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Controversies in maternal effort during labor and delivery
CONTROVERSIES IN MATERNAL EFFORT DURING LABOR AND DELIVERY*
Elizabeth Noble, R.P.T.
ABSTRACT American prepared childbirth techniques and common obstetrical practices cause women to expend more energy in labor than is necessary or physiological. Alternative approaches to maternal position, controlled breathing, and forced pushing in second
stage are discussed.
INTRODUCTION
Childbirth in the United States is regarded as complex hard work. Parents expend much effort in the preparation for childbirth as well as in the actual delivery. This conviction, that effort is virtue, is itself open to question, as are specific controversies about the roles of position, breathing control, and pushing in maternal effort. Almost all of the childbirth films today reinforce the expectation that birth involves tremendous physical output. Mother is shown panting and straining, coached along by those around her as she labors flat on her back. These American films do not reveal the elements of birth, but instead illustrate the roles and working
* Adaptation of paper originally presented at “Obstetrical Management and Infant Outcome” sponsored by The American Foundation for Maternal and Child Health and The International Childbirth Education Association, New York City, 14 November, 1979. Address correspondence to: Ms. Elizabeth Noble, Maternal & Child Health Center, 2362 Massachusetts Avenue, Cambridge, MA 02140.
Journal of Nurse-Midwifery Copyright
Q 1981, Elizabeth Noble
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interaction of the obstetric team. As such, typical birth films are instructive rather than enlightening and confirm a particular teaching method. Even when labor is progressing smoothly, our attitudes and customs invariably demand undue maternal effort. This does not contribute to the progress of labor and may even make things more difficult. Traditionally, the conduct of labor and delivery in our hospitals involves unnatural positions, controlled breathing, and forced pushing. Such intervention is often encouraged with the best of intentions, but scientific studies are now showing that normal physiology is disturbed. I shall expand on these examples of unnecessary maternal effort and advocate alternative approaches. In our culture, the work ethic pervades even childbirth. We have heard of “Childbirth Without Pain” and “Childbirth Without Fear” but not “Childbirth Without Effort”! After all, the word labor denotes hard work, and fear and pain are still with us. Fear of the pain has led to the adoption of techniques for distraction, disassociation, control, and exertion. The goal of much childbirth
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education is to “stay on top”-of the situation and of the contractions. Mother must shut out internal stimuli and be determined not to “give in” or “lose control.” Social values condone hard work and disapprove of gains that are too easy or rewards that are not well earned. Historically in the United States, proponents of the “awake and aware” childbirth needed to provide a total program of active mastery to substitute for the use of scopolamine and general anesthesia. A “Let go and flow” approach would not have been as acceptable 30 years ago as the “Olympic Games” model adopted instead, which still persists today. AS a result, women continue to be trained with the philosophy of work, control, and achievement. Rehearsed, resolute, and goal-oriented, these couples go into labor as into combat. MATERNAL POSITION Let us look at how maternal position can prolong labor and involve undue maternal effort. This should no longer be a point of controversy due
to the wealth of research that has been available for many years. Yet 13
women continue to labor and deliver flat on their backs, not just in the United States, but all over the world, often as a result of American influence. Women are not usually free to walk around or even change position, particularly with the advent of fetal monitoring and routine intravenous. Confining a pregnant woman on her back puts a strain on the circulatory system as major blood vessels are compressed. Contractions are less efficient, labor is longer, and the mother thus works overtime. Worse is to come in second stage if she remains flat. Then she has to exert herself against the force of gravity and actually push the baby uphill through the pelvic outlet. Maintaining a fixed position, especially an unnatural one, with the legs cramped in stirrups, is fatiguing and uncomfortable. Many researchers, such as Caldeyro-Barcia, l Dunn, 2 Newton, 3 and Humphrey4 have shown that labor is more physiological and contractions more efficient when the mother works with gravity instead of assuming the supine position (Fig. 1). Caldeyro-Barcia showed that labor in a vertical position-that is, the trunk at an angle of about 40 degrees-is shorter and contractions are stronger than if the mother is horizontal. The drive angle of the uterus is wider if the mother is upright, increasing the efficiency of the contractions. Caldeyro-Barcia found a significant association between supine position
Elizabeth Noble,
R.P.T.,
is the author
Essential Exercises for the Childbearing Year and Having
of
Twins and is the director of the Maternal and Child Health Center in Cambridge, OWGYN
MA. She founded
the
Section of the American
Physical Therapy
Association
and is
on the advisory board of the Zntemational Association Protection Nutrition.
14
Childbirth
Education
and the Society for the of the Unborn
through
and forceps delivery. The vertical position, however, did not increase molding of the fetal head. Flynn5 found that ambulation shortened the duration of labor and decreased the need for analgesics and the incidence of fetal heart abnormalities. Apgar scores were greater in the ambulant group; more patients in the recumbent group required augmentation with oxytocic drugs. Ehrstrom,6 who designed a Swedish birth chair, discovered from x-rays of the pelvis that the outlet was increased by up to 1.5 cm in a sitting position.
CONTROLLED RESPIRATION
We have seen that the supine position forces women to operate at a mechanical disadvantage. Now let’s look at the rules and regulations for breathing which further increase the mother’s work load. Breathing is an activity that can be both voluntary and involuntary. Mostly, we never think about this essential life-sustaining activity as the body in its wisdom automatically adjusts the rate or depth. Despite this natural efficiency, most couples learn through childbirth education to adopt artificial breathing patterns. Mothers are encouraged to change breathing levels as labor contractions become more intense. Control of breathing by contrived techniques is taught for its distraction value. Like drugs and medication, control of breathing obviously has its place, such as in hyperventilation or lung disease. Exertive breathing may “work” just fine in a short labor, but it becomes extremely depleting if prolonged. There is an enormous range in one basic feature of breathing-individual respiratory rate. This is a personal and naturally regulated activity depending on body size, position, activity, metabolism, and so on. The average respiratory rate is 16 breaths/min. However, it is interesting to discover your own resting rate. Simply time yourself for 1 min and count the number of breaths, without
altering your speed in any way. The range is between four and twentyfive breaths/min, which is more meaningful to the individual than the average. Recipes for paced respiration rarely take individual variation into account. In pregnancy, many physiological adjustments have occurred in the respiratory and cardiovascular system. Alveolar ventilation, tidal volume, cardiac output, and blood volume are increased, to give just a few examples. The whole system is perfectly designed so that maternal and fetal blood gases are adequately exchanged. It is difficult to understand the justification for altering something as fundamental as normal breathing, especially during the increased metabolic demands that occur in labor. However, true knowledge is what you experience yourself, and is superior to second-hand experience, however enthusiastically it may be promoted. Let’s see what feels better. Quietly observe your breath. Do NOT attempt to control it or to count it. Allow yourself to be quiet, passive, and to feel as if you were being breathed. Just open up and let the air flow in and out. You may even sense a pause between the exhaled and inhaled breath. This is a subjective feeling of a nonactive phase which occurs when the breathing is easy and effortless as in deep relaxation. Now let’s perform some slow deep breathing, typically known as Level One. Deliberately control your breath now, moving your diaphragm consciously. Choose a rate of about 10 breaths/min, which is a cycle every 6 sec. Now stop pacing the respiration. Return to pure observation. Tune in to what is happening with your breath, without doing anything to make it happen. People are usually amazed to feel the amount of effort required in pacing respiration, even at the lowest calmest level with no likelihood of hyperventilation. Control of breathing, of course, becomes
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147 min
(4-10
Propped (>40”)
I
Time cm
dilatation)
Horizontal Contractions are More Efficient in the Propped Position
Intrauterine Pressure
mmHg
Propped
Horizontal
FIGURE 1
Labor is more efficient and comfortable in the upright position. After Caldeyro-Barcia.’ more tiring the longer we have to do it and the more complex the technique. Slow deep breathing does not impair physiology, but any control of respiration expends energy, disrupts body rhythms, and diminishes relaxation. Paced respiration cannot, by definition, be normal breathing. It always involves effort because an involuntary process is being controlled. As long as the breathing is forced or restrained, tension results and the gap between the mind and the body widens. Of course, many childbirth educators have exactly that aim--to direct the mind away from the body. However, this divides the mother’s consciousness of herself and disperses the energy that she needs to .Inm-nnl nf NIww-Mirhiferu
??
