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Natural Childbirth
Natural Childbirth PAUL A. BOWERS, M.D.*
THE subject of childbirth is discussed wherever women assemble. The bridge club is the usual forum before which the mysteries of reproduction are debated and new methods of care praised or pilloried. Prominent among the discussants today are those women who have participated in, or who are looking forward to "natural childbirth." The majority of writers on the subject feel that the term is not a good one. Probably "trained childbirth" more adequately describes the process, but "natural childbirth" has been used so extensively that a change should not be made at this late date. Most women, and a few physicians, have a misconception of what "natural childbirth" signifies. Also the choice of natural childbirth will probably always be the patient's responsibility and it is doubtful for many reasons that it will ever be universally acceptable. However, those patients who evidence an interest in the project may well be encouraged, for it possesses several definite advantages. At the onset it might be well to review something of the beginning of this subject. In 1929 Dr. Edmund Jacobson wrote a book, published in England, on "Progressive Relaxation."l Dr. Jacobson, who is a physiologist as well as a physician, felt that a more relaxed muscular state could be induced by technical training. Dr. Grantley Dick Read accepted and applied the principles set forth by Jacobson, added a modicum of psychological support, and published what has since become the bible of natural childbirth, "Childbirth Without Fear."2 Dr. Read fclt that all women approached pregnancy, and particularly delivery, with fear; fear led to tension which resulted in the cervix becoming more firm and rigid; this rigid cervix required more contractions, and therefore a longer time for dilatation. These contractions were painful, and this in turn led back to fear. Thus, a vicious cycle was started. Dr. Read diagrammed it thus: From the Department of Obstetrics and Gynecology, JejJeTson Medical College and Hospital, Philadelphia.
* Associate in Obstetrics and Gynecology, Jefferson Medical College; Ward Chief, Department of Obstetrics, Jefferson Medical College Hospital; Chief of Obstetrics and Gynecology, Philadelphia General Hospital. 1789
Paul A. Bowers
1790
FEAR
\
PAIN/-E:<~-
TENSION
The aim of natural childbirth is to break this cycle, and we attempt to do this by abolishing fear. Basically, natural childbirth consists of (1) an understanding of the changes which are tahng place in the patient's body during pregnancy, (2) approach to labor 1L'ith confidence, and (3) active participation in the birth process. Frequently the patient who has only superficially considered the subject feels that this is a way to painless childbirth. This is not the case, and practically all writers on the subject are prompt in reporting that there is some discomfort, or actual pain, in certain stages of labor and delivery. However, it is important for the patient to know the reason for the occurrence of this pain, and that something can be done about it. THREE WEAPONS FOR BREAKING THE TRIAD OF FEAR-TENSION-PAIN
It is felt that through education the unknown can be explained; through training, relaxation can be more complete; and through the support of those in attendance, fear can be abolished. This is the backbone of natural childbirth. Education
Education may be secured from (1) M others' Classes, (2) reading and (3) discussion u:ith patient's physician. The usual Mothers' Classes present the anatomy of the female and the physiologic changes which take place in pregnancy. By means of charts the growth and development of the fetus is explained along with the reasons for the various changes in the body. Slides and motion pictures are excellent means of instruction. A liberal question-and-answer period at the close of each formal session is helpful. At the conclusion of the last class, the group is usually taken on a tour, beginning at the hospital admission room, through the labor and delivery rooms, past the nurseries, and terminating in the ward or hospital room which the patient has reserved. The education of the patient should not be completely delegated to the Mothers' Classes. The physician must discuss fully, and to the patient's satisfaction, many of the changes taking place. An attempt should be made to explain to the patient the underlying basis of many of her symptoms. This all takes time, but is a means of instilling confidence and granting support which is a necessary part of the program.
Natural Childbirth
1791
Exercise
Exercise is less important than "Education" or "Support" in a successful natural childbirth program. Edmund Jacobson believes that if patients are adequately trained in relaxation methods alone, their labor and delivery can be made a good deal more satisfying. He feels that the exercises involved do not per se help the patient to relax; they merely teach the patient to recognize when various muscle groups are contracting, so that by recognition she understands when a tension state exists and can then be trained not to contract these muscles, thereby achieving relaxation. The exercises prescribed have two major purposes; one, to assist the patient in relaxing; two, to develop the muscles which may be called into play in the birth process. It may be that a third purpose should be considered, and that is to keep the patient busy and thinking along the lines of her planned program. Also patients in general are encouraged and stimulated by being in association with others who think and have similar interests; by taking the exercises, the patient makes a positive contribution to the program. The exercises can be taught by a trained nurse or physiotherapist. Many of the exercise classes are group affairs which the patient can practice with her "sisters" at regular intervals, and regular daily practice at home is encouraged. The patient is advised to make these exercises a part of her housekeeping chores and to become sufficiently adept so that even when distracted she can perform them. Exercises for childbirth have been described in detail by the late Helen Heardman. 3 The Maternity Center Association of New York City has published a well diagrammed pamphlet entitled "Reminder Sheets for Exercises in Preparation for Childbearing." Space does not permit a reproduction of these exercises. It would be ideal, however, if the instructress who taught the exercises could be present with the patient throughout her labor. Support
The most potent "weapon" in breaking the triad of fear-tension-pain is support rendered in labor by (1) care by sympathetic and understanding nurses, (2) presence of the patient's husband, and (3) sustained attendance by the patient's physician. The solicitous attitude of the nurses in attendance adds a great deal to the patient's sense of well-being. Too often delivery room personnel, by constant exposure, become hardened to the process of labor and delivery, and Mrs. Jones becomes "just another old multip," or the physician who is called out at night forgets that the event which is taking place ranks in importance in the patient's mind with her engagement or the wedding ceremony and will forever be remembered. The patient's husband may contribute a great deal to the success of
