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| J Perinat Educ. 2004 Spring; 13(2): 51–56. doi: 10.1624/105812404X109546. | PMCID: PMC1595200 |
Copyright 2004 A Lamaze International Publication Teaching Normal Birth Interactively Barbara A. Hotelling, BSN, CD (DONA), LCCE, FACCE Barbara Hotelling is an independent childbirth educator and doula in Rochester Hills, Michigan. She currently serves as president of Lamaze International and as a faculty member of Lamaze. She has also served as president of Doulas of North America (DONA) and chair of the Coalition for Improving Maternity Services (CIMS). |
Abstract In this column, the author provides examples of teaching strategies that childbirth educators may utilize to illustrate each of the six care practices supported by Lamaze International to promote normal birth: labor begins on its own, freedom of movement throughout labor, continuous labor support, no routine interventions, non-supine (e.g., upright or side-lying) positions for birth, and no separation of mother and baby with unlimited opportunity for breastfeeding. Keywords: childbirth education, teaching strategies, care practices, normal birth |
In today's birth climate of fear and a lack of confidence in one's ability to give birth, educators are faced with a challenging task. Empowering women to trust their inner wisdom and make wise choices in birth is a great accomplishment requiring unique learning tasks. While childbirth educators may have started out teaching to improve satisfaction in women's birth experiences, they must also consider another important aspect, especially when taking into account the unnecessary medicalization in today's birthing environment—safety. Currently, the maternal-infant outcomes in North America are not improving with the increased use of technology. Women's choices in birth are not completely dependent upon childbirth educators' teaching efforts. However, childbirth education classes exert a strong influence on expectant parents' beliefs and actions during birth. Educators need all the help they can get in presenting normal birth to a technological birth culture. When educators use effective learning strategies, expectant parents internalize the information and, thus, learning becomes an optimal experience. This column offers a selection of some of the finest learning tasks related to each of the six care practice papers on normal birth (as published by Lamaze International for the organization's Lamaze Institute for Normal Birth * and presented on pages 6–41 in this issue of the Journal of Perinatal Education). When childbirth educators really want their students to retain important information, they pay close attention to rules that enhance the education of adult learners. Based on adult-learning theory, teaching opportunities are successful when they - address the specific needs of the learner,
- encourage the learner to take responsibility,
- are integrated with the learner's values and prior experiences, and
- shift the focus of attention every 8–10 minutes.
With these rules in mind, I searched for learning tasks that illustrate each of the six papers comprised in Lamaze International's Care Practices that Promote Normal Birth. The following suggestions offer interactive teaching strategies to help childbirth educators empower expectant parents to have the confidence to choose normal birth. |
Care Practice #1: Labor Begins on Its Own Penny's Arrow This learning task affectionately refers to Penny Simkin and colleagues' depiction of changes in the uterus, fetus, mother, membranes, and placenta during the last weeks of pregnancy in preparation for birth ( Simkin, Whalley, & Keppler, 2001). Purpose Provide expectant parents with a demonstration of the normal physiological changes that might not occur if labor is not allowed to begin on its own. Process Give each class member a photocopy of “Penny's Arrow” depicted in Pregnancy, Childbirth, and the Newborn: The Complete Guide—Revised and Updated ( Simkin et al., 2001, p. 132). Instruct students to fold the paper once at any place, top to bottom—but they may not fold it halfway. After folding and reopening their papers, tell parents to pretend that induction was begun at the fold in their paper. Ask them to describe the importance of all the developments to the right of the fold. Help encourage group discussion on the advantages of allowing labor to begin normally. Payoff Parents will understand that the woman's body is designed to progress gradually in preparation for birth. They will learn how tradeoffs disrupt and disturb the birth's natural process. |
