesic an anesthetic drugs not specifically required to correct a complication”
  • “in addition to pharmacological pain management, also recommended: breathing and relaxation techniques taught in childbirth classes, counterpressure, focal point, comfort and support from your labor coach and ice chips and hard candies
  • “institutions offering options for pharmacologic and non pharmacologic approaches to pain relief (such as tubs/showers, access to natural light, environmental designs/adaptations…”

Second stage

  • “routine directed pushing, sustained bearing down and breath holding UNLIKELY to be beneficial; lithotomy & supine positions harmful/ineffective
  • “in most cases, bearing down is reflexive and spontaneous during 2nd stage labor. Delivery can be accomplished with the mother in a variety of positions…”
  • no statement
  • no statement
  • “many women give birth to their babies while propped up in bed, with their legs braced against foot rests. There are other birth positions you can try (lying on your side, for instance) as long as your health care provider approves”
  • “spontaneous pushing in the woman’s preferred positions


  • restricted (As needed) episiotomy policies appeared to give a number of benefits compared with using routine episiotomy
  • “most, including us, advocate individualization and do not routinely perform episiotomy
  • “has an episiotomy rate of 20% or less”
  • “has an episiotomy rate of 20% or less, with a goal of 5%”
  • according to a march 2000 news release, ACOG does not recommend routine episiotomies. This recommendation was reaffirmed in 2006 press release
  • no routine interventions
  1. Teaching techniques
Discussions of differences in caregivers’ routines

Spirals or blocks? Beneficial to teach small doses and repeat frequently rather than to teach all about anatomy, exercises in one, labor support in another etc. Spiral curriculum so those who miss a class don’t miss whole subject. Progress from general to specific and each week build on info taught in previous week.

Spiraling by topics

Stages and phases of labor: Cover labor onset to birth each week

  1. Overview physical and emotional aspects of textbook labor from onset to birth
  2. Present variety of normal labor patterns with physical and emotional challenges of each variation
  3. Discuss baby’s trip through pelvis and birth canal related to coping skills and labor support
  4. Show DVDs/video clips (any or every week) that show realistic appearance of laboring women – their emotions, coping skills and support throughout labor
  5. Describe various scenarios of labor in a rehearsal
  6. Relax with a birth visualization of flow of labor

Relaxation: Teach new techniques, building on previous skills, each week

  1. Progressive relaxation, relaxing words and images
  2. Release to touch; massage
  3. Selective relaxation (neuromuscular control); autogenic phrases
  4. Visual imagery
  5. Combining it all and designing your own teamwork
  6. Hear what worked for others and practice it all

Breathing: Teach, review and build on breathing strategies each week

  1. Awareness of own breathing – nose, mouth; chest, abdomen, depth, rate
  2. Slow breathing with various techniques – counting, colors, images
  3. Practice various rates and strategies – counting, colors, images, patterns
  4. Second stage breathing: discuss spontaneous and directed pushing
  5. Put it all together in labor rehearsal
  6. See what other couples used and brainstorm own “creations”

Exercises: Just pick a few favorites and repeat variations of them each week

  1. Kegel, calf stretch, pelvic tilt, wall squat
  2. Passive pelvic tuck, extended Kegel, position for rotating breech
  3. Wall stretch – contracting and isolating abdominals, pelvic floor, thighs, buttocks, to prepare for pushing awareness
  4. Kegel, pelvic tilt, squat, as they relate to pushing
  5. Pelvic rock on hands and knees for comfort both during pregnancy and labor
  6. How all above should be done postpartum

Support: Teach labor partner to build on skills taught in previous class

  1. Hawthorne effect; observing tension and how she relaxes; emotions to expect in various phases of labor
  2. Support techniques for very long to very short labor pattern; tune into environment; learn effective touch for pregnant woman. Discuss role of doula
  3. Sensory stimulation (goody bag supplies); pressure and touch in relation to baby’s positioning in pelvis
  4. What to do if she panics; partners role in pushing – adapting positions, modeling quiet encouragement
  5. Relaxing visualization, to include partner
  6. Listen to suggestions from returning couples; partner’s support role in postpartum, with new baby, breastfeeding etc

Baby: Keep focus on baby throughout entire course

  1. Presentations, movements felt/counted
  2. Discuss 4 Ps = passenger, passageway, power, psyche; integrate with labor pattern variations; emphasizing baby’s labor
  3. Baby’s role in labor onset; baby’s trip through pelvis
  4. Baby’s reaction to birth environment in DVDs
  5. Happenings at birth – cord, circulation change, color, Apgar, appearance; normal newborn characteristics, the new family
  6. Reality check: seeing real babies at reunion or on a tour

Positioning: Comfort Positions for Pregnancy & Labor (workbook pgs 20-23)

  • Teach comfort positions in the first hour of your first class, so students will know you are going to teach them something they can use! They can bring own pillows. Birth balls. Show pictures and assign a position to each couple to try. Can use as model and show variations. Divide into groups and each group has to position one person in a comfortable position. Present to class. Position posters on wall and move from station to station, duplicating positions in ways they find comfortable.
  • Spiraling positions into each class: Positions for sleeping/relieve aches of pregnancy. Breathing awareness in various positions. Massage, touch, stroking to each position. Rationale for positioning, in relation to position and descent of baby. Position relating to other sensory stimulation (feet on cold floor; hands pressing on bedrail; vibrating pillow in rocking chair). Advantages of being able to move freely in labor to facilitate birth and relieve pain.
  • Resources: Labor Progress Handbook,
  • DVDs: Comfort measures for labor; Celebrate birth!

See breastfeeding and postpartum below for spiraling ideas

Interactive Teaching Strategies

  • Learning tasks instead of traditional lecture – see Section IV
  • Return demonstration – demonstrate a skill and allow students to do it in return
  • Quizzes, games and role plays– can use Internet at home or work in small groups. Or for their eyes only. Competition between couples/genders.
  • Interactive lecture – involve students in discussion, Q&A session, small group analysis between segments. Lecture alone does not allow for personal interaction of exploring participants’ feelings and attitudes. Involve students in discussion, Q&A sessions, small group analysis etc between segments.
  • Storytelling – discussion follows story. Funny stories provide laughter. Lots of birth stories available. Unfortunately students will share far too many frightening or frustrating stories. Ask them “what could you have done differently to have a more positive outcome?” sharing solutions to potential problems or telling encouraging birth stories can increase women’s confidence in their own ability to give birth. Adapt or create a story to tell a point
  • Bonding with class – when introduce yourself, share your passion with them. Let them know of the importance of birth memories and how you want to help them have the best possible experience to remember. Rehearse. First impression sets class. when you introduce yourself to the class, share your passion with them. Let them know of the importance of birth memories and how you want to help them have the best possible experience to remember. The first impression of a first class is very important to the success of your course. Rehearse your “opening talk”, involving them in your agenda, and sharing your knowledge and skills with them in many and varied ways.
  • Books on interactive teaching: Using brain science to make training stick; design for how people learn; the accelerated learning handbook; from telling to teaching: a dialogue approach to adult learning; creative training techniques handbook; the art of teaching adults

Teaching Strategies

Complete chart to help you determine your priorities and preferred teaching strategies

Rate each 1- 4 from not important to very important; indicate strategies you think would be most effective. Make sure you have selected a variety for all learners:

Possible Strategies: lecture (with or without PowerPoint, storytelling, learning task, large group discussion, small group discussion, brainstorming, problem-solving, values-clarification, games/role play, audiovisuals, demonstration/return demonstration, practice, rehearsal, handouts, homework, other)

Important of Topics/Teaching Strategies

  • Normal labor, birth and postpartum
  • Positioning and movement to facilitate progress and comfort
  • Massage techniques
  • Comfort measures (tub or shower, use of heat, cold, pressure etc)
  • Relaxation skills, including breathing
  • Labor support
  • Communication skills
  • Problems which could occur
  • Analgesia and anesthesia
  • Routine procedures/interventions
  • Cesarean birth
  • Breastfeeding and postpartum
  • Healthy lifestyles
  • Other

Talking the Talk – speaking skills important. Educators frequently asked to speak to peers & other professionals.

  • Prepare – develop your objectives
    • What do you hope to accomplish with your presentation?
    • Do you plan to inform, present facts?
    • Do you plan to persuade, change behavior or attitude?
    • What do you want your students to learn?
    • How will you involved your audience in your presentation?
  • Visualize – imagine yourself in front of your group at your very best
    • How are you dressed? (Be comfortable whether causal or formal)
    • Where are you positioned (lectern, podium, table, chair floor)
    • Will you use a microphone? (If so, do you know how it works?)
    • Think about your natural gestures and good posture
    • Picture yourself without nervous habits
    • Imagine a positive audience response
  • Practice, practice, practice – in all situations
    • Anticipate questions and how you will answer them
    • Practice with your visual aids in a similar room
    • Record and listen to at least 10 min of your talk (can be painful, but do it)
    • Have someone video your practice session or an actual class (can even be more painful, but you will learn a lot)
  • Focus, concentrate, breathe and relax- use these skills you know well
    • Play music you like as you set up the room and check your A-Vs, lights etc
    • Get to your room early enough to relax and focus before participants arrive
    • Concentrate on your introduction – the rest will flow if you have prepared
    • Take a cleansing breathe before you speak
  • Deliver with confidence
    • Use strength of voice and vocal variety
    • Teach to all temperaments, using a variety of teaching techniques
    • Make eye contact with friendly faces first. They will encourage you
    • Move around the room or away from a lectern
    • Use notes rather than a script
    • Enjoy your group
    • Feel passionate about your subject, if possible
    • Be knowledgeable about your subject


For quiet, organized intellectuals, a speaker should be: organized, timely, knowledgeable, trustworthy, thoughtful, intellectual, logical. They prefer discussion with small groups of intellectuals, lecture, research-based studies, slides, handouts, factual videos, homework, research

For relaxed, easygoing mediators, a speaker should be empathetic, nurturing, responsible, happy, intuitive, trustworthy, non-judgmental. They prefer open discussion, games if everyone wins, demo and return demo, videos with positive outcomes

For fun-loving, outgoing talkers, a speaker should be: emotional, creative, intuitive, imaginative, humorous, entertaining, energetic. They prefer discussion of feelings, role play, return demonstration, hands-on, videos of people and feelings, games

For outgoing, hard-working leaders, a speaker should be authoritative, in control, competent, efficient, futuristic, open minded, visionary. They prefer discussions, if they can lead, lecture, debates, analysis, meeting goals and objectives.

Showing the Talk

Visuals, props and music

  1. ‘VACCINATE’ PPs, DVDs, posters, and flip charts
  2. Using childbirth class props: the pelvis, knitted uterus and baby model
  3. Respect the baby prop as a parenting teaching tool

Make sure visual aids enhance and not replace. Models, video clips and toys. Don’t read slides. Keep lights on. VACCINE. Visible – slides high on screen. ACCURATE – verify stats. CLEAR – large, easy to read letters. CONCISE – short and simple. INTERESTING AND INFORMATIVE – color, symbols, pictures, graphs, charts. NEAT – visuals and handouts legible and clean. EFFECTIVE – desired image to emphasize point and increase retention.

Tips for flip charts – write on every other page to prevent marker from bleeding through. Leave a blank page between subjects to serve as topic transition. Use tabs or paper clips on side of pages for ease in flipping to topics. Don’t talk and write at same time unless very good at it. Trace lines or images lightly in pencil, then draw over them with marker. Write notes of points to remember lightly on sides of pages. Always have good markets with you. 1-2 inch letters. Colored stickers (dots in various sizes for bullets). Errors may be corrected by cutting out and pasting a correct version on top.

PowerPoint tips – see above

Using PowerPoint effectively

Need more than bullet points, charts and graphs to be interactive. Images can be used to show a position or exercise, while the instructor or class member demonstrates the proper movement and all students return the demonstration. Slide is visible to all as student experiments. An anatomical drawing appears larger on a screen than on a poster. Wipe in feature allow students to answer questions about an unlabeled drawing, then answers are reinforced when they appear through animation feature. Video clips or music can be embedded on a slide so that you don’t have to involve another piece of equipment. Music can be timed and used for a stretch break or a relaxation sequence. A video can introduce a subject that will be followed by a discussion or learning task. Use slides as a tool to help you keep track, but don’t let them become your entire presentation that your audience could simply read on their own.

For a more engaging presentation, use mostly graphics on your slides. If you use words, use no more than 5-7 words per line in 5-7 lines. Use words or phrases, not sentences. Add graphics to text to make slides more visually appealing. Use bullets, not numbers. Wipe in one bullet at a time to allow for discussion without your audience’s being distracted by reading ahead. Animation may be used sparingly to gain attention and to emphasize a point. Always have a hard copy of your teaching notes with you in case you must give your presentation without electricity or computer!


  • Overuse of animation, such that it becomes a distraction
  • More than 2 typefaces on one slide
  • More than 3 colors per visual (unless it’s a full-color photo)
  • “Data dump” – too much info per slide and too many slides
  • Too much time with lights low
  • Positioning yourself between visual and audience
  • Turning your back on the audience to look at the screen
  • Waving a pen or pointer in the air
  • Bright light left on screen (insert a blank, colored background slide or turn off projector).

Polishing Your Presentation

  • Start on time- greet them as they arrive; begin with icebreaker
  • Convey your presence and confidence with alert, erect posture
  • Tell them what you plan to teach – agenda on board or handout
  • Teach them – interactive participation; involved students in content every 8-10 min. Adults listen with understanding for 60-90 min, but with retention for 20 min or less. Use a variety of teaching techniques
  • Tell them what you taught them – review, summarize, feedback, reaction sheets, evaluation
  • Speaking techniques – if use notes, talk, don’t read; speak loudly for all to hear; vary voice level, pitch and pace to maintain interest; keep pace that will allow most to follow and understand; become aware of speech distractors such as um and ahh – silence is preferable while you think or reflect; enunciate clearly. Don’t mumble. Don’t speak too fast. Use pauses to emphasize points, and help listeners contemplate and reflect message. Be sensitive to audience – read them constantly
  • Use humor – but try to keep it spontaneous and related to content
  • Vary format – whiteboard, slides, models, demonstrations, and discussions. Don’t just talk at group
  • Maintain eye contact w audience – speak to group, not wall, paper or screen. Move eyes from person to person. Do not favor 1 person or location. Avoid looking exasperated, disgusted, or bored, esp when responding to students
  • Maintain interest by moving around with certainty, rather than standing in 1 place
  • Have fun and enjoy yourself!


Communicate, Communicate, Communicate (pg 3 in handbook): Discussion Points: understanding each other as relationship grows, mood swings, heightened emotions. Stereotypes. Some men want to talk and some women want to listen. Communication differences. Communication styles of different personalities/temperaments. Men are from mars, women are from Venus. 5 love languages.

4 Temperaments (Please Understand Me book:)

  • The Artisan: talks of things in present, more than past or future. Tells stories/jokes filled w details. Dramatic/impulsive. Little interest in definitions, hypotheses or theories. Speaks with colorful phrases/current slang.
  • The Guardian: believes in wisdom of past. Learns, remembers, repeats facts. Prefers to discuss facts, not theories. Observes details. Organizes thoughts. Gives warnings and precautions.
  • The Idealist: speaks more of what can be imagined than of what can be observed. Sensitive to hints or mere suggestions. Moves from a few particulars to sweeping generalizations.
  • The Rational: speaks on what can be observed/experienced rather than imagined. Logical to the extreme. Does not state obvious or waste words.

Important for students to know and educator to understand how to speak so all temperaments will listen. Meyers Briggs…

What’s Going on During Pregnancy?

Chart on pg 4 in handbook helps to keep expectant parents focused on development of baby, along with physical and emotional changes they themselves are experiencing. Discussions of pregnancy discomforts, exercise and nutrition can easily tie into the changes noted in the 3 trimesters of pregnancy.

  • Update: Birth Hormones. Childbirth Connection is to publish online Hormonal Physiology of Childbearing by Dr. Sarah Buckley, author of Gentle Birth, Gentle Mothering. Evidence based info on orchestration of labor, birth, breastfeeding and attachment by “Birth hormones” – oxytocin, endorphins, catecholamines, and prolactin. Receptors for oxytocin, endorphins, and prolactin increase throughout pregnancy in preparation for labor, birth and the postpartum period. Believed that prolactin during pregnancy helps pregnant women deal with stress.
  • Small group activity/learning task – if male/female couples, divide by sex into small groups. Give each flip chart and markers. Ask to discuss and record answer on chart – how have you changed during this pregnancy? How has your partner changed during this pregnancy? Make own notes to ensure important parts you wish to make are covered. (Pg 4 in workbook)
  • Guided discussion with visual aids – Emotions During Pregnancy graph pg IV-5. Video teaching fetal growth and development, especially helpful for early pregnant class to relate own physical/emotional experiences to growth/development of baby. Milner Fenwick’s “A Nine Month’s Journey” – short, comprehensive and visually appealing.
  • Books – A Child is Born, Understanding your moods when you’re expecting; In the Womb
  • DVDs: A nine-month journey; in the womb
  • Video Clip: the VisualMD “From conception to birth”
  • Websites – Stress and pregnancy
  • Fetal
  • Emotions During Pregnancy chart – good for PowerPoint slide pg IV-5
    • Ambivalence about pregnancy, acceptance of pregnancy, physical changes, pride (growing bond with baby), mood swings, concern over partner, quickening, fear of injury, feeling unattractive, nightmares, fulfillment, LABOR, numbness, BIRTH (relief, joy)

Emotions During Pregnancy Chart Over Time: highest is labor

Try This for Comfort – pg 5 workbook: When presenting discomforts of pregnancy, try to find positive aspects of what women are experiencing. Focus on growth of baby as a good thing, even if organs must compensate. Convince them body is best place for baby for 9 months. Being uncomfortable an incentive to look forward to labor (but not to induce).

  • Discuss “aches and pains” women experiencing and plot on chart. Include hemorrhoids, constipation, incontinence that may not be brought up.
  • Ask what people have heard or tried for relief of similar discomforts. If they mention an exercise, let class try.
  • Discuss how to prevent discomforts through exercise and nutrition.
  • Lecture/Discussion with Visual Aids: anatomical charts. PowerPoint slides. Pelvic model to discuss pregnant body changes. Reinforce positive aspects – hormones which cause muscles and ligaments to relax may be responsible for heartburn and urine leaks, but will allow birth canal and pelvis to open for birth of baby. Female pelvis differs from males (wider) and more flexible. Baby is protected in pelvis when it is most vulnerable in early months and by amniotic sad throughout pregnancy. Birth Atlas. Pelvic tilt for backache. Calf stretches for leg cramps. Proper posture.
  • Puzzle Page – matching game on pg 113 of handbook for homework
  • Demonstration and Return demonstration – proper posture and body mechanics, pelvic tilt for backache, calf stretches for leg cramps
  • Pregnancy simulation – to reinforce to men what it feels like to carry around extra weight, decreased breathing capacity and experience pressure on bladder, some use Empathy Belly. Can build own by adding weights (Bags of beans, rice etc) to backpack as a dad to be has in on backwards. Use canvas bag with long straps – can put in different shapes and sizes for maternal stores (7 lbs), breasts (2 lbs), body fluids (4 lbs), blood (4 lbs), uterus (2 lbs), baby (7.5 lbs), amniotic fluid (2 lbs), placenta (1.5 lbs)
  • Small group activity/learning task – scenarios pg IV-82. Divide class into 3 groups
  • Game/Quiz – terms may be used in quiz/matching group as in II-1.
    • Term and definition cards can be used as icebreaker. Make separate index cards for term and definition and find match
    • Use anatomy t shirt or PowerPoint slide to point to parts of body
    • Pin them on the body (Velcro) on a poster of growing uterus (such as one of With Child Conception to Birth Charts from Childbirth graphics

Anatomy of Pregnancy

Discussion Points

Health Recommendations flyer pg IV-12 includes exercise 30 min a day, caffeine, fish/mercury, listeriosis, and cesarean increased risk when induced

Nutrition – early pregnancy, this is great topic. Baby’s brain is growing, protein is important, hints for 3rd trimester nutrition can be integrated with snack time, openers, puzzles and quizzes. Beneficial weight gain pg IV-17; pg 9 handbook; Canadian rainbow guide, class to suggest healthy snacks and easy nutritious meal; Healthy Eating Quiz pg IV-15. Bring snack of a particular nutrient to share with class or for show and tell; research on what to bring for their assigned or chosen nutrient – Refreshment Sign Up Sheet in Section I

  • Workbook Puzzle – Nutrition Crossword Puzzle pg 101. Diet evaluation on pg 103. Awareness of what nutrients they are consuming; tell them to record what they eat for several days. How much protein, fat, calcium etc they normally consume. Mention serving size when counting nutrients. Counter on page 102.
  • Quotes to remember
  • “1 for the road” – never leave house without snack for road – trail mix, nuts, seeds, raisins, cheese and crackers, banana, apple
  • “Colorful plate is a healthy plate” variety of fruits/veggies; brown bread doesn’t necessarily mean whole grains – read labels
  • “Eating for 2” – get plenty of calcium; caffeine decreases absorption of calcium. Iron supplements for healthy blood. It’s difficult to get enough iron even in well planned diet. Protein necessary for baby’s growth and brain development. Want good birth weight and well-nourished tissues with increased energy for mom.
  • Books – Your pregnancy and childbirth; expect the best: your guide to healthy eating before, during and after pregnancy; eating for pregnancy: the essential nutrition guide and cookbook for today’s mothers to be
  • Web:



Body Mechanics pg 14-15 in workbook– proper body mechanics can prevent some common discomforts of pregnancy.

  • Visual Aids – illustrations of body mechanics and all exercises are included on PowerPoint CD. Have 1 student read instructions for 1 of actions as another performs
  • Role Play – with partner wearing empathy belt, have him perform activities suggested by class – tie shoe, roll over on bed, pick up item etc. Play correctly getting into out of car/bed, working at desk or other daily activities
  • DVD: Celebrate birth! Moving with pregnancy and birth
  • Book: Exercising Through Your Pregnancy.
  • Birth Fitness Exercises (pg 16-19 in workbook) Prenatal dance classes gaining popularity; prenatal yoga helps to tune in to bodies and better cope with everyday stress in lives with added benefit of camaderie with other pregnant women
  • Teaching Points
  • Exercise decreases physical discomforts, hastens recovery, does not increase risk of exercise related injury
  • Women who exercise have shorter, less complicated labors and recover more quickly after childbirth
    • 1 study shows women who exercised vigorously had significantly less ob interventions including highly significant reductions in both elective and indicated labor stimulation, episiotomy and use of epidural anesthesia as well as both vaginal and abdominal operative delivery
    • reduced risk for cesarean
    • levels of endorphins are increased during pregnancy in women who exercise; exercisers decreased need for epidural
  • Benefits of prenatal yoga to release tension, easy pregnancy discomforts, decrease preterm births and even decrease length of labor. Many childbirth educators say women who do yoga seem more in tune with bodies and more confident about ability to cope with labor
  • Reduce back pain – weak abdominals, esp with growing belly can cause pain in lower back, whereas strong muscles will reduce it
  • Numerous benefits of Kegels – see pg 19 in workbook
  • Quick-flicks and extended Kegels – 10-20 sec after potty break; easier to remember than red light. Pg 18 of handbook
  • Incontinence doesn’t have to be result of pregnancy. In addition to Kegels, strengthen abs, inner thighs and buttocks. Core can be strengthened through pilates, yoga or other programs that help to align and tone body
  • Music – Do the Kegel. Vulva Puppet.
  • Handouts – Kegel stickers around classroom. Neon labels – 30 to a page. Master for printing stickers included on CD
  • Guidelines for exercise – rather than list of don’ts, use remember to on page 100 in workbook. Benefits of slow stretching alone or with an aerobic sequence
  • Snack on exercise, with several short bouts a day
  • Begin slowly and increase gradually
  • Avoid excessive fatigue and dehydration
  • Use support for abs and breasts for comfort
  • If it hurts, stop and evaluate
  • If it feels good, it probably is
  • Sample Stretch breaks – pg 16-17 of handbook. Break up every hour of sitting with a few min of activity. Stretches should be done daily at work/home. Reinforce benefits of stretching throughout day and teach in class.
  • Stand near wall and do wall stretch; add standing pelvic tilt and Kegel, calf stretch; wall squat
  • Sitting – do tailor reach, shoulder stretch, circulation exercise, cross leg with ankle on opposite knee, gently press downward to release tension
  • Lying down – back flexion, leg stretch, curl down, pelvic tilt
  • Hands and knees – pelvic tilts and circles, tail wagging
  • Ball to rock, bounce and stretch. Replace chair at desk with it

Demonstration/return demonstration – introduce 1 new exercise a class instead of all at one. Spiral info

  • Class 1 – Kegel. Wall stretch with standing pelvic tilt for reducing backache and good posture. Pelvic tilt on all 4s to reduce backache. May increase comfort during labor and help rotate baby in posterior position
  • Class 2 – pelvic tilt on all 4s, adding back massage and Kegel. Passive pelvic tilt side lying
  • Pelvic tilt all positions. Kegel with and without tilt
  • Awareness of tension in pelvic floor. Various pushing positions. Abs contracted
  • Pelvic tilts – walking, leaning against wall, hands and knees, over birth ball, side lying and pushing
  • Pelvic tilts to postpartum lifting/bending over baby

Diastasis recti – or diastasis is separation of ab muscles along midline. Before end of pregnancy, many women develop. As ab muscles stretch as uterus grows, hormones softer muscles. Strain on vulnerable muscles causes them to separate. May be possible to avoid if 1 avoids excess stress on tense muscles by exercising and moving properly.

