Group Process: Challenging Group Dynamics

This is post #7 in my weekly series on “Group Process in Childbirth Education: Building and Supporting a Community of Learners.”

New childbirth educators tend to worry about these issues a great deal. To be honest, you’ll encounter mild difficulties from time to time with classes, but it’s rarely a big deal. The students in your class will be adult learners, which in general means they may be more engaged and better behaved than the students you remember from high school. Also, they chose to be in your class, and are motivated to learn what you have to share, which also improves behavior.

If you have quiet students:

  • ask more open-ended questions
  • go around the circle and ask each person to share a response to a simple question
  • use grab bag exercises or games where everyone has an assigned “job” to do
  • do more small group activities – it’s easier to talk in a small group

If you have loud students who over-participate:

  • break eye contact with them
  • walk away from them – toward the white board, toward a poster…
  • look at your watch
  • interrupt if needed: say “thanks for that” then ask “have other students had that experience?”

If you have issues with students’ attention wandering:

  • move around
  • pick something up or point at a visual aid
  • look at the person whose attention has wandered
  • ask a question
  • make students laugh – the inattentive one will wonder what she missed

For “side talk” (two students talking):

  • move toward them
  • look at them, then look to the one who is speaking
  • engage them
  • change the activity – get up and move around, pull out an AV.

If you have a hard time keeping the class focused, and find yourself wandering off target: Always write the outline on the board. If discussion is getting un-focused, you can point at it and say “I love this discussion, but we have more we need to cover today, so let’s get back on track.”

More tips for difficult students:

Group Process: Activities to Build Connections

This is part 6 of my weekly series on “Group Process in Childbirth Education: Building and Supporting a Community of Learners.”

If you spent all your class time lecturing, showing videos, and demonstrating, your students would get a lot of information out of your class. But they would have missed out on one of the other benefits of taking childbirth classes: the chance to meet and connect with other parents. Consider spending a portion of each class on building community. (A side benefit for you: As students get more comfortable with each other, they will participate more, ask more questions, and learn more from the class.)

Here are some activities to try:

Tune Out, Tune In. Each week when students arrive at class, they’re often not quite “present” when they walk in. Their mind may be on work, or traffic, or the errands they need to run after class, or many other things. Try a warm-up activity each week to give them time to get present.

  • Check-Ins:
    • What’s on your mind today? What worries have come up? What questions?
    • Highs / Lows: What have been the best and worst parts of your last week?
    • What have you learned since last week? What have you read? Did you have an appointment with your caregiver? Did you see anything about birth on TV?
  • Question of the week related to the topic:
    • Name something that helps you when you’re feeling sick, in pain, or worried?
    • What’s one item you plan to bring to the hospital with you?
    • What’s your biggest worry about medical procedures and interventions?
  • Agenda setting: Any questions left over from last week? What questions do you have about tonight’s topic you want me to be sure to answer?

Small Group Work – the bigger the class, the more important it is to fit in some small group work into your classes, so people have a chance to connect. Sometimes keep couples together and pair up two or three couples. Other times, encourage a couple to separate and join different groups so they hear different perspectives.

  • Small group discussions. Examples:
    • Discuss experiences they have in common, like: common discomforts mom is having or plans for postpartum and baby care.
    • Labor words: Pass out a list of adjectives that could be used to describe labor. Ask them to mark 4 or 5 words that resonate with them. Then discuss with your group: what did they mark? If their labor was like that, what support would they need?
    • Scenarios for discussion: make up cards which describe variations scenarios or other challenges that may arise in labor. They read one out loud, then discuss what they think is happening, and what they would do.
  • Quizzes – make up cards that review the info you covered in the last class session – write a question on one side of the card, the answer on the other. Pass them out to small groups of students. They read the question, guess at the answer, check to see if they’re right.
  • Brainstorms: Assign them a topic (write it on a big piece of easel paper). Have them brainstorm all the ideas they can come up with. Example: pros and cons of vaccinations, circumcision, and breastfeeding.
  • Separate moms and support people. (Works best if you have two rooms.)
    • Ask moms to self-guide a discussion on common discomforts of pregnancy while you facilitate a confidential discussion with partners on what they’re worried about related to their ability to provide labor support.
    • Ask moms to self-guide a discussion on postpartum support resources and imagining how they’ll adapt to life as a mom while you teach dads/partners some newborn care skills (like baths, cord care, nail trimming). Allows dads/partners to be the “expert” on a topic so moms have to ask them how to do it.

