ICEA Study Guide 7 – Coping Skills for Labor


OBJECTIVES At the conclusion of Part 7 the learner will:

  • List the three R’s of labor as defined by Penny Simkin.
  • Compare and contrast three support people for labor and birth.
  • List the benefits of relaxation as a life skill and in particular for labor and birth.
  • Teach a relaxation technique used during labor.
  • Describe five tools to enhance relaxation.
  • Demonstrate a massage that facilitates comfort.
  • Demonstrate a breathing pattern that may be used for labor.
  • Describe positions that facilitate comfort in the first stage of labor.
  • Describe a class space that is conducive to teaching relaxation and comfort skills.


  1. Support for labor and birth
    1. Three R’s: Relaxation Rhythm, Ritual
    2. Partner and family, the nurse, the doula
    3. Scope and practice of the doula


Finding Your Own Way to Cope with Labor Pain: The Three R’s: Your response will depend on nature of your labor, your coping style, your goals/expectations and how prepared you feel for labor. Those who cope well have 3 behaviors in common: 3 R’s: Relaxation, Rhythm and Ritual.

Relaxation: May move about between contractions and let their muscles relax during contractions. May become active during contractions (swaying, rocking, stroking bellies) and relax only between contractions. Or may remain quiet and unresponsive to their surroundings during and between contractions.

Rhythm: Rhythmic activity calms the mind and lets a woman work well with her body. May rhythmically breathe, moan or chant during contractions. May rhythmically tap or stroke something or someone. May rock, sway or dance in rhythm. May curl her toes in rhythm. Partner or doula’s role is to enhance the rhythm and reinforce it through contractions. Can breathe/sway in rhythm/dance/direct.

Ritual: Repetition of meaningful rhythmic activity during contractions. Relaxation, breathing (223) and attention-focusing (208) common rituals that childbirth educators teach. Help women in early labor establish effective coping style. Most spontaneously adapt their planned rituals or find a new one to increase ability to cope as labor progresses. Partner’s behavior and actions can influence the effectiveness of a ritual. He must not do anything to change your ritual. Having someone act in same way during each contraction will be reassuring to you.

May be: maintaining eye contact with you, repeating the same words or phrases, counting your breaths through each contraction. If focus is inward, partner may be close by and protect you from interruption. Can switch ritual at anytime – look to doula, partner or caregiver for suggestions. Hospital policies, options or interventions may limit your options so make sure to practice one you can do during disturbances, such as self-talk (silent or vocal), tapping or stroking. Ex: rock in rocking chair, partner stroking leg, partner points out when halfway through contraction; swaying through contractions

The Three R’s: After several hours (or even a day or longer), you’ll be unable to ignore your contractions – can’t walk or talk without having to pause at its peak. Activities are no longer distracting or fun. This marks a shift in your coping strategy. Instead of using distracting activities, use the three R’s (p 206).

Partners: Prep hospital bag/gas in car or house (tidy up/enough food) if it’s a homebirth. If mama becomes quiet, become quiet with her. Don’t hover over her or stare. Touch tense areas ~ “Try to breathe away tension in shoulders.” Remind to sip water after every contraction or 2 and follow her rhythm. (Ch 11 relaxation techniques).


Choosing a Birthplace:

Hospital: Most women in North America – each hospital differs with philosophy – take a tour and see which one suits you. Some hospitals only allow low risk pregnancies. Others have tertiary care – intensive care, complete OB and anesthetic services, blood bank, 24 hour lab and NICU. Can find credentials of anesthesia staff. Find out about birthing/postpartum rooms/bathtubs. Mother friendly/ baby friendly hospitals. If dislike particular routine, caregiver may be able to write orders that override it.

Hospital Tour Questions: Ratio of patients: nurses during early labor/active labor/birth/post birth; are they RNs or paraprofessionals? Floating/traveling nurses? Birth plans? Equipment to monitor baby’s heart rate? Move around while being monitored? Laboring women have IVs? Eat/drink during labor? Anesthesia available at all times? Non drug methods of pain relief? Bathtubs/how often used in labor/ give birth in them? Who can be with me? Doulas? Cesarean – how many people attend? Length of stay after birth? Procedure for baby after birth? Who will examine baby? When? Breastfeeding specialists? Available support after leave hospital? Postpartum/newborn follow up after leave hospital?

Tours usually involves visit to triage area, birthing room, postpartum room, nursery and family waiting area (not for cesarean).

Birth Doulas: Cochrane Report – 2007 – dehumanization of women’s birth experiences recommends labor support.

Benefits: shorter labor, less need for medication, more spontaneous vaginal births, less dissatisfaction.

Ask friends, childbirth educator or caregiver for recommendations.

Health insurance rarely covers but some at low/no cost, especially those with tight finances.

Partners: Take care of yourself (stay hydrated and keep up energy by eating nutritious snacks; physical supporting mama – good body mechanics – Let others know if you need rest).

All PCNGuides in PDF here:

Doula: Knows birth plan, pain medication preferences, hopes, comfort measures. Some hire for partner as much as laboring woman, esp. if partner has hypoglycemia, becomes queasy at sight of blood, has physical limitations, or doesn’t want pressure of knowing comfort measures.


Acupressure for Comfort and Progress in Labor: Hoku (back of hand where thumb and index bones come together) and Spleen 6 (inner side of leg, 4 fingers above anklebone). 10-60 seconds, rest for same amount before repeating 3-6x. Reduce pain/speed up labor. Don’t press before due date – preterm labor.

Partners: Practice timing contraction beginning to end; practice with ice cube with and without comfort measure; remind mama to move around; be aware of facial expressions and tone of voice


Labor Support: Doula – “woman’s servant”. Options available in community. Study on 20 fathers: 4 were “coach”, 4 were “teammate”, 12 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.

YouTube: DONA International – The Essential Ingredient: Doula. (14:18)

Word doula comes from ancient Greek, “a woman who serves. First used by medical anthropologist Dana Rafael in her 1973 book “The Tender Gift: Breastfeeding” to refer to a woman who provider postpartum care. As a result of pioneering work of Marshall Klaus and John Kennell, the meaning of the word doula has expanded to include work during prenatal time and during childbirth.

Dr. Marshall Klaus – started out in Guatemala – could they enhance breastfeeding by putting mom and baby together (in those days moms and babies separated in nurseries). Interviewed all mothers – one had stayed w every mother and had salutatory effect. Something happened when had someone with them all of the time – very different result from birth. So hired 3 established woman to stay w mother and discussed training. They were the first doulas.

Annie Kennedy – 1 of DONA founders – family thinks baby is cuter/smarter than other families w doulas; woman likes partner better.

Woman have always surrounded women at childbirth; until 100 years ago, 90% of births took place at home. Laboring woman would’ve been supported by a sisterhood. Used to be common for woman to witness many births before having own baby.

Penny Simkin – women don’t forget birth experiences; we can control how we care for women.

Must consider important facts:

  • Cesarean rates rose to 30% and rising w no decrease in mortality. True in most countries around world. WHO says shouldn’t exceed 10-15%. Higher rates expose women to higher risks.
  • Doula reduces risks of interventions. Interventions increase risks to moms/babies.
  • Postpartum doulas increase bonding bw mom and baby and decrease risk of postpartum depression. Help transition them to becoming a family.
  • Behaviorally, women feel better about themselves. Babies benefit from less drugs, less separation (surgery of mom).
  • In ancient times, there was always loving women around women giving birth.
  • Women who become doulas usually have a great drive to help other women.

Mothers Advocate. The timeless way: Birth Images from Ancient Times (4:22) 

For thousands of years, people have celebrated the power of women in birth in their art. Early people worshipped goddesses as well as gods. And carvings of women giving birth can be seen as far back as Ice Age 20,000 years ago.

Tlazolteotl, Aztec goddess of birth, 12th century A.D. – stone sculpture from Mexico; goddess of agriculture. She gives birth unassisted, squatting.

Hindu goddess Kali, 18th century wood carving, S. India

For all cultures, birthing goddess is a figure of great strength and power honoring they mysterious female powers of fertility and life giving. But she can also teach us much about how women gave birth in the past. (Ex: goddess supports self in squatting position holding rope).

Every women has something of the goddess inside her, but don’t birth alone. Women need assistance during labor and most often get it from other women.

Sculpture – Ancient Cyprus, 6th century B.C. – women giving birth in upright posture w support from woman behind and midwife in front with arms reached out to catch the baby. Seen again and again in other cultures (ex. Ancient Greece & Rome); might call this classic birthing pose.

In another Greek relief, see mom on birthing stool supported by 2 women helpers who hold her closely.

Similar birth scenes found on clay pots from Peru (Pre-Columbian Peru 500 A.D). Show same classic pose of 3 figures – a helper and receiver. Notice how midwife is small compared to mother, who is most important person in group.

Chowke people of Africa – Angola and Zaire – 3 people again.

Another classic pose found in sculpture from Kraja people from Amazon Basin, South America. 3 women working together.

Similarities in birth art produced by many different cultures (Yoruba people, Nigeria, Africa) traditional way human birth – mom in upright posture – sitting, kneeling, squatting etc. Assisted by other women. Mother seen as strong person and innate ability to give birth is respected.

DVDs: Doulas: A documentary; Doula: The Ultimate Birth Companion; Special Women

Books: “Deliver! A Concise Guide to Helping the Woman you Love through Labor”; “The Doula Book”; “The Labor Partner”


Companion(s) of the Mother’s Choice: Women have helped other women throughout history –it was assumed and assured until place of birth moved from homes to hospitals.

In mid 1960s, one California father handcuffed himself to his wife’s wrist so he could be at her side during baby’s birth; one father had to be agreed to be strapped into a wheelchair in case he fainted in the delivery room.

Until recently, in most of E. Europe and former Soviet Union, separation of mother and her family was extreme – she couldn’t see them until she was discharged, 7 days after delivery.

Mid 1990s brought dramatic changes in former Soviet states. Maternity policies now encourage a support companion for women in labor.

Several remote areas of Canada, women are transported to a residential holding facility in a larger city at 36 weeks, where she lives until she gives birth in regional hospital. If she lacks personal funding for family lodging/companion, she labors alone.

Study: supported mothers had significantly shorter labors, were awake more after delivery, stroked, smiled and talked to babies more. Fewer perinatal complications, less cesarean sections, less oxytocin augmentation and fewer infants admitted to NICU.

6 weeks postpartum: more likely to be exclusively breastfeeding, 4x less likely to report breastfeeding problems, 2x as likely to be feeding at flexible intervals and far less likely to stop feeding because of “insufficient milk”.

More likely to give birth spontaneously, less likely to use pain medications, more satisfied. Better when not hospital staff who is support and when they begin in early labor. Unsupported women more likely to have stopped breastfeeding by 1-2 months.

Zambia – Health staff didn’t want birth companions, but now allow. They weren’t allowed to sit up or assume any other position; if she did, they scolded her and told her to shut up. They would exert pressure on womb forcibly during labor and do painful procedures including repairing episiotomy with minimal local anesthesia and manual separation of placenta. As a result of research documentation, many have instituted many baby friendly changes.

Although brief training helpful, the mere presence has great outcomes. Cost effective in short run.

*Care women receive in labor impacts their ability to care for their babies.*


ICEA Position Paper on the Role and Scope of the Doula

The International Childbirth Education Association recognizes the vital role that birth doulas play as a member of the maternity health care team.

In addition, doulas offer guidance and community resource referrals to families regarding maternal self care, lactation, and other issues pertinent to healthy parenting through the first six weeks postpartum.

A doula provides emotional, educational and physical support. In contrast to the doula’s role, a labor and delivery nurse tends to the clinical needs of the laboring woman in a hospital or birth center. A nurse who studies further to become a Certified Nurse Midwife can deliver babies and prescribe medicine. A monitrice, who may or may not be a nurse or a midwife, has received training in clinical skills related to birth, such as checking fetal heart tones, maternal blood pressure and cervical change.

Statistical data from one of the largest study reviews demonstrates the following benefits of women who have labor support and women who do not.

Women who do have labor support are:

  • 28% less likely to have a cesarean section;
  • 31% less likely to use synthetic oxytocin to speed up labor;
  • 9% less likely to use any pain medication; and
  • 34% less likely to rate their childbirth experience negatively.

Over twenty years of research and a multi-clinical trial study show that doulas can have a significant impact on the birth process.

If a birthing facility has taken steps to reduce the cesarean section rate, then the first percentage value may not be precise.

  • 50% reduction in the cesarean rate
  • 25% shorter labor
  • 60% reduction in epidural requests
  • 40% reduction in oxytocin (Pitocin) use
  • 30% reduction in analgesia use
  • 40% reduction in forceps delivery

Prior to birth, a doula provides information to her clients about the birth process in general, a variety of comfort measures and coping skills, and common procedures

As a doula accompanies a woman in labor, her primary responsibility is to be present in every sense.

The doula, as a servant, lays aside any preconceived ideas she may have and supports the mother in the way that the mother chooses to labor.

A doula also supports the father and others who are present, helping them to participate in the birth experience to the extent that they are comfortable.

A doula physically supports the mother in a variety of ways:

  • She will suggest alternative (upright and gravity positive) positions for the mother
  • Remind her to maintain her fluid intake
  • Make sure she goes to the bathroom frequently
  • Offer the use of heat/cold therapy for stress and pain relief.
  • May help with coping skills such as breathing techniques, relaxing touch or visualization.
  • May suggest dimming the lights or playing music – whatever creates a soothing environment for the mother.

There is a misconception that doulas only provide care for those interested in natural childbirth/ unmediated births

A doula does not give medical advice or perform any medical tasks. While it is beneficial for a doula to be knowledgeable about medical procedures, her job is not to make decisions for the client.

Doulas do not contradict health care providers.

A doula protects the privacy of her clients. Per HIPAA, no personal health information (PHI) should be shared unless the client has given her express consent.

Doulas provide a bridge in the maternity care gap

Continuous labor support has been shown to have positive pregnancy outcome benefits, including improved satisfaction with the birth and a rise in self-esteem of the mother. This could positively impact the mother-baby relationship in the postpartum period as well as breastfeeding initiation and continuance

ICEA, therefore, believes that birth doula care should be available to every woman who needs or wants continuous labor support.

