Labor & Birth Positions. Comfort Measures. Medical Interventions.
Three BIG topics containing TONS of information for childbirth educators to cover, right?

I must admit, I had never thought it possible to address these three issues during a single 2 ½ hour class, there's just so much real estate to cover in each topic alone. And yet, last week, we somehow went over all of the above in one class session.

Again, the class started with a ~ 20 minute video about comfort measures for labor and birth which demonstrated body positioning, movement, vocalization and strategies employed by other members of the birth team. Sadly, when the class was given the opportunity to submit questions/comments to the group following the video, one of the women had only been able to focus on the pain. 'That whole video - everything it showed, it just looked like a whole lot of pain. Like never-ending pain.'

The woman's obviously traumatized perception was that the video had shown twenty minutes' worth of non-stop, painful labor contractions. And let's face it, that is a lot of what we see in many childbirth education videos. To this, the instructor adeptly explained that the video was intended to depict different ways women can cope with pain and discomfort associated with labor and that, to show women hanging out in between contractions wouldn't exactly be beneficial to the class. (One could argue the opposite - that there's a lot to be said for what a laboring woman and her support team do between contractions to help sustain her for the duration. But that's another blog post.) Listening to this exchange, I found myself recalling Penny Simkin's excellent post series about assessing pain versus suffering during labor and birth, and how important it is to teach expectant parents the difference between the two.

We next made use of the classroom which had been previously set up with labor position stations around its circumference. The instructor went around, demonstrating the positions indicated by taped-up signs ('dangle,' 'rocking on doula ball,' 'lunges' and the like) and then asked couples to rotate through the various stations, trying out the positions indicated by the associated sign. Myself, and another guest of the class - a new doula just completing her training - roamed the room along with the instructor, offering little suggestions here and there for maximizing the benefit of each position. The couples seemed to have fun trying out the different stations, discussing their likes and dislikes with each other. Some couples erupted into nervous laughter - others approached each station with studious intent.

***

After a quick break, we dove into medical interventions (and when I say 'dove,' I mean DOVE). Again, the discussion was preceded by a video on the topic. I was glad to see the BRAIN acronym presented in the video, as a reminder of how to approach a discussion about medical interventions with a woman's provider:

Benefits
Risks
Alternatives
Intuition
No/not now

Following this, the video discussed not ruling out the possibility of switching maternity care providers, should an expectant woman discover she is philosophically opposed to her provider's approaches to certain labor & birth practices. The video never suggested switching providers with abandon, but rather urged the importance of knowing ahead of labor and birth, whether or not a woman is mostly on the same page with her provider about medical interventions. And, in the case when irreconcilable differences exist, making the switch to a more like-minded provider just might be the best option available.

Again, I come to my love-hate relationship with childbirth education videos, and with how we address medical interventions, in general. There are certainly a variety of ways we can discuss medical interventions in childbirth education class: we can placate our expectant parents, by telling them 'not to worry' too much about medical interventions - turning decisions like these over to their providers entirely; we can scare the bejesus out of them by listing every single, solitary side effect that can, might be, and ever has been, associated with an intervention; we can list off the side effects with the speed and authority of an auctioneer, but then end with a blanket statement like, 'but that stuff hardly ever happens,' and then watch our students exit the room at the end of class looking like a deer-in-the-headlights, not knowing what to believe; we can make black and white lists of the pros and cons associated with each intervention - leaving ultimate judgments and decisions up to our students.

My point here? Handling 'the big talk' in our classes is tough stuff.

As much as many of us try to remain neutral in the presentation of material in our classes - delivering evidence-based information and guidance while taking ourselves and our opinions out of the equation - if there is a time in which personal bias will creep into childbirth education class, it's probably during 'the big talk.' Likewise, a careful observer can detect similar bias in the childbirth education videos.

Whether the information comes from a personal childbirth educator, a video, or an online childbirth education resource, the language used, the tone of voice, the background music - all of it influences how the information is received. For example, when discussing epidural analgesia, the narrator of the video we watched last week sweetly reassured viewers that 'the insertion point is below the spinal cord' [and unlikely to cause any nerve damage] and that it is generally considered 'safe pain relief.' Disclosure of risks associated with epidurals were limited to 'possible effects on early breastfeeding,' 'little known effects on the baby' and 'other rare, serious effects.' The inaccuracies presented here are, again, easily missed by a less discerning viewership and yet, no less important. Especially because much of the inaccuracy was in the form of information omission. For example, while the spinal cord does stop at the top of the second lumbar vertebra and therefore epidurals are typically inserted below the level of the cord, the cauda equina - strands of nerves extending from the spinal cord and serving both the lower limbs and the pelvis - extends down to the sacrum (or darned close) and well below the site of epidural insertion. Nerve damage from epidural insertion is not an impossibility. And certainly, there is now plenty of evidence pointing to effects of epidural analgesia on the fetus as well as the postpartum breastfeeding experience - enough, at least, to warrant more than a sweeping, watered-down caution. (Since I'm likely preaching to the choir here, I won't list the other well-known side effects of epidural analgesia.)

It's hard to deliver tough news. It really is. It's hard to face a room full of students, hopeful, excited and anxious about their babies' births, and tell them that the options which they may have perceived as making childbirth 'easy' or 'pain-free' are not without significant potential side effects. They are not, in fact, 'easy.' We already fight an uphill battle in our classes called 'fear.' More and more women (and men) approach childbirth with an embedded sense of fear, thanks to unfortunate media portrayals of birth and acquaintance-propagated horror stories. The last thing we want to do is add to that fear with a militaristic laundry list of all the bad things that can happen to a woman the second she steps foot into a hospital.

And yet, we balance this caution with the desire to properly educate.

In my mind, all the class sessions leading up to the talk about medical interventions serve a dual purpose: information dissemination and rapport building. Because, by the time you get to 'the big talk' you want to have established yourself as a well-researched educator who delivers 'just the facts, ma'am' with just the right amount of both tenderness and assertion. And when it comes to talking about interventions, scare tactics are generally translucent to most discerning audiences. But so is the glossing over method.

Expectant parents come to us with the desire for deep-rooted guidance: free of bias, free of drama and free of gloss. How much time are we spending setting the stage? Are we setting the stage so much that it gets in the way of information dissemination? How much time are we allotting to each (important) topic? How well are we delivering evidence-based information about childbirth choices and practices?

To you, reader, I ask: how do you approach the discussion of medical interventions with your expectant clients?

Posted by: Kimmelin Hull, PA, LCCE

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