Nitrous Oxide for Labor Pain

Nitrous oxide (also called “laughing gas” or “gas and air”) has long been in common use for labor pain in other countries, being used by more than half of laboring women in such countries as England, Finland, Sweden, and Canada. It has not been common in the United States in recent decades (it was only available at 5 hospitals in 2012); however, its popularity is now increasing as equipment becomes more widely available, and may soon be seen in more hospitals and out of hospital birth centers. This online article is intended as a supplement to chapter 13 of the 2016 edition of Pregnancy, Childbirth, and the Newborn which does not cover nitrous oxide.

How Administered

Nitrous oxide is a gas. It is mixed 50/50 with oxygen, and inhaled through a mask. (Note: If you’ve had nitrous at the dentist, that’s a 70/30 or 80/20 mixture. So the dose given in labor is lower than the dose at dental procedures, and has a milder effect.) The laboring mother holds the mask to her face whenever she wants a dose. The gas only flows when she inhales. When she moves the mask away, the medication stops. (To see what the equipment looks like in use, do an online image search for “nitrous oxide in labor.”)

The peak pain relief effect kicks in about 50 seconds after you start inhaling. But the peak intensity of contraction pain tends to be 25 – 45 seconds into a contraction. That means you need to start inhaling 30 seconds BEFORE the next contraction is expected so the gas is in full effect when the contraction pain peaks. It can be tricky to get timing just right.

Benefits

Nitrous oxide stimulates the brain to release endorphins and dopamine, hormones that help to reduce pain. Nitrous oxide does not completely relieve labor pain, but women are less bothered by the pain. It reduces anxiety, and can cause a mildly euphoric feeling. Women describe themselves as feeling relaxed and calm while using it. Women report that they liked the fact that they had control over the administration. (To learn more about the laboring person’s experience of nitrous, watch this video from Vanderbilt at https://www.youtube.com/watch?v=lPyuerAoKg8)

Other benefits are that it’s inexpensive (at some hospitals, there’s no extra charge – it’s included in room cost), it takes effect quickly, and if you stop using it, the effects fade quickly (it has a half-life of 3 minutes) rather than remaining in your system for a long time. That means that if you decide nitrous does not provide enough pain relief, it’s easy to move on to other options, such as epidural analgesia.

Effectiveness

One study (Pasha, 2012) found that 92% of women had less pain with nitrous than without. They were also less likely to have severe pain. On nitrous, 41% reported severe pain and 10% reported very severe pain. In the no-nitrous group, 55% had severe pain and 27% had very severe pain.

It’s important to note that nitrous oxide is a mild pain reliever. You should not expect it to take away all your pain. An epidural is much more effective at that; however, an epidural also has more tradeoffs and side effects, so you may choose to start with nitrous and see if that offers enough relief. Some nurses describe the choice to have nitrous as “why not try it and see if it helps.”

Rather than thinking of nitrous as pain relief, it may help to think of it as a ‘coping boost.’ One study showed that it did not reduce the intensity of pain much (as measured on a visual analog pain scale), but after the study period, when given the option to stop using it, women wanted to continue using it anyway. (Carstinou, 1994) The unpleasantness of the pain was reduced, and seemed more manageable. Another study found that 98% of users were satisfied with the experience of using nitrous oxide. (Pasha, 2012) Studies also show that women say they would use it again in a subsequent labor.

Tradeoffs

Unlike epidural analgesia, nitrous does not require extra procedures or extra monitoring. You will not need an IV or continuous fetal monitoring. You are also able to stand, move, and change positions. (If the oxygen comes from a portable tank, you can move around with it, but if the oxygen is piped in from the wall, you’ll need to stay near the bed.)

Possible Side Effects

Side effects on mother and baby are minimal, and less than those experienced with epidural analgesia and with IV / IM narcotics. They can include nausea, dizziness, drowsiness and a hazy memory of events. There is a small chance you could lose consciousness, but if you do, you drop the mask away from your face, and quickly recover. Nitrous does not slow labor and does not affect your ability to push. It does not appear to affect baby at birth. The portable pump is loud, but nurses report this does not seem to bother the user.

Nitrous is contra-indicated if you have persistent anemia / vitamin b12 deficiency.

Timing in Labor

Can be used at any time in labor, except you cannot have nitrous if you have had narcotics in the past two hours. You must wait for them to wear off.

