Pregnancy, Childbirth, and the Newborn: The Complete Guide, 4th Ed.

CHAPTER 11 Comfort Techniques for Pain Relief and Labor Progress

As your due date approaches, you may wonder how you’ll cope when your contractions become intense, or what you can do if your labor becomes slow or extra challenging. Comfort techniques such as rhythmic breathing, body positions, and relaxation exercises can help you cope with labor pain and maintain progress with less need for intervention.

This chapter describes how you and your partner can practice and adapt comfort techniques during pregnancy so they can help you effectively manage the pain and stress of labor. Instead of using pain medications, you may use these techniques to keep your pain at a manageable level. Or you may use them along with pain medications to enhance your comfort and reduce the amount of medication you need. In either case, comfort techniques can help make the birth of your child a rewarding, fulfilling, and joyful experience by allowing you to participate in the event more fully.

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In this chapter, you’ll learn about:

• The Three Rs: relaxation, rhythm, and ritual (the essential tools for coping with labor and birth)

• How to practice relaxation exercises, positions and movement, breathing techniques, and other comfort techniques with your partner, and adapt them to suit your needs

• How to use comfort techniques to rehearse for labor

• Comfort techniques to help relieve back pain, speed up or slow labor, or manage an irregular labor

Finding Your Own Way to Cope with Labor Pain: The Three Rs

Every woman responds to labor pain in her own way. Your response will depend on the nature of your labor, your coping style, your goals and expectations, and how prepared you feel for labor.1 Although you can learn about labor from other people and resources, such as your caregiver or childbirth preparation classes, only you can develop your own approach to handling labor pain. You have your own learning style, values, and ways of dealing with change, stress, and pain. With the help of your partner and others on your support team, you can adapt the following comfort techniques to suit your labor and modify them to match your personality and preferences.

THE THREE RS: RELAXATION, RHYTHM, AND RITUAL

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Although every woman responds to labor differently, those who cope well have three behaviors in common: relaxation, rhythm, and ritual. These Three Rs describe the instinctual coping behaviors observed in hundreds of women who were managing labor well.

Relaxation

Women who cope well in labor use relaxation in various ways. They may move about between contractions and let their muscles relax during contractions. They may become active during contractions (for example, swaying, rocking, and stroking their bellies) and relax only between contractions. Or they may remain quiet and unresponsive to their surroundings during and between contractions for all or part of labor. (For more information on relaxation techniques, see page 216.)

Rhythm

Women who cope well in labor rely on rhythm in various forms. Rhythmic activity calms the mind and lets a woman work well with her body. For example, she may rhythmically breathe, moan, or chant during contractions. She may rhythmically tap or stroke something or someone. She may rock, sway, or dance in rhythm. She may even curl her toes in rhythm!

A partner’s (or doula’s) role is to enhance the rhythm and reinforce it through contractions. For example, if you’re breathing and swaying in rhythm, your partner can follow the same rhythm when rubbing your back. If you start to lose the rhythm during a contraction, your partner can help you find it again. If you aren’t coping well, your partner can help you find rhythm by dancing with you or directing you to breathe rhythmically.

Ritual

In labor, ritual is the repetition of a meaningful rhythmic activity during contractions. Relaxation, breathing (see page 223), and attention-focusing (see page 208) are common rituals that childbirth educators teach expectant women and couples. These planned rituals help women in early labor establish an effective coping style.

As labor progresses and intensifies, most women spontaneously adapt their planned rituals to increase their ability to cope, instead of struggling to maintain the planned ritual. That is, if they feel uninhibited and are free to move (change positions, walk, sway, rock, and so on), they’ll spontaneously adapt a ritual or find a new one to help them cope with labor pain.

A partner’s behavior and actions can influence the effectiveness of a ritual. If your partner is part of your ritual, he or she must not do anything to change it. Given the anxiety and uncertainty of labor, having someone act in the same way during each contraction will be enormously reassuring to you. Your partner’s job may include maintaining eye contact with you; holding, touching, or stroking you; swaying with you; repeating the same words or phrases; or counting your breaths through each contraction. If your coping style is to focus inward, your partner’s job simply may be to remain close by and do little but protect you from interruption.

Although it’s difficult to know beforehand exactly what you’ll do or need in labor, expect to change your ritual from time to time. If you begin to feel overwhelmed and can’t carry on with a ritual, look to your support team for help. Your partner, doula, or caregiver may be able to help you reestablish a ritual or create a new one.

If you plan to give birth in a hospital, be aware that it may be difficult to find your own ritual if hospital policies, routine procedures, or medical interventions limit your options or interrupt your rhythm. For this reason, make sure to practice a rhythmic activity that you can maintain during disturbances, such as self-talk (silent or vocal), tapping, or stroking. Your partner or doula can help you focus by maintaining the rhythm you established before the interruption, or by using the Take Charge Routine (see page 256).

Unplanned Rituals

The following are examples of unplanned rituals discovered by women in labor:

• Rocking in a rocking chair in rhythm with her breathing

• Silently repeating, “Be still like the mountain; flow like the river”

• Having her partner stroke her lower leg up and down in rhythm with her breathing

• Having her partner softly count her breaths and point out when she has probably passed the halfway point of the contraction

• Having her partner continuously repeat a word or phrase with her during contractions (One couple said, “Ruuusssh!” together through many hours of labor.)

• Having her partner move with her in a way that she finds comforting (One couple walked everywhere during labor—in the park, grocery store, and hospital. With every contraction, they’d stop, embrace, and sway until the contraction was over.)

Comfort Techniques for Labor

Most pain is associated with injury, illness, or stress. Labor pain, however, is associated with a normal, healthy body function. Recognizing that labor pain is a productive part of the birthing process is key to keeping the pain manageable.

As you prepare for labor, remember the Three Rs (see page 206). Think about what helps you relax, such as listening to music, having a massage, hearing soothing voices, taking a warm bath or shower, meditating, praying, chanting, humming, recalling pleasant places and activities, or visualizing empowering images. Then think about the people and objects that help you feel safe and comfortable, such as your partner, mother, sister, friend, or doula, as well as your pillow, nightgown, pajamas, or favorite photo. Plan to use these activities, people, and objects to help you relax or feel secure.

When rehearsing your response to contractions, try the following comfort techniques. You’ll probably prefer some more than others, but be ready to try more than one if a particular favorite loses its appeal during labor. Visit our web site, http://www.PCNGuide.com, to download a checklist of comfort techniques; use it to record the ones you prefer.

TUNING IN AND TUNING OUT

To cope with labor, you may find it most helpful to tune in to the pain by focusing on it, accepting it, and tailoring your response to it. Or you may prefer to tune out the pain by using distraction techniques, concentrating on outside stimuli, or performing mental activities.

ATTENTION-FOCUSING

During contractions, focus your attention to calm yourself and help keep your mind from wandering to pain or anxiety. (See page 178 to learn why distraction can help women cope with labor pain.) The following sections describe attention-focusing techniques that laboring women have used. Some techniques were planned before labor began, but many were unplanned.

Visualization

Closing your eyes and visualizing an encouraging or empowering image can help you cope with labor pain by “seeing” a goal or a positive way to interpret the labor process. Here are suggestions:

• Picture your uterine muscle contracting and pulling your cervix open. Visualize your baby pressing your cervix open.

• Imagine calm, pleasant places or recall happy, peaceful events.

• Like a gull soaring above choppy waves, picture yourself as lightly breathing above your contractions.

• Visualize each contraction as a hurdle to clear, a steep hill to climb, a race to run, or a wave to ride.

Cognitive Attention-focusing

By focusing on a mental activity, such as thinking or saying the words of a song, poem, verse, or prayer, you can direct your attention to the activity and away from the labor pain. You may plan this activity in advance. One woman imagined herself in labor as the “Little Engine That Could” and planned to say to herself as each contraction built to a peak, “I think I can, I think I can.”2 As each contraction subsided, she planned to repeat, “I thought I could, I thought I could.”

Conversely, you might not think of doing this activity until you’re in labor and find yourself choosing a word or phrase to use on the spot. One woman began rhythmically stroking her belly and chanting, “Keep stirring and you won’t boil over.” The day before she went into labor, she had become distracted while making fudge and had allowed the ingredients to boil over, so repeating this phrase seemed an appropriate way to prevent herself from becoming overwhelmed by her contractions.

Some women combine cognitive attention-focusing with physical activity. For example, they’ll rhythmically count along with rocking, swaying, walking, dancing, tapping, or stroking.

Visual Focus

Instead of closing your eyes to visualize a positive image, you may prefer to focus on an image within your sight. Here are some suggestions:

• Look at your partner’s face, a picture or design, a reminder of your baby (perhaps a toy or a bootie), a flower, or the view from your window. One woman chose to stare at a hole in her pillowcase—not an inspiring image, but it worked for her!

• Focus on a line, such as the edge of a window casing, and visually follow that line around the object during each contraction.

Sounds

Many laboring women use sounds as a way to focus their attention. To use this technique, try listening to your favorite music, your partner’s soothing voice, repeated rhythms, or a recording of rhythmic environmental sounds such as a pounding surf, rainfall, or babbling brook. Or you can make your own rhythmic sounds by moaning, sighing, counting your breaths, singing, reciting poems or prayers, or chanting. In the past, maternity care experts disapproved of vocalizing during labor and birth, but today many recognize its usefulness. Rhythmic moaning (or vocal breathing) isn’t the same as screaming in fear or panic. If you make rhythmic low-pitched sounds, like moaning, you’re using an effective technique for maintaining a sense of control while releasing tension. If your sounds are high-pitched, frantic, or nonrhythmic, your support team should guide you to make low-pitched rhythmic sounds instead.