Vol. 26.
center on the birth experience. Breathing techniques have been traditionally taught to emphasize the chest component of breathing, for the inexplicable rationale that the “irritable diaphragm must be lifted off the uterus in labor.” However, tense anxious people use the chest rather than the abdomen and diaphragm. Similarly, chest breathing leads to tension and anxiety as well as not permitting adequate exchange of gases in the lungs, as there must be sufficient air intake to traverse the anatomical dead-space. This is why so many women, practicing in childbirth preparation classes, complain “I just feel all out of breath” or “I just have to stop and take in a deep breath”. No. 2. March/Am-i1 1981
Alan Hymes, M.D., writing in the Science of Breath, cites the observation of psychoanalysts that people who restrict the movement of their diaphragm are attempting to isolate feelings of fear and sex, which are associated with lower parts of the body, and thus ty to push these feelings out of awareness. Certainly much of our childbirth education directs the mother outside her body. She is taught to block rather than to receive messages from this controversial pelvic area. Breathing patterns, then, are used to limit feeling and awareness, whereas allowing the breath and energy to flow freely would heighten the parturient’s experience and integrate the functions of her mind and body.
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Instructing a mother to stare at a focal point is another example of needless effort. Aldous Huxley, in his classic, The Art of Seeing, * describes how focusing the vision leads to shallow or suspended breathing, as well as tension around the eyes and psychological strain. It is always fatiguing to repress natural bodily movement, however small. Less effort is required to integrate bodily experiences rather than to suppress them. Yet instead of learning to observe, explore, and open up, mothers learn conditioned responsesnew habits to tack onto old habits. It would seem a good idea to study the effects of normal breathing before deciding to alter it, but like fetal monitoring, usage validated its acceptance prior to a thorough investigation of the benefits and hazards. The few studies that have examined breathing are related to electric shocks rather than childbirth, have conflicting results, or else compare one breathing pattern with another instead of using normal breathing as a control. The difficulty with this is that as soon as you measure and monitor breathing, it is altered and no longer “normal”. One study by Holmes et a1.gfound that control of respiration was least effective in controlling response to the threat of electric shocks. The group that was asked to sit quietly and relax scored best on subjective and objective analysis. The investigators concluded that people find their own ways of coping and that by imagining them to be more helpless than they actually are, we often intervene unnecessarily. Another study by Cohen et al.‘O used a birth film to create a stress situation. They found no change in respiration rate, but increased tension in the respiratoy muscles of the chest, not the abdomen. The exhalation phase was lengthened and the pause shortened. Yet another study by Harris et al., l1 found that pacing the respiration to 8 breaths/min, about half the normal rate, lowered only one measure of
16
autonomic response (the skin) but had no effect on heart rate. So here we have our mother, probably restricted by an IV and electronic fetal monitor, in a horizontal position, changing her breathing levels like gears on a car as she stares and pants through first stage. Usually deprived of nourishment as well, the mother is nearing exhaustion by the time she must perform the greatest work of all: pushing. SECOND STAGE
Not only are women made to push longer and harder than is necessary or good for them, but they are often forced to do so even before the uterus is ready. Ironically, the less the desire to push, the harder the mother is usually encouraged to strain. However, there is often a physiological lull between full dilatation and the establishment of the natural expulsive urge. This interval, seen more in that laboratory of alternatives, homebirth, has been described as a “time of peace.” In the hospital it is usually unobserved because of the preoccupation with haste and “active management”. The expulsive urge begins to be felt as the fetal head descends low enough to stimulate the stretch receptors in the pelvic floor muscles. Stimulation of the pelvic stretch receptors leads to increasing levels of endogenous oxytocin. This neuroendocrine response is known as Ferguson’s reflex. l* Any woman in labor can verify that an artificial rupture of the membranes, manual rotation, or any vaginal examination causes subsequent stronger contractions. Breastfeeding to encourage separation of the placenta is another example of this type of biological phenomenon. Dr. Alois Vasicka, Chief of Obstetrics and Gynecology at North Central Bronx Hospital in New York, has studied the natural increase of plasma oxytocin levels with the progress of labor. Oxytocin levels rise as
the vertex descends in the pelvis, especially after full dilatation of the cervix, and culminates with the greatest peak at crowning. It is thought that higher oxytocin levels are required to maintain uterine contractions as the build-up of lactic acid and carbon dioxide in the myometrium increases with the progress of second stage. Dr. Vasicka found that any form of regional anesthesia, paracervical, epidural, spinal, or pudendal, has the effect of abolishing Ferguson’s reflex. With sensation gone, the stretch receptors are no longer stimulated. Therefore, without the natural expulsive effort of the uterus, mothers often have to force the pushing even harder in compensation and may also require instrumental delivery. Mothers resent having to force pushing before this guiding urge is felt. Imagine if, as you read this, you were forced to move your bowels, in the absence of any internal desire to do so, within the next five minutes. I’m sure you would report an uncomfortable and unnatural experience. Unfortunately, a great many people do force bowel movements with excessive effort and accessory muscles. Thus, it is commonly accepted that the straining required for chronic constipation is the best description and example of how a woman gives birth. Researchers, led notably by Caldeyro-Barcia, are now examining spontaneous pushing efforts for the first time. Pushing, like breathing, has long been directed by others in childbirth before normal parameters were understood. Caldeyro-Barcia13 has recently measured the progressive increase in the work done by the uterus and the abdominals. “Work” is this natural force, measured by amplitude of the contraction and the duration of the effort. For the purposes of analysis, he divided second stage into three phases. By the final phase, the spontaneous pushing efforts of the mothers had increased threefold, as illustrated in Fig. 2.
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300 units Maternal Work (Intrauterine Pressure X
Duration of effort)
End
Beginning Stage II FIGURE 2 Spontaneous pushing Caldeyro-Barcia. ‘:I
Fetal Heart Rate
increase
almost
three-fold
as Stage
II progresses.
After
The women in Caldeyro-Barcia’s study were not directed when and how to push. They simply pushed according to the varying length and intensity of the urges within contractions, and from contraction to contraction. The average number of pushing efforts per contraction was about 4 with an average duration of 5 sec. Average pressure at the top of the efforts was 88, 107 and 119 mmHg in the first, second, and third phases of second stage. The resting interval between spontaneous efforts within one contraction averaged 2 sec. Figure 3 illustrates the fetal monitor tracing for a typical spontaneous pushing contraction. Rest and breathing movements during these intervals minimized the fall in maternal p0, and rise in pC0, during the second stage. Transient Type 1 dips of the fetal heart rate may occur, showing head compres-
200-
160 ’
(Beats/ Min)
Intrauterine Pressure @mHg)
1 10
1
0
I 20
I 30
I 40
I 50
I 60
I 70
I 80
1 90
Seconds FIGURE 3 Spontaneous
pushing
causes
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transient
??
Dips in fetal heart rate. After Caldeyro-Barcia.’
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sion during the expulsive urge, but these are quite benign. No difference in fetal blood values was found between short second stages and those that lasted up to 120 min, nor were there any differences in the Apgar scores. In fact, the average value of fetal p0, (27 mmHg in the umbilical artery and 33 mmHg in the umbilical vein) and pH (7.33 and 7.38) were higher than “normal” values. However, what typically happens in American hospitals during second stage contractions? Mother is ordered to lift both her lower limbs (unless they are confined in stirrups) and her upper trunk, against the force of gravity. Even if she is propped, pulling on her legs tenses her body. The staff usually insist that her breath be held. Indeed, the slightest sound alarms them that air is escaping and the force of the effort is waning. Interrupting the respiration is undesirable, but excessive straining with the breath held has severe cardiovascular effects. This forced effort with a closed glottis is known as the Valsalva maneuver, It was named after an Italian physician in the 17th century who recommended this technique for expelling pus from the middle ear. The danger of the Valsalva maneuver during childbirth is that it is unnecessarily forced in combination with the natural expulsive effort (and, as we have seen, sometimes even in its absence). If straining is prolonged beyond 5 or 6 set, maternal and fetal physiology are disturbed. Figure 4 illustrates the closed pressure system that is formed within the body by the Valsalva maneuver. At the onset of strain, the breath is blocked by closure of the glottis. Initially the blood pressure is greatly raised, but this falls as no venous blood can flow back to the heart against such high intrathoracic pressure. The subsequent fall in cardiac output obviously affects circulation to the entire body, and significantly, to the placenta. Pooling of blood in the pelvis and legs also predisposes to varicosities. 18
FIGURE 4
“Blocking” the breath produces a closed pressure system. Abdominal muscles and pelvic structures undergo unnecessary
strain during the Valsalva maneuver.