Some cases where it might be especially helpful: during transition, during anxiety provoking procedures (such as vaginal exams, IV starts, stitches for a tear), for women who arrive at the hospital in heavy labor and need quick relief, and at any time by someone who wants to delay getting an epidural. Birth center midwives also report using it when a mom is considering a transfer to the hospital for pain medication. Anecdotally, they say that about half the time it has allowed the client to remain at the birth center.

Comparison to Other Methods

On page 211 – 212 of the book, we offer a chart called “Nonmedicated Labor versus Medicated Labor” that compares what labor is like if no pain medications are used, or if IV narcotics or epidural analgesia are used. Here is that same information for nitrous oxide, so you can easily compare and contrast to the other options.

Pain-Relief Option Used Nitrous Oxide
How it affects your experience of pain Increases pain-relieving endorphins, eases anxiety or fear, and enhances your mood. Small decrease in pain intensity, but makes pain less unpleasant. Can boost your ability to cope.
Feedback from women who used it “Labor was still intense, but it took my fear away and helped me calm down. It made it seem like coping with the pain was doable.”
How it affects your mental state You’re relaxed, calm, may be drowsy or light-headed.
How it affects your mobility You can walk, move around and change positions. If the equipment is hooked up to the wall (rather than being on a mobile cart), you will have to stay close to the bed.
What you’ll need from your support people You’ll still be experiencing pain (though you’ll be less distressed by it). You’ll still want support with comfort techniques and emotional support. Also, they can tell you when a contraction is about to start so you can begin inhaling. (Nitrous oxide is most effective if you start 30 seconds before the contraction.)
Equipment and precautions required You’ll hold the mask that dispenses the nitrous, inhaling from it as desired. Some women need an oxygen sensor on their fingers.
Impact on labor progress Does not affect labor progress.
Timing Can be used at any time, especially during anxiety provoking times in labor.
Availability Very limited availability in the U.S.
Possible risks to you Minimal. (See above.)
Possible risks to baby No apparent risks
Cost Inexpensive
Best option for you if… You just need a little boost to your ability to cope, or need to reduce your anxiety.

For more information:

Source for study data cited: Pasha, et al. Maternal expectations and experiences of labor analgesia with nitrous oxide. Iran Red Crescent Medical Journal, 2012. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3587869/

 

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Labor Hormones in under 10 minutes

Note: this page is about how professionals can TEACH this concept to expectant parents. If you’re an expectant parent looking for info on labor hormones, their effect on labor pain, and what your partner can do to help you have a shorter and less painful labor, click here.

In my childbirth classes, and with doula clients, I want them to understand that our emotions, and the support we receive, absolutely affect labor on a physiological basis, by influencing our hormones. The big message is that fear and anxiety slow labor down and make it more painful. Support and feeling safe make labor faster and easier. I have simplified the complex details into a simple stick figure drawing that takes 5-10 minutes.

Before I talk about my teaching method, let’s start with a basic summary* of hormones

Hormone What Does It Do What doesn’t help What does help
Oxytocin Causes labor contractions that dilate cervix Anxiety, bright lights, feeling observed, feeling judged

Pitocin – if have synthetic oxytocin, make less hormonal oxytocin

To increase oxytocin: Skin-to-skin contact.
Nipple stimulation, making love.To increase endorphins: social contact and support from loved ones.To increase oxytocin and endorphins and to reduce adrenaline: create an environment where we feel private, safe, not judged, loved, respected, protected, free to move about.(So, partners, if you remember nothing else about labor support, remember that if she feels safe, loved and protected her labor will be faster, and less painful)
Endorphins Relieve pain, reduce stress (cause euphoria and feelings of dependency) Stress, lack of support

Narcotics (if you have an external opiate, your body will start producing less internal opiate… even after the narcotics wear off, you’ll have less endorphins)

Catecholamines (adrenaline, etc.) In early / active labor: slow labor down(Imagine a rabbit in a field. If it doesn’t feel safe, it wants to keep baby inside to protect it)

In pushing stage: Make you and baby alert and ready for birth, give you energy to push quickly.
(If the rabbit is about to have a baby, and something frightens it, it wants to get the baby out as quickly as possible so it can pick it up and run with it.)

Stress / anxiety / fear

Lack of control

Feeling trapped

Hunger, cold

 

So, in class how do I convey these ideas in just a few minutes, so it’s easy to understand and to remember?