BATHS AND SHOWERS

At most birthplaces, using baths and showers for pain relief and relaxation is an available option. A long soaking bath, whirlpool bath, or shower can be a marvelous comfort measure during labor. The warmth and buoyancy of the bathwater or the gentle massage provided by the showerhead or whirlpool jets can help your body relax.

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If you take a bath during labor, you may get instant relief or it may take up to twenty minutes before you feel relaxed. (Try to stay in the water for at least this long before giving up and trying another pain relief option.) When in the water, you can lean back against a bath pillow or folded towels. If the tub is large enough and you’re uncomfortable sitting up or lying on your back, try kneeling and leaning over the side of the tub (especially helpful for relieving back pain) or lying on your side with your head elevated on a bath pillow.

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Be sure the water temperature stays around your normal body temperature: 98°F to 99°F (36.7°C to 37.2°C). This temperature is warm enough that you can comfortably stay in the water for an extended period (possibly up to ninety minutes), but not so warm that you become overheated and need to get out of the water to cool off. If you let your body temperature rise, you’ll increase your baby’s temperature, which will cause her heart to beat too rapidly.

Advice from the Authors

If you’re planning a home birth, be aware that long showers or soaks in a large tub may use up your regular hot water supply before you’re ready to get out of the water. To ensure you’ll have enough hot water during labor, turn up the temperature on your water heater in advance. As a precaution against burns, leave a note that warns of the hot water temperature by each faucet in your home, and make sure to keep small children away from faucets.

If you take a shower, lean against the shower wall or sit on a towel-covered stool or birth ball so you can rest. Direct the spray where it best relieves tension. (Directing it against your lower back helps immensely to relieve back pain.) If you like (and if there’s room), your partner can accompany you in the shower or tub to provide additional comfort measures such as massage. (If you’ll be birthing in a hospital or birth center, make sure he or she packs a swimsuit.)

In the past, maternity care experts believed that letting a woman bathe after her membranes had ruptured would lead to infection; however, the results of several studies show that this belief is false.3 Rather, in addition to relieving pain, taking a bath or shower may lower blood pressure if it’s elevated and can affect labor progress. For example, taking a warm bath in early labor may slow down your contractions,4which is helpful if your labor progress has been slow and you need to rest. As a result, however, you may need a medical intervention such as the medication Pitocin to speed up labor later on. If you don’t want to slow down contractions in early labor, take a shower and use other comfort measures instead of taking a bath. In active labor, taking a bath often speeds up labor while delaying the intensity of the pain.5

FOODS AND FLUIDS

To keep up your energy in early labor, eat high-carbohydrate foods that appeal to you, such as fruit, pasta, toast, rice, and waffles. Also eat and drink easy-to-digest foods and beverages, such as soup, broth, and herbal tea. As labor progresses, you may become less interested in food; however, hunger (or low blood sugar levels) may decrease your tolerance for pain. You may lose your appetite when you begin active labor, but your need for fluids will continue. If labor progresses normally, you can sip clear broths, suck on Popsicles, or drink water, tea, juice, or sports drinks to quench your thirst and keep your body hydrated. Because a full bladder may slow labor and increase pain, be sure to empty your bladder often.

If you’re planning to give birth at home or at a freestanding birth center, your caregiver will probably encourage you to eat and drink during labor. If you’ll be giving birth in a hospital, find out the policy on eating and drinking during labor, so you’ll know what to expect in advance. Some hospitals have no restrictions against eating and drinking in labor. Other hospitals restrict eating throughout labor or after active labor begins, but permit drinking fluids. A few hospitals don’t permit women to eat or drink in labor, in case they need a cesarean section or require general anesthesia; however, this policy is controversial. A recent review of the research found no clear advantages or disadvantages of eating or drinking during labor for women at low-risk of needing general anesthesia. It concluded that women should be free to eat and drink in labor as they wish.6

If your caregiver won’t permit you to drink fluids in labor, your labor is prolonged, or you’re vomiting, you’ll probably receive fluids intravenously to prevent dehydration. A rolling intravenous (IV) unit allows you to move around, walk, and shower or bathe while receiving fluids. You may develop a very dry mouth; sucking on ice chips, a Popsicle, or a sour lollipop will help moisten it. You may also try brushing your teeth or rinsing your mouth with cold water or mouthwash.

Water Births

The idea of water birth appeals to some expectant parents as a relaxing and gentle way to bring a baby into the world, and they seek out a birthplace and caregiver that support this option. Many caregivers who attend births at homes and at freestanding birth centers (unaffiliated with a hospital) are comfortable with water births.

Sometimes a woman who hadn’t planned ahead for a water birth discovers during labor that a bath is so relaxing and helpful for relieving pain, she doesn’t want to leave the water when she’s ready to push. If she’s giving birth in a hospital, however, she might not have a choice. Although laboring in the bath is common in most U.S. and Canadian hospitals, few have policies that allow women to give birth in water. Many hospital administrators (and caregivers) have the following objections to water births:

• Concerns about the baby’s safety

• The caregiver’s need to master new techniques to facilitate birth positions and to protect the woman’s perineum

• The physical agility needed by the caregiver to deliver the baby

• Extra difficulty managing a difficult or complicated birth

• Other practical concerns, such as extra precautions for infection control (for example, shoulder-length gloves for caregivers and nurses) and insufficient room around the tub for access to the woman

Although these concerns can be addressed, few U.S. and Canadian hospitals do so. If you’re interested in learning more about water birth, visit http://www.waterbirth.org.

HEAT AND COLD

An electric heating pad or hot-water bottle on your lower abdomen, back, groin, or perineum relieves labor pain. Another soothing heat source is a cloth bag or sock filled with uncooked rice or other grain and heated in a microwave. You can also soak washcloths in hot water, wring them out, and apply them wherever you need relief. Wrapping these warm compresses in plastic retains their heat longer. If you’ll be birthing in a hospital, check whether there are any restrictions on heating devices brought from home. (If so, only warm compresses will be allowed.)

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A cold pack on your lower back can relieve back pain, too. (Ice packs may also soothe your perineum immediately after the birth.) Examples of cold packs include a cool wet cloth, a bag of ice cubes or frozen peas, frozen wet washcloths, cold cans of soda, or frozen gel packs used to treat athletic injuries (preferably those with straps so you can move about while wearing one). When using a cold pack, wear a warm robe or use a blanket to avoid feeling chilled.

Two Views on Comfort Measures

By the time we reached the hospital, my contractions were quite stunning! I was 3 centimeters dilated. I used the birth ball, but it seemed to increase the pain. The whirlpool tub saved me! I spent an hour in there, which helped me relax. When I got out of the tub, I’d dilated to 10 centimeters, so I could push.

—Clarissa

Once labor began, it felt natural and empowering to use the tub, birth ball, and breathing and vocal rhythms to process the pain. Thanks to those comfort measures and my doula’s and my husband’s gentle coaching, I was very aware throughout labor.

—Susan

During labor, your tolerance for heat and cold might be affected, and you might not notice that a compress is too hot or cold for your skin. To prevent injury, have your partner test the heat source or cold pack before applying it to your skin. He or she should be able to hold it in his or her hand for several seconds without pain. Have one or more layers of cloth between your skin and the heat source or cold pack to protect your skin and to let you adapt to the temperature change gradually. If you’re given pain medication that causes loss of sensation (such as epidural anesthesia), avoid using heat or cold on numbed areas to prevent skin damage.

COMFORT ITEMS

The following is a list of items that can provide comfort during labor. You may already have some; most others are easy to find.

• Rolling pin or rolling massage devices, plus other massage aids (for back pain—see page 231)

• Gardener’s foam knee pad (for kneeling on the bed, floor, or in the tub)

• Shawl or rebozo (for abdominal lift—see page 229)

• Warm blanket and socks (Hospitals typically provide only light cotton blankets.)

• Fan (Labor is often hard, sweaty work.)

• iPod or MP3 player (Listening to favorite music or motivating dialogue can provide encouragement and comfort.)

• Transcutaneous electrical nerve stimulation (TENS) unit (See page 231.)

• Birth ball (See below.)

You may have other objects in mind, but these items provide a good foundation for comfort and pain relief in labor.

Birth Ball

birth ball is the same thing as a physical therapy or fitness ball: a large inflatable plastic ball that provides a soft yet firm place to sit comfortably. Because the ball forces you to have proper posture when you sit on it, it can help decrease muscle strain.

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When in labor, you can use a birth ball to help with positioning and relaxation. For example, to help relax your trunk and perineum, sit on the ball and sway your hips from side to side during and between contractions. Or to help relieve back pain and adjust your baby’s position, place the ball on your bed, then either kneel on the bed or stand next to it and lean over the ball. Sway your hips from side to side or from front to back. The ball allows such movement to be comforting and almost effortless—a definite advantage when you’re tired from the hard work of labor.

Many hospitals and birth centers provide birth balls, but you may wish to own one. You can inflate it to your desired firmness and use it at home for comfort and for prenatal or postpartum Comfort Techniques for Pain Relief and Labor Progress

exercises. (You can also use a birth ball after the birth to soothe your baby by bouncing gently on the ball while holding him.) Birth balls are available at many chain discount retailers such as Target and Walmart, hospital physical therapy departments, sporting goods stores, and birth supply companies.