  • How to Check – lie on back with knees bent, lift head and shoulders off floor, feel for soft bulge between 2 sheaths of ab muscles; 1-2 finger width not uncommon in 3rd If more than 2, corrective exercises should be done
  • How to Correct – in book Essential Exercises for Childbearing Year, recommends doing morning and night and in postpartum 5x a day until correction accomplished. Back with knees bent, support abs with crossed hands. Slowly exhale and you raise head toward chest until just before bulging begins. Pull in abs with hands while breathing out

Perineal Massage – reduces likelihood of perineal trauma (mainly episiotomies) and reporting on ongoing perineal pain and generally well accepted by women. Pg IV-25 handout


Prenatal Perineal Massage – will help you prepare for the stretching and pressure you will feel as the birth canal opens and your baby’s head crowns. Learning to relax as you feel the stretching will help you to release when you feel that burning sensation during the birth. Prenatal massage may help the tissues to stretch during birth so that an episiotomy won’t be needed.   The purpose is not to enlarge the opening.

According to current research, 1st time mothers who do prenatal perineal massage are less likely to need episiotomies during childbirth and are less likely to experience tears which need repair (stitches).

Begin perineal massage about 6 weeks before due date. 1x/day for ~5 min. do not massage if you have active genital herpes or any other genital infection. Always use clean hands with short fingernails and avoid touching opening of urinary tract.

To learn the process, it may be helpful first to prop a mirror so you can see your vagina and perineum. You can see and feel the perineum move as you do the Kegel exercise. Practice relaxing the muscles with a warm washcloth held on the perineum. (Some women prefer to take a warm bath to help them relax before massage). A lubricant may help to soften massaging fingers or thumbs, and to increase elasticity of perineum. You may use cocoa butter, K-Y jelly, wheat germ oil or even vegetable or olive oil from your pantry.

Place either your thumbs or index fingers an inch or 2 inside your vagina and press downward toward the rectum. As you press, you will feel a slight burning, stretching sensation. At that point, hold the pressure for 1-2 min until the stinging subsides. Slowly move your fingers or thumbs up along the lower sides of the vagina with the same steady pressure. Massage back to center and up the sides, pulling slightly forward, for 3-4 min. this will work the lubricant into the tissues. Practice releasing the perineum to the sensation of the stretch, as you will do at your baby’s birth. In a week you should notice that the tissue stretches much easier as you massage. Do Kegels to help increase muscle tone of the pelvic floor.

Directions for prenatal perineal massage:

  • Wash hands
  • Lean back in a comfortable semi-sitting position, with pillows supporting your back and knees
  • Put a lubricant on fingers and perineum
  • Massage, firmly but gently, relaxing your muscles as you feel the pressure or stinging
  • Tell you partner how much pressure to apply if they do the massage for you.

On the Ball” Birth Balls (pgs 20-21 workbook) – used by physical therapists for neurological, orthopedic and fitness applications, encourage mamas to use during pregnancy. Use only physical therapy grade, burst-resistant balls.

  • Benefits: before, during and after labor. Abdominal and lower back muscles are used to stabilize and maintain balance, which lessens back pain and improves posture. Pelvic inlet is tilted forward in relation to the spine, which encourages anterior position of baby’s head. Rhythmic movement that is natural can improve circulation and most likely comforting to baby. Can alleviate discomfort from hemorrhoids. Rocking pelvis, changing positions and shifting weight in upright position encourages baby to descend. Does not interfere with electronic fetal monitoring or induction of labor. Kneeling position allows for free movement of pelvis, while gravity encourages largest and heaviest part of baby to rotate off mom’s back to an occiput anterior position. Standing, while leaning on ball that is placed on bed/table, encourages pelvic swaying and rotation, which may help relieve pain and encourage the baby to descend. Standing, leaning your back on the ball against the wall offers pleasant pressure for an aching back or support for wall-squat position.
  • Size: should fit like a chair. Hips, knees and ankles bent to 90 degrees. 4’10-5’2: 55cm; 5’2-5’10: 65 cm; 5’10-6’2: 75 cm
  • Safety: stored away from heat/sunlight. Clothing free of sharp objects. Support while using the ball if needed. Use good posture and body mechanics. Unobstructed space around ball. Barefooted or rubber soled shoes. Can be cleaned with standard hospital disinfectants as long as there is no label about no PVC on vinyl surfaces.
  • Positions: circular/figure 8 – relaxes back and pelvis and helps establish balance. Lean back into partner who is sitting on chair next to you. Lean forward relaxing on a pillow placed on a table, bed or chair. In shower while you enjoy warm water. Kneel on floor or on bed with ball in front of you ; lean over ball, rolling it forward and back to find a comfortable position for your upper body to rest. Arms may hug ball or be relaxed hanging over it. Partner can apply back pressure to help relieve pain. Stand by bed, leaning over ball placed on bed – breathe and relax. Stand with back or chest leaning in to ball placed against wall. Sway gently side to side. Sitting and side-lying with a peanut ball.
  • Peanut Ball – helpful for those with epidural analgesia. Labor nurses have found labor progress enhances when laboring woman either sits up with one leg draped over ball or lies on side with upper leg resting on ball.
  • After birth: Soothe baby against chest or over lap and move side to side or bounce softly.

Comfort Positions for Pregnancy & Labor (workbook pgs 20-23)

  • Teach comfort positions in the first hour of your first class, so students will know you are going to teach them something they can use! They can bring own pillows. Birth balls. Show pictures and assign a position to each couple to try. Can use as model and show variations. Divide into groups and each group has to position one person in a comfortable position. Present to class. Position posters on wall and move from station to station, duplicating positions in ways they find comfortable.
  • Spiraling positions into each class: Positions for sleeping/relieve aches of pregnancy. Breathing awareness in various positions. Massage, touch, stroking to each position. Rationale for positioning, in relation to position and descent of baby. Position relating to other sensory stimulation (feet on cold floor; hands pressing on bedrail; vibrating pillow in rocking chair). Advantages of being able to move freely in labor to facilitate birth and relieve pain.
  • Resources: Labor Progress Handbook,
  • DVDs: Comfort measures for labor; Celebrate birth!

Teaching Relaxation (pgs 24-26 workbook): first learn to relax yourself, then it will be much easier to teach others. Begin with a recorded session that you play for your class as you join them in relaxing. Model a relaxing position as you introduce session with a soft, relaxing voice. Dim lights, play soft music and shut out distracting noises. Scripts in Prepared Childbirth – The Family Way (pgs 104-106). Begin and end sessions with time to slowly lead in and out of relaxed state – do not rush! Offer a variety of techniques for releasing tension as not everyone responds to the same method. Give time for couples to give feed back to each other. If they can’t communicate their needs now, they won’t be able to in a time of tension. Open discussion after.

Various Relaxation Techniques:

  • Progressive relaxation helps students become aware of how a muscle feels when it is contracted, stretch and released. Work 1 muscle at a time from head to toe. Ask students if its easier to release a muscle after tensing, stretching or neither (pg 104 handbook)
  • Selective relaxation reinforces muscle isolation. not all muscles are tense or all released at the same time. In labor, it is beneficial for some women to focus on relaxing other muscles as the uterus contracts
  • Touch and massage techniques should be demonstrated and practiced so each student learns to perform them. Different types of massage are described on pg 26 in handbook. Allow time for each to be the giver and receiver of the massage, and to feed back to one another they type of touch each prefers. Practicing massage is a popular homework assignment
  • Visual imagery is a useful tool to help a woman reduce stress, relax, cope with her pain, and to think positively. It can even help labor progress. When using imagery, remember to: consider environment (space, music, lights, temp, pillows); suggest distractions are fewer if they close their eyes; begin the image in the room where they are grounded and safe; address distracting thoughts – they may put them away and have them back after the exercise; suggest a range of sensations they may experience; end the image envisioning the same scenes passed as they left the room; follow up with class discussion of the experiences of those who will share
  • Biodots: small temperature sensitive pads which may be placed on each student’s hand before a relaxation session. Extremities warm as relaxation occurs, causing the Biodot on the hand to change color. Remind students to check the color of their dot, both before and after the relaxation exercise. A color key is usually included. ICEA bookstore sells. Can wear the next day to see how it changes according to activity/stress levels.

Spiraling relaxation into each class:

  • Class 1) progressive relaxation and tension awareness; hand massage.
  • Class 2) selective relaxation; release to touch; autogenic phrases
  • Class 3) Massage, stroking in various positions
  • Class 4) Visual imagery; positive affirmations
  • Class 5) Partners find mom’s “hidden tension” and help her to release
  • Class 6) Review all relaxation skills in a labor rehearsal

References: The relaxation and stress reduction workbook. Mother massage – a handbook for relieving the discomforts of pregnancy. Massage during pregnancy B. Waters

DVD: Penny Simkin’s Comfort measures for childbirth

Relaxation: Awareness Exercise: (sitting in chairs or on floor). Teach tuning into bodies and awareness of bodies early in pregnancy. Script summary “awareness of tension is mastered by consciously focusing on each area of your body – how it moves and how it feels and how it relates to the space around it. 1st, focus on surroundings, then move inward. Feel eye muscles as you look around – what do you see (colors of light, walls, ceiling). Be aware of what you see. What you hear (fan, outside noises). Smell (air, aromas, fragrances, like/dislike, think of smell comforting to you and remember it), feel your presence in this room – you are with others, in a building on this ground on this earth, which you are apart of. Can have eyes focus on point in room or inward. Take a cleansing breath and signal body to let go. Acknowledge thoughts and let them pass. Concentrate on head – tension may cause headaches or may be present with a busy mind. Many muscles and nerves in face and scalp. Think of a pleasant sensation for your head – good hair brush, shampoo/scalp massage, warm hair dryer, cool wind blowing through hair. Try to IMAGINE those you find pleasant (pause for several breaths). Lift fingers and run them through your hair in a way that feels good to you (pressing, massaging, scratching, stroking). EXPERIENCE that sensation now. Try to wiggle scalp. Find the muscles in your scalp – move them – then concentrate on the tension leaving as you allow them to release. Breathe air in through nose – feel it go to lungs and expand your chest/rib cage. Feel release of tension as you sign air out through mouth. Tune into how you breath. Movement of chest/belly. Feel cool air as you breathe in and warm air go to lungs. Can picture a color of the air. May breathe in relaxing color and release a different color. Try for several breaths. Consider jaw – is it tight with clenched teeth? Stretch it open wide, drag it down, yawn, let it go. Let it remain loose with teeth not touching. Move focus to shoulders. Rub them. Feel for tight muscles. Pull shoulders down toward feet to stretch tension away. Release. Drop chin to chest. Feel stretch in back of neck. Feel it with hands. Hold for several seconds. Lift head and look forward. Put right hand on left side of head and pull. Hold. Change hands. Put hands in lap. Think about hands and fingers. Stretch and release stretch. Think of all the wonderful things hands do for you. Cleansing breath and feel release in head, neck, shoulders, arms and down your back. Readjust sitting position. Rock pelvis to be sure you are sitting on “sit bones”. Let tension go from pelvis and let legs flow to your toes. Scan body from head to toe, paying attention to how each of you feels when tension has been released – head, scalp, face, eyes, jaw, tongue, shoulders, neck, arm hands, fingers, back, hips, legs, feet, toes. When you feel tension in any of these during the day, send a relaxing breath to that part. Breathe softy, consciously, with awareness. Return to a state of alertness, slowly increasing pace of breaths. Look around. Move hands and arms, feet, legs. Discuss experience with partner.

Progressive Relaxation Script page 104 in handbook: If lying on floor: “Get as comfortable as you can. If pregnant, lie on side. Place pillow under head, between knees and under upper arm so you can release into pillows, feeling well supported. Partners – can place pillow on back and under knees. Legs uncrossed. Lying on floor and seated “Purpose of exercise is to learn how a muscle group feels when tense and when it is released. Let go of any worries in your mind. Allow a deep, soothing relaxation to come over your body. Take a deep breath in and let it out. Take breath in and let tension release with a sigh. Think about forehead – is it released or tense? Raise eyebrows in a look of surprise. Release. Frown and feel deep furrows in brow. Hold and release. Imagine someone smoothing your brow, with a warm hand or cool cloth. Move eyes slowly and hold briefly in each direction – look up, down, right, left. Feel tension in your eyes as you move them, then close softly, peering into darkness. Press lips in a tight pucker. Release. Part lips after moistening with tongue. Stretch an exaggerated smile and then release to a soft, relaxed smile. Press tongue to top of mouth – feel what a strong muscle it is – even it can carry tension. Release it to fall loosely in mouth. Bite teeth together gently. Feel tension in jaw as you hold even a gentle bite. Allow jaw to fall open so teeth do not touch. Stretch your jaw by dragging it down, wide open. Yawn if you wish. Allow jaw to close but keep it loose and slack. Pull head into shoulders like a turtle. Release. Let chin drop to chest. Hold. Arc chin to right shoulder. To left. Back to center. Clench fists – hold tight. Release. Be aware of the sensation. Stretch fingers long. Relax. Round shoulders forward. Feel stretch across back as you hold. Release. Pull shoulders back and down. Release. Pull arms tightly against your body. Hold. Now let rest loosely by side. Breathe deeply- filling lungs with air. Blow air out of mouth in a deep sigh. Feel belly rise and pull belly inward as you slowly exhale. Moms body will hug baby with the breath out. Release hug as you inhale and allow baby to float peacefully. Pinch buttocks together. Feel tightness. Release. Push feet and legs together. Release. Push hips and knees outward. Hold. Release. Flex right foot and stretch your leg. Drop foot and leg. Repeat with opposite. Curl toes gently without pointing foot. Hold feel. Release. Wiggle toes. Scan body, thinking of each muscle we just worked. Release them all. Concentrate on this feeling of relaxation. As your practice, the time required to reach this state will shorten.” With more energy “Now it’s time to leave this relaxed state. Do not move quickly. Take time to readjust. Think about the room you are in and the people around you. Be read for the lights to brighten. Slowly move arms and legs. When you are ready, return to a state of alertness. You will feel quite refreshed.”

Release to Touch– practice in a variety of positions. Refer to illustrations on pg 22-24 in Prepared Childbirth – The Family Way.

Can be done in slow dance, walking and supported standing, but ideal positions are side lying, which provides partner with easy access to mom’s arms, legs, hips and back while she is fully supported and supported sitting, which allows partner to reach limbs, belly, face and neck, while maintaining eye contact.

Script: “Moms, take shoes off and find a comfortable position so you will feel fully supported as you learn to release to touch. Partners, take your place facing her if she is on her side or in front of her or to the side of her if she is sitting so you can reach her shoulders and arms, then hips and legs. Try to keep space on both sides of her as you will have to move around during this sequence. Partners- rubs hands briskly together to warm, then place both hands- warm and relaxed – on mom’s shoulder nearest you. Hold them there, allowing her time to release her tension toward the warmth of your hands. Both of you take a cleansing breath together as a signal to let go of your tension. Partner’s hands should be loose. Gently stroke down her arm with both your hands – all the way to the fingertips, “pulling” the tension from her body. Do not allow her hand to fall. Gently place it back where it was as your hands leave hers. Ask her if she wants more or less pressure. Repeat that motion on the same arm, adjusting pressure to suit her. Hands pause on her shoulder, stroke down the arm, off the hand. Her arm should now feel very loose and relaxed. Notice the difference in the feeling of relaxation in her two arms. Now, place your hands on the crest of her hip. Mom, release to the touch of warm hands as your partner strokes down the top and sides of the leg with both hands…slowly, gently, firmly…all the way to the foot. Pull all her tension out her toes. Ask her about pressure. Adjust it, then repeat stroking the leg from the hip, to the knee, ankle and off the foot. Move to opposite side and repeat the entire sequence. Hands pause on shoulder, stroke down the arm, off the hand. Move to hip, stroke down leg, all the way to her foot and out her toes. Now move to a position behind mom, so you can comfortably reach her shoulders and head. Place both hands together at base of her neck, with your fingers spreading to the tops of her shoulders. Gently press down with the heel of your hands. Mom, release your tension to the pressure of warm hands. Partners, move your touch to a new point on top of her shoulders and press down gently, firmly. Before we move on, ask mom if she likes having her head touched. If she does not, you can massage her shoulders again. Place hands on her head with your fingers touching and the heels of your hands above her ears. Moms, imagine that your partner’s hands are magnets that attract tension and pull it away. Partners, press in very gently with your hands, then just hold slight pressure on her head. Partner’s hand very slowly begin to release pressure, then barely touch your hair. Pull away slowly into the space around the head. Your tension has gone with your partner’s hands. Partners, shake your hands out, then repeat, adjusting again for pressure as she desires. If you are comfortable on side, back is open for touch. If sitting, lean forward so partner may touch and stroke down your back. When doing long strokes on the back, be sure that one of your hands maintains contact with her body at all times. Begin with the heel of your hand near her left shoulder. Stroke firmly with your open palm all the way down her back and hip. Before you release that hand from her hip, place your other hand near her shoulder, just to the right of your last stroke. When that hand begins to move, release the first hand from her hip. Slowly work across her back, hand over hand, stroke after stroke- until you reach her left shoulder. Keep your strokes firm and slow. Discuss your reaction with your partner. Did it help you release tension? Was any touch more irritating than relaxing? Then, reverse roles. Mom, stroke, press or massage partner in a manner to show him how you like to be touched. Demonstrate the pressure and speed you like, then listen to your partner’s feedback. You will probably find you like different types of touch. In the future, you will know how to touch your partner according to their desire, not yours.

Hand Massage: position partners hand so it is supported for relaxation, and for you to work comfortably with it. If you choose to use a massage oil or lotion, pour it on your hands, then rub it together to warm it before touching your partner’s hand.

Squeeze and hold gentle pressure with both hands, moving to various positions around the hand. Turning the palm up, use both thumbs to apply pressure in the middle of the palm, just under the knuckles, using counter-pressure on the back of the hand with your fingers. Hold for about 10 seconds. Slowly walk the thumbs randomly throughout the palm of the hand with slow, firm presses or circling motions. One finger at a time, rub on all sides of each finger from the palm to the fingertip. Turn the hand over. Grasp the hand with your thumbs together on the back of the hand. Pull your thumbs firmly to each side as if “breaking a popsicle”. Repeat several time. Supporting your partner’s hand with one of your hands, use your free hand to stroke from the wrist down to the tip of each finger and thumb. Massage and gently pull each finger. With your fingers toward the wrist, place one of your hands on top and one on the bottom of the hand begin massaged. Squeeze firmly and hold to a count of 5, then lighten the pressure and slowly pull your hands down the wrist and of the fingers. Repeat 3x.

Foot Massage: Position the foot so that it is supported in a relaxed position, and it is comfortable for you to work with it. Socks may be left on the feet or, if barefooted, you may choose to use a massage oil or lotion. Pour the oil or lotion on your hands and rub them together to warm it before touching the foot. Use firm strokes and both hands to massage the foot.

Squeeze and hold gently pressure with both hands, moving to various positions around the foot. Press just under the ball of the foot with your thumbs and hold for about 10 seconds. Walk the thumbs around the bottom of the foot with slow presses or circling motions. Use your knuckles to massage the instep and the outer edges of the heel. Use your fingertips to make small circles around the top of the foot. Stroke from the top of the ankle down between each toe. Massage and gently pull or wiggle each toe. Squeeze and release the top of the foot with both hands several times.   Squeeze and release the bottom of the foot with both hands several times. With fingers pointing towards the ankle, place one hand on top and one on the bottom of the foot. Squeeze firmly and hold to a count of 5, then lighten the pressure and pull hands down the foot and off the toes slowly. Repeat 3x.

Visual Imagery: House of Colors – Discuss how colors affected them after this exercise. Did they learn anything about how colors make them feel? Were any colors more stimulating, stressful or relaxing than others? Can be a cue for colors to use in labor, nursery, or in home.

Script: Spend a few moments making yourself as comfortable as possible. Let go of any worries or concerns that may be in your mind. You can have them back when this exercise is over…but let the next few minutes be your time…to experience colors.

As you participate in this imagery session, you may discover how different colors affect you. Some colors you may find relaxing, others more alerting; some may make you feel the sensation of warmth and others may cool you; some colors are pleasant and comfortable and others are not. First, notice this room. Think of the colors you see, and the textures and temperature you feel around you. Then you may wish to close your eyes and take a brief journey in your mind to the remarkable House of Colors.

Imagine if you will, walking up the sidewalk to a fascinating old Victorian style house. Now imagine walking up to the front door. You turn the door handle and enter the first room of the house. This room has been completely decorated in the color red. The ceiling is red, the walls are red, the floor is red, everything in the room is red. What objects do you see in your red room? Pause. Notice how you feel in the red room. Notice how you feel being completely surrounded by the color red. Even the air you breathe is red. Pause. Now prepare to leave the red room behind and open the door to the next room – the orange room.

Repeat with rooms of other colors – Yellow, Green, Blue, Purple, White. The room has been completely decorated in the color ____. The ceiling is _____, the walls are _______, the floor is _______, everything in the room is ______. What objects do you see in your _____ room? Pause. Notice how you feel in the _____ room. Notice how you feel being completely surrounded by the color ______. Even the air you breath is ____.

Now it is time to leave the House of Colors. Imagine yourself leaving the white room, going out the back door, and walking around the front walk, to the sidewalk.   Pause. Now it is time to return to this classroom. Remember the colors and lights in this room. Feel the floor under you. Move your arms and legs a little. When you are ready, let your eyes open.

Visual Imagery: Your Special Place

Script: Spend a few moments making yourself as comfortable as possible in any position you choose. You may take off your shoes, glasses, and put them safely aside. Settle into your pillows, and let the next few minutes be your special time. Visual imagery is really just directed daydreaming. I will ask you to imagine a place where you can become very relaxed. This can be a place that really exists, or simply a place in your imagination. Perhaps you will remember a special vacation – sunning on a warm, sandy beach; enjoying a fireplace in a cabin in the woods; or lounging in a hammock by a cool mountain lake. Or, this can be a place where you have never been, but perhaps have dreamed about. It doesn’t even have to be a real place. In your own imagination you can even be floating on a cloud. It doesn’t matter. The important thing is that this place can become very special to you – it is a place where you can totally relax and enjoy yourself now, and can return to at any time.

Now, if you have settled in, allow a deep, soothing relaxation to come over you as you participate in this imagery exercise. Take a deep breath in…and gently let it out. Take another deep breath in…and gently let it out. As you take a third deep breath in, feel yourself release comfortably into your pillows. And as you breathe out again, let any remaining tension flow away with your exhalation. You may wish to let your eyes close, to shut out distractions. Picture yourself now, leaving this room…and the are where you live. Your imagination takes you to a road. Walk along this road until you come to a spot where you can see forever. Look out from this spot and find an inviting and comforting place…a place in your mind that will become your special place… Pause

Now imagine that you are there in your special place. Pause. Are you by yourself? Or is there someone with you? Pause. What are you doing? Pause. When you look around, what do you see? Pause. Are you indoors? Or outdoors? Pause. What does the air feel like around you? Pause. Are there any special smells in this place? If so, take a moment to enjoy them. Pause. When you listen, what sounds do you hear? Pause. Are there any special sensations that you feel? Take a few moments to enjoy all the sensations that you are feeling in your special place. Enjoy the feeling of relaxation. Pause.