  1. Comfort techniques for labor
    1. Attention-focusing
    2. Baths and showers
    3. Foods and fluids
    4. Heat and cold
    5. Comfort items
    6. Massage and touch
  1. Attention-focusing

Comfort Techniques for Labor: Remembering labor pain is part of process helps keep pain manageable. Think about what helps your relax: listening to music, massage, soothing voices, warm bath, meditation, praying, chanting, humming, recalling pleasant places, visualization, empowering images. Think about what makes you feel safe – pillow, nightgown…

“Tune in to pain or tune out the pain”

  • Tuning In/Out: Tune into pain by focusing on it, accepting it and tailor your response to it. Tune out pain by using distraction techniques, concentrating on outside stimuli or performing mental activities.
  • Attention-Focusing: Focus attention to calm self and keep from wandering to pain/anxiety (distraction good).
  • Visualization: Encouraging/empowering image – picture uterine muscle contracting and pulling cervix open. Visualize baby pressing cervix open, imagine calm, pleasant places or recall happy, peaceful events, each contraction as hill to climb, race to run, wave to ride.
  • Cognitive Attention Focusing: Thinking/saying words of song, poem, verse or prayer. Count with rocking, walking, stroking.
  • Visual focus: Focus on image. Partner’s face, picture, reminder of baby, flower, candle. Focus on line around object.
  • Sounds: Favorite music, partner’s soothing voice, repeated rhythms, recording of environmental sounds, rainfall, babbling brook. Poems, prayers, chanting. Rhythmic moaning. Low pitched sounds.
  1. Baths and showers

Baths and Showers: Gentle massage, helps body relax. May get instant relief or take 20 minutes (try for this long before other pain relief option). Lean against folded towels. Kneeling/leaning over side of tub for relieving back pain. Lying on side with head elevated. Temperature around body temperature- don’t want to become overheated.

Shower: Towel covered birth ball/stool. Spray water to relieve tension. Lower back for back pain. Partner can join shower and give massage (pack swimsuit for hospital). Can lower blood pressure.

In early labor, bath may slow it down and may need medical intervention to speed it up so take shower instead.

In active labor, bath speeds up labor while delaying intensity of pain.


  1. Foods and fluids

Foods and Fluids: high carb (fruit, pasta, toast, rice and waffles). Easy to digest food/beverages (soup, broth, herbal tea). May become less interested, but hunger (or low blood sugar levels) may decrease tolerance for pain. If not hungry, keep hydrated: sip clear broths, popsicles, water, tea, juice, sports drink. Empty bladder often – may slow labor/increase pain. Studies of women eating/drinking during labor show no disadvantage for low risk. IV if vomiting/prolonged labor to prevent dehydration; rolling IV moves around. If dry mouth – ice chips, popsicle or sour lollipop. Brush teeth/rinse mouth with cold water/mouthwash.

Adverse effects of dehydration in labor

  • Women require ~50-100 kcal/hr to maintain adequate muscle function. Research supports free use of oral intake – both fluid and solids. Women may need to be reminded. Important in prolonged labor.
  • Non-acidic, easy to digest carbohydrate snacks and drinks available (broth, electrolyte-balanced sports drinks, fruit, honey, toast etc).
  • Have her drink to thirst both to prevent hyponatremia (which may cause prolonged labor due to overhydration from forced oral fluids) and maternal exhaustion caused by dehydration and poor caloric intake.

Assessment includes:

  • Urine (every 2 hours- light in color; dark, concentrated or scant suggests inadequate fluids);
  • Ketonuria (accumulation of ketones as result of metabolizing stored fat in absence of carbs; research controversy over whether this is a sign of maternal compromise);
  • Temperature (slight rise in temp normal but >1 F and labor prolonged, may signal dehydration; significant rise (>100.4 F) esp in presence of ruptured membranes may signal infection, a serious intrapartum complication);
  • Emesis (vomiting common but if prolonged or persistent, dehydration may result so make sure additional intake of fluids);
  • Fluid loss through perspiration (in warm conditions, esp warm water baths need additional fluids. Remind to drink to thirst – offer, don’t push after each contraction or 2);
  • Maternal distress (anxious, exhausted, sick. Severe dehydration can exacerbate nausea and vomiting. Intravenous rehydration may be necessary).


Modifiable Labor Influences: Eat and Drink, Or “Labor is Work”: Odds of dying of aspiration in labor are less than being struck by lightning 2x in 1 year. Mother-friendly care includes letting women drink and eat light foods during labor. Uterine muscle, like every muscle, requires hydration and nourishment to contract effectively. Skipping even 1 breakfast in late pregnancy can trigger “accelerated starvation” and bring unpleasant and dangerous symptoms of hypoglycemia: lightheadedness, shakiness and fatigue. Depriving uterine muscle of nourishment can cause inefficient and painful contractions, resulting in longer, more stressful labor for mother and baby, which are risk factors for delayed lactogenesis. Alternative is IV hydration; edema of lactating breast can prevent baby from effectively latching on and feeding. Infants exposed to maternal overhydration lose excess water weight quickly, leading to early supplementation. During pregnancy, need 200-300 kcal a day and during breastfeeding, 500-650 kcal.

Effects of IV Hydration on Maternal Stress, Breast Edema and Lactogenesis: Increased use of epidural accompanied by increased use of IV hydration- prevent supine hypotension. Breast, nipple and areolar edema on 2nd or 3rd postpartum day seem to be correlated with IV fluid hydration. Edema inhibits or prevents deep attachment at the breast. Preventing milk stasis by ensuring early and effective milk drainage is the most critical strategy for ensuring normal lactogensis. Not enough milk is the most reported reason that babies are given supplemental feeds and mothers stop breastfeeding. Milk stasis longer than 6 hours after birth interferes with normal establishment of full lactation. Postpartum breast engorgement is a major barrier to establishment of effective and comfortable breastfeeding. Oxytocin and oxytocin augmentation and induction in labor can cause fluid retention in mother. Reverse pressure softening to overcome severe breast edema. Moms leave hospital 2-4 days after birth with no lactation support.

Effects of IV Hydration on Infant Status, Ability to Feed and Risk of Supplementation:

  • Excess fluids in laboring women related to infant hypoglycemia, hyponatremia, electrolyte imbalances and hyperbilirubinemia.
  • Develop jaundice more often.
  • Any respiratory compromise affects baby’s ability to feed.
  • Jaundiced babies feed poorly and are more likely to be supplemented.
  • Babies whose mothers had glucose IVs were 3x more likely to by hypoglycemic, causing lower muscle tone and delayed habituation to various stimuli at 2 hours of age.
  • No change in suck and root reflex, but muscle tone related to infant sucking and feeding ability.
  • Hypoglycemic babies often separated from mom for testing. Appropriate therapy is IV glucose, not oral fluids. Excessive weight loss in early neonatal period often a reason for aggressive supplementation.

Other Effects of IV Hydration and Caloric Restriction in Labor: Instrumental deliveries higher in moms who had restricted food.

Global Aspects of Hydration in Labor: Withholding food & liquid in warm climates. Offering fluid noted fasted labor and better newborn Apgar scores. If acetone (ketones) is present in woman’s urine, suspect poor nutrition and give dextrose IV.

2008 – 59% of mothers had IV hydration.

Summary: Outdated process that doesn’t improve birth outcomes; can lead to electrolyte imbalances, jaundice and other problems in newborn requiring separation and impacting breastfeeding; can cause edema, perceived by mothers as painful, stressful and restrictive of movement which can lead to prolonged labor and other interventions that impact early breastfeeding.

  1. Heat and cold

Heat & Cold: Electric heating pad/hot water bottle on lower abdomen, back, groin or perineum relieves labor pain. Cloth bag/sock filled with rice and heated in microwave. Soak washcloths in hot water; wrapping in plastic retains heat longer.

Cold pack on lower back can relieve back pain. Ice packs for perineum after birth. Cool wet cloth, bag of ice cubes or frozen peas, frozen wet washcloths, cold cans of soda, frozen gel packs w straps. Wear warm robe or use blanket.

Have partner hold in hand for few seconds to test and have cloth in between source and skin. If have pain medication, avoid using on numb areas.

Touch and Massage – touch can be as simple as holding woman’s hand, stroking her body, and embracing her. Determine woman’s preferences (where, who, how). Woman with history of sexual abuse or cultural beliefs may be uncomfortable. Women who see touch as positive experience less pain, anxiety and need for pain medication. Can also involved very specialized techniques that manipulate human energy field.

Therapeutic Touch (TT) uses concept of energy fields within the body called prana (thought to be deficient in some people who are in pain). Uses laying on of hands by specially trained person to redirect energy fields associated with pain.

Head, hand, back and food massage. Hand and foot may be esp helpful in advanced labor when hyperesthesia limits a woman’s tolerance for touch on other parts of her body. Combing with aromatherapy oil or lotion enhances. Experiment during pregnancy to see what works.

Application of Heat and Cold – warmed blankets, warm compresses, heated rice bags, warm bath/shower or moist heating pad can reduce pain. Heat relieves muscle ischemia and increases blood flow to area of discomfort. Heat effective for back pain caused by posterior position or general backache from fatigue.

Cold application such as cold cloths, frozen gel packs or ice packs applied to back, chest, or face during labor may be effective in increasing comfort when woman feels warm. Can also be applied to areas of musculoskeletal pain. Cooling relieves pain by reducing muscle temp and relieving muscle spasms. Woman’s culture may make use of cold unacceptable.

Heat and cold may be used alternately for greater effect. Don’t apply over ischemic or anesthetized areas. 1-2 layers of cloth should be placed between skin and hot/cold pack.

Acupressure and Acupuncture – can be used in pregnancy, labor and postpartum to relieve pain and discomfort. Pressure, heat or cold is applied to acupuncture points called tsubos. These points have an increased density of neuroreceptors and increased electrical conductivity. Its said to promote circulation of blood, harmony of yin and yang and secretion of neurotransmitters, thus maintaining normal body functions and enhancing well-being. Best applied over skin without lubricant. Pressure applied w heel of hand, fist or pads of thumbs/fingers. Tennis balls or other devices may be used. Pressure applied with contractions initially and then continuously as labor progresses to transition phase at end of 1st stage of labor. Synchronized breathing by caregiver and woman suggested for greater effectiveness. Acupressure points found on neck, shoulders, wrists, lower back including sacral points, hips, area below kneecaps, ankles, nails on small toes and soles of feet. Acupressure may help to reduce pain and decrease use of pharmacologic pain relief.

Acupuncture is insertion of fine needles into specific areas of body to restore flow of qi (energy) and to decrease pain, which is though to obstruct flow of energy. Effectiveness may be attributed to alteration of chemical neurotransmitter levels in body or to release of endorphins as a result of hypothalamic activation. Trained certified therapist should do it. Arranging to have one available during labor may be challenging.

HoKu acupressure point (back of hand where thumb and index finger come together) used to enhance uterine contractions without increasing pain.

  1. Comfort items

Comfort Items: Rolling pin/rolling massage devices, gardener’s foam knee pad, shawl/rebozo, warm blanket and socks, fan, iPod, transcutaneous electric nerve stimulation (TENS), birth ball

Birth Ball – Since forces you to have proper posture when you sit, decrease muscle strain. To help relax trunk and perineum, sit on ball and sway hips side to side. Relieve back pain and adjust baby’s position, ball on bed and kneel on bed or stand next to it and lean over ball. Sway hips from side to side or front to back. Practice before labor.

  1. Massage and touch

Massage and Touch– 2 of most effective ways to direct attention away from labor pain. Firmly stroke, rub or knead your neck, shoulders, back, feet or hands. Lightly stroke back or thighs. Press firm on tense areas such as hips, thighs, shoulders, hands, lower back. Tightly embrace partner. Shower head. Lightly rhythmically stroke belly, following lower curve of uterus – imagine stroking baby’s head. Dust hands with baby powder. Match movements with breath.

Crisscross Massage– Ease back pain and relax lower back muscles. Kneel forward on hands and knees or over birth ball or lean forward onto counter, chair or birth ball. Flex hips so thighs are about 90 degrees from spine. Partner stands or kneels next to you, facing your side. Places hand on each side of your body at narrowest part of waist. Presses into sides, moves each hand up and over back following waistline

Acupressure for Comfort and Progress in Labor: May reduce pain/speed up labor. Hoku (back of hand, in V formed where bones extending below thumb and index finger come together) and Spleen 6 (inner side of leg, 4 fingers above inner anklebone). Press thumb steadily into pint for 10-60 seconds, then rest for same amount of time before pressing again. Repeat 3-6x whenever you want during labor. Don’t use before due date because may cause contractions and increase risk of preterm labor.

Practice during pregnancy so you’ll remember to use in labor. Have start time, practice for 30-60 seconds. Take turns starting contractions so you’ll get used to it whether ready or not. Ice cube with and without comfort measure. Be aware of facial expression, tone of voice, and touch. Be confident, speak softly and massage smoothly/softly.


Breathing Techniques – Provide distraction, thereby reducing perception of pain and helping woman maintain control through contractions. In 1st stage, can promote relaxation of abdominal muscles and thereby increase size of abdominal cavity. This lessens discomfort generated by friction between uterus and abdominal wall during contractions. Because muscles of genital area also become more relaxed, they do not interfere w fetal descent. In 2nd stage, breathing is used to increase abdominal pressure and thereby assist in expelling fetus. Breathing can also be used to relax pudendal muscles to prevent precipitate expulsion of fetal head.

Nurses can model breathing techniques and breathe in synchrony with woman and partner. Paced breathing most associated with prepared childbirth and includes slow-paced, modified-pace and patterned-paced (pant-blow) breathing techniques.

All patterns begin with deep, relaxing, cleansing breath to greet contraction and end with another deep breath exhaled to gently blow contraction away. Deep breaths ensure adequate oxygen for mom and baby and signal that contraction is beginning or has ended. As breath is exhaled, respiratory and voluntary muscles relax. Slow paced breathing performed at approx. half woman’s normal breathing rate and is initiated when she can no longer walk/talk through contractions. 6-8 breaths per minute. Slow paced breathing aids in relaxation and provides optimum oxygenation. Woman should continue to use as long as it reduces perception of pain. As contractions increase, woman often needs to change to more complex breathing technique, shallower and faster than normal rate of breathing but shouldn’t exceed 2x her resting respiratory rate. Modified paced breathing requires she remain alert and concentrate more fully on breathing, thus blocking more painful stimuli than simpler slow-paced breathing pattern.