Paul A. Bowers
1792
the program. He perhaps has encouraged his wife from the beginning; now he may be expected to assume his own part in the undertaking. He should have been brought into the picture by attending "Mother and Father Classes"; perhaps he has practiced the exercises along with his wife, and now by his constant presence through labor may relieve the feeling of strangeness and aloneness induced by hospital surroundings. No one would want to return to the days of home delivery, but many would like to bring something of the familiar and friendly atmosphere of the home into the hospital. In this respect the presence of the husband may add much to the patient's comfort. It is to be stressed that the physician must also have established liaison with his patient during her prenatal period, instilled in her a belief in the "worthwhileness" and value of natural childbirth, and strengthened 'her confidence in her ability to see it through. During early labor frequent visits with explanation as to what is taking place and what is to be expected mean a great deal to the patient. During advanced labor constant attendance and constant support are essential. THE PATIENT HERSELF
What type of patient seeks natural childbirth? The majority of these women have some medical background; many are the wives of physicians, medical students or psychologists; former nurses, medical technicians and medical secretaries are interested in such a program. There also is a group who may be called "contacts" whose friends have been natural childbirth patients. It has frequently been observed that those patients who have successfully experienced natural childbirth are loud in its praise and are anxious to convince their friends of its value. Then, there are a few who feel it is an indication of superior intelligence to inquire about natural childbirth. Perhaps they have been "talked into it" but are basically afraid of being judged as an ordinary female if they appear disinterested. The women in this group also feel that by requesting natural childbirth they can be sure of more constant attendance by their physician. These patients speak glibly about relaxation, but find it very difficult to relax with their beginning contractions. After a painful labor (from the obstetrician's point of view) they may admit that someone failed-perhaps Dr. Read. Finally, there have been several borderline neuropsychiatric patients with some insight into their problem. These women looked on natural childbirth as a form of therapy and felt that it would serve to bolster up their psychic ego. This type of patient undoubtedly needs a great deal of support, but not at the expense of moderate sedation. There are very few failures among that group of patients who are sincere in their desire for natural childbirth. As the pregnancy progresses the physician can reasonably well judge as to how competent his patient
Natural Childbirth
1793
will be. The emotionally mature woman who is interested and has prepared herself will invariably be successful. HOW TO MAKE A SUCCESS OF NATURAL CHILDBIRTH
In our experience the following points are of importance in making a success of natural childbirth: 1. The physician should arrive at the hospital shortly after the patient's admission. 2. After the patient is examined, the findings are explained to both the patient and her husband. 3. The husband is permitted to remain with his wife. 4. The couple is encouraged to "relax"; play cards, read to one another, or just talk. 5. The physician should remain in the hospital until the patient has delivered. 6. Frequent visits are made to the patient's room with observation as to her progress. The patient is informed of the findings. The position of the baby in the uterus may be outlined on the mother's abdomen and both patient and her husband permitted to listen to the fetal heart tones. 7. During the contractions, the husband can encourage his wife with her breathing and perhaps massage the lumbosacral region of her back. 8. Small doses of sedation may be given to aid in relaxation if necessary. 9. The physician should be in constant attendance during the "transition stage" as the presenting part is slipping through the completely dilated cervix. It is well to remind the patient that this period is short and that soon she will experience a desire to "bear down" which will give her something positive to do. 10. When the vertex reaches the pelvic floor, the patient (and her husband in some cases) is taken to the delivery room. 11. Progress may be more rapid with the patient's legs in stirrups and with handles to pull on. . 12. The patient is told that anesthesia is available if needed, or complications arise. 13. The patient is prepared for delivery with explalilation by the physician as to what he is doing. 14. The findings of vaginal examination are explaililed. 15. A mirror should be situated so that the patient can see the perineal region and observe her progress. 16. Pudendal block or local infiltration of the perineum permits episiotomy, as the presenting part begins to crown. (Dr. Read and many English physicians allow the parts to stretch, which is bound to result in overdilatation or tearing of the deeper tissues.) 17. If the patient experiences unusual discomfort or reque!5ts it, 50
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Paul A. Bowers
per cent nitrous oxide and oxygen may be administered with each contraction; this is rarely necessary. The patient may experience a sense of distention, perhaps a "burning or splitting" sensation as the baby's head slips out of the grasp of the vulva. This is followed by a great sense of comfort and accomplishment. 18. The baby is held up for the mother's inspection and may be placed on her abdomen until the cord has stopped pulsating. 19. After the usual baby care, the infant may be placed in the mother's eager arms until the episiotomy has been repaired. 20. The infant may be nursed for a few minutes on the delivery room table. In our own institution breast feeding is encouraged while the mother is still on the delivery room table. This gives the mother the emotional satisfaction of not only bearing her baby, but of providing nourishment for his growth and development. It is surprising how well the new baby takes to the breast, and what a comfort it seems to be for him. It is true that very little actual nourishment is provided, but if a baby can be introduced to the breast before the bottle, the chances for successful nursing is much better. An important part of any program of natural childbirth should be rooming-in of baby and mother together. Ordinarily the day following delivery the patient may at least be sitting up, or perhaps be out of bed to the bathroom. It is then that she will want to start learning about her own baby and participating in its care. An excellent way of doing this is to place the baby's crib beside the mother's bed for increasing periods of time each day. There is no substitute for experience, and here is an ideal time for the new mother to become acquainted with her baby, and yet not assume too great a responsibility, since the nursery nurses are at her beck and call. Who can describe to the new mother the difference in cry between a hungry baby and a sick baby; the difference between excess mucus and an acute respiratory infection, or the consistency of a normal stool? Personal observation is a great teacher, and what a wonderful place and time to take those lessons while one is in the protecting shelter of a hospital. Most patients find time hangs heavily upon them if their babies are kept in the nursery; they see them at only preregulated hours; they are left for only short periods. If the baby is at the patient's bedside, his needs can be more promptly attended to, and this also encourages the patient to ambulate early. Many physicians now encourage the mother to nurse when her baby appears to be hungry; this is called "demand feeding" and is in contrast with a rigid three or four hour schedule maintained in many nurseries. When an infant cries vigorously, it usually indicates some degree of diseomfort, such as a wet diaper, possibly pain, but more likely hunger. The mother is encouraged to nurse her baby, especially if some time has elapsed since the last feeding, regardless of the schedule. It is found