Remember, that anytime you want to, you can return to your special place in your mind, and you can feel the peaceful relaxation that you are enjoying now. Pause.

Look around you before you say goodbye. Now it is time to leave your special place and return to the spot where you could see forever. Walk along the road in your mind, until you return to this room. Feel the floor beneath you. Remember the colors and the lights in this room. Begin to stretch your arms and legs a little. And when you are ready, let your eyes open and come to a sitting position.

Visual Imagery: Birth (for all relaxation and imagery exercises, speak slowly and clearly)

Script: Spend a few moments making yourself as comfortable as possible. You may wish to take off your shoes, and if you wear glasses, you may take them off and put them safely aside. Choose the position that is most comfortable for you. Your arms and legs should be bent at every joint and separate with pillows so that you can be totally release. Let go of any worries or concerns that may be in your mind. You can have them back when this exercise is over…but let the next few minutes be *your* time. Do nothing at all except allow a deep, soothing relaxation to come over you as you participate in this imagery session.

Although this exercise is directed to the pregnant women, I would like the partners to imagine what is happening to her and how you will be able to best support her when it comes time for the baby to be born.

Take a deep breath in, and gently let it out. Take another deep breath in, and gently let it out. As you take a third deep breath in, feel yourself release comfortable into your pillows. And as you breathe out again, let any remaining tension flow away with your exhalation. You may wish to let your eyes close, to shut out distractions.

For this exercise, I would like you to imagine your baby’s birth. It may occur a few days before, or after your due date, or even exactly on the day that you have been expecting your baby. In this exercise, you will think about the sensations that I will be describing, but you will not actually experience these sensations until it is time for your baby to be born.

Think for a moment about the positive aspects of your pregnancy…the amazing way that your belly has grown to make room for your growing baby…the way your breast have gotten bigger to prepare for nursing your infant…the way that your baby communicates with you by kicking and moving around. Many scientists think that when the time is right, your baby will release tiny amounts of a hormone that will instruct your uterus to being contracting. Pregnancy is an amazing, natural process. You are feeling strong, healthy, and confident about giving birth.

Toward the end of your pregnancy, your hormones will instruct your body to prepare for birth. Your cervix may move from a position tilting towards your back to facing forward, right into the birth canal. Your cervix will soften, “ripen”. Periodically you may feel the uterus tighten, as it begins to prepare for labor. These contractions will come and go intermittently, whether or not you feel them. Your baby will settle down into your pelvis. On the day of your baby’s birth, these contractions will gradually become stronger, longer, and closer together…and they will continue to occur…instead of stopping as they have done on previous days. The cervix will stretch and open: 3 cm, 5 cm, 7 cm…this process takes time. Each contraction sends a signal to your brain to release oxytocin. The oxytocin will cause contraction to increase in strength,. And, as the strength increases, labor will progress, and you will be that much closer to holding your baby.

You will find that the pain of labor has a purpose. It will help you discover ways to help your labor progress. You will move and change positions in response to pain. You may walk…slow dance to the music you bring with you…stand under warm water in the shower…or do pelvic tilts on all fours r on your bed. Moving in response to the pain of contractions will actually help you…and will encourage your baby to move into position and down the birth canal. Narcotic-like endorphins are released by your brain in response to pain…to decrease your perception of pain. High levels of endorphins also allow you to “go into yourself,” and tune into your natural instincts, which will help you to manage your labor. Your internal focus on your labor will become more important to you that the surrounding environment. But you will want to have people with you who will encourage you quietly and patiently, so that you will not be afraid. You will feel totally supported, and comforted, as you flow with your labor. Even if labor is long, you will have the energy you need to persevere. You will rest between contractions, paying no attention to the time. Even 30 seconds of rest is a gift. Surround yourself with people who trust the birthing process and who will know that you have the strength and the confidence to give birth. Labor is hard work, but you can do it.

Finally, your cervix will open to 10 cm. your body will rest for a few minutes, then you will begin to feel an urge to push. You tune into the strong sensations that you are feeling, and bear down with your contractions. Your baby will move and rotate, find a way through the birth canal.

After your final push, you will reach out to hold your baby. You will feel joy, excitement, relief, and pride. You and your baby will gaze at one another…in awe of one another. Slowly your baby will nuzzle at your breast, then begin to suck. Sucking will cause oxytocin to be released, and the uterus to tighten. You will then push out the placenta with very little effort. It is a perfect design. The miracle of birth will overwhelm you. A new star in your family constellation will change you forever.

As we end this birth visualization, I would like you to return your mind to the classroom. While you are still relaxed, take a moment to think about what you need to make your birth experience what you want it to be. Pause.

Over the next week, talk to your partner, and to those who will be with you during labor and birth…about those things that will help you to give birth as you wish. Will you have the support and encouragement you need? …the freedom to move around and choose the comfort strategies that best help you? … The patience to let the miracle of birth take place as rapidly or as slowly as it is meant to happen for you? Pause

When you feel ready, slowly begin to increase your breathing rate, move or stretch your arms and legs, then come to a sitting position.

Womb Matesincreasing number of moms of multiples. Section IV special classes has sample course outline. See pg 27 workbook

  • Graphics- illustrations of twins and triplets on PowerPoint CD
    • Childbirth graphics has a chart set – Multiple Pregnancy and fetal positions
  • DVDS – Multiples – More of everything
  • YouTube (Inspiring): Natural birth of twins and triplets:
  • Books: When you’re expecting twins, triplets or quads; mothering multiples – breastfeeding & caring for twins or more; Dad’s guide to twins: how to survive the twin pregnancy and prepare for your twins; Oh yes you can breastfeed twins! Plus more tips for simplifying your life with twins

To Be or Not To Be Concerned (pg 30 workbook): assure expectant parents that most of the time, discomforts of pregnancy are normal occurrences that go along with growing, changing body. Seek help if think/feel something is wrong. See chart on pg 30 which outlines warning signals: signals of preeclampsia, infection, placental problems and preterm labor.

  • Most of the time, a mother just needs reassurance that what she feels is normal
  • It is a positive sign that the body gives warning signals – don’t ignore them
  • Know what to do if the signals of preterm labor occur
  • There are degrees of such discomforts of swelling, headaches and dizziness. The pregnant woman must determine what is normal or what needs attention
  • It is important to keep all prenatal appointments for checks on those “silent” signals we cannot feel or see: bp, protein and sugar in urine, fetal heart tones etc
  • Prenatal tests – questions to ask on informed decision making cards (IV 101)
  • References: do chocolate loves have sweeter babies; pregnancy, childbirth and newborn

Labor Support: Doula (pg 33 handbook) – “woman’s servant”. Options available in community. Study on 20 fathers: 4 were “coach”, 4 were “teammate”, most were “witness”. Role of doula: physical support through comfort techniques, emotional support, knowledge of birth process, supports couple by being liaison. Resource: DONA Position Paper.

How Long Will Labor Last & Normal Labor Variations (workbook pgs 34-35)

A short labor isn’t the easiest because of the element of panic involved; her body is racing away from her mind and it’s difficult to feel any sort of control.

Recent research has shown that the Friedman Curve, used to monitor labor progress in the past is now obsolete. Experts say normal labor may take much longer than thought safe in past and are now saying “6 is the new 4” – active labor now defined at beginning at 6 cm- when labor begins to progress more quickly for most woman; they suggest that cesareans for dystocia not be suggested before this time.

Guided Discussion/Q&A:

  • Ask how long students expect labor to last. Remind that them phases don’t always have signs/symptoms when progress; may meld into next
  • Ask about when they have heard to go to the hospital – emphasize importance of staying home in early labor. Women admitted early at increased risk for cesarean. At home, women can eat, drink fluids and change positions easily. May be more relaxed in home and have access to shower/bath (getting in tub too early in labor may slow contractions so wait until they are firmly established). Check with caregiver about when to go
  • Remind students If pregnant woman is sent home, this is to her advantage

Brainstorm – activities you can do in early labor to pass time. Don’t forget rest/sleep

Lecture/Discussion with Visual Aids

  • Illustration of uterus and discuss Braxton Hicks
  • Cut out 2 pregnant shapes of bodies in With Child Conception to Birth Chart Set before and after lightening. Put one on top of other to show difference in fundal height. Point out pressure on bladder, space for diaphragm before and after lightening
  • Baby doll, knitted uterus and pelvis – can show effacement, dilation, cardinal movements etc
  • Poster showing uterus and utero-sacral ligament will help them see why contracting uterus may be felt in the back as the muscles shorter and pull on the sacrum
  • Use poster/PowerPoint to show rupture of membranes, discuss leak vs gush; C-O-A-T (color, odor, amount, time) to report to care provider

DVD: animation of loss of mucous plug, rupture of membranes and contracting/dilating uterus seen in Celebrate Birth! And Stages in Labor

Table 1: How Long is Normal Labor? (previously based on Friedman/current ACOG &SMFM)

Latent: beginning with maternal perception of regular contractions

Active: point at which rate of change in cervical dilation significantly increases

  • 1st stage- latent:
    • Previous nulliparous: prolonged if >20 hours (avg 8.6 hrs (+6/- hrs to go from 0-4)
    • Previous multiparous: prolonged if >14 hrs
    • Current: no limits on latent labor since active labor not considered to begin until cervix 6 cm – nothing should be diagnosed before this time
  • 1st stage – active:
    • Previous nulliparous: cervix dilates at least 1.2 cm/hr (avg 4.9 hrs (+/- 4 to go from 4-10)
    • Previous multiparous: cervix dilates at least 1.5 cm/hr
    • Current: cesarean reserved for women beyond 6 cm w ruptured membranes who fail to progress despite 4 hrs of adequate uterine activity or at least 6 hr oxytocin. Women whose cervix dilated to 2 cm upon admission may take up to 20 hrs to reach 10 cm
  • 2nd stage:
    • Previous nulliparous: 2 hours (avg 1 hr (+/- .8 hrs) (extra hr if epidural)
    • Previous multiparous: 1 hour (extra hr if epidural)
    • Current nulliparous: at least 3 hrs pushing
    • Current multiparous: at least 2 hrs pushing
    • Current: specific absolute time has not been identified; longer durations individualized basis – epidural/fetal malposition if progress is being documented
    • Current nulliparous: 95th %: 3.6 hrs with epidural and 2.8 hrs without

How Long Will Labor Last Curve/Graph pg 58: time in stage 1 labor from beg. of active labor

  • Short fast labor: 2 hrs
  • Average 1st labor: 6 hrs
  • Very slow labor: 11 hrs

Pain (pgs 36-37): some educators, esp those that use “hypnotic” birthing methods avoid using the word pain entirely. When the word is used, its important to consider positive aspects of labor pain and the psychological rewards and increased self-esteem that some women feel after conquering it

Pain is Purposeful, Anticipated, Intermittent and Normal. Make a poster, write on board or display PowerPoint slide to reinforce (fly in words)

Guided Discussion:

  • Purposeful – Labor Pain
    • Tells a woman how to move and what to do to help her labor progress
    • Promotes the release of stress hormones in baby, which can help adjustment to the extrauterine environment
    • Promotes release of endorphins
    • Results in birth of baby
  • Anticipated – You Can
    • Learn and practice coping strategies to be used in labor – you know it is coming!
    • In labor, anticipate (and enjoy) the time between contractions
  • Intermittent – You can
    • Focus on periods when the uterus relaxes between contractions
    • Consider the difference between intermittent pain and continuous pain
    • Put time in perspective…even when contractions are 4 min apart in active labor, there are 15 min of contractions and 45 min of rest each hr
  • Normal– remember
    • Labor pain is not an indication that something is wrong, but hat something is very right
    • Enlist support people who believe labor pain is normal and purposeful
  • Q&A/Brainstorming
    • How have you handled pain in the past? Answers such as rubbing, soaking, ice, heat and medication will be answered. Hugs and touch; others want to be left alone, rest and quiet for some, or distraction for others
    • Who and what would you like to have with you in labor to feel safe (partner, doula, mother). Consider environment and all 5 senses – what might you want to taste, touch, smell, hear see? Discuss difference between labor room with bright lights and no music/scents vs dimmed lights, batter candles, soft music, scent of baby lotion, favorite massage or essential oil in air. Handbook pg 108
  • Storytelling– comparing walk in rural Ireland to challenges of labor. Can compare to marathon, lengthy bike ride, hike or mountain climb. Pacing, breathing, rhythm, and support important. After number of hours, muscles begin to strain. Lactic acid begins to build and pain increases. Might wonder why she decided to do this. Endorphins kick in. sometimes words of support can make the difference. Can describe marathon and ask group what you are talking about and they will say natural childbirth. During athletic event, everyone cheers participants on and no one encourages them to quit whereas in childbirth, some are quick to recommend medication rather than encourage to keep going when things get tough.

Lecture/Discussion: Pain Management Theories

The Fear-Tension-Pain cycle is an old standard that still gives good rationale for what we teach. Draw the circle on a board or poster or display the PowerPoint slide. Show how the cycle can be changed:

  • Reduce fear of unknown and fear due to prior conditioning and misinformation, with education. Show images of women coping well with labor and birth, and discuss positive birth stories
  • Reduce tension by teaching relaxation techniques, the benefits of warm showers and baths, and active birth strategies such as walking, changing positions, and rhythmic movements
  • Reduce pain by reducing the fear and tension, and by teaching coping strategies and how they work

Fight or flight response is normal, protective response for fear. Its not helpful to fight or flee from labor; instead we try to elicit relaxation response. Ask students to name which:

Fight or flight or sympathetic system/relaxation or parasympathetic system

  • Pupils dilate/ pupils constrict
  • Mouth dry/ mouth moist
  • Rapid breathing and heart rate/ breathing and heart rate slow
  • Cold sweat/warm sweat or none
  • Blood to extremities/ blood to internal organs
  • Digestion slows; digestion efficient
  • Adrenaline increases and oxytocin decreases/adrenal secretions decrease
  • Muscle tension increases/muscle tension decreases
  • Bp increases/ bp decreases
  • Extremities cold/ extremities warm
  • Body odor increases/ no body odor

Endorphins: long distance runners familiar with these chemically similar to morphine; produced in response to pain and levels increase during pregnancy, then dramatically rise during labor as contractions increase in intensity, peaking with birth of baby. women who exercise during pregnancy have even greater levels. Massage and TENs during labor stimulate production

Sensory stimulation and gate control theory – understanding of neurophysiologic basis for pain reducing strategies is important (see article nonpharmaceutical pain relief by Suzanna Hilbers) alternating various comfort measures such as heat, cold, pressure and movement, pregnancy woman can modify painful stimuli. Painful internal stimuli travel along small diameter nerve fibers while more pleasant tactile sensations travel along faster moving larger diameter fibers. Pain relief is achieved when gate is closed to painful stimuli due to processing of positive stimuli by brain. Brainstorm various ideas that may work; involve all senses and rehearse.

Simulating contractions:

  • Clothespin for muscle fatigue – thumb and first finger to pinch and release the clothespin rapidly for 60 seconds. Lactic acid is formed when oxygen to muscle is depleted. This demonstrates one reason to relax all voluntary muscles in labor while the uterus contracts.
  • Ice as pain stimulus – use various techniques – breathing, vocalizing, moving, focusing, massage etc to block painful stimulations. Can be put in zip lock, in bowls for hands to be immerged, small balloons (can be reused – latex can cause allergy).
  • Wall Squat – when thigh muscles begin to feel tense, a cleansing breath and breathing pattern is begun. They will see the progress in the length of the “contraction” they can handle if they practice this with various coping techniques.

For those who plan natural/unmedicated childbirth: Lamaze has defined 6 healthy birth practices that promote safe and healthy birth:

  • Let labor begins on its own
  • Walk, move around and change positions
  • Bring a loved one, friend or doula for continuous support
  • Avoid interventions not medially necessary
  • Avoid giving birth on back and follow body’s urges to push
  • Keep baby and mom together –best for mom, baby and breastfeeding

Can download at or Show short video clips during class or assign as homework.

  • Code word – some use a code word for pain medications
  • YouTube: Pain vs suffering during labor youtube/watch?v=rlj9ehB-hLc
  • DVDs: 3 R’s, Natural born babies
  • References: official Lamaze guide, deliver me from pain


P: purposeful

A: anticipated

I: intermittent

N: normal

Signs of Labor (pg 38 workbook)


  • What heard from friends/family about onset of labor?
  • What might expect in weeks leading to labor? Lightening, nesting, show/plug
  • Hours preceding birth? Flu like symptoms, backache, contractions, rupture of membranes
  • How likely bag of waters breaking first sign? Note it most often breaks when sleeping rather than running errands or when in hospital in active labor
  • Discuss different feelings of uterine contractions – cramps low in front, pain in back, pressure in groin, tidal waves. Assure them very few women didn’t know they were having a contractions
  • Emphasize importance of staying at home in early labor
  • Reassure students sent home its to their advantage – can eat, drink, change positions, use bath

Lecture/Discussion with Visual Aids

  • Illustration of uterus and discuss Braxton Hicks
  • Cut out 2 pregnant shapes of bodies in With Child Conception to Birth Chart Set before and after lightening. Put one on top of other to show difference in fundal height. Point out pressure on bladder, space for diaphragm before and after lightening
  • Baby doll, knitted uterus and pelvis – can show effacement, dilation, cardinal movements etc
  • Poster showing uterus and utero-sacral ligament will help them see why contracting uterus may be felt in the back as the muscles shorter and pull on the sacrum
  • Use poster/PowerPoint to show rupture of membranes, discuss leak vs gush; C-O-A-T (color, odor, amount, time) to report to care provider; use graphics on family way PowerPoint slide to show mucus plug and rupture of membranes

DVD: good animation of loss of mucus plug, rupture of membranes and contracting/dilating uterus in celebrate birth! And Stages of Labor

How To Time Contractions (graph):

  • Duration – beginning to end of 1 contraction
  • Frequency – beginning of 1 contraction to beginning of next

How Birth Hormones Prepare Mother and Baby for Birth: Online -The Hormonal Physiology of Childbearing by Dr. Sarah Buckley.

Roles of hormones in preparing pregnant woman and fetus for birth (oxytocin, endorphins, catecholamines, prolactin). Receptors for these hormones increase throughout pregnancy. Best when labor begins on its own and receptors are at ideal numbers. Receptors for catecholamines do not increase, but surge of endogenous steroids and catecholamines in days before onset of spontaneous labor – this prepares fetal lungs for extrauterine life by clearing fetal lung fluid, increasing lung elasticity and increasing lung surfactant. In ~24 hours around time of spontaneous labor, oxytocin reduces oxygen requirements in fetal brain, which protects fetal brain for duration of labor and birth. In animal studies, this neuro-protective effect was reversed when high doses of Pitocin were given, making fetal brain more vulnerable to hypoxia during labor.

Immediate and uninterrupted skin to skin after birth can help restore flow of birth hormones for those who had interventions.

First Stage of Labor and Comfort Strategies (pgs 39-42 workbook): one phase of labor flows into the next. Pg 39-42 in Prepared Childbirth – The Family Way frequently used by students to remind them of things they may try. 6 is the new 4 – active labor now being defined at beginning at 6 cm. Strongly recommended that cesareans for dystocia NOT be suggested before 6 cm.

  • Visual Aids – effacement and dilation. When using doll, treat as a baby. Can use foods from cheerios to bagels or dilation chart. Remember, cervix is a soft, supple organ designed to stretch and open.
    • Progress in Labor poster from Birth International shows soft, rounded images of baby’s head causing cervix to thin and open
    • Knitted uterus or turtleneck sweater creates a realistic image of how uterus pulls back and opens the cervix for the baby to come through. (Baby’s head or your own head)
    • Model of a pelvis and baby doll, show how baby navigates canal as it flexes, rotates and extents
    • Rubber bands in various diameters and thickness (ones that come on veggies).
  • Charts – ICEA and Childbirth Graphics.
  • Graphics – color copies of illustrations on pages 7 and 39-42 of PowerPoint CD
    • Cervix pg 7. Follow effacement and dilation as it progresses through 2nd stage
    • Notice rotation of baby from transverse to anterior
    • Notice how position of baby moves from flexion to extension
    • Refer to pg 7 for discussion of presentation and positions
    • Project illustrations of uterus with different stages of dilation. When played quickly on PowerPoint slide slow, movement and rotation of baby with dilation of cervix are emphasized
  • Discussion:
    • Notice representation of waves of contractions on pages 39-42 as peaks become higher and closer together as contractions intensify
    • A discussion of labor support is reinforced by these charts which provide a cheat sheet for partner in labor
    • Use labor road map graphic by Penny Simkin while discussing variations of labor, partner roles and comfort measures. Cart and tear sheets available through childbirth graphics
  • Storytelling: personal stories – tell of women who coped effectively with several days of prelabor contractions. Tell stories of coping with transition. Have former students tell stories. Always ask permission, change names, times, locations to protect identity.

Simple story of birth2 weeks prior to baby’s birth for 1st time moms and closer to baby’s birth for 2nd/subsequent babies, baby drops down into mother’s pelvis. When baby’s lungs full mature, baby releases protein that signals moms baby to begin labor. Oxytocin, endorphins, adrenalin all prepare mom and baby for transition to outside world

  • Small Group activities/learning tasks
  • Give each group a card with scenario of pregnant woman, can use handbook to look up answers.   See 3 scenarios in overview of labor pg 82 or on cD
  • Labor time line game and role play
  • DVDs: show labor and birth in positive light
    • Celebrate birth! – an inside look at labor; excellent view of 2nd stage in Connie’s birth and poetic segment of women giving birth in Everyday Miracles
    • Of nature and birth – 3 min DVD with inspiring chant “Beautiful Baby”
  • Game: labor time line – groups 2-4 ppl; give pics of phases of labor and put in timeline – before labor begins, early labor, active labor, transition, pushing. Put things such as rupture of membranes, nausea, panic, hot/cold, leg cramps, anxiety, walk, eat, drink, empty bladder, turn off TV, dim lights etc. can put things in more than one category
  • Role play: contraction with vocalization, movement, moaning with focal point, loss of focus and panic. After role play, discuss ways partner helped or could have helped. Other role play is to demonstrate baby’s trip through pelvis, showing cardinal movements (tuck chin, rotate, extend etc)

Pain Management Strategies and comfort measures – don’t underestimate comfort measures

  • Waterbirth – so effective people call it aquadural. Show at least 1 DVD with women laboring or giving birth in labor
  • Music During Labor – play wide variety; partner songs.
  • Goody bag demonstration – pg 96. Ask them to pack one for last class. Have each person pick an item and guess its use.
  • Tool belt demonstration – Teri Shilling’s Staying Energized card set   Massage tool circle – small, hand held massage tools. Ask people to bring a tool from home.
  • Rehearsals/ role playing – having them role play the same situation at the same time decreases performance anxiety. Discuss what strategies were used.
  • For final labor rehearsal of series, set up labor stations. Position/activity. Have as many stations as students. Can make posters. Birth Companion pamphlet by Childbirth Graphics. Childbirth Skills Teaching Kit. Add massage toys, music player, warm/ice pack etc to stations. Sample rehearsals on pg 83, 84. Aromatherapy. Rebozo.
  • Possible Labor Stations: Sensory Station. Hot/cold pack. Vibrators/massages. Focal point, music, aromatherapy suggestions. Ideas for goody bag. Standing Station: birth ball or lean over on table. Against wall. Rebozo, ice wrap, massage tool. Slow dancing. Standing, leaning forward or back. Abdominal lifting. Sitting Station: chair, birth ball, massage tools. Sitting upright, sitting leaning forward, sitting leaning back. Kneeling and all fours station: mat, chair, ball. Side lying with relaxing images station: mat/blanket. Side lying picture. Relaxing images. Touch relaxation station: mats/chairs. Handout for hand massage. Touch relaxation. Movement station: chair/ball. Pictures of movements: birth ball swaying, rocking, swaying, stepping, dancing, knee press, hip squeeze, lunge. Other stations: pushing, breath awareness, birth art, mom’s choice, partner’s choice.
  • Handouts on Web:; 3 R’s;
  • Handouts for purchase: Penny Simkin’s road map of labor.
  • Breathing strategies: (scroll to correct journal)
  • Collection of Labor Stories: a midwifes story; ill never have sex with you again; birthing a better way; orgasmic birth; belly button bliss; labor of love; adventures in natural childbirth; baby catcher
  • Labor station card sets: childbirth skills teaching kit. Labor lab-interactive learning for labor coping skills. ICEA stations of labor.
  • Creative teaching strategies: The idea box and staying energized by T. Shilling on

Labor Scenarios

  • Group 1: Emily, a first time mother to be (“primip”) at 38 weeks gestation goes to her health care provider for a regular check-up. She lost 2 lbs in the last week and has lost her mucous plug. An exam shows that her cervix is 20% effaced and 1 cm dilated. She has been having Braxton-Hicks contractions for the past 3 months. Recent ones are hurting a bit more
    • Is it too early for labor to begin?
    • Is it dangerous to lose weight?
    • What is the mucous plug?
    • What does the exam tell you?
    • Are these contractions normal?
    • Is she in labor?
    • What should she do?
  • Group 2: One week before her due date, Lupe goes to bed late after cleaning the kitchen and arranging the baby’s room. She sleeps for a while, then gets up tot go to the bathroom. When she stands up, she decides that she waited too long because she feels a wet trickle down her leg. She returns to bed after emptying her bladder and sleeps fitfully, waking periodically with cramps. At 6AM, she rolls over again, trying to get comfortable, when she realizes the bed is really quite wet
    • What is going on?
    • What should she do? When?
    • What does she wish she had done to the bed?
    • What might she soon be feeling?
  • By 2 that afternoon, she is at her birth location. Her cervix is 5 cm dilated and contractions are coming every 4 min and last 60 seconds
    • Is this time frame reasonable?
    • How long until the baby is born?
    • What might she be doing?
    • What might she be feeling?
  • Group 3: Jasmine gets up early on Sunday morning because she just can’t sleep. She does pelvic tilts in a warm shower to help her aching back. After breakfast, she goes for a long walk with her partner. When they return home, he gives her a backrub. They decide to go to the movies. After returning home, Jasmine is ready for a nap. When she lies down, she notices that the baby seems to be “all balled up inside.” Then she relaxes and so does the baby. Over the next hour, that same “Balling up” feeling happens 5 more times
    • What might Jasmine be experiencing?
    • If she is at 34 weeks gestation, what should she do?
    • If she is at 41 weeks gestation, what should she do?
  • By 7PM, she is at her birth location; her cervix is dilated 8 cm. she is having very strong contractions every 2 min that last for 90 sec
    • What is her mood likely to be?
    • What physical symptoms might she be having?
    • How long until the baby is born?
    • What might her labor partner be doing?