The high pressure is transmitted, hydraulically according to Pascal’s law, throughout the body fluids. Tissues are strained, such as the pelvic floor and the rectus sheath where the abdominal muscles unite (and sometimes separate) in the midline. Bas-
Journal of Nurse-Midwifery
majian’s studies, described in Musc/es Alive: Their Functions Revealed by Electromyography14 confirmed that the pelvic floor muscles tense protectively when subjected to strain from above. Caldeyro-Barcia associates forced straining with the
??
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Fetal Heart Rate (Beats/ Min)
Intrauterine Pressure (mmHg)
Maternal Blood Pressure CmmHg)
FIGURE 5 Forced pushing leads to fetal hypoxia. After Caldeyro-Barcia. ’
need for episiotomy, as there is insufficient time and relaxation for the perineum to distend adequately. A breaking point is reached when the Valsalva maneuver activates reflexes involving the respiratory center in the medulla and the pressure receptors in the aorta. The victim now gasps, and a subsequent imbalance of pressure through the various systems of the body occurs which can be harmful. Abnormal EEG and ECG changes have been measured, and of course, geriatric patients have even died straining on the bedpan. Tests measuring the effects of the Valsalva maneuver are usually done on young males performing handgrip tests for just a few seconds-much less exertion than our childbearing women must display! And quite a display it is-purple
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face, bloodshot eyes, burst capillaries. Unconcerned, the maternity staff usually assemble like a cheering squad. Exhorting the mother to push, push, push, they then often command this flexed ball of tension to RELAX! This is clearly difficult if her hands are clenched and eyes tightly closed! At best, they encourage her to selectively relax the pelvic floor, which we have seen is impossible. Figure 5 illustrates CaldeyroBarcia’s research on the effects of the Valsalva maneuver during childbirth. Pushing efforts that are directed by the attendant are always longer than those spontaneously elicited from the mother. The amplitude of the effort is over 100 mmHg, which is why the peaks were not recorded on the standard monitoring apparatus. One bearing-down effort almost lasted 20
Vol. 26, No. 2, March/April 1981
sec. Maternal blood pressure, measured in the femoral artery, fell to about 70/50 mmHg. The greatly reduced blood flow to the placenta is reflected in the fetal heart tracing. After the end of the contraction, the fetal heart rate, originally about 160 beats/min falls to between 100 and 130 beats/min and the drop lasts longer after the contraction. This is considered a prolonged late deceleration, a Type II dip, associated with uteroplacental insufficiency resulting in fetal hypoxia, acidosis, low Apgar scores and cesarean section. Clearly, second stage conducted in this manner has been limited to 1% to 2 hr for good reason. Could mother and fetus stand much more of the stress and strain of prolonged Valsalva maneuvers?
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RECOMMENDATIONS FOR AN ALTERNATIVE APPROACH TO CHILDBIRTH
Nurse-midwives are usually concerned with the level of interference in the natural process of birth and are committed to understanding and respecting normal physiology. We have seen that maternal effort is increased by immobility, paced respiration, and straining with the breath held. How then, do we reduce undue exertion and replace contrived techniques with physiological alternatives? Think how much pressure can be taken off the birthing couple if they learn observation of the natural process rather than control of labor. To forget about staying on top of the increasingly difficult contractions and to spontaneously flow with the process. Trusting in their bodies, mothers would not have to ask those two quesions commonly reported by maternity staff, “Am I doing it right?” and “What should I do next?’ As well as trying to “control” their labor, these couples are also concerned with their performance and self-control. Feldenkrais, in his book Awareness Through Movement, l5 describes how goal-oriented activity and expectations increase effort and reduce sensitivity and awareness. If you are concerned with the next step, you automatically tense towards that future accomplishment. Past experience, on the other hand, is the basis of our beliefs and values. Fixing on the past, however, involves fear that the future experience may not be compatible and thus a defensive reaction occurs. Letting go frees you to experience the present, without regard to the past or future. Of course, there is always the question of pain. Nobody denies pain in childbirth. The question is rather how to approach it-with effort and blocking or with acceptance and understanding. Also, how much pain during labor is due to tension and resistance induced in the body through artificial techniques and the fatigue they cause? 20
How can midwives and childbirth educators help couples value their own first-hand experience and discover the potential in their minds and bodies? Our students need to develop confidence so they can open up to learning about themselves rather than learning what we want to teach them with all the charts and formulas we hand out in class. I believe we should help them observe and interpret messages from their bodies, rather than to control or disregard them. Initially, marathon runners practice disassociation, but they soon discover its limitations, according to an article in Psychology Today. I7 The winners turn instead to associating, receiving signs from the whole body and making necessary adjustments as they run. The philosophy behind childbirth preparation is more significant than the techniques, but a few approaches to help “letting go” can be reviewed. Nostril discrimination is an interesting experiment to improve observation skills. If any of you were asked what your left and right arms were doing, you would be embarassed if you couldn’t reply. Yet despite the significance of breath, most people are unaware that air flow alternates between the nostrils and could not tell you, without practice, which nostril was open at this time. This natural biological rhythm is regulated by erectile tissue in the lining of the nose and relates to one’s state of physical and psychological health. An observation exercise that is useful for parents is to become aware of the air flowing through one’s nostrils. Observe if the left, right, or (rarely) both nostrils are open. This experience is next extended to include awareness of the natural breathing movements of the chest and abdomen. Couples, by alternating controlled breathing patterns with observation of the breath, can experience the comparison for themselves. The great majority prefer to let the breath flow at its natural rhythm, but there are always some people who prefer control, who are
comfortable “doing” rather than “being”. Simple stretching exercises, especially those that involve the hamstrings, can be used to help cope with pain. Extending the body’s habitual postures in a variety of positions will meet with resistance, which is one of the edges of pain. Forcing and determination will set you back. But focusing directly on the edges of the pain, integrating your breathing so that you relax and move info the pain actually disperses it. A great deal of physical resistance has mental origins and thus reorganization within the nervous system is required. Experiments with visualiiation bear testimony to this, whether they involve turning a breech or curing cancer. Feldenkrais15 describes how a class can spend hours physically achieving a certain posture, whereas if they repeat the activity only in their imagination on the opposite side, the same results are achieved within minutes. Commitment to early preparation during pregnancy allows women to bond with their bodies. With the foundations secure, they can more easily trust in the natural functions of labor and thus let go at the time of birth. In order to help mothers experience their labors as deeply as possible, childbirth educators need to give less not more. After all, the experience of birth is intensely private and never duplicated even in the same woman. In our dedication, we never consider that our good intentions could be interventions. We want to pass on all the tools, goodies, options, choices, rights, and responsibilities that we learn about. Classes become more complex, paralleling the handling of birth as a high-risk technological event. Childbirth educators themselves are going through an endless proliferation of classes, workshops, examinations, certification, and recertification procedures. Politics emerge, with each professional group setting up barriers to entry, protecting their own turf, whatever their method. The philosophical