Natural Childbirth
1795
that a new baby, several days old, may nurse every two to three hours, but soon settles down to a fairly regular schedule of its own at three to four hour intervals. The rooming-in of baby and mother goes hand in hand with natural childbirth and demand feeding. Certainly no mother will permit her baby to cry for long without investigating possible causes. If special nurses were available the new baby would not receive the constant loving care rendered by his mother occupying a bed within reach of his crib. THE ADVANTAGES OF NATURAL CHILDBIRTH
1. It has been stated that the length of labor is shorter; it is theorized that because of less tension in the patient, the cervix is more easily dilatable. Even if the actual length of labor were not shortened, it would seem shorter because the patient is better able to tolerate her lab or and is not frightened with the very first contraction. 2. Another factor in favor of natural childbirth is that there is no delay in initiating respiration and the babies appear healthier. It is not at all unusual to have a baby cry as soon as the head is out of the birth canal, while the remaining portion still lies in the vagina and uterus. Certainly the need for stimulation and mechanical resuscitation is much less than in the patient who receives large doses of an analgesia and may have been anesthetized during her delivery. 3. Following natural childbirth the patient usually makes a more rapid recovery. She has probably had less trauma than a patient who was delivered with instruments; she moves about more freely at an earlier time and is usually anxious to get out of bed. All this aids in a return to normal of both bowel and urinary function as well as hastening involution of the uterus. 4. The advantages of natural childbirth mentioned above are imp ortant~in fact, very important~but it appears that the greatest factor of all is the cementing of family relationship which takes place at thif: time. The father no longer seems an outsider, but feels that he has played an active part in the delivery of his child. He has lent his support from the very beginning of pregnancy by attending classes, participating in the exercises, and adding encouragement to every step of the way. He sat with his wife through labor, coaching her when needed, rubbing her back and giving her confidence to go on; perhaps he was permitted to go into the birth room, where he was able to witness the actual delivery of "our" baby. It would seem that this experience should bring the family more closely together. ARGUMENTS ADVANCED AGAINST NATURAL CHILDBIRTH
Some physicians feel that the term "natural" implies a return to primitive obstetrics where the patient was more or less left to lab or and delivered without the benefit of professional help. Certainly the close
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relationship between physician and patient in natural childbirth is a far cry from medieval midwifery. It has been stated that many patients who are given some insight into the possible complication of obstetrics may worry; that is, "a little knowledge is a dangerous thing." An occasional patient may be alarmed, but usually this easily disturbed patient is not the type who seeks natural childbirth. The opponents of natural childbirth also state that the required training and support border on hypnosis-in other words, a highly suggestible state is achieved. The same statement might also be made about the patient who is about to undergo a surgical procedure and expresses confidence in her surgeon's judgment as to what is best for her. All of us will agree that more of the physician's time is required; there is a need for additional trained personnel. However, this can scarcely be considered an argument against natural childbirth. How many of us would want to return to the days when an abdominal operation required only the presence of the doctor and perhaps a nurse, with a neighbor providing sheets and boiled water? There is also the feeling in some quarters that by bringing the husband into the picture with his cooperative observing wife, we may expose our "trade secrets"; that we shouldn't permit the public to know how simple uncomplicated obstetrics may be. The reverse is the case-both parents are fully aware of the importance of the physician's presence and often find it difficult to adequately express their appreciation. It is unlikely that any physician has ever lost a patient because the "multiparous father" feels he has learned enough to take over. There is evidence that many physicians have been practicing a form of natural childbirth for years without this label. The old family physician with his home deliveries of necessity administered minimal amounts of analgesia and anesthesia; he relied on familiar surroundings and the support of family and friends. When the search for the perfect obstetrical drug began, the pendulum swung to the extreme of overdependence upon drugs, with neglect of the time-honored support of the patient by her physician. Today in natural childbirth we have a return to many of the principles of physiologic obstetrics. Perhaps there is a still bl;ltter type of obstetric practice, but in natural childbirth if we err, at least we err on the safe side. MORE ABOUT THE HUSBAND'S ROLE
We have frequently referred to the husband's presence in the delivery room. This is not possible in many hospitals, but I am firmly convinced it is one of the most important parts of the natural childbirth program. In most clinics the father is brought into the picture and given instructions which should enable him to play a supportive role during pregnancy and especially during labor. With few exceptions, however, the husband
Natural Childbirth
1797