Most difficult time to maintain control comes during transition, when cervix dilates from 8-10 cm. Even for prepared woman, concentration hard to maintain. Patterned-paced (pant-blow) suggested. Performed at same rate as modified paced and consists of panting breaths combined w soft blowing breaths at regular intervals. Patterns may vary (pant, pant, pant, pant, blow 4:1 or 3:1. Undesirable reaction is hyperventilation. Watch for symptoms of resultant respiratory alkalosis: lightheadedness, dizziness, tingling of fingers, circumoral numbness. Have woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis. It enables her to rebreathe carbon dioxide and replace bicarbonate ions. Woman can also breathe into cupped hands. Maintaining breathing rate no more than 2x normal rate will less chance. Partner can help maintain rate with visual, tactile or auditory cues.

As fetal head reaches pelvic floor, woman may feel urge to push and may automatically begin to exert downward pressure by contracting abdominal muscles. During 2nd stage pushing, woman should find a pattern that’s relaxing and feels good to her and is safe for her baby. any regular or rhythmic that avoids prolonged breath holding during pushing should maintain a good oxygen flow to fetus.

Woman can control urge to push by taking panting breaths or by slowly exhaling through pursed lips (blowing candle). Can be used to overcome urge when cervix not fully prepared (<8 cm dilated, not retracting) and to facilitate slow birth of head.


Effleurage and Counterpressure – Effleurage (light massage) and counterpressure have brought relief to many women during 1st stage. Gate-control theory may supply reason for effectiveness. Effleurage is light stroking, usually of abdomen, in rhythm with breathing during contractions. Used to distract woman from contraction pain. Often presence of monitor belts makes it difficult to perform it; therefore, thigh or chest may be used. As labor progresses, hyperesthesia (hypersensitivity to touch) may make it uncomfortable and less effective.

Counterpressure is steady pressure applied by support person to sacral area with firm object (Tennis ball) or fist/heel of hand. Pressure can also be applied to both hips (double hip squeeze) or to knees. Helps woman cope w sensations of internal pressure and pain in lower back. Esp helpful for back pain caused by pressure of occiput against spinal nerves when fetal head is in a posterior position. Counterpressure lifts occiput off these nerves, thereby providing relief. Hard work so will need to take breaks.

Paced Breathing Techniques

  • Cleansing Breath – relaxed breath in through nose and out through mouth. Used at beginning and end of each contraction
  • Slow-Paced Breathing (approx. 6-8 breaths per min) – performed at approx. half normal breathing rate; in-2-3-4/out 2-3-4/in 2-3-4/out 2-3-4
  • Modified-Paced Breathing (approx. 32-40 bpm) – ~2x normal breathing rate; in/out, in/out, in/out, in/out; for more flexibility and variety, woman may combine slow and modified breathing by using slow breathing for beginnings and ends of contractions and modified breathing for more intense peaks. This conserves energy, lessens fatigues and reduces risk for hyperventilation
  • Patterned-Paced or Pant-Blow Breathing (same rate as modified) – enhances concentration; 3:1 patterned breathing in-out/in-out/in-out/in-blow or 4:1


  • Relaxation – a life skill
    1. Benefits
      1. Conserves energy and reduces fatigue
      2. Reduces pain
  • Calms the mind and reduces stress


Relaxation and Tension Release: Remaining relaxed especially important in early labor. Practice releasing muscle tension then so you get used to it. If you tense up in early labor, you’ll have trouble relaxing later.

  1. Conserves energy and reduces fatigue If you don’t consciously relax during contraction, you’ll probably unconsciously tense them. Tension wastes energy and increases pain/fatigue
  2. Reduces pain Relaxation allows more oxygen to reach contracting uterus, which may decrease pain because a working muscle becomes painful when deprived of oxygen. Consciously releasing tension focuses attention away from contractions and reduces awareness of pain.
  3. Calms the mind and reduces stress Relaxed body leads to relaxed state of mind, which reduces stress. Anxiety, anger or fear causes stress in labor, which produces excessive catecholamines (stress hormones) such as epinephrine (adrenaline) and norepinephrine (noradrenaline). High levels of hormones can prolong your labor by decreasing efficiency of contractions and can harm baby by decreasing blood flow to uterus.
  4. Teaching relaxation
    1. Provide a safe, relaxing, environment for practice
    2. Relaxation awareness
    3. Progressive relaxation
  • Release to touch relaxation
  • Relaxing in different positions and with movement


  1. Provide a safe, relaxing, environment for practice

Simple physical comfort measures increase woman’s sense of mastery and reduce her stress and labor fight-or-flight reaction. Atmosphere that encourages woman’s spontaneous self-comforting behaviors and those learned in class:

  • Relaxation techniques/rhythmic movements
  • Calming vocalizations (moans, sighs)
  • Rhythmic breathing (Ch.10 pg 371-373)
  • Guided imagery/visualization.

Partner Suggestions:

  • Massage and pressure techniques
  • Timing contractions or counting breaths to let her know where she is in contraction
  • Encouraging rhythm in movements, breathing and moaning even in mental activities
  • Wiping her face with cool damp cloth; giving words of praise and encouragement
  • Speaking rhythmically in a soothing low tone.
  • Encourage woman or couple to use all available amenities: hot/cold packs, bath/shower, birth ball, cold/hot beverages/ice chips, lounge, music player/TV
  • Women more likely to become uninhibited and instinctual – signs neocortex is undisturbed and body’s natural powers are in play.
  1. Relaxation awareness

Recognizing Muscle Tension: In order to release muscle tension, must be able to recognize. Make right tight fist, feel muscles in forearm with left hand. Relax, feel muscles. Shrug shoulders towards ear. Lower and feel.

Practice with Partner: Observation (how do you look when anxious, uncomfortable, calm, content, asleep). Touch (muscles feel hard or soft). Floating a limb (heaviness that signals relaxation – like lifting sleeping baby’s arm).

Tighten body part and have partner find. Have him find different ways to relax it: warm compress, massage, reminding you to release. Discover which body parts tense most: shoulders, forehead, mouth, jaw, fists.


Relaxation Techniques: By focusing on different parts of the body and consciously releasing the tension in them, you can relax both your body and mind. Lie on side with plenty of pillows or sit in a comfortable chair; then try standing, walking. Begin in quiet calm area then try in more active surroundings. When done, stretch arms and legs.

Passive Relaxation: Try with a partner or relaxation CD – you’ll get used to the sounds and will find it familiar and relaxing during labor.

Practicing: Lie on side or sit in semi-reclined position with floor or bed supporting head and limbs. Breathe slowly, easily and fully (how you breathe as you fall asleep). Body and mind release tension and thought, breathing slows and pausing slightly at the end of each inhalation an exhalation (watch someone as they fall asleep). (See below for script)

Relaxation: Awareness Exercise: (sitting in chairs or on floor). Teach tuning into bodies and awareness of bodies early in pregnancy.

“When you become aware of the existence of tension in your body, you can more easily learn to release it. 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. First, focus on your surroundings, and then move inward.

With your eyes open, very slowly look around you. You may turn your head if you wish, but be sure to feel the eye muscles as they look up, down and off to each side. What do you see in this room? Notice the colors, the amount of light, the covering on the floor, the walls, the ceiling.  Be aware of what you see. What do you hear? Listen… (fan, outside noises).

What do you smell? Is it just the air, or are there aromas or fragrances that you like, or dislike? Think of a smell that is comforting to you – remember it.

Feel your own presence in this room – you are with other people… in this building… on this ground, which is a part of this earth… of which you are apart.

As you become aware of the sensations of sight, of smell, of sound, and of tension and release, you may wish to keep eyes open and focused on some point in the room, or gently closed to focus inwardly.

Take a cleansing breath – a deep breath in, with a sigh out to cleanse your mind of outside thoughts, and to signal your body to let go. Thoughts may enter your mind from time to time – acknowledge them, then let them pass. Don’t dwell on those thoughts now.

Concentrate for a moment on your head – tension may cause headaches, or may just be present with a busy mind. There are many muscles and nerves in your face and scalp. Think about a pleasant sensation for your head – either the stimulation, or softness, of a good hair brush; – of receiving a shampoo with a relaxing scalp massage; – the feel of warm water, a warm hair dryer, or cool wind blowing through hair. Try to IMAGINE those sensations which you find pleasant (pause for several breaths).

Now, lift your 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 your scalp. It will move when you stretch or contract your forehead as you do when you frown, or express surprise. Find the muscles in your scalp – move them…stretch them…contract hem – then concentrate on the tension leaving as you allow them to release.

Breathe air in through your nose – feel it as it goes to your lungs, expanding your chest and rib cage – then feel the release of tension as you sigh the air out through your mouth. Feel each breath you take, and notice where you feel the movement – chest…belly…or both. Tune into how you breathe. Feel the cool air as you breathe in through your nose or mouth…and the warmth of the air as it enters your lungs, and is exhaled. Your mind may color the air if you wish. It may be one color that you imagine as you breathe in and out – a color that comforts you. Or, you may breathe in a relaxing color and release a different color as it takes away your tension. Try it. Breathe a color now…(pause for several breaths)

Consider your jaw – is it tight with clenched teeth? Or is it loose and relaxed? If you carry tension in your jaw, become aware of it. Release it consciously and frequently. Stretch it open wide…drag it down…yawn…then let it go. Let it remain loose, with teeth not touching… your tongue thick and loose in your mouth…your lips either softly together or slightly parted.

Move your focus to your shoulders. If you wish, you may grasp them with your fingers…rub the muscles that span the neck and shoulder area…feel for tight muscles…rub the shoulder joint with your thumb and fingers…Then remove your hands and just pull your shoulders down toward your feet to stretch the tension away. Release. Now slowly and gently drop your chin to your chest…

Feel the stretch in the back of your neck. Place one hand on your head and let the weight of your hand add a gentle stretch to the muscles of your neck. Hold this for several seconds to allow the stretch to pull away the tension…(pause). Now lift your head and look forward. Place your right hand on the left side of your head and let the weight of your hand pull your right ear toward that shoulder. Hold…(pause). Now change hands… Rest your left hand on the right side of your head…allow a gentle stretch in the opposite direction. Hold…(pause). As you return your head to center, let your arms fall comfortably into your lap.

Think about your hands and fingers. Stretch them long, opening the pal – then release the stretch and notice how the fall- not clinched into fists, but fingers softly curled.  Enjoy this feeling, thinking of all the wonderful things your hands do for you.

Take another cleansing breath and feel the release and comfort in your head…neck…shoulders… arms… and down your back.

If necessary, readjust your sitting position. Rock your pelvis slightly to be sure you are sitting on your “sit bones”, not slouched on your tail bone. Adjust your legs so they are not touching one another but are comfortably supported by your chair and the floor. Concentrate on letting the tension from your pelvis and your legs flow all the way out your toes.

Now scan your body from head to toe, paying attention to how each part of you feels when the tension has been released – head…scalp…face…eyes…jaw… tongue…Shoulders…neck…arms… hands…fingers; Back…hips…legs…feet…toes.

Remember this feeling of release, so that when you become aware of tension in any part of your body through your busy day, you can send a relaxing breath to that part, and return to this feeling of release. Breathe softy…breathe consciously…breathe with awareness.

And now- to return to a state of alertness, slowly increase the pace of your breaths. Look around your…begin to move your hands and arms – your feet, your legs- and when you are ready – and your partner is ready – the two of you discuss this exercise as you experienced it. 

iii. Progressive relaxation

Relaxation Countdown: once learned to recognize muscle tension and have mastered passive relaxation, use following technique to release tension quickly. This uses breathing to create a wave of relaxation that passes from your head to your toes. Particularly helpful when want to fall back to sleep, when stressed, or when trying to relax after contraction

Practicing – inhale through nose. As exhale through mouth, release tension in following order. By time you count down to one, you’ll be fully relaxed.

5– Head, neck and shoulders

4– Arms, hands and fingers

3 – Chest and abdomen

2 -Back, buttocks, and perineum

1 – Legs, feet and toes

Use 5 slow breaths (one for each area) to count down. Try to relax all 5 areas while slowly exhaling one deep breath (rapid relaxation). During labor, use first or last breath of each contraction as rapid relaxation countdown to max tension release and reduce discomfort.

Touch Relaxation (219)– relax or release tension in response to partner’s comforting touch. During labor, use touch, stroke or massage as cue to relax.

Lie on side or sit in comfortable position. Contract set of muscles and have partner use firm yet relaxed hand to touch tense are, molding his hand around muscles. Release tension and relax into partner’s hand. Imagine tension leaving part of body.

Try different touches; tell what you prefer:

  • Still touch– partner places relaxed hand on tensed area while you release tension until you’re relaxed
  • Firm pressure– partner firmly presses tense area, then gradually relaxes the pressure as you release the tension
  • Stroking – light strokes in direction of fingers or toes for arms and legs and in circles on belly
  • Massage– firmly rubs or kneads tense muscles; give feedback on pressure.

Partner: Keep one hand in contact with body; when mom closes eyes, hard to relax if partner’s touch disappears.


  • Eyes/brow
  • Jaw
  • Neck
  • Shoulders
  • Arms/hands
  • Abdomen
  • Buttocks
  • Legs/feet.

Roving Body Check– Sometimes think you’re relaxed but are still holding tension in body; this helps you systematically release tension throughout entire body, allowing for deeper relaxation.

Practicing: Get into comfortable position and begin breathing slowly, rhythmically and easily, inhaling through nose, exhaling through mouth. Focus on one area of body with each breath. Inhale and notice tension in area. Exhale and release.

Move from:

  • Brow/eyes/eyelids
  • Jaws/lips
  • Neck/shoulders
  • Right arm and hand
  • Left arm and hand
  • Upper back
  • Lower back
  • Buttocks and perineum
  • Right leg and foot
  • Left leg and foot.

Use during or between contractions.

Relaxing in Different Positions and While Active: Practice in different positions because will be in different positions during labor. For example, can’t relax legs while standing, but can relax shoulders and face.


illustrations on pg 22-24 handbook

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.

Moms, take your 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 her hips and legs. Try to keep space on both sides of her as you will have to move around during this sequence.

