Category Archives: Theory of CBE

Activities for Online Birth Classes

In the past year, so many of us have moved our classes online. We may continue to be online through coronavirus and beyond, as some instructors are considering continuing to offer online classes from now on, in addition to in-person. We’ve discovered that online classes can help make our classes more accessible to people from a broader geographic area, to people with limited transportation, folks who don’t want to deal with commuting to and parking at a class site, folks with disabilities, parents on bed rest, and more.

How do we make our online classes as engaging and memorable as possible? Here are lots of ideas for interactive birth class activities. My examples will go in order from pregnancy topics through the stages of labor and into postpartum and baby care. Most of the techniques can be adapted to many more topics than I address in my example.

Healthy Pregnancy

Due to my state’s Medicaid requirements, we have to cover several specific topics, including substances (alcohol, drugs, tobacco), healthy nutrition and food safety, exercise, sexuality and more. To address these topics, you could create an online Jeopardy game, or create a quiz in Kahoot to use in class, or use Zoom polls to quiz them during class. Or you could use Google Forms to create a quiz to send to the students as “homework.” You could use these wellness cards for ideas for questions and answers to include. You could adapt a grab bag activity by having a slide show with pictures of items and asking them to talk about them.

Anatomy Pictionary

Sharon Muza has a great icebreaker activity where she has students draw anatomy. You can easily adapt this to online classes by splitting students up into breakout rooms, have them use the Zoom whiteboard to create drawings, then screen capture those and return to the main room to share.

Jamboard Signs of Labor

This is an interactive bulletin board type activity, where there are post-its listing symptoms that labor may be starting. Students sort them into possible, probable, and positive signs of labor. Find it here, and make a copy for your use: https://jamboard.google.com/d/1a_zy4wqWA6koO0bfuQ_6aAbZIWjekdMjinHLaO_mjdo/edit?usp=sharing

On a Zoom call, the way you would use this is: paste the link into chat. Everyone goes to the link and they can all manipulate it together, and you can talk them through it. (Learn more about using outside apps with Zoom.) If you’re meeting in-person, I’ve got an old school version of this activity where you print the cards and they sort them.

Comfort Techniques Chat Storm

Tell them “I’m going to ask you all to type some ideas into chat… First, I want you to think about when you’re sick – what helps you to feel better?” They start typing, then you can prompt them more… “It may help you to think – when you were a kid, what did your parent do to help you feel better? Or what did you wish they had done that you think would have helped.” As all the ideas pour in over chat, you can read some out loud, affirm them, comment on how these might be used in labor. Then do another storm for “what helps you to relax?” (more questions)

Comfort Tools Scavenger Hunt

Either during your presentation on comfort techniques for early labor, or in a discussion of “what to pack for the hospital”, send students off to find something in their house that helps when they’re in pain, or sick, or feeling worried. Have them do show and tell, and talk about how you could use those in labor.

Virtual Background for Hospital Routines

When you discuss arriving at the hospital, you can use a photo of triage room as your virtual background. (Learn how to use virtual backgrounds in Zoom.) When you discuss moving to the hospital room, change your background to reflect that.

Word Cloud – what will labor be like?

During in-person classes, I’ve used a worksheet where people can circle words that represent what they think birth will be like (words like: messy, excruciating, beautiful, long…). Then they discuss – if your birth is like that, what support will you need? (Or if you’re providing labor support, and the birth is like that, how will you best support the laboring person?) In a virtual class, you could do this as a word cloud, where all the students add their words, and you’d see common themes arise, as words that multiple people type are shown bigger than those only added by one. I have directions on how to do a word cloud in mentimeter here: https://janelledurham.com/guide…/use-other-apps-with-zoom/

Jigsaw Puzzle Stages of Labor

Take your favorite poster / infographic of the Stages of Labor, and convert it to a jigsaw puzzle, as Mallory Emerson describes here: https://www.lamaze.org/Connecting-the-Dots/Post/series-brilliant-activities-for-birth-educators-solve-the-puzzle-of-virtual-teaching. For copyright purposes, you should only use images that you otherwise have the rights to use in your classroom. You can purchase a variety of images. I like the Road Map of Labor from Childbirth Graphics, but there’s also good stuff available through Plumtree, Better Birth, and Birthing with Guinever. (Find links to those products in my post on Where to Find AV Aids.)