Review of Stage 1 and practice situations

Review of Stage 1: For each of following situations answer 1) is this true labor and b) what should you both be doing?

  • You wake up in the night to go to the bathroom and become aware of Braxton Hicks contractions that seem stronger than you ever felt before
  • After taking a long walk in the park, you notice that your underwear feels very damp. When you go to the bathroom to empty bladder, you feel you do not have control over flow.
  • You have been having contractions mostly in you back all day long. There are getting stronger but there is no pattern to them. You must really concentrate on your focal point and use your breathing patterns to stay on top of them.

Labor Rehearsal: what are possible coping techniques for the following?

  • 5AM, Dilation? : You and your partner are asleep at home. You wake up to go to the bathroom. Go back to bed. Up again at 5:15 AM. Another bathroom trip. Feels different. Cant go back to sleep. Backache.
  • 8AM, dilation? Contractions have been coming every 20 min since 5:35AM but are very mid, requiring only conscious release for comfort
  • Noon, dilation?: contractions are now coming every 4, then 6, then 4, then 6 min apart. You are feeling some back pressure and must really use concentration and breathing to stay on top of the contractions
  • 1PM, 3 cm dilated: contractions are occurring every 3 min. your partner is parking the car, taking a long time! You are in your hospital room alone
  • 3PM, 5 cm dilated: contractions have really slowed down.   You are starting to worry that your cervix will never dilate past 5 cm
  • 5:30PM, 6 cm dilated: after some time in the shower, you are sitting in a rocking chair and feeling much better. A hospital anesthesiologist peeks in and asks if you would like an epidural
  • 7PM, 7-8 cm dilated: your legs begin shaking uncontrollably. You complain of nausea and say that you CANNOT do this anymore
  • 7:30PM, dilation? Both of you are alone in the birthing room. At the peak of a contraction, you feel pressure and call out “The baby’s coming! Now”
  • 8:15PM, 10 cm: After 45 min of pushing in the semi-sitting position, you are discouraged and say “I can’t push anymore. My back hurts too much!”

Comfort Measures for Labor: Aromatherapy

Smell is the most primitive and powerful of the senses. Many people can be transported to a different time and place by smelling a certain odor. Ask students to pay attention to smells when touring labor/delivery. For some women, even faint smells of disinfectant and hospital odors can trigger tension and fear. Challenge students to think of ways they can create pleasant smells in labor room (Bring pillow from home, a fresh flower or fav scented massage lotion). At home, can use scented candles or soak in scented bath water.

Pregnant women are very sensitive to smell. Two most popular aromas for labor and birth are jasmine and lavender. Jasmine is considered to have a stimulating effect upon uterine tone and should not e used during pregnancy prior to labor. When used in a massage oil/lotion during labor, is said to relieve pain and strengthen contractions. Also a powerful antidepressant and helps to relax and restore confidence in laboring woman. Lavender is perhaps most well known aroma for promoting relaxation and sense of well-being. Neroli (orange blossom), geranium, clary sage and rose are others.

  • if using essential oils, use only high quality, pure oils. Although expensive, tiny amounts go a long way.
  • Some labor and birth units have purchased electric vaporizers or diffusers for use in labor rooms.
  • Small devices which plug into electric outlets and warm a pad to which an essential oil has been added are available
  • Very small amounts of essential oils (3-8 drops) may be added to full tub of bath water. Don’t have pure oils come in contact with body as may irritate
  • Sachets may be placed inside a pillow case or in other locations in birthing room. Sensual sachets may contain jasmine, rose and citrus; calming ones may contain lavender, sage, cypress. Remove from room if becomes offensive
  • Scented massage lotions wonderful during labor

The Rebozo: a traditional shawl used by indigenous people worldwide to carry their babies. Inexpensive and versatile baby carrier. Used in attachment parenting (Dr. Sears). Can wear with a baby doll inside in class.

  • DVD: Comfort Measures for Childbirth: The Rebozo Way by Guadalupe Trueba. Try hip squeeze with rebozo (handbook pg 47), abdominal lifting with the rebozo, sensory stimulation with strap on cold/heat pack, slow dance with light pressure, squatting with rebozo as a rope. Can be purchased through DONA.
  • Comfort Measures for Labor: The Rebozo: Comfort Measures for Childbirth: The Rebozo Way. Hip squeeze with rebozo. Abdominal lifting with rebozo. Sensory stimulation with strap on cold/heat pack. Slow dance with light pressure. Squatting with rebozo as a rope. Purchase from

Breathing Strategies for Labor – pg 43

It is the awareness of one’s breathing and the rationale for attention focusing, that are more important for the educator to teach than any specific breathing technique. Breathing and relaxing go hand-in-hand. For some, it is easier to demonstrate that breathing slows as they relax; for others, relaxing is enhanced by consciously slowing their breathing. A variety of approaches will benefit the most students.

Teaching strategies to integrate into classes:

  • Draw the attention of the students to the depth and rate of their natural breathing…when they are exercising, when they are sitting, and when they are relaxing in your class
  • After a relaxation sequence, have students attend to their breathing and note if it has slowed
  • In another relaxation sequence, suggest that students consciously slow their breaths to enhance their relaxation. Offer strategies such as counting or phrases to help them slow down.
  • When students are relaxed, ask if they feel movement in the chest or in the abdomen as they breathe

Breathing Practice: while some educators believe that it is not necessary to practice breathing at all, because women will find their own pace and rhythms in labor, others feel that practicing various techniques will build confidence in women who have a need to feel prepared by knowing “something to do” during labor. Just be sure to stress that there is not one “right” way to breathe. They may modify and adapt what is taught.

  • For those that like visuals, refer to page 107 in workbook. Describe the wavy lines as possible paces and patterns. Experiment with the suggested strategies. Some people will find visuals confusing, while others will benefit from them
  • Explain and demonstrate a cleansing breath. It cleanses the mind of distracting thoughts, gives an oxygen boost to the body, and signals relaxation. Some prefer to call it a relaxing breath or a sign. It is a full breath taken to a comfortable depth, not a stressful one
  • Suggest that students experiment with several one minute time periods: breathing through nose, mouth, then in nose and out mouth. Ask for feedback then process comments
  • Give examples of breathing colors. Breathe in air of a relaxing color to soothe the body and exhale a color of tension. Or imagine one favorite color while breathing in and out. Ask for feedback.
  • Give examples of affirmations that might be said or thought in rhythm to inhaling and exhaling. Ask for feedback
  • Suggest they count slowly in and out to the same number as they breathe to a comfortable depth. Remember that number. Experiment with other numbers to vary the depth of each breath in a contraction for the sake of concentration
  • Demonstrate breathing with vocalizations, so they will understand that moaning, counting aloud, or making other sounds can be helpful and that they are free to make noises as they wish
  • Experiment with various patterns and paces so students will understand the guidelines, yet feel encouraged to make their own adaptations in labor. Some women like to have their partner direct their pattern or pace; others do not.

Focused Breathing – focusing attention on breathing and on other comfort techniques, rather than on pain, is a positive strategy for many women in labor. Respiratory physiologists refer to breathing at a rate and depth which is voluntarily controlled as “paced breathing.” Besides helping to maintain the blood oxygen and carbon dioxide at appropriate levels, the mental concentration required to maintain the pace can help divert the breather’s attention from intruding thoughts or painful contractions and can prevent hyperventilation, as well as other stress responses such as increased heart rate and muscle tension. Encourage women to pace their own breathing during labor to the depth and rate that is most comfortable to them.

Slow breathing increases the ability to relax, conserves energy, fully oxygenates the body and provides a positive focus. When fully relaxed, most people breathe at about ½ their normal resting breathing rate.

During labor if slow breathing ceases to be comfortable, a woman will often increase her breathing rate as the contraction increases in intensity. Breathing faster over the peak may help her to cope, but theoretically her pace should not exceed 2x her normal breathing rate to keep her from hyperventilation or becoming more fatigued. Breathing patterns can help her to get into a ritual that is rhythmic and relaxing. Additional attention-focusing is attained by adding words, phrases or images to her rhythmic breathing. Using a strategy of counting to 4 or 5 or more with each inhalation and exhalation may be effective for her. If she practices yoga, she will likely turn to the pranayama she uses in her practice.

Any breathing pattern or pace may be used at any time during labor. For many women, changing breathing strategies (pg 43 of handbook) will offer diversion of focus and decreased pain perception, while maintaining adequate oxygenation and encouraging the relaxation response.

DVDs: Penny Simkin’s comfort measures for childbirth and Relaxation, rhythm & ritual: The 3 R’s of childbirth.

Second Stage – (pgs 42, 44-45 in workbook):

Current research and recommendations

  • “Laboring Down” – encouraging her to listen to signals her body is giving her and to bear down as she desires works beautifully for woman who doesn’t have epidural. With epidural, she may not be able to feel signals her body is giving her. Research indicates it’s most often safe for her to rest without actively pushing, until uterus alone pushes baby down to a +1 station. After this period of laboring down, an urge to push spontaneously. Some caregivers may use directed pushing if baby’s descent is too slow.
  • Coached vs physiologic pushing
    • Researchers found that at 3 months postpartum, women who were coached during 2nd stage had impaired pelvic floor and bladder function as compared to women who were instructed to do what comes naturally
    • Kathleen Simpson found that babies whose mothers were instructed to begin pushing upon full dilation and to push while holding their breath to a count of 10 had less oxygen in their blood than women who were allowed to wait until they felt the urge to push and to push without holding their breath. The women in the breath-holding group had more perineal lacerations.
  • ACOG/SMFM Recommendations: in their 2014 joint consensus statement, ACOG and Society for Maternal-Fetal Medicine recommend that health care providers give women more time in 2nd stage before recommending cesarean surgery for failure to progress than under the old guidelines established by the Friedman Curve. They say “A specific absolute maximum length of time spent in the 2nd stage of labor beyond which all women should undergo operative delivery has not been identified. “ They go on to recommend that nulliparous women be allowed to push for at least 3 hours and multiparous women, 2 hours. However, they also say that “longer durations may be appropriate on an individualized bases (epidural/fetal malposition) as long as progress is being documented”

AWHONN Recommendations (AWHONN is professional organization that includes labor and delivery nurses) – since ’00, has recommended that nurses encourage physiologic pushing during 2nd stage.   Their evidence-based recommendations include the following:

  • The information that pregnant women receive before labor about 2nd stage should include realistic expectation about the length of 2nd stage; sensations women may experience; the benefits of spontaneous (non-directed) pushing over directed pushing; the benefits of upright positions and the risks of the supine position; and the benefits of labor support, including doulas
  • A woman should be allowed to rest until she feels the urge to push
  • A woman should be encouraged to try a variety of upright positions during 2nd stage
  • Spontaneous bearing down, rather than directed pushing, should be encouraged
  • Breath-holding for longer than 6-8 sec should be discouraged
  • Noises such as grunting, groaning and exhaling should be supported
  • Nurses should validate the normalcy of the sensations and sounds the laboring woman is making

Lecture/Discussion Points

3 phases of 2nd stage

  • Lull or resting phase – when baby’s head leaves uterus, that muscle is no longer stretched as much as it was when baby was totally inside. There may be a welcome lull in the contractions as the uterus now works to take up the slack which before was tight around the baby. the muscle fibers shorter, but the mother may not be aware of contractions. Sheila Kitzinger refers to this as “rest and be thankful” time which may last up to 20-30 min. Once uterus is again hugging the baby tightly, the urge-to push generally begins. If not, a squatting position, as long as baby has descended to 1 station, may help bring it on
  • Active or descent phase – the contractions resume and intensify, with the urge-to-push occurring at the peak of each wave during the contraction. If allowed to push spontaneously, a mother will generally bear down intermittently with lighter breaths between her urges. She may wish to change positions to facilitate the baby’s descent during this phase.
  • Crowning or perineal phase – the last few contractions from crowning to birth are intense, both physically and emotionally. Emotionally the woman is ready to give birth, but physically she experiences an intense burning and stretching sensation which signals her to stop pushing hard and to allow the birth to happen gently. If being directed by the care provider, she may be instructed to blow to counteract the urge-to-push. Her reluctance to push to vigorously at this time often allows the perineum to stretch so that an episiotomy is unnecessary. The labor woman’s bod knows what to do to birth this baby!

The new baby and the importance of immediate skin-to-skin contact – celebrate the birth of the baby! if the new parents have chosen not to find out the sex of the baby ahead of time, encourage them to ask their caregiver to allow them to announce the sex of their new son or daughter.   Describe the appearance of the baby at birth; explain the Apgar score. Emphasize that immediate skin-to-skin contact with the mother helps to stabilize the baby’s temperature, heartbeat, and respiration. Because of catecholamines secreted by the mother during 2nd stage, most babies are born wide awake and eager to look into their parents’ eyes. Many babies will search for the familiar deep voice of their fathers in the birthing room. Skin-to-contact also increases the flow of birth hormones that aid breastfeeding and attachment. It is especially important for women who have cesarean delivers or births with many interventions.

Swedish breastfeeding researcher Ann Marie Widstrom has identified 9 instinctive stages that a baby moves through when placed skin-to-skin on his mother’s belly immediately after birth. Left undisturbed, the baby will gradually make his way to the breast to self-attach. This can take as long as 90 min. Dr. Widstrom believes that if a baby is allowed to move through these 9 phases without being “helped,” he is very likely to be successful at breastfeeding. Students who have learned about the 9 instinctive stages in their childbirth classes are fascinated to watch their own babies move through these phases. As long as the baby is healthy, even cesarean mothers can experience the same uninterrupted skin-to-skin contact immediately after birth. If the hospital(S) where your students will be giving birth do not offer this option, bring the research and DVDs to the attention of the nursing staff.

“Microbial seeding” – increasing scientific evidence supports the critical importance to the healthy development of the immune system of the “microbial” seeding” that takes place as the baby passes through the birth canal during vaginal birth. This process is further enhanced by skin-to-skin contact and breastfeeding. Research is underway looking at ways of providing babies born by cesarean with “microbial seeding”. The 2014 film MicroBirth powerfully describes it.

Delayed Cord Clamping – in their book Optimal Care in Childbirth, Henci Goer and Amy Romano describe the important role of delayed cord clamping in aiding the transformation from fetal circulation to air breathing in the newborn. For a newborn who does not require emergency resuscitation, research now indicates that delaying cord clamping for 2-3 min (or more) aids this transition, poses no harms, and may improve iron stores for up to 6 months of age. According to a 2013 Cochrane Review, “a more liberal approach to delaying clamping of the umbilical cord in healthy term infants appears to be warranted, particularly in light of growing evidence that delayed cord clamping increases early hemoglobin concentrations and iron stores in infants. Delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available.” A 2014 study published in Lancet reassures health care providers that the benefits of delayed cord clamping still hold true when the baby is placed immediately on the mother’s chest after birth. Penny Simkin effectively demonstrates the benefits of delayed cord clamping in a YouTube video clip.


  • Baby Blockhead – you can use this to show students why the baby must rotate for the birth to occur. The wider diameter of the pelvic inlet, then outlet, matches the wider diameter of the baby’s head, then shoulders, as the baby rotates through the pelvis. It becomes evident that this process will require time, even after the cervix has fully dilated (these models are no longer for sale).
  • Pelvic model and fetal model– demonstrate the cardinal movements as the baby descends, flexes, rotates internally, extends and finally rotates externally (2 pelvic models that allow the bones to give as demonstrate cardinal movements are available from ICEA or Childbirth Graphics).

Practice – Because the emphasis today is on encouraging the laboring woman to tune into her body’s signals and to bear down spontaneously, there is not a lot of pushing practice that needs to be done in childbirth classes. However, a variety of positions with discussion of the benefits of each should be practiced, so that the laboring woman will feel comfortable using them during 2nd stage.


  • DVDs: 2nd Stage: showing powerful images of women giving birth spontaneously will help to increase the confidence of women in your classes. The births in Celebrate Birth! Are excellent. The Timeless Way shows how women have used upright positions and benefited from labor support throughout the ages. Your students will be amazed by how easy birth appears in the stunning video, Birth in the Squatting Position. Spontaneous pushing, the natural pause at the beginning of 2nd stage, vocalization and superb support from the nurse-midwife are all featured in Jasmine’s birth in the VIDA video, Open Minds to Birth. The powerful video, Kangaroo Mother Care, illustrates the benefits of immediate skin-to-skin contact for both full-term and preterm babies.
  • Handouts: Health Children Project: The first hour after birth: A baby’s 9 instinctive stages
  • DVDs:
  • Breastfeeding: Baby’s Choice
  • The magical hour: holding your baby skin to skin for the first hour after birth
  • Skin to skin in the first hour after birth: practical advice for staff after vaginal and cesarean birth

Penny Simkin on Delayed Cord Clamping

Possible Challenges of Labor (pg 44 workbook): after presenting a textbook labor to class, don’t fail to integrate the many challenges that a woman might face into scenarios of possible labors. Not much is certain in labor. Rarely utter the words always or never when speaking of the birth experience! Nausea, chills, shakes, leg cramps, and back pain are all challenges that may or may not occur in a woman’s labor, but she needs to be advised what to do in case it happens to her.

  • Research update: term “back pain” replaces “back labor”- researchers found that babies change position often during labor and that final position for birth is not established until very late in labor. According to periodic ultrasounds, more than 1/3 (36%) of babies were in OP at some point during labor. Women who had babies in OP early in labor did not complain of more back pain than mothers with babies in OA position and were not more likely to request epidural. Women who chose epidural were more likely to have a baby in OP at birth, establishing a strong association between OP and epidural.
  • Models – pelvis and doll are used to show OA and OP positions and how an all-fours position during labor could possible help (gravity will pull heavier backside of baby toward floor and away from mom’s back. This relieves back pain and facilitates rotation to OA).
    • Some use funnels of varying shapes and sizes to create visual images of different types of labors women may experience. Some compare opening of funnel with 1st stage and neck with 2nd stage, can also compare neck to pre-labor and early phase and opening of funnel to rest of labor. The funnel with both a long neck and large opening represents a slow long hard labor – the type of labor which often accompanies labor induction, especially if the cervix is not ripe.


  • Pelvic rock in all fours
  • Passive pelvic tuck on side
  • Lunge (standing and kneeling)
  • Counterpressure to relieve backache
  • Panic routine

DVDs: Comfort Measures, 3Rs, Understanding Birth (Injoy)

Possible Challenges of Labor: nausea, chills, shakes, leg cramps and back pain are all challenges that may or may not occur, but she needs to be advised what to do in case.

  • “Back pain” replaces “Back labor” – more than 1/3 of babies were in OP at some point during labor according to ultrasounds. Mothers who had baby in OP in early labor didn’t complain of more back pain and were not more likely to request epidural analgesia. However, women who chose epidural analgesia were more likely to have a baby in OP at birth, established a strong association between epidural and OP position.
  • Models: pelvis and doll used to show OA and OP position and how all fours could possibly help (Gravity will pull back heavier backside of baby toward floor and away from mom’s back, which relieves back pain and facilitates rotation to OA).
  • Practice: pelvic rock in all fours; passive pelvic tuck on side; lunge (standing and kneeling), counter pressure to relieve backache, panic routine
  • DVDs: Comfort Measures, 3Rs, Understanding Birth (Injoy)

Movements for Labor (pg 47 workbook)– also included on PowerPoint CD.

Demonstration and return demonstration:

  • Lunge – hold pelvic model in front of you; gently open 1 ischium slightly outward in the direction that you lunge. The movement of lunge may pull open the pelvis just enough to allow a baby in OP to rotate to OA. If hips turn to the direction the knee points, the lunge does not open the pelvis. Make sure their hips are facing forward while knee points to side. During labor, have her lunge to which side feels better
  • Abdominal lifting – pregnant woman interlocks fingers beneath her belly. Lifting her belly up and slightly inward helps to align the long axis of the baby with the axis of the pelvic inlet. In rare cases, it might compress abdominal cord, so should only be done when there is someone available to listen to fetal tones during contractions. In pregnancy, its helpful with the pelvic tilt to relieve pressure
  • Hip squeeze – using rebozo to do so may ease discomfort caused by stretching of sacroiliac joints as baby moves down in the pelvis. Practice with 1 person pulling on rebozo, then try w 2 people – 1 pulling each end of crossed shawl.
  • Knee press – relieves back pain by having femur push into hip joint to release sacroiliac joints. Woman should be seated with her hips at the back of the chair and her knees level with her hips. May need a book under feet for proper height if legs are short. Do not do if has knee problems.