Partners– Rub your hands briskly to warm them, then gently 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. Partners, your hands should be loose as the rest on her shoulder. Now, gently but firmly, stroke down her arm with both your hands encircling it– stroke 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.

Partners – 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 the hip. Stroke down the leg…slowly…gently…firmly… all the way to the foot. Pull all her tension out her toes.

Partners – 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 to the next part of this exercise, ask mom if she likes having her head touched. If she does not, you can massage her shoulders again.

Place your 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. Moms, imagine that the magnets are pulling the tension away from your head as your partners hand’s VERY slowly begin to release pressure…then barely touch your hair…then pull away slowly into the space around your 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 situated on your side, your back is open for touch. If you are sitting, lean forward so partner may touch and stroke down your back.

Partners, 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.

Now take a few minutes to discuss with one another your reaction to this execise. Did it help you release tension? Was any touch more irritating than relaxing?

Now, trade positions.

Moms– 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.

  1. Relaxing in different positions and with movement

Movements and Positions for Labor: May speed up labor by changing shape of pelvis and by using gravity, both of which help baby rotate and descend into birth canal. Being upright might give greater sense of control and active involvement than laying down. During 1st and 2nd stages of labor, can sway, rock, etc. Change positions every 30 minutes

1st or 2nd Stage:

  • Standing -makes contractions less painful and more productive; may increase urge to push during 2nd stage
  • Walking -can tire if walk for too long
  • Leaning forward-sitting or standing, relieves back pain, good for back rub, more restful than standing, encourages to rotate baby OP
  • Slow dancing -comfort, back pressure
  • Lunge -widens one side of pelvis, encourages rotation if OP, standing or kneeling, foot on chair
  • Sitting upright -good resting, uses gravity, birth ball, desk chair
  • Sitting or rocking in chairrocking may speed up labor
  • Open knee chest – if baby OP, will rotate, relieve back pain, encourage cervical dilation, reduces pressure on cervix if swollen in later labor
  • Semi-prone– may help baby rotate; one knee bent up on pillow
  • Toilet – effective pushing, prevents holding back
  • Semi-sitting – knees pulled to chest; may increase back pain and does not allow expansion of pelvis
  • Hands and knees -helps relieve back pain, helps rotate if OP, pelvic rocking, takes pressure off hemorrhoids, may reduce premature urge to push, may slow rapid 2nd stage bc of gravity
  • Side-lying – good for rest, may reduce back pain, safe if pain med, neutralizes effects of gravity, useful for slowing rapid labor, pressure off hemorrhoids, sacrum to shift to create wider opening

2nd stage:

  • Squatting – relieve back pain, gravity, widens pelvic outlet but may diminish pelvic inlet so good for 2nd not 1st, rotate in difficult birth; helpful if don’t feel urge to push
  • Lap squatting – reduces strain on knees and ankles, more support and less effort, loved ones touch
  • Supported Squat – greater mobility of pelvic joints, lengthens trunk, allowing more room for baby to maneuver, baby’s head movement to change shape of pelvis
  • Dangle – partner is supported so easier to sustain
  1. Enhancing relaxation
  2. Visualization and imagery
  3. Movement
  • Music, humming, and mantras
  1. Massage and massage tools
  2. Using a birth ball
  3. Using a rebozo


  1. Visualization and imagery

Teaching Relaxation: 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 & 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 feedback 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 one muscle at a time from head to toe. Ask students if it’s easier to release a muscle after tensing, stretching or neither (pg 104)
  • 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 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. 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 pain, and to think positively. Can 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 it

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 by B. Waters

DVD: Penny Simkin’s Comfort Measures for Childbirth


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 area 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.

  • Are you by yourself? Or is there someone with you?
  • What are you doing?
  • When you look around, what do you see?
  • Are you indoors? Or outdoors?
  • What does the air feel like around you?
  • Are there any special smells in this place? If so, take a moment to enjoy them.
  • When you listen, what sounds do you hear?
  • 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 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.

  1. Movement

See above (list of positions)

 All encourage fetal rotation and relieve back pain.

  • Lunge (313)
  • Slow dancing (316)
  • Walking (315),
  • Pelvic rocking/ pelvic tilt (311)
  • Swaying, rocking (323)
  • Open knee-chest position (293)
  • Abdominal lift (318)
  • Abdominal stroking (317)


Modifiable Labor Influences: Freely Move About, or “Gravity Works”: Ancient works or art and sculpture show birthing women in upright positions. Changed when Dr. James Young Simpson used ether amnesia for birth in 1847, assisting a woman with a deformed pelvis. He then was appointed to Queen Victoria, who used diethyl ether (chloroform) to give birth. When anesthesia is used, mother cannot move around freely or remain upright for birth. Dr. Joseph DeLee formally introduced the lithotomy (on back, legs in stirrups) position to U.S obstetrics in his 1913 textbook.

1979 – study from Dr. Caldeyro-Balcia in Uruguay showed vertical mothers had 36% shorter first stages; less pain and infants were less likely to have marked molding on head after delivery.

2006 study- “risks of both maternal and perinatal adverse outcomes rise with increased duration of second stage, particularly for duration longer than 3 hours in nulliparous women and longer than 2 hours in multiparous women. Found upright positions associated with shorter, less painful 2nd stages, small reductions in instrumental deliveries and reduction in episiotomy but increase in 2nd degree lacerations.

Squatting women had faster 2nd stages, required less labor stimulation with oxytocin, fewer assisted deliveries than semi-recumbent mothers. Squatting group also had fewer episiotomies and severe lacerations.

Fetal oxygenation compromised by horizontal, especially supine, maternal positions during labor. Longer labor puts more stress on the infant and mother, which increases drug consequences to the mother and infant, which affect breastfeeding. Longer labor also causes poorer oxygenation of the infant, which reduces the infant’s readiness for birth and feeding.

Electronic Fetal Monitoring: instrumental delivery and cesarean surgery rates higher

  • Woman undergoing EFM is confined to bed (unless capability for walking telemetry, which is very expensive and uncommon)
  • EFM conveys a clear message to a woman in labor, through the belts and leads and machinery, that she and her unborn baby are labor patients who must be monitored with noisy and often intimidating technology. Moving to and from toilet or changing position in bed becomes a problem, requiring the assistance of a nurse
  • If there is internal monitoring, the fetal scalp must be lanced to allow the application of the monitor lead, which causes pain to the fetus; opens a wound, which increases risk of infection; and may impact the newborn’s comfort and ability to breastfeed
  • There is a well-documented association between apparently false interpretations of fetal distress and EFM, which if not confirmed with additional fetal blood sampling lead to a rush for instrumental or cesarean delivery. These interventions bring another cascade of interventions that impact breastfeeding.

Survey: 71% of mothers did not walk around once they were admitted to the hospital in labor. 4 years later, 76% did not walk…

Odent began researching squat and other positions in 1980s.

Summary Points:

  • No evidence that directly links maternal position in labor with breastfeeding outcomes
  • No evidence shows safety or restricting mother’s movement or position in labor, except to correct specific complications
  • Restriction of movement strongly associated with longer labors; more instruments which can injure mom or baby, more pain for mom and poorer oxygenation for baby
  • 2006 BFHI Mother Friendly Childbirth supports moving around in labor

iii. Music, humming, and mantras


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 your 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.

Relaxation and Breathing Techniques

Focusing and Relaxation Techniques – be reducing tension and stress, focusing and relaxation techniques allow a woman in labor to rest and conserve energy. Attention-focusing and distraction are effective. Some bring a favorite object such as photograph or stuffed animal to labor room and focus their attention on this object during contractions. Others fix their attention on something in labor room.

With imagery, woman focuses attention on pleasant scene, a place where she feels relaxed, or an activity she enjoys. She can imagine walking through a restful garden or breathing in light, energy and a healing color and breathing out worries and tension. Choosing subject and practicing during pregnancy enhances effectiveness.

During childbirth classes, partner can learn how to palpate woman’s body to detect tense and contracted muscles. Woman then learns how to relax tense muscle in response to gentle stroking of muscle. Woman and partner say word “relax” at onset of each contraction and throughout it as needed. With practice, the coach can effectively use support, feedback and touch to facilitate woman’s relaxation and enhance progress of labor.

Drinking herbal tea can also help women relax (chamomile), reduce nausea (lemon balm, peppermint), enhance energy and reduce fatigue (ginger, ginseng). Can also maintain fluid balance.

Nurse can assist by providing quiet and relaxed environment, offering cues as needed and recognizing signs of tension (frowning, change in tone of voice, clenching fists). Relaxed environment created by controlling sensory stimuli )light, noise, temp) and reducing interruptions. Nurses should remain calm and unhurried and sit rather than stand.

  1. Massage and massage tools

Hand Massage: Position partner’s 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 times. 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.

  1. Using a birth ball

On the Ball” Birth Balls – 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


  • 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.


  • 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.

Using Peanut Ball During Labor & Delivery – (3:38) – after small study – use of peanut ball w mothers who had epidurals can shorten 1st stage (90 min) and 2nd stage (23 min). Has decreased cesarean rates by 13 percentage points. (Mercy Medical Center Des Moines)

Positions for mom who has epidural – moms lie on sides (encouraged for good oxygenation to placenta) –

  • Peanut ball in between legs, and if pull ball up, almost in squatting position. Very comfortable for mom for more pelvic room. Mom can put head up (raise bed) so gravity can help.
  • Lunge – one leg down, 1 leg up.
  • Laboring/Pushing – help nurses backs – use of stirrup and peanut ball together.


Peanut Balls for Labor – A Valuable Tool for Promoting Progress?

For women resting in bed or w an epidural.

45 cm or 55 cm sized ball recommended. Used bw legs to open up pelvic outlet, don’t want it to be as large as balls that are used for sitting/swaying. If moms didn’t like it during labor, may be too big.

Most commonly used when mom needs to remain in bed. 2 main ways to use w plenty of room for variation. First is w mom in semi reclined position, 1 leg over ball, 1 leg to side of ball. Ball pushed as close to mom’s hips as comfortable. Rolled up towel can be used to hold in place as ball can have tendency to slide away from mom. Promotes dilation and descent w well-positioned baby.

2nd common use: mom in side-lying/semi-prone position w peanut ball being used to lift upper leg and open pelvic outlet. Ball can be angled so leg hooks around narrower part or aligned w both mom’s knee and ankle resting on ball. Mom’s comfort level is key to right placement. Can use to rotate posterior baby to more favorable position.

Research – 1st stage 90 min shorter; 2nd stage 22 min shorter. Vacuum/forceps lower. No adverse events.

More upright semi Folwer’s position helpful in preventing increase in operative deliveries seen w epidurals; Cochrane review found insufficient evidence.

Babies in OP can increase length of 2nd stage and rate of operative delivery, reports of posterior babies turning w peanut balls big reason for effectiveness.

Unmedicated moms preferred upright positions to peanut ball nearly ever time. Moms w epidural liked ball almost universally, but some said made butt go numb. Difficult to sleep with. Switch every 1-2 hrs or every 20 min.

Ball most beneficial for moms not able to change positions frequently and utilize gravity (epidural).

After birth: can use for exercise. Soothe baby against chest or over lap and move side to side or bounce softly.

LPH Pgs 367-368 Birth Ball: Physical therapy ball made to support adult weights (usually 300 lb. weight limit – make sure to check). Most widely used sizes are 65 cm and 75 cm.

  • Below 5’3: 55 cm
  • 5’3-5’9: 65 cm
  • 5’10+: 75cm.
  • Can be inflated to varying degrees of firmness according to woman’s comfort (balls sometimes differ to manufacturer and stretch with use).
  • Round shape makes swaying effortless. Cover ball with waterproof bed pad, towel, or blanket. Can be cleaned with same disinfectant used on birthing bed mattress.
  • Other shapes – Peanut/egg are limited in versatility.
  • First few times she sits on ball – have her hold bed or partner until she is secure. Hold while getting ready to sit so does not roll away. Once seated, feet in front of her 2-2.5 ft apart.
  • Can use kneeling or standing if feel insecure sitting.
  • Some hospitals have to use during labor.
  • Can be used after baby is born to soothe fussy baby – much easier on parent’s back rather than walking with baby.
  • Can be used in postpartum exercise.
  1. Using a rebozo

The Rebozo: 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.


  1. Movements and positions for first stage of labor


Physical Comfort Measures: see above

Physiologic Measures: To prevent underlying factors that can lead to dystocia:

  • Encourage to empty bladder every hour or two (can increase pain/interfere with descent; contractions sometimes reduce one’s awareness so may have to remind)
  • Well hydrated but not overhydrated (juices, frozen juice bars, teas, water; too much: >2.5 L over 8-10 hr labor or 300 mL/hr in longer labors. Hyponatremia and prolonged second stage more likely when drink excessively or receive intravenously. No evidence most women need IV to prevent dehydration. Drink to thirst.)
  • Positions comfortable to her seem to enhance labor progress
  • Encourage woman to relax her voluntary muscles: particularly in butt, pelvic floor, thighs, abdomen and low back.

Why focus on Maternal Position? In late pregnancy, changes in hormone production relax the ligaments and cartilage of the pelvic joints, allowing greater mobility in sacroiliac joints and pubic symphysis. Pelvic mobility allows for subtle changes in shape and size in pelvis, which may facilitate optimal position of fetal head in first stage as well as cardinal movements of flexion, internal rotation and fetal descent in second stage.

  • Alignment of pelvic bones and resulting shape and capacity of pelvis
  • Frequency, length and efficiency of contractions
  • “Drive angle” – the angle formed by the axis of the fetal spine and the axis of the birth canal
  • Effects of gravity
  • Oxygen supply to fetus.

Frequent position changes in labor optimize chance of a “good fit” between fetus and maternal pelvis (helping resolve occiput posterior position, asynclitism and deflexion). Less pain when better aligned. Continuous movement (pelvic rocking, swaying, walking) can “nudge” fetus into place. Random trials – first stage shorter for those upright or walking. Ch 9 has different positions.


The Labor Progress Toolkit: Part 2 – Comfort Measures: Nonpharmacologic methods to relieve pain. Acknowledge the benefits of a well-time epidural in serious cases of dystocia: as a precursor to painful interventions; as aid for exhausted mother to get some sleep and possibly to create a mind-body split where deep-seated fear/anxiety is cause of dystocia.