You could either use this as homework – send students a link to do at home after class, or you could do it collaboratively during an online class – maybe as a warm-up before starting class or as a breaktime activity. It’s low key, interactive, and good for the visual and kinesthetic learners to review labor stages by interacting with the images.

Continuum Exercises

In a classroom, I have used a continuum exercise for something like: “If you have TONS of experience taking care of lots of newborn babies, go to that end of the room. If you’ve never held a baby under 6 months old, go to that end. The rest of you array yourself somewhere on that continuum.” It’s helpful to me to see the range of knowledge and helpful to them to see that they’re not the only ones… I have never done this for topics that I feel like people can be judgmental about… “oh, I knew she was one of those people.” But online you can do this anonymously. Have a slide showing a continuum like the pain medication preference scale, and you can have them annotate it to mark where they are. (You could also do this a poll or using another – rate on a scale of 1 – 10 type tool.)

Thumbs Up / Thumbs Down Reactions

They can use Zoom reactions to vote. Could be used for something like: “is this normal or is this a warning sign?” Or “is it time to go to the birthplace?” Or “True or False.”

More Ideas / Training

For more general ideas you could adapt to perinatal topics, check out my Zoom Guide for more ideas on Demo Physical Activities on Zoom, Games and Interaction on Zoom, Use Other Apps with Zoom, Using Zoom on Facebook Portal, and more.

If you’d like to learn more about exactly how to use virtual teaching techniques in the birth class setting, I highly recommend the Creative and Confident classes offered by Sharon Muza, FACCE and Mallory Emerson, LCCE.

AV Aids for Birth Classes – 3-D Models

In a separate post, I cover where to find: posters, PowerPoints, illustrations, and handouts. This post is focused on 3-D models: pelvis, breast, fetal dolls, placentas, and so on.

Note, all prices and links are current as of February 2021, and all may change (especially the Etsy items.)

Childbirth Graphics is the most comprehensive source. They’ve got all the basics: pelvises, fetal dolls, placentas, and breasts. And a whole lot more: cervix models, milk fat comparisons, pregnancy bellies… Durable and high quality. Sample prices: set of pelvis, doll, placenta, perineum is $256; pelvis $74 or $133; newborn doll $69; breast model $87.

Cascade Health Care Products has a number of products… they appear to all be Childbirth Graphics items that they are selling. Some of their prices are higher than Childbirth Graphics and some are lower, so it’s worth comparing. Set $279; doll $64; breast $97.

Birthing, Bonding, and Breastfeeding. Has rubber breast models ($20), crocheted breasts, and a breast model scarf. They say “The rubber silicone-filled breast forms a seal to allow for demonstration of flange fitting and nipple positioning. Breast reacts to pump and simulates what pumping should look like when the nipple placement is correct.”

Anatomy Warehouse. They have multiple pelvis styles and a placenta. They also have lots of anatomical training models that are not items you would use in a class. Pelvises range from $41 – $70.

Brilliant Activities for Birth Educators. This is not a site that sells AV aids… it’s a blog that tells you how to make your own! Lots of fun ideas for interactive activities.

Crochet or Knit Your AV’s: this post has links to patterns.

DIY Pelvis. How to make a pelvis model from 2 file folders!

Amazon

You can buy models on Amazon. They sell the Childbirth Graphics set, but it’s $275, and you can get it for $256 direct from CG. They have multiple inexpensive pelvises that claim to be life-size and flexible, but the reviews often say they are not life-size, not flexible and not that well-made. (But, they do have one that’s just $39, so maybe that’s a fair compromise?) They have this mini doll and pelvis for $39 or the doll, pelvis and placenta for $69, but the quality looks poor. (And they also have identical products that are sold under many brand names for a wide variety of prices, which is typical of low quality imports.) I think you would be better served by saving up money for one of the professional quality models from Childbirth Graphics (which last for decades!) or picking one of the Etsy items below.

(Note: the Amazon links are affiliate links – if you purchase anything on Amazon after clicking on one, I do get a small referral fee.)

Etsy Shops

Edy’s Wonderland. Set of pelvis, uterus, baby, placenta $167 (can buy pieces separately.) Miniature set of baby, placenta, uterus, beanie, diaper $56. Breast $17.