Childbirth Choices (pg 49 workbook)

Teaching Points

  • Evidence- Based Care (See Section III)
  • Normal birth and the cascade of interventions – by showing video and slide images of laboring women using comfort techniques and having students in class practice, you will help increase their confidence to give birth. If a woman wants to walk around during labor, she should arrange for periodic auscultation of baby’s heart or intermittent electronic monitoring. If she believes epidural is best for her, she will most likely be confined to bed. Cascade of Interventions is included on CD.
  • Can childbirth educators make a difference? Randomized controlled trial conducted to determine whether adding a special 45 min curriculum on risks and benefits of elective induction would reduce #. With cesarean rate at 33%…
  • Progress report: reducing elective inductions: mounting evidence of increased risks to babies of late-preterm (34-37 weeks) and early term (37-38 weeks) births and possible increased risk of cesarean with labor induction, the Joint Commission now requires hospitals with 1100+ births//yr to report elective births before 39 weeks. Most hospitals now ban before 39 weeks.
    • Early term – between 37 weeks and 39 weeks
    • Full Term – Between 39 weeks and 41 weeks
    • Late term – between 41 weeks and 42 weeks
    • Postterm – 42 weeks+
    • When is it good to induce postterm pregnancies? There is good and consistent evidence to induce labor after 42 weeks, but there is only limited or inconsistent evidence to induce between 41 and 42 weeks
  • New (in the USA) analgesia option – nitrous oxide – around the world, it’s one of most popular options for pain relief in labor. Prestigious medical centers such as Vanderbilt and Dartmouth offer it. Studies indicate it does not affect baby and that any effects on mother dissipate within 5 min after mother’s last breath of nitrous. Can provide just the right amount of pain relief for women who want to avoid narcotics and epidurals.
  • Informed Decision Making
    • Nature/purpose of proposed treatment/procedure
    • Risks and benefits
    • Alternatives
    • Risks and benefits of alternative
    • Risk and benefits of not receiving or undergoing a treatment
  • Informed Decision Making Cards
  • Is this an emergency, or do we have time to talk?
    1. In true emergencies, life and death decision have to be made quickly, without time for thorough discussion; emergencies are rare. In vast majority, there is plenty of time to obtain info.
  • What would be the benefits of doing this?
  • What would be the risks?
  • If we do this, what other procedures or treatments might we end up needing as a result?
  • What else could we try first or instead?
  • What would happen if we waited an hour or two (A day or two, a week or two etc) before doing it?
  • What would happen if we didn’t do it at all?
  • Assessment of effective coping during labor– Joint Commission mandated that hospital providers do a better job of assessing pain; hospital nurses now ask patients to rate pain on a regular basis. They have stated it is fine for nurses to asses rather than ask how much pain she is feeling. See pg IV-115 for form.
  • Birth Plans – a woman planning for a natural birth will need to arrange for continuous labor support, freedom of movement during labor and access to nonpharmacologic pain management strategies. She will have to make sure ahead of time those supporting her will provide encouragement without hesitation. A woman planning an epidural will need to know what other interventions are required; some women are unaware that they most often come with IV fluids, continuous EFM and Pitocin. Birth plans helpful for providers/nurses changing during woman’s labor. They can become a problem when woman arrives with long list of do’s and don’ts and when care providers see it as a lack of trust. Some have standardized birth plans they encourage clients to bring. Look for Win-Win Birth Plan under Articles and Handouts on Penny Simkin’s home page.
  • Lecture/Discussion: see pg IV-112 for recommendations for care in normal labor. Info on indications, advantages, disadvantages and alternatives often presented in this format.
  • Large group discussion: ask entire class what they’ve heard about controversial topics such as epidural. Encourage them to do most of the talking and only interject when you need to correct. Takes pressure off teacher having to list all benefits and risks. Show magazine, newspaper article or Internet story featuring controversial topic and ask people what they think. People Magazine has feature births of celebrities.
  • Internet Search – ask students in class to volunteer to research common interventions. Each takes one topic such as epidural or fetal monitoring. Be sure to include discussion about credibility of websites
  • Small group activities/learning tasks:
    • Intervention Folder: divide class into small groups to research common medical interventions. Suggestions on pg VII-22-24. Should have pros/cons of each. List of ACOG medical indications for induction on pg IV-116. May want to include copy of chart on pg IV 112-113.
    • Interventions Card Game: to review key info about childbirth options and interventions. Divide class into groups. Give each a heading card for option/intervention and a set of cards listing facts. Have them put together header with fact cards. Consider prizes to group who finished first. Samples in Appendix. Can put on colored cardstock paper. Make several sets. If make each on a different color, it will be easier to keep all together (all yellow together for complete set etc)
    • Drawing activity: divide class into small groups. Give each a copy of drawing on pg IV-117 and some colored markers. Ask to draw additional interventions a laboring woman might need if labor is induced. Ask them to draw comfort measures. Consider prices for those who come up with most.
    • Story telling activity: suggest that pregnant students write a story (or verbally tell partner) about their birth in the wall they hope to tell it after baby is born. Have them put as much detail into story as they can. Ask what will it take to make the story come true. They can then form birth plan with most desired feature, but be reminded that flexibility is important.
  • Values clarification exercises: icebreakers II-5 under topics to contemplate can be used to promote discussion about topics
  • Teaching aid: wearing different hats for opinion vs fact
  • Role Play:
    • Induction/Surgical Birth: create pretend hospital equipment from household items. Air-pillow bag (packaging) or small inflated balloon to represent bag of IV fluids; yarn for tubing; ace bandages to represent external monitor belts and or bp cuff. Have class members brainstorm comfort measures. Similar role play can be done for cesarean IV-131
    • Communication strategies: provide each student w 2 cards. Have practice conversations at same time so no pair is in spotlight. IV-118 and on Educator’s Guide CD
  • DVDs –
    • Choices in childbirth – cesarean birth
    • Natural born babies
    • Pain management for childbirth
    • Understanding birth includes chapters Understanding Medical Procedures and Understanding Cesarean Birth
  • Professional references

International and National Guidelines for normal, low risk pregnant women

  • Cochrane Library Most Recent Reviews or A Guide to Effective Care in Pregnancy & Childbirth (00)
  • William’s Obstetrics 2010 (Policies at Parkland Memorial Hospital)
  • Baby-Friendly Hospital Initiative 2009
  • CIMS
  • ACOG
  • Canadian Professional Birth Related Organizations

Position & Movement:

  • “… clean and important evidence that walking and upright positions in the 1st stage of labor reduces the duration of labour, the risk of cesarean the need for epidural…”
  • “We give women without complications the option of electing either recumbency or supervised ambulation during labor”
  • “offers all birthing mothers: freedom to walk, move about, and assume the positions of her choice during labor and birth…”
  • “provides the birthing woman with the freedom to walk, move around, and assume the positions of her choice”
  • “if you feel like it and your health care provider says its OK, walk the halls”
  • “The SOGC and its partners providing maternity health care recommend freedom of movement throughout labor”

Elective Induction:

  • “the decision to bring pregnancy to an end before the spontaneous onset of labor is one of the most drastic ways of intervening in the natural process of pregnancy and childbirth. There has been very little methodologically sound research on the indication for elective delivery…”
  • No elective inductions – “we consider 41 week pregnancies without other complications to be normal. Thus, no interventions are practiced solely on fetal age until 42 completed weeks”
  • “…has an induction rate of 10% or less”
  • “has rate of 10% or less for induction and augmentation (presently under review)
  • “in cases in which continuing the pregnancy is more risky than delivering the baby, the health care provider might induce labor. The risks depend on method chosen and include change in fetal heart rate, increased risk of infection in the woman and her baby, umbilical cord problems, overstimulation of the uterus and uterine rupture (rarely)
  • ‘ The SOGC and its partners providing maternity health care recommend spontaneous onset of labor”

Fetal Monitoring:

  • “regular auscultation by a personal attendant, as used in the randomized trials, therefore seems to be the policy of choice for these (low-risk, without induction or augmentation) labors”
  • “intermittent auscultation or continuous electronic monitoring is considered an acceptable method of intrapartum surveillance in both low and high risk pregnancies”
  • “does not employ practices and procedures that are unsupported by scientific evidence, including but not limited to the following…EFM”
  • ‘ does not employ practices and procedures that are unsupported by scientific evidence, including but not limited to the following: ECM”
  • according to ACOG practice bulletin #106 “given that the available date do not show a clear benefit for the use of EFM over intermittent auscultation, either option is acceptable ina patient without complications”
  • recommend use of fetal surveillance by intermittent auscultation

Foods & Fluids:

  • “since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labor for women at low risk of complications”
  • “food should be withheld during active labor and delivery…according to AAP and ACOG, sips of clear liquids, occasional ice chips and lip moisturizers are permitted”
  • “does not employ practices and procedures that are unsupported by scientific evidence, including…withholding nourishment”
  • “does not employ practices and procedures that are unsupported by scientific evidence including withholding nourishment
  • “according to ACOG committee opinion, modest amounts of clear liquids may be allowed for patients with uncomplicated labor. Women scheduled for a cesarean may drink clear liquids up to 2 hrs before anesthesia
  • “no routine interventions”

Labor Support

  • “continuous support during labor has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labor and birth”
  • “parkland policy: 2 support persons allowed
  • “”offers all birthing mothers: unrestricted access to the birth companions of her choice ,including fathers, partners, children, family members, and friends AND support from a doula”
  • “unrestricted access to the birth companions of her choice, including fathers, partners, children, family members and friends AND support from a skilled woman, for example, a doula
  • “another issue to think about is whom you’d like at your side during labor and delivery. It’s a good idea to choose someone who may be best at helping you stay relaxed and calm. A childbirth partner can be a spouse, partner, relative, or close friend. A growing trend is the sue of a doula, a layperson who has received special training in labor support and childbirth
  • recommend continuous labor support

Pain Management

  • “there is some evidence to suggest that immersion in water, relaxation, acupuncture, massage and local anesthetic nerve blocks or non-opioid drugs may improve management of labor pain, with few adverse effects” epidural analgesia provides effective pain relief but at the cost of increased instrumental vaginal birth
  • parkland policy: nurse-midwives utilize a variety of physical comfort measures as well as emotional support in addition to narcotics and epidural anesthesia. No showers or baths available.
  • “educates staff in non drug methods of pain relief and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication”
  • “educates staff in non-drug methods of pain relief and do not promote the use of analgesic an anesthetic drugs not specifically required to correct a complication”
  • “in addition to pharmacological pain management, also recommended: breathing and relaxation techniques taught in childbirth classes, counterpressure, focal point, comfort and support from your labor coach and ice chips and hard candies
  • “institutions offering options for pharmacologic and non pharmacologic approaches to pain relief (such as tubs/showers, access to natural light, environmental designs/adaptations…”

Second stage

  • “routine directed pushing, sustained bearing down and breath holding UNLIKELY to be beneficial; lithotomy & supine positions harmful/ineffective
  • “in most cases, bearing down is reflexive and spontaneous during 2nd stage labor. Delivery can be accomplished with the mother in a variety of positions…”
  • no statement
  • no statement
  • “many women give birth to their babies while propped up in bed, with their legs braced against foot rests. There are other birth positions you can try (lying on your side, ,for instance) as long as your health care provider approves”
  • “spontaneous pushing in the woman’s preferred positions


  • restricted (As needed) episiotomy policies appeared to give a number of benefits compared with using routine episiotomy
  • “most, including us, advocate individualization and do not routinely perform episiotomy
  • “has an episiotomy rate of 20% or less”
  • “has an episiotomy rate of 20% or less, with a goal of 5%”
  • according to a march 2000 news release, ACOG does not recommend routine episiotomies. This recommendation was reaffirmed in 2006 press release
  • no routine interventions

The Cascade Effect of Obstetric Interventions: induction/continuous EFM -> inactivity, confined to bed -> increased anxiety -> false positive monitor readings -> slowed labor -> AROM -> Pitocin -> increased pain -> pain meds/anesthesia -> abnormal FHR patterns -> (failed) forceps or vacuum -> cesarean surgery

Assessment of Effective Coping During Labor

Upon admission, ask the laboring woman about her preferences:

Which of the following best describes your plan for pain management during labor?

  1. I would like to have an unmedicated birth. Please do not offer me any type of pain medication. If I decide that I want medication for pain, I will ask for it
  2. I want to see how it goes. I would like to tray nonpharmacologic (non-drug) pain management strategies, but I may decide to use pain medications too
  3. I would like to have a small dose of pain medication (narcotic) by injection (shot) or put into my IV (if I have an IV)
  4. I would like to have epidural analgesia

During labor, ask the laboring woman how well she feels she is coping with her contractions. Give her a scale of 0 (coping well) to 10 (not coping well).

Coping Rating/Suggested Nonpharmacologic Nursing Comfort Strategies

0-3 /Coping Well

  • Encourage her –tell her how well she is doing
  • Reassure her that labor is going normally; provide reassuring touch to shoulder or hand
  • Offer to stay with the laboring woman if her labor partner needs a short break.
  • Inform her of options available such as a tub and/or shower.

4-7/she is struggling with her contractions

  • If possible provide continuous support; provide reassuring touch to shoulder or hand
  • Reassure her that what she is feeling is normal; give her info on her progress
  • Encourage her – tell her how well she is doing and try the following to help her more:
  • Modify environment – turn down lights, play music (of her choice)
  • Encourage upright positions
  • Encourage rhythmic movements such as: slow dancing, walking, gently bouncing or swaying on birth ball; rocking in a chair
  • Encourage her to try a warm bath or shower
  • Massage (or show her partner how to) shoulders, back, hands, feet, to help her relax
  • Provide hot packs (shoulders, back) or cold packs (back, cool cloth to forehead, neck)
  • Encourage her to vocalize during contractions (I can do it, I can do it)
  • Add aromatherapy (jasmine or lavender scent in bath water, lotion or essential oil on a cotton ball)
  • Is she is experiencing severe back pain: encourage her to try all fours position or pelvic tilts; encourage her to try lunge; do knee press, counterpressure, double hip squeeze; provide hot or cold packs for lower back; offer intradermal water block

8-10/She is overwhelmed, unable to cope effectively with her contractions

  • Between contractions, try strategies listed above
  • Reassure her that you will stay with her to help her
  • Reassure her that what she is feeling is normal; acknowledge her pain
  • Have partner, other support person provide counterpressure to back as needed
  • During contractions, use the “panic routine” – position yourself so that you can heave eye to eye contact wither her; with permission, place hands on shoulders or arms; breathe with her to help her establish a rhythm

Medical Reasons for Induction

  • The placenta begins to separate form the inner wall of the uterus before the baby is born (abruption placentae)
  • Infection in the uterus (chorioamnionitis)
  • High blood pressure caused by pregnancy (gestation hypertension or more serious conditions known as preeclampsia or eclampsia)
  • Premature rupture of membranes (bag of water has released too early)
  • Postterm pregnancy (>42 weeks)
  • Mothers health problems such as kidney or lung disease
  • Baby is not growing as he/she should and/or environment insider uterus is no longer safe for baby

A large or even very large baby is NOT a medical reason for induction (ACOG)

Thinking about labor induction – draw or write other interventions that may be required if a pregnant woman is thinking about having labor induced. Also draw/write comfort measures that may help her cope.

Communication Role-Plays

Pregnant Woman, Health Care Provider: PW is 39 weeks. HCP is leaving town for a medical convention and recommends induction so that he can be present at birth.

Laboring Woman, Anesthesiologist: A tells laboring women that he may be tied up with some surgeries for quite a while. If she wants an epidural, it would be good to have it now.

Laboring Woman, Labor Nurse: Although intermittent fetal heart rate monitoring was agreed upon as long as baby doing well, nurse wants to put on belts for continuous monitoring.

Pregnant Woman, Health Care Provider: PW asks HCP about policy regarding IVs in labor, as she would like to avoid one. HCP tells her he prefers that all his patients have one in place during labor.

Pregnant Woman, Partner: If baby is a boy, mom doesn’t want him circumcised, but dad does.

Pregnant Woman, Health Care Provider: HCP tells PW that she would like to do a “Quad Screen” to screen for down syndrome and spina bifida. PW isn’t sure she wants test.

Laboring Woman, Health Care Provider: Labor is progressing very slowly. HCP asks LW to consider going with cesarean delivery.

New Mother, Labor Nurse: 20 min after birth, nurse tells mom she needs to take baby to newborn nursery. Mom wants to keep baby with her.

New Mother, Nursery Nurse: Mom wants to have baby room-in during the night. Nurse recommends that mother let baby sleep in nursery so that mother can get a good night’s sleep.

New Mother, Mother-in-law: Late in afternoon after several days at home, baby is fussy. MIL recommends mother try giving baby a little formula to make sure baby is not hungry.

Emergency Birth: some people want to know about anything that could go wrong, worst case scenarios – what most class members do not want to hear. Pg 54 in The Family Way is for those who worry about not making it to hospital. Say can become familiar with local fire stations between home or work and hospital. A paramedic who could help with birth would most likely be found there. If birth seems imminent, they can pull off road and call 911. A quick count of the number of your students who had to deliver their own babies, compared to the number you have taught etc.

Are All Cesareans Necessary? (pg 55 workbook) – because cesareans poses increased risk for mom and baby, government looking to reduce rates.

Unplanned Cesarean – accepting the cesarean as a positive birth experience and necessary procedure is more likely if she is given the freedom to move, good labor support and choice of procedures. Women should know their options and the risks that some procedures carry in increasing the likelihood of surgery

Cesarean by maternal request – ACOG says its ethical to offer elective cesarean (2003). Survey shows only 1% of women requested and its not cause of increasing rate. 2007 – ACOG says cesarean delivery on maternal request not recommended for women desiring several children, given that risks of placenta previa, placenta accrete and need for gravid hysterectomy increase with each cesarean. 2013 – ACOG given balance of risks and benefits, in absence of maternal/fetal indications for cesarean, plan for vaginal delivery is safe and appropriate and should be recommended to patients.

  1. “I don’t want to worry about urinary incontinence later in life” – study 2002 urinary incontinence in group of nuns equivalent to women who had vaginal birth. Biological sisters – 1 who had given birth and 1 not, no difference in rates. High concordance in continence status between sisters, suggesting familiar predisposition
  2. “I don’t want to risk damage to my pelvic floor from the birth process” – some research that vaginal birth associated with bladder, bowel and sexual problems for a few women, other studies suggest that it is interventions such as routine episiotomy, forceps and coached pushing that are responsible. Study showed increased damage 3 months after giving birth to women who were directed to push forcefully to a count of 10 as compared to spontaneous pushing.
  3. “I am afraid” – women who have given birth by cesarean and vaginally say pain recovering from major abdominal surgery is much worse and lasts far longer than pain of vaginal delivery. Refer to professional esp trained to deal with such fears. Learn about methods of pain relief and benefits of labor support. Women with extreme fear who had vaginal births have found it to be healing.

Discussion Points:

  • New efforts to reduce primary cesarean rate – as life-threatening complications due to multiple repeat cesareans have increased, ACOG 2014 issued new guidelines that allow more time for both 1st and 2nd stage than in past (IV-58), avoiding elective inductions, increasing operative vaginal deliveries, encouraging vaginal delivery of twins when first twin is cephalic, encouraging continuous labor support and other evidence-based strategies.
  • Choices that increase a woman’s change of a vaginal birth – continuous emotional support. Staying home until labor is well-established. Walking and changing positions increase strength of contractions and increase sense of control. Delaying start of anesthesia until well into active labor and administration of light epidural lessens likelihood of dystocia and other potential complications. Handout IV-127 and on CD
  • The wide range of normal labor variations – if women is sent home, if has a long, prodromal labor, lengthy 2nd stage, can still maintain positive outlook if she knows these are realistic expectations. Less likely to give up on self if knows that progress is measured in more than just centimeters. Alert her to progress of change of cervical position, ripening, effacement and rotation/descent of baby.
  • Use of nonpharmacologic pain-management techniques – heat/cold/warm baths/showers/soothing touch/massage can inhibit or diminish pain awareness. Relaxation, attention-focusing, with patterned breathing, music, or imagery will reduce her negative psychological reaction to pain. May eliminate need or postpone start of anesthesia. Studies show if anesthesia given after 4-5 cm, less likely to interfere with progress of labor
  • Birth options and informed decision making – give her informed decision making cards

Build confidence in normal birth

  • Build confidence in every mother you teach – let her hear often she is strong and capable and has inborn wisdom and ability to give birth. Help her discover comfort measures that work for her to reduce pain/anxiety
  • Build competence in labor skills – relaxation and other pain management skills not easily learned without practice. Teach variety of skills and allow practice in each class. She will learn confidence through rehearsal. Will help her perception of having control which will add to birth satisfaction
  • Help her see birth as normal – present birth as natural rather than medical event. Pregnancy is not an illness but a state of good health for most women. Present facts on risks of cesarean
  • Discuss pain as a positive – purposeful, anticipated, intermittent and normal. There is pain in labor – even with epidural. Woman’s body will produce endorphins in direct correlation with strength of contractions (unless medications used which decrease endorphin production)
  • Encourage informed decisions – all studies not in agreement. Present facts. Mother can make choices for herself. Chances of vaginal birth increased when women involved in decision making. If informed that early epidural may increase chance of dystocia (and possible cesarean), she may choose to: stay home during early labor, request epidural later in labor or request light epidural. If informed of studies that show association between maternal fever and duration of epidural, or that length of time an epidural is given may relate to baby’s difficultly in latching on, she may delay. Or she can anticipate fever and have more patience with breastfeeding. Pamphlet – What Every Pregnant Woman Needs to Know About Cesarean – childbirth Connection
  • Books: The c-section epidemic in America
  • Vaginal or cesarean birth: What is at stake for women and babies?
  • What hospitals don’t want you to know about c-sections (consumer report)
  • Lamaze members only: Infographic on cesarean
  • – Cesarean Statistics


Top 10 (Proven) Ways to Avoid Cesarean Surgery

  1. Let labor begin on its own. Medical studies have clearly shown that induction almost doubles the likelihood of cesarean surgery for a first time mom
  2. Hire a doula or arrange for a woman experience with childbirth to stay with you and your partner throughout labor. A good doula will not interfere in the relationship between you and your partner. Instead, she will provide reassuring support for both of you and recommend comfort measures
  3. Stay at home in early labor. Labor takes much longer than most people think. Recent studies suggest that the average labor for a first birth is somewhere between 12-17 hours. At home, you can move around freely, take a walk in a nearby park, relax in your tub and eat lightly according to your appetite. Once you get to the hospital, there may be a focus on getting birth “done” in a certain time period
  4. Ask that your baby be monitored intermittently (at regular intervals) rather than continuously –ACOG states that intermittent monitoring is just as safe for low risk women as continuous monitoring and that continuous monitoring is associated with increased risk of cesarean
  5. Ask for a “hep lock” or “saline lock” rather than IV fluids – being hooked up to IV restricts ability to move freely and to use comfort measures such as bath/shower. ACOG says its safe for women with uncomplicated labors to drink clear fluids during labor
  6. Move around! Bring birth ball and use it. Ask for a room with a rocking chair. Staying upright, walking and changing positions frequently may shorten your labor by about an hour. When labor progresses at a good pace, it is less likely that your health care provider will recommend a cesarean for “failure to progress”
  7. Try natural methods of pain relief to delay/avoid epidural anesthesia – although it is controversial as to whether epidurals increase risk for cesarean, there is no question that interventions required when you have an epidural (continuous monitoring and IV fluids, medications to speed up labor, catheter in bladder, forceps/vacuum) change ways in which you labor/birth. Many women find a warm bath substantially reduces pains of labor. A shower, walking or slow dancing, bouncing or swaying on birth ball, massage and reassurance form partner, doula and health care team will help you cope with contractions. Remember hardest part of labor is also shortest part
  8. Ask for more time – as long as you and baby are doing well, it is okay for labor to last a long time. In avg labor for 1st time moms is 12-17 hrs, then some normal labors will take much longer. Plateaus, when labor slows or even stops for a while, are normal
  9. Do not begin pushing until you feel the urge – some health care providers want baby born within specified time after you begin pushing. Whether you have epidural or not, waiting to push until you feel urge will decrease time you spend pushing. Pushing in response to body’s urges, rather than being coached, is safer for you and baby
  10. Believe in birth and in yourself – most women (85-90%) can and should give birth vaginally. Do all that you can to make birth as safe as possible for you and baby.

Cesarean Birth (pg 56) – may be taught spiraled or block. Advantages of spiral are that tune out is more likely avoided. Students who tend to deny they may undergo surgery are more likely to hear. Disadvantage to spiral as it may interfere with picture of natural birth before complications and interventions are introduces.