Care Practice #2: Freedom of Movement throughout Labor Ann Tumblin, a Lamaze Certified Childbirth Educator in North Carolina, lives in basketball country and offers this learning task. Purpose Demonstrate the usefulness of upright positions in labor and birth. Process You'll need a hand-sized basketball and a model of a woman's pelvis for this activity. Hold out the model pelvis and ask for a volunteer to sink a shot with the basketball. As the volunteer lines up for a shot, ask him/her if he/she wants the pelvis tilted backwards (as if the birthing mother were on her back) or forward (as if the birthing mother were upright). Once the shooter has asked for the pelvis to be tilted forward, ask why he/she chose this position and compare the ease of the shot with choosing a more comfortable position for birth. Payoff Parents will gain more understanding of the usefulness of upright positions for labor and birth. |
Care Practice #3: Continuous Labor Support Deserted Island This delightful teaching strategy is one of many creative learning tasks found in Teri Shilling's publication, The Idea Box for the Creative and Interactive Childbirth Educator ( Shilling, n.d.-a). For additional teaching ideas, check out Shilling's Staying Energized! More Creative Ideas for the Childbirth Educator ( Shilling, n.d.-b), a supplement to Shilling's first guide. Purpose Reinforce information learned about labor support. Process On a poster board, draw an island with a coconut tree and two stick figures representing a pregnant woman and her partner. Draw waves, a sun, and even add a shark fin. Display the poster in class and describe how the two figures are stranded on a deserted island and the woman begins labor. Ask class participants what the couple can do. Possible answers include using a leaf for fanning, the tree trunk for maintaining an upright position, the shark for fixing on a focal point, coconuts for providing milk and applying massage techniques, the partner's torn and soaked clothing for cool compresses, and sand for molding into an upright chair position. Compliment the group on their creativity and point out that they covered all the key points: position, comfort, massage, and so on. Reassure them they will have many more options than the couple on the deserted island for the labor, but the principle of creativity is the same. Payoff Review of important key points related to labor support. |
Care Practice #4: No Routine Interventions Sometimes, I surprise myself. When recently asked what is so bad about cesarean birth, I replied, “Leader dogs for the blind are a lifesaver to many people, but I don't need one.” Once parents understand that a medication, treatment, or intervention may be an answer to a family's prayers but is not necessary for all births, we will see a decline in the serious side effects of unnecessary medicalized birth. Here are some ways to impart that message to expectant families. The Cascade Effect of Obstetric (OB) Interventions Debby Amis and Jeanne Green (2000) developed this handout that you have permission to reproduce. Purpose Demonstrate to expectant parents how a seemingly noninvasive intervention can affect physical and emotional aspects of labor and, ultimately, lead to an unexpected outcome. Discuss alternatives to these invasive events. Process Give each expectant parent in your class a copy of Amis and Green's (2000) waterfall illustration (see Figure). Encourage class members—either in small groups or in guided discussions—to follow the path of the OB waterfall and name alternative care practices for each labor process that will bring normalcy to the birth (e.g., methods to remain active with continuous fetal heart rate monitoring, ways to decrease anxiety, or reasons for and against artificial rupture of membranes).  | The Cascade Effect of OB Interventions |
Copyright From Amis, D., & Green, J. (2000). Prepared childbirth: The educator's guide. Plano, TX: The Family Way. Reprinted with permission. Based on “The Cascade Effect in the Clinical Care of Patients,” by James W. Mold, MD, and Howard F. Stein, PhD, The New England Journal of Medicine, 314(8) (Feb. 20, 1986), 512–514. Payoff Parents will realize they have more choices than they think, even when their birth preferences seem to dwindle. Informed Consent, Informed Refusal The Maternity Center Association (MCA) included statements on informed consent and informed refusal in its recently released consumer publication, What Every Pregnant Woman Needs to Know About Cesarean Section (2004). Purpose Inform parents of their right to be fully informed of the risks, benefits, and alternatives to any medication, treatment, or intervention and their right to refuse medications, treatments, or interventions after being fully informed. Process Many parents are aware of informed consent, but how many understand the concept of informed refusal? You can offer parents information about their rights by including MCA's statements (see Box) in your handouts and using them to discuss how to negotiate for the birth expectant parents want. Payoff Many parents will benefit from knowing that, with assertive rather than aggressive behavior, they can discuss with their caregivers the medical necessity for interventions and make decisions for themselves. |