General Guidelines for Comfort during a Slow Labor:

  • Frequent position changes (every 20-30 min)
  • Rhythmic movement reduces both pain and anxiety
  • Pressure techniques
  • Heat and cold
  • Hydrotherapy
  • Relaxation, rhythmic breathing, moaning patterns, bearing down efforts
  • Experienced doula/labor support brings continuous emotional support


Nonpharmacologic Physical Comfort Measures

  • Heat: Use any time she shows pain, anxiety, muscle tension, when she’s chilled or in 2nd stage for perineum to enhance relaxation of pelvic floor.
    • Warm moist towel, heating pad, gel pack, rice pack or hot water bottle to lower abdomen, groin, thighs, lower back, shoulders or perineum
    • Warm shower on shoulders, abdomen, lower back or immerse
    • Warmed blanket
    • Rice filled microwaveable packs can be made by filling large tube sock with 1.5 pounds of dry uncooked rice. Place in microwave 3-5 min; can add lavender seeds or flowers. Be careful of contamination with woman’s body fluids. Can also be used as cold pack.
    • Caution: Side effect of epidural is alteration in thermoregulation. She also lacks sensation.
  • Cold: Compresses to lower back, perineum using ice bag, gel pack, rick pack, latex glove filled with ice chips, frozen wet washcloth, cold soda an, plastic bottle of water etc.
    • Use for woman’s face.
    • Use against anus to relieve painful hemorrhoids in 2nd Put layer between.
    • Helps musculoskeletal and joint pain
    • Decreases muscle spasm (works longer than heat)
    • Slows transmission of pain and other impulses
    • Caution if woman has epidural
  • Hydrotherapy: Shower, bath (Caution: water temp no more than 100 degrees – can cause fetal tachycardia). Leave bath after 1.5 hours for 30 minutes. Can return after 30 minutes. Can use hand held Doppler designed for underwater use or have woman lift abdomen out of water or step out of shower as needed for intermittent monitoring. Possible alternative to bed rest for women with pregnancy-induced hypertension.
    • Shower can be used in any phase of 1st stage or early 2nd
    • Bath should be used after active labor is established because can slow contractions in early labor. Can be used to stop preterm contractions or give woman temporary rest.
    • Entrance into water before 5 cm is associated with longer labor and greater need for oxytocin augmentation.
    • *Don’t use bath if bleeding or fetal distress, on narcotic medications or using epidural.
  • Touch and massage: Hands, feet, scalp, shoulders, back. Light, firm stroking, kneading, still pressure. Hands or massage devices. With or without oils, lotions, powders. When woman seems tense, frightened, anxious. Don’t use if not culturally acceptable or is uncomfortable. Can improve blood pressure. Always ask for permission and make sure hands are clean and warm. Use unscented massage oil. Once begin, don’t remove both hands until you are done – unsettling to know when hands will reappear.
    • Shoulder Massage: place hands on shoulders. Stroke firmly from neck to shoulders, then over shoulders to upper arms. Knead upper arms a few times, and stroke firmly toward neck. 3-4x. Knead or squeeze and release shoulder muscles 1-2 min. Make brief deep circles on tops of her shoulders and along spine with middle three fingers – 15-30 sec each spot.
    • Criss-cross massage – Notice where waist is narrowest – one hand on each side, below her ribs; hands pointing opposite directions. Stroke hands firmly up and across her back toward each other. Cross one hand over the other and move to the original starting spots.
    • Hand Massage – If clenches fists, grabs bedrail etc. Thumbs placed side by side on back of wrist. Pads of fingers press into palm. Slowly slide thumbs apart and off her hand. Repeat 10x. Be careful with swollen hands/ carpal tunnel
    • 3 part foot massage: Sitting on bed – grab one foot with both hands. Have thumbs touch each other and press into sole of foot. Squeeze until it’s firm enough. Slowly slide thumbs apart and off foot. 10x. “Squeeze Apple” – press heel of hand firmly into arch of her foot and grasp her heel; squeeze and release several times as if squeezing tennis ball. Deep circle massage in magic spot – top of foot just below ankle. 30-60 sec.
  • Acupressure: Press firmly on point for 10-60 seconds. Rest for equal time. Repeat up to 6x. Contractions may speed up during this time. Can also apply ice filled washcloth to Hoku for 20 min at a time. Helps clear blockage of energy flow along particular meridians in body. Good when poor progress so smooth functioning occurs. Don’t use before term.
  • Acupuncture: Can turn breech babies, relieve labor pain and induce labor

Continuous Support from Doula, Nurse, Midwife – only if she wants one. Doula results in 26% fewer cesareans, 41% fewer instrumental delivers, 28% of mothers less likely to receive pain medication; 33% less likely to be dissatisfied. Support in early labor better than in active labor. 8% births in US attended by midwives and 3% have doulas. Needs to be non-nursing staff for greatest benefit.

Psychosocial Comfort Measures: Excessive production of stress hormones (catecholamines) can affect uterine and placental function

Assessing Woman’s Emotional State: Sometimes best way is to ask her “What was going through your head during the last contraction?”

  • When distressed during latent phase, more risk of prolonged labor, nonreassuring fetal tones, intolerance of labor and all interventions that accompany such problems – not true of women in active labor/transition.
  • Provide reassuring or comforting sensory stimuli: music the woman likes: massage, backrub, touch; lighting; juice or frozen bars in a flavor she likes; pleasant smelling massage lotion; electronic fetal monitoring audible if it reassures her.
  • Provide reassurance and praise – ask what sensations she’s having and reassure her they are normal
    • “Your body knows just what it’s doing”
    • “It won’t be that much longer”
    • Compliment her “you’re doing so well” “Don’t change a thing” “You’re doing perfect” help her reframe distressing thoughts
    • “Can you imagine your strong contractions doing exactly what they are supposed to do – opening your cervix and bringing baby to you?
  • Tell her to go to bathroom (remind her of call light in bathroom if she feels urge to push).
  • Confirm rhythmic motions “you’re great at finding what works for you”.
  • Ask her if it helps to do something during a contraction if not sure.
  • If she is silent, in her own world, do not distract her.


Techniques and Devices to Reduce Back Pain

  • Counterpressure – On woman’s sacrum with the heel or fist of one hand. Place other hand on woman’s hip to help her keep balance.
  • Double hip squeeze – One or two people may do. If 1: place hands on outsides of woman’s hips, over gluteal muscles – over meatiest part of her butt and press inward toward center of her pelvis with whole palms steadily through contraction. 2 person is easier – woman kneels over birth ball, seat of a chair over lowered foot portion of birthing bed over a pile of pillows.
  • Knee press: If woman is seated, press hand over knees, lean towards woman through each contraction. If side lying, two partners are needed – only upper knee is pressed, other partner presses sacrum during contractions to stabilize her. Press knee toward hip joint.
  • Cook’s Counterpressure Technique No 1: Ischial tuberosities – woman lies on side or on hands and knees, and apply pressure on both spots with thumbs, heels of hands, fists or tennis balls to sit bones. In Chinese medicine, its acupuncture points UB36 (Urinary Bladder). Can use when woman has a premature urge to push before complete dilation with a cervical lip or swelling. Don’t do if has a preexisting symphysis pubis problems or past pelvic trauma.
  • Cook’s Perilabial Counterpressure Technique No. 2 – Late in 2nd stage, caregiver presses externally with thumbs or fingers just outside woman’s labia against both inferior pubic rami to counteract forces of fetal head against pubic arch and pelvic musculature. *Not appropriate for doula unless she is asked by caregiver* Do when has uncontrollable premature urge to push before complete dilation. When woman is pushing and head is approaching crowning. At crowning when woman is trying not to push in order to protect perineum. Caution as above approach.
  • Cold /Heat – Pressing and rolling a cold can of juice over woman’s low back is sometimes more appreciated than steady pressure in one area. Use a layer in between. Warm compress if has low back pain. Use caution if had epidural
  • Hydrotherapy – Shower/bath
  • Movement – Lunge, slow dancing, walking, pelvic rocking, pelvic tilt, swaying, rocking, open knee chest position, abdominal lift and abdominal stroking all encourage fetal rotation and relieve back pain
  • Birth Ball – see pg 367 in document
  • TENs – Transcutaneous electrical nerve stimulation – hand held battery operated device that causes transmission of mild electrical impulses through skin where they stimulate nerve fibers. 4 pads place d on low back on paraspinal muscles on either side of the spine, two with top edges at level of lowest ribs and two with bottom edges slightly above level of gluteal cleft. Alternating mode after a contraction helps keep woman from habituation to one kind of stimulation. Increase intensity during contractions. It inhibits awareness of pain as described in Gate Control Theory of Pain. May also increase local endorphin production. Greatest benefit if started early in labor, especially if has back pain. Gives her a sense of control. Don’t use with hydrotherapy.
  • Sterile water injections for back pain – Intracutaneous or subcutaneous (sometimes called sterile water blocks) reduce back pain and easily performed by clinical personnel. Saline injections do not have same effect.
  • Breathing techniques – see pg 373 further down in document
  • Bearing down techniques for 2nd stage: Spontaneous bearing down (pushing) – she bears down when has the reflexive urge, usually 5-7 seconds. May hold her breath, moan, release air or bellow. Breathe quickly and lightly for several seconds in between.
  • Self-directed pushing – When bearing down is unfocused, ineffective and diffuse, without progress for 30 minutes. Eyes clenched shut. Encourage woman to try new position. Gravity enhancing positions. Have her open eyes and gaze at vaginal outlet.
  • Directed pushing – Directed how, when and how long to push. Usually holds breath for 10 seconds with 1 short breath in between. Aka purple pushing. Use when anxious and asks for help or if has epidural but should be delayed until fetal head visible or woman feels urge to push.



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*

(pgs 39-42 workbook)


First Stage of Labor and Comfort Strategies: 1 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


  • 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.


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)


Rhythms in first stage of labor: In vast majority of hospital births, progress is assessed by vaginal examination. This normative mindset is so powerful that few midwives have had opportunity to observe labors where none have occurred. For millions of years, childbirth was not obsessed with labor duration. Gaskin discovered word “pasmo”; labor stopped and everybody went home until it started again.

Friedman’s Legacy: Emanuel Friedman was first to graphically record cervical dilation over time. His work in mid 1950s showed understanding of average lengths of labor for primigravid and multigravida women. In 70s, Philpott and Castle gave guidance for what to do if labors were slow. Alert line at 1 cm/hr, transfer line at 2 hours behind alert line and action line 2 hours behind that. O’Driscoll used in his protocol for ‘active management of labor’- artificial rupture of membranes and IV oxytocin if labor didn’t progress at 1 cm/hr. UK studies show up to 57% of low risk primigravid women have their labor augmented with exogenous oxytocin.

Organizational Factors: Martin railed against assembly line childbirth in the 1980s but it was not until Perkins critique of USA maternity care citing it as Henry Ford car assembly line. Hospitals still practicing active management of labor are among the largest in Europe with over 8000 births/year.

An Emergent Critique: Albers concluded from her research in 1990s that nulliparous women’s labors were longer than Friedman had said (17.5 hours vs. 8.5 hours for nulliparas and 13.8 vs 7 for multiparas). Primiparous women remained in first stage for 26 hours and multiparous women for 23 hours without adverse effects. The acceleratory phase occurred after 5 cm in multiparous women and after 6 cm in many nulliparous women and labor did not decelerate toward full dilation as Friedman had suggested. They restated their view that a parabolic curve of labor was much more realistic than linear versions of cervical dilation.

  • Oxytocin – “the benevolent queen” – direct on uterine contractions and in generation feelings of nurture, protection and altruism towards baby.
  • Adrenaline – (fight or flight) – noradrenaline (peacemaker) prepare and empower a woman for hard labor of birthing by mobilizing her strengths and inner resources.
  • Complete removal of pain with epidural stimulates noradrenaline, which wrongly interprets labor is stopping so feeds back to stop the release of oxytocin so labor is becalmed again.
  • Inner high of endogenous endorphins, secreted when body is in chronic pain.

Rhythms in early labor– Can’t validate woman who had labor pains for 7 days because we dare not record a length of labor longer than 24 hours. Less than 60% experienced contractions at the starting point of their labors. The remainder described fluid loss (38%), constant pain (24%), blood stained loss (16%), gastrointestinal symptoms (6%), emotional upheaval (6%) and sleep alterations (4%) as heralding the start of labor, none of which fit the textbook definition.

6000 women showed no differences in cesarean section rates and other morbidities between partogram and no partogram.

Pasmo” – physiological delays were known about in 19th century.

Now recommends a cervical dilation rate of .5cm/hr in nulliparous women and this has been endorsed by NICE intrapartum guideline.

Alternative Skills for Sussing out Labor: Intuition – midwife’s need to defecate, ebb and flow of tide. Pets, farm animals.

Prolonged Labor: Encourage mobility and posture change. Acupuncture. Hypnosis. Acupressure. Nipple stimulation. ARM has for decades been first option but does not shorten labor and may contribute to higher cesarean rate. Oxytocin’s propensity to hyperstimulate uterus and link between it and poor neonatal outcome, so use only minimum amount. *Lactic acid levels in women with prolonged labor may help distinguish those likely to respond to oxytocin and those who will not* Dystocia over diagnosed and over treated in Western world.

“Being with not doing to laboring women” most important.

Conclusion: Greater focus on birth environment and role of birth companions. Help mom discover labor rhythm. Care for prolonged labor should prioritize physiological/ psychological/ social support before medical interventions. Exogenous oxytocin should be reserved for dystocia that does not respond to any other intervention and then used sparingly. Services should review their use of vaginal examinations in labor.

ESNLB Pgs 66-70 Mobility and Posture in Labor: In Rediscovering Birth, Kitzinger shows indigenous practices in varying places of the world. Coppen’s book covers history of childbirth posture. Native American Indians used supported squat with a sling hung from above. Archaeological evidence from artifacts, cave drawing and writings show upright birth in ancient Egyptian, Green and Roman civilizations.   One of earliest writings lying down for birth is 1678.

Forceps established the bed as central to parturition. Became mainstream not just for assisted vaginal birth but for normal birth.