Wicked Stitches. The full set shown of sperm, uterus, placenta, baby, breast, belly balls, and baby poop / diaper is $131. All sold separately. Sample cost – breast $18.

Mother Hen Doula – Felt Pelvis for $6. Knitted breast $8, placenta $9, uterus $17.

Viva Doula. Non-pregnant uterus with detachable vagina and vulva; full-term uterus, placenta and sac; breast $234 for set; pieces sold separately. Sample cost breast $53. Also has miniature sets, dolls, knit penis, weighted doll $197.

Birth Matters NW. Weighted Dolls. $50

Mam Amour Dolls. Breast model and breastfeeding baby doll, $221. VBAC Mama Doll $234.

Namsis Craft. Breast and latch $25; placenta $110; doll $80, pelvis $60, uterus.

Milk Mama Milk. Placenta, baby, uterus $119; breast and latch puppet $34, diaper with poop $13, belly balls $12.

Your Birth. Doll $20. Cesarean birth apron $65.

Bebek liked ishop. Placenta, non-pregnant uterus, 4 breasts for $170. Placenta $48.

Soul Mama Crochet. Breast $22, breast and placenta $44

Hazel Creates Threads. Cloth pelvis, uterus and amniotic sac, crochet placenta and breast $133

Clover Care Doula Services. Uterus, placenta and membranes $108.

More ideas?

If you know of other great sources, add them in the comments!

Free Illustrations for Birth Professionals

Years ago, I created LOTS of simple line drawings for use in birth education materials. I’m putting them here for anyone who wants to use them for any perinatal education or birth support purpose, whether that’s for class handouts, PowerPoints, to show to a client over a video call, or whatever. Everything on this page is free for you to use, no need to credit me as the source. For any of them, just right click on it, and choose copy or save as.

Positions for Labor

Sitting or Resting

Standing / Moving

Forward Leaning

Pushing Positions

Anatomy

Maternity Care

Monitoring

Interventions

Complications

Fourth Stage / Skin to Skin

Breastfeeding

Anatomy

Positions

Breastmilk Expression

Birthplace Options

Babywearing

Rebozo Techniques

Teaching Birth Prep on a Portal

I recently wrote a review of Facebook Portal for those who are considering a purchase. On this page, I’ll just give you a quick overview, and then comment specifically on how well I think it would work for online childbirth preparation classes.

Overview

The Facebook Portal is a video-chatting device. You can also use it for streaming or surfing the web, but it was primarily designed as a device for teleconferencing software such as Facebook Messenger, What’s App, and now Zoom. (Not for Teams or Skype)

Zoom works fairly well on the Portal, although it does not have a few of the features you’ll find on your app on your computer – you don’t appear to be able to run breakout rooms or do polls from it. You also don’t seem to be able to share directly from the Portal, but you can easily share from another device without having to log it in to Zoom. See the full review for more details.

Audio Video Quality

It’s got really good speakers, multiple microphones and a camera with good video quality. The camera has movement tracking software, which follows you if you move around the room. I was hopeful that this would be good for birth classes, providing a better view of comfort techniques than I can manage with my laptop.

It turned out, as you can see in the second video, that the motion tracking did not work well for this purpose. The camera focuses around your face, so when you’re trying to demo foot placement for a lunge, the camera will show you from the waist up or even shoulders up.

You can do manual control of the camera, where you can zoom in or out, and aim it where you want it, so you can create just a nice wide angle that shows most of your body. It looks better and sounds better than it does when I use my laptop’s webcam. You’ll see this in the second video.

Using for Birth Classes

So, here’s how a few techniques for birth classes look on my laptop with its external mic.

Here’s how things look on the Portal – the first part of the video has the camera using motion tracking – the second part is manual control. You’ll notice even in the still images here that the color and picture quality is much better on the Portal than on my Lenovo laptop.

Conclusions

The Portal experience is not a game changer, and I wouldn’t necessarily run out to purchase one. However, if the price ($129 – 179 in November 2020) is manageable, I think the improved audio / video quality and the ability to get the wide-angled shot offer some appealing benefits for me.

For more info on using Zoom

I have LOTS of tutorials about how to use Zoom – for brand new beginners, experienced hosts, musicians, preschool teachers and more. Check out: https://janelledurham.com/guide-to-zoom/.