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question, of course, is how can there be a method for childbirth? Let us now pass over the preparation for first stage and examine the physiology of second stage. How can we modify energy output and encourage a more comfortable delivery in line with natural forces? Firstly, the mother should not have to push before the expulsive urge is well established. She should push only when it is irresistible. Until that time her effort is wasted. Some women have a Z-hr second stage or even longer, but perhaps give only a few good grunts at the end. Women’s labors, it seems, never go fast enough for the accoucheur and the criteria are getting stricter all the time. The Friedman curve is an average; that is, as many women have long labors to the right of the curve as have short labors to the left. Yet women’s labors and their so-called deviations are plotted according to this “mythical” average. The Chinese have a simpler system. According to the Barefoot Doctor’s Manual, l7 there are just two stages of labor. The first ends with the birth of the baby and the second with the expulsion of the placenta. Our standard time divisions in labor create their own added stress, often setting up self-fulfilling prophesies, such as the stormy time in “transition” and a premature urge to push. In the United States, each stage of labor has its own drama and each drama is acted on a separate stage. Many women fritter their valuable energy as they are admitted in one area, labor in another, deliver in a third, and recover in a fourth! A senior midwife once commented that you can’t teach a woman how to push anymore than you can teach someone how to have an orgasm (or any other reflex activity). The body knows what to do. We mush help women feel free to do what feels right. Vocalization must be approved and encouraged. This includes grunting, groaning, moaning, roaring, whatever. For some women this is a valid expression of accomplish-
Journal of Nurse-Midwifery
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ment as well as a physiological response. Partial closure of the glottis, which results in the characteristic noises of second stage, recruits the abdominals in their role as the muscles of forced exhalation. Exhalation is the natural relaxation component of the respiratory cycle. Exertion, whether in exercise, karate, weight-lifting or childbirth, is performed on the outward breath. This allows the muscles to contract efficiently, by shortening, as toothpaste is squeezed from a tube by an increase in pressure due to a decrease in volume. Contrast this with the Valsalva Maneuver. Place your hands on your abdomen and hold your breath. Now strain, keeping the glottis closed and feel the abdominal wall move out. The muscles tighten isometrically but the wall bulges away from the uterus, displaced by the descent of the diaphragm. The analogy here is that of a balloon-an increase in pressure due to an increase in volume. Now leave one hand on your abdomen and make a fist with the other. Blow hard into your fist as if you were blowing a trumpet. Your other hand will feel the active abdominal muscle contraction. You will note there is no strain on the pelvic floor as the pressure is released from above instead of being directed below as in forceful straining. Any maternal effort then, is directed to the abdominal muscles while the rest of the body remains uninvolved and relaxed. Permitting mothers to birth with ease and dignity can be simple. The key is letting go, the opposite of control. After all, in a normal unmedicated unanesthetized birth, the uterus knows best. Tension, effort, fight, and flight all have their uses in daily life. However, during birth, the mother can best help by simply allowing it to happen. Coaching from outside, particularly with a stopwatch, cannot be based on direct experience and furthermore distracts the mother from what is happening within. Effort and resistance increase
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if the mother tries to control the dynamics of birth. Unnecessary muscle work reduces sensitivity, which in turn requires that a greater exertion be used to accomplish the result. This further reduces sensitivity and a vicious circle develops as one needs greater effort to maintain control. Learning to let go has benefits reaching beyond the childbearing year. Much therapy today deals with insomnia, sexual dysfunction, anxiety, and stress. Interestingly, all these problems share the same common solution-letting go. You cannot master your response in these situations by control because we are dealing with the law of reversed effort. If you ty to fall asleep, ty to have an orgasm, ty to relax, ty to remember the word that is on the tip of your tongue-you move backward not forward. Such analogies are more appropriate to the birth experience than is constipation, although bowel movements are a biological function that you need only allow to happen, without forcing. You cannot make yourself relax-it happens indirectly as the mind is quieted. Even direct “conscious release” is not physiologically possible as there are no nerve endings in muscles that convey the state of muscle tension to the cerebral cortex. The mind works within fixed habits, and we expand our awareness by sensorimotor experience. Progress is made by trying not to try, by gaining awareness through experience, and by trusting the body. We have considered our common cultural approaches to childbirth and the effort and potential hazards involved. Individually, each may not always be serious, but their adverse effects can be cumulative. Similarly, Caldeyro-Barcia found that the excellent outcome of his studies of spontaneous birth were not related to just one particular modification. The unforced pushing efforts of short duration, avoiding the Valsalva maneuver, and allowing ventilation of the lungs between pushes is common sense. The sitting position and the spontaneous rupture of the
21
membranes also enhance the natural process. The women in his study had no artificial rupture of the membranes, sedatives, analgesics, anesthesia, or oxytocin which is also significant. All of us involved with birth should review our philosophy of birth. It is not enough to make a few piecemeal changes. We need a total holistic approach. It is essential that we too learn how to let go. To feel free to move ahead rather than to defend our past practices. Clinging to any method impairs our ability to recognize and promote the physiology and individuality of birth. By reducing our own effort and intervention, we will also make birth safer, easier and more enjoyable for our couples. REFERENCES 1. Caldeyro-Barcia R: The influence of maternal position on labor, and the influence of maternal bearing-down efforts in the second stage of labor on fetal wellbeing. in Kaleidoscope of Childbearing: Preparation, Birth and Nurturing, (eds., Simkin P and Reinke C) Seattle, Pennypress, 1978.
in fetal pH during the second stage of labour when conducted in the dorsal position. J Obstet Gynaecol Brit Commonwealth 81:600, 1974. 5. Flynn AM, Kelly J, Hollins G, Lynch PF: Ambulation in labour: Brit Med J 2:591-3, 1978. 6. Ehrstrom C: “Forlossingstolar” Reprint from Recip Reflex (13/72, 1973) cited in Kirchoff, H, “The woman’s posture during childbirth,” Organorama 14:1, 1977, Organon Nederland, Oss. The Netherlands. 7. Swami Rama, BaIIentine R, Hymes A: Science of Breath: A practical guide. Honesdale, PA, Himalayan Institute of Yoga Science and Philosophy, 1979. 8. Huxley A: The Art of Seeing, 1975 ed. Seattle, Montana Books, ~19. 9. Holmes DS, McCaul KD, Solomon S: Control of respiration as a means of controlling responses to threat” J Personality Social Psycho1 36:2, 198-204, 1978. 10. Cohen HD, Goodenough D, Witkin HA, Oltman P, Gould H, Shulman E: The effects of stress on components of the respiratory cycle Psychophysiology 12:4, 1975.
2. Dunn P: “Obstetric delivery today: for better or for worse?” Lancet 1, 79631790-93, 1976.
11. Harris C, Katkin E, Lick J, Habberfield T: Paced respiration as a technique for the modification of autonomic response to stress: Psychophysiology 13:5, 1976.
3 Newton M, Newton N: The propped position for the second stage of labor. Obstel Gynecol 15( 1):28-34, 1960.
12. Ferguson JKW “A study of the motility of the intact uterus at term” Surgery, Gynecol, Obstet 73:359-66, 1941.
4. Humphrey MD, Change A, Wood EC, Morgan S, Hounslow D: A decrease
13. Starch
22
Caldeyro-Barcia R, Giussi G, E, Poseiro JJ, Laufaurie N, Ket-
tenhuber K, Ballejo G: The bearing down efforts and their effects on fetal heart rate, oxygenation and acid base balance. Presented at the 1st International Berlin Meeting of Perinatal Medicine, June 1516, 1979. Berlin. 14. Basmajian JV: Muscles Alive: Their functions as revealed by electromyography. 3rd ed. Baltimore, Williams and Wilkins, 1974. 15. Feldenkrais M: Awareness Through Movement, New York, Harper and Row, 1972. 16. Morgan marathoners” 1978.
W: “The mind of the Psycho1 Today, April
17. A Barefoot Doctor’s Manual: A Guide to Traditional Chinese and Modern Medicine. Prepared by the Revolutionary Health Care Committee of Hunan Province, Mayne Isle and Seattle, Cloudburst press, 1977. BIBLIOGRAPHY Caldeyro-Barcia R: “Physiological and psychological bases for the modem and humanized management of normal at the International labor”, presented Year of the Child Commemorative International Congress Tokyo, Japan, 21 and 22 October 1979. Noble E: Essential Exercises for the Childbearing Year, Boston Houghton Mifflin, 1976. Noble E: Respiratory considerations for childbirth. and Rationale for prenatal and postpartum exercises. in Kaleidoscope of Childbearing-Preparation, Birth and Nurturing, (Eds. Simkin P and Reinke C Seattle, Pennypress, 1978.
Journal of Nurse-Midwifery
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Vol. 26, No. 2. March/April 1981
Elizabeth Noble, R.P.T.
