Introduction

Fetal Development

The Danger Signs of Pregnancy

The Pregnant Patient's

Sexual Intimacy

Weight Gain

Communication Skills

Labor Coping Strategies

Birth Options and Preferences

What to Take to the Hospital

Labor

Addendum

Labor Coping Strategies

Labor and birth are important life-changing events in a woman’s, and a couple’s life.  How labor is perceived prior to the event often affects how the event is experienced.  Labor is a powerful, yet healthy, force.  Labor is mostly commonly a normal physiological event.

A woman’s ability to cope with labor is influenced by a great number of factors including the following:

Psychological Preconditioning

Self Trust
Individuals with a sense of self-esteem and the attitude of “I’m OK and I like who I am,”. are known to generally handle life’s stresses better than individuals who don’t feel good about themselves.  A woman who likes herself will cope better with the intensity of labor than a woman who feels that she is not a worthwhile person.  Psychologists teach that you can alter your perception of yourself by self-talk, such as, “I am OK and I like who I am.  I can cope with labor and its stresses…..”  This self-talk must be practiced daily and for several weeks before one’s mind begins to change its perception of one’s worthiness.  But it can be done.

Attitudes Toward “Pain” and “Blood”
Most people entering childbirth classes fear the expected pain of labor and the probability of seeing blood.  These two events should be welcomed, however, as they are useful indicators of progress of labor.

Strong contractions accomplish the work of opening the cervix so that the baby may be pushed out into the world.  Although, once achieved, active labor with its forceful contractions is strong and can be painful; these contractions more efficiently dilate the cervix than a series of moderate and more tolerable contractions.  Strong, active labor should, therefore, be welcomed as a sign of progress.

Bloody show is also a sign of progress and is a normal part of labor.  As the woman dilates, she has a small amount of bloody vaginal discharge.  This bleeding is not a result of injury but, rather, is directly due to advancing cervical dilation.  Both the “pain” of labor and the “blood” of labor should be seen as welcome signs of progress.

Cultural Expectations
Most women give birth according to the culture (the arts, beliefs and customs that make up a way of life for a group of people at a certain time) which they are accustomed to.  For many of us, our cultural way of giving birth is to go to a hospital to be attended to by a professional staff.  Our coach may be allowed to be present but not our extended family or friends.  We may never have attended a birth ourselves.  Despite our attempts to educate ourselves on the process of birth, it still remains somewhat shrouded in secrecy and mystery.

For other women in other cultures, they may go to a special birthing place and be attended to by other women-relatives and/or friends-until the birth is accomplished.  Or the women of the group may come to the birthing woman’s home and attend to her there until she gives birth.  Or the laboring woman may go off alone until the birth is accomplished

However one chooses to give birth, it is known that we cope better with that which is known and familiar, than with that which is unknown and uncertain.

Shared Life Experiences
Most women remember the duration and the intensity of their labors.  Their perspective of the event, however, is oftentimes skewed.  A woman may have had an 18 hour labor of which only the last 4 hours involved active labor and intense contractions.  When this woman recounts her labor experience, she will tell you the labor lasted 18 hours and then proceed to tell you how intense the labor was without clarifying that only the last few hours were difficult.  Frequently, these labor stories become embellished, making them more dramatic than they actually were.  These kinds of stories are not helpful to the prospective mother who still has her own labor and delivery to look forward to.

Physiological Influences

Fear-Tension-Pain Syndrome
The Fear-Tension-Pain Syndrome teaches that when a woman in labor gives in to fear, either through a lack of knowledge or misinformation, she unconsciously tenses her muscles as a response to her fears.  Tense muscles constrict, or reduce, blood flow through the blood vessels thereby reducing oxygen delivery to the muscles.  Muscles in a state of low oxygenation feel pain more acutely.  The ability to maintain relaxation, therefore, is very important as it allows unrestricted blood flow and oxygen delivery to the muscles which prevents an increased sense of pain due to tension.

The most important muscle to maintain good blood and oxygen flow to during labor is the uterus.  This can be accomplished by mastering the relaxation techniques prior to labor, and by using them during labor to maintain relaxation and optimal blood flow to all of the muscles.

Endorphins (Enkepbalins)
Endorphins are the body’s natural morphine, or pain killers.  They are secreted from the brain.  With the initial introduction of a stressor, such as labor, there is an increased secretion of endorphins from the hypothalamus.  A continuing, chronic stress response can deplete the endorphin secretion level thereby negating its beneficial effect.  If an individual’s response to a stressor is one of control and relaxation, however, then the initially increased endorphin level may be maintained.