Note: the links to products in this post are affiliate links. If you click through to Amazon and purchase anything, I will get a percentage of the revenue. That helps support my work writing this blog and others.

Teaching about Birth Plans

Here are the steps I teach for how to develop a birth plan. I do a brief walk-through of a birth planning process. For each, describe how to do the step, who participates, and the primary goal.

  • Birth Plan Checklist – Pregnant Parent and Partner
    • Find a checklist such as http://www.pcnguide.com/wp-content/uploads/2016/03/2-Preparing-Your-Birth-Plan.pdf. The pregnant parent and the primary support person walk through this together, making sure they understand what each of the options are (and if not, learning more), and making sure the support person knows her preferences for each. There is no need to share this detailed checklist with their care providers, it’s just for their own reference – it’s worth tucking it in the bag they’ll take to the hospital in case they would like to refer back to it in labor.
  • Top 3 – 5 Priorities – Discuss with Care Provider.
    • While completing the checklist, they can determine what their top priorities are. They should discuss these with their care provider at a prenatal appointment. Will these choices be options for them during their birth process? What can they do to increase the likelihood of reaching those goals? This discussion allows them to develop realistic expectations and increase the chance the expectations will be met. (Note, sometimes this can lead a parent to re-examine whether the caregiver and birthplace choices they have made are the best fit for their goals.)
  • Written Birth Plan – To Share with Nurses at the Hospital
    • A birth plan is the primary tool for communicating with nurses about the family’s goals and priorities, and what kind of support from caregivers would be most helpful to them.
    • It should never be more than one page long (in a easily readable format.)
    • One format is to have three sections. The first describes who they are as a family and who will be at the birth and what they have done to prepare for this birth. The second gives the big picture of their preferences for labor support, pain medication, and interventions. The third is optional, and explains any special information that “if the nurse only knew this about me, they could better support me.” This is a good place to address religious or cultural preferences, history of sexual abuse or other personal history that may affect them during the birth process, any particular worries they have about the birth.
    • If parents are planning a home birth, they may not need a written birth plan for their midwife if they’ve been in deep discussion for the whole pregnancy. However, they absolutely should have a written birth plan in case of transfer. In a survey of birth satisfaction, some of the lowest rates were for people who had planned an out-of-hospital birth and transferred. They could increase the chance of a satisfying birth experience by taking time to articulate their wishes.
    • Sample birth plans are available at http://www.pcnguide.com/wp-content/uploads/2016/03/2-Preparing-Your-Birth-Plan.pdf. Feel free to print several examples to share in class to show there’s no one right way to write a birth plan.

Childbirth Educators can support students with figuring out their top 3 – 5 priorities using the Birth Plan Card Sort exercise: https://transitiontoparenthood.files.wordpress.com/2018/10/birth-plan-card-sort.pdf. Instructions are on the last page.

Learn more about the steps of teaching about Informed Decision Making, including Values Clarification, and how to make the decision after gathering information.

Simple Guide to Having a Baby 2016

Simple Guide 2016

The 2016 edition of Simple Guide to Having a Baby has gone to print, and will be available to the public at the end of July. (We’re hoping to have copies for sale at the DONA conference in Bellevue, WA) It will be available from Amazon, Barnes and Noble, Walmart, and probably Target.

Simple Guide covers essential information about pre-conception, pregnancy, birth, breastfeeding and newborn care at a 6th grade reading level, in a short, accessible format. It is written by the authors of Pregnancy, Childbirth, and the Newborn. Although we are writing at a different literacy level, we do our best to incorporate the same foundation of current, research-based information and our practical experience of working with thousands of birthing parents over many decades.

What’s new in 2016: increased cultural diversity and sensitivity in photographs and writing, incorporation of the visual aid “The Road Map of Labor“, more links to online resources for more information, and more details on baby care. We have also extensively updated all the medical information. I have an extensive post on all the updates we did to Pregnancy, Childbirth and the Newborn – we weren’t able to incorporate all of these details into Simple Guide, but they certainly did inform our revision of this shorter work.

If you would like to write a review of Simple Guide, I do have galley proofs available. Contact me and jdurham at parenttrust dot org, and tell me about yourself and where you publish reviews, and we can make arrangements to get a proof to you.