Care Practice #5: Non-Supine (e.g., Upright or Side-Lying) Positions for Birth A great learning tool, using only a clear plastic water bottle and a marble. Jan Mallak developed this strategy, which is included in Teri Shilling's publication , The Idea Box for the Creative and Interactive Childbirth Educator ( Shilling, n.d.–a). Purpose Demonstrate the best positions for giving birth. Process Remove the label from a plastic water bottle and insert a marble. Hand the bottle to a volunteer. Ask him/her to hold the bottle horizontally and try to shake out the marble. After shaking the bottle for quite some time, the marble will fly out. Next, ask the volunteer to consider another way to remove the marble without touching it. He/She will turn the bottle upside down and the marble will fall out with ease. Ask the group which position they think would be easiest for giving birth. Box Your Legal Right to “Informed Consent” and “Informed Refusal” What Does It Mean to Give “Informed Consent”? Informed consent is a process to help you decide what will and will not be done to you and your body. In the case of maternity care, informed consent also gives you the authority to decide about care that affects your baby. The purpose of informed consent is to respect your right to self-determination. It empowers you with the authority to decide what options are in the best interest of you and your baby. Your rights to autonomy, to the truth (as best as it can be known at the time), and to keep yourself and your children safe and free of harm are very basic human rights. Whenever a medical procedure, drug, test, or other treatment is offered to you, you have the legal right to “informed consent.” This means your doctor, midwife, or nurse is responsible for explaining: - why this type of care is being offered;
- what it would involve;
- the risks and benefits that are associated with this type of care; and
- alternatives to this care, and their respective risks and benefits.
You have a right to clear and full explanations about your care. You are entitled to get answers to any and all questions that you may have about your care. You are also within your rights to request a copy of your medical records and to get a second opinion. Then, by law, you have the right to decide whether to accept the care that is offered. If you disagree with your caregiver and decide not to accept care that is offered to you, this is called “informed refusal.” And, even if you have made your decision and signed a form agreeing to a particular type of care, you have the right to change your mind. Although these are established legal rights, they have been challenged in a few recent cases that you may have heard about. It can be challenging to carry out the informed consent process in the context of busy health-care routines. Yet you and your caregiver can set aside the time to discuss many of these issues during your pregnancy. You don't want to be learning about these procedures and options for the first time when you're in labor and facing such important decisions. What Happens If My Caregiver and I Disagree? Your caregiver has rights, too. He or she has the right to agree or disagree to provide care that you may request. For example, if you request a cesarean and have no medical need for this procedure, your caregiver has the right to refuse to do the surgery. These issues speak to how important it is to have a good collaborative relationship with your caregiver that includes open communication, mutual respect, and shared points of view. Making a careful choice of a doctor or midwife who respects your needs, values, and goals can help avoid conflict down the road. Talking with Your Caregiver Make a list of your questions before each visit, and take notes on the answers. You may wish to bring your partner or someone else close to you along to listen to what is said. Don't be shy; nothing is off limits. While talking with your caregiver, don't hesitate to say: - I don't understand.
- Please explain this to me.
- What could happen to me or my baby if I do that?
- What are my other options?
- Please show me the research to support what you're recommending.
- Where can I get more information?
- I have some information I'd like to share with you.
- I'm uncomfortable with what you are recommending.
- I'm not ready to make a decision yet.
- I'm thinking about getting a second opinion.
