Teaching Normal Birth, Normally

Abstract

Teaching normal-birth Lamaze classes normally involves considering the qualities that make birth normal and structuring classes to embrace those qualities. In this column, teaching strategies are suggested for classes that unfold naturally, free from unnecessary interventions.

I would like to pose a question: “What do normal-birth classes really look like?” They certainly aren't classes based upon the curriculum of the early days that educators wrote and gained approval for from Lamaze faculty. Are they the updated, evidence-based, interactive classes that address the needs of adult learners? Is there something more we should facilitate in our classes to support the tenets of normal birth that we promote and to empower young parents?

Lamaze education was brought to the United States by Marjorie Karmel, who gave birth to her first child in France with Dr. Fernand Lamaze and attended her preparatory classes with Mme. Blanche Cohen. In her book, Thank You, Dr. Lamaze (first published in 1959), Karmel describes her awesome journey from fear to empowerment and how new knowledge moved her birth from darkness to light. Karmel met Elisabeth Bing and, working together, they introduced the Lamaze method to mothers in North America (Hotelling, 2008). This method included a set of breathing tools, relaxation exercises, information, and coaching. Pain was to be avoided or modulated. In later years, childbirth educators added to this method information about Friedman's Curve, medications, cesarean surgery, parenting, and breastfeeding. Fathers were taught to “coach” the mother through birth, and classes were primarily taught in homes.

Lamaze International has always been an organization that values evidence-based practice. Through the years, as the evidence has changed, Lamaze has changed as well. Even before the promotion of normal birth by Lamaze in 2002, Lamaze educators had begun to move farther away from a one-size-fits-all method of childbirth education toward a student-directed curriculum. There is no real “Lamaze Method” today. Preparation focuses on providing parents with information and using teaching styles that maximize internalization of that information. The ultimate goal is a world of confident women choosing normal birth.

As one of the aging Lamaze educators, I remember teaching to parents who sat tailor style (cross-legged) on the floor for much of the class. I would hand out colorful lunch bags to put into their “goodie bags,” so that when they hyperventilated from the breathing techniques I demonstrated, they could recoup some of their carbon dioxide. (I have since heard that a recording of the breathing techniques had been sent from England to the United States, and the speed on replay was a little faster than what was originally recorded.) Our charts were illustrations we could find or personal artwork from private artists we had found to create them. We used colorful poster boards and sealed them with contact paper. Our information was validated when professional charts were created. For early labor, I handed each mother a charting record decorated at the top with babies' faces. During early labor, the mother was instructed to write down each contraction's start-and-stop time so that she wouldn't miss knowing when to go to the hospital. I showed videos that demonstrated the father's participation at birth, the mother moving through the stages and phases of labor, and, of course, the stretching of the perineum. I wasn't a bad teacher. In fact, my teaching had been observed by several educators before I became Lamaze-certified. What I didn't have then was the knowledge of normal birth and labor support that came later when wise birth advocates brought forth information from midwives and doulas.

At this time in my teaching, the world's finest educators have mentored me. Lamaze continually updates its programs to provide me with evidence about normal birth and more appropriate adult-education techniques. I have taught all but 3 years independently. Inspired by other educators who taught in their homes, I now teach in my living room on high, supportive couches, giving parents healthy snacks and permission to take bathroom breaks according to their own bodily needs. I teach using learning tasks rather than outlines, and the information I present is more parent- than educator-initiated. The few minutes of video I show demonstrate realistic scenes of women and their support people moving through birth in active and supported ways, newborns crawling to the breast, and infants mimicking their parents' smiles and grimaces.

Yet, I wonder if there isn't a higher level of teaching to achieve that will enable parents to trust their innate wisdom and choose normal birth. If we want women to yield to the strength of labor and let nature take its normal course, how do we support that effort? After reading several of my favorite guides to normal birth, I have selected qualities that could provide more empowerment and knowledge of how safe and satisfying normal, undisturbed labor and birth can be. As Cathy Daub, President of Birth Works International, says in her introduction to Michel Odent's (1994) book Birth Reborn:

Michel Odent's challenge, which is the challenge of all birth educators, is how to convince women to climb down from the pillar of technology and begin to believe in themselves and their own ability to give birth without the routine use of technology. (p. x)

PRIVACY

Odent (1994) notes that having a feeling of privacy depends on one's feeling secure and protected. He writes, “Let us recall that the first midwives were substitutes for the mother of the woman in labor, and a mother is, first and foremost, a protective person” (p. xix). As educators, we have traditionally shied away from discussing a woman's choice of caregiver or place of birth. For one thing, most educators are employed by hospitals where referrals to classes come from the resident physicians. Whether or not the educator values the evidence of safe birth in birth centers or in the home, she cannot maintain her job if parents begin choosing providers or places of birth other than those that brought them to the hospital-based class.