First, I say: “In labor, our emotions and our environment effect our hormones. Our hormones have a huge effect on labor. Let’s look at a couple scenarios for labor.” [I draw two stick figures on the board.] “This one is awash in stress hormones which will make labor longer and more painful. Let’s label it adrenaline. This one is under the influence of oxytocin and endorphins. These help the laboring person shift into an altered state where labor pain is milder (less intense and less unpleasant) and also help labor progress more quickly.” [Add labels to drawings, add sad face and smiley face.]

Picture2

Then I say “So, you are all probably familiar with adrenaline. What do we call it? Yes, the fight or flight hormone. This is the idea that if an individual ran into a tiger in the woods, they would choose either to fight it or to run away. Do you know what we call oxytocin? Many call it “collect and protect” or “tend and befriend.” If a tiger is coming into our village, we gather everyone together, because we are safest together.” [I add these labels to my drawing.]  (I sometimes throw in the tidbit here that men who are not dads are more likely to release adrenaline during stressful situations; women and dads are more likely to release oxytocin – it’s the “gather the babies and protect them” response.)

Picture3

“So, what effect do these hormones have?”

“With adrenaline, all your muscles tighten. All your energy goes to your limbs in case you need to fight or run away. So, oxytocin production drops and labor slows down. (It’s hard for your cervix to open when you feel scared…)  You are also more sensitive to pain – this is useful if you’re at risk of injury – your body tells you what to move away from. But, in labor it’s not helpful – it just means labor hurts more!”

“With oxytocin and endorphins all your muscles relax. Energy is sent to the uterus and oxytocin increases. (Oxytocin is often called the love hormone, because it increases when we feel loved, and its peak levels are when we orgasm, when we birth, and when we breastfeed. It’s all about making babies, birthing babies, and feeding babies.) We also get an increased endorphin flow, which makes us less sensitive to pain, can cause euphoria, and can cause feelings of love and dependency in us… “I love you man….””

[As you talk, write the notes, and draw on the figures like this to show effects…]

Picture4

[If you teach the 3R’s method for coping with labor pain – relaxation, rhythm, and ritual, you can also add in here: If you’ve got oxytocin and endorphins flowing, you may also have more rhythm – you may rock, moan or sway rhythmically. If your partner helps to reinforce your ritual, it will help build your oxytocin and endorphins.]

“So, what causes adrenaline rushes? Fear, anxiety, feeling watched or judged, feeling like you have no control over your situation, being hungry or cold.”

“How can we tell a person in labor is rushing adrenaline? They act vigilant or panicky, have lots of muscle tension, and a high pitched voice.”

“What causes oxytocin and endorphins to flow? Feeling safe, loved, protected, having privacy, having support, eye contact, skin-to-skin contact, and love making.”

“How can we tell if someone is in an endorphin / oxytocin high? They seem open and trusting, their muscles are relaxed, and their voices are low-pitched and husky.”

[Add notes about causes and signs to your picture.]

Picture5

“So, partners, what’s the big picture summary?”

“If you remember nothing else from this class, remember this: If a person in labor feels safe, loved, and supported, her labor will be faster and less painful. If in doubt about what to do, always return to this! Anything that helps her relax, gain her rhythm and feel cared for will help her.”

More Info

* If you want a great overview of hormones in labor, read Pathways to Birth. If you want all the details on hormones in labor, read Hormonal Physiology of Childbearing. You can find them both at: http://transform.childbirthconnection.org/reports/physiology/.

To read more of my blog for childbirth educators and doulas, click here. For lots of ideas for interactive activities for childbirth education classes, click here. To learn more about any topic related to the perinatal period, check out our book Pregnancy, Childbirth, and the Newborn: The Complete Guide.

Pain Med Preferences

In classes, we talk about the Pain Medication Preference Scale from Pregnancy, Childbirth, and the Newborn. We have the expectant parents look at it together, and then encourage the pregnant parent to choose the number that best represents their preferences, and the support partner to choose what they WISH the pregnant parent would choose.

Then we have them discuss. Often they align, but not always. Sometimes there is a pregnant parent who is hoping for an un-medicated labor who has a partner who can’t bear the idea of seeing them in pain. Sometimes a pregnant parent wants medication, but the partner has concerns about side effects on them or the baby. I would much rather this issue come up during pregnancy when they can resolve it rather than arising without warning in labor.