There is speculation from recent research, as well, that massage may facilitate and stimulate the brain’s ability to produce endorphins.

The Gate-Control Theory
The Gate-Control Theory proposes that there is a gating mechanism involved in the transmission of pain impulses to the cerebral cortex area of the brain (level of awareness).  Pain from the contracting uterus travels to the brain along small diameter nerve fibers.  Messages relayed along small diameter nerve fibers travel to the brain more slowly than messages relayed along large diameter nerve fibers.  It has been demonstrated that large diameter nerve fibers are stimulated by touching, massage and rubbing.  Stimulation of the large diameter nerve fibers can become the primary signal to the cerebral cortex when

coupled with concentration on a focal point, relaxation skills and a patterned breathing style.  Once the cerebral cortex area of the brain has received its primary message (massage, focal point, relaxation, patterned breathing), a “gate” closes to prevent other impulses from being interpreted as the primary message.  Other messages attempting to enter the cerebral cortex are then regulated to a secondary position and are, therefore, less focused upon.

The following factors affect the “gate”:

Left and Right Brain Stimulation
Recent research indicated that if both hemispheres of the brain can be stimulated simultaneously, than the brain’s ability to interpret a painful or noxious stimulus is reduced.  Left brain stimulating functions in a Lamaze childbirth class include the reception of factual information, processing the information and acting upon it.  A right brain stimulating function is the regular inclusion of some favorite music during the practice of one’s Lamaze labor coping skills (focal point, relaxation, patterned breathing, massage, etc.)  The practical application of this theory is for the laboring woman to employ the labor coping techniques of her choice (a rational, logical, left brain stimulating function) combined with soothing music playing in her laboring environment (a right brain stimulating function).

Personal Attitude and Self Trust
The course of labor is greatly influenced by the mental preconditioning of the pregnant woman.  Each woman may choose to believe sensationalized and usually distorted media presentations of birth, and embellished personal accounts of others.  Or each woman may choose to trust in her own personal strengths, the coping strategies she has learned, and in her ability to access the numerous mechanisms that are naturally in place to help her cope with the intensity of labor.  Ultimately, the choice is each woman’s to make.

Visualization
“Imagery (visualization) is really a form of daydreaming with direction and purpose.  It is a conscious experience in which an individual is able to maintain a focus on one object  of concentration through involving perceptual and emotional participation”  (Sandra Steffes).  Visualization, used as a tool in childbirth preparation, allows the laboring woman to mentally focus on a positive image.  This focusing of her mental attention can decrease the woman’s perception of pain and improve her coping abilities.  Guided imagery and visualization have been used successfully in clinical settings to improve vision, to relieve intractable pain, and to restructure negative images surrounding the childbirth experience.

Following is a sample visualization script that the pregnant woman and her coach may practice on a regular basis until the woman goes into labor.  Before beginning the practice, the woman should be resting comfortable with all parts of her body supported.  There should be soothing, relaxing music playing in the background and the room should be darkened.  With calm, clear tones, the coach may say the following:

• “Relax your body.
• Your mind is calm and clear.
• Your breathing is slow and even.
• You can visualize easily and with great clarity.
• Your mind is a screen and you can see any picture you wish.
  Picture yourself ____________(Choose a favorite scene such as at the beach, the   mountains, taking a warm bath, sailing, etc.  Describe the scene.)
• Be aware of the details.
• Be aware of the senses (warm, gentle rocking, etc.).
• Look closer at the details.
• Now see yourself in the picture and be descriptive (on a towel at the beach; walking on a flower-bordered mountain path; luxuriating in a warm bath; gently bobbing over the waves in your sailboat; etc.).
• Be aware of your senses.  Look at the scenery.  Be aware of the smells and of the sounds.  Is there a breeze?  (Take time with this part to explore the positive and restful parts of the “picture”.”  You are leaving   ____________and returning slowly to the present.
• Move your right arm slowly.  Now move your left arm slowly.
• Open your eyes when you are ready.
• Maintain your calm, relaxed state and remember it.
• Know that you may return to your special place any time that you wish”.

Positive Affirmations
Positive affirmations can be either pleasant, helpful and positive thoughts by the woman, or similar statements made to her by her coach.  Affirmations can help a woman maintain a positive frame of mind which can significantly and positively affect her response to the activity and intensity of labor.