  • Class 1: in course overview, mention possibility of cesarean with statistics of occurrence. Note that its becoming accepted to offer it as a choice and cover risks of choice later class. Relate medical indications when you discuss anatomy
  • Class 2: Prevention of unnecessary cesareans integrated with variations of labor patterns; thing to try if labor stalls
  • Class 3: Slides to show delivery (operating) room, in addition to LDRs; slides, graphics or video to show procedure. Discuss what she might see, hear, feel, smell
  • Class 4: Anesthesia for cesarean integrated with medications discussion; possibility of cesarean in relation to inductions and other interventions. Discuss risk vs benefits of choosing cesarean birth without medical cause
  • Class 5: Cesarean recovery integrate with postpartum discussion. Breastfeeding encouraged for cesarean moms
  • Class 6: Reunion couples may discuss cesarean. VBAC introduced

Block format may encourage students not to come. Info covered would be: indications, labor, procedure, anesthesia, recovery, postpartum and breastfeeding. Do not use negative words.

Say instead

  • Cesarean section -> cesarean surgery
  • Failure to progress ->labor has stalled; cervix is not opening
  • They will section you (or they will take baby) -> a surgical birth may be necessary
  • They cut you open -> an incision is made
  • Inadequate pelvis -> baby does not fit through pelvis
  • Abnormal presentation -> breech, shoulder, transverse etc presentation

Role play and discussion (see pgs IV-125). Numerous people present – ask who they think.   Mother, anesthesiologist, 2 OBs, scrub nurse, rotating nurse, pediatric nurse, mothers partner and any others routinely there or there if it is an emergency. If there is delay in partners entry, will he/she still be allowed in? where will they wait? who will be with them? Show where each person might be placed around mom. What will her partner be allowed to see? If she is not sedated, she may be hypersensitive to all around her

  • What might the mother be experiencing in her environment?
  • Transfer to delivery room on bed; how is she moved to delivery table?
  • What might she see? (people, bright lights, instrument tray, anesthesia equipment, caps, gowns, masks, drapes in front of her face)
  • What might she hear? (rolling trays, metal-to-metal sounds, doors, monitors, beepers, conversations, joking, staples) we hope she will also hear words of concern, encouragement, and reassurance from partner, doctors and nurses
  • What might she smell (cautery can be a frightening, burning odor; oxygen mask, solutions)
  • What might she feel? (oxygen mask if it is given, test probes to check anesthesia level, tugging sensations as baby is being born)
  • What is the procedure? Demonstration of the surgery could be “performed” using the fabric-layer model placed on the abdomen of the role-player (male or female)
  • Include a discussion about immediate skin-to-skin contact between mother and baby as the surgery is completed

Microbial seeding (see pgs III-15 and IV-91) – increasing scientific evidence supports the importance to the healthy development of the immune system of the “microbial seeding” that takes place as the baby passes through the birth canal during vaginal birth. Research is now underway looking at ways or providing babies born by cesarean with this advantage. Some women are requesting that vaginal swabs be wiped on their newborns delivered via cesarean. Watch Microbirth or read article by Carey Goldberg pg IV-95.


  • Layers of fabrics can be used to emphasize why it takes time to “close” after the birth. It is easy to make an incision through many layers of muscle and tissue (skin, fat, fascia, abdominal muscles, peritoneum, uterus and amniotic sac), but more time-consuming to repair each level. Use fabrics of different textures for visual memory. Instructions
  • The knitted uterus with the zipper may also be used for demonstration of the birth

Graphics – Childbirth Graphics has 7 pg flip chart w posters for cesarean and VBAC

DVD– not necessary to show too much detail of surgery. Point of interest is attention paid to the mother and the birth of the baby. some videos spend far more timer on up=close of incision and blood than parents will ever see. Emphasize importance of partner’s being present to help mom relax, to talk to her, encourage her and hold her hand. He does not need to watch the surgery itself to benefit from being present at the birth. Understanding Cesarean Birth – Ch 6 from Injoy Videos shows animation of the surgery along with dialog.

Books – The caesarean; cut, stapled and mended

Mock Cesarean Role-Play– ask for volunteers; don’t have pregnant person play pregnant woman. Give each a sign to hold and maybe a hat or mask

  • Pregnant woman
  • Ob
  • Assisting OB (assisting surgeon)
  • Anesthesiologist
  • Scrub nurse
  • Circulating nurse
  • Nursery nurse
  • Labor partner

Also use students to represent major pieces of equipment. More fun if you create equipment from everyday objects

  • IV pole (air pillow (packaging) or small inflated balloon for IV bag)
  • Fetal monitor belt (ace bandages or wide elastic with ribbon)
  • Bp cuff( band of fabric with Velcro)
  • Cardiac monitor. oxygen saturation monitor (using tubing, ribbon, or pressure bandage around finger)

Have “pregnant woman” lie comfortably on floor or on table if have one. Place other volunteers around. Go through usual steps:

  1. Epidural or spinal anesthesia placed
  2. Foley catheter inserted
  3. Abdomen scrubbed
  4. Sterile sheets draped over body
  5. Anesthesia screen put in place
  6. Incisions made through skin, fat, fascia, abdominal muscles, peritoneum, uterus and finally amniotic sac (can show different colors/textures of fabric; use transparent for amniotic sac)
  7. Baby removed
  8. Placenta removed
  9. Uterus repaired (uterus may be removed from abdominal cavity for repair)
  10. Other layers repaired (staples may be used for skin)

Be sure to discuss what pregnant woman may be experiencing with all her senses:

  • Hearing clinking of instruments, beeping of monitors, sounds of suction and cautery, conversations of staff and hopefully voices with explanation/encouragement
  • Smelling burning odors of cautery sealing blood vessels, amniotic fluid
  • Feeling pressures and tugging sensations as baby and placenta are removed
  • Seeing baby as he or she is born

As long as mom/baby are stable, baby can be placed immediately skin-to-skin on moms chest. Baby can remain skin to skin with mom as they are transferred to recovery room and can remain there until baby has self-latched and nursed. Celebrate birth of baby!

VBAC (PG 59) – cesarean rate 33%, likely some of students will end up with unexpected cesarean surgeries. They may not take childbirth classes again, so important to give them info.

A cesarean (or other uterine surgery) scar on uterus places both pregnant woman and baby at greater risk during future pregnancies. The more she has, the greater her risk for major complications such as placenta accrete. Since rate is so high, many experts fear complications from repeat surgeries may become serious public health issue that risks of uterine rupture for women having trials of labor. The individual woman having cesarean has to weigh the very small (but very scary) risk of uttering rupture during trial of labor vs complications associated with cesarean for both current and future pregnancies. May help her to know the risk is about the same as risk of a serious complication occurring during labor and birth for any 1st time mom.

ACOG promotes option of trial of labor for most women who have had cesareans with low transverse incisions. In Aug 2010, it expanded list of possible candidates to included women who’ve had 2 prior cesareans, women with twins, and women with unknown type of uterine incision.

If have woman planning TOL, may find she needs extra support and encouragement. More likely to succeed if care provider supports VBAC and if she goes into labor on her own. A doula will help her and partner cope with difficult parts of labor that bring back memories of prior labor that ended in cesarean. Some educators and hospitals offer VBAC classes.

Unexpected Outcomes (pg 60) – least favorite topic. Time often “runs out” before its covered. Disappointment and grief need to be discussed as well.

Discussion Points

  • Has anyone reluctantly moved to a new community, leaving behind friends or family?
  • Has anyone ever lost or had stolen something very meaningful to them?
  • Has anyone lost a loved one?

Ask how they felt immediately, what emotions followed in next days or weeks. Most likely will hear stages of grieving. Do not need to speak directly about loss of a baby. make a PowerPoint slide from burden concept of grief on CD or pg IV-135 or use unexpected outcomes on PowerPoint CD. It’s normal to grieve loss of perfect birth experience if things do not go as they hope. They can have a healthy baby, but still need to grieve a less than perfect birth experience. Let partners know this is normal and acceptable and with support they will come to acceptance.

Storytelilng – welcome to Holland. Appropriate story to begin discussion

Books – unexpected outcomes – a childbirth educators guide – Photographers Volunteer for Stillborn Babies

Welcome to Holland – raising a child with a disability. traveling to Italy vs Holland. Just a different place. Go out and buy new guidebooks/learn a new language. Meet a whole new group of people you would have never met. Slower paced, less flashy. If spend life mounting fact you didn’t get to Italy, may never be free to enjoy very special, very lovely things about Holland.

The Burden Concept of Grief Graph: Bereavement-Loss vs Time: Diminishing Burden: Shock, denial; anger; isolation/depression/numbness/physical symptoms/awareness of reality/guilt/waves of sadness/disorganization of life/preoccupation with grief/dreams of situation/ability to take care of loss

Breastfeeding: Pgs 63-69 of handbook – correct latch.

  • Class 1) Changing body, supportive partner.
  • Class 2) Nutrition, weight loss benefits
  • Class 3) Breastfeeding grab bag
  • Class 4) Skin-to-skin contact immediately after birth and rooming in. Place on mother’s chest and let baby move.
  • Class 5) Possible effects of interventions and medications on early breastfeeding. Breastfeeding easier for cesarean mothers than artificial feeding.
  • Class 6) DVD – Amazing Talents of the Newborn. Effective latch, early feeding cues, how to know baby is getting enough milk, support for mother. Checklist – You know breastfeeding is going well when…

Cosleeping controversy – controversial. AAP recommends baby sleep in same room, but not same bed. But many breastfeeding moms practice Cosleeping. Research shows moms breastfeed for longer and sleep better when share a bed. LLL has identified 7 key requirements for safe bed sharing: mother non smoker, sober and breastfeeding; baby healthy, on back, lightly dressed and unswaddled; and they share a safe surface. No more at risk for SIDS than baby sleeping in crib if meet 7 requirements. Infant suffocation have occurred when fatigued new mothers purposed avoided taking babies into bed with them to nurse and instead chose unsafe sleep environments such as sofas for feeding and then unintentionally fell asleep.

Handouts on co-sleeping


  • The 9 instinctive stages:
    • Skin to skin in the first hour after birth: practical advice for staff after vaginal and cesarean birth
    • The magical hour: holding your baby skin to skin for the first hour after birth
    • Breastfeeding: baby’s choice
  • General breastfeeding
    • Babybabyohbaby breastfeeding
    • Baby-led breastfeeding: the mother-baby dance
    • Biological nurturing: laid-back breastfeeding
    • Breastfeeding – coping with the first week
    • Delivery self-attachment
    • Follow me mum – the key to successful breastfeeding
    • Infant cues: a feeding guide
    • Kangaroo mother care
    • Through their eyes (images to play as couples come to class)
    • More than food – breastfeeding moments (lovely closing)
    • Everyday miracles in Celebrate birth! For closing


  • The Breastfeeding Café
  • The Milk Memos: How Real Moms Learned to Mix Business with Babies – and How You Can Too
  • Ina May’s Guide to Breastfeeding
  • The Nursing Mothers Companion
  • Breastfeeding Made Simple
  • Breastfeeding Answers Made Simple
  • Nursing Mother, Working Mother
  • A Beginners Guide to Breastfeeding
  • Impact of Birthing Practices on Breastfeeding
  • Keep it Simple- Breastfeeding

Teaching Strategies

Videos on web: Animated Baby Latch

Baby crawling to breast:

Breastfeeding organizations:

  • The Academy of Breastfeeding Medicine:
  • Baby Friendly USA:
  • International Lactation Consultants Association:
  • La Leche Leagues:
  • US Breastfeeding Committee:

Cosleeping References: a quick guide to safely sleeping with your baby; sleeping with your baby: a parent’s guide to cosleeping; nighttime and naptime strategies for the breastfeeding family

Breastfeeding Grab Bag

  • Picture of a cow & calf – cows milk is composed of nutrients needed for the rapid musculoskeletal growth needed by calves who walk right away; the nutrients in human milk promote the rapid brain growth of newborn babies
  • Toy doctor kit – babies fed artificial milk have more illnesses than breastfeeding babies, including some chronic diseases such as type I diabetes
  • Diploma – babies who are not breastfed for at least 3 months have lower IQ scores
  • Allergy mask – formula fed babies more likely to develop asthma, dermatitis, and eczema
  • Small scale or picture of a scale – formula fed babies more likely to be obese
  • Picture of mountains or other nature scene – artificial feeding is more harmful to the environment
  • Pictures of instructions for breast self-exam: mothers who formula feed are at higher risk for breast and ovarian cancers
  • Travel magazine or toy airplane – those who formula feed need far more equipment when on the go
  • Thermometer – artificial milk must be heated and temperature checked before feeding; breastmilk is always the perfect temp
  • Toothbrush– bottle fed baby more prone to cavities if bottle is left in mouth for extended periods; jaw development is better in breastfeeding babies
  • Diaper – the poop of formula fed babies has a foul odor whole the poop of breastfed babies does not have a bad odor
  • Clock – it takes time to prepare a bottle of formula; breastmilk is immediately available
  • Play money – formula costs $1500-$2000 for first year
  • Heart – formula feeding moms don’t get the release of oxytocin associated with the let down of breastmilk
  • Picture of hurricane or tornado, or road evacuation sign – during natural disasters, breastmilk is available and accessible; no worries about electricity or supply as long as mom and baby are together

Correct Latch picture (baby whole mouth over nipple) vs Incorrect Latch – just on nipple

Postpartum (pgs 71-84 workbook)

  • Class 1) benefits of exercise and relaxation. Good communication.
  • Class 2) Nutrition.
  • Class 3) massage for newborn and family members
  • Class 4) appearance of baby at birth/Apgar score. Immediate skin to skin. Baby remaining in room.
  • Class 5) effects of interventions/medications on postpartum recovery.
  • Class 6) Book Your Amazing Newborn. DVD Amazing Talents of the Newborn.

Postpartum Mood Disorders – include PTSD. DVD – healthy mom, happy family.

Reunion class from previous series to final class.

Handouts – Time Sharing – pg 112 in Family Way handbook. Postpartum Support Inventory. IV- 151

Newborn Care – newborns can’t be spoiled. Harmful effects of scheduled feedings and sleep training, especially if breastfed. Swaddling. Cosleeping.

Role-model: Wear “baby” during class.

Postpartum grab bag– breast pads, panty liner, baby sleeping sign, shower scrubby, cell phone, baby sling, baby product catalog, sexy nightie, water bottle, back to sleep sign, tucks, baby lotion, box of tissues, plate with serving sizes, peri-bottle, feather duster, eye mask, movie tickets

Ways to soothe crying baby – pass baby doll around with newborn crying. Each asked to name soothing technique. People can choose to pass. Happiest Baby on Block.

DVDs: BabyBabyBabyOhBaby infant massage; What babies want

Books: life will never be the same: the real mom’s postpartum survival guide; mothering the new mother; understanding your moods when you’re expecting: emotions, mental health, and happiness – before during and after pregnancy

Books Traumatic Birth, PTSD, PMAD: traumatic childbirth; beyond the blues – a guide to understanding and treating prenatal and postpartum depression; understanding postpartum psychosis

Books Newborn Care; heading home with newborn: from birth to reality; your amazing newborn; 25 things every new mother should know; the bayb book: everything you need to know about your baby from birth to age 2

Fathers: Father’s first steps: 25 things every new dad should know

Sleep Training


Vitamin K

Ideas for Postpartum Robe:

  • Breast pads – breasts may leak during sex (or when mom hears baby cry)
  • Panty liner (lochia – some show a real peripad)
  • Baby sleeping sign – limit visitors; noise levels in home
  • Shower scrubby – lack of time for self-care
  • Cell phone – whom will she call when she needs help
  • Baby sling – benefits, convenience of baby-wearing
  • Baby product catalog – what babies really need and don’t need
  • Sexy nightie – resumption of sex
  • Water bottle – importance of hydration while breastfeeding and during exercise
  • Back to sleep sign – importance of placing baby on back to sleep and tummy time
  • Tucks – hemorrhoids
  • Baby lotion – benefits baby massage
  • Box of tissues – baby blues vs postpartum depression
  • Plate with serving sizes – healthy eating choices; freeze meals during last weeks of pregnancy; ask family/friends to bring meals
  • Peri-bottle – peri-care
  • Feather duster – housework can be delegated
  • Eye mask – taking time for self care; napping when baby naps
  • Movie tickets – plan date night; arrange for sitter and baby will take expressed breast milk

Postpartum Support Inventory – write names of people who can help you in first 6 weeks after birth of baby

Check: share good times or talk about troubles/breastfeeding help/parenting skills/provide meals/housekeeping help/childcare/ transportation


Close Family:

Work/School Contacts:

Extended Family


If does not have checks in many of boxes, may want to consider a postpartum doula.

The Cascade Effect of Obstetric Interventions: induction/continuous EFM -> inactivity, confined to bed -> increased anxiety -> false positive monitor readings -> slowed labor -> AROM -> Pitocin -> increased pain -> pain meds/anesthesia -> abnormal FHR patterns -> (failed) forceps or vacuum -> cesarean surgery

Table 1.1 Comparison of maternity care in U.S., Canada and U.K.

Primary maternity Caregivers:

  • U.S. – Obs 87%; midwives/family doctors 13%. Maternity nurses provide most care during labor in hospital with OB managing problems and delivery. 2 types midwives: CNM and CPM, latter out of hospital only.
  • Canada– family doctors with OBs and autonomous midwives increasing. Nurses provide most care in hospital. Registered Midwife exists; not available in all provinces.
  • U.K. – mostly midwives, some general practitioners, with OBS caring for women with complications. No maternity nurses; midwives provide all intrapartum care and conduct most deliveries, with a small % providing home birth care.

Autonomy and independence of caregiver:

  • U.S. – great variation among independent doctors. Nursing care varies according to orders of physician/hospital. Insurance and HMOs limit doctors’ practices that are not costs effective. Midwives dependent on back-up services of doctors; in many areas, midwives’ practices are severely limited because no drs are willing to provide
  • Canada – gov limits payment for some interventions and regulates # of physicians/hospitals, giving doctors less autonomy than U.S. Midwives also closely regulated.
  • U.K.- midwives have little autonomy and practice according to policies of institution, established by authorities and gov.

Participation by childbearing women in decision-making:

  • S.- informed consent in law, though most women expect OB to make decisions. Most midwives/family Drs share decision making
  • Canada- similar to U.S.
  • K.- informed choice and woman centered care now standards of care, and extensive efforts being made by gov and childbirth activists to ensure women are well informed

Continuity of caregiver throughout childbearing year:

  • U.S.- not considered cost effective, feasible or desirable by policy-makers in health care. Rarely available except for out of hospital births, though to many women it’s a highly desirable option. Some try to obtain continuity of care through birth plans/doulas and by verbalizing concerns.
  • Canada– small group practices of family drs/midwives available. Continuity of care more likely than in U.S., although maternity nurses provide most care in labor
  • K.- considered a very important feature of woman centered care; programs ensuring continuity of care replacing old system of different midwives for pre/postnatal care

Influence of scientific evidence on maternity practices:

  • S.- highly variable, but customs, peer practices, opinions and prior experience of practitioner and fear of litigation are more powerful influences. Failure to adhere to evidenced based may contribute to increases in maternal and neonatal mortality and morbidity, cesareans and labor inductions
  • Canada– leaders in obstetrics, family medicine, midwifery and nursing are actively engaged in scientific evaluation of numerous unproved clinical practices. National professional societies promote evidence based practice
  • U.K. – same as Canada expect midwives also actively involved in original research. Widespread acceptance of scientific approach to maternity care

Influence on fear of malpractice litigation on maternity practices:

  • U.S. – chances of physicians being sued for malpractice is a constant worry and malpractice insurance premiums are extremely expensive, which has driven cost of maternity care. Insurers advise on how to reduce likelihood of lawsuits. Such advice is not based on science, safety or effectiveness, but on risks of being sued
  • Canada– trends similar to U.S. although to a lesser degree. Fear of litigations has less impact on care than scientific findings, costs, customs and other factors
  • U.K. – similar to Canada

Teaching Idea Sheet – Informed Consent

Informed consent is the process by which people receiving health care make decisions about their care. To give informed consent you need enough information to be able to make decisions about your care and then the opportunity to make those decisions.

Info should include:

  • What proposed treatment is
  • What benefits of treatment are
  • What risks of treatment are
  • What alternatives are to treatment proposed; their risks and benefits
  • What would happen if you did nothing

Informed consent is NOT simply signing a form. It requires knowledge – given in your language, in a way you can understand. There should be no penalties if you do not agree to recommended treatment.

May be emergency situations where participating in process will not be desirable or possible, but in most cases she should be able to do so. Parents should learn during pregnancy alternatives in procedures, treatments or drugs for labor so they will have time to decide what’s best.

Obstetrics, like other medical specialties, is not an exact science. Tests, procedures and medications are sometimes given out of habit and custom, rather than because of scientific proof that they are safe or helpful.

Encourage asking questions. Ask questions about: prenatal care, medication for labor/birth, labor management, hospital stay, postpartum routines, newborn care routines, how to care for baby, lab tests, postpartum check-ups.

She should find out: what her caregiver wants to do, why he/she wants to do it, what will happen if she doesn’t do it, what risks are, what else she could do. Recommend writing down questions and bringing them w her to visit. Tell her to keep asking questions, even in labor. Never too late to change one’s mind about anything.

  1. Birth DVDs that show a variety of choices
  2. Role-playing of discussions regarding choices
  3. Activities to enhance decision-making: 
1. Checklist of various labor, birth, and postpartum considerations 2. Medication choice line
3. Labor rehearsals that feature decision-making
4. Research reports
  4. Benefits-risk chart-making
  5. Family-friendly practices
A. CIMS Mother-Friendly Initiative – Are Your Birth Classes Mother-Friendly?
  6. UNICEF/WHO Baby-Friendly Hospital Recognition

 Guidelines for Informed Consent – according to U.S. National Library of Medicine, the physician should disclose and discuss with patient:

  • The patient’s health problem and the reason for treatment
  • What happens during the treatment
  • The risks of the treatment and how likely they are to occur
  • How likely the treatment is to work
  • Other options for treating the health problem
  • Unknown risks or possible side effects that may happen later
  • If treatment is needed now or can wait

Patients have the right to refuse treatment if they are able to understand the health condition, treatment options and the risks and benefits of each option.

Sample informed decision-making cards:

  • Is this an emergency, or do we have time to talk?
  • What would be the benefits of doing this?
  • What would be the risks?
  • If we do this, what other procedures or treatments might we end up needing as a result?
  • What else could we try first or instead?
  • What would happen if we waited na hour or 2 ( a day or 2, a week or 2) before doing it?
  • What would happen if we didn’t do it at all?

See master on CD

Making a decision? Ask “What is the B.R.A.I.N?”

  • Benefits
  • Risks
  • Alternatives
  • Intuition tells you
  • Now now? Never?
  1. CIMS Mother-Friendly Nurse recognition

  1. Birth doula care

  1. PCN Ch 2 see above
  2. Birth plan or birth preferences
  3. Requires knowledge of options

PCN Pgs 148-161 The Importance of Planning for Birth and Postpartum – Main purpose of planning is to establish a line of communication between you and those providing your care; if everyone understands and respects your wishes, you’re more likely to be satisfied with the care you receive than if your wishes are unrecognized.

If only have 1 or 2 midwives providing care, you’ll naturally get to know one another. But if caregiver belongs to a group practice (and most in U.S. do), may be harder to build personal relationships. They rotate who is on duty during specific shifts. During shift change in hospital, nurse whose shift has ended communicates preferences with nurse coming on. More important than direct spoken communication is medical chart. Caregiver electronically records info on physical and psychological well-being in chart at each prenatal visit and frequently during hospital stay.

Birth plan aka birth preference list, wish list or goal sheet is a 1-2 pg letter you write to everyone attending to your care during labor/birth. Lets you express your priorities and preferences, but isn’t a contract which guarantees that care. It lets everyone know which safe options are most important to you.

Reactions to birth plans vary; some might not be familiar with them. Some argue they wouldn’t administer treatment without woman’s consent so there’s no reason to express wishes beforehand; however it’s helpful for a woman to know in advance her wishes especially when it can be stressful for her to explain while coping with contractions.

If caregiver is clearly opposed to birth plan, can give up birth plan and do what caregiver requires, try to negation with him/her or try to find another caregiver.

Preparing Birth Plan – requires plenty of time – ideally start a few months before due date. Decide general approach to maternity care; learn about specific options, make a rough draft and discuss with caregiver then prepare a brief final birth plan.

Preferred approach to maternity careself-reliant approach (want to actively participate in labor by using non medical measures for comfort and labor and by taking part in decisions about procedures/care options) vs caregiver-reliant approach (those providing care to decide how to manage labor and pain).