Introduction of anesthesia and narcotics confirmed centrality of bed for birth, for now women were not safe to mobilize. Dangers of supine hypotension syndrome well known so problem addressed by putting soft wedges under women’s backs.

1970s – Caldeyro’s study revealing disadvantages of supine postures for labor and birth, particularly for fetus.

Mobility in 1st stage: Mobility in labor reduces need for analgesics, shortens labor and improves satisfaction with care.   Stronger uterine contractions, less augmentation, fewer operative deliveries, less fetal distress. Not associated with any adverse outcomes. Sense of “grounding”. Free standing units located on ground floor. Connectedness to earth. Dance of labor. Benefits of interventions like EFM have to be weighed against these counter-productive effects and every effort made to accommodate woman’s changes of posture by adjusting belts and leads.

  1. Breathing techniques for comfort
    1. There is no right or wrong way to breath during labor
    2. Effective breathing techniques have three benefits:
      1. Enhances relaxation
      2. Reduces pain by supplying oxygen to the body
      3. Provides a focus to calm and distract
    3. Avoiding hyperventilation
    4. Slow breathing
    5. Light breathing
    6. Adaptations to breathing techniques


  1. There is no right or wrong way to breath during labor


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.
  • 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: Comfort Measures, 3 R’s

  • Breathing in a consistent rhythmic pattern is self-calming; it encourages tension release and a sense of well-being
  • Helps to quiet cortical activity of the brain, putting woman in more instinctual state of mind.
  • Use when distressed by contractions or if have not mastered other coping techniques.
  • Don’t use if woman is successfully using other coping/breathing techniques or if she resists/cannot respond to your teaching. 


Slow, light breath:

  • Can be taught on spot in labor: when woman cannot walk or talk through peak of contractions: “Sigh” through contraction with full, easy, audible breaths that may or may not be accompanied by moaning.
  • Combine breath with imagery
  • “Every out breath is a relaxing breath”
  • “Send each in breath to tense area and each out breath send tension away”
  • “Imagine each breath is another step up the mountain that is your contraction. When you get to peak, breathe your way down”
  • “Let’s count your breaths as you go through your contractions so we’ll be able to tell when you’re halfway through. It will make your contractions seem shorter.”

Light breathing reserved for active labor when woman becomes discouraged or finds that slow breathing isn’t helping. Encourage woman “good…that’s the way…just like that…that’s right…yes”

If woman in advanced labor, may be impossible to teach her very much. Help her find a rhythm if she lacks one. Get her to look at your hand, move hand up and down in rhythm “Breathe with my hand…that’s right…stay with it…good”

  1. Effective breathing techniques have three benefits:

Breathing Techniques as Comfort Measures: When you swim, run, practice yoga, sing, or play a musical instrument, you need to regulate your breathing to perform effectively and efficiently.

Breath awareness has the following benefits: enhances relaxation, helps reduce pain by supplying your muscles with oxygen, provides a focus to calm you and distract you from pain.

Breathing won’t make labor pain completely disappear, but it’ll help make pain more manageable.

In early labor, you’ll likely use slow breathing for as long as it relaxes you. You may switch to light breathing or some variation in late labor.

During pregnancy, try to master the breathing techniques described in the following sections, even though you might not use them all. Practice in positions show on pgs 221-223. Can combine with other comfort measures, such as moaning, movement, massage, tension release, hot or cold packs, bath shower etc.



  1. Avoiding hyperventilation

Avoiding Hyperventilation: When you breathe too deeply or too quickly (or both), you exhale too much carbon dioxide, which alters the balance of oxygen and carbon dioxide in your blood and may cause over breathing. While rarely serious, it makes you feel lightheaded or dizzy, or can make your fingers, feet, or the area around your mouth tingle. If you master rhythmic breathing before labor, you’ll unlikely hyperventilate during contractions.

If it occurs: breathe into cupped hands, a paper bag or a surgical mask; hold breath after a contraction until you feel need to inhale – this will allow carbon dioxide levels in your blood to normalize; relax and reduce tension/anxiety – take a shower, bath, have a massage, use touch relaxation or listen to music; breathe with a slower rhythm or breath more shallowly. Partner can help with a visual cue (like orchestra), talking to you, or rhythmic stroking or by breathing with you.

  1. Slow breathing

Slow Breathing: Can calm you in labor. Keys are keeping an even rhythm and trying to release tension during exhalations. Begin using when contractions become so intense that you can’t walk or talk through them or can’t be distracted from them. Use it for as long as it comforts you – probably until you’re well into the first stage of labor and possible all throughout labor. Shift to light breathing or a variation if you strain to keep your breathing slow at the peaks of contractions.

  • As soon as contraction begins, inhale fully and easily and sigh as you exhale, releasing all tension. Use this as you “organizing” breath or as a signal to your partner. If partner is timing contractions, he will note time.
  • Focus your attention (See pgs 208-209)
  • Inhale slowly through nose and exhale completely through mouth. Pause for a moment before you inhale. Take about 5-12 breaths per minute (half normal breathing rate).
  • Inhale quietly, but keep mouth slightly open and relaxed when exhaling so someone nearby can hear your breath. In labor, you may also vocalize or moan as you exhale.
  • Keep should down and relaxed. Relax your chest and belly so they can swell as you inhale. Partner should touch you, move around you and talk to you in rhythm with you breathing
  • Signal to your partner as contraction ends or take a final deep breath. May prefer to yawn to mark end of a contraction
  • Completely relax, change positions, sip liquids, and do whatever need to feel comfortable

Rehearsing Slow Breathing for Labor: Rehearse until your confident in using for 60-90 seconds a time (typical length of contraction). Practice with different positions. With each exhalation, focus on relaxing different part of your body (See pg 219 for Roving body check) so you can relax every muscle that’s not required to maintain your position. If uncomfortable to inhale through nose and out mouth, can breathe through only which is comfortable. May want to let belly expand first, then chest as you inhale deeply (belly breathing). Or may let chest expand as you inhale (deep chest breathing). Make sure its rhythmic, calming and relaxing.


  1. Light breathing

Light Breathing: helps manage labor pain when you can no longer relax during contractions, when contractions are too painful with slow breathing, or when you instinctively begin speeding up your breathing. Many women switch when contractions are close together and intense. When in active labor, let responses to contractions help you decide when to use. If partner notices you losing rhythm, tensing, grimacing, clenching your fists, or crying at peak of a contraction, he may suggest switching to light breathing.

  • As soon as you feel contraction begin, take a quick, shallow inhalation and signal to your partner that the contraction has begun. Exhale quickly to release all tension – go completely limp.
  • Focus your attention (pgs 208-209)
  • Take short, light and shallow breaths, inhaling and exhaling through mouth – one breath every second or two. Keep inhalations quiet (so you don’t hyperventilate) and exhale audibly either by emitting short “puffs” or air or by making light sounds. Continue light breathing in a steady rhythm. Let contraction guide rate and depth of breathing. Keep mouth and shoulders relaxed. Continue breathing in this way until contraction ends.
  • When contraction ends, use last exhalation to “Sigh” the contraction away. Then tell partner contraction is over.
  • Completely relax and do whatever you need to feel comfortable, such as change positions, sip liquids and so on.

Rehearsing Light Breathing for Labor – You may not feel this is right for you when you practice – may make you tense or that you’re not getting enough air. With practice, it will become 2nd nature and you’ll be able to work with body easier during labor. Will come more naturally as labor becomes more intense. Just as running makes you breathe faster to meet oxygen needs. Take 1 breath every second or 2, for 10 seconds. If you take between 5 and 10 breaths in that time, you are doing it correctly. Continue for 30 sec – 2 minutes. When you can do effortlessly for 2 minutes, try adaptation is following section.

If you become lightheaded/dizzy, try to focus on exhalations, perhaps by making small sounds while exhaling such as “hee hee hee” or “puh puh puh” – by doing so, body will naturally inhale as much air as it needs. Breathing lightly through open mouth may cause dryness. Try touching tip of tongue to roof of mouth just behind teeth or hold moist washcloth near your mouth. During labor, may also sip water or other fluids between contractions or suck on ice or popsicle. Brushing teeth, rinsing mouth can also relieve dry mouth.

Partners: Encouraging words. Ex: 1, okay, 2 good, 3 let go, 4, just like that, 5 great. During labor, the # of breaths per contraction won’t vary significantly from one to the next, so you’ll be able to figure out peak and half over. Point out when she’s passed half way.


  1. Adaptations to breathing techniques

Adaptations to Breathing Techniques: Ways to adapt rhythmic breathing by combining slow and light breathing patterns. During labor, try switching to one of these techniques to cope if you become overwhelmed/ exhausted, can’t relax or begin to despair. May even discover a spontaneous rhythmic pattern of your own in labor.

Vocal Breathing: Combines slow or light breathing with vocalization.

  • As you exhale with each rhythmic breath, you moan, sigh, count, sing, recite poems, recite affirmations, chant or make or say other sounds or words.
  • Low-pitched moans.
  • Loud high pitched sounds, especially if lost rhythm, may indicate suffering or fear – partner can ask “Are the sounds you’re making helping you?”
  • If they aren’t, partner can help lower pitch by moaning with you and maintaining your rhythm with the Take Charge Routine (pg 256).
  • If it helps you cope, no one should change.
  • *Support team should keep doors closed so you can make sounds as you please*

Contraction – Tailored Breathing: Use intensity of contraction to guide rate and depth of breathing. If contractions peaking slowly, breathe slowly when each contraction begins. As contraction intensifies, quicken and lighten breathing past the peak. As contraction subsides, gradually slow and deepen breathing. Think of each exhalation as a way to relax completely. If contractions are peaking quickly, slow breathing wont help you cope. Instead, use light breathing throughout each contraction.

Slide Breathing – Some women, especially with respiratory condition such as asthma, find that quicker pace of light breathing makes them uncomfortable and tense, regardless of how often they practice. If you can’t master light breathing after several attempts, slide breathing is a good alternative.

Inhale deeply and slowly, then exhale with 3 or 4 light puffs of air. Pause, then repeat process. To help guide breathing, say “in” to yourself as you inhale, drawing out the word to match the length of your inhalation, then say “out” with each puff of air you exhale. Although deep inhalations make slide breathing similar to slow breathing, the change in rhythm provides a different focus.

Variable Breathing: Combines light, shallow breathing with a longer or more pronounced exhalation, sometimes called “pant pant BLOW” or “hee-hee-HOO” breathing. Just with slide breathing, this is an option for women who feel uncomfortable or short of breath when using light breathing. Also helpful for women who need breathing patterns to have structure.

Use light breathing for 2-4 breaths, then take another light inhalation followed by a long, slow, emphasized exhalation (the “blow”). The last exhalation helps you steady your rhythm and release tension. Some women emphasize it by making a drawn out “hoo” or “puh” sounds. Find a comfortable pattern and repeat throughout contraction. Partner can count breaths to keep rhythm. “1, 2, 3, Blow!” or can count breaths to yourself to focus attention.

Rehearsing Breathing Adaptations for Labor: Include favorite adaptations and practice in various positions. Relax for only 30 sec or so between practice contractions to prepare for brief rest you’ll experience during late 1st state of labor. In this stage, contractions may last 2 minutes or they may occur in pairs with little break between the 1st and 2nd contractions (coupling). Be prepared to use light breathing or its adaptations for up to 3 minutes without losing breath.

Using Breathing Techniques to Avoid Pushing – May have early urge to push at peak of a contraction – this urge is considered premature if it occurs before cervix is completely dilated. If you have urge and don’t know if completely dilated, alert nurse or caregiver – they can confirm dilation by vaginal exam. If dilation not complete, you’ll be asked to resist urge to push.

To avoid pushing, lift chin and either breathe deeply, pant, or blow lightly until the urge subsides. Can say/sing “puh, puh, puh” or “hoo, hoo, hoo” with each exhalation. When urge to push passes, resume rhythmic breathing for the rest of the contraction. Changing positions can also help reduce the premature urge to push (try hands and knees, side-lying and open knee-chest positions). These won’t take away body’s urge to push, but will keep you from holding breath and bearing down with urge.

Rehearsing Breathing Techniques to Avoid Pushing: Occasionally practice a premature urge to push. Hold your breath or grunt as you breathe to signal to your partner that you have an urge to push. They can remind you how to resist urge until it passes. Rehearsing this can be silly and fun, but its good practice.

  1. Comfort techniques for back pain and challenging labors
    1. Positions and movements
    2. Back pain


  1. Positions and movements

Comfort Techniques for Back Pain, Slow Labor or an Extra Challenging Labor – contractions may begin to couple or become irregular. Labor may become prolonged. Baby’s position may give you back pain (pg 285 for positions).

Positions and Movement – To reduce pressure of baby’s head on back or to speed up slow labor, use positions to help baby rotate into a better position or movements that decrease back pain

  • Open Knee-chest: Hands and knees, lower head and chest to floor/bed. Move knees back enough so hips are high in air. 30 min.   Partner can support you. Best in prelabor or very early labor to eliminate back pain and reposition baby.
  • Leaning Forward – May help baby get into OA position and keep him there. Lean over birth ball, labor bed, counter (kneeling, standing, sitting). Hands and knees also effective. These relieve back pain by easing pressure of baby’s head against sacrum.
  • Pelvic Rocking – While kneeling and leaning forward over birth ball or chair seat, rock pelvis forward and back or move hips in a circle. Helps ease baby up out of pelvis and position encourages to rotate out of OP
  • Abdominal Lift – Standing, interlace fingers and place hands palms up, beneath belly and against pubic bone. During contractions, bend knees (to tilt pelvis slightly) and use hands to lift abdomen up and slightly in. Relieves back pain and improves position of baby.
    • Partner can help with woven shawl or rebozo. 5 in wide, position around waist and below belly. Partner stands behind you and crosses ends of shawl behind back.
    • During the contraction, your partner will pull on each end of the shawl to lift your belly.
    • Adjust both the shawl and strength of partner’s pulling so the lift feels good.
    • Caution: if baby wiggles a lot during abdominal lift, he may be experiencing uncomfortable pressure so discontinue
  • Standing, Walking, Slow Dancing, Stair Climbing: Take advantage of gravity and align baby with upper part of pelvis (pelvic inlet) and encourage descent into birth canal. Moving allows pelvis to change shape slightly, which encourages baby to rotate.