During labor woman can hear, accept and process positive directions or comments.  Negative comments, such as “Don’t tense,” require mental processing to be understood, analyzed and acted upon.  This can be an increased mental burden for the actively laboring woman.  She may reject these comments because they are temporarily perceived to be annoying and/or confusing.

Examples of positive affirmations are as follows:

Relaxation Skills

Progressive Relaxation
Progressive relaxation is a basic tension-relaxation exercise where one’s goal is to tense a muscle and be aware of the tension and what it feels like, and then to relax the muscle and focus on what each muscle feels like when completely relaxed.  This increased level of awareness of the state of tension or relaxation in the muscles is the foundation for progressing to the next level of relaxation.  For a complete “Progressive Relaxation” exercise and practice script, see the Addendum.

Neuromuscular Control Relaxation and Feedback
It is well understood that when one muscle group of the body tenses, additional  muscles groups surrounding that area tend to also tense causing additional discomfort and decreased perfusion and oxygenation to the area.  Neuromuscular Control Relaxation teaches the learner that one muscle group may be isolated as it is tensed, while surrounding muscle groups can remain in a relaxed state.  In labor, this skill is translated into the woman’s ability to maintain surrounding muscle groups in a relaxed state while the uterus continues to contract involuntarily.

This N-M Control Relaxation skill needs to be practiced regularly until the woman actually goes into labor. When practicing, the following rules should be remembered:

1. Practice in a quiet environment.
2. Have pleasant, soothing music softly playing in the background.
3. Assume a comfortable position with all parts of the woman’s body supported and relaxed.
4. Have a mental device, which means to focus on the relaxed state of the muscles.

A sample script for the coach may go as follows:

1. The coach may say “Contract your left arm.”  The coach now checks each of the woman’s major muscle groups from head to toe for relaxation and encourages additional relaxation with comments such as “Your jaw is relaxed,” or “Your right arm is heavy,” or “Relax your back,” and so on. When the coach has completed the check, the coach instructs the woman to “Relax your left arm.”
2. “Contract your jaw.”  The coach again checks the woman’s other major muscle
   groups for relaxation.  The coach then instructs the woman to “Relax your
   jaw.”
3. “Contract your right leg.” (with the toes pointed up, not forward, so as to avoid a cramp).  The coach checks the woman for relaxation and then instructs her to “Relax your right leg.”
4. Continue this practice by naming each of the major muscles one at a time, having the woman tense one, access the other major muscle groups for relaxation, encourage additional relaxation, and then have the woman release the muscle previously tensed.

Massage and Effleurage
Massage has the potential for providing comfort and for restoring a sense of well-being.  Massage facilitates venous (blood) and lymphatic flow, and tissue stretching from stimulation of skin and pressure receptors.  Touching and rubbing stimulate the fast-moving afferent neurons (nerves) which, in turn, inhibit the conduction of pain impulses to the spinal cord from the slower-moving efferent neurons from the uterus.  Massage can exert and analgesic (pain-reducing) effect as recent research suggests that it may facilitate the production of endorphins.

Effleurage is a form of massage which provides a controlled focus on concentration.  Most often, effleurage is practiced as a rhythmic abdominal massage in synchrony with the patterned  breathing styles of the woman in labor.  As the hands massage in a double-circular manner around the enlarged abdomen, it is easy to visualize that one is drawing a heart shape around the baby.  Effleurage complements breathing and relaxation skills.  It, too, stimulates the fast-moving afferent neurons.

Following are some considerations for effective cutaneous (skin) stimulation by use of massage or effleurage:

• Attitude-An essential component of effective therapy using massage or effleurage is the coach’s desire to help or be helpful.
  
  
• Quiet-A quiet, calm environment has been identified as essential to allow the sense of touch to be focused on as a primary stimulus.
  
  
• Warmth-A comfortable warm room and the warm hands of the woman or her coach (including the choice of lubricant being prewarmed) adds to the sense of well-being.
  
  
• Positioning-The woman’s body should be well supported and in good alignment with no extremities resting or pressing on each other.
  
  
• Pressure-Light pressure is oftentimes interpreted as feeling ticklish or annoying.  Pressure of moderate intensity is comforting and allows the woman to focus on the massage stimulus.  The coach may use his/her body weight for pressure rather than muscle force alone.
  
  
• Area of Stimulation-The areas to be stimulated by massage or effleurage may include the skin over the contracting uterus, the skin around or near the contracting uterus, or any unrelated area of the body the woman prefers.
  