Interactive activities

  • Invite participation in class. Give plenty of time for questions from students. Ask them plenty of questions.
  • Play games.
    • Try the Breastfeeeding myths and truths game: Each student reads a card and says whether they thinks it’s a myth or think it’s true. You follow up with more details.
    • Try the Signs of Labor game – write on the board “maybe, probably, definitely” or “possible, prelabor, positive” if you prefer. Give students a card describing a sign of labor, and ask them to tape it where it goes.
    • Birth Matters has a collection of game ideas, as does Passion for Birth. and Stacie Bingham.
  • Do role plays. Example: print these labor scenarios. Cut up the cards describing stages in labor, and put the posters on the wall. Have a couple read one scenario out loud, then suggest a comfort technique or two to try from the list of options (breathing techniques, comfort techniques, position). Everyone practices together.
  • Mocktail party. Laurie Levy invented this activity, where she brings tacky margarita glasses and offers several types of non-alcoholic mixed drinks for people to try (with recipes), puts on party music, and encourages them to mix and chat while drinking. You could combine this with a wide variety of icebreaker type games.

What do you do to build connections amongst your students?

Consensus Statements and Real-World Implications

2014 ACOG / SNFM statement

In March, ACOG and SMFM released a consensus statement on prevention of primary cesareans. It made several significant recommendations, such as:

  • A prolonged latent phase (eg, greater than 20 hours in nulliparous women and greater than 14 hours in multiparous women) should not be an indication for cesarean delivery.
  • Cervical dilation of 6 cm should be considered the threshold for the active phase of most women in labor….
  • Before 41 0/7 weeks of gestation, induction of labor generally should be performed based on maternal and fetal medical indications. Inductions at 41 0/7 weeks.. should be performed to reduce the risk of cesarean delivery… perinatal morbidity and mortality.
  • Cesarean delivery to avoid potential birth trauma should be limited to estimated fetal weights of at least 5,000 g… [Note: that’s 11 pounds]

All potential game changers, right? And there’s more! If you haven’t read the statement yet, do. All childbirth educators would benefit from the info on typical length of pregnancy, length of labor, etc.

But, I find myself wondering. Will it be a game changer?

How much effect does a consensus statement (even a major one like this) have on actual practice and how long does it take for that effect to appear?

2010 VBAC Consensus Statement

So, let’s look back at another major consensus statement: Vaginal Birth after Cesarean, an NIH consensus statement from March 2010.

First, the context for the NIH consensus panel: This was at a time when VBAC rates had been dropping steadily since 1997. One factor in these dropping rates was availability of VBAC as an option. In 1999, ACOG released a practice guideline that trial of labor should only occur in hospitals where physicians and anesthesiologists are “immediately available” 24 hours a day to perform emergency cesareans. A joint statement from ACOG and ASA in 2008 re-affirmed this.  Surveys found that 30% of hospitals (especially smaller hospitals and rural facilities) stopped offering trial of labor because they could not provide immediate surgical and anesthesia services.

The NIH recommendations in 2010 included:

  • Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision.
  • When trial of labor and elective repeat cesarean delivery are medically equivalent options, a shared decision-making process should be adopted and, whenever possible, the woman’s preference should be honored.
  • We are concerned about the barriers that women face in gaining access to … trial of labor. Given the low level of evidence for the requirement for “immediately available” surgical and anesthesia personnel… we recommend [ACOG and ASA] reassess…

What effect did this NIH statement have on ACOG?