Ina May Gaskin (2003) developed Sphincter Law to describe the basic assumptions about the cervix that guide her work as a certified professional midwife. In Ina May's Guide to Childbirth, she explains the sphincters' general functions and properties associated with labor and birth, and she presents the very first basis of Sphincter Law:

Excretory, cervical, and vaginal sphincters function best in an atmosphere of intimacy and privacy—for example, a bathroom with a locking door or a bedroom, where interruption is unlikely or impossible. (p. 170).

According to Gaskin, high levels of adrenalin (stress hormone) actually prevent the opening of sphincters and “function best in an atmosphere of familiarity and privacy” (p. 170). Even when open, sphincters may close suddenly when the laboring mother becomes startled or frightened.

Teaching Strategies

• Although it may be difficult or challenging to introduce choices such as home birth, birth centers, or midwives into class discussion, skillful educators can make this information known. When referring to providers, distributing handouts that include midwives will make midwifery more familiar to parents and invite discussion of the midwifery model of care that can be implemented in hospital settings.

• Giving parents a resource list, including Web sites, for further learning can promote normal birth and offer choices they were not even aware they had.

• Lothian and DeVries (2005) recommend gathering birth stories from women who have experienced normal birth. “The most important thing you should learn is the simple story of normal birth” (p. 94). Birth stories may come from family or friends and can give parents confidence from others who have gone before them. If parents don't have access to women who have given birth at home or with midwives, provide them with a list of mothers who have (with permission, of course).

• Introducing parents to the reality of hospital culture can evolve into a discussion of how mothers might transfer their wishes for familiar sights, sounds, smells, tastes, and touch into their hospital births. They can be empowered to find their own ways to reduce noise, lower the lighting, modify the hurried pace of activity in their rooms, and get adequate nutrition and hydration.

• Take parents back to a time in their life when they were in transition and required support. Ask them to identify how they found their support, what they wanted for support, and how they felt about having support after the transition was complete. Then, ask them to consider what type of support they will need for labor and birth, breastfeeding, and parenting. Give them time in class to develop their own resource list for support during these transition times. Follow up with a list of referrals for support (e.g., doulas, breastfeeding classes, prenatal yoga, a local birth network, etc.).

• Conduct a lively discussion of Gaskin's (2003) Sphincter Law, especially the properties of sphincters. Focus on things that help open the cervix, such as laughter, deep breathing, warm water baths, a relaxed mouth (“horse lips” or “raspberries,” p. 179), and avoiding unnecessary vaginal exams. Include discussion of situations that close the cervical sphincter as part of the natural fight-or-flight response, such as uncompassionate pelvic exams, the presence of a strange person in the birth room, or the unfamiliarity of the environment.

• Compare giving birth with lovemaking. Invite parents to discuss with their partners a delicious setting for lovemaking and, then, ask them to create as much of that same setting as they can in their place of birth.

PATIENCE AND TIME

Friedman's Curve and Active Management of Labor have reversed the age-old method of watchful waiting. One reason why normal labor is not attractive to the television industry is that there is so little trauma and drama that viewers' short attention spans would not tolerate such a seemingly boring production. However, I've often found nurses, medical students, or residents attracted to the normal-birth events going on within the occasional hospital rooms with doula-attended births. The mother creates her private space with low lighting and soft music, and her attendants reflect her activity. Hospital staff members who had been racing around outside the room often lower their voices, slow their footsteps, and relax a little in this comforting environment. No one seems in a hurry, however, when birth takes place at home or in a birth center. The pace and energy are much faster in hospitals, where birth is viewed as pathological, and the sooner the mother and baby are out of danger, the better.

Teaching Strategies

• Although it is important in childbirth classes (unlike birth) to start on time, consider relaxing the pace to reflect the naturalness and ease of birth. Music, soft lighting, pillows and furniture that allow for position changes, a smile, and a soft voice convey to parents that birth is relaxed and not rushed.

• Ask parents to reminisce about a favorite vacation spot and their activities while they were there. Discuss what makes a vacation spot so positively memorable and what they do to create that relaxation. Then, ask them to take those same qualities and apply them to their intended place of birth. Plan with them ways in which they can control the environment in their chosen place of birth.