  
• Use of the Hands-The coach’s hands should be contoured to the body part or extremity being massaged.  Firm strokes should proceed in the direction of venous blood flow (the direction of the blood as it returns to the heart).  A rhythm of stoke and unbroken contact should be maintained.

Focal Point and Attention Focusing
A focal point may be either an external visual object to focus on, or an internal focus of attention.  The focal point, whether internal or external, is a primary indicator of the woman’s ability to maintain concentration and control in labor.

An external focal point is the fixing of one’s visual attention upon an object which is a comfortable distance from one’s eyes.  The focal point reduces the stimuli taken in from the peripheral environment.  It allows the individual to focus and concentrate on inner process such as breathing patterns or body rhythms.  Examples of an external focal point are a pattern on the wallpaper, a stuffed animal, a favorite picture, a wrinkle in the bed sheets, and so on.

An internal focal point is closing one’s eyes and using a mental image, picture or visualization as the primary visual focus.  In pain threshold studies, groups using attention focusing (either external focal point or visualization), relaxation, plus coach feedback, were most able to tolerate the introduction of a painful stimulus.

Music
Calm, soothing music is known to shift the listener into his/her right brain hemisphere which, in turn, stimulates the parasympathetic nervous system (PNS).  Relaxation is enhanced when the PNS is stimulated.  In a relaxed state, one’s pain threshold is increased so that pain impulses are interpreted in a more tolerable manner.

Margo McCaffery, RRN, pain researcher, also indicated that the listener’s active tapping out of the musical rhythm (mouthing the words if there are lyrics, singing along, head nodding, finger tapping, etc.) helps to increase concentration.  This can be an effective blocking technique for the interpretation of painful stimuli.

Lamaze Breathing Techniques
Patterned breathing techniques are a learned skill which enhances relaxation.  Rhythmic breathing develops body awareness and improved oxygenation. The relaxation and oxygenation  aspects of the breathing techniques reduce pain perception.

Slow, rhythmic breathing of mild intensity stimulates the parasympathetic nervous system, the tranquilizing portion of the nervous system.  Rapid and/or tense breathing
stimulates the sympathetic nervous system, which is the arousal portion of the nervous system and is associated with stress and panic.

The optimal pace for respirations is one in which the individual woman breathes slowly and rhythmically to comfort.  The inspiration should be rhythmically followed by the exhalation with no pause at the apex (top) of the breath cycle but, rather, with the pause at the end of the exhalation.  The focus of each breath should be on the exhalation which is the portion of each breath cycle associated with calm.

All of the Lamaze patterned breathing techniques begin and end with a cleansing breath.  A cleansing breath is a moderately-increased-over-normal inhalation and exhalation.  The breath is inhaled through the nose and exhaled through the gently opened and relaxed mouth.  Although the depth of air exchange is exaggerated, it is still done to comfort.  The cleansing breath signals the beginning or the end of a contraction, provides a balance of oxygenation, fosters relaxation due to improved oxygenation, and provides a focus for the laboring woman.

Slow-Paced Breathing
This is a gentle and slow nasal inhalation with an exhalation through the relaxed, slightly opened mouth.  These gentle, slow, inhalations and exhalations are repeated throughout the entire contraction.  Facial movements are kept to a minimum and a forceful blow is not attempted.  Each breathing cycle (or stimulated practice contraction) begins and ends with a cleansing breath.  While practicing, the coach may assist the woman by saying “Contraction begins.  Take a cleansing breath.”  The woman takes her cleansing breath and then uses the slow-paced breathing technique through the remainder of the contraction.  As the contraction (or practice contraction) ends, the coach may say “Contraction ends. Take another cleansing breath.”

It has been recommended that the slow-paced breathing technique be practiced at approximately half the rate of one’s normal resting respiratory rate (normal adult resting rates are between 12-20 breaths per minute).  Each woman should, however, find the slow and rhythmic rate which is most comfortable for her regardless of the specific number of breaths inhaled and exhaled per minute.

Modified-Paced Breathing
This breathing style also begins and ends with a cleansing breath.  Modified-paced breathing is different from the slow-paced technique in that most women choose to do all of the inhalations and exhalations through  the mouth.  After the cleansing breath, each inhalation is a shallow intake of air with an even, short and shallow exhalation accompanied by a vowel sound.  Some women choose to make a short, crisp, “Hee” sound as they exhale.  With the air exchange, the face remains relaxed, the lips are slightly parted, and the sound (“Hee”) is made with the placement of the tongue close to the roof of the mouth.  Each practice contraction now consists of a cleansing breath, several vowel (Hee”) sounds throughout the contraction, ending with another cleansing breath.