ACOG did update their clinical guidelines on VBAC in August of that year. There was some positive progress toward VBAC access there, such as the statement “Most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about vaginal birth after cesarean delivery (VBAC) and offered a trial of labor after previous cesarean delivery (TOLAC).” However, despite the NIH recommendation to reassess this requirement, they retained the wording “TOLAC [should] be undertaken in facilities with staff immediately available to provide emergency care”

What effect did the NIH statement have on VBAC rates?

In 2009, VBAC rate was 8.4%. The NIH statement was released in March of 2010. The 2010 rate was 9.2%, 2011 was 9.7%, and 2012 was 10.2%. [Data is not yet available for 2013.]

So, we have seen some improvement since the consensus statement, which is good news for VBAC advocates.

However, we are nowhere near the rates seen in the mid-1990’s before ACOG recommended “immediate access” requirement for hospitals allowing VBAC.

VBAC rate

Obviously, there are many factors at play in the VBAC rate, beyond the NIH recommendations and the ACOG Guidelines, such as financial reimbursements for procedures, liability concerns and more. Plus, practitioners may be slow to change their practice.

I suspect that some of the new guidelines from the 2014 ACOG / SMFM statement will become standard practice quickly, others are already being viewed as controversial, and are less likely to become standard practice.

Group Process: Encourage Connection

This is part 5 of my weekly series on “Group Process in Childbirth Education: Building and Supporting a Community of Learners.”

Giving “permission” for connections

Talk about the benefits of connecting to other parents. Talk in the first class about peer support, and what a fabulous resource new parents can be for each other, offering both practical advice, and support (i.e. helping you realize that you’re not the only one who’s having a hard time adjusting.) I say something like: “one of the best things for new parents is to talk to other parents, get support, get advice, share frustrations, etc. We’re going to start practicing that here today, and start talking to other people who are in your same life situation… It’s easy to think that because I’m teaching the class, I’m the expert in the room, but I guarantee that you all have things to teach each other and to learn from each other as well.” I then go on to give examples of how having connections to other parents will help you throughout your child’s life (get tips on potty training your 3 year old; talk to other parents about starting kindergarten, get recommendations for driver’s ed classes, get support from other parents are adjusting to having their child go away for college.)

Encourage connection. Assume your students want to meet and talk with other parents, but may need guidance for when and how to do that. Just before each break, encourage them to connect over break. Give them a couple questions to ask each other or discussion topics. I say something like ““go ahead and run to the bathroom, or get some water, then come back and chat with your classmates. Maybe you can get some good ideas for baby names, or where to shop for baby bathtubs, or share some positive birth stories you’ve heard.”

Or put out displays around the room which encourage them to wander around and chat informally with each other. Try “lift-the-flap” cards. First, think up trivia questions. Write the answers on a 4×6 index card. Then cover the answer up with a 3×5 post-it note. Write the question on the post-it note. Students ask themselves the question, then lift the flap to check their own answers. Works great for nutrition, pop quiz review of labor, baby development trivia, etc.

Breaks: Allow plenty of time at break for them to make these connections! (Note: breaks also allow the introverts to slip out of the room for a little while and get a breather.)

Snacks: People naturally connect over food. If you have snacks in your class, you will have a better group dynamic. The whole class will go better. Consider providing a simple, inexpensive snack in week one and asking parents to volunteer to bring snacks to all the other classes.

Encourage on-going connections

Connection outside of class: Suggest students get together. Consider setting up a Facebook group for them to use to connect. Hand out copies of a class roster with student contact information. (In week one, tell them you’ll be doing this, and pass around a roster, so they can make any changes, or mark out any info they do not want to appear on the roster you distribute.)

