Relaxation and Child Birth

For most American women in labor they expect to be in unbearable pain, and to be begging for an epidural upon arriving at the hospital.  Images of purple sweat dripped brows come up when most people think of birth. However, with the use of relaxation techniques childbirth can be a calm, relaxing event. Use of Cognitive Behavior Therapies (CBT), especially   Behavioral Relaxation Training (BRT), a doula counselor- a professional birth partner (Simkin, Bolding, Keppler, Durham, & Whalley, 2010) trained to use microskills for influencing a client in positive ways (Ivey, Ivey, & Zalaquett, 2010, p. 25) There are a number of birth methods that use relaxation as their key component- Hypnobirthing the Mongan Method®, Hypnobabies®, Bradly Method®, and The Curtis Method. What all of these methods have in common, is that they use (CBT) relaxation as a way to teach women to relax. Gender normative wording will be used in this paper. It is important to change pronouns when the situation calls for it.

In CBT few intervention formats are as diverse, and as easily applied to so many situations, as that of Relaxation. Relaxation can be used for stress, hypertension, muscle tension, tachycardia, and even child birth (O’Donohue & Fisher, 2009, Location 17992; Gedde-Dahl & Fors, 2012). Relaxation is a technique all in of itself, but it also uses other CBT interventions as well, including mindfulness, guided imagery, and diaphragmatic breathing.

Relaxation especially “progressive relation” and “systematic desensitization” work with the fact that only one of the two Autonomic Nervous System parts can be working at a given time in a muscle group- the sympathetic and the Parasympathetic ("ANS," 2014). When the sympathetic is engaged muscles are tense, and a fight or flight response happens. This causes sphincters to close, and remain closed- including the cervix and perineum.  In progressive relation and systematic desensitization, a client will contract and relax different muscle groups to learn to relax the whole body (O’Donohue & Fisher, 2009, Location 18021). Contractions are just natural waves of muscles tightening and relaxing (Mongan, 2005). The relaxation techniques of engaging muscles, and thinking of it as normal, and practicing relaxing all muscles after a natural tension has engaged, always a mother to work with the normal patterns of labor, and can reduce the pain and stress involved. BRT is a five-part relaxation therapy designed so that a counselor can instruct a client to relax when their behaviors call for it (O’Donohue & Fisher, 2009, Location 18048), in this case in preparation and during childbirth.

Before teaching BRT for childbirth the mother should be informed of the importance of mindfulness. Mindfulness is simply being in the moment (O’Donohue & Fisher, 2009, Location 14522). While a mom is labor remind her to keep her mind on exactly what is happening. This lets her feel in control of the events going on in her body. She can focus on the sensation of her muscles moving up and down combing mindfulness and systematic desensitization. She can feel the decent of the baby, experiencing the passage through the pelvis and out. Awareness of her body give a mother the ability to control tearing, because she will be in the moment as her baby is at the perineum and can control her body stretching.

Start BRT by have the mother and her birth partner get comfortable and use blankets and fans to control the temperature. Allow the couple to lay on the floor, in a recliner or holding each other. For home practice of these techniques use recorded guided imagery that tells the couple to get comfortable (O’Donohue & Fisher, 2009, Location 18139).  When using this step during childbirth make the birthing space as inviting as possible. The lights can be off. A sign can be placed on the door requesting respect of a relaxation space. Most birthing centers, and some hospitals permit unscented candles. Affirmations can hang around the room. Practice with music on, and play it during the birth, this will give a conditioned response (O’Donohue & Fisher, 2009, Loation 20709) for relation in any space. Do not feel that you have to stay in one position, or restrict movement. Being comfortable in your surroundings is critical to relaxing in birth; having freedom of movement can help a mother relax, and even rest, more than laying on her back in a bed (Shilling, Romano, & DiFranco, 2007).

Next BRT has you remind the couple of why they are doing this, and the importance of practicing this skill just as if it was any other skill.  A study by Chang et al (2015) on adherence to practicing relaxation for childbirth, 58% of the 57 participants in the experimental group completed daily 13-minute guided meditation sessions until the birth of their child. They saw increased adherence rates for those with higher SES and/or college degrees. Because of this adherence rate of 1 out of every 2 not practicing it is crucial for doula counselors to reiterating the importance of practicing to get the most benefit from relaxation. Gedde-Dahl and Fors (2012) found value in practicing with a guided relation cd 24 times prior to labor; further showing the value in emphasizing the importance of practicing this skill. During labor, especially during transmission when a panic state tends to kick in (Simkin et al, 2010), remind the mother that she is bring a baby into the world. That she is the only one who can do this. That she IS doing this. Positive regard and repeating her affirmations can relax a mother. Having her become mindful of the moment is important. If there is a pain or panic moment, observation of emotion and body language (Ivey, Ivey, & Zalaquett, 2010) should be used as the tools the doula counselor utilizes to know what the mother needs to continue to relax. The second step of BRT is about continually reminding the mother of their goals.

Step three is two parts, the first is breathing. Diaphragmatic breathing techniques (O’Donohue & Fisher, 2009, Location 6191) encourage mindfulness, and reduce panic by switching from the sympathetic to the parasympathetic nervous system. Take breaths from the lower abdomen- the location of the diaphragm (O’Donohue & Fisher, 2009, Location 6322)- slowly inflating like a balloon. On the exhale allow your breath to slowly release. Hypnobirthing The Mongan Method says to release for a count of 20 (Mongan, 2005, p. 111), however any slow count will help relax the body.  The muscles in the diaphragm can help calmly move baby down, when a mom holds her breath, it works against muscle relaxation and can make delivery more difficult for both the mother and baby (Mongan, 2005, p. 112). The high quality of breath that comes from diaphragm breathing helps to oxygenate both the mother and baby. There is one time during birth that relaxation breathing can be counterproductive. This is when the mother is experiencing the “ring of fire- a burning sensation showing that the perineum needs time to stretch (Simkin et al., 2010, Chapter 9).” The ring of fire is while the baby is crowning and only takes a few moments, though to a mother in a mindful state it may feel like it takes much longer. Taking fast shallow breaths will cause the body to want to close the sphincter. Though this may sound like the reverse of the desire to relax the muscles for ease of movement, this give the perineum the time it needs stretch to avoid tearing. Once the body feels like it has stretched enough, and a mother who is in a state of relaxed mindfulness will be able to feel a difference, controlled diaphragmatic breathing can resume and the baby can be born.

The second step of the third stage of BRT is locate parts of the body that are not in a relaxed state. Relaxing the throat and forehead can help open a cervix. Tension in the shoulders and back prevent overall relaxing. The mother should use the techniques from systematic desensitization to tense and release these muscle groups (O’Donohue & Fisher, 2009, Location 18209).

The fourth step involves correcting any behaviors (CBT, location 18234). This should be actively done during any practices sessions observed by the doula counselor, and during the child birth.

The fifth and final stage is observation (Ivey et al., 2010, p. 131), active listening (Ivey et al., 2010, p. 151), and emotional awareness (Ivey et al., 2010, p. 182) of the mother by the doula counselor to discover what is and isn’t working. The doula counselor should make adjustments accordingly to maximize relaxation.

Cultures can change how a mother acts while in a relaxed mindful birth. Some women when they tap into this state will becomes very vocal and full of movement (Shilling et al., 2007). Cultures when child birth is a celebration may choose to incorporate drums, chanting, and other primal instincts. When working with women from highly patriarchy societies do not be surprised if the women are timid and small in there sounds and movement. Being silent during child birth is highly prized in these cultures, an example of this is how the women birth in the Fundamentalist Latter Day Saint (FLDS) culture