In the past, it has been recommended that this breathing technique be done at a one-every-two-seconds-rate, or at a rate that is approximately twice the woman’s  normal resting respiratory rate.  If done too rapidly, however, this shallow chest breathing technique increases the work of the accessory muscles of the chest.  This results in extra oxygen being consumed due to the increased work effort by the respiratory muscles.  Although this technique is usually done, more quickly then at the normal resting respiratory rate, it should be done at a pace which the individual woman finds comfortable and which maintains relaxation.

Patterned-Paced Breathing
Patterned-paced breathing is actually modified-paced breathing with an extra “blow” interspersed at either regular, or irregular, intervals.  The extra “blow” is slightly increased inhalation-exhalation in relation to the vowel sounds (“Hees”).  Patterned-paced breathing requires increased attention-focusing by the laboring woman with either a set number of “Hees” to the “blow”, or a random number of “Hees” to the “blow”.  The pace is the same as for the modified-paced breathing techniques above.

Some sample Patterned-Paced Breathing can be as follows:

• 3:1  The contraction begins with a cleansing breath.  The woman then does 3 “Hees” and a “blow”, 3 “Hees” and a “blow”, and so on until the contraction ends with another cleansing breath
• 5:3:1.  The contraction begins with a cleansing breath.  The woman does 5 “Hees” and a “blow”, 3 “Hees” and a “blow”, then 1 “Hee” and a “blow, then 5 “Hees” and a “blow”, 3 “Hees” and a “blow”, then 1 “Hee” and a “blow”,  and so on until the contraction ends with another cleansing breath.
• Hand Signals: With this variation, the coach hold up 2 fingers indicating that the woman is to do 2 “Hees” before the “blow”.  The coach then changes to any umber of fingers to indicate how many patterned-paced breaths the woman is to take before the “blow” each time (the coach is restricted to one hand so may choose any umber  between 1-5 only).  With each “blow” the number of fingers changes indicating the change in number of “Hees” to be done.  Hand signals are intended to be a random pattern as opposed to the above preset patterns.

Breathing/Coaching

“Hee-Blows” To Control The Urge To Push
There are several reasons why a woman may not be encouraged or allowed to exercise her expulsive efforts when she experiences the urge to push.  The most common reasons to resist the urge to push include when her cervix is not yet fully dilated or when the doctor has not yet arrived for the delivery.  If a woman is directed to resist the urge to push, she will be instructed to blow through the contractions in a rapid and forceful manner.  This forceful, rapid and constant inhalation and exhalation of air prevents the woman from bearing down with the contractions.  Although the woman does not add her expulsive effort to the contractions when she is doing rapid “Hee-blow” breathing, her uterus continues to contract and push down on the baby.

“Hee-blow” breathing to control the urge to push is accomplished by taking in a large breath and then exhaling it forcefully with a “Hee” sound, inhaling another breath and exhaling it with a forceful blow, inhaling a large breath then exhaling it with a “Hee” sound, and so on and so on until the contraction ends.  The woman must remember to take in a breath for every sound or exhalation she makes.  She must also maintain a fairly rapid cycle of inhalations and exhalations as a slower cycle may allow her to hold her breath and bear down which is what she is trying to avoid doing with this technique.

Coach Support and Input
Coach support and input can be important as it affects the woman’s ability to trust in herself and to effectively use the labor coping strategies of her choice.   Coaching measures may include, but are not limited to, the following:

• Positive Affirmations
• Assessing Relaxation
• Feedback
• Comfort Measures
• Massage
• Ice Chips
• Fanning
• Encouraging Position Changes
• Encouraging Use of the Bathroom
• Simultaneous Breathing with the Woman
• Interpretation of Information
• Doing Nothing If Appropriate

Staff Support Input
The support of the staff and its input can be very important as it affects a woman’s ability to trust in herself and to effectively use the labor coping strategies of her choice.  It can be difficult for a woman to trust in herself when she perceives conflicting messages or information coming from “experts.”

Environmental Considerations
There are numerous environmental factors which have been shown to have an impact on the progress of labor.  Following is a list of factors which have been identified as possibly having a beneficial or a detrimental effect on the progress of labor:

Next: Birth Options and Preferences