Learn options and identify preferences – pay attention to whether resources you use are evidence based – see appendix c for listing of recommended resources. Natural/low tech options are more compatible with self reliant approach while options that rely on technology and medicine more compatible with caregiver reliant approach. See pcnguide to download birth plan work sheet.

Prepare a rough draft and discuss with caregiver – list of topics: care preferences for managing labor pain, normal labor and pain, unexpected events including complications and a cesarean birth, postpartum care. May need to schedule a longer than usual prenatal appointment.

Prepare Final Draft – incorporate any suggestions or modifications from discussions with your caregiver and others. Use bullet points, and don’t exceed 2 pages. Include phrases such as “unless medically necessary” to allow for deviations from birth plan. Make sure plan is friendly, respectful, flexible and promotes mutual trust and collaboration. Make copies for yourself, partner, caregiver, nurses, and doula. Bring extra copies with you when you arrive at hospital.

Components of birth plan – limit discussion of topic to 1 short paragraph or a bulleted list that summarizes just the essential points.

  • Practical Info – names, due date, names of caregiver, doula, other support people, and baby’s caregiver. Can include statements like “we realize our birth plan isn’t a contract or a guarantee of an uncomplicated labor. Our highest priority is the health of our baby and me. Thank you for your help”
  • Introducing Yourselves – a little info about yourselves. Ex “We’ve been together 6 years and this pregnancy finally happened after 3 years of trying to conceive. Were hoping for a natural, non-medicated birth, and would value your support”
  • Issues, Fears or Concerns – if had previous miscarriage, traumatic birth, unpleasant experiences, childhood trauma etc
  • Preferences for Managing Labor Pain – see pain medications preference scale on page 187. Ex “I feel strongly about avoiding pain medication. Please don’t offer them to me; ill ask for them if needed”
  • Preferences for Normal Labor and Birth- caregivers always recommend monitoring mother and baby in labor, such as checking baby’s heart rate and mothers temp, blood pressure and contractions. Some interventions might be routine in hospitals; however they might not be necessary especially if there’s not an indication of a problem.   Examples of interventions include IV fluids, continuous EFM, AOM, and suctioning baby’s nose and mouth. Other interventions exist for convenience of staff or caregiver, including supine position and separation of baby from mother right after birth for newborn testing and observations. Other interventions required by state or gov such as administering antibiotics to baby’s eyes and conduction newborn screening for various conditions
  • Preferences for unexpected events, including a cesarean birth – when creating birth plan, consider separating it into plan A and plan B. Plan A covers preferences when labor and birth go smoothly. Plan B addresses how you’ll want possible complications to be handled.
  • Preferences for healthy newborns care – consider options on pages 370-371, balance concerns for baby’s comfort and well being with potential benefits and risks. Some one time common routines are now unnecessary or even harmful such as feeding sugar water or formula to healthy breastfed babies.
  • Preferences for unexpected problems with newborn – forethought will prevent having to make such decision when upset and unable to think clearly
  • Preferences for postpartum period in hospital – stay will likely last 1-3 days

Postpartum Plan – quite different from a birth plan in that its designed for you, yoru friends, and your family. Don’t need to create formal document. Discuss wishes with partner and any friends/relatives who will be helping you. The first weeks will be more challenging and stressful than you expected.

Decisions to Make:

  • Who will you want to see after birth? How will you restrict visitors if you’re tired and frazzles and are trying to figure out breastfeeding
  • Resources available in first weeks after birth such as classes, support groups, books and DVDs. Visit PCNGuide to download form
  • Breastfed vs formula fed baby. what help will you need with feeding
  • Help you will need with transportation, housework, meal prep, shopping and child care for older children
  • Who will help you
  • If feel overwhelmed/depressed, who can you call
  • What equipment, supplies and prep will you need for baby
  • Cloth vs disposable diapers
  • Work outside home after birth? When start? Can you and partner share child care duties. Continue to breastfeed while working. Place at work to pump
  • Financial situation after birth

Postpartum resource list – contact info of people who can help – caregiver, postpartum doula, lactation consultant childbirth educator, internet resources

Equipment/clothing for Newborn – hooded towels for baby; some babies too big for newborn clothing. Baby thermometer – see pg 388

Sample birth plans – #1 newborn care plan – immediately after the birth: bonding time is very important to us. Wed like to have our baby placed naked on my chest as soon as possible after the birth, unless there’s a medical reason not to do so. Newborn procedures: please delay newborn procedures until after the first hour. Vaccinations: please don’t give our baby a hepatitis shot. Well have the pediatricians give vaccinations when recommended

Birth plan 2 – issues fears concerns – only essential people come in. preferences for managing pain – ill be disappointed if I elect to use pain medication. Please don’t suggest it to me. If I get discouraged, please suggest comfort measures and encourage me. Code word. 2nd stage – warm compresses, support of perineum, let baby’s cord stop pulsating before being cut, after baby’s birth, immediate skin to skin and breastfeeding. 3rd stage and first hour after birth – delay all routine procedures until an hour after birth or first feeding; decline Hep B shot, keep baby in room at all times unless otherwise requested or required, breastfeeding only, no supplements unless needed. Preferences for unexpected labor events: prolonged labor – if induction is necessary, ill try self help measures and acupuncture first. Please explain reasons for any suggested procedure.

Table 19-1 Expected Maternal Progress During 1st Stage of Labor:

Criterion/0-3cm (Latent)/ 4-7cm (Active)/ 8-10 cm (Transition)

  • Duration: 6-8 hrs; 3-6 hrs; 20-40 min
  • Contractions
    • Strength: mild to moderate; moderate to strong; strong to very strong
    • Rhythm: irregular; more regular; regular
    • Frequency: 5-30 min apart; 3-5 min apart; 2-3 min apart
    • Duration: 30-45 sec; 40-70 sec; 45-90 sec
  • Descent
    • Station of presenting part: nulliparous 0, multiparous -2cm to 0; nulliparous 1-2cm, multiparous 1-2cm; nulliparous 2-3cm, multiparous 2-3 cm
  • Show
    • Color: brownish discharge, mucus plug or pale pink mucus; pink to bloody mucus; bloody mucus
    • Amount: scant; scant to moderate; copious
  • Behavior and appearance: excited, thoughts center on self, labor and baby, may be talkative or silent, calm or tense, some apprehension, pain controlled fairly well, alrt, follows directions readily, open to instructions/ becomes more serious, doubtful of pain control; more apprehensive; desires companionship and encouragement; attention more inwardly directed; fatigue evidenced; malar (cheeks) flush; has some difficult following directions/ pain described as severe; backache common; frustration; fear of loss of control; and irritability may be voiced; express doubts about ability to continue; vague in communications; amnesia between contractions; writhing with contractions; nausea and vomiting, esp if hyperventilating; hyperesthesia; circumoral pallor, perspiration of forehead and upper lip; shaking tremor of thighs; felling of need to defecate; pressure on anus

* In nullipara, effacement is often complete before dilation begins; in multipara it occurs simultaneously with dilation

*Duration of each phase influenced by such factors as parity, maternal emotions, position, level of activity and fetal size, presentation and position. Labor of nullipara tends to last longer on avg than labor of multipara. Women who ambulate and assume upright positions or change positions frequently during labor tend to experience a shorter 1st stage. Descent is often prolonged in breech presentations and OP positions.

* Women w epidural may not exhibit these behaviors

Box 19-3 Psychosocial Assessment of Laboring Woman

Verbal Interactions

  • Does woman ask questions?
  • Can she ask for what she needs?
  • Does she talk to her support person?
  • Does she talk freely with nurse or respond only to questions?

Body Language

  • Does she change positions or lie rigidly still?
  • What is her anxiety level?
  • How does she react to being touched by nurse or support person?
  • Does she avoid eye contact?
  • Does she look tired? If she appears tired, ask her how much rest she has had in past 24 hours

Perceptual Ability

  • Is there a language barrier?
  • Are repeated explanations necessary because her anxiety level interferes with her ability to comprehend?
  • Can she repeat what she has been told or otherwise demonstrate her understanding?

Discomfort Level

  • To what degree does the woman describe what she is experiencing including her pain experience?
  • How does she react to a contraction?
  • How does she react to assessment and care measures?
  • Are any nonverbal pain messages noted?
  • Can she ask for comfort measures?

Stress in Labor – Observe couple for stress (father can be stressed too). Has couple attended childbirth classes? What role does this person expect o play? Does he or she do all talking? Is he or she nervous, anxious, aggressive or hostile? Does he or she look hungry, tired, worried confused? Does he or she watch TV, sleep or stay out of the room instead of paying attention to the woman? Where does he or she sit? Does he or she touch the woman? What is the character of the touch?

Cultural Factors – 1 m immigrants come to U.S. each year. >30% of U.S belongs to cultural group. Will be more than half of population by 2050. Nurses should be committed to providing culturally sensitive are. Some cultures, its unacceptable for man to examine pregnant woman, take placenta home, certain nourishments during labor, believe cutting body as with episiotomy allows spirits to leave body and that rupturing membranes prolongs not shortens labor.

Cultural Consideration Box

  • Somalia – women extremely stoic during childbirth (don’t like to show any sign of weakness)
  • Japan – natural childbirth; may labor silently; may eat during labor; father may be present
  • China – stoic response to pain; father not usually present; side-lying position preferred because thought to reduce infant trauma
  • India – natural childbirth; father not usually present; female relatives present
  • Iran – father not present; female support and caregivers preferred
  • Mexico – stoic about discomfort until 2nd stage and then may request pain relief; father and female relatives may be present
  • Laos – may use squatting position for birth; father may or may not be present; female attendants preferred

Some women believe screaming or crying out in pain is shameful if a man is present. If woman’s support person mother, may have to behave more strongly than if support person is husband. Some women who lose control or cry out may be scolded.

Culture and Father Participation – in Western societies, father is viewed as ideal birth companion. Laotian (Hmong) husbands traditionally participate in labor process. Some cultures father’s presence in labor room not considered appropriate; nurse may perceive as lack of concern, caring or interest. Women from many cultures prefer female caregivers and want to have at least 1 female companion present.

  1. Facilitates communication skills
  2. Informed consent and informed refusal skills
  3. Educators recognize the right of adult learners to accept or reject class concepts


ICEA Position Paper on the Role and Scope of the Childbirth Educator

ICEA defines childbirth educators as professional sources of information, with skills to support for parents as they prepare for pregnancy, labor, birth and parenthood. ICEA believes they positively impact birth outcomes and parent satisfaction.

ICEA’s Philosophy of Childbirth Education – CEs positively impact birth outcomes and parent satisfaction. Birth of baby represents birth of a family. ICEA- evidence-based family-centered maternity care and use of nonmedical and self-care techniques to encourage a normal, physiologic, pregnancy, labor and birth. ICEA endorses health care circle (team) and at center is pregnant woman.

Childbirth Educator:

  1. Upholds right of pregnant woman to care that is accessible, affordable and acceptable
  2. Does not discriminate in services or alternatives on basis of race, color, culture, age, language, marital status, or method of payment
  3. Recognizes that birth can safely take place in hospitals, birth centers and homes
  4. Functions as advocate who supports/protects natural process of birth
  5. Supports right of pregnant woman to be accompanied by person of her choice
  6. Supports right of woman to make informed decisions based on knowledge of benefits, risks and alternatives
  7. Encourages parental and family participation in childbirth
  8. Promotes mother, baby and family centered care as well as breastfeeding and parent-infant bonding
  9. Supports maternity care system based on needs of family, not provider
  10. Supports open communication and shared decision-making
  11. Cooperates w medical, midwifery and nursing communities, health and social service agencies and woman’s circle
  12. Views parents as capable of understanding healthcare technology and responsibility for own healthcare and that of their baby
  13. Recognizes education is only one of interrelated factors affecting process and outcome of birth
  14. Provides evidence-based info anchored in current research
  15. Identifies need for guidance and referral and offers them when appropriate
  16. Accepts parents point of view about what constitutes a good birth experience and does not set arbitrary standards or expectations and
  17. Helps parents develop realistic goals for pregnancy, birth and early parenthood.

CE is advocate for families, supporting family’s growth and development as they transition through pregnancy to parenthood and an advocate for women, promoting the health, autonomy, individuality and integrity of women as human beings.

CE maintains the role of CE is to act as:

  1. Teacher who provides info about physiology, psychology and sociology of pregnancy, childbirth, postpartum and early parenthood; demonstrates skills to assist women and their support persons to cope with pregnancy, childbirth, postpartum and early parenthood; and encourages communication between pregnant woman and other members of her health care circle.
  2. Facilitator who helps families better understand and value the experience of the transition to parenthood;
  3. Advocate for pregnant women, their partners, infants and families; and
  4. Spokesperson for development of maternal-child health care system that provides access for parents to safe, low-cost and family centered maternity care both within and outside the hospital.

All men and women have right of access to education about sexuality, reproduction, pregnancy, birth and parenthood. Educational programs should be financially and geographically accessible in all communities and be sensitive to individual differences of age, culture, race, health status, socioeconomic status and partner status. To ensure that CE programs are accessible to all women and their families ICEA encourages gov and other agencies to provide 3rd party reimbursement for CE services.

CE and parent education should be an integral part of the school health curriculum to encourage assumption of personal responsibility for reproductive health decisions by males and females ant to promote healthy attitudes and knowledge about sexuality, reproduction and parenthood.

Every woman should have the opportunity to give birth as she wishes in an environment that supports her physical and emotional needs.

  1. ICEA promotes informed decision-making, evidence-based care, and family- centered care to promote the best health for childbearing families

VII. The childbirth educator’s personal philosophy of birth influences her class expectations.

Your Philosophy of Childbirth – will influence the content of your class series and the amount of time you spend on various topics. Will you spend more time showing images of natural birth or possible complications? How will you divide time between lecture, small group activities and practicing skills? Will you present normal birth before interventions or will you weave them into a chronological description of labor and birth?

Society/Media tends to portray birth as potentially dangerous and regard epidural as “the only way to go.” Some feel they should contradict this view by encouraging natural birth. These educators spend little time on medical technology and medications. Others believe they should present comprehensive, evidence-based information regarding the use of medical technology and pain medication in an unbiased way, so that consumers can make their own decisions regarding these issues. Still others present medical interventions in only a positive manner in order to prepare women for the high-tech birth they will most likely have in some locations.

Reality is that most will probably do a little of all 3 above. They want to encourage women that natural childbirth is a possibility, they want women to make truly informed decisions regarding use of interventions and medications and want all women to have positive birth memories, regardless of the use or non-use of interventions and medications.

Think about what it is you want to accomplish in your classes. Answer the following questions, then design your curriculum accordingly: what is the most important goal you have in teaching childbirth education classes? What do you think is the most important goal of students attending your classes? If there is a difference between your goal as a childbirth educator and the goal of your students, how will you address this?

In considering your own philosophy of childbirth, may wish to incorporate elements developed by authoritative organizations, which are active in the field. The following info from Coalition for Improving Maternity Services addresses many of the issues associated with contemporary childbirth. Position papers form DONA, ICEA and Lamaze are included in Appendix.

The CIMS Philosophy of Childbirth – the Coalition for Improving Maternity Services (CIMS) is a national alliance of 27 childbirth organizations and many prominent individuals who came together in 1996 to create the “Mother-Friendly Childbirth Initiative” national childbirth organizations which have ratified this document include Lamaze International, ICEA, the Bradley method, AWHONN, ACNM, DONA, LLL and many more. These prominent organizations believe the philosophical cornerstones of mother-friendly care to be:

Normalcy of the Birthing Process

  • Birth is a normal, natural and healthy process
  • Women and babies have the inherent wisdom necessary for birth
  • Babies are aware, sensitive human beings at the time of birth, and should be acknowledged and treated as such
  • Breastfeeding provides the optimum nourishment for newborns and infants
  • Births can safely take place in hospitals, birth centers and homes
  • The midwifery model of care, which supports and protects the normal birth process, is the most appropriate for the majority of women during pregnancy and birth


  • A woman’s confidence and ability to give birth and to care for her baby are enhanced or diminished by every person who gives her care, and by the environment in which she gives birth
  • A mother and baby are distinct yet interdependent during pregnancy, birth and infancy. Their interconnectedness is vital and must be respected.
  • Pregnancy, birth and the postpartum period are milestone events in the continuum of life. These experiences profoundly affect women, babies, and families and have important and long-lasting effects on society

Autonomy– Every woman should have the opportunity to

  • Have a healthy and joyous birth experience for herself and her family, regardless of her age or circumstances;
  • Give birth as she wishes in an environment in which she feels nurtured and secure, and her emotional well being, privacy and personal preferences are respected
  • Have access to the full range of options for pregnancy, birth and nurturing her baby and to accurate information on all available birthing sites, caregivers and practices
  • Receive accurate and up to date info about benefits and risks of all procedures, drugs and tests suggested for use during pregnancy, birth and postpartum, with rights to informed consent and informed refusal
  • Receive support for making informed choices about what is best for her and her baby based on her individual values and beliefs

Do No Harm

  • Interventions should not be applied routinely during pregnancy, birth or the postpartum period. Many standard medical tests, procedures, technologies and drugs carry risks to both mom and baby, and should be avoided in the absence of specific scientific indications for their use
  • If complications arise during pregnancy, birth or postpartum, medical treatments should be evidence based


  • Each caregiver is responsible for the quality of care she/he provides
  • Maternity care practice should be based, not on needs of caregiver or provider, but solely on needs of mother and her child
  • Each hospital and birth center is responsible for the periodic review and evaluation, according to current scientific evidence of the effectiveness, risks, and rates of use of its medical procedures for moms and babies
  • Society, through both its government and the public health establishment, is responsible for ensuring access to maternity services for all women, and for monitoring quality of those services
  • Individuals are ultimately responsible for making informed choices about the health care they and their babies receive

See CIMS website at

History of Childbirth Education – when birth took place in homes, the birthing woman was surrounded by women who provided advice, encouragement and support. When birth moved into the hospital in the 20th century, women lost the wisdom gained from being present at births throughout their lifetimes.

Dr. Grantly Dick-Read is credited with the birth of modern childbirth education. He offered a woman chloroform and she said no thank you, it doesn’t hurt and that changed his life. His book Childbirth Without Fear was published in 1942. He sought to reduce fear by educating women about what to expect during birth, and to reduce tension by teaching relaxation techniques. He helped countless women break the “Fear-Tension-Pain” cycle.

In 1950s, French Dr. Fernand Lamaze adapted Russian techniques of psychoprophylaxis. Early Lamaze strategies included focused breathing, relaxation techniques, and continuous support by a special nurse known as a monitrice. American women who gave birth with him returned to U.S. and wrote book Thank You, Dr Lamaze which helped to spark natural childbirth in the U.S. in 1960, Lamaze and ICEA were formed. Both have continued to inform birthing women since that time. ICEA mission is to support educators and other health care providers who believe in freedom of choice based on knowledge of alternatives. Lamaze International works to promote, support and protect natural, safe and healthy birth through education and advocacy through the dedicated efforts of professional educators, providers and parents.

For more info see: Birth – The Surprising history of how we are born by T. Cassidy, Lying in- a history of childbirth in America by Wertz or Deliver me from pain – anesthesia & birth in America by Wolf. Also The timeless way video clips.

Significant Events in U.S. Childbirth History:

  • 1800s – physicians started attending normal births in mid 1800s. most babies born at home. 1847- Semmelweis instituted hand-washing in Vienna; Simpson introduced ether into obstetric practice in Scotland
  • 1900s- 50% of births attended by midwives; 50% by physicians
  • 1910s – American women marched in streets for right to have “twilight sleep”; 1915- low cervical cesarean significantly decreased infection/rupture (maternal mortality 600/100,000; infant mortality 124/1000)
  • 1920s – 1920 – DeLee published The Prophylactic Forceps Operation; 1925 – Frontier Nursing Service, staffed by nurse-midwives founded
  • 1930s – only 15% of births attended by midwives; births split 50/50 home/hospital. NY Academy of Medicine campaigned against unnecessary instrument and drug intervention. Sulfa drugs discovered; blood banks established (maternal mortality 620/100,000; infant mortality 65/1000; cesarean rate 2.5%)
  • 1940s – 1942 – Childbirth Without Fear by Dr. Grantly Dick-Read publishes; penicillin became widely available (maternal mortality 355/100,000; infant mortality 47/1000)
  • 1950s – 95% of all births in hospital; 1956 – La Leche League held 1st meeting; 1959 – Thank You, Dr Lamaze published (maternal mortality 83.3/100,000; infant mortality 29.2/1000)
  • 1960s- natural childbirth movement underway, with formation of both ASPO/Lamaze and ICEA in 1960; fathers fought to enter delivery room (maternal mortality 32.1/100,000; infant mortality 26/1000; cesarean rate 4.9%)
  • 1970s- electronic fetal heart monitors introduced without randomized, controlled trials; EFM led to wider use of epidural anesthesia (maternal mortality 21.5/100,000; infant mortality 20/1000; cesarean rate 5.5%)
  • 1980s- first large scale, random studies of continuous EFM: showed no benefit (maternal mortality 9.4/100,000; infant mortality 12.6/1000; cesarean rate 16.5%)
  • 1990s- 1992 – DONA International formed (originally Doulas of North America); Lamaze Philosophy of Birth adopted; Childbirth Summit (Birth of CIMS); VBAC increased from 12.6% in 1988 to peak of 28.3% in 1996 (maternal mortality 8.2/100,000; infant mortality 9.2/1000; cesarean rate 22.7%)
  • 2000s – ‘00- WHO Code adopted by Lamaze International; ‘01- VBAC safety questioned, rate plummeted to 9.2% in ‘04; ‘03- ACOG states its ethical to do elective primary cesareans (maternal mortality 8.9/100,000; infant mortality 6.89/1000; cesarean rate 22.9%)
  • 2010s – ’10- NIH Consensus Development Conference on VBAC; ’10- Lamaze and ICEA celebrate 50th anniversaries with joint conference; ’14- Joint Commission Perinatal Quality Measures on elective births before 39 weeks; low-risk cesarean rates; and exclusive breastfeeding at discharge become mandatory for hospitals with >1100 births. ’14- ACOG recommends generally no inductions except for medical reasons and inductions for post-dates after 42 weeks (maternal mortality 21/100,000; infant mortality 6.5/1000; cesarean rate 32.7%)
  • People seem to be busier than ever. Engage them in the first class. Consider a free class early in pregnancy to get them interested, remaining classes can start in mid 2nd Encourage early start dates to begin building confidence by providing information sooner. Word of mouth spreads benefits of a good program.
  • More class bonding in series with same group. If comfort measures practiced every class, students will gain more confidence.
  • Prefer 5-8 weekly classes, but weekend “fast-track” classes are a necessity for some people. Not as much bonding takes place and not as much info retained. Too often these are the ones that have no time to read. If 2 full day classes are held a week apart instead of the same weekend, more time for assimilation of info and practice between sessions is possible. Make these classes highly interactive.
  • New formats for childbirth classes: Thinking “Outside the Box”
  • “Flipped classroom” is gaining popularity in some colleges. Lectures heard online and classroom is an interactive experience used for skill development and projects with peers. Could make your own YouTube video for them to watch! Use class time for hands-on skills practice, discussion on the assigned topics and/or their concerns and fears. Small groups can work together on learning tasks, games, and review of their understanding. Drawback would be if students didn’t to independent learning prior to class. Format best for self-motivated learners. Often, 1 person of a couple fits this description and the other doesn’t.
  • Preconception class helps parents to be learn what they can do to prepare for a healthy pregnancy. Opportunity to learn about choice of providers – midwife, family practice doctor, or OB – as well as choices of birth locations available in their area.
  • Early pregnancy classes focus on nutrition, exercise and dealing with stress as well as of pregnancy for pregnant woman, her partner and the baby. Communicate with healthcare provider regarding prenatal testing, as well as options for labor and birth.
  • Prenatal yoga, belly-dancing, movement, and exercise classes can be offered throughout pregnancy to give pregnant women the opportunity for healthy exercise as well as support from other pregnant women and the instructor.
  • In mid pregnancy, expectant parents are often eager to learn more about breastfeeding, baby equipment and baby care.
  • Later in pregnancy, they may want to learn about their options for pain relief during labor, and to practice comfort measures.
  • After the birth, mothers’ support groups, infant massage, breastfeeding and parenting classes, all ease the transition to parenthood.
  • Single-topic classes on a wide variety of subjects, from nutrition to birth options to baby-wearing are being offered. Participants either pay by the class or as a package plan with unlimited classes. Package might include online information and support form the educator. Online forums for expectant parents having similar due dates may be combined with in-person classes.
  • Posting some info on the web can be helpful. However, its rare for a woman and her partner to both sit in front of a computer at the same time for a full childbirth class. Use web to hook students and to entice them to attend one or more in person classes, which provide opportunity for birth partners to meet one another and to hear that most pregnant women are experiencing the same emotions.