Birth balls come in different sizes. A ball with a 65-centimeter diameter is best for a woman of average height (63 to 70 inches). A much shorter woman may require a ball with a 55-centimeter diameter, and a much taller woman may require a ball with a 75-centimeter diameter. Make sure the ball is strong enough to hold your weight without bursting; a ball strength of at least 300 pounds should be adequate for most women.

Practice using a birth ball before your labor begins. Put one hand on the ball as you carefully lower yourself onto it. Use your other hand to hold on to someone or a stable object. With practice, you’ll be able to use the ball without support. Because the ball may get sticky or pick up germs from being on the floor, cover it with a towel before sitting or leaning on it.

MASSAGE AND TOUCH

Massage and touch are two of the most effective ways to direct your attention away from labor pain. Being massaged or touched in a manner that you find enjoyable can convey encouragement, reassurance, support, and love. Having someone firmly stroke, rub, or knead your neck, shoulders, back, feet, or hands can be soothing and relaxing. Having someone lightly stroke your back or thighs can also help with relaxation and pain relief. You may find relief if someone presses firmly on tense areas such as your hips, thighs, shoulders, hands, or lower back. Other tactile ways to focus your attention away from pain include tightly embracing your partner or directing the spray from a hand-held showerhead onto tense areas.

To relax and relieve pain by yourself, try lightly and rhythmically stroking your belly, following the lower curve of your uterus, imagining that you’re stroking your baby’s head. Or stroke your belly in circles with one or both hands. To make your hands slide more easily on your skin, dust your palms with cornstarch or baby powder. Breathe slowly as you massage your belly, matching your movements with your breaths.

Crisscross Massage

The crisscross massage can ease back pain and relax your lower back muscles during or between contractions. Here’s how you and your partner can practice this technique in pregnancy so it’s most helpful during labor.

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Kneel forward on your hands and knees or over a birth ball, or lean forward onto a counter, chair, or birth ball. Flex your hips so your thighs are about 90 degrees from your spine. Your partner stands or kneels next to you, facing your side. He or she then places a hand on each side of your body at the narrowest part of your waist, with the fingers on the far hand pointing down and the fingers on the near hand pointing up. (See illustration.)

Next, your partner firmly presses into your sides, then moves each hand up and over your back, following your waistline with each hand passing the other as it continues to the other hand’s starting place. Your partner then uses the same firm pressure to return the hands to their original starting positions. Have your partner repeat this motion for as long as you like, trying to match the movements with the rhythm of your breathing or moaning.

Acupressure for Comfort and Progress in Labor

By pressing a finger or thumb on a certain acupressure point, you or your partner may reduce your pain and speed up labor. The two most popular points are Hoku and Spleen 6. The Hoku point is on the back of your hand, in the V formed where the bones extending below your thumb and index finger come together. The Spleen 6 point is on the inner side of your leg, about the width of four fingers above your inner anklebone.

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Press your thumb steadily into the point for ten to sixty seconds, then rest for the same length of time before pressing again. Repeat this pattern three to six times whenever you want during labor. Be aware that these spots are sensitive and may hurt a bit when pressed.

Warning about Acupressure

Maternity care experts advise against pressing on the Hoku and Spleen 6 points before your due date, because doing so can cause contractions and may increase the risk of preterm labor. During your pregnancy, have your partner find these points on his or her body but not press them on your body until after your thirty-eighth week of pregnancy.

A NOTE TO FATHERS AND PARTNERS

Practicing comfort measures and relaxation techniques during pregnancy not only allows you and your pregnant partner to adapt them to your own style, but it also increases the likelihood that you’ll remember how to do them when under the stress of labor.

Here are suggestions for how you can practice together. Many of these tips will also be useful in labor.

• To signal the beginning of a practice contraction, your partner says, “Here it comes,” or begins to breathe rhythmically. You both practice coping techniques for the next thirty to sixty seconds, until she says, “It’s over.” Take turns starting the contractions so you both get used to beginning a coping technique whether you’re ready or not.

• To understand the effectiveness of a comfort measure, try this experiment: Each of you holds an ice cube in one hand for a minute while breathing rhythmically or using another comfort measure. Then switch the ice cube to the other hand and hold it for another minute without using the comfort measure. You’ll probably be surprised and reassured to discover how much better you tolerated the cold when using the comfort measure.

• If the above experiment helps your partner realize the effectiveness of a comfort measure, suggest that she hold ice cubes to simulate contractions as you practice other comfort measures together. It may help her determine which techniques are most effective.

• While practicing, try to detect any tension your partner is holding. Help her relax by touching or massaging her, talking to her, reminding her to move around, breathing with her, or steadying her breathing with a visual cue such as by moving your hand as though conducting an orchestra to keep a rhythm.

• Be aware of your facial expressions, tone of voice, and way of touching your partner. You’ll convey anxiety by having a troubled expression, speaking loudly or worriedly, and rubbing your partner brusquely or distractedly. You’ll convey reassurance and encouragement by having a confident expression, speaking soothingly, and massaging your partner smoothly and slowly.

Relaxation and Tension Release

Relaxation is the art of recognizing and releasing muscle tension; it’s the key to finding comfort during labor. Remaining relaxed is especially important during early labor, when contractions are usually manageable. If you consciously release muscle tension during early contractions, you’ll establish a habit of keeping relaxed during the intense contractions of active labor and transition. Conversely, if you tense up during early contractions, you’ll have trouble relaxing in later labor.

Here are just some of the benefits of relaxation during labor:

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Conserves energy and reduces fatigue

If you don’t consciously relax your muscles during contractions, you’ll probably unconsciously tense them. Tension wastes energy and increases pain and fatigue.

Calms your mind and reduces stress

A relaxed body leads to a relaxed state of mind, which in turn reduces stress. Anxiety, anger, or fear causes stress in labor, which produces excessive catecholamines (stress hormones) such as epinephrine (adrenaline) and norepinephrine (noradrenaline). High levels of these hormones can prolong your labor by decreasing the efficiency of your contractions and can harm your baby by decreasing the blood flow to your uterus.7 (See page 242 for more information on stress hormones.)

Reduces pain

Relaxation allows more oxygen to reach your contracting uterus, which may decrease pain because a working muscle becomes painful when deprived of oxygen. In addition, consciously releasing tension focuses your attention away from the contractions and reduces your awareness of pain.

RECOGNIZING MUSCLE TENSION

In order to release muscle tension, you first need to be able to recognize it. Try this exercise to practice recognizing muscle tension:

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1. Sit on a chair or the floor.

2. Make a tight fist with your right hand. Pay attention to how hard the muscles in your forearm feel. Touch them with your left hand.

3. Relax your right hand, letting it droop. Notice how soft the forearm muscles feel.

4. Raise your shoulders toward your ears and tense up. Notice how tight you feel when your shoulders are tense.

5. Lower your shoulders and relax. Then relax even further. Do you notice an additional release? You can often release residual muscle tension when you become aware of it.

PRACTICING TENSION RELEASE WITH YOUR PARTNER

As you become aware of muscle tension and learn how to relax, your partner also can learn how to recognize when you’re tense and when you’re relaxed by using the following methods:

• Observation (How do you look when you’re anxious, uncomfortable, calm, content, or asleep?)

• Touch (How do your muscles feel? Hard or soft?)

• “Floating a limb” (Your partner lifts one of your arms or legs, and moves the joints, feeling for the looseness and heaviness that signal relaxation.)

Help your partner practice spotting muscle tension by deliberately tightening the muscles of your arm or leg and having your partner locate the tense limb. If your partner assesses your body calmly and gently, you’ll develop confidence in his or her ability to help you relax in labor.

Once your partner has located the tension, find out what releases it. Your partner may touch or massage the area, place a warm compress on it, or simply remind you to let those muscles relax. You may explore other options together to determine what techniques best release your tension. See below for a discussion on relaxation techniques.

As you practice together, you’ll learn which muscles you tense most often (and thus may be the most difficult to relax). You may discover that you frequently tense your shoulders, forehead, mouth, jaw, or fists. These areas, or tension spots, should receive special attention as you practice relaxation and especially during labor.

Relaxation Techniques

Once you can recognize muscle tension in your body, the next step is to learn how to release that tension. By focusing on different parts of your body and consciously releasing the tension in them, you can relax both your body and mind.

Some women are able to relax more easily than others, but almost anyone can learn to relax with practice. The following sections describe several relaxation techniques. Try them all at least once, but practice only those that appeal to you and seem to best relax you.

When you first begin practicing a relaxation technique, lie on your side with plenty of pillows supporting you, or sit in a comfortable chair with your head and arms supported. After you’ve mastered the relaxation technique in this position, practice it while sitting up (or lying down, if your first position was sitting), standing, and walking. You’ll use various positions during labor, so you’ll need to be able to relax in any position.

Begin practicing a relaxation technique in a quiet, calm area. As you master the technique, progress to practicing it in louder, more active surroundings. Especially if you’ll be laboring in a hospital, you’ll need to be able to relax in a noisy, busy environment.

When you’re done practicing a technique, stretch your arms and legs and rise slowly (if seated or lying down) to avoid becoming lightheaded or dizzy.

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PASSIVE RELAXATION

This exercise calls for your partner to guide you through steps to relax your entire body, while you rest in a comfortable position. (If your partner is unavailable, use a relaxation CD to guide you. Consider playing pleasant, relaxing music each time you practice this technique. Playing the same music will help create a familiar and relaxed environment that you’ll find comforting when you use this technique during labor.

Practicing Passive Relaxation

To get into position for this exercise, lie on your side or sit in a semi-reclined position with the floor or bed supporting your head and limbs. Take your time getting comfortable. You may want to put pillows under or between your knees, beneath your head, or under your belly to increase comfort and support.

