Continuing Education Module Styles Vary When Teaching Expectant Parents About Medications

Abstract

In this column, the author presents information from prominent Lamaze childbirth educators and from the literature to describe various options that educators can share with expectant parents regarding the use of pain relief medications during labor and birth. Ann Tumblin teaches about epidurals in a hospital class without losing sight of evidence-based practices that support normal birth. Jessica English focuses her classes on the natural processes of giving birth and spends only a little time presenting information about pain medications. Judith Lothian encourages educators to consider a new framework for Lamaze classes that involves letting go of the details and incorporating Lamaze’s six Healthy Birth Practices and storytelling.

Teaching expectant parents about pain relief medications involves more than teaching the benefits, risks, and alternatives of the various pain management options for labor and birth. Lamaze childbirth educators must also consider what each expectant mother’s past experiences with pain have been and what resources she used to cope with that pain. How well does the mother know that her body is designed to give birth? What are the hospital policies that deal with pain management, and do childbirth educators teach hospital policies or offer full, evidence-based information? What are the woman’s partner’s experiences with and beliefs about pain management?

Lamaze International has created a continuing education homestudy based on this article. Visit the Online Education Store at the Lamaze Web site (www.lamaze.org) for detailed instructions regarding completion and submission of this homestudy module for Lamaze contact hours.

Lamaze International’s (2011) Childbirth Educator Program 2011 Study Guide includes the “Checklist for Required Topics in Curriculum Design,” which details topics that should be covered in a Lamaze Certified Childbirth Educator’s (LCCE) class. The topics related to pain medications are not limited to just one section. They are woven into several topics such as evidence-based information about common interventions, pain theories, comfort measures, and the role of pain. The use of pain medications affects labor progress, birth, breastfeeding, and, ultimately, the postpartum period. Medications may interfere with oxytocin production, endorphin release, and fluid retention in the breasts, making it more difficult for the baby to latch.

The use of pain medications affects labor progress, birth, breastfeeding, and, ultimately, the postpartum period.

Few articles in the literature advise childbirth educators on how to teach the topic of the use of pain medications during labor and birth, demonstrating the difficulty educators have in presenting information about pain relief methods. In this article, I offer some resources and call on prominent childbirth educators to share their methods in teaching expectant parents about pain medications.

INTERACTIVE TEACHING

Ann Tumblin, an LCCE educator in North Carolina, teaches parents and trains Lamaze educators both nationally and internationally. She is a master of interactive education and published an article in The Journal of Perinatal Education in 2007 describing how she managed to teach evidence-based, normal birth information in a hospital and, at the same time, adhere to the hospital’s policy to teach about epidurals (Tumblin, 2007). Tumblin was reprimanded by her supervisor because several couples in her childbirth education classes evaluated her as being “biased against epidurals and pain medications” (p. 68). She freely admitted to teaching the whole story about interventions, including harms, benefits, and alternatives. She also realized she had to change her teaching methods to present both evidence-based information and make her message appear unbiased. Tumblin managed to weave the information about pain management during labor and birth into several classes so the parents’ knowledge grew over time instead of in just one event. Here is how she does it.

In the first class, while discussing the discomforts of pregnancy, Tumblin (2007) asks class participants to attempt an exaggerated lateral Sims position to demonstrate a comfortable sleeping position. She also mentions it is a good laboring position if a woman chooses to have an epidural. When discussing “the hormonal orchestration of birth and the powerful endorphins,” Tumblin mentions that “if a woman chooses to use narcotics or an epidural, the medications will reduce or suppress the endorphin production” (p. 69). During her presentation of fetal development and the role of the placenta, Tumblin informs class participants that if “the mother has been avoiding alcohol, over-the-counter medications, caffeine, fish high in mercury, and other potential risks for the baby, the medications given during labor and birth will be transferred to the baby” (p. 69).