Encourage them to meet for dinner nearby before class, or go out for lunch after a class.

One of our instructors would ask students at the beginning of each class: “where did you guys get together this week” – her tone assumed that of course they had done so. The first week or two they would hem and haw, but then after that they started answering!

Reunion: Plan a reunion after all the babies are born. It’s a great opportunity for them to re-connect. Have them all email each other (or post on Facebook) when their babies are born as a lead-up to reunion. At reunion, hand out roster again. Encourage them to meet again.

Group Process: Class Begins


This is post #4 in my weekly series “Group Process in Childbirth Education: Building and Supporting a Community of Learners.” It’s about the first ten minutes of class – this is the most important time in terms of establishing effective group dynamics for the rest of the class series. People won’t connect unless they feel comfortable and feel like they belong.

Arrival and First impressions

Your students form an impression of you, their fellow students, and whether they belong in the first ten seconds after entering the room, so it’s important to get first impressions right.

Be early for the first class and have everything ready so you can focus on welcoming students. Pay attention to how you are dressed. Try to dress in a similar style to your students, but one step more formal, since you are the “authority.” Introduce yourself when they arrive, and begin a conversation (great topics: when are they due, what they’ll name the baby, traffic and weather.)

Have an attendance sheet or class folder with their name on it. This reassures them they’re in the right place.

Have them make nametags. Rather than little tags they wear on their chests, fold a piece of cardstock in half to make a little “tent”. Have them write first names and due date with a marker so it’s easily visible from across a room. They set it on the floor in front of them. Or, you can use the spiffy white board style nametags shown at the top of the page.

Have snacks available, or at least water and cups.

Play music to set a friendly, relaxed tone. Try to find music that’s fairly universally appealing, not something aimed at just one demographic.

Have an icebreaker activity available in case lots of students arrive early – it’s better to get them moving and talking, instead of sitting passively in their chairs. Choose one that helps people find commonality and appreciate the diversity of experience. Try Icebreaker Bingo – each student is given a sheet with 25 questions on it. Their job is to find someone in the room that can answer yes to the question and write their name down.

Class Begins

Your introduction: This partially serves to establish your credibility as the instructor for the class (what you know and how you learned it) but it also helps to establish you as a human being they can relate to – an approachable mentor on the parenting path.

Student Intros: If you’re teaching a one-time two-hour class with 12 couples, you may not do full introductions of all the students. But for smaller classes and multi-week classes, always make time for intros. Minimum intros are names and due dates. If you have time, try the 3 part intro:

  • Who Are You? (Name and Due Date)
  • What do you already know? (Could ask professional background, but that can set up social class distinctions. Could ask what they know about birth and baby care. Could say “In this class, we’ll be talking about some things that are new to you that you might worry whether or not you’ll be good at. I want you all to remember that you can learn new skills and get good at them. Share with us something new you’ve learned and gotten good at in the past few years.”)
  • What do you want to know? (What are you hoping to learn in this class? If you’re in a hurry, ask them to say in one word what they’re hoping to learn. If you have more time, you don’t need to limit it in this way.)

When they introduces themselves, show interest in them as an individual. But then also generalize what they said so it relates to everyone. “Yes, a lot of people worry about that. We will definitely be talking about that in week two.” “Thanks for that question on diaper wipes. We’ll be talking more about all things diaper related in the newborn care class.”

Housekeeping. Tell them how to get basic physical needs met: where the bathrooms are, where they can get food / drink, when you will be taking breaks. If you’re teaching a class that’s more than 3 hours, say that it’s OK to sit on the floor, or stand, or sit on the birth ball, or whatever they need to do to be comfortable for all that time. If people are comfortable, they can learn. But if they’re wondering when /how they’ll get to eat or pee, they’re not learning.

Go over the class outline so they know what to expect out of each session of class. Also define social norms and expectations for participation and interaction.

In next week’s post, we’ll look at more ways to build community as the class goes on.