I have designed a new worksheet that asks more questions about labor coping preferences that they can fill out separately, then discuss, to further illuminate these issues and enhance the discussion they can have about goals and preferences before labor begins. You can see the Pain Preferences Worksheet here – feel free to print and use in class.

New Ways to Talk about Labor Pain III: Diffuse Noxious Inhibitory Control

Diffuse Noxious Inhibitory Control (DNIC) is one of the mechanisms we can use for managing pain. That name is a mouthful, so I call these counter-irritants. (Read my post on birth combs as a DNIC tool here.) The principle is that if a laboring mom adds a pain or discomfort on her body during a contraction (like biting her lip, pressing her fingernails into her palm, or putting ice on her back), that helps to distract her brain from the pain. TENS, sterile water injections, acupressure, and birth combs are all DNIC tools for labor.

One theory for why these are effective is that the pain from these sensations causes a release of endorphins, endogenous opiates that help to reduce our perception of pain.

Another has to do with how the brain processes stimuli coming in on various pathways. (This is similar to the Gate Control mechanism of pain, which says that when we provide stimuli on fast-moving nerve pathways – like through sound, smell, touch with our sensitive fingers and toes – then those block some of the pain coming in on slower pathways – like labor pain.)

Chaillet, et al says that DNIC primarily reduce the intensity of pain. I believe that they can also help to reduce the unpleasantness of the pain. (see my post here for the difference between the intensity of pain and the unpleasantness of pain.) If mom is in control of the counter-irritant, it may give her more of a sense of control over the labor pain. She may feel like she can’t escape the labor pain (it’s highly “unpleasant”) but that she could stop biting her lip anytime she wants… being in control of something is better than feeling totally out of control. It’s one way of “working with labor pain.”

In childbirth classes, we can talk about counter-irritants by suggesting options to the pregnant parent (ice, squeezing something, TENS). We can use the concept to better explain sterile water injections (some parents are mis-educated in advance, and think that the injections themselves relieve pain… they’re shocked at how much the injections hurt! So, we want to explain in advance that they do hurt… like a bee sting… and that’s the idea, because they trigger an endorphin release.

In classes, we can also let the support person know that some people in labor develop a spontaneous ritual where they are causing pain to themselves (like pulling their hair)… help the partner understand that the person in labor is looking for counter-irritant – an uncomfortable sensation to distract her from the pain, and they can help her find one that gives that counter-stimulation but doesn’t harm her (like squeezing birth combs).

In the Bonapace method (I’ll post on that tomorrow), the DNIC mechanism that is taught is for the partner to do painful pressure on acupuncture trigger points. I personally prefer using only counter-irritant techniques that the person in labor applies and controls. I personally don’t like to teach partners to do anything painful to a woman, even if it might have benefit for labor pain. (A licensed massage therapist who has been clearly trained in safe high pressure massage I have no concerns about.) If I were to teach this in a class, I would set clear expectations that the laboring woman controls this firm massage – she asks for it to be done, and if she doesn’t like it, she tells her partner to stop, and her partner should stop.

New Ways to Talk About Pain II – Working with Labor Pain

Many years ago, I created a class I called Working with Labor Pain. I had realized that if women were expecting non-drug comfort techniques to take away their pain like an epidural can, then they would be disappointed. If they imagined that if they used a few deep breathing techniques and some visualization, then labor would be “easy”, they were in for a shock. But, if they understood that the techniques we taught could help them feel like they were working with their pain,  then the pain would feel more manageable. Coping with labor would be hard work, but it didn’t have to be suffering. (See my last post for more on this distinction.)

Nicky Leap, a professor of midwifery at the University of Technology, Sydney, Australia, has done some great writing on this subject.

For her dissertation (Leap N 1996a A Midwifery Perspective on Pain in Labour – described here) she did a literature search on labor pain, including novels, poetry, short stories, plays, biographies, oral history and books on childbirth aimed at pregnant women, and she interviewed 10 midwives. “The midwives described two distinct approaches to pain in labour. I named these the dominant paradigm (or ‘mind set’) of ‘pain relief’ and the paradigm of ‘working with pain.'” The pain relief approach has the goal of reducing pain through medication. It assumes that not offering pain relief in labor is cruel in the days of modern analgesia. Working with pain is based on an understanding that normal pain is part of the process of labor.