To practice this exercise, begin breathing slowly, easily, and fully. This is how you breathe as you fall asleep: Your body and mind release tension and thought, your breathing slows, and you pause slightly at the end of each inhalation and exhalation. (To see this process in action, observe the way someone else’s breathing gradually slows as he or she falls asleep.)

Next, have your partner read the following script in a calm, relaxed voice.

Script for Passive Relaxation

Have your partner read the following script calmly and slowly, letting you focus on releasing the tension in each area of your body. Take a couple of breaths after you release each area.

1. Yawn or exhale completely.

2. Focus on your toes and feet. Feel how warm and relaxed they are.

3. Think about how floppy and loose your ankles are. They’re relaxed and comfortable.

4. Now focus on your lower legs. Let those muscles become loose and soft. Good.

5. Now focus on your knees. They’re supported and relaxed—you’re not holding your legs in any position. Wiggle them to see how relaxed they are.

6. Think about your thighs. Their large, strong muscles are soft and relaxed, and they’re fully supported. Good.

7. And now think about your buttocks and perineum. This area needs to be especially relaxed during labor and birth, so just let it become soft and yielding. When the time is right, your baby will travel down the birth canal, and the tissues of your perineum will spread to let your baby make her way out. You’ll release, letting your perineum relax and open for your baby.

8. Focus on your lower back. Imagine that someone with strong, warm hands is giving you a lovely backrub. It feels so good. Your muscles are relaxing, and your lower back is comfortable. Notice the tension leaving your back.

9. Let your thoughts turn to your belly. Let those muscles relax. Let your belly rise and fall as you breathe in and out. Good. Now focus on your baby within your uterus. She’s floating or wiggling and squirming in the warm water of your womb—a safe place where you’re meeting all your baby’s needs for nourishment, oxygen, warmth, movement, and stimulation. Your baby hears your heartbeat, your voice, my voice, and other interesting sounds. What excellent care you’re giving your baby.

10. Now focus on your chest. As you inhale, your chest swells easily, making room for the air. As you exhale, your chest relaxes to help the air flow out. Breathe easily and slowly, letting the air flow in and flow out, almost as though you’re asleep. Good.

Now try inhaling through your nose and exhaling through your mouth—slowly and easily, letting the air flow in and out. At the top of an inhalation, notice just a little tension in your chest, which you can release with an exhalation. Listen as you exhale. Your breath sounds relaxed and calm, almost as if you were asleep. Every exhalation is relaxing. Use your exhalations to breathe away any tension. Good.

11. Focus on your shoulders and upper back. Imagine you’ve just had them massaged. Let those muscles release. Feel the warmth as the tension slips away.

12. Now focus on your arms. As you exhale, let your arms go limp—from your shoulders, all the way down your arms, to your wrists, hands, and fingers. Let them become heavy, loose, and relaxed.

13. And now your neck. All the muscles in your neck are soft because they don’t have to hold your head in any position. Your head is either comfortably balanced or completely supported, so just let your neck relax. Good.

14. Focus on your lips and jaw. They’re slack and relaxed. You’re not holding your mouth closed or open. It’s comfortable; no tension there.

15. And now your eyes and eyelids. You’re not keeping your eyes open or closed. They’re the way they want to be. Your eyes are unfocused and still. Your eyelids are relaxed and heavy.

16. Focus on your brow and scalp. Think about how warm and relaxed they are. You have a calm, peaceful expression on your face, reflecting a calm, peaceful feeling inside.

17. Take a few moments to enjoy these feelings of calmness and well-being. You can relax this way anytime—before bedtime, during an afternoon rest, or during a quiet break. This is how you’ll want to feel in labor. Of course, during labor, you won’t lie down all the time. You’ll walk, sit up, shower, and change positions. But whenever a contraction comes, you’ll let yourself relax all the muscles you don’t need to hold a position, and you’ll let your mind relax, giving you a confident, peaceful feeling. This feeling will help you yield to contractions, letting you focus on breathing and finding comfort through each one.

18. Now it’s time to end the exercise. Gradually open your eyes, stretch, tune in to your surroundings, and slowly rise. Take your time. There’s no need to rush.

RELAXATION COUNTDOWN

Once you’ve learned to recognize muscle tension and have mastered passive relaxation, use the following technique to release tension quickly. This exercise uses your breathing to create a wave of relaxation that passes from your head to your toes. It’s particularly helpful when you want to fall back to sleep, when you’re stressed, or when you’re trying to relax after a contraction.

Practicing the Relaxation Countdown

Inhale through your nose. As you exhale through your mouth, release muscle tension in the following order. By the time you count down to one, you’ll be fully relaxed.

5. Head, neck, and shoulders

4. Arms, hands, and fingers

3. Chest and abdomen

2. Back, buttocks, and perineum

1. Legs, feet, and toes

At first, use five slow breaths (one for each of the five areas) to count down to total body relaxation. Then try to relax all five areas while slowly exhaling one deep breath (rapid relaxation countdown).

During labor, you can use the first or last breath of each contraction as a rapid relaxation countdown to maximize tension release and reduce discomfort or pain.

TOUCH RELAXATION

For this technique, you relax or release tension in response to your partner’s comforting touch. During pregnancy, this exercise is a pleasurable way to practice relaxation. During labor, you’ll use your partner’s touching, stroking, or massaging as a cue to relax.

To begin this exercise, lie on your side or sit in a comfortable position. Next, contract a set of muscles (for example, stiffen one arm or leg) and have your partner use a firm yet relaxed hand to touch the tense area, molding his or her hand around the muscles. Release the tension and relax into your partner’s hand. Imagine the tension leaving that part of your body.

Have your partner try the following types of touch. Tell him or her which types you prefer, but be sure to practice all of them. Your preference may change during labor.

Still touch

Your partner places a relaxed hand on the tense area while you release the muscle tension until you’re relaxed.

Firm pressure

Your partner firmly presses on the tense area, then gradually relaxes the pressure as you release the tension.

Stroking

Your partner lightly strokes the tense area as you let the tension flow out. If stroking your arms or legs, he or she strokes in the direction of your fingers or toes. When stroking your belly, your partner may make circles.

Massage

Your partner firmly rubs or kneads your tense muscles. Give feedback on the amount of pressure that feels best to you.

Whenever your partner uses a touch relaxation technique, he or she should always keep one hand in contact with your body. When your eyes are closed, it’ll be hard for you to relax if your partner’s touch disappears, leaving you to wonder where and when it’ll reappear.

Practicing Touch Relaxation

Practice contracting the following muscle groups, then releasing them in response to your partner’s touch.

• Brow and eyes

• Jaw

• Neck

• Shoulders

• Arms and hands

• Abdomen

• Buttocks

• Legs and feet

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ROVING BODY CHECK

Sometimes you may think you’re entirely relaxed, but you’re still retaining tension in one or more areas of your body. This exercise helps you systematically release tension throughout your entire body, allowing for deeper relaxation.

Practicing the Roving Body Check

Get into a comfortable position and begin breathing slowly, rhythmically, and easily, inhaling through your nose and exhaling through your mouth. Focus on one area of your body with each breath. As you inhale, notice any tension in that area. As you exhale, deliberately release that tension. Then focus on another area. Note any tension as you inhale and release it as you exhale. Repeat, moving your attention from one area to another in the following order:

1. Brow, eyes, and eyelids

2. Jaw and lips

3. Neck and shoulders

4. Right arm and hand

5. Left arm and hand

6. Upper back

7. Lower back

8. Buttocks and perineum

9. Right leg and foot

10. Left leg and foot

Use the roving body check during or between labor contractions to make sure you’re releasing tension throughout your body. Your partner can help by telling you which area to relax with each exhalation, or by touching or stroking a different area with each exhalation. You may prefer to have your partner focus only on those areas you know are tense.

RELAXING IN DIFFERENT POSITIONS AND WHILE ACTIVE

During labor, you’ll use various positions and frequently move around to find comfort and to help your labor progress. For this reason, it’s important to practice relaxation techniques when you’re not lying down and inactive. Different positions require different muscle groups to support you, and your aim is to completely relax the muscles you don’t need to use while in a position. For example, you can’t relax your legs while standing, but you can relax your shoulders, arms, and face. Relaxing these muscle groups will help you achieve the same relaxed mental state you have while practicing passive relaxation (see page 216).

Movement and Positions for Labor

Moving around and changing positions allow you to discover ways to be comfortable during labor. Using different positions may speed up a slow labor by changing the shape of your pelvis and by using gravity, both of which help your baby rotate and descend into your birth canal. Changing positions can also affect your mind-set during labor. For example, being in an upright position may give you a greater sense of control and active involvement in your labor than when you’re lying down.

The following chart describes positions and movements that you can use during the first and second stages of labor. You may also find swaying from side to side, rocking, or making other rhythmic movements to be comforting. Plan to change positions at least every thirty minutes, especially if your labor progress is slow.

Positions and Movements for the First Stage of Labor

Position or Movement

• Standing

• Walking

• Standing and leaning forward on your partner, bed, or birth ball

• Slow dancing

• Lunge (See page 230.)

• Sitting upright*

• Sitting or rocking in chair

• Sitting, leaning forward with support

• Open knee-chest position (See page 229.)

• Semi-prone*

• Sitting on toilet or commode*

• Semi-sitting*

• Hands-and-knees*

• Side-lying*

What This Position or Movement Does

• Takes advantage of gravity.

• Makes contractions less painful and more productive.

• Helps your baby descend by lining him up with the angle of your pelvis.

• May speed up labor if you’ve been lying down.