Asymmetrical Movement and Positions: Lunge, Side-lying and Semi-Prone- one side of body is doing something different than other side. Try on both sides. Use the side that’s more comfortable or alternate sides.

  • Lunge – Usually done during contractions. Find a sturdy armless chair that wont move when you lean against it. Stand in front of the chair, facing to the side. Lift the foot that’s closest to the chair and set it on the seat, with your toes pointing to the back of the chair (90 degree angle from direction body is facing). Remain upright, lunge sideways towards chair and return to start. Should feel a stretch in both inner thighs. Rest when contraction is over. Repeat for 5-7 contractions. If uncomfortable, use other leg.
  • Sidelying: Lie on side with hips flexed and knees bent. Place pillow between knees. Switch every 30 min when you’re awake for as long as baby’s heart rate is normal.
  • SemiProne: Lie on side with lower arm behind you and lower leg out straight. Flex hip of upper leg and bend knee, resting it on doubled up pillow. Roll slightly toward your front. Alternate with side lying when you must remain in bed.
  1. Back pain

A Note to Fathers and Partners About Relieving Back Pain – the following can help reduce back pain and make her move more comfortable. If one doesn’t work, try another.

  • Counterpressure – Use fist or heel of your hand to steadily press on partner’s lower back – as much pressure as she wants. If on hands and knees, can hold front of her hips with one hand and press steadily in one spot on her lower back 4-6 inches below her waist, slightly away from her spine. Exact spot will vary over the course of labor. Between contractions, rest or massage the area you pressed.  
  • Double Hip Squeeze– Have mom kneel and lean forward on a birth ball, chair or besides bed. If on floor, place pad beneath knees. During a contraction, stand close behind her, then press on the roundest part of each buttock with your palms. Apply steady pressure (instead of pressing and releasing repeatedly) as you try to press her hips together to relieve pelvic pressure and ease back pain. Try other places on her hips to press. If another person is available to help, the 2 person double hip squeeze is easier to do. Each person stands on each side of her, facing each other. Place one hand on roundest part of closer buttock, then together press on her buttocks – coordinate timing and amount of pressure.
  • Knee Press– Sitting upright in chair that won’t slide. May have to elevate feet so thighs are parallel to floor. Kneel in front of her and cup a hand over each knee. Lean toward her so your hands press straight back toward her hip joints. Keep pressure steady throughout contraction.

Other Comfort Measures to Reduce Back Pain – Heat and cold, baths, showers and:

  • Rolling Pressure – Move a rolling pin over your lower back. Soothing way to relieve back pain and muscle tension during and between contractions. Can use a can of frozen juice, cold can of soda, or hollow rolling pin filled with ice because cold helps numb the area. Use cloth between back and object.
  • Transcutaneous Electrical Nerve Stimulation (TENS) –Relieves back pain during contractions by creating tingling, buzzing or prickly sensations. Reduces awareness of pain by increasing your awareness of pleasant or distracting stimuli. Gradually increases endorphin production in area where it’s applied. If TENS begins in early labor, the level of endorphins in lower back will increase by the time labor intensifies.


4 stimulating pads are placed on back, then connected to small hand held battery operated generated. Between contractions, set intensity to level that feels comfortable and set stimulation to burst mode. When contraction begins. Change stimulation to continuous mode. As back pain increases, increase intensity. Specially designed maternity TENS available – Check with caregiver.


Possible Challenges of Labor – pg 44.

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)

  1. Tips for the educator when teaching coping skills
    1. Simulating contractions
      1. Partners are never asked to inflict pain to one another
      2. Clothespins, frozen water balloons, wall squat


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.

    1. Building confidence for partners as a labor team
      1. Encourage partners to adapt techniques to individual styles
      2. Never ask one partner to touch someone in another client pair
      3. The partner/team take all cues and rhythms from the laboring woman
      4. Make sure the class space feels safe and comfortable for class practice: close doors and window blinds, dim lights, minimize distractions.
      5. As the educator, move through the room during practice with quiet positive comments at their level (get down on one knee if necessary).


  1. Building confidence for partners as a labor team

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 LW 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. an become familiar with local fire stations bw 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

  1. Encourage partners to adapt techniques to individual styles
  2. Never ask one partner to touch someone in another client pair
  3. The partner/team take all cues and rhythms from the laboring woman
  4. Make sure the class space feels safe and comfortable for class practice: close doors and window blinds, dim lights, minimize distractions.




Labor Tool belt: activity to use in last class; last 30 min of class. Good review. Positive way to end class.


Tool belt from hardware store – ask partner volunteer to put it on and as pull out of pockets talk about each for labor support.


Hints on each item so adults can feel confident they know right answer (makes them more likely to volunteer when they can answer questions).

  • Oversized sunglasses – watch for signs positive/negative stress
  • Thinking cap – mom goes into primal self, so need someone else to take on thinking cap
  • Popcorn – mom should eat to hunger
  • Water bottle – drink to thirst
  • Bag of peas – cold pack or hot pack; cover before putting on skin. Be careful when had epidural
  • Fan – fanning mom in labor can be helpful
  • Playdoh – patience; her body is made to model to baby’s shape and baby’s head to mom
  • Socks – not slipping, in & out of shower
  • Playing cards – distraction in early labor is helpful
  • Scented shower wash – scents, water helpful
  • Idea cards – positions
  • Cell phone
  • Mints – watch breath if drinking coffee
  • Work gloves – touch her often, if helpful, w massage, stroking etc to remind her she’s not alone
  • Toilet paper roll – get to the bathroom often; every hr
  • Chinese finger trap – watch for and commend her relaxation skills for letting go
  • Chap stick – breathing patterns can cause dry lips


  1. Provide very specific directions and practice for the labor team
      1. Spiral comfort techniques through the classes with specific directions
      2. Encourage feedback time for mom and partner/labor team
      3. Provide practice time in every class for mastery


  1. Spiral comfort techniques through the classes with specific directions

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

Slideshow: Labor Positions – by involving partner, might feel greater support.

  • Kneeling over birthing ball
  • Swaying – standing or walking can help labor gain momentum, esp in early stages. Lean on partner for support during contractions or slow dance – good position for back rub
  • Rocking – rhythmic motions can be soothing. Rock while sitting on chair, edge of bed or birthing ball
  • Leaning forward – if back hurts. Good for back rub
  • Lunging – might help baby rotate/descend. Raise 1 foot on chair – lean toward foot during contraction. If chair too high, use footstool
  • Sitting w 1 foot up – flexing/extending elgs might help baby rotate/descend. Asymmetrical position offers variety. Can lean toward raised foot during contractions. Support under knee helpful
  • Kneeling – can help ease back pain. Kneeling while leaning forward can open pelvis. Use birth ball or pile of pillows. In hospital, raise head of bed. Kneel on lower part of bed while resting arms/upper body on top
  • Squatting – opens pelvis, giving baby more room to rotate. May help bearing down when time to push. Use chair or squatting bar for support. Or against wall
  • Hands and knees – takes pressure of spine, might ease back pain. Kneeling while leaning forward can open pelvis. Might boost baby’s oxygen supply. To give arms a break, lower shoulders to bed/mat and place head on pillow
  • Lying on side – rest/ease pain in first stage. Pillows between knees. Left side maximizes blood flow to uterus and baby.

Positions for labour and birth

  • Close physical contact, encouraging and soothing words, and eye to eye contact help
  • Although most delivery rooms have a bed, lying on back slows labor. Lift bottom and lean forward w contractions (facing towards bed)
  • Rest w feet lower than bottom to keep pelvis open. Stay upright
  • Sway hips from side to side against wall or holding onto open door
  • Firm pressure or massage on lower back can help during contraction
  • Blowing out air can help during contraction
  • If progress slows, walk up stairs sideways or try kneeling on one knee
  • Pelvis will open wider if knees lower than hips
  • Rocking comforting. If need continuous monitoring, you can still be upright position
  • Try kneeling if tired
  • Hands and knees

Comfort in Labor PDF

  • Healthy Birth Practice 1:Let labor begin on its own
  • Healthy Birth Practice 2:Walk, move around and change positions throughout labor
  • Healthy Birth Practice 3:Bring a loved one, friend or doula for continuous support
  • Healthy Birth Practice 4:Avoid interventions that are not medically necessary
  • Healthy Birth Practice 5:Avoid giving birth on your back and follow your body’s urges to push
  • Healthy Birth Practice 6:Keep mother and baby together – It’s best for mother, baby and breastfeeding

DVDs: Comfort Measures for Labor; Celebrate Birth!

Biodots (see above)

  1. Encourage feedback time for mom and partner/labor team

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. Books: 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…


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 Nonpharamcologic 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
  1. Provide practice time in every class for mastery


Passive Relaxation – Lie on side or sit in semi-reclined position with floor or bed supporting head/limbs. Can put pillows under/between knees, beneath head or under belly. Begin breathing slowly, easily and fully – this is how you breathe as you fall asleep. Your body and mind release tension and thought, your breathing slows and you pause slightly at the end of each inhalation and exhalation (observe someone as they fall asleep). Have partner read script in a calm, slow, relaxed voice. Take a couple breaths after you release each area.


  • Yawn or exhale completely.
  • Focus on your toes and feet. Feel how warm and relaxed they are.
  • Think about how floppy and loose your ankles are. They’re relaxed and comfortable.
  • Now focus on your lower legs. Let those muscles become loose and soft. Good.
  • Now focus on your knees. They’re supported and relaxed – you’re not holding your legs in any position. Wiggle them to see how relaxed they are.
  • Think about your thighs. Their large, strong muscles are soft and relaxed, and they’re fully supported. Good.
  • And now think about your buttocks and perineum. This area needs to be especially relaxed during labor and birth, so just let it become soft and yielding. When the time is right, your baby will travel down the birth canal, and the tissues of your perineum will spread to let your baby make her way out. You’ll release, letting your perineum relax and open for your baby.
  • Focus on your lower back. Imagine that someone with strong, warm hands is giving you a lovely backrub. It feels so good. Your muscles are relaxing, and your lower back is comfortable. Notice the tension leaving your back.
  • Let your thoughts turn to your belly. Let those muscles relax. Let your belly rise and fall as you breath in and out. Good. Now focus on your baby within your uterus. She’s floating or wiggling and squirming in the warm water of your womb – a safe place where you’re meeting all you baby’s needs for nourishment, oxygen, warmth, movement, and stimulation. You baby hears your heartbeat, your voice, my voice and other interesting sounds. What excellent care you’re giving your baby.
  • Now focus on your chest. As you inhale, your chest swells easily, making room for the air. As you exhale, your chest relaxes to help the air flow out. Breathe easily and slowly, letting the air flow in and flow out, almost as though you’re asleep. Good. Now try inhaling through your nose and exhaling through your mouth – slowly and easily, letting the air flow in and out. At the top of an inhalation, notice just a little tension in your chest, which you can release with an exhalation. Listen as you exhale. Your breath sounds relaxed and calm, almost as if you were asleep. Every exhalation is relaxing. Use your exhalations to breathe away any tension. Good.
  • Focus on your shoulders and upper back. Imagine you’ve just had them massaged. Let those muscles release. Feel the warmth as the tension slips away.
  • Now focus on your arms. As you exhale, let your arms go limp – from your shoulders, all the way down your arms, to your wrists, hands and fingers. Let them become heavy, loose and relaxed.
  • And now your neck. All the muscles in your neck are soft because they don’t have to hold your head in any position. Your head is either comfortable balanced or completely supported, so just let your neck relax. Good.
  • Focus on your lips and jaw. They’re slack and relaxed. You’re not holding your mouth closed or open. Its comfortable; no tension there.
  • And now your eyes and eyelids. You’re not keeping your eyes open or closed. They’re the way they want to be. Your eyes are unfocused and still. Your eyelids are relaxed and heavy.
  • Focus on your brow and scalp. Think about how warm and relaxed they are. You have a calm, peaceful expression on your face, reflecting a calm, peaceful feeling inside.
  • Take a few moments to enjoy these feelings of calmness and well-being. You can relax this way anytime – before bedtime, during an afternoon rest, or during a quiet break. This is how you’ll want to feel in labor. Of course, during labor you won’t lie down all the time. You’ll walk, sit up, shower and change positions. But whenever a contraction comes, you’ll let yourself relax all the muscles you don’t need to hold a position, and you’ll let your mind relax, giving you a confident, peaceful feeling. This feeling will help you yield to contractions, letting you focus on breathing and finding comfort through each one.
  • Now it’s time to end the exercise. Gradually open your eyes, stretch, tune in to your surroundings, and slowly rise. Take your time. There’s no need to rush.

Relaxation Countdown: After mastering passive relaxation, use following to release tension quickly. Helpful when you want to fall back to sleep, stressed, or when trying to relax after a contraction

Inhale through nose and exhale out mouth, releasing muscle tension in the following order: Head, neck, shoulders; arms, hands, fingers; chest and abdomen, back, buttocks and perineum; legs, feet and toes. Use 5 slow breaths at first (1 for each of the 5 areas). Then try slowly exhaling one deep breath for all 5 areas (rapid relaxation countdown). During labor, first or last breath of each contraction can be rapid relaxation countdown.

Practice time as a Rehearsal for Labor – Learn how to work with partner to use techniques effectively. Practice enough so you’re comfortable with them and review periodically. – practice guide. Practicing these exercises, breathing rhythms, and relaxation techniques will increase your confidence in your ability to handle labor and birth.