When Tumblin (2007) shows birth videos in class, she carefully introduces each birth, stressing the choices the mother has made. For example, when showing the video Everyday Miracles: A Celebration of Birth (Injoy Videos, 2002), Tumblin mentions that the women giving birth in the video choose not to use pain medications. When showing her hospital’s required video segment on epidurals from Works of Wonder, Tumblin calls attention to and discusses the comprehensive list of the side effects of epidurals presented in the video.

For more evidence of the need to improve education regarding the use of pain medications in childbirth, read Hidaka’s and Callister’s report of their qualitative study to describe the birth experiences of women using epidural analgesia, titled “Giving Birth With Epidural Analgesia,” on pages 24–35 in this issue of JPE.

Before conducting her class session on interventions, Tumblin (2007) invites participants to choose an intervention and present the benefits, trade-offs, and alternatives at the next class. In this way, “the participants become the ‘experts’ . . ., and questions are filtered through them” (p. 69). Tumblin finds these presentations by class participants are balanced, and the benefit is that the information is not coming out of her mouth.

If any of her class participants plan to have an epidural, Tumblin (2007) encourages discussion of how mothers “can minimize the trade-offs” (p. 69) by delaying the epidural and choosing a lesser dosage of medication. When she presents the topic of second-stage labor to class participants, Tumblin advises women to push whenever they feel the urge, whether or not they have an epidural.

Focus on the Natural Processes of Giving Birth

Jessica English, who teaches in Michigan, taught Bradley classes before becoming an LCCE educator. She directly addresses pain medications only about 30 minutes out of a 20-hour class. She believes this approach sets the expectation for natural birth; indeed, 90% of women in English’s classes who give birth vaginally actually do have unmedicated births. English described how she introduces and discusses pain medications in her class:

We do talk about the fact that medication can be helpful to maximize the chances of vaginal birth if you have exhausted other options, and we talk about the difference between pain and suffering. But they need to know the trade-offs in order to make an informed choice. Using Penny Simkin’s chart on types of medications and data from www.Childbirthconnection.org as a reference, we discuss the risks of both epidurals and narcotics, and the accoutrements that in particular come along with an epidural (IV, continuous monitoring, bladder catheter, etc.). I speak only to epidurals and narcotics because those are the only medication tools I have ever seen used in my area for a vaginal birth. (J. English, personal communication, September 15, 2011)

English has found other resources helpful in teaching pain management. She uses Penny Simkin’s (2001) Pain Medications Preference Scale and finds her students usually fall between the scores of −5 and −9, with −7 (see Table 1) being the most common score (J. English, personal communication, September 15, 2011).

TABLE 1. Pain Medications Preference Scale.

Rating	Definition
+10	I want to be numb, to get anesthesia before labor begins. [An impossible extreme.]
+9	I have great fear of labor pain, and I believe I cannot cope. I have to depend on the staff to take away my pain.
+7	I want anesthesia as soon in labor as the doctor will allow or before labor becomes painful.
+5	I want epidural anesthesia in active labor (4–5 cm). I am willing to try to cope until then, perhaps with narcotic medications.
+3	I want to use some medication but as little as possible. I plan to use self-help comfort measures for part of labor.
0	I have no opinion or preference. I will wait and see. [A rare attitude among pregnant women.]
−3	I would like to avoid pain medications if I can, but if coping becomes difficult, I’d feel like a “martyr” if I did not get them.
−5	I have a strong desire to avoid pain medications, mainly to avoid the side effects on me, my labor, or my baby. I will accept medications for difficult or long labor.
−7	I have a very strong desire for a natural birth, for personal gratification along with the benefits to my baby and my labor. I will be disappointed if I use medication.
−9	I want medication to be denied by my support team and the staff, even if I beg for it.
−10	I want no medication, even for cesarean surgery. [An impossible extreme.]

Note. Adapted from “Clarifying Your Feelings About Pain and Medications in Childbirth. Pain Medications Preference Scale (PMPS)” by P. Simkin (2001). Retrieved from http://www.childbirthconnection.org/pdfs/PMPS.pdf. Reprinted with permission from Penny Simkin.