ABSTRACT American prepared childbirth techniques and common obstetrical practices cause women to expend more energy in labor than is necessary or physiological. Alternative approaches to maternal position, controlled breathing, and forced pushing in second
stage are discussed.
INTRODUCTION
Childbirth in the United States is regarded as complex hard work. Parents expend much effort in the preparation for childbirth as well as in the actual delivery. This conviction, that effort is virtue, is itself open to question, as are specific controversies about the roles of position, breathing control, and pushing in maternal effort. Almost all of the childbirth films today reinforce the expectation that birth involves tremendous physical output. Mother is shown panting and straining, coached along by those around her as she labors flat on her back. These American films do not reveal the elements of birth, but instead illustrate the roles and working
* Adaptation of paper originally presented at “Obstetrical Management and Infant Outcome” sponsored by The American Foundation for Maternal and Child Health and The International Childbirth Education Association, New York City, 14 November, 1979. Address correspondence to: Ms. Elizabeth Noble, Maternal & Child Health Center, 2362 Massachusetts Avenue, Cambridge, MA 02140.
Journal of Nurse-Midwifery Copyright
Q 1981, Elizabeth Noble
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interaction of the obstetric team. As such, typical birth films are instructive rather than enlightening and confirm a particular teaching method. Even when labor is progressing smoothly, our attitudes and customs invariably demand undue maternal effort. This does not contribute to the progress of labor and may even make things more difficult. Traditionally, the conduct of labor and delivery in our hospitals involves unnatural positions, controlled breathing, and forced pushing. Such intervention is often encouraged with the best of intentions, but scientific studies are now showing that normal physiology is disturbed. I shall expand on these examples of unnecessary maternal effort and advocate alternative approaches. In our culture, the work ethic pervades even childbirth. We have heard of “Childbirth Without Pain” and “Childbirth Without Fear” but not “Childbirth Without Effort”! After all, the word labor denotes hard work, and fear and pain are still with us. Fear of the pain has led to the adoption of techniques for distraction, disassociation, control, and exertion. The goal of much childbirth
Vol. 26, No. 2, March/April 1981
education is to “stay on top”-of the situation and of the contractions. Mother must shut out internal stimuli and be determined not to “give in” or “lose control.” Social values condone hard work and disapprove of gains that are too easy or rewards that are not well earned. Historically in the United States, proponents of the “awake and aware” childbirth needed to provide a total program of active mastery to substitute for the use of scopolamine and general anesthesia. A “Let go and flow” approach would not have been as acceptable 30 years ago as the “Olympic Games” model adopted instead, which still persists today. AS a result, women continue to be trained with the philosophy of work, control, and achievement. Rehearsed, resolute, and goal-oriented, these couples go into labor as into combat. MATERNAL POSITION Let us look at how maternal position can prolong labor and involve undue maternal effort. This should no longer be a point of controversy due
to the wealth of research that has been available for many years. Yet 13
women continue to labor and deliver flat on their backs, not just in the United States, but all over the world, often as a result of American influence. Women are not usually free to walk around or even change position, particularly with the advent of fetal monitoring and routine intravenous. Confining a pregnant woman on her back puts a strain on the circulatory system as major blood vessels are compressed. Contractions are less efficient, labor is longer, and the mother thus works overtime. Worse is to come in second stage if she remains flat. Then she has to exert herself against the force of gravity and actually push the baby uphill through the pelvic outlet. Maintaining a fixed position, especially an unnatural one, with the legs cramped in stirrups, is fatiguing and uncomfortable. Many researchers, such as Caldeyro-Barcia, l Dunn, 2 Newton, 3 and Humphrey4 have shown that labor is more physiological and contractions more efficient when the mother works with gravity instead of assuming the supine position (Fig. 1). Caldeyro-Barcia showed that labor in a vertical position-that is, the trunk at an angle of about 40 degrees-is shorter and contractions are stronger than if the mother is horizontal. The drive angle of the uterus is wider if the mother is upright, increasing the efficiency of the contractions. Caldeyro-Barcia found a significant association between supine position
Elizabeth Noble,
R.P.T.,
is the author
Essential Exercises for the Childbearing Year and Having
of
Twins and is the director of the Maternal and Child Health Center in Cambridge, OWGYN
MA. She founded
the
Section of the American
Physical Therapy
Association
and is
on the advisory board of the Zntemational Association Protection Nutrition.
14
Childbirth
Education
and the Society for the of the Unborn
through
and forceps delivery. The vertical position, however, did not increase molding of the fetal head. Flynn5 found that ambulation shortened the duration of labor and decreased the need for analgesics and the incidence of fetal heart abnormalities. Apgar scores were greater in the ambulant group; more patients in the recumbent group required augmentation with oxytocic drugs. Ehrstrom,6 who designed a Swedish birth chair, discovered from x-rays of the pelvis that the outlet was increased by up to 1.5 cm in a sitting position.
CONTROLLED RESPIRATION
We have seen that the supine position forces women to operate at a mechanical disadvantage. Now let’s look at the rules and regulations for breathing which further increase the mother’s work load. Breathing is an activity that can be both voluntary and involuntary. Mostly, we never think about this essential life-sustaining activity as the body in its wisdom automatically adjusts the rate or depth. Despite this natural efficiency, most couples learn through childbirth education to adopt artificial breathing patterns. Mothers are encouraged to change breathing levels as labor contractions become more intense. Control of breathing by contrived techniques is taught for its distraction value. Like drugs and medication, control of breathing obviously has its place, such as in hyperventilation or lung disease. Exertive breathing may “work” just fine in a short labor, but it becomes extremely depleting if prolonged. There is an enormous range in one basic feature of breathing-individual respiratory rate. This is a personal and naturally regulated activity depending on body size, position, activity, metabolism, and so on. The average respiratory rate is 16 breaths/min. However, it is interesting to discover your own resting rate. Simply time yourself for 1 min and count the number of breaths, without
altering your speed in any way. The range is between four and twentyfive breaths/min, which is more meaningful to the individual than the average. Recipes for paced respiration rarely take individual variation into account. In pregnancy, many physiological adjustments have occurred in the respiratory and cardiovascular system. Alveolar ventilation, tidal volume, cardiac output, and blood volume are increased, to give just a few examples. The whole system is perfectly designed so that maternal and fetal blood gases are adequately exchanged. It is difficult to understand the justification for altering something as fundamental as normal breathing, especially during the increased metabolic demands that occur in labor. However, true knowledge is what you experience yourself, and is superior to second-hand experience, however enthusiastically it may be promoted. Let’s see what feels better. Quietly observe your breath. Do NOT attempt to control it or to count it. Allow yourself to be quiet, passive, and to feel as if you were being breathed. Just open up and let the air flow in and out. You may even sense a pause between the exhaled and inhaled breath. This is a subjective feeling of a nonactive phase which occurs when the breathing is easy and effortless as in deep relaxation. Now let’s perform some slow deep breathing, typically known as Level One. Deliberately control your breath now, moving your diaphragm consciously. Choose a rate of about 10 breaths/min, which is a cycle every 6 sec. Now stop pacing the respiration. Return to pure observation. Tune in to what is happening with your breath, without doing anything to make it happen. People are usually amazed to feel the amount of effort required in pacing respiration, even at the lowest calmest level with no likelihood of hyperventilation. Control of breathing, of course, becomes
Journal of Nurse-Midwifery
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Vol. 26, No. 2, March/April 1981
147 min
(4-10
Propped (>40”)
I
Time cm
dilatation)
Horizontal Contractions are More Efficient in the Propped Position
Intrauterine Pressure
mmHg
Propped
Horizontal
FIGURE 1
Labor is more efficient and comfortable in the upright position. After Caldeyro-Barcia.’ more tiring the longer we have to do it and the more complex the technique. Slow deep breathing does not impair physiology, but any control of respiration expends energy, disrupts body rhythms, and diminishes relaxation. Paced respiration cannot, by definition, be normal breathing. It always involves effort because an involuntary process is being controlled. As long as the breathing is forced or restrained, tension results and the gap between the mind and the body widens. Of course, many childbirth educators have exactly that aim--to direct the mind away from the body. However, this divides the mother’s consciousness of herself and disperses the energy that she needs to .Inm-nnl nf NIww-Mirhiferu
??