  • Conditioning exercises AKA Kegels (95). Continue practicing until birth
  • Comfort measures for discomforts (103).
  • Body awareness exercises (215; see earlier in doc)
  • Passive relaxation (216 see earlier in doc)
  • Relaxation countdown (218 see earlier in doc). At first, use several breaths to relax, then work toward relaxing with one breath
  • Perineal massage (235). During last 5-6 weeks of pregnancy, do 5-6x a week
  • Slow breathing (224 see earlier in doc)
  • Touch relaxation (219 see earlier in doc)
  • Roving body check (219 see earlier in doc); practice by self and with partner
  • Slow breathing with roving body check (224, 219 see earlier in doc)
  • Attention focusing (208 see earlier in doc)
  • Crisscross back massage (213 see earlier in doc)
  • Possible positions for 1st stage of labor (221-222). Practice slow breathing in each position. See earlier in doc
  • Light breathing (225). Experiment with depth and rate of you breathing
  • Adaptations of slow and light breathing – contraction-tailored, vocal, slide and variable breathing (226-227). See earlier in doc
  • Variety of positions for first stage of labor (221-222) while practicing breathing adaptations. See earlier in doc
  • Ways to decrease back pain in labor (229-232). Double hip squeeze, counterpressure, abdominal lift, open knee-chest position, knee press and lunge. Combing with breathing patterns. See earlier in doc
  • Ways to avoid pushing (228 see earlier in doc)
  • Spontaneous bearing down and directed pushing (232-234). Practice gently bearing down and incorporate the bulging exercise (p 96). Occasionally, practice panting to avoid pushing in middle of practice contraction
  • Positions for 2nd stage of labor (222-223). Try while practicing spontaneous bearing down (expulsion breathing)
  • Labor rehearsal: practice all the coping techniques during a series of pretend contractions. Partner can help by observing and helping your fully relax in all positions.


Show 1 water birth/ labor. Music during labor (Play variety so people can see what they like; partner songs).

Goody bag demonstration – pg 96. Ask them to pack one for last class.

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:

Maintaining Freedom of Movement

Research shows that moving freely in labor improves a woman’s sense of control, decreases her need for pain medication, and may reduce the length of her labor. Sometimes it is hard to move in labor due to routine procedures or lack of support and space. A recent US study found that 71 percent of laboring women did not walk at all during active labor. Instead, women often labor in bed propped up with pillows. Women who have labored this way say next time they want to be more upright. This list provides evidence-based tips for women who want to stay free to move in labor.

  1. Choose a care provider and your birth place carefullyto make sure you will be encouraged and supported to move and change positions. Find a care provider who will support you in choosing the positions that work best for you. When choosing a birth setting, look for birth balls, rocking chairs, squatting bars, and tubs.
  2. No matter where you give birth, stay home until you are in active labor, when contractions are five minutes apart and last about one minute. If your cervix is not dilated more than 4 centimeters
    when you arrive at your birth setting, consider going home or for a walk until your cervix
    dilates more. It’s often easier to move and respond to your labor at home. You can rock, slow
    dance, walk, or sit on your birth ball. Listen to your body and rest when needed.
  3. Once at the birth setting, request that your care provider not use any unnecessary intervention that may make it harder to move around. This will mean that continuous monitoring of the baby’s heart rate (“continuous EFM”) and intravenous lines (IV’s) are only used when needed for medical reasons. If there is a medical reason for these, tell your care provider that you want to maintain as much freedom of movement as possible. There may be ways to minimize the effect of these interventions on your ability to move freely.
  4. Arrange to have continuous support in labor from a professional labor assistant (a doula) or a close friend or family member who makes you feel safe and confident. Ask them to remind you to trydifferent positions or activities in labor.
  5. Consider the impact that pain medications will have on your ability to freely move during labor. All pain medications make it hard to stand or walk in labor. It is usually impossible when an epidural is used. You may hear about a “walking epidural” but this usually just allows you to move your legs in bed or walk short distances. Pain medications often lead to the need for other interventions, such as IVs and continuous electronic
    fetal monitoring, which restrict movement. Choose to birth at a place that provides easy access to a tub. Using water in labor decreases the need for pain medication. If you want an epidural in labor as a pain coping technique, wait until labor has progressed and you have already used lots of movement to help the baby rotate and move down in the pelvis.
  6. Attend a childbirth class that focuses on active labor, giving you and your partner plenty of movement and position options. Keep a list of the positions that you like best and bring it with you as a reminder in labor. Practice positions and movements before your labor begins, so you and your partner feel comfortable and confident using them.

Quick checklist for place of birth

  • Safe place to walk
  • iPod, smart phone, other MP3 player for dancing music
  • A tub
  • Birth ball
  • Rocking chair
  • Squatting bar
  • Telemetry (portable device used for continuous fetal monitoring)
  • Policy for intermittent auscultation
  • Policy for respecting women’s choices for labor support; Wrong Link – see correct link above

Handouts for purchase: Penny Simkin’s Road Map of Labor.

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

PCEG IV-86 to 87 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 – It’s the awareness of one’s breathing and the rationale for attention focusing that’s more important than any breathing technique. Breathing and relaxing go hand in hand.

Teaching Strategies to Integrate in Class: Draw attention to breath when sitting, exercising, relaxing in class. After relaxation sequence, see if breathing has slowed. Offer strategies such as counting or phrases to help slow down. Ask if they feel movement in chest or abdomen as they breathe.

Breathing Practice: pg 107 Prepared Childbirth The Family Way. Wavy lines as possible paces and patterns. Cleansing breath. One minute periods breathing through nose, mouth, in nose out mouth – ask for comments. Breathing colors. Inhale peace, exhale tension. Affirmations.


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 Rs of childbirth.

  1. Additional ICEA resources to read
    1. ICEA Position Paper on the Role and Scope of the Doula
    2. ICEA Birth Doula Certification Program –
    3. ICEA Position Paper on Comfort Measures
    4. YouTube about Three R’s


  1. ICEA Position Paper on the Role and Scope of the Doula
  2. ICEA Birth Doula Certification

(Face to Face or Online).

  1. C. ICEA Position Paper on Comfort Measures

The laboring woman’s perception of labor events and her response is a priority concern for healthcare professionals. Risk factors for application or ingestion of chemicals or herbal products are unwelcome in an evidence-based practice setting. In keeping with a family centered maternity care philosophy, and in recognition of the client- centered bill of rights, healthcare organizations support the utilization of comfort measures in labor. It is recognized that they contribute to a holistic approach to care. Informed decision-making is magnified as a focal point in childbirth education programs.

Comfort measures are those actions a laboring woman initiates or requests to facilitate positive reactions, responses, and or emotions during labor and delivery. Her sense of smell, touch, taste, and sound are supported by comfort measures in labor. Acupuncture aromatherapy, freedom of movement, hydration and sustenance, hydrotherapy, massage and therapeutic touch, music and song, and support are commonly used comfort measures. Comfort measures help laboring women maintain control of her labor progress. Contrast to medical interventions, comfort measures and complementary therapies are gaining recognition.

A supportive partner and empathetic healthcare team work in concert to energize the laboring woman. Their united efforts enhance her sense of wellbeing within a safe therapeutic milieu. The woman and her partner can be assisted during marked periods of stress by a Doula or Montrice. Comfort measures are implemented based on the woman’s expressed desires as she adjusts and adapts to her labor process.

The Childbirth Educator facilitates knowledge and understanding of comfort measures, their advantages, disadvantages, and potential for adverse effects. All information provided should be designed with focused attention on healthcare literacy skills. The role of the Educator advances the philosophy of ICEA in recognition of “…the pregnant woman’s right to make informed choices based on knowledge of benefits, risks, and alternatives…”

Comfort Measures

  • Acupuncture– ancient remedy for a long list of ailments and disease processes. Primarily used in Asian cultures, the practice is gaining world-wide acceptance and has been incorporated in maternity settings to alleviate some discomforts of pregnancy. Use of acupuncture in labor and delivery has not been supported by a large number of large scale research studies. These authors report that although there is a limited amount of scientific evidence to support its practice it is “…a safe intervention in labor, and we need more options for pain management that do not increase risk for the mother or baby. The role of the Childbirth Educator is to “…provide accurate and factual information based on current research
  • Aromatherapy – sense of smell is one of the most affective mechanisms for those experiencing distress. Some women in labor who experience the fight or flight response to the stress of labor benefit from the pleasing aroma of an essential oil. The olfactory nerve transmits calming signals in response to scents such as lavender and sweet almond. Aromatherapy can initiate a sense of wellbeing by creating a calm and relaxing environment. Additional research is needed to substantiate the efficacy of the use of aromatherapy in labor.
  • Freedom of Movement, Therapeutic Touch and Massage – When the laboring woman has freedom of movement her sense of balance and homeostasis is maintained. Muscle strength and stability is realized as she stretches in preparation for the delivery process. In randomized trial, found that a 30 minute lumbar massage reduced pain in labor.
  • Effleurage, a light touch and massaging like movement over the pregnant abdomen is a comfort measure that is frequently practiced by many women without conscious effort. This movement sends signals to nerve endings on the surface of the skin initiating a sensation of comfort and relief. Exteroceptors are close to the body surface and are specialized to detect sensory information from the external environment (such as visual, olfactory, gustatory, auditory, and tactile stimuli). Receptors in this class are sensitive to touch (light stimulation of the skin surface), pressure (stimulation of receptors in the deep layers of the skin, or deeper parts of the body), temperature, pain, and vibration. Nerve endings known as proprioception function within a neuroanatomical structure that conveys information from the muscular skeletal system to the central nervous system
  • Hydration and Sustenance – Labor and delivery requires an energy store to sustain the powers of labor and delivery. Assessment of thirst, adequate fluid intake, skin turgor, edema, and urination are indicators of hydration, vascularity, and circulation. Women who choose to drink fluids like water, juices, and herbal teas are acting in recognition of their knowledge gleaned from prepared childbirth education classes. Maintenance of her electrolyte balance is essential to uterine muscle contractility, blood pressure regulation, and maternal-fetal-placental circulation. Small light meals may be requested to provide the needed calories to fuel and sustain oxygenation and cellular metabolism . In a national review of midwifery practices pertaining to the use of herbal preparations for labor augmentation, induction, and cervical ripening, reported that herbal remedies were preferred for their “natural” effects. Three questionnaires were excluded due to incomplete data or blank questionnaires. No significant differences were noted in relations to geographical region, midwifery education, or highest level of education between the CNM respondents who did and those who did not use alternative methods to stimulate labor. Of the CNMs who used herbal preparations to stimulate labor, 64% used blue cohosh, 45% used black cohosh, 63% used red raspberry leaf, 93% used castor oil, and 60% used evening primrose oil. CNMs who used herbal preparations to stimulate labor were younger (43 versus 45 years, P < .01) and more likely to deliver at home or in an in-hospital or out-of-hospital birthing center (P < .0006), than CNMs who never used herbal preparations to stimulate labor
  • The Childbirth Educator informs about the risks associated with some herbal preparations as found in a variety of beverages marketed as homeopathic remedies. Risks can be associated with uterine overstimulation, rupture, or birth defects. An advantage to some herbal beverages is their mineral content needed for muscle fiber contractility and the immune response. Research and documentation to support safe decision making about the use of herbal remedies during labor is available on the National Institute of Health website (NIH, 2013).
  • “Herbs with the potential to cause uterine stimulation and miscarriage are blue and black cohosh, feverfew, aloe, ephedra, Epsom salts, and Chinese tea rose” “While homeopathic remedies are frequently confused with herbs, they are different in their legal status and side effects. Herbs are categorized by the U.S. FDA as a food product, while homeopathic remedies are categorized by the U.S. FDA under the Homeopathic Pharmacopoeia of the U.S. (HPUS)”
  • Hydrotherapy – Immersion in a warm water bath during labor is reported by many women as an experience that releases the sensations of pain and pressure in the abdomen and pelvis. As reported in the Cochrane review in 2009…, “Women who used water immersion during the first stage of labour reported statistically significantly less pain than those not labouring in water (40/59 versus 55/61) (OR 0.23, 95% CI 0.08 to 0.63, one trial).”
  • Music and Song – Most women in labor will incorporate one or two comfort measures at the same time. They will perform effleurage while moving about freely, slowly swaying back and forth to enhance gravity’s force upon fetal descent. Music, song, and dance are three practices akin to cultural celebration, a time to welcome a change. A research study conducted in Western Iran reported the differences between laboring woman in regard to pain relief while exposed to either massage or music therapy. The researchers reported that of a population of 101 first time mothers who were randomly stratified into two groups a significant difference (p=0.001) was observed in terms of pain severity after the initiation of (music, n=50) or (massage, n=51) therapies. The women in the massage group reported the lowest pain levels. A small sample size and the only statistical reference is to a (p level) limit the generalizability of this study.

Support from a Doula or Monitrice – The ICEA (2013) philosophy encourages all Educators to recognize that collaborative efforts within family- centered care are essential to promote the health and wellbeing of the laboring women. The practice setting for the Childbirth Educator is one that provides for the “…encouragement for the optional participation of labor support person(s) of the woman’s choice…” The authors of a Cochrane review on the significance of support of women in labor found that of 15,061 women who were enrolled in the study those who received continuous support among other things, were more likely to deliver vaginally (RR 1.08, 95% CI 1.04 to 1.12), shorter labors (mean difference -0.58 hours, 95% CI -0.86 to -0.30), and less medical intervention.

Implications for Practice – Comfort measures are incorporated in childbirth education classes to emphasize the significance of support, healthcare provider assistance, and self- regulation of labor discomfort, anxiousness, and pain.

Comfort measures may be used in combination with medical interventions to enhance and facilitate rest and relaxation. They (comfort measures) are used to help laboring women to conserve energy and to decrease or eliminate anxiety, fear, and painful sensations.

As childbirth educators, it is important that class participants are informed about comfort measures from an evidence-based research practice that includes both risk and benefits associated with acupuncture, aromatherapy, hydration and sustenance, freedom of movement, therapeutic touch, and massage, music and song, and the support from a doula or monitrice. ICEA childbirth educators teach to inform pregnant women and their partners; teach to inform and to increase knowledge and understanding of alternatives within the ICEA’s philosophy of family-centered maternity care.

  1. YouTube about Three R’s (6:35) 

Scene from Penny Simkin’s Comfort Measures – The 3 R’s & Slow Breathing – Relaxation, Rhythm and Ritual

By attending the births of 100s of women in labor, these 3 characteristics in those who cope well:

Relaxation: At least between contractions if not during

Rhythm: Breathing, moaning, swaying, stroking,

Ritual: Repetition of same 1 activity 1 contraction to the other


Slow Breathing: Take long breath and hold it. Out breath is your relaxing breath. Release tension on every out breath. Sighing way through contraction – sigh of relief. Partner can count breaths for a minute (avg contraction; those in early labor will be shorter, those in late labor longer) to see how many breaths take when nice and relaxed. 9 breaths – half of avg breathing rate. Partner can mention to relax shoulders, jaw, forehead etc. Start using breathing when you can’t talk through contraction – when labor stops you in your tracks.

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