Nonpharmacologic should be first method: labor support combined with Gate Control or counter-irritant. If not enough, and woman is suffering, then combine pain meds with nonpharmocologic, especially support.

The midwives felt that in normal labor, pain triggers endorphins that help the women to cope. Pain is an ally which tells women to summon support and find a safe place to give birth. Pain is a signal of labor progress. If a woman is supported through the pain by people who are confident in her ability to cope with it (to work with it), then she has heightened joy at the end of the process from the triumph of walking through that pain. In a normal labor, with safety and support, women aren’t sent more pain than they can handle. (Abnormal pain is associated with abnormal labor that might require intervention and might require pain relief.)

The midwives were concerned that when we offer the full menu of pain relief choices, with the benefits and risks of each method, that we create “a culture where both women and their attendants end up seeing some form of ‘pain relief’ … as a necessary part of the process of giving birth.”

In “Journey to Confidence: women’s experiences of pain in labour and relational continuity of care” (Leap, et al, JMWH 2010), Leap documents interviews with ten women who had midwifery care. They linked their confidence about pain coping to the way their midwives talked about labor pain openly, candidly, and calmly, explaining that it’s not like other pain, and that it’s manageable pain. During labor, when they were feeling overwhelmed, it was helpful reassured by the midwife that although labor was painful, the contractions were bringing the baby down, and being reassured that they could manage the pain. After labor, “women consistently linked their pride about coping with pain to feeling strong and confident and to a positive start to new motherhood.”

In Working with Pain in Labor (Leap, et al. New Digest, 2010) she says that if the pain relief paradigm is applied, then even when women say they hope for a drug-free labor, they may still begin labor with the expectation that they’ll need some form of pain relief. If they have unrealistic expectations about pain, they are not prepared for labor, and if “a woman experiencing normal labour is offered pharmacological pain relief, she will find it irresistible.”

On the other hand, if the caregivers have a philosophy where pain as seen as a normal physiological process, and mothers are given privacy and protection from disturbances, they can go into an altered state where oxytocin and endorphins help them cope.

In childbirth classes, we should think more about how we talk about working with labor pain for a normal labor that’s intense but not unbearably unpleasant versus how we talk about pain relief as a useful tool for any abnormal labor or any point where the pain has become suffering.

In the last edition of Pregnancy, Childbirth, and the Newborn, we added a chart comparing what labor is like without pain medications versus with pain meds. For the 2016 edition, I’m working on a clearer description that the role of pain meds is pain relief and the role of non-pharmacological options is to help us feel like we are working with labor pain and it is manageable and we can triumph over it.

New Ways to Talk about Labor Pain, 1: Intensity &Unpleasantness

scales

Melzack and Casey* described multiple components of pain:

  • Intensity (they called it sensory-discriminitive): how intense it is, the quality of pain and where it is located – more objective
  • Unpleasantness (motivational-affective): are you suffering and how badly do you want to escape from the pain – more subjective
  • Interpretation (cognitive-evaluation): how intense and unpleasant a pain seems to us is influenced by things like our cultural beliefs and whether we believe the pain to be a sign that “something must be really wrong”

In our book, Pregnancy, Childbirth, and the Newborn, we discuss the difference between pain and suffering. You can have pain without suffering – ask anyone who has run a marathon or climbed a mountain…. it’s hard, grueling effort, but they feel utterly exhilarated when they reach their goal. You can have suffering without physical pain, such as that experienced with grief over a loss or betrayal by someone you had trusted. Suffering can be eased with support or worsened through isolation.

So, some women in labor have very intense pain, but it’s low in “unpleasantness” – they’re not suffering if they feel like they are working with their labor pain and they have the support they need to meet the challenge.

We offer in our book the illustrations shown at the top of this page. The pain intensity scale is often used in hospitals for post-operative patients to determine whether they have sufficient pain medications or need more. We encourage women that if they are asked to rate pain intensity, they do so. But then they can offer a second rating – on unpleasantness – how hard they are struggling vs. how well are they coping. A rating of 0 would mean they were really suffering and felt desperate to escape. But a rating of 7 or 8 acknowledges “yeah, sure it’s unpleasant… but I’m doing OK.”

So a person in labor might rate their intensity very high, but also be high on the pain coping scale. They are working with their labor pain. Another person might not be as high on intensity, but might be very low on the coping scale – they’re suffering, and might choose pain medication to reduce their pain intensity.