is separated from his wife when he could be of most support to her. This usually occurs when the obstetrician feels that delivery will soon occur and the prospective father bends over, kisses his wife, and utters something that sounds like "be brave." Why should the father's participation have to end then? For the past several years it has been our practice to carry natural childbirth a step farther. We have permitted and actually encouraged the husband to accompany his wife to the delivery room. I am sure if the mother-to-be had a choice between her husband's participation in labor and his presence at the actual delivery she would choose the latter. During the early stages of labor the reassurance and presence of a sympathetic nurse is most helpful; as labor progresses the patient naturally looks to her obstetrician for support. As the presenting part of the baby begins to slip through the completely dilated cervix the strongest contractions are recurring at frequent intervals and it is then that most patients need all possible encouragement, and there is no substitute for the husband. In the delivery room the prospective father wears a complete gown with cap and mask. He is given a stool to sit on just beside his wife where he can lend his support as needed. An easy exit from the delivery room is always provided, but to date this has never been used. As the baby's presenting part begins to crown, the husband is called to a vantage point where he can clearly see what is taking place. The obstetrician's description of the process is directed to both mother and father-to-be and frequently the father is not only a passive observer, but lends his vocal interpretation to each step. After the actual delivery the new father returns to his stool beside his wife and their enthusiasm seems to know no bounds. I have asked several patients to express their feelings in reference to their husband's presence through both lab or and delivery: Cl • • • • The husband-wife relationship undergoes a permanent change. Their relationship is strongly cemented by sharing this thrilling experience. Where there has always been a fundamental closeness between them, this experience of witnessing their child's birth is a spiritual one which cannot be equaled by any other experience. Our personal feeling is that if it were not possible to share this experience another time we would feel most cheated." Cl • • • • One of the most important factors in keeping me in a calm, confident, and happy state of anticipation about the actual delivery of my child was the knowledge that my husband would be with me throughout labor and delivery. In a program designed to have a well informed relaxed woman consciously helping to give birth to her child, this was one of the main cornerstones. Just as we are always at our best when we are together, I knew that I would be best able to do my job with my husband present to help. What could he do to help? Merely his presence would and did help. Merely the feeling of his,confidence in me ana his love for me, the feeling only of never being alone in a not very familiar place, but of being with the very best loved one; all of these were of the highest importance in my ability to relax at the right time and to work at the right time. The actual birth of our baby was a thrilling, happy event for
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both of us, much as we had anticipated. What we had never anticipated to its fullest was our extreme joy and our wonderful pleasure in being able to share immediately in that joy when our daughter was completely born. My husband walked back and forth between our daughter and me, saying, 'I don't know where to look, at my daughter, or at my wife.' Every time he looked at me he said, 'You look wonderful; you've never looked so well.' We were two extremely happy people full of satisfaction at a job well done together. We love remembering and talking about the happy event, and we're looking forward with eagerness to the next time, and the time after that." " .... The best part of my experience was the active share that my husband was able to take in the labor and delivery of our own baby. 'Mother's little helper' he was called derisively by a skeptical member of the nursing staff. 'Yes, I am,' he answered earnestly. For so he was and wanted to be." " .... I wanted my husband to be able to share with me the wonderful experience that I knew natural childbirth would be. Why should he be deprived just because he is a layman? I wanted him with me, and when the baby was born all I saw in his face was great joy and wonder-not a trace of shock, horror, disgust-none of the negative reactions some people had anticipated for him. For me, his presence meant the difference between complete relaxation and confidence, or possible fear."
How do the new fathers feel? This is what one has to say: " .... Obviously, I could not experience natural childbirth in the same way in which my wife could as she gave birth, but in being with her through the delivery I could share her experience on a feeling level as well as on an intellectual plane. I could become part of the labor by being of real help to her and by this I mean psychological help since I am not in the slightest competent in the medical arts. Being present in the delivery room was the culmination of the long time we had shared vital life experiences. Our courtship, our marriage, our desire for children-the pregnancy which we always felt was 'ours' and not just my wife's. "When our doctor invited me to attend, my wife's anxiety faded-but mine began. To be perfectly candid, while wanting very much to be present at my child's birth, there was a little piece of me that held back. I was not sure how I could or would or should react to the scenes in the delivery room. One hears so much about complications and all sorts of difficulties which arise sometimes when a child is born. Did I want to be a part of this? How would I feel about my wife lying exposed and the doctor handling her? On the other hand, I was frankly very curious and wanted to know just what childbirth was actually like. Above all, I had a deep abiding desire to do whatever would make my wife happier and more relaxed. "It is difficult to recapture in words the thrill, elation, awe, mystery and sense of the miraculous I felt all in one wave of emotion when I saw my daughter actually born. I felt immensely close to my wife for having shared this experience with her. My baby was more real and closer to me than she could have been through a glass partition hours after her birth. I felt myself immeasurably fortunate. I did not have to pace the floor for hours, waiting for news. I had a tremendous pleasure of seeing my child immediately begin to suckle at the breast and further awe and wonder at this instinctive response. I had the satisfaction of seeing my wife enjoy her birth experience. Never would I bear in me the guilty questions as to whether I had inflicted pain and agony upon my wife. I knew that for us childbirth was as natural as breathing. Most important for the baby, she had her mother and father with her right from the beginning, surrounded by warmth, love, and a sense of belonging."
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From the experience of these mothers and fathers, I believe we can derive much in shaping the course of our future obstetric practice. As an obstetrician, I can only express my impressions of the husband-wife relationship throughout the entire birth process. From them we find something entirely satisfying and basically sound. We am returning to the "Cornelian Corner" with intimate mother and baby relationship--why shouldn't the father be brought more closely into the group? REFERENCES 1. Jacobson, E.: Progressive Relaxation. Chicago, University of Chicago Press, 1938.