• May increase your urge to push during the second stage of labor.

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• Same as standing, plus:

• Causes rhythmic shifts in the shape of your pelvis, nudging your baby to rotate and descend.

• Can tire you if you walk for too long.

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• Same as standing, plus:

• Relieves back pain.

• Is a good position for a back rub.

• May be more restful than standing.

• Encourages your baby to rotate if he’s occiput posterior (OP—see page 285).

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• Same as walking, plus:

• Enhances your sense of well-being, because a loved one is embracing you.

• Increases comfort through rhythm and music.

• Is a good position for your partner to give back pressure.

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• Widens one side of your pelvis.

• Encourages your baby to rotate if he’s OP.

• Can be done while standing or kneeling.

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• Is a good resting position.

• Uses gravity (to a degree).

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• Same as sitting upright, plus:

• May speed up your labor because of the rocking movement.

• May increase your comfort.

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• Same as sitting upright, plus:

• Relieves back pain.

• Is a good position to receive a back rub.

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• If your baby is OP and you use the position in early labor, gravity will encourage your baby to back his head out of your pelvis and rotate.

• Helps in early labor to relieve back pain and encourage cervical dilation.

• In later labor, reduces pressure on your cervix if it’s swollen.

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• Same as side-lying (see page 222), plus:

• May help your baby rotate into a position better suited for birth.

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• Same as sitting upright, plus:

• Helps with effective pushing and prevents holding back (because of the position’s association with bearing down to have a bowel movement).

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• Same as sitting upright, plus:

• Is an easy position to get into (on the bed or delivery table).

• Is a common birthing position.

• Disadvantage: May increase back pain and does not allow expansion of the pelvis.

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• Helps relieve back pain.

• Helps your baby rotate if she’s OP.

• Allows for pelvic rocking (see page 229).

• Takes pressure off hemorrhoids.

• May reduce premature urge to push.

• May slow a rapid second stage of labor because the position neutralizes the effects of gravity.

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• Is an excellent resting position.

• May reduce back pain.

• Helps lower your blood pressure.

• Is a safe position if you’ve received pain medications.

• Neutralizes the effects of gravity, making the position useful for slowing a rapid labor.

• Takes pressure off hemorrhoids.

• In the second stage, allows your sacrum to shift to create a wider opening for your baby’s descent.

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Positions and Movements for the Second Stage of Labor

Position or Movement

• Squatting

• Lap squatting

• Supported squat

• Dangle

What This Position or Movement Does

• May relieve back pain.

• Takes advantage of gravity.

• Widens your pelvic outlet (but may diminish your pelvic inlet, which is why this position is best to do in the second stage and not the first).

• May enable your baby to rotate and descend in a difficult birth.

• Is helpful if you don’t feel an urge to push.

• Allows you the freedom to shift your weight for comfort.

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• Same as squatting, plus:

• Reduces strain on your knees and ankles (when compared to squatting).

• Allows more support and requires less effort (ideal if you’re exhausted).

• Enhances your sense of well-being, because a loved one is embracing you.

• Disadvantage: If you’re much heavier than your partner, this position might not be possible.

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• Allows greater mobility of pelvic joints than any other position, and eliminates external pressure (from the bed, chair, and so on).

• Takes advantage of gravity.

• Lengthens your trunk, allowing more room for your baby to maneuver into position.

• Allows your baby’s head movements to change the shape of your pelvis.

• Disadvantage: Requires your partner to have strength enough to support you for long periods.

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• Same as the supported squat, except your partner sits so his or her legs are braced and well supported, making this position easier to sustain.

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For more information on labor positions, see pages 229–230.

* Can be used if you receive epidural anesthesia (although you may need support).

Breathing Techniques as Comfort Measures

When you swim, run, practice yoga, sing, or play a musical instrument, you need to regulate your breathing to perform effectively and efficiently. In this way, labor is no different from any other activity that requires physical coordination and mental discipline. Each childbirth preparation method focuses on some form of breath awareness because of the following benefits:

• Enhances relaxation.

• Helps reduce pain by supplying your muscles with oxygen.

• Provides a focus to calm you and distract you from pain. Breathing won’t make labor pain completely disappear, but it’ll help make pain more manageable.

The rhythm you’ll use to breathe during labor depends on your preferences and on the nature and intensity of your contractions. In early labor, you’ll likely use slow breathing for as long as it relaxes you. You may continue to breathe slowly for your entire labor, or you may switch to light breathing or some variation in late labor.

During pregnancy, try to master the breathing techniques described in the following sections, even though you might not use them all. You can’t be sure that your favorite techniques before labor will be the same during labor. Practice rhythmic breathing in the positions shown on pages 221–223. Use the illustrations accompanying the descriptions of the breathing techniques as a visual guide to the typical length and intensity of contractions.

You can combine rhythmic breathing with other comfort measures, such as moaning, movement, massage, tension release, hot or cold packs, bath, shower, and so on. Through practice, experimentation, and adaptation, you’ll discover how best to use and adapt the techniques to help you relax in labor.

AVOIDING HYPERVENTILATION

When you breathe too deeply or too quickly (or both), you exhale too much carbon dioxide, which alters the balance of oxygen and carbon dioxide in your blood and may cause hyperventilation(overbreathing). While rarely serious, hyperventilation makes you feel lightheaded or dizzy, or it can make your fingers, feet, or the area around your mouth tingle. If you’ve mastered rhythmic breathing before labor begins, you’re unlikely to hyperventilate during contractions. Without even thinking about it, you’ll adapt the pace and depth of your breathing to your changing needs in labor.

If hyperventilation occurs, try these suggestions to correct it:

• Breathe into your cupped hands, a paper bag, or a surgical mask (available if you’re in a hospital).

• Hold your breath after a contraction until you feel the need to inhale. This will allow carbon dioxide levels in your blood to normalize.

• Relax and reduce tension and anxiety, which can lead to hyperventilation. Taking a shower or bath, having a massage, using touch relaxation (see page 219), or listening to music may help you relax.

• Breathe with a slower rhythm or breathe more shallowly. Your partner can help you pace your breathing with a visual cue (such as by moving a hand as though conducting an orchestra to keep a rhythm), by talking to you in time with your breathing, by using rhythmic stroking, or by breathing with you. (Note: If your partner hyperventilates, he or she should use any of these measures to correct it.)

SLOW BREATHING

In labor, slow breathing can help calm you. The keys to the technique are keeping an even rhythm and trying to release tension during exhalations. Begin using slow breathing when your contractions become so intense that you can’t walk or talk through them or can’t be distracted from them. Use slow breathing for as long as it comforts you—probably until you’re well into the first stage of labor and possibly throughout your entire labor. Shift to light breathing or a variation if you strain to keep your breathing slow at the peaks of contractions.

Using Slow Breathing in Labor

Here are the steps that explain how to use slow breathing in labor.

1. As soon as a contraction begins, inhale fully and easily and sigh as you exhale, releasing all tension. Use this as your “organizing” breath or as a signal to your partner. If your partner is timing contractions (see page 175), he or she will note the time.

2. Focus your attention. (See pages 208–209.)

3. Inhale slowly through your nose and exhale completely through your mouth. Pause for a moment before you inhale. Take about five to twelve breaths per minute (this is about half your normal breathing rate).

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4. Inhale quietly, but keep your mouth slightly open and relaxed when exhaling so someone nearby can hear your breath. In labor, you may also vocalize or moan as you exhale.

5. Keep your shoulders down and relaxed. Relax your chest and belly so they can swell as you inhale. Your partner should touch you, move around you, and talk to you in rhythm with your breathing.

6. Signal to your partner as the contraction ends or take a final deep breath. You may prefer to yawn to mark the end of a contraction.

7. Completely relax, change positions, sip liquids, and do whatever you need to feel comfortable.

Rehearsing Slow Breathing for Labor

Rehearse slow breathing until you’re confident in your ability to use the technique for sixty to ninety seconds at a time (the typical length of a contraction). Practice it while in different positions. With each exhalation, focus on relaxing a different part of your body (see page 219 for the Roving Body Check) so you can relax every muscle that’s not required to maintain your position.

While practicing slow breathing, you may find it uncomfortable to inhale through your nose and exhale through your mouth. If this is the case, you can breathe only through your nose or mouth. You may find that you prefer letting your belly expand first, then your chest, as you inhale deeply (belly breathing). Or you may prefer letting only your chest expand as you inhale (deep chest breathing). However you practice slow breathing, make sure it’s rhythmic, calming, and relaxing.

LIGHT BREATHING

Light breathing helps you manage labor pain when you can no longer relax during contractions, when the contractions are too painful with slow breathing, or when you instinctively begin speeding up your breathing. Many women feel the need to switch to light breathing when contractions are close together and intense. When you’re in active labor, let your responses to contractions help you decide when to begin using light breathing. If your partner notices that you’re losing your rhythm, tensing, grimacing, clenching your fists, or crying out at the peak of a contraction, he or she may suggest switching to light breathing.

Using Light Breathing in Labor

Here are the steps that explain how to use light breathing in labor.

1. As soon as you feel a contraction begin, take a quick, shallow inhalation and signal to your partner that the contraction has begun. Exhale quickly to release all tension—go completely limp.

2. Focus your attention. (See pages 208–209.)

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3. Take short, light, and shallow breaths, inhaling and exhaling through your mouth—one breath every second or two. Keep your inhalations quiet (so you don’t hyperventilate), and exhale audibly either by emitting short “puffs” of air or by making light sounds. Continue light breathing in a steady rhythm. Let the contraction guide the rate and depth of your breathing. Keep your mouth and shoulders relaxed. Continue breathing in this way until the contraction ends.