Using these terms in our childbirth classes gives people in labor other ways to talk about their pain, and it can also offer reassurance to partners: their support may not be able to reduce the intensity of labor pain, but it can make it much more bearable… much less unpleasant.

* Melzack R, Casey KL. Sensory, motivational, and central control determinants of pain. In: Kenshalo DR, editor. The skin senses. Springfield, IL: Charles C. Thomas; 1968. pp. 423–443.

Grab Bags

Grab bags are a fun and interactive teaching technique that is easily adapted to a wide variety of topics. Basically, you gather up a collection of small items that symbolize each topic you want to cover – you may find these things around your house, in your kid’s toybox, at a Goodwill or a dollar store. Put them in a bag. At class, pass the bag around, and each student takes one (or each couple, depending on how many items there are). They then hold it up to show the other students, and they talk about how they think it relates to the topic, and you follow up with any additional information or discussion to add some more “meat” to the conversation.

What kinds of topics it works well for:

I use it for places where I have lots of little things I want to talk about that don’t need to come out in any special order… basically, whenever I find myself with a  lecture with 7 or more bullet points, I know that will seem like just an endless jumble of info to my students, so I start thinking about other techniques to use, and this is a great one.

I also find it works well for introducing the awkward topics. During the prenatal wellness section, when discussing all the things students “shouldn’t do”, it’s easy to turn into a nag. Here, when the candy cigarette appears, I “have to” talk about smoking but it  feels less judgmental. During postpartum, when the condom appears, it introduces the topic of sexuality after baby in a gentler way than me announcing “Sex” or writing it on the board.

However, don’t overuse it! I think it would feel gimmicky and tired if you used it multiple times in one series.

Here are examples of topics I have used it for:

Prenatal Wellness Lunchbox: I use one of my daughter’s old lunchboxes to contain this – I think it’s nice for our students to see signs that we are parents – it helps them connect. I fill  it with items that symbolize healthy choices for pregnancy, and not-so-healthy choices.

Sample items: calcium tablets, iron supplements, raisins, protein bar, tuna, caffeinated soda, a prenatal appointment reminder card, flyer for prenatal exercise class, cigarette, alcohol, Tylenol, condom, plastic baggies with “substances” in them. I label them so they know what it’s supposed to represent, and what it really is: “cocaine (baking powder)”, “marijuana (parsley)”, and so on.

Comfort items for labor: When I introduce it, I talk about how every pregnancy book has a list of items you should take to the hospital. But you often don’t need them all. For example, if it says “eye drops” and you don’t own any eye drops, you don’t need to go out and buy them! They’re not one of the comfort items you use in your life. But they are a good reminder to people who wear contacts to consider bringing contact supplies or a pair of glasses if needed. Then I say “So, this bag is just a collection of ideas about what kinds of things people find helpful for comfort in labor. Hold up your item, say how you think it would be useful in labor, and then say whether you think you would find it helpful.”

Sample items: heating pad, ice pack, massage tool, tennis ball, snack (clif bar, peanut butter crackers…), water bottle, CD (note that many students will use their smart-phone for music… the CD is a little dated, but I’m not putting my phone in the bag…), reflexology combs, toothbrush, mints, shorts, sweater, etc.

Postpartum adjustment: items that address physical, emotional, and lifestyle adjustment. Sample items: Maxi pad, peri bottle, tucks pads, stool softeners, condoms, breastmilk pads, kleenex (to symbolize baby blues), phone number for PPMD hotline, alarm clock (to represent sleep / frequent wake-ups), easy-to-eat food, phone to represent reaching out for support, red silk rose to talk about romance / relationship after baby.

A grab bag alternative… If you feel like you’re over-using the grab bag technique, but want some of the same effect, Teri Shilling from Passion for Birth has a postpartum bathrobe, where she fastens all these symbols all over a bathrobe that she wears when she presents this topic. It’s a very entertaining visual aid!

Try some experiments with grab bags. They’re always entertaining!

A note on number of items: My class size can vary from 6 couples to 14 couples. I may have 14 items in a bag. If I have 14 couples, they draw one item per couple. If I have 7 couples, they draw one item per person. But if I have ten couples, then I have two options for how to handle it. Pass the bag around once and have them take one item per couple, then pass it again, asking those who are willing to take a second so we can cover them all. Or, I can edit the bag before passing it around and only include the 10 most important items and put four others away.