• Consider what kind of message is conveyed when 6 weeks of classes are compressed into a single day. The pace matches that of the hospital, where progress is timed and efforts are made to produce a product within a predetermined amount of time.

• Reinforce Lamaze's Care Practice #1: Labor Begins on Its Own. In light of today's soaring induction rates, more time will need to be allotted to this topic than in years past. Introduce your class to the amazing symphony of hormones and how their ebb and flow produce just the right amount needed in labor and birth.

FOLLOW THE MOTHER

I live by Phyllis Klaus's words to this very day. She once told a group of birth doulas that our job is to take a woman from where she is and help her get to where she wants to go. Klaus's philosophy also extends to family and friends, and it is useful in teaching Lamaze classes. Yet, many of the mothers who come to class are fearful and want to know how to manage the pain of childbirth until they get their epidural. That doesn't mean that we simply give them a few breathing and relaxation tools and send them on their way. It is important to know where they really are, how they got there, and if they know any other path to birth.

I can't really know what expectant mothers need until I know what they already know and how they learned it. Their mother's experiences of birth are deeply imbedded, and yet, they may not even be aware of the story of their birth. Judith Lothian describes her own family's experiences in sharing birth stories (Lothian & DeVries, 2005). Her grandmother, Nora, learned about birth from her mother, Nellie. “Over time,” Lothian notes, “surrounded by the quiet comfort and encouragement of her mother and sisters, Nora birthed six children in the bed where they were conceived” (p. 89). Yet, birth had changed when Nora's daughter Ruth (Lothian's mother) gave birth:

The birth culture of my mother's childbearing years disconnected her from the birth wisdom of her own family. The lost stories included not just Nora's and Nellie's, but also my mother's own story. My mother never shared her birth stories with me or my sisters. Robbed of consciousness, joy, and the ability to remember her births, she felt she had nothing to share. (p. 89)

Lothian eventually became a nurse. As a nursing student, she attended an unmedicated birth where the woman was supported by her husband. “From that day on,” Lothian claims, “I carried with me the life-changing image of a strong woman laboring and birthing naturally” (p. 89).

Teaching Strategies

• The history of birth in our culture is a valuable one to share with new parents. How can they understand why interventions have risen to an unsafe level unless they experience the story of birth when midwives supported women in their homes? Sharron Gibbs, a Lamaze seminar trainer with Douglas College in Vancouver, British Columbia, Canada, has collected pictures of women in the 1700s, 1800s, and beyond and asks class members to guess what time frame each woman represents. Discussion progresses to what was happening in birth during that time period, what women's lives were like at that time, and how the media portrayed birth.

• As you invite mothers and fathers to learn the stories of their own births, read aloud “Judith's Story of Learning about Birth” from Lothian and DeVries's (2005) The Official Lamaze Guide.

• Use Lamaze's Six Care Practices That Support Normal Birth to evaluate births in the various decades. These care practices serve as an extraordinary measuring tool and flow into the discussion of normal and medicalized births. The general public may think that the opposite of normal birth is abnormal birth. We can empower mothers and fathers more effectively when we honor the value of technology and give it its rightful place in birth.

• As we encourage mothers to move around in labor and birth according to their instincts, we might rethink the physical structure of our classes to value the mother's need to reposition herself. When setting up seating in our classroom, offering a variety of choices will empower mothers and fathers to take control of their own comfort needs. By having nourishment available throughout the class, parents can snack as they need rather than at a formal break time.

WELLNESS AND NORMAL BIRTH

Wellness should be considered when designing our classes. Odent (1994) tells us that “a woman's daily habits have as much influence as her mental attitudes on her experience of giving birth” (p. 21). The actual experience of taking a short walk and feeling better has a stronger impact than simply describing the benefits of walking during pregnancy. Singing and dancing can be joyous ways to move labor along. If we want women to feel secure in adopting these activities during labor, we should provide opportunities in Lamaze class for them to experience such activities. Stress interferes with neonatal development and labor. Exploring ways in which parents already decrease their daily stressors benefits everyone in the class.

SHARE YOUR IDEAS

So much similarity exists between creating a peaceful environment in birth and mirroring that creation in the normal-birth classes we teach. The opportunities are endless. If the suggestions in this column spark some creativity in you, please share your ideas with others by submitting them to The Journal of Perinatal Education. Lothian and DeVries (2005) state that “a normal birth is one that unfolds naturally, free of unnecessary interventions” (p. 1). I invite you to revisit your current classes, consider your interventions, and evaluate them based on how necessary they are.