Vol. 26.
center on the birth experience. Breathing techniques have been traditionally taught to emphasize the chest component of breathing, for the inexplicable rationale that the “irritable diaphragm must be lifted off the uterus in labor.” However, tense anxious people use the chest rather than the abdomen and diaphragm. Similarly, chest breathing leads to tension and anxiety as well as not permitting adequate exchange of gases in the lungs, as there must be sufficient air intake to traverse the anatomical dead-space. This is why so many women, practicing in childbirth preparation classes, complain “I just feel all out of breath” or “I just have to stop and take in a deep breath”. No. 2. March/Am-i1 1981
Alan Hymes, M.D., writing in the Science of Breath, cites the observation of psychoanalysts that people who restrict the movement of their diaphragm are attempting to isolate feelings of fear and sex, which are associated with lower parts of the body, and thus ty to push these feelings out of awareness. Certainly much of our childbirth education directs the mother outside her body. She is taught to block rather than to receive messages from this controversial pelvic area. Breathing patterns, then, are used to limit feeling and awareness, whereas allowing the breath and energy to flow freely would heighten the parturient’s experience and integrate the functions of her mind and body.
15
Instructing a mother to stare at a focal point is another example of needless effort. Aldous Huxley, in his classic, The Art of Seeing, * describes how focusing the vision leads to shallow or suspended breathing, as well as tension around the eyes and psychological strain. It is always fatiguing to repress natural bodily movement, however small. Less effort is required to integrate bodily experiences rather than to suppress them. Yet instead of learning to observe, explore, and open up, mothers learn conditioned responsesnew habits to tack onto old habits. It would seem a good idea to study the effects of normal breathing before deciding to alter it, but like fetal monitoring, usage validated its acceptance prior to a thorough investigation of the benefits and hazards. The few studies that have examined breathing are related to electric shocks rather than childbirth, have conflicting results, or else compare one breathing pattern with another instead of using normal breathing as a control. The difficulty with this is that as soon as you measure and monitor breathing, it is altered and no longer “normal”. One study by Holmes et a1.gfound that control of respiration was least effective in controlling response to the threat of electric shocks. The group that was asked to sit quietly and relax scored best on subjective and objective analysis. The investigators concluded that people find their own ways of coping and that by imagining them to be more helpless than they actually are, we often intervene unnecessarily. Another study by Cohen et al.‘O used a birth film to create a stress situation. They found no change in respiration rate, but increased tension in the respiratoy muscles of the chest, not the abdomen. The exhalation phase was lengthened and the pause shortened. Yet another study by Harris et al., l1 found that pacing the respiration to 8 breaths/min, about half the normal rate, lowered only one measure of
16
autonomic response (the skin) but had no effect on heart rate. So here we have our mother, probably restricted by an IV and electronic fetal monitor, in a horizontal position, changing her breathing levels like gears on a car as she stares and pants through first stage. Usually deprived of nourishment as well, the mother is nearing exhaustion by the time she must perform the greatest work of all: pushing. SECOND STAGE
Not only are women made to push longer and harder than is necessary or good for them, but they are often forced to do so even before the uterus is ready. Ironically, the less the desire to push, the harder the mother is usually encouraged to strain. However, there is often a physiological lull between full dilatation and the establishment of the natural expulsive urge. This interval, seen more in that laboratory of alternatives, homebirth, has been described as a “time of peace.” In the hospital it is usually unobserved because of the preoccupation with haste and “active management”. The expulsive urge begins to be felt as the fetal head descends low enough to stimulate the stretch receptors in the pelvic floor muscles. Stimulation of the pelvic stretch receptors leads to increasing levels of endogenous oxytocin. This neuroendocrine response is known as Ferguson’s reflex. l* Any woman in labor can verify that an artificial rupture of the membranes, manual rotation, or any vaginal examination causes subsequent stronger contractions. Breastfeeding to encourage separation of the placenta is another example of this type of biological phenomenon. Dr. Alois Vasicka, Chief of Obstetrics and Gynecology at North Central Bronx Hospital in New York, has studied the natural increase of plasma oxytocin levels with the progress of labor. Oxytocin levels rise as
the vertex descends in the pelvis, especially after full dilatation of the cervix, and culminates with the greatest peak at crowning. It is thought that higher oxytocin levels are required to maintain uterine contractions as the build-up of lactic acid and carbon dioxide in the myometrium increases with the progress of second stage. Dr. Vasicka found that any form of regional anesthesia, paracervical, epidural, spinal, or pudendal, has the effect of abolishing Ferguson’s reflex. With sensation gone, the stretch receptors are no longer stimulated. Therefore, without the natural expulsive effort of the uterus, mothers often have to force the pushing even harder in compensation and may also require instrumental delivery. Mothers resent having to force pushing before this guiding urge is felt. Imagine if, as you read this, you were forced to move your bowels, in the absence of any internal desire to do so, within the next five minutes. I’m sure you would report an uncomfortable and unnatural experience. Unfortunately, a great many people do force bowel movements with excessive effort and accessory muscles. Thus, it is commonly accepted that the straining required for chronic constipation is the best description and example of how a woman gives birth. Researchers, led notably by Caldeyro-Barcia, are now examining spontaneous pushing efforts for the first time. Pushing, like breathing, has long been directed by others in childbirth before normal parameters were understood. Caldeyro-Barcia13 has recently measured the progressive increase in the work done by the uterus and the abdominals. “Work” is this natural force, measured by amplitude of the contraction and the duration of the effort. For the purposes of analysis, he divided second stage into three phases. By the final phase, the spontaneous pushing efforts of the mothers had increased threefold, as illustrated in Fig. 2.
Journal of Nurse-Midwifery
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300 units Maternal Work (Intrauterine Pressure X
Duration of effort)
End
Beginning Stage II FIGURE 2 Spontaneous pushing Caldeyro-Barcia. ‘:I
Fetal Heart Rate
increase
almost
three-fold
as Stage
II progresses.
After
The women in Caldeyro-Barcia’s study were not directed when and how to push. They simply pushed according to the varying length and intensity of the urges within contractions, and from contraction to contraction. The average number of pushing efforts per contraction was about 4 with an average duration of 5 sec. Average pressure at the top of the efforts was 88, 107 and 119 mmHg in the first, second, and third phases of second stage. The resting interval between spontaneous efforts within one contraction averaged 2 sec. Figure 3 illustrates the fetal monitor tracing for a typical spontaneous pushing contraction. Rest and breathing movements during these intervals minimized the fall in maternal p0, and rise in pC0, during the second stage. Transient Type 1 dips of the fetal heart rate may occur, showing head compres-
200-
160 ’
(Beats/ Min)
Intrauterine Pressure @mHg)
1 10
1
0
I 20
I 30
I 40
I 50
I 60
I 70
I 80
1 90
Seconds FIGURE 3 Spontaneous
pushing
causes
Journal of Nurse-Midwifery
transient
??
Dips in fetal heart rate. After Caldeyro-Barcia.’
Vol. 26, No. 2, March/April
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17
sion during the expulsive urge, but these are quite benign. No difference in fetal blood values was found between short second stages and those that lasted up to 120 min, nor were there any differences in the Apgar scores. In fact, the average value of fetal p0, (27 mmHg in the umbilical artery and 33 mmHg in the umbilical vein) and pH (7.33 and 7.38) were higher than “normal” values. However, what typically happens in American hospitals during second stage contractions? Mother is ordered to lift both her lower limbs (unless they are confined in stirrups) and her upper trunk, against the force of gravity. Even if she is propped, pulling on her legs tenses her body. The staff usually insist that her breath be held. Indeed, the slightest sound alarms them that air is escaping and the force of the effort is waning. Interrupting the respiration is undesirable, but excessive straining with the breath held has severe cardiovascular effects. This forced effort with a closed glottis is known as the Valsalva maneuver, It was named after an Italian physician in the 17th century who recommended this technique for expelling pus from the middle ear. The danger of the Valsalva maneuver during childbirth is that it is unnecessarily forced in combination with the natural expulsive effort (and, as we have seen, sometimes even in its absence). If straining is prolonged beyond 5 or 6 set, maternal and fetal physiology are disturbed. Figure 4 illustrates the closed pressure system that is formed within the body by the Valsalva maneuver. At the onset of strain, the breath is blocked by closure of the glottis. Initially the blood pressure is greatly raised, but this falls as no venous blood can flow back to the heart against such high intrathoracic pressure. The subsequent fall in cardiac output obviously affects circulation to the entire body, and significantly, to the placenta. Pooling of blood in the pelvis and legs also predisposes to varicosities. 18
FIGURE 4
“Blocking” the breath produces a closed pressure system. Abdominal muscles and pelvic structures undergo unnecessary
strain during the Valsalva maneuver.