4. When the contraction ends, use your last exhalation to “sigh” the contraction away. Then tell your partner that the contraction is over.

5. Completely relax and do whatever you need to feel comfortable, such as change positions, sip liquids, and so on.

Advice from the Authors

Tips for Partners When Practicing Light Breathing

During a one-minute practice contraction, interject encouraging words or phrases as you count your pregnant partner’s breaths. For example, say, “One, okay. Two, good. Three, let go. Four, just like that. Five, great….” During labor, the number of breaths she’ll take to get through a contraction won’t vary significantly from one contraction to the next.

This means you’ll be able to figure out when a contraction is at its peak and half over. When counting her breaths, point out when she has passed the halfway point—information she’ll be encouraged to receive. As one woman recalled, “Having my partner tell me when a contraction was half over seemed to cut its intensity in half. I knew that when I had passed the peak, I could make it the rest of the way.”

Rehearsing Light Breathing for Labor

When you first begin practicing light breathing, you may feel that the technique isn’t right for you. It may make you tense, or it may make you feel as though you’re not getting enough air. With practice, however, light breathing will become second nature and you’ll be able to work with your body much more easily during labor.

Also keep in mind that light breathing will come more naturally as your labor becomes more intense. Just as running makes you breathe faster to meet your oxygen needs, the rising intensity and frequency of contractions will increase your need for oxygen, which will naturally guide your breathing rate during labor.

Begin practicing light breathing by taking one breath every second or two, for ten seconds. If you take between five and ten breaths in that time, you’re doing the technique correctly. Continue breathing at this rate for thirty seconds to two minutes. When you can do light breathing effortlessly for two minutes, try the adaptations described in the following sections.

Notes:

• If you become lightheaded or dizzy while doing light breathing, try to focus on your exhalations, perhaps by making small sounds while exhaling, such as “hee-hee-hee” or “puh-puh-puh.” By doing so, your body will naturally inhale as much air as it needs.

• Breathing lightly through an open mouth may cause dry-ness. To help moisten the air that you breathe, try touching the tip of your tongue to the roof of your mouth just behind your teeth, or hold a moist washcloth near your mouth. During labor, you may also try sipping water or other fluids between contractions, or sucking on ice or a Popsicle. Brushing your teeth or rinsing your mouth occasionally may also help relieve a dry mouth.

ADAPTATIONS TO BREATHING TECHNIQUES

The following are ways to adapt rhythmic breathing by combining slow and light breathing patterns. During labor, try switching to one of these techniques to help you cope if you become overwhelmed or exhausted, can’t relax, or begin to despair. You may even discover a spontaneous rhythmic pattern of your own in labor.

Vocal Breathing

This technique combines slow or light breathing with vocalization. As you exhale with each rhythmic breath, you moan, sigh, count, sing, recite poems, recite affirmations, chant, or make or say other sounds or words. For example, one woman found that repeating, “One, two, three, Max!” (her baby’s name) let her maintain a rhythm and keep a sense of control during contractions. Another woman chanted, “Epidural, epidural” during contractions because she felt that as long as she could say the word, she didn’t need the epidural.

If you make sounds when vocal breathing and you’re coping well, they’ll probably be rhythmic low-pitched moans. Loud high-pitched sounds, especially if you’ve lost your rhythm, may indicate suffering or fear.

If your sounds are high-pitched and not rhythmic, your partner can ask, “Are the sounds you’re making helping you?” If they aren’t, then your partner can help you lower the pitch by moaning with you and maintaining your rhythm with the Take Charge Routine (see page 256). Of course, if making rhythmic high-pitched sounds helps you cope, then no one should try to make you change what you’re doing! Your support team should keep doors closed so you can make sounds without worrying about disturbing others.

Contraction-tailored Breathing

For this technique, use the intensity of the contraction to guide the rate and depth of your breathing. If your contractions are peaking slowly, breathe slowly when each contraction begins. As the contraction intensifies, quicken and lighten your breathing past the peak. As the contraction subsides, gradually slow and deepen your breathing. Think of each exhalation as a way to relax completely.

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If your contractions are peaking quickly, slow breathing won’t help you cope. Instead, use light breathing throughout each contraction.

Slide Breathing

Some women, especially those with a respiratory condition such as asthma, find that the quicker pace of light breathing makes them uncomfortable and tense, regardless of how often they practice the technique. If you can’t master light breathing after several practice attempts (see page 225), slide breathing is a good alternative. To do this technique, inhale deeply and slowly, then exhale with three or four light puffs of air. Pause, then repeat this process. To help guide your breathing, say “in” to yourself as you inhale, drawing out the word to match the length of your inhalation, then say “out” with each puff of air you exhale. Although the deep inhalations make slide breathing similar to slow breathing, the change in rhythm provides a different focus.

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Variable Breathing

Because variable breathing combines light, shallow breathing with a longer or more pronounced exhalation, it’s sometimes called “pant-pant-BLOW” or “hee-hee-HOO” breathing. Just as with slide breathing, variable breathing is an option for women who feel uncomfortable or short of breath when using light breathing. It’s also helpful for women who prefer their breathing patterns to have structure.

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With variable breathing, use light breathing for two to four breaths, then take another light inhalation followed by a long, slow, emphasized exhalation (the “blow”). This last exhalation helps you steady your rhythm and release tension. Some women emphasize it by making a drawn-out “hoo” or “puh” sound.

Find a comfortable pattern and then repeat it throughout the contraction. To help keep your rhythm, your partner can count your breaths: “One, two, three, BLOW!” Or you can count your breaths to yourself as a way to focus your attention.

Rehearsing Breathing Adaptations for Labor

When practicing breathing techniques, include your favorite adaptations and practice them while in various positions. Relax for only thirty seconds or so between practice contractions to prepare for the brief rest you’ll experience between contractions during the late first stage of labor. In this stage, contractions may last two minutes or they may occur in pairs with little break between the first and second contractions (coupling). During labor, you’ll need to be prepared to use light breathing or its adaptations for up to three minutes without losing your breath.

USING BREATHING TECHNIQUES TO AVOID PUSHING

During labor, you may have an early urge to push at the peak of a contraction. This urge is considered premature if it occurs before your cervix is completely dilated. If you have an urge to push and you don’t know if your cervix is completely dilated, alert your nurse or caregiver. He or she will confirm dilation by vaginal exam. If dilation isn’t complete, you’ll be asked to resist the urge to push. To avoid pushing, lift your chin and either breathe deeply, pant, or blow lightly until the urge subsides. You may find it helpful to say or sing “puh, puh, puh” or “hoo, hoo, hoo” with each exhalation. When the urge to push passes, resume rhythmic breathing for the rest of the contraction. Changing positions can also help reduce the premature urge to push (Try hands-and-knees, side-lying, and open knee-chest positions.)

These breathing techniques won’t take away your body’s urge to push. Instead, they’ll help you keep from holding your breath and bearing down with the urge.

Rehearsing Breathing Techniques to Avoid Pushing

When rehearsing breathing techniques, occasionally practice a premature urge to push. Hold your breath or grunt as you breathe to signal to your partner that you have an urge to push. He or she can remind you how to resist the urge until it passes. Rehearsing this technique can be silly and fun, but it’s also good preparation for avoiding premature pushing during labor.

Comfort Techniques for Back Pain, Slow Labor, or an Extra Challenging Labor

Certain circumstances may make it challenging to cope with contractions. For example, your contractions may begin to couple (occur in pairs with little break between the first and second contractions) or become irregular. Your labor may become prolonged. Your baby’s position in your womb may give you back pain. See page 285 to learn more about the possible positions your baby can assume, such as occiput posterior (OP) and occiput anterior (OA), and the effects each position can have on your labor.

The following sections describe measures that can help you cope with back pain or a slow or extra challenging labor.

POSITIONS AND MOVEMENT

To reduce the pressure of your baby’s head on your back or to help speed up a slow labor, use positions that encourage your baby to rotate into a better position, or use movements that decrease back pain.

Open Knee-chest Position

Get onto your hands and knees, then lower your head and chest to the floor or bed. Move your knees back enough so your hips are high in the air. (See illustration on page 221.) Try to remain in this position for thirty minutes. Your partner can help support you, if necessary. This position is best used during prelabor or very early labor to help eliminate back pain and possibly reposition an OP baby.

Leaning Forward

Positions that allow you to lean forward may help rotate your baby into the OA position and help keep him there. Examples include leaning over a birth ball, the labor bed, or a counter (while kneeling, standing, or sitting). The hands-and-knees position is also effective. These positions also relieve back pain by easing the pressure of your baby’s head against your sacrum.

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Pelvic Rocking

While kneeling and leaning forward over a birth ball or a chair seat, rock your pelvis forward and back or move your hips in a circle. The motion helps ease your baby up out of your pelvis, and the position encourages her to rotate out of the OP position.

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Abdominal Lift

While standing, interlace your fingers and place your hands palms up, beneath your belly and against your pubic bone. During contractions, bend your knees (to tilt your pelvis slightly) and use your hands to lift your abdomen up and slightly in. This movement often relieves back pain while improving the position of your baby.

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Because the abdominal lift can be hard work for you, your partner can do it using a woven shawl or rebozo. Fold the shawl so it’s about 5 inches wide, then position it around your waist and below your belly (the same place that you’d put your hands). Have your partner stand behind you and cross the ends of the shawl behind your back. During the contraction, your partner will pull on each end of the shawl to lift your belly. Adjust both the shawl and the strength of your partner’s pulling so the lift feels good.