Visit the Childbirth Connection Web site for best evidence on labor pain relief options: http://www.Childbirthconnection.org.

English uses the video Dr. Lennart Righard’s Delivery Self-Attachment (Geddes Productions, 1995), a video that emphasizes the importance of minimizing drugs given to a mother in labor and of skin-to-skin contact in establishing easy breastfeeding. Also, English recently found a YouTube video that is helpful in explaining the interventions that accompany epidural use: Doulas and CB Educators: Demonstrating Interventions Used for Epidurals by Janice Banther (2011).

Visit Childbirth Graphics online at http://www.childbirthgraphics.com/storefrontB2CWEB/ or call toll-free (800) 299-3366.

Visual Resources

Simkin (2010) recently released a new slide show entitled “A Guide to Pain Medications for Labor and Birth” that will appeal to educators using PowerPoint slides in their teaching. There are 66 slides available for the educator to use, and these can be obtained from Childbirth Graphics.

Injoy Videos (2011) also has a new two-volume video, Pain Management for Childbirth, that offers information on pain relief methods that childbirth educators can present in class, such as mental and physical comfort techniques (in Volume 1) and the use of analgesics and epidurals (in Volume 2). Injoy Videos has a history of supporting evidence-based care, shared decision making among women and their care providers, and normal, easier birth.

Back to Basics

An article that sums up the concepts of teaching any part of the Lamaze educator curriculum was written by Judith Lothian in 2007 for The Journal of Perinatal Education. In “Selling Normal Birth: Six Ways to Make Birth Easier,” she answers a reader’s question about declining childbirth class attendance and why women are not choosing normal birth in spite of the overwhelming evidence that supports normal birth.

Lothian (2007) tells the story of speaking about The Official Lamaze Guide: Giving Birth with Confidence (Lothian & DeVries, 2010) at a book signing in New York. To entice women to the 1-hour seminar, she entitled her presentation “Five Things You Can Do To Make Your Labor Easier.” A record number of women attended. Lothian talked about the six Lamaze (2009) Healthy Birth Practices that promote, support, and protect natural, safe, and healthy birth. She did not present risks of or indications for medical interventions. From this experience, she advises educators to consider two things: the content and process of childbirth education. She also encourages women to choose a more simple approach to labor and birth, allowing fewer interventions.

“Easy” means different things to different women. Here’s what I suggest we mean (consistent with Webster’s Dictionary): uncomplicated, unproblematic, trouble free, straightforward, simple. Easy does not mean painless, effortless, or undemanding. . . . Easier means fewer complications and interventions for both mother and baby. The key to an easier labor and birth is to let labor and birth unfold in the way nature intended. (Lothian, 2007, p. 45)

Lothian (2007) suggests childbirth educators replace in-depth discussions of stages and phases of labor, medical interventions, hospital policies, and complications with framing classes around Lamaze’s (2009) six Healthy Birth Practices. She writes, “Let go of trying to fit everything in. Women don’t need to know everything about labor and birth” (p. 46).

Lothian (2007) also invites childbirth educators to recall how women traditionally learned about birth and to use those strategies such as storytelling. She suggests, “Storytelling is a powerful way to convey basic information about physiology, coping strategies, and confidence” (p. 46).

“Storytelling is a powerful way to convey basic information about physiology, coping strategies, and confidence.”

The models of teaching from Ann Tumblin and Jessica English reflect Judith Lothian’s wisdom. When Lamaze education began in the 1960s, information about the processes of and choices in childbearing were scant. Now there are many books, videos, YouTube videos, and magazines that give expectant parents the information. In their classes, childbirth educators can add storytelling from friends and family about their experiences with pain medication during labor and birth, allowing educators and their class participants to learn from the wise women who went before them.

Biography

BARBARA A. HOTELLING is the perinatal nurse coordinator for the Maternal and Child Health Program and a nurse practitioner in the Department of Family Medicine at the University of North Carolina School of Medicine in Chapel Hill. She has served as the president of Lamaze International and of DONA International, as well as chair of the Coalition for Improving Maternity Services.