The high pressure is transmitted, hydraulically according to Pascal’s law, throughout the body fluids. Tissues are strained, such as the pelvic floor and the rectus sheath where the abdominal muscles unite (and sometimes separate) in the midline. Bas-
Journal of Nurse-Midwifery
majian’s studies, described in Musc/es Alive: Their Functions Revealed by Electromyography14 confirmed that the pelvic floor muscles tense protectively when subjected to strain from above. Caldeyro-Barcia associates forced straining with the
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Vol. 26, No. 2, March/April
1981
Fetal Heart Rate (Beats/ Min)
Intrauterine Pressure (mmHg)
Maternal Blood Pressure CmmHg)
FIGURE 5 Forced pushing leads to fetal hypoxia. After Caldeyro-Barcia. ’
need for episiotomy, as there is insufficient time and relaxation for the perineum to distend adequately. A breaking point is reached when the Valsalva maneuver activates reflexes involving the respiratory center in the medulla and the pressure receptors in the aorta. The victim now gasps, and a subsequent imbalance of pressure through the various systems of the body occurs which can be harmful. Abnormal EEG and ECG changes have been measured, and of course, geriatric patients have even died straining on the bedpan. Tests measuring the effects of the Valsalva maneuver are usually done on young males performing handgrip tests for just a few seconds-much less exertion than our childbearing women must display! And quite a display it is-purple
Journal of Nurse-Midwifery
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face, bloodshot eyes, burst capillaries. Unconcerned, the maternity staff usually assemble like a cheering squad. Exhorting the mother to push, push, push, they then often command this flexed ball of tension to RELAX! This is clearly difficult if her hands are clenched and eyes tightly closed! At best, they encourage her to selectively relax the pelvic floor, which we have seen is impossible. Figure 5 illustrates CaldeyroBarcia’s research on the effects of the Valsalva maneuver during childbirth. Pushing efforts that are directed by the attendant are always longer than those spontaneously elicited from the mother. The amplitude of the effort is over 100 mmHg, which is why the peaks were not recorded on the standard monitoring apparatus. One bearing-down effort almost lasted 20
Vol. 26, No. 2, March/April 1981
sec. Maternal blood pressure, measured in the femoral artery, fell to about 70/50 mmHg. The greatly reduced blood flow to the placenta is reflected in the fetal heart tracing. After the end of the contraction, the fetal heart rate, originally about 160 beats/min falls to between 100 and 130 beats/min and the drop lasts longer after the contraction. This is considered a prolonged late deceleration, a Type II dip, associated with uteroplacental insufficiency resulting in fetal hypoxia, acidosis, low Apgar scores and cesarean section. Clearly, second stage conducted in this manner has been limited to 1% to 2 hr for good reason. Could mother and fetus stand much more of the stress and strain of prolonged Valsalva maneuvers?
19
RECOMMENDATIONS FOR AN ALTERNATIVE APPROACH TO CHILDBIRTH
Nurse-midwives are usually concerned with the level of interference in the natural process of birth and are committed to understanding and respecting normal physiology. We have seen that maternal effort is increased by immobility, paced respiration, and straining with the breath held. How then, do we reduce undue exertion and replace contrived techniques with physiological alternatives? Think how much pressure can be taken off the birthing couple if they learn observation of the natural process rather than control of labor. To forget about staying on top of the increasingly difficult contractions and to spontaneously flow with the process. Trusting in their bodies, mothers would not have to ask those two quesions commonly reported by maternity staff, “Am I doing it right?” and “What should I do next?’ As well as trying to “control” their labor, these couples are also concerned with their performance and self-control. Feldenkrais, in his book Awareness Through Movement, l5 describes how goal-oriented activity and expectations increase effort and reduce sensitivity and awareness. If you are concerned with the next step, you automatically tense towards that future accomplishment. Past experience, on the other hand, is the basis of our beliefs and values. Fixing on the past, however, involves fear that the future experience may not be compatible and thus a defensive reaction occurs. Letting go frees you to experience the present, without regard to the past or future. Of course, there is always the question of pain. Nobody denies pain in childbirth. The question is rather how to approach it-with effort and blocking or with acceptance and understanding. Also, how much pain during labor is due to tension and resistance induced in the body through artificial techniques and the fatigue they cause? 20
How can midwives and childbirth educators help couples value their own first-hand experience and discover the potential in their minds and bodies? Our students need to develop confidence so they can open up to learning about themselves rather than learning what we want to teach them with all the charts and formulas we hand out in class. I believe we should help them observe and interpret messages from their bodies, rather than to control or disregard them. Initially, marathon runners practice disassociation, but they soon discover its limitations, according to an article in Psychology Today. I7 The winners turn instead to associating, receiving signs from the whole body and making necessary adjustments as they run. The philosophy behind childbirth preparation is more significant than the techniques, but a few approaches to help “letting go” can be reviewed. Nostril discrimination is an interesting experiment to improve observation skills. If any of you were asked what your left and right arms were doing, you would be embarassed if you couldn’t reply. Yet despite the significance of breath, most people are unaware that air flow alternates between the nostrils and could not tell you, without practice, which nostril was open at this time. This natural biological rhythm is regulated by erectile tissue in the lining of the nose and relates to one’s state of physical and psychological health. An observation exercise that is useful for parents is to become aware of the air flowing through one’s nostrils. Observe if the left, right, or (rarely) both nostrils are open. This experience is next extended to include awareness of the natural breathing movements of the chest and abdomen. Couples, by alternating controlled breathing patterns with observation of the breath, can experience the comparison for themselves. The great majority prefer to let the breath flow at its natural rhythm, but there are always some people who prefer control, who are
comfortable “doing” rather than “being”. Simple stretching exercises, especially those that involve the hamstrings, can be used to help cope with pain. Extending the body’s habitual postures in a variety of positions will meet with resistance, which is one of the edges of pain. Forcing and determination will set you back. But focusing directly on the edges of the pain, integrating your breathing so that you relax and move info the pain actually disperses it. A great deal of physical resistance has mental origins and thus reorganization within the nervous system is required. Experiments with visualiiation bear testimony to this, whether they involve turning a breech or curing cancer. Feldenkrais15 describes how a class can spend hours physically achieving a certain posture, whereas if they repeat the activity only in their imagination on the opposite side, the same results are achieved within minutes. Commitment to early preparation during pregnancy allows women to bond with their bodies. With the foundations secure, they can more easily trust in the natural functions of labor and thus let go at the time of birth. In order to help mothers experience their labors as deeply as possible, childbirth educators need to give less not more. After all, the experience of birth is intensely private and never duplicated even in the same woman. In our dedication, we never consider that our good intentions could be interventions. We want to pass on all the tools, goodies, options, choices, rights, and responsibilities that we learn about. Classes become more complex, paralleling the handling of birth as a high-risk technological event. Childbirth educators themselves are going through an endless proliferation of classes, workshops, examinations, certification, and recertification procedures. Politics emerge, with each professional group setting up barriers to entry, protecting their own turf, whatever their method. The philosophical