Pregnancy and Disability

Janelle 32 wks

Someone recently asked me to share my perspectives on how perinatal professionals can provide sensitive, supportive care for people with disabilities. Here are some initial thoughts on that question.

First, a caveat to any advice I offer below: I can only speak to my own experience. The needs of each person are unique and depend on such things as:

  • What is the disability?
  • How long have they had it and how experienced are they at working around it?
  • What is their self-image / identity – if they think of themselves as “disabled” they are likely to have more worries about the perinatal period than someone who doesn’t see their disability as a primary part of their identity or life experience

My experience: I had bone cancer when I was 15 years old, and had my leg amputated above the knee. I wore an artificial leg for a few years, but discovered I can move around faster and easier on crutches than with an artificial leg. I don’t really think of myself as “handicapped” because there’s little I can’t do. I can’t “run” very fast. But, I can ski, swim, roller-blade, ice skate, and ride a tandem bike. I can carry things while walking on crutches, take care of all my household chores, drive, work full-time, and so on.

When I became pregnant with my first, I’d already been an amputee for 11 years, so I was very used to making the physical adaptations I needed to make. So, throughout my pregnancy, I never questioned my ability to handle pregnancy, birth, and caring for a baby. I didn’t know all the exact details of how I would adapt everything, but I had complete confidence I would figure it out. And I did… I’ve now birthed and cared for 3 children – I don’t actually find it that difficult.  (OK, honestly, we all find parenting difficult! I’m just saying that having one leg did not make it particularly more challenging.)

My care providers vs. others:  During my pregnancies, I don’t remember my disability being a big issue for anyone. My care providers never implied that there would be anything especially challenging about my case, which I appreciated.

But that’s not always the case. Once a public health nurse called and asked me to doula for someone delivering at Valley. I told her I didn’t travel that far. But then she told me why she’d called me specifically. The client was a double amputee who used a wheelchair. She had been told that she would need to deliver by cesarean because she was an amputee. I was dumbfounded! It’s not like you need legs to have a vaginal birth. I ended up not assisting that mother because of timing, but I did meet with her and talk to her about her options, and she did end up planning and having a vaginal birth.

What care providers can do:

  • First and foremost: Assume she is capable of pregnancy, birth and baby care. (You may be one of the few who treat her this way.)
  • If you see accommodations that you think could be made, ask her if she would like your help brainstorming how to handle something. If she’s had her handicap for more than a few months, she probably knows a great deal more about her needs than you do. Respect that.
    • For example, I happened to have a dad who was an arm amputee attend a newborn care class I was teaching. I approached him on break, and said “I am wondering if you have any specific questions that are unique to your situation. I don’t know anything about having one arm, but I know a lot about baby care, so if you have things you’re wondering about, maybe you and I can put our knowledge and experience together and brainstorm some kind of solution together.”
    • Once when I attended a prenatal yoga class, the instructor approached me before class, and said “let me know if there’s anything I can do to help you with the exercises.” I told her: “I can usually do a better job than you can of figuring out how to adapt things, but it helps me to know what my goals are. So, when you teach a position, if you can tell me whether the goal is to stretch my hamstring, or stretch my calf muscles, or strengthen my glutes or whatever, that helps me adapt the exercise in a way that reaches that goal.”
  • Don’t “other” someone.  Don’t do things that imply that they are a weird aberration from a normal human being. Examples from my experience:
    • When a caregiver is going to a pelvic exam on me, they always pull out both stirrups as per their usual habit. I like it if they then calmly put one away instead of getting all flustered and awkward when they realize that I don’t have a foot to put in the right side stirrup.
    • When a nurse opened a package of non-slippy socks, I liked that she calmly set one aside on the table, saying “here’s an extra for later”
    • If you make a “mistake”, calmly apologize and move on. Don’t make a big deal of it.
    • If someone gushes over me like “wow! You’re so brave to take this on. If I were handicapped, I would be too afraid to try this,” they may think that’s supportive, but it’s easy for that to come off as “something’s wrong with you. You’re less capable of parenting than other people are.”
  • Be sensitive about their “appliances”. Their wheelchair, hearing aids, glasses – whatever – should be treated with the same respect with which you treat their body.
    • My crutches may seem like inanimate objects to you, but they are an essential part of my independence and mobility. It is VERY important to me that no one take my crutches and move them across the room without my permission. Although I can hop short distances, I can feel “trapped” in place the second my crutches are out of my reach, which can be anxiety inducing.
    • I also wear glasses as I am very near-sighted. I need to know where they are at all times, because when I don’t have them on, I can’t find them! And I feel mentally competent with my glasses on, and severely limited without them.
  • A person with a disability also often has a long history with health care providers and medical institutions. Her experiences may be positive, negative, or a very complex mix.
    • If you sense any defensiveness or animosity toward you, or if she “over-reacts” to a situation, realize there may be a very good reason for her reaction.
    • Respect that she may have some expertise that a non-disabled layperson might not have. For example, I can tell you that I’ve had many I.V’s in my life, and been told by many health care providers that my veins are tiny and tend to roll, and it’s hard to get an I.V. into me. If a patient tells you something like that, respect that. I appreciate when care providers have said “Oh, thanks for letting me know. I’m actually going to ask X to come in and start this I.V. because she’s a wizard at finding a vein.”
    • Ask her: “I’m guessing you’ve had some experience with medical care – tell me what kinds of things you find most helpful or let me know if what I’m doing is not helpful.”
  • Don’t assume that their handicap defines them. Although the fact that I have one leg is certainly the first thing people notice about me, it is only a very small part of all the things that I am.
    • Someone once asked me: “Wouldn’t you have loved to take a childbirth class that was specifically aimed at people with disabilities and that could really focus on your unique needs?” I answered “not really.” Not that I have anything against the idea, but it also didn’t feel like something I needed. When I was pregnant for the first time, my disability was old news. I didn’t need peer support with it. Becoming a parent for the first time was new… I needed support from other expectant parents. Whether they had a disability like me, or liked Broadway musicals like I do, or enjoy Indian food like I do didn’t matter. The key was that they were other first-time parents like me.
    • If there are support services in the community that are unique to specific populations, learn about them! When you have a client that fits that demographic, let them know the resource is out there. But also tell them about all the other support services that might be a good match for them. Don’t assume you know which are the best match. Let them choose the support services that they feel best meet their needs.

 

Decision-Making Values Clarification

In teaching informed decision-making, it’s not just about teaching birth plans, or just teaching key questions. There need to be at least four steps:

  1. Figure out your goals and preferences first (values clarification)
    1a. Choose the care provider and birth place that are most in alignment with your goals, preferences, and unique health needs (caregiver choices)
  2. Articulate those priorities for care providers (birth plan)
  3. Then if an intervention is proposed that is outside your birth plan, gather data on it (key questions).
  4. Then take that information and weigh it against your values to make the decision that is right for you. (informed decision-making)

And teaching these things is not just about Theory – we also have to Practice!

A quick note about step 1a: Ideally, this would always be the process. If I was talking to someone in early pregnancy who hadn’t yet chosen, I would absolutely cover that step. But, in childbirth classes, when I’m speaking to people in their third trimester, that choice was made long ago. So I won’t cover 1a. (But some of the other steps may lead students to question for themselves whether the caregiver choice they made was the right one.)

Let’s look at options for teaching each of those.

1. Values Clarification: The goal is to talk about what they want their birth to look like – what kind of labor support do they want, what are their views on interventions and pain medications, how involved they want to be in decision-making, and generally: what would help this birth be satisfying for them. There are many ways you could do this. I created a worksheet that could be used in class, or as a homework assignment, that would be one way of exploring these questions. The pregnant parent fills out one form with their values, the partner fills out a slightly different form with their values. Then they compare their answers and discuss them. How do they come to have a common vision of their goals and priorities? (And if they can’t, with birth, the pregnant parent’s priorities need to win in the end, so they may need to agree to that.) They can also discuss here whether their caregiver and birthplace share those values. Here’s the Values Clarification worksheet.

1a. Choose the caregivers that match that. (Check out the quiz at the beginning of the Great Starts Guide for one approach to this step.)

2. Articulate those priorities in a birth plan – learn more about what to teach about developing a birth plan. (Or see Pregnancy, Childbirth, and the Newborn for more details on our approach to birth plans.)