Designing Your Course

  • Needs assessment – should be tailored to needs of all students. Can communicate via email, IM, text or phone before class. Learn about them and needs/expectations. If not appropriate beforehand, do at first class. Or ask them to write questions or hopes on a sticky note. Provide white board or easel with words “this class will meet my needs if…” so people can write while gathering. Provide ample time for discussion, questions, and answers and also asking for feedback at end of every class will help you assess if needs met
  • Goals and objectives: increasing confidence for birth and promoting informed decision-making. Need to think about why including each topic in course design. May choose to identify purpose of teaching that topic as in purpose-process-payoff method or can identify objective you have in mind. Behavioral objectives indicate specific behaviors students must demonstrate to indicate learning has occurred
  • Developing and sequencing content – fun part is deciding what to teach. Begin with simple concepts (birth is normal/natural) and build content to more complicated concepts (informed decision making). Most believe its important to present normal process before introducing complications. Rather than teaching in blocks, spiral info
  • Teaching strategies – students learn best if actively involved. Use wide variety of (mostly interactive) strategies. Use mini lecture and class discussion to teach common interventions, then later play a game such as jeopardy to review
  • Evaluation: observe them do pelvic tilt or listen to them discuss birth plans with one another.

Using Chart/Outline- Once you have: considered big picture, set goals for classes, thought about content, and how to teach it so learners will learn and answered question of who, when, where, how often, and how long to teach your classes…then you need a specific course design! Charts and outlines specifically used for this purpose. Chart includes:

  • Objective – what is purpose? What do you want learner to know or be able to do?
  • Topic – 1 topic may meet several objectives or 1 objective may cover several topics
  • Teaching strategies – how will you teach this? What will you be doing?
  • Learners activities – what will student be doing to learn what you are teaching?
  • Time frame – how many min will you spend to teach it
  • Evaluation – how can you tell objective was met. Do they like it? Get it? Can they do it? Do they use it?

Look over topic outlines in this guide. Modify to make them your own or start from scratch with an outline you devise. Think about what it is you want student to know, understand, or be able to do after completing your classes. What teaching activities will it take to accomplish your purpose? How will you construct a learner-centered course? How will you know if students learned what you taught?

  1. Write down topics you plan to cover
  2. For each, consider: need to know, nice to know
  3. How are you going to teach? List teaching strategies; list teaching aids
  4. List ways you can evaluate learning

If charts/outlines aren’t your style, read further to learn about mind-mapping on page I-13

Using a mind map to design your course – a thinking tool that uses free-form, flowing pictures of ideas using colors, words, images and imagination. Aka graphic organizer. Idea is to brainstorm on paper, either alone or in a group. Ideal way to gather your ideas for teaching strategies, evidence-based facts, and comfort skills on a particular topic.

Make a mind map for each of the topics you want to cover:

  • Write a word or short phrase, or draw a symbol to cover
  • Draw a circle around it
  • Think about what you want to teach and how
  • Write in points you want students to learn about that topic by branching off main circle or image with smaller ones
  • Use lines to connect these thoughts
  • Branch off again with your teaching methods or other details

Using mind maps, make a plan for each of your classes. Divide your topics into chunks of time you have in each class. Can use sticky notes or note cards for easy shifting around. Write what you will spiral into other classes. Figure out how you want to tie it all together. Use colors, various sized circles, curved or dotted lines etc. write as your brain thinks! Gather colored pencils or markers, eraser, colored sticky notes and a marker board or a big piece of paper.

Write class number in center and add or delete rectangles as needed to plan a class.

Topic Outline for 6 Week Series: pgs I28-29 have suggestions for spiraling

Class 1:

  • Icebreaker “Getting to know you”
  • Orientation and introductions
  • Overview of course
  • Discomforts of pregnancy 4-5
  • Body mechanics and birth fitness exercises 14-19, 100
    • Aerobic exercise 19
    • Pelvic tilt 16
    • Kegel 18
    • Wall squat 17
  • Pain management thought: Fear-Tension-Pain cycle
  • Breathing awareness 43
  • Positioning and movement for pregnancy, labor and birth 20-23, 47
  • Relaxation 24
    • Progressive relaxation 25, 104
    • Slow paced breathing 43, 105
  • Simple story of birth; birth hormones
  • Overview of labor (with pregnant anatomy) 6-7, 39-42
  • Labor support – doulas and or partner roles 33
  • DVD/Video Clip/PowerPoint slide capturing joy of birth

Class 2:

  • Icebreaker “Nutrition Crossword Puzzle” (hw from class 1) 9-13, 101
  • Discussion about childbirth experiences of mother, siblings etc
  • Labor pain discussion 36-37
  • Pain management thought: fight or flight/relaxation responses
  • Signs of labor 38
  • Stage 1 labor 39-41
  • Variations of labor and strategies to enhance progress and coping 34-35
  • Relaxation
    • Conditioned relaxation (progressive without tensing first)
    • House of colors IV-50
    • Checking for relaxation
    • Selective relaxation 25
    • Review slow paced breathing 43, 107
    • Foot and hand massage IV 48-49
  • DVD/Video Clip/PowerPoint slide segment capturing joy of birth

Class 3:

  • Students bring focal point
  • Icebreaker: breastfeeding grab bag, or other opening activity to stimulate discussion of reasons to breastfeed 63
  • Pain management thoughts: gate control
    • Sensory stimulation techniques 108
  • Relaxation
    • Touch relaxation 26
    • Massage 26
    • Review slow paced breathing 43, 107
    • Modified paced and patterned breathing 43, 107
  • Challenges of labor 46-48
  • Review stage 1 with practice labor situations (incorporate relaxation skills)
  • DVD/Video Clip/PowerPoint slide segment capturing joy of birth

Class 4:

  • Icebreaker: feeling wheel, pain management pie, or top 10 list
  • Stage 2: 42, 44-45
  • Practice positions for stage 2 45
  • Stage 3: 42
  • Birth video
  • Newborn appearance, capabilities, needs 77-84
  • Relaxation:
    • Visual imagery: your special place 105-106
  • DVD- Delivery Self-attachment or Breastfeeding: Baby’s Choice

Class 5:

  • Icebreaker: pain medications preference scale 110
  • Anesthesia and analgesia risks and benefits 51-53
  • Tour or slides of labor and delivery area
  • Childbirth choices and birth plan 49-51, 111
  • Unexpected outcomes 60
  • Cesarean birth 55-59
  • Communication skills
  • Relaxation
    • Visual imagery: Birth 25, 106
  • DVD/Video Clip/PowerPoint slide segment capturing joy of birth

Class 6:

  • Students bring packed goody bag 96
  • Icebreaker: “time sharing” 112
  • Early breastfeeding and brief postpartum 63-84
    • Dvd – amazing talents of the newborn or other newborn/breastfeeding
  • Labor rehearsal with labor stations
  • Closing DVD/Video Clip/PowerPoint slide segment emphasizing joy of birth
  • Wrap up and evaluations

Class 1 Review Sheet (to give to students)

Tonight we covered:

  • Body mechanics 14-15
  • Birth fitness exercises 16-19, 100
  • Positions for pregnancy, labor and birth 20-23
  • Terminology and anatomy 6-7
  • Progressive relaxation 25, 104
  • Slow breathing 42, 107
  • Overview of labor 39-42

Over the next week I hope you both will:

  • Read your handbook
  • Remember challenging situations you have faced. What helped you to cope? Think about who you would like to support you during labor and birth. Discuss whether a professional labor support person or doula might be helpful
  • Do the nutritional crossword puzzle on pg 101 and fill out diet evaluation on pg 103. If desired, begin fetal movement counting chart on pg 98
  • Use good body mechanics and include birth fitness exercises into your daily routine
  • Choose a form of aerobic exercises that is right for you, and plan how you will include it in your daily schedule. Read over ACOG guidelines for exercise on pg 19
  • Do extended Kegel (hold 20 sec) several times a day.   Easy way to remember is to do one each time you go to the bathroom, after you have emptied bladder
  • Tune in to your body to try to become aware of tension. Release tension away. Practice progressive relaxation. Consider adding music to your practice session to reduce stress
  • Practice slow, deep breathing. Try using it during periods of stress
  • Arrange to take breastfeeding and baby care classes (phone number to call)

Bring to class next week:

  • Handbook
  • Pillows for comfort
  • Snack




Topic Outline for Weekend Classes pg 20-21

Teachers and Learners: Women of childbearing age today fit into 2 categories: “Generation X” (born between 1961-1980) and “Millennials” (born between 1981-2000). Tech-savvy, multi-task, want to have fun while learning, think visually and like experiential learning. Expect good communication.

Prep you do before 1st class will largely determine the success of your series. Should receive text, email or written confirmation of their registration. Need time, date, location of classes, clear directions and map, instructions on what to wear/bring. Might be posted on FB page. Some give info form to be filled out before first class. Sample info forms in Appendix

Contact each couple before class to introduce self and to determine special concerns/needs. Knowing about labor partners may keep you sensitive to language you use. Ask gay, lesbian, bi-sexual, transgender how they would prefer that you refer to them.

Physical needs met before social/higher level needs. Provide snacks for first class. Food enhances social atmosphere and may meet needs of students who missed meal to get there on time. Snacks should be healthy. Can do sign up sheet and ask couples to take turns. Should have access to water.

Make classroom comfortable. Ask them to bring pillows. Ask them if temp, lighting, noise etc is okay.

Most comfortable teaching is often your home, but when looking for a classroom: carpeting/mats for practicing comfort measures on the floor, windows and good lighting with dimmer for relaxation time, pictures on walls – multicultural pics of babies, pics of breastfeeding moms/babies, nature pics, photos that can relate to birth (Harriette Hartigan), variety of seating options – comfortable chairs, beanbags, birth balls, back supports for sitting on floor. Arrange seating in circle or U-shape, so students can see each other.

Learning Preferences:

  • For quiet, organized intellectuals, educator should: organize self and class; provide an agenda; give facts and theories, use logic; have written resources available; show practical application; allow class time to practice skills. They like to think, will read and study, like to be prepared, are organized people. They enjoy good lectures, may not participate in class discussions, like quiet time.
  • For relaxed, easygoing mediators, educator should: balance pros/cons, risks/benefits, listen to and acknowledge them, if they speak, tell positive stories of pregnancy and birth, come to consensus, make group decisions, play cooperative games and work puzzles, practice skills in class. They do not like conflict, may not often speak up; need time to reflect, are nurturing people who give and desire respect. They do not often show strong emotion, have difficulty making decisions, would rather listen than talk.
  • For fun-loving, outgoing talkers, educator should: have fun, relate subject to real life experience, change activities often, be spontaneous, do things – role play, games, puzzles, contests, rehearsals, touch things – pelvis, baby doll, partner, show things they enjoy – videos, demonstrations, instructor role plays, share experiences. They prefer to play as they learn, are bored in a traditional classroom, are emotional people. They will tune out of long lectures, may become the “clown” if bored, find verbal and visual work far more appealing than paper and pencil.
  • For outgoing, hard-working leaders, educator should: state class goals and objectives, hold debates, contests, discussions, provide books, scientific journals, references. They will set goals and plan ahead, ask why, like problem solving, will lead small groups and report back. They may try to take over class, need to understand, explain, predict, experiment, control.

Reach out to all learners: some come to have fun/hear happy stories about birth; some come eager to ask questions, hear about latest technology and research or seemingly to challenge you. Others want to learn to relax and breathe and be encouraged about giving birth.

  • Have an agenda on board or as a handout. If need to deviate from it, tell students your plans and invite their input
  • Have material you plan to teach organized in your mind. Have teaching aids and references arranged for easy access
  • Make class learner-centered. Encourage participation, questions, additions to agenda, group leadership etc
  • Listen to stories and experiences of students
  • Be able to back up statements and theories with research, providing studies if asked
  • Encourage use of comfort techniques throughout class – pillows, water, balls, prop up feet. Adjust lights and temp for comfort
  • Present both sides of controversial subjects. Offer pros and cons, risks, harm and benefits
  • Share positive birth stories
  • Show images of birth that build confidence
  • Include games, role plays, and rehearsal as as well as lectures and discussions
  • Manipulate models, demonstrate comfort tools, show DVDs and graphics. Practice skills; vary your presentation and have fun
  • Provide a safe environment for discussion of thoughts and sharing of feelings by being open and accepting of each students birth-day wishes
  • Provide a method of feedback, so you know that students are leaning and having needs met. Weekly reaction sheets are helpful
  • Preview at beginning and review at end of class
  • Sequence: icebreaker, work phase, application phase
  • Give clear instructions (verbal or handout) of how you wish them to prepare for following class
  • Show sense of humor

See pgs 28-38 spirals or blocks elsewhere in doc

Educator’s Self-Evaluation

Evaluate yourself:

  • I have a basic teaching plan with clear objectives for each session I teach
  • I analyze the needs, constraints and preferences of my students/audience
  • I include a preview and review of important topics
  • My introduction will attract attention and provide background info
  • The visual aids I choose to use are simple, easy to see/read and serve a purpose
  • I use an appropriate number of different types of visual aids
  • My presentation is logical and evidenced based (but not boring)
  • I communicate with enthusiasm
  • I focus on my class/audience, not on my notes
  • I rehearse using my visual aids and timer
  • I practice responding to anticipated questions
  • I arrange seating and check A-V equipment before my presentation
  • I maintain eye contact with participants
  • I use vocal variety and physical movements to hold attention
  • I listen to my recorded presentation to hear my annoying or overused sounds and phrases (umm, ahh, ok, right, you know)
  • I included learning activities that build confidence in students’ abilities

What are my greatest strengths as a teacher/presenter?

What weaknesses am I trying to overcome?

What would I like to hear said about me after my presentation?

Ask a peer to evaluate you:

What are my greatest strengths as a teacher/presenter?

What weaknesses should I try to overcome?

What is your perception of how I came across to the class?

DONA – Birth Doula’s Contribution to Modern Maternity Care Position Paper –

ICEA Mission – a professional organization that supports educators and other health care providers who believe in freedom to make decision based on knowledge of alternatives in family-centered maternity and newborn care.

ICEA’s goals are to provide:

  • Training and continuing education programs
  • Quality educational resources
  • Professional certification programs

Brief History: ICEA Is a nonprofit organization. Since its formation in 1960, ICEA members and member groups have remained autonomous, establishing their own policies and creating their own programs. There are no membership requirements for individuals other than a commitment to family-centered maternity care and the philosophy of freedom to make decisions based on knowledge of alternatives in childbirth.

Philosophy: Family-centered maternity care is ICEA’s primary goal and the basis of ICEA philosophy. In 1986 UCEA adopted the McMaster University definition of FCMC:

Philosophy: The birth of a baby represents, as well, the birth of a family. The woman giving birth and the persons significant and close to her are forming a new relationship, with new responsibilities to each other, to the baby, and to society as a whole. Family-centered reproductive care may be defined as care which recognizes the importance of these new relationships and responsibilities, and which has as its goal the best possible health outcome for all members of the family, bot as individuals and as a group.

Family-centered care consists of an attitude rather than a protocol. It recognizes a vital life event rather than a medical procedure. It appreciates the importance of that event to the woman and to the persons who are important to her. It respects the woman’s individuality and her sense of autonomy. It realizes that the decisions she may make are based on many influences of which the expertise of the professional is only one. It requires that all relevant information be made available to the woman to help her achieve her own goals, and that she be guided but not directed by professionals she has chosen to share the responsibility for her care.

Practice: the practice of family-centered maternity care is founded on this philosophy and encompasses birth practitioners, birth places, and maternity-newborn care, as determined by the needs and choices of each woman and her family.

Lamaze International

Mission: to advance safe and healthy pregnancy, birth and early parenting through evidence-based education and advocacy

Lamaze Healthy Birth Practices – based on the best medical evidence available, and are designed to promote a safe and healthy pregnancy and birth

  • Let labor begin on its own – letting the body go into labor on its own is almost always the best way to know that the baby is ready to be born and the body is ready for labor
  • Walk, move around and change positions throughout labor – moving in labor (not confined to a bed) helps women cope with strong and painful contractions, while gently moving the baby into the pelvis and through the birth canal
  • Bring a loved one, friend or doula for continuous support – in childbirth, a woman feels better when supported by people she trusts and those who use encouragement
  • Avoid interventions that are not medically necessary – when interventions (induction, epidural, continuous monitoring) are used in a routine manner, women and babies are exposed to unnecessary risks
  • Avoid giving birth on your back and follow your body’s urges to push – upright positions are safe during pushing and can make it easier to push the baby out. This could mean squatting, sitting or lying on the side
  • Keep mother and baby together – its best for mother, baby and breastfeeding – mother and baby share a natural instinct to be close after birth, and experts recommend that a healthy newborn be placed and cared for skin to skin on the mothers abdomen or chest

Lamaze’s Fundamentals for Birth

  • Birth is normal, natural and healthy
  • Women have an innate ability to give birth
  • The experience of birth profoundly affects women and their families
  • Women’s confidence and ability to give birth is either enhanced or diminished by the care provider and place of birth
  • Women have the right to give birth free from routine medical interventions
  • Birth can safely take place in homes, birth centers and hospitals
  • Childbirth education empowers women to make informed choices in healthcare and take responsibility for their health and to trust their innate ability to give birth

VIII. Other Part 2 References

  1. The Rights of Childbearing Women The Rights of Childbearing Women


Statement was developed in response to serious and continuing problems w maternity care in U.S., including:

  • S. is only wealthy industrialized nation that does not guarantee access to essential health care for all pregnant women and infants. Many women, esp those w low incomes, lack access to adequate maternity care
  • A large body of scientific research shows that many widely used maternity care practices that involve risk and discomfort are of no benefit to low-risk women and infants. On the other hand, some practices that clearly offer important benefits are not widely available in U.S. hospitals.
  • Many women do not receive adequate info about benefits and risks of specific procedures, drugs, tests and treatments or about alternatives
  • Childbearing women frequently are not aware of their legal right to make health care choices on behalf of themselves and their babies, and do not exercise this right.

Must ensure women have access to info/care based on best scientific evidence available and that they understand and have opportunities to exercise their right to make health care decisions. Women whose rights are violated need access to legal or other recourse to address their grievances.

Every Woman’s Rights:

  1. Health care before, during and after pregnancy and childbirth
  2. Receive care that is consistent w current scientific evidence about benefits and risks. Harmful, ineffective or unnecessary practices should be avoided. Unproven interventions should be used only in context of research.
  3. Choose a midwife OR physician.
  4. Choose her birth setting from full range of safe options available in her community
  5. Leave her maternity caregiver and select another if she becomes dissatisfied w her care
  6. Info about professional identity and qualifications of those involved w her care, and to know when those involved are trainees
  7. Communicate w caregivers and receive all care in privacy, which may involve excluding nonessential personnel.
  8. Receive maternity care that identifies and addresses social and behavioral factors that affect her health and that of her baby. Access to social services and behavioral change programs that could contribute to their health
  9. Full and clear info about benefits, risks and costs of procedures, drugs, tests and treatments offered to her, and of all other reasonable options including no interventions. She should receive this info about all interventions likely to be offered during labor and birth well before onset of labor
  10. Accept or refuse procedures, drugs, tests and treatments and to have her choices honored. She has the right to change her mind. (this established legal right has been challenged in a number of recent cases)
  11. Informed if caregivers wish to enroll her or her infant in a research study; she has right to decide whether to participate, free from coercion and without negative consequences
  12. Unrestricted access to all available records about her pregnancy, labor, postpartum course and infant; to obtain a full copy of these records; and to receive help in understanding them, if necessary
  13. Receive maternity care that is appropriate to her cultural and religious background, and to receive info in a language in which she can communicate
  14. Have family members and friends of her choice present during all aspects of her maternity care
  15. Continuous social, emotional and physical support during labor and birth from a caregiver trained in labor support
  16. Receive advance info about risks and benefits of all reasonably available methods for receiving pain during labor and birth, including methods that do not require the use of drugs. She has the right to choose which methods will be used and to change her mind at any time
  17. Freedom of movement during labor, unencumbered by tubes, wires or other apparatus. The right to give birth in the position of her choice
  18. Virtually uninterrupted contact w her newborn from moment of birth, as long as she and her baby are healthy and do not need care that requires separation
  19. Receive complete info about benefits of breastfeeding well in advance of labor, to refuse supplemental bottles and other actions that interfere w breastfeeding, and to have access to skilled lactation support for as long as she chooses to breastfeed
  20. Decide collaboratively w caregivers when she and her baby will leave the birth site for home, based on their conditions and circumstances.
  21. Goer, H. & Romano, A. (2012). Optimal care in childbirth: The case for a physiologic approach. 
Seattle, WA: Classic Day Publishing. (No questions from this text are on the ICEA International PCBE Exam)
  23. Birth by the Numbers: The Update: 8/29/14 by Gee Declercq (1st version 2008). 4

U.S vs Comparable Countries: neonatal, maternity, perinatal mortality

  • S. cesarean rate up 50%
  • VBAC down 70%
  • 2012: ~4MM births 2012 (dropped 8% past 12 years); 1.3MM Cesareans; 9.2% VBACs
  • Prematurity dropped 9.8% in past 6 yrs (‘06-‘12)
  • 35k gave birth at home, 47k gave birth at birth centre; who prob have given birth at hospital before
  • Comparative Neonatal Mortally Rates – U.S. ranks 37th; some countries don’t have any mortalities bc low births. So need to compare countries w 100k births – other well-developed countries.
  • Neonatal Mortality Rate – Infant deaths first 28 days/live births x 1000. 4/1000 in U.S; last compared to other developed countries.
  • Perinatal Mortality Rate – Fetal Deaths + Deaths in 1st week / live births + fetal deaths x 1000 (difference in countries just in measurement).
  • Maternal Mortality Ratio – Maternal Deaths* all causes x 100k / live births (death up to 42 days postpartum). Comparison to at least 300k births a year. U.S. 2nd If break down to race, black non-Hispanic 3x that of whites.
  • Key trends in Maternity Outcomes– S. getting better neonatal mortality rate past 10 years but other countries improving at a better rate. If U.S. had avg of other countries, that would be 7k fewer deaths annually.
  • Perinatal Mortality – we are closer to other countries; U.S. hasn’t given rate since 2006.
  • Maternal Mortality – other countries flat; U.S. up 71% 2000-2011. Part of this case ascertainment – doing better job of measurement; other countries also doing better measurement.
  • S. Cesarean Rates 1989-2012 – if we kept same rate as in 96, 500k fewer cesareans a year. Black non-Hispanic mothers more likely than white or Hispanic.
  • Cesarean Rate – primary – decline early 90s, rise after 96
  • VBACs – VBAC Rate went up to 28%.   Rates vary enormously by state. Compared to other countries – not highest (Portugal, Italy, but Italy has better outcomes). U.S. has lowest VBAC rate compared to other countries.
  • Economic Consequences – gestational age – peak 40 weeks, normal curve. Now 2012- peak is at 39 weeks, 2nd highest 37-38 weeks, and 40 weeks even lower.
  • Costs – birth 2nd and 3rd reasons for hospitalization in U.S.
  • Vaginal births no complications – cesarean no complications 70% more expensive
  • Total cost to society – $52B
  • Better evidence and advocacy needed – ACOG and Society for Maternal-Fetal Medicine – Safe Prevention of Primary Cesarean Delivery; Choices of Childbirth NYC, Business of Being Born, Childbirth Connection (Translating evidence into actions); Listening to Mother Surveys, Orgasmic Birth (DVD extra became base for Birth from Numbers), Our Bodies Ourselves (student run website)
  • What We Learned – things getting better, but not fast enough. Groups working to make it better. Join them.

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