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question, of course, is how can there be a method for childbirth? Let us now pass over the preparation for first stage and examine the physiology of second stage. How can we modify energy output and encourage a more comfortable delivery in line with natural forces? Firstly, the mother should not have to push before the expulsive urge is well established. She should push only when it is irresistible. Until that time her effort is wasted. Some women have a Z-hr second stage or even longer, but perhaps give only a few good grunts at the end. Women’s labors, it seems, never go fast enough for the accoucheur and the criteria are getting stricter all the time. The Friedman curve is an average; that is, as many women have long labors to the right of the curve as have short labors to the left. Yet women’s labors and their so-called deviations are plotted according to this “mythical” average. The Chinese have a simpler system. According to the Barefoot Doctor’s Manual, l7 there are just two stages of labor. The first ends with the birth of the baby and the second with the expulsion of the placenta. Our standard time divisions in labor create their own added stress, often setting up self-fulfilling prophesies, such as the stormy time in “transition” and a premature urge to push. In the United States, each stage of labor has its own drama and each drama is acted on a separate stage. Many women fritter their valuable energy as they are admitted in one area, labor in another, deliver in a third, and recover in a fourth! A senior midwife once commented that you can’t teach a woman how to push anymore than you can teach someone how to have an orgasm (or any other reflex activity). The body knows what to do. We mush help women feel free to do what feels right. Vocalization must be approved and encouraged. This includes grunting, groaning, moaning, roaring, whatever. For some women this is a valid expression of accomplish-
Journal of Nurse-Midwifery
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ment as well as a physiological response. Partial closure of the glottis, which results in the characteristic noises of second stage, recruits the abdominals in their role as the muscles of forced exhalation. Exhalation is the natural relaxation component of the respiratory cycle. Exertion, whether in exercise, karate, weight-lifting or childbirth, is performed on the outward breath. This allows the muscles to contract efficiently, by shortening, as toothpaste is squeezed from a tube by an increase in pressure due to a decrease in volume. Contrast this with the Valsalva Maneuver. Place your hands on your abdomen and hold your breath. Now strain, keeping the glottis closed and feel the abdominal wall move out. The muscles tighten isometrically but the wall bulges away from the uterus, displaced by the descent of the diaphragm. The analogy here is that of a balloon-an increase in pressure due to an increase in volume. Now leave one hand on your abdomen and make a fist with the other. Blow hard into your fist as if you were blowing a trumpet. Your other hand will feel the active abdominal muscle contraction. You will note there is no strain on the pelvic floor as the pressure is released from above instead of being directed below as in forceful straining. Any maternal effort then, is directed to the abdominal muscles while the rest of the body remains uninvolved and relaxed. Permitting mothers to birth with ease and dignity can be simple. The key is letting go, the opposite of control. After all, in a normal unmedicated unanesthetized birth, the uterus knows best. Tension, effort, fight, and flight all have their uses in daily life. However, during birth, the mother can best help by simply allowing it to happen. Coaching from outside, particularly with a stopwatch, cannot be based on direct experience and furthermore distracts the mother from what is happening within. Effort and resistance increase
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if the mother tries to control the dynamics of birth. Unnecessary muscle work reduces sensitivity, which in turn requires that a greater exertion be used to accomplish the result. This further reduces sensitivity and a vicious circle develops as one needs greater effort to maintain control. Learning to let go has benefits reaching beyond the childbearing year. Much therapy today deals with insomnia, sexual dysfunction, anxiety, and stress. Interestingly, all these problems share the same common solution-letting go. You cannot master your response in these situations by control because we are dealing with the law of reversed effort. If you ty to fall asleep, ty to have an orgasm, ty to relax, ty to remember the word that is on the tip of your tongue-you move backward not forward. Such analogies are more appropriate to the birth experience than is constipation, although bowel movements are a biological function that you need only allow to happen, without forcing. You cannot make yourself relax-it happens indirectly as the mind is quieted. Even direct “conscious release” is not physiologically possible as there are no nerve endings in muscles that convey the state of muscle tension to the cerebral cortex. The mind works within fixed habits, and we expand our awareness by sensorimotor experience. Progress is made by trying not to try, by gaining awareness through experience, and by trusting the body. We have considered our common cultural approaches to childbirth and the effort and potential hazards involved. Individually, each may not always be serious, but their adverse effects can be cumulative. Similarly, Caldeyro-Barcia found that the excellent outcome of his studies of spontaneous birth were not related to just one particular modification. The unforced pushing efforts of short duration, avoiding the Valsalva maneuver, and allowing ventilation of the lungs between pushes is common sense. The sitting position and the spontaneous rupture of the
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membranes also enhance the natural process. The women in his study had no artificial rupture of the membranes, sedatives, analgesics, anesthesia, or oxytocin which is also significant. All of us involved with birth should review our philosophy of birth. It is not enough to make a few piecemeal changes. We need a total holistic approach. It is essential that we too learn how to let go. To feel free to move ahead rather than to defend our past practices. Clinging to any method impairs our ability to recognize and promote the physiology and individuality of birth. By reducing our own effort and intervention, we will also make birth safer, easier and more enjoyable for our couples. REFERENCES 1. Caldeyro-Barcia R: The influence of maternal position on labor, and the influence of maternal bearing-down efforts in the second stage of labor on fetal wellbeing. in Kaleidoscope of Childbearing: Preparation, Birth and Nurturing, (eds., Simkin P and Reinke C) Seattle, Pennypress, 1978.
in fetal pH during the second stage of labour when conducted in the dorsal position. J Obstet Gynaecol Brit Commonwealth 81:600, 1974. 5. Flynn AM, Kelly J, Hollins G, Lynch PF: Ambulation in labour: Brit Med J 2:591-3, 1978. 6. Ehrstrom C: “Forlossingstolar” Reprint from Recip Reflex (13/72, 1973) cited in Kirchoff, H, “The woman’s posture during childbirth,” Organorama 14:1, 1977, Organon Nederland, Oss. The Netherlands. 7. Swami Rama, BaIIentine R, Hymes A: Science of Breath: A practical guide. Honesdale, PA, Himalayan Institute of Yoga Science and Philosophy, 1979. 8. Huxley A: The Art of Seeing, 1975 ed. Seattle, Montana Books, ~19. 9. Holmes DS, McCaul KD, Solomon S: Control of respiration as a means of controlling responses to threat” J Personality Social Psycho1 36:2, 198-204, 1978. 10. Cohen HD, Goodenough D, Witkin HA, Oltman P, Gould H, Shulman E: The effects of stress on components of the respiratory cycle Psychophysiology 12:4, 1975.
2. Dunn P: “Obstetric delivery today: for better or for worse?” Lancet 1, 79631790-93, 1976.
11. Harris C, Katkin E, Lick J, Habberfield T: Paced respiration as a technique for the modification of autonomic response to stress: Psychophysiology 13:5, 1976.
3 Newton M, Newton N: The propped position for the second stage of labor. Obstel Gynecol 15( 1):28-34, 1960.
12. Ferguson JKW “A study of the motility of the intact uterus at term” Surgery, Gynecol, Obstet 73:359-66, 1941.
4. Humphrey MD, Change A, Wood EC, Morgan S, Hounslow D: A decrease
13. Starch
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Caldeyro-Barcia R, Giussi G, E, Poseiro JJ, Laufaurie N, Ket-
tenhuber K, Ballejo G: The bearing down efforts and their effects on fetal heart rate, oxygenation and acid base balance. Presented at the 1st International Berlin Meeting of Perinatal Medicine, June 1516, 1979. Berlin. 14. Basmajian JV: Muscles Alive: Their functions as revealed by electromyography. 3rd ed. Baltimore, Williams and Wilkins, 1974. 15. Feldenkrais M: Awareness Through Movement, New York, Harper and Row, 1972. 16. Morgan marathoners” 1978.
W: “The mind of the Psycho1 Today, April
17. A Barefoot Doctor’s Manual: A Guide to Traditional Chinese and Modern Medicine. Prepared by the Revolutionary Health Care Committee of Hunan Province, Mayne Isle and Seattle, Cloudburst press, 1977. BIBLIOGRAPHY Caldeyro-Barcia R: “Physiological and psychological bases for the modem and humanized management of normal at the International labor”, presented Year of the Child Commemorative International Congress Tokyo, Japan, 21 and 22 October 1979. Noble E: Essential Exercises for the Childbearing Year, Boston Houghton Mifflin, 1976. Noble E: Respiratory considerations for childbirth. and Rationale for prenatal and postpartum exercises. in Kaleidoscope of Childbearing-Preparation, Birth and Nurturing, (Eds. Simkin P and Reinke C Seattle, Pennypress, 1978.
Journal of Nurse-Midwifery
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Vol. 26, No. 2. March/April 1981