2. Read, G. D.: Childbirth Without Fear. New York, Harper Brothers, 1944. 3. Heardman, H.: A Way to Natural Childbirth. Baltimore, Williams & Wilkins Co., 1948. 2031 Locust Street Philadelphia 3, Pennsylvania
THE subject of childbirth is discussed wherever women assemble. The bridge club is the usual forum before which the mysteries of reproduction are debated and new methods of care praised or pilloried. Prominent among the discussants today are those women who have participated in, or who are looking forward to "natural childbirth." The majority of writers on the subject feel that the term is not a good one. Probably "trained childbirth" more adequately describes the process, but "natural childbirth" has been used so extensively that a change should not be made at this late date. Most women, and a few physicians, have a misconception of what "natural childbirth" signifies. Also the choice of natural childbirth will probably always be the patient's responsibility and it is doubtful for many reasons that it will ever be universally acceptable. However, those patients who evidence an interest in the project may well be encouraged, for it possesses several definite advantages. At the onset it might be well to review something of the beginning of this subject. In 1929 Dr. Edmund Jacobson wrote a book, published in England, on "Progressive Relaxation."l Dr. Jacobson, who is a physiologist as well as a physician, felt that a more relaxed muscular state could be induced by technical training. Dr. Grantley Dick Read accepted and applied the principles set forth by Jacobson, added a modicum of psychological support, and published what has since become the bible of natural childbirth, "Childbirth Without Fear."2 Dr. Read fclt that all women approached pregnancy, and particularly delivery, with fear; fear led to tension which resulted in the cervix becoming more firm and rigid; this rigid cervix required more contractions, and therefore a longer time for dilatation. These contractions were painful, and this in turn led back to fear. Thus, a vicious cycle was started. Dr. Read diagrammed it thus: From the Department of Obstetrics and Gynecology, JejJeTson Medical College and Hospital, Philadelphia.
* Associate in Obstetrics and Gynecology, Jefferson Medical College; Ward Chief, Department of Obstetrics, Jefferson Medical College Hospital; Chief of Obstetrics and Gynecology, Philadelphia General Hospital. 1789
Paul A. Bowers
1790
FEAR
\
PAIN/-E:<~-
TENSION
The aim of natural childbirth is to break this cycle, and we attempt to do this by abolishing fear. Basically, natural childbirth consists of (1) an understanding of the changes which are tahng place in the patient's body during pregnancy, (2) approach to labor 1L'ith confidence, and (3) active participation in the birth process. Frequently the patient who has only superficially considered the subject feels that this is a way to painless childbirth. This is not the case, and practically all writers on the subject are prompt in reporting that there is some discomfort, or actual pain, in certain stages of labor and delivery. However, it is important for the patient to know the reason for the occurrence of this pain, and that something can be done about it. THREE WEAPONS FOR BREAKING THE TRIAD OF FEAR-TENSION-PAIN
It is felt that through education the unknown can be explained; through training, relaxation can be more complete; and through the support of those in attendance, fear can be abolished. This is the backbone of natural childbirth. Education
Education may be secured from (1) M others' Classes, (2) reading and (3) discussion u:ith patient's physician. The usual Mothers' Classes present the anatomy of the female and the physiologic changes which take place in pregnancy. By means of charts the growth and development of the fetus is explained along with the reasons for the various changes in the body. Slides and motion pictures are excellent means of instruction. A liberal question-and-answer period at the close of each formal session is helpful. At the conclusion of the last class, the group is usually taken on a tour, beginning at the hospital admission room, through the labor and delivery rooms, past the nurseries, and terminating in the ward or hospital room which the patient has reserved. The education of the patient should not be completely delegated to the Mothers' Classes. The physician must discuss fully, and to the patient's satisfaction, many of the changes taking place. An attempt should be made to explain to the patient the underlying basis of many of her symptoms. This all takes time, but is a means of instilling confidence and granting support which is a necessary part of the program.
Natural Childbirth
1791
Exercise
Exercise is less important than "Education" or "Support" in a successful natural childbirth program. Edmund Jacobson believes that if patients are adequately trained in relaxation methods alone, their labor and delivery can be made a good deal more satisfying. He feels that the exercises involved do not per se help the patient to relax; they merely teach the patient to recognize when various muscle groups are contracting, so that by recognition she understands when a tension state exists and can then be trained not to contract these muscles, thereby achieving relaxation. The exercises prescribed have two major purposes; one, to assist the patient in relaxing; two, to develop the muscles which may be called into play in the birth process. It may be that a third purpose should be considered, and that is to keep the patient busy and thinking along the lines of her planned program. Also patients in general are encouraged and stimulated by being in association with others who think and have similar interests; by taking the exercises, the patient makes a positive contribution to the program. The exercises can be taught by a trained nurse or physiotherapist. Many of the exercise classes are group affairs which the patient can practice with her "sisters" at regular intervals, and regular daily practice at home is encouraged. The patient is advised to make these exercises a part of her housekeeping chores and to become sufficiently adept so that even when distracted she can perform them. Exercises for childbirth have been described in detail by the late Helen Heardman. 3 The Maternity Center Association of New York City has published a well diagrammed pamphlet entitled "Reminder Sheets for Exercises in Preparation for Childbearing." Space does not permit a reproduction of these exercises. It would be ideal, however, if the instructress who taught the exercises could be present with the patient throughout her labor. Support
The most potent "weapon" in breaking the triad of fear-tension-pain is support rendered in labor by (1) care by sympathetic and understanding nurses, (2) presence of the patient's husband, and (3) sustained attendance by the patient's physician. The solicitous attitude of the nurses in attendance adds a great deal to the patient's sense of well-being. Too often delivery room personnel, by constant exposure, become hardened to the process of labor and delivery, and Mrs. Jones becomes "just another old multip," or the physician who is called out at night forgets that the event which is taking place ranks in importance in the patient's mind with her engagement or the wedding ceremony and will forever be remembered. The patient's husband may contribute a great deal to the success of