3. Key Questions. Here’s what we teach:
Whenever a test or procedure is offered, first ask how urgent / severe the situation is and whether you have time to ask questions, discuss options, and consider the information you’ve learned. Then, ask:

  • Benefits: What’s the problem we’re trying to identify, prevent, or fix? How is the test or procedure done? Will it work?
  • Risks: What are the possible tradeoffs, side effects, or risks for my baby or me? How are they handled?
  • Alternatives: What other options are available? What if I wait? Or do nothing?
  • Next steps: If the procedure doesn’t identify or solve the problem, what will we need to do next?

[Note: here’s a document you can print with questions for informed consent.]

It would be all too easy to stop with the key questions, thinking we’ve done our job, but we just missed they key point of decision making: MAKING THE DECISION!

We need to remind them that although their caregiver is an expert source of information and advice on benefits and risks, that only they can take into account all their goals and priorities and make the choice that is best for them. We also need to acknowledge that sometimes the choice we need to make is NOT something we wanted. But we want parents to feel in retrospect, that the choice they made DID line up with their values, and WAS the best decision available at the time.

4.Teaching Informed Decision-Making. Check out my next post for this one… https://transitiontoparenthood.wordpress.com/2015/07/31/teaching-informed-choice/

New Ways to Talk about Labor Pain V: Research on Effectiveness of 3 Mechanisms

table

In 2012, a new Cochrane review of pain management for women in labor was released. Although it had positive things to say about the non-pharmacological techniques, it also said that research into their efficacy was unclear due to limited evidence…

“WHAT WORKS: Evidence suggests that epidural, combined spinal epidural (CSE) and inhaled analgesia effectively manage pain in labour, but may give rise to adverse effects. … WHAT MAY WORK: There is some evidence to suggest that immersion in water, relaxation, acupuncture, massage and local anaesthetic nerve blocks or non-opioid drugs may improve management of labour pain, with few adverse effects.  Evidence was mainly limited to single trials. …INSUFFICIENT EVIDENCE: There is insufficient evidence to make judgements on whether or not hypnosis, biofeedback, sterile water injection, aromatherapy, TENS, or parenteral opioids are more effective than placebo… Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby, however, their efficacy is unclear, due to limited high quality evidence.”

A 2014 review by Chaillet, et al (Chaillet, et al. (2014) Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2): 122-37. http://www.ncbi.nlm.nih.gov/pubmed/24761801) is a significant addition to the research about non-drug approaches.

Chaillet, et al pooled techniques into three categories. If you’ve read my posts from the past few days, you’ll be familiar with these concepts. Also, see the chart at the top of this post for more information.

  • Gate Control mechanism = apply non-painful stimuli on the painful area. Methods included massage, bath, positions, walking, and birth ball. The theory is that this will block some of the intensity of the pain.
  • Diffuse Noxious Inhibitory Control (counter-irritant) = create pain or discomfort anywhere on the body. Methods included acupressure, acupuncture, TENS, sterile water injections. The theory is that this discomfort causes the body to release endorphins which reduce pain intensity. (Birth combs also fit in this category although they were not included in the research.)
  • Central Nervous System Control (cognitive/support techniques). Methods included  attention focus, education, relaxation, hypnosis, continuous labor support.

By pooling studies together, you get larger sample sizes which increases the statistical significance of the results. Note, all techniques were compared to “usual care” which might have ranged broadly depending on the preparation of the laboring family and the support they were given by caregivers. It is possible that some in the “usual care” groups were also using a variety of coping techniques. So, the true difference between people who use some coping techniques and those who use none may be even greater than these results indicate.

The results of this review were:

  • Gate Control mechanism. Those who used these techniques had lower pain intensity (as predicted), were less likely to use epidural, and needed less Pitocin.
  • Diffuse Noxious Inhibitory Control (counter-irritant). Those who used these techniques had lower pain intensity, were less likely to use epidural, and more satisfied with birth. (Two trials found women felt safer, more relaxed, and more in control.)
  • Central Nervous System Control (cognitive/support techniques) Those who used these techniques were less likely to use epidural, Pitocin, less likely to need instrumental delivery or cesarean, and had a higher satisfaction with birth. The CNSC did not reduce the intensity of the pain so much as they reduced the unpleasantness of the pain. (See more on intensity and unpleasantness here.) So, although labor still hurt a lot, women felt better able to cope – more like they were working with labor pain.