Caution: If your baby wiggles a lot during the abdominal lift, he may be experiencing uncomfortable pressure. Discontinue the abdominal lift and use another comfort technique.

Standing, Walking, Slow Dancing, and Stair Climbing

These movements take advantage of gravity and help align your baby with the upper part of your pelvis (pelvic inlet) and encourage her descent into the birth canal. Moving also allows your pelvis to change shape slightly, which encourages your baby to rotate.

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Asymmetrical Movement and Positions: Lunge, Side-lying, and Semi-prone

The lunge, side-lying, and semi-prone are considered asymmetrical because one side of your body is doing something different from the other side. Try them on both sides of your body. If you’re more comfortable on one side than on the other, use that side to lunge or be in a side-lying or semi-prone position. If you have no clear preference, alternate sides.

Lunge

The lunge is usually done during contractions. Find a sturdy armless chair that won’t move when you lean against it. Stand in front of the chair, facing to the side. Lift the foot that’s closest to the chair and set it on the seat, with your toes pointing toward the back of the chair (so they’re at a 90 degree angle from the direction your body is facing). Remaining upright, slowly and rhythmically lunge sideways toward the chair (by further flexing your knee) and return to the starting position. You should feel a stretch in both inner thighs. Lunge throughout the contraction, then rest when the contraction is over. Repeat this exercise for five to seven contractions. If lunging is uncomfortable with one leg, try using the other leg during the next contraction. Continue lunging with the leg that feels best to you.

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Side-lying

Lie on your side with your hips flexed and your knees bent. Place a pillow between your knees. (See illustration on page 222.) Try switching sides about every thirty minutes whenever you’re awake, for as long as your baby’s heart rate is normal.

Semi-prone

Lie on your side with your lower arm behind you and your lower leg out straight. Flex the hip of your upper leg and bend the knee, resting it on a doubled-up pillow. Roll slightly toward your front. (See illustration on page 221.) Alternate this position with side-lying when you must remain in bed.

A NOTE TO FATHERS AND PARTNERS ABOUT RELIEVING BACK PAIN

The following measures can help reduce your laboring partner’s back pain and make her more comfortable. If any measure causes her more pain or doesn’t help her, discontinue it and try another comfort measure.

Counterpressure

Throughout each contraction, use your fist or the heel of your hand to steadily press on your partner’s lower back. Use as much pressure as she wants. You can give counterpressure while she’s in various positions. For example, when she’s in the hands-and-knees position or an upright position, hold the front of one of her hips with one hand (to help keep her balance) and press steadily and firmly in one spot on her lower back 4 to 6 inches below her waist, slightly away from her spine. The exact spot will vary over the course of the labor; she’ll let you know where to press to give her the best relief. Between contractions, rest or massage the area you pressed.

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Double Hip Squeeze

Have your laboring partner kneel and lean forward on a birth ball or chair seat, or get on her hands and knees on the bed or floor. (If on the floor, place a pillow or pad beneath her knees.) During a contraction, stand close behind her, then press on the roundest part of each buttock with your palms. Apply steady pressure (instead of pressing and releasing repeatedly) as you try to press her hips together to relieve pelvic pressure and ease back pain. Try other places on her hips to press and apply as much pressure as she needs.

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If another person is available to help, the two-person double hip squeeze is easier to do than the usual technique. Instead of standing behind your pregnant partner, you and the other person stand on opposite sides of her, facing each other. You each place one hand on the roundest part of the closer buttock, then together press on her buttocks. Be sure to coordinate timing and amount of pressure. Ask your partner if the pressure feels even, and adjust accordingly.

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Knee Press

Have your laboring partner sit upright in a chair that won’t slide when you press your weight against it. If necessary, elevate her feet so her thighs are parallel to the floor. Kneel in front of her and cup a hand over each knee. Lean toward her so your hands press straight back toward her hip joints. Keep the pressure steady throughout the contraction.

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OTHER COMFORT MEASURES TO REDUCE BACK PAIN

Heat and cold (see page 211) are excellent comfort measures to relieve back pain, as are baths and showers (see page 209). The following sections describe additional measures that you may want to try.

Rolling Pressure

Have your partner move a rolling pin over your lower back. This is a soothing way to relieve back pain and muscle tension during and between contractions. You may find additional relief if your partner uses a can of frozen juice, a cold can of soda, or a hollow rolling pin filled with ice, because the cold helps numb the area. If the rolling object is cold, make sure there’s a layer of cloth on your back so the object isn’t in direct contact with your skin.

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Transcutaneous Electrical Nerve Stimulation (TENS)

TENS relieves back pain during contractions by creating tingling, buzzing, or prickly sensations on your skin. According to the Gate Control Theory of Pain (see page 178), TENS reduces your awareness of pain by increasing your awareness of pleasant or distracting stimuli. Another theory to explain the effectiveness of TENS is that it gradually increases endorphin production in the area where it’s applied. Endorphins are your body’s natural pain relievers that block transmission of pain signals. If TENS begins in early labor, the level of endorphins in the lower back will increase by the time labor intensifies. Many women find TENS helpful for relieving back pain, but some don’t.

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TENS devices are simple to use. Four stimulating pads are placed on the back, then connected to a small hand-held battery-operated generator that produces tingling, buzzing, or prickly sensations. Models vary but all have controls to regulate the intensity of the sensation and to switch the pattern of the stimulation between a continuous mode and an intermittent burst mode.

Either you or your partner can hold and control the device. Between contractions, set the intensity to the level that feels comfortable and set the stimulation to burst mode. When the contraction begins, change the stimulation to continuous mode. When the contraction ends, switch it back to burst mode. As your back pain increases, increase the intensity.

Specially designed maternity TENS devices are widely available in Canada and the United Kingdom, but are hard to find in the United States. You may be able to learn more about TENS from a physical therapist who uses it to treat numerous pain conditions. If you plan to hire a birth doula (see page 23), she may be trained to use TENS and have a device to loan you. You can purchase a maternity TENS device online at a retailer such as http://www.bodyclock.net.

Although there are no known harmful side effects of TENS, be sure to check with your caregiver before using it.

Comfort Techniques for the Second Stage of Labor (Pushing)

Many of the comfort techniques used during the first stage of labor are also helpful during the second stage. Here are some ideas specific for helping you find comfort when pushing out your baby.

WORKING WITH THE URGE TO PUSH IN LABOR

Around the time your cervix becomes completely dilated, your breathing rhythm will change and you’ll feel pressure on your pelvic floor as your baby moves deep into your pelvis. These developments will cause you to have an irresistible urge to push. At first, you may mistake this urge for the need to have a bowel movement. (See page 255.)

Note: If you have an epidural, you’ll feel the urge to push much less clearly or you might not feel it at all. See pages 233–234 and page 259 for more information on directed or delayed pushing with an epidural.

SPONTANEOUS BEARING DOWN

Your responses to contractions during the second stage will depend on the sensations you feel. You’ll probably feel several strong surges (irresistible urges to push) during each contraction. Each surge will last a few seconds. During a surge, you’ll use expulsion breathing. Simply breathe using whatever technique suits you, until you have an urge to push and your body begins bearing down (a spontaneous reaction to the urge). Bear down for as long as you feel the urge. Then breathe lightly until either you feel another urge or the contraction ends. Expect to bear down three to five times per contraction, with each effort lasting about five to seven seconds. Between contractions, rest and relax.

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How hard you bear down in response to an urge is similar to how hard you sneeze in response to an irritant in your nose. Both sneezing and spontaneous bearing down are involuntary reflexes. Sometimes you need one tiny sneeze to clear an irritant; other times, you need several explosive sneezes. Sometimes you need to gently bear down; other times, you’ll feel compelled to push with all your strength.

Spontaneous bearing down is recommended if labor is progressing normally and you haven’t had anesthesia. If you have anesthesia, you’ll use delayed pushing (see page 259) or directed pushing (see below). Anesthesia diminishes the pushing sensations and the effectiveness of your ability to spontaneously bear down.

Using Spontaneous Bearing Down in Labor

Here are steps that explain how to use spontaneous bearing down in labor.

1. As the contraction begins, start slow or light breathing (see pages 224 and 225).

2. Focus on a positive image, such as your baby moving down and out of your uterus.

3. Breathe rhythmically as the contraction intensifies. When you can no longer resist the urge to push, bear down or strain while holding your breath or while slowly releasing air by grunting or vocalizing, whichever feels best. Relax your pelvic floor! (See page 96.) Your partner may need to remind you to relax your perineum.

4. Exhale when the urge passes (usually after five to seven seconds) and breathe rhythmically for several seconds until you feel another urge to push. Then, bear down again. The urge to push will come in waves during the contraction, giving you time to “breathe for your baby” (that is, to oxygenate your blood to provide enough oxygen for your baby between urges).

5. When the contraction ends, slowly lie or sit back (or stand up if squatting) and take one or two relaxing breaths.

Rehearsing Spontaneous Bearing Down for Labor

When practicing comfort techniques for the second stage of labor, bear down just enough to feel your pelvic floor bulge. (See page 96.) Don’t bear down forcefully. To practice more effectively, use different positions and imagine what will be happening when you’re pushing in labor. Visualize your baby descending and rotating into your birth canal. Remind yourself that contractions are proof that your baby is working to be born and it’s important to relax and bulge your pelvic floor.

DIRECTED PUSHING

Unlike with spontaneous bearing down, when you push in response to an urge, directed pushing is bearing down when someone tells you to do so. You’ll use this type of pushing in the following circumstances:

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• You’ve had an epidural and don’t feel contractions.