Paul A. Bowers
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the program. He perhaps has encouraged his wife from the beginning; now he may be expected to assume his own part in the undertaking. He should have been brought into the picture by attending "Mother and Father Classes"; perhaps he has practiced the exercises along with his wife, and now by his constant presence through labor may relieve the feeling of strangeness and aloneness induced by hospital surroundings. No one would want to return to the days of home delivery, but many would like to bring something of the familiar and friendly atmosphere of the home into the hospital. In this respect the presence of the husband may add much to the patient's comfort. It is to be stressed that the physician must also have established liaison with his patient during her prenatal period, instilled in her a belief in the "worthwhileness" and value of natural childbirth, and strengthened 'her confidence in her ability to see it through. During early labor frequent visits with explanation as to what is taking place and what is to be expected mean a great deal to the patient. During advanced labor constant attendance and constant support are essential. THE PATIENT HERSELF
What type of patient seeks natural childbirth? The majority of these women have some medical background; many are the wives of physicians, medical students or psychologists; former nurses, medical technicians and medical secretaries are interested in such a program. There also is a group who may be called "contacts" whose friends have been natural childbirth patients. It has frequently been observed that those patients who have successfully experienced natural childbirth are loud in its praise and are anxious to convince their friends of its value. Then, there are a few who feel it is an indication of superior intelligence to inquire about natural childbirth. Perhaps they have been "talked into it" but are basically afraid of being judged as an ordinary female if they appear disinterested. The women in this group also feel that by requesting natural childbirth they can be sure of more constant attendance by their physician. These patients speak glibly about relaxation, but find it very difficult to relax with their beginning contractions. After a painful labor (from the obstetrician's point of view) they may admit that someone failed-perhaps Dr. Read. Finally, there have been several borderline neuropsychiatric patients with some insight into their problem. These women looked on natural childbirth as a form of therapy and felt that it would serve to bolster up their psychic ego. This type of patient undoubtedly needs a great deal of support, but not at the expense of moderate sedation. There are very few failures among that group of patients who are sincere in their desire for natural childbirth. As the pregnancy progresses the physician can reasonably well judge as to how competent his patient
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will be. The emotionally mature woman who is interested and has prepared herself will invariably be successful. HOW TO MAKE A SUCCESS OF NATURAL CHILDBIRTH
In our experience the following points are of importance in making a success of natural childbirth: 1. The physician should arrive at the hospital shortly after the patient's admission. 2. After the patient is examined, the findings are explained to both the patient and her husband. 3. The husband is permitted to remain with his wife. 4. The couple is encouraged to "relax"; play cards, read to one another, or just talk. 5. The physician should remain in the hospital until the patient has delivered. 6. Frequent visits are made to the patient's room with observation as to her progress. The patient is informed of the findings. The position of the baby in the uterus may be outlined on the mother's abdomen and both patient and her husband permitted to listen to the fetal heart tones. 7. During the contractions, the husband can encourage his wife with her breathing and perhaps massage the lumbosacral region of her back. 8. Small doses of sedation may be given to aid in relaxation if necessary. 9. The physician should be in constant attendance during the "transition stage" as the presenting part is slipping through the completely dilated cervix. It is well to remind the patient that this period is short and that soon she will experience a desire to "bear down" which will give her something positive to do. 10. When the vertex reaches the pelvic floor, the patient (and her husband in some cases) is taken to the delivery room. 11. Progress may be more rapid with the patient's legs in stirrups and with handles to pull on. . 12. The patient is told that anesthesia is available if needed, or complications arise. 13. The patient is prepared for delivery with explalilation by the physician as to what he is doing. 14. The findings of vaginal examination are explaililed. 15. A mirror should be situated so that the patient can see the perineal region and observe her progress. 16. Pudendal block or local infiltration of the perineum permits episiotomy, as the presenting part begins to crown. (Dr. Read and many English physicians allow the parts to stretch, which is bound to result in overdilatation or tearing of the deeper tissues.) 17. If the patient experiences unusual discomfort or reque!5ts it, 50
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per cent nitrous oxide and oxygen may be administered with each contraction; this is rarely necessary. The patient may experience a sense of distention, perhaps a "burning or splitting" sensation as the baby's head slips out of the grasp of the vulva. This is followed by a great sense of comfort and accomplishment. 18. The baby is held up for the mother's inspection and may be placed on her abdomen until the cord has stopped pulsating. 19. After the usual baby care, the infant may be placed in the mother's eager arms until the episiotomy has been repaired. 20. The infant may be nursed for a few minutes on the delivery room table. In our own institution breast feeding is encouraged while the mother is still on the delivery room table. This gives the mother the emotional satisfaction of not only bearing her baby, but of providing nourishment for his growth and development. It is surprising how well the new baby takes to the breast, and what a comfort it seems to be for him. It is true that very little actual nourishment is provided, but if a baby can be introduced to the breast before the bottle, the chances for successful nursing is much better. An important part of any program of natural childbirth should be rooming-in of baby and mother together. Ordinarily the day following delivery the patient may at least be sitting up, or perhaps be out of bed to the bathroom. It is then that she will want to start learning about her own baby and participating in its care. An excellent way of doing this is to place the baby's crib beside the mother's bed for increasing periods of time each day. There is no substitute for experience, and here is an ideal time for the new mother to become acquainted with her baby, and yet not assume too great a responsibility, since the nursery nurses are at her beck and call. Who can describe to the new mother the difference in cry between a hungry baby and a sick baby; the difference between excess mucus and an acute respiratory infection, or the consistency of a normal stool? Personal observation is a great teacher, and what a wonderful place and time to take those lessons while one is in the protecting shelter of a hospital. Most patients find time hangs heavily upon them if their babies are kept in the nursery; they see them at only preregulated hours; they are left for only short periods. If the baby is at the patient's bedside, his needs can be more promptly attended to, and this also encourages the patient to ambulate early. Many physicians now encourage the mother to nurse when her baby appears to be hungry; this is called "demand feeding" and is in contrast with a rigid three or four hour schedule maintained in many nurseries. When an infant cries vigorously, it usually indicates some degree of diseomfort, such as a wet diaper, possibly pain, but more likely hunger. The mother is encouraged to nurse her baby, especially if some time has elapsed since the last feeding, regardless of the schedule. It is found
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that a new baby, several days old, may nurse every two to three hours, but soon settles down to a fairly regular schedule of its own at three to four hour intervals. The rooming-in of baby and mother goes hand in hand with natural childbirth and demand feeding. Certainly no mother will permit her baby to cry for long without investigating possible causes. If special nurses were available the new baby would not receive the constant loving care rendered by his mother occupying a bed within reach of his crib. THE ADVANTAGES OF NATURAL CHILDBIRTH
1. It has been stated that the length of labor is shorter; it is theorized that because of less tension in the patient, the cervix is more easily dilatable. Even if the actual length of labor were not shortened, it would seem shorter because the patient is better able to tolerate her lab or and is not frightened with the very first contraction. 2. Another factor in favor of natural childbirth is that there is no delay in initiating respiration and the babies appear healthier. It is not at all unusual to have a baby cry as soon as the head is out of the birth canal, while the remaining portion still lies in the vagina and uterus. Certainly the need for stimulation and mechanical resuscitation is much less than in the patient who receives large doses of an analgesia and may have been anesthetized during her delivery. 3. Following natural childbirth the patient usually makes a more rapid recovery. She has probably had less trauma than a patient who was delivered with instruments; she moves about more freely at an earlier time and is usually anxious to get out of bed. All this aids in a return to normal of both bowel and urinary function as well as hastening involution of the uterus. 4. The advantages of natural childbirth mentioned above are imp ortant~in fact, very important~but it appears that the greatest factor of all is the cementing of family relationship which takes place at thif: time. The father no longer seems an outsider, but feels that he has played an active part in the delivery of his child. He has lent his support from the very beginning of pregnancy by attending classes, participating in the exercises, and adding encouragement to every step of the way. He sat with his wife through labor, coaching her when needed, rubbing her back and giving her confidence to go on; perhaps he was permitted to go into the birth room, where he was able to witness the actual delivery of "our" baby. It would seem that this experience should bring the family more closely together. ARGUMENTS ADVANCED AGAINST NATURAL CHILDBIRTH
Some physicians feel that the term "natural" implies a return to primitive obstetrics where the patient was more or less left to lab or and delivered without the benefit of professional help. Certainly the close
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relationship between physician and patient in natural childbirth is a far cry from medieval midwifery. It has been stated that many patients who are given some insight into the possible complication of obstetrics may worry; that is, "a little knowledge is a dangerous thing." An occasional patient may be alarmed, but usually this easily disturbed patient is not the type who seeks natural childbirth. The opponents of natural childbirth also state that the required training and support border on hypnosis-in other words, a highly suggestible state is achieved. The same statement might also be made about the patient who is about to undergo a surgical procedure and expresses confidence in her surgeon's judgment as to what is best for her. All of us will agree that more of the physician's time is required; there is a need for additional trained personnel. However, this can scarcely be considered an argument against natural childbirth. How many of us would want to return to the days when an abdominal operation required only the presence of the doctor and perhaps a nurse, with a neighbor providing sheets and boiled water? There is also the feeling in some quarters that by bringing the husband into the picture with his cooperative observing wife, we may expose our "trade secrets"; that we shouldn't permit the public to know how simple uncomplicated obstetrics may be. The reverse is the case-both parents are fully aware of the importance of the physician's presence and often find it difficult to adequately express their appreciation. It is unlikely that any physician has ever lost a patient because the "multiparous father" feels he has learned enough to take over. There is evidence that many physicians have been practicing a form of natural childbirth for years without this label. The old family physician with his home deliveries of necessity administered minimal amounts of analgesia and anesthesia; he relied on familiar surroundings and the support of family and friends. When the search for the perfect obstetrical drug began, the pendulum swung to the extreme of overdependence upon drugs, with neglect of the time-honored support of the patient by her physician. Today in natural childbirth we have a return to many of the principles of physiologic obstetrics. Perhaps there is a still bl;ltter type of obstetric practice, but in natural childbirth if we err, at least we err on the safe side. MORE ABOUT THE HUSBAND'S ROLE
We have frequently referred to the husband's presence in the delivery room. This is not possible in many hospitals, but I am firmly convinced it is one of the most important parts of the natural childbirth program. In most clinics the father is brought into the picture and given instructions which should enable him to play a supportive role during pregnancy and especially during labor. With few exceptions, however, the husband
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is separated from his wife when he could be of most support to her. This usually occurs when the obstetrician feels that delivery will soon occur and the prospective father bends over, kisses his wife, and utters something that sounds like "be brave." Why should the father's participation have to end then? For the past several years it has been our practice to carry natural childbirth a step farther. We have permitted and actually encouraged the husband to accompany his wife to the delivery room. I am sure if the mother-to-be had a choice between her husband's participation in labor and his presence at the actual delivery she would choose the latter. During the early stages of labor the reassurance and presence of a sympathetic nurse is most helpful; as labor progresses the patient naturally looks to her obstetrician for support. As the presenting part of the baby begins to slip through the completely dilated cervix the strongest contractions are recurring at frequent intervals and it is then that most patients need all possible encouragement, and there is no substitute for the husband. In the delivery room the prospective father wears a complete gown with cap and mask. He is given a stool to sit on just beside his wife where he can lend his support as needed. An easy exit from the delivery room is always provided, but to date this has never been used. As the baby's presenting part begins to crown, the husband is called to a vantage point where he can clearly see what is taking place. The obstetrician's description of the process is directed to both mother and father-to-be and frequently the father is not only a passive observer, but lends his vocal interpretation to each step. After the actual delivery the new father returns to his stool beside his wife and their enthusiasm seems to know no bounds. I have asked several patients to express their feelings in reference to their husband's presence through both lab or and delivery: Cl • • • • The husband-wife relationship undergoes a permanent change. Their relationship is strongly cemented by sharing this thrilling experience. Where there has always been a fundamental closeness between them, this experience of witnessing their child's birth is a spiritual one which cannot be equaled by any other experience. Our personal feeling is that if it were not possible to share this experience another time we would feel most cheated." Cl • • • • One of the most important factors in keeping me in a calm, confident, and happy state of anticipation about the actual delivery of my child was the knowledge that my husband would be with me throughout labor and delivery. In a program designed to have a well informed relaxed woman consciously helping to give birth to her child, this was one of the main cornerstones. Just as we are always at our best when we are together, I knew that I would be best able to do my job with my husband present to help. What could he do to help? Merely his presence would and did help. Merely the feeling of his,confidence in me ana his love for me, the feeling only of never being alone in a not very familiar place, but of being with the very best loved one; all of these were of the highest importance in my ability to relax at the right time and to work at the right time. The actual birth of our baby was a thrilling, happy event for
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both of us, much as we had anticipated. What we had never anticipated to its fullest was our extreme joy and our wonderful pleasure in being able to share immediately in that joy when our daughter was completely born. My husband walked back and forth between our daughter and me, saying, 'I don't know where to look, at my daughter, or at my wife.' Every time he looked at me he said, 'You look wonderful; you've never looked so well.' We were two extremely happy people full of satisfaction at a job well done together. We love remembering and talking about the happy event, and we're looking forward with eagerness to the next time, and the time after that." " .... The best part of my experience was the active share that my husband was able to take in the labor and delivery of our own baby. 'Mother's little helper' he was called derisively by a skeptical member of the nursing staff. 'Yes, I am,' he answered earnestly. For so he was and wanted to be." " .... I wanted my husband to be able to share with me the wonderful experience that I knew natural childbirth would be. Why should he be deprived just because he is a layman? I wanted him with me, and when the baby was born all I saw in his face was great joy and wonder-not a trace of shock, horror, disgust-none of the negative reactions some people had anticipated for him. For me, his presence meant the difference between complete relaxation and confidence, or possible fear."
How do the new fathers feel? This is what one has to say: " .... Obviously, I could not experience natural childbirth in the same way in which my wife could as she gave birth, but in being with her through the delivery I could share her experience on a feeling level as well as on an intellectual plane. I could become part of the labor by being of real help to her and by this I mean psychological help since I am not in the slightest competent in the medical arts. Being present in the delivery room was the culmination of the long time we had shared vital life experiences. Our courtship, our marriage, our desire for children-the pregnancy which we always felt was 'ours' and not just my wife's. "When our doctor invited me to attend, my wife's anxiety faded-but mine began. To be perfectly candid, while wanting very much to be present at my child's birth, there was a little piece of me that held back. I was not sure how I could or would or should react to the scenes in the delivery room. One hears so much about complications and all sorts of difficulties which arise sometimes when a child is born. Did I want to be a part of this? How would I feel about my wife lying exposed and the doctor handling her? On the other hand, I was frankly very curious and wanted to know just what childbirth was actually like. Above all, I had a deep abiding desire to do whatever would make my wife happier and more relaxed. "It is difficult to recapture in words the thrill, elation, awe, mystery and sense of the miraculous I felt all in one wave of emotion when I saw my daughter actually born. I felt immensely close to my wife for having shared this experience with her. My baby was more real and closer to me than she could have been through a glass partition hours after her birth. I felt myself immeasurably fortunate. I did not have to pace the floor for hours, waiting for news. I had a tremendous pleasure of seeing my child immediately begin to suckle at the breast and further awe and wonder at this instinctive response. I had the satisfaction of seeing my wife enjoy her birth experience. Never would I bear in me the guilty questions as to whether I had inflicted pain and agony upon my wife. I knew that for us childbirth was as natural as breathing. Most important for the baby, she had her mother and father with her right from the beginning, surrounded by warmth, love, and a sense of belonging."
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From the experience of these mothers and fathers, I believe we can derive much in shaping the course of our future obstetric practice. As an obstetrician, I can only express my impressions of the husband-wife relationship throughout the entire birth process. From them we find something entirely satisfying and basically sound. We am returning to the "Cornelian Corner" with intimate mother and baby relationship--why shouldn't the father be brought more closely into the group? REFERENCES 1. Jacobson, E.: Progressive Relaxation. Chicago, University of Chicago Press, 1938.
2. Read, G. D.: Childbirth Without Fear. New York, Harper Brothers, 1944. 3. Heardman, H.: A Way to Natural Childbirth. Baltimore, Williams & Wilkins Co., 1948. 2031 Locust Street Philadelphia 3, Pennsylvania