And remember any question that you have is a question worth asking. It's important to let your caregiver know when you don't understand. Ask again, until you do. |
Payoff Parents internalize the demonstration of upright positions for birth and the usefulness of gravity. |
Care Practice #6: No Separation of Mother and Baby with Unlimited Opportunity for Breastfeeding Mother-Baby Intimacy A learning task adapted from “Your Teenager's Game” in Linda Smith's (2002) book, Coach's Notebook: Games and Strategies for Lactation Education. Purpose Demonstrate the importance of keeping the mother and her baby together after birth in order to enhance the development of trust and breastfeeding. Process Form two groups in the class. If possible, each group should include both sexes. Appoint a scribe in each group to record answers to the situation his/her group will be assigned. Direct the first group to list possible ways that intimacy is prevented from developing between two teenagers spending many hours together in one of their homes. Direct the second group to list strategies that may help create intimate moments between two parents who have two toddlers. After they have had a few minutes of brainstorming, ask each group to agree on their top five best answers. List the answers for all to see on a flip chart or poster board. Finally, compare their answers with the postbirth environment. Encourage each couple to include in their birth planning the tools and strategies they will need for promoting mother-baby intimacy following the birth. Payoff Expectant parents decide that activities such as lack of privacy, not being able to have skin-to-skin contact, constant interruptions, and time limits interfere with the intimacy the mother and baby will need to establish trust and successful breastfeeding outcomes. Amazing Talents of the Newborn Parents may accomplish this learning task at home, allowing them time to view and review the incredible video, Amazing Talents of the Newborn ( Johnson & Johnson Pediatric Institute, 1994). Purchasing copies of this video for your class is inexpensive; thus, two copies may be given out each week until all class members have viewed it. Purpose Demonstrate the senses of the newborn, the infant's sleep/wake states, and the importance of recognizing engagement, disengagement, and feeding cues. Process Two families take the video home and bring it back the next week for two other families to take home. When all expectant parents have viewed the video, start a class discussion by asking them what was the most unusual thing they saw the babies do. Payoff Parents learn that infants not only hear and see but also react to their environment. Effective parenting skills are demonstrated by experts simulating positive infant stimulation and quick response to infant crying. Building Confidence I was always looking outside myself for strength and confidence, but it comes from within. It is there all the time. —Anna Freud Believe in yourself! Have faith in your abilities! Without a humble but reasonable confidence in your own powers you cannot be successful or happy. —Norman Vincent Peale Self-confidence is the first requisite to great undertakings. —Samuel Johnson |
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References - Amis, D; Green, J. 2000. Prepared childbirth: The educator's guide. Plano, TX: The Family Way.
- Johnson & Johnson Pediatric Institute (Producer). 1994. Amazing talents of the newborn [Video]. Available from Johnson & Johnson Pediatric Institute ( www.jjpi.com or call, toll free, 1-877-565-5465).
- Maternity Center Association. 2004. What every pregnant woman needs to know about cesarean section. New York: Author.
- Shilling, T. n.d.-a. The idea box for the creative and interactive childbirth educator. Available from the Lamaze International Bookstore and Media Center ( www.lamaze.org, or contact the bookstore, toll-free, at 1-877-952-6293).
- Shilling, T. n.d.-b. Staying energized! More creative ideas for the childbirth educator. Available from Lamaze International Bookstore and Media Center ( www.lamaze.org, or contact the bookstore, toll-free, at 1-877-952-6293).
- Simkin, P; Whalley, J; Keppler, A. 2001. Pregnancy, childbirth, and the newborn: The complete guide—Revised and updated. New York: Meadowbrook Press.
- Smith, L. 2002. Coach's notebook: Games and strategies for lactation education. Sudbury, MA: Jones and Bartlett.
- Robertson, A. 1994. Empowering women: Teaching active birth in the '90s. Sydney, Australia: ACE Graphics.
- Simkin, P. 2001. The birth partner: Everything you need to know to help a woman through childbirth (2nd ed.). Boston: Harvard Common Press.
- Vella, J. 2000. Taking learning to task. San Francisco: Jossey Bass.
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