• You don’t have an urge to push or you’re not pushing effectively when spontaneously bearing down, even after trying gravity-enhancing positions such as squatting, sitting, dangling, lap squatting, or standing upright (see pages 221–223).

• Directed pushing is routine for your hospital or for your caregiver.

Directed pushing is typically more forceful than spontaneous bearing down, which means it may be more stressful for both you and your baby. For this reason, many caregivers reserve this type of pushing for births that may require forceps delivery or vacuum extraction. Before the birth, check whether directed pushing is routine for your caregiver or birthplace. If it is, find out when and under what circumstances it’s used.

Using Directed Pushing in Labor

Here are the steps that explain how to use directed pushing in labor. Your caregiver, nurse, or partner will tell you when, how long, and how hard to push. You can use various positions to do directed pushing.

1. At the beginning of a contraction, take two or three breaths. When you’re told to push, inhale and hold your breath. Curl forward, tucking your chin on your chest, and bear down, tightening your abdominal muscles.

2. Relax your pelvic floor muscles. Bear down for five to seven seconds. Quickly exhale as directed, then take another few breaths.

3. Repeat steps 1 and 2 until the contraction subsides.

4. When the contraction ends, slowly lie or sit back (or stand up if squatting), rest, and breathe normally.

Note: Directed pushing will continue for each contraction until your baby’s head is almost out. At that point, your caregiver may tell you to stop pushing to allow your baby’s head to pass slowly through your vaginal opening. Relax and exhale completely to decrease your risk of developing a vaginal tear.

Rehearsing Directed Pushing for Labor

Because with directed pushing you’ll be told when and how hard to push, you need to practice this technique only enough to coordinate holding your breath with bearing down and bulging your pelvis (see page 96), as your partner coaches you through the contractions as described above. You may find it helpful to occasionally hold your breath and bulge your perineum during perineal massage (see page 235).

PROLONGED DIRECTED PUSHING

In labor, prolonged directed pushing requires you to hold your breath and push hard for ten seconds. For those reasons, caregivers generally don’t recommend the technique, but some circumstances may require it. (See page 289.) Because you’d use prolonged directed pushing only under your caregiver’s guidance, there’s no need to practice it before labor.

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POSITIONS FOR THE SECOND STAGE OF LABOR

Just as moving around and changing positions can help with labor progress and pain relief during the first stage of labor, these comfort measures can help you during the second stage. Until you’re in labor and ready to push your baby out, you won’t know which positions will feel right. Try to practice spontaneous bearing down (see page 232) in all the positions shown on pages 221–223 so you’re prepared to effectively bear down while in any of them.

If your baby descends rapidly, you might not have the time or desire to change positions; however, if your second stage progresses slowly, you’ll have a chance to try many positions.

Other factors may influence the positions you can try during the second stage, such as your caregiver’s preferences or your willingness and freedom to change positions. Some procedures and equipment may impair your mobility, including electronic fetal monitors, catheters, anesthetics, IV equipment, and narrow beds. But with help and encouragement, you can safely work around these obstacles.

Discuss birthing positions when preparing your birth plan (see Chapter 8) Although some caregivers are comfortable with any birthing position a woman chooses to use,8 most are confident only with the supine (woman lying on her back) or semi-sitting position for delivery. Ask whether you can use other positions that allow the pelvic outlet to open fully during the beginning of pushing, until your baby is close to being born.

PERINEAL MASSAGE

Prenatal perineal massage stretches the inner tissue of your lower vagina. It teaches you to respond to pressure in your vagina by relaxing your pelvic floor muscles. In this way, it’s a rehearsal for responding to the sensations of vaginal stretching during birth.

Perineal massage is also thought to enhance the hormonal changes that soften connective tissue during late pregnancy, which can reduce your chances of needing an episiotomy (see page 289) or developing a serious tear during birth.9 Massaging your perineum five to seven times a week during the last five to six weeks of pregnancy may help you avoid an episiotomy or serious tear.

Some caregivers aren’t familiar with the benefits of perineal massage, and don’t recommend it. Even if their caregivers recommend perineal massage, some women find it distasteful and don’t want to do it. Others, however, feel the massage is worthwhile if it can reduce the chances of an episiotomy or a serious tear. Some even find it enjoyable, especially after they’ve learned to relax while it’s done.

Note: If you have vaginitis, a genital herpes sore, or another vaginal problem, perineal massage may worsen the condition. Wait until the problem is completely gone before beginning perineal massage.

How to Do Perineal Massage

You or your partner can do this massage with clean hands and short fingernails. If either of you has rough skin, consider using disposable vinyl or latex gloves. If doing the massage yourself, you may want to use a mirror at first, to help you see your perineum.

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1. Get into a semi-sitting position (if your partner is doing the massage—see page 222 for a description of the position) or stand with one foot on the side of the tub or a chair (if doing the massage yourself).

2. Use a squeeze bottle to squirt vegetable oil on your thumb or partner’s index finger(s). (Dipping your fingers into the oil can contaminate it.) Wheat germ oil has a high vitamin E content, which may be soothing on your skin. You can also use another vegetable oil or a water-based lubricant such as K-Y Jelly. Don’t use baby oil, mineral oil, petroleum jelly, or hand lotion—many women who used these products reported that their skin didn’t tolerate them well.

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3. Place your thumb, or have your partner place an index finger (one at first, then both as you become comfortable), well inside your vagina (up to the second knuckle). Do a few Kegel exercises (see page 95) so you can feel your pelvic floor muscles tense. Relax the muscles. Curl your thumb, or have your partner curl his or her finger, and gently pull it outward and downward toward your anus, then rhythmically move it within your vagina in a U motion. Focus on relaxing your pelvic floor muscles. Do this massage for about three minutes. At first, your vaginal wall will feel tight. After a few days of practice, it’ll relax and stretch more easily.

4. Concentrate on relaxing your muscles as you feel the pressure and stretching. As you become comfortable with the massage, increase the pressure just enough to make the tissue begin to sting or burn slightly. (The same sensation will occur as your baby’s head is being born.)

5. If you have questions after trying the massage, ask your caregiver, childbirth educator, or someone who’s familiar with this technique for advice.

Practice Time as a Rehearsal for Labor

When taking the time to practice these comfort techniques with your partner, try to think of it as a rehearsal for labor. Discuss when you may use the techniques and why. Review what you’ve learned about the emotional and physical events of labor. (See Appendix B.) Most importantly, learn how to work together to use the techniques effectively and adapt them to fit your needs.

AMOUNT OF PRACTICE TIME

You don’t have to practice every day to master comfort techniques, especially if you and your partner attend childbirth preparation classes together. Practice enough so you’re completely comfortable with each technique and have time to figure out any adaptations you may want to use. Then, review them periodically so they become familiar and easy.

SUGGESTED PRACTICE SEQUENCE

The following sequence will help you master the techniques discussed in this and other chapters. (Visit our web site, http://www.PCNGuide.com, for an additional practice guide.) You may choose to take a few months to complete the sequence, or you may decide to begin closer to your due date and finish it in a few weeks. Either way, practicing these exercises, breathing rhythms, and relaxation techniques will increase your confidence in your ability to handle labor and birth.

1. Conditioning exercises (see pages 95): Continue practicing these exercises until the birth.

2. Comfort measures for discomforts (see page 103): Use as needed.

3. Body awareness exercises (see page 215)

4. Passive relaxation (see page 216)

5. Relaxation countdown (see page 218): At first, use several breaths to relax, then work toward relaxing with one breath.

6. Perineal massage (see page 235): During the last five to six weeks of pregnancy, do five to six times a week.

7. Slow breathing (see page 224)

8. Touch relaxation (see page 219)

9. Roving body check (see page 219): Practice this exercise by yourself and with your partner’s direction.

10. Slow breathing with roving body check (see pages 224 and 219)

11. Attention-focusing (see page 208)

12. Crisscross back massage (see page 213)

13. Possible positions for the first stage of labor (see pages 221–222): Practice slow breathing in each position.

14. Light breathing (see page 225): Experiment with the depth and rate of your breathing to find what works for you.

15. Adaptations of slow and light breathing—contraction-tailored, vocal, slide, and variable breathing (see pages 226–227)

16. Variety of positions for the first stage of labor (see pages 221–222) while practicing breathing adaptations

17. Ways to decrease back pain in labor (see pages 229–232): Practice the double hip squeeze, counterpressure, abdominal lift, open knee-chest position, knee press, and lunge. Combine these techniques with breathing patterns.

18. Ways to avoid pushing (see page 228)

19. Spontaneous bearing down and directed pushing (see pages 232–234): Practice gently bearing down and incorporate the bulging exercise (See page 96). Occasionally, practice panting to avoid pushing in the middle of a practice contraction.

20. Positions for the second stage of labor (see pages 222–223): Try the positions while practicing spontaneous bearing down (expulsion breathing).

21. Labor rehearsal: Practice all the coping techniques during a series of pretend contractions. Your partner can help by observing you and helping you fully relax in all positions.

Key Points to Remember

• Every woman responds to labor differently, but those who cope well use the Three Rs: They relax during or between contractions; they move, breathe, and vocalize in rhythm; and they have a ritual during which they repeat the same rhythmic activities through many contractions.

• Figure out which comfort techniques may be most effective in labor by practicing them with your partner during pregnancy. Have pretend contractions while practicing techniques to make each practice session a rehearsal for labor.

• Mastering several comfort techniques and adapting them to suit your needs will increase your confidence and ability to cope with labor pain.

• When you’re in labor, be prepared to discover and use unplanned coping techniques and rituals.