The most effective technique overall was continuous labor support, such as that offered by a doula. The effectiveness of support was already demonstrated in a Cochrane review by Hodnett et al, (Hodnett E, Gates S, et al.. Continuous support for women during in childbirth. Cochrane Database Syst Rev. 2013. CD003766)

The best results in pain coping were from combining the labor support and education which reduce the unpleasantness of pain with gate control or DNIC techniques that reduce the intensity of the pain.

Recommended: be sure to also check out Henci Goer’s discussion of this study on Science and Sensibility.

New Ways to Talk about Labor Pain, IV: Bonapace Method

The Bonapace Method for reducing pain during childbirth can be used instead of, or in conjunction with, a traditional childbirth education class.

This method does not just teach pain coping techniques, but also teaches about the role of labor pain, how pain messages are transmitted in the body, and three mechanisms that help moderate the perception of pain. Those mechanisms are:

Cognitive structuring / central nervous system control (CNSC). Understanding labor pain and progression – what’s happening and why – enhances a sense of self-control. Focusing on something positive (like a self-affirmation) helps with labor pain.

Gate ControlTheory. Non-painful stimulation blocks part of the pain message transmitted by the spinal cord. Note: Bonapace interprets this differently than I have see elsewhere, saying specifically that it is pleasant sensation applied where the pain is located. The description on their website says “To activate this mechanism during childbirth, the fingers must be run lightly over the painful area, particularly during contractions.”

Diffuse Noxious Inhibitory Control (DNIC). (I call this counter-irritation) Creating a second pain elsewhere on the body (i.e. not where you’re already hurting). The brain wants to reduce the pain’s effect on the body as a whole, so releases endorphins to do so. But the sensations near the second pain are still felt because the body is assessing them. (So, under this theory, holding a birth comb tightly causes a release of endorphins which helps with the labor pain, but the user is still aware of the pressure points from the comb on their palm.) In the Bonapace method, sensitive points on the body (trigger areas) are massaged by the partner, causing pain.

In a journal article (“Evaluation of the Bonapace Method: a specific educational intervention to reduce pain during childbirth”, J Pain Res 6: 653-661 at http://www.dovepress.com/articles.php?article_id=14256), Bonapace et al, compare the results of a “traditional childbirth training program” (TCTP) with the Bonapace method. Study participants chose which class to take from these options.

The TCTP was a 4 week class, with a total of 8 hours of class time, started around the 23rd week of pregnancy. It covered A&P of childbirth, exercises, stages of labor, variations, pain meds and newborn care. Relaxation, visualization, massage, and labor positions were not taught. Only breathing techniques were practiced.

The Bonapace class was 4 weeks, 8 hours, starting in the 30th week. The entire program was dedicated to pain management and partner participation. It covered 1) CNSC through breathing, relaxation, and cognitive understanding of labor pain and endorphins, 2) Gate control – non-painful stimuli such as walking and light back massage between contractions, and 3) DNIC where the partner did painful massage of acupuncture triggers points in the lower back, hands, and buttocks.

39 women participated in the full study. In labor, every 15 minutes, participants were asked to rate their pain on two scales: intensity and unpleasantness. (If pain medications were given, they stopped assessing pain after the medication. If that participant had pain scores for two phases of labor, they were kept in the study, if not, they were dropped.

Those who had learned the Bonapace method had an average of 45% less pain intensity and 47% less unpleasantness than those who had received the “traditional” childbirth education. No difference was found in the use of pain medication.

The reduction in intensity of pain was consistent for nulliparous and multiparous parents. On the “unpleasant” ratings, there was a larger reduction in scores for nulliparous than multiparous. This is likely due to anxiety… a nulliparous woman with no birth experience and no training / childbirth preparation is likely to be anxious about labor pain (and, of course, anxiety increases pain). With the TCTP, her anxiety may have been somewhat reduced and thus her pain unpleasantness would be reduced, but with the Bonapace method, her anxiety and thus unpleasantness were much more reduced.

This study indicates that being given information about the physiology of pain, and plenty of education in clear, simple techniques to manage it, has a significant impact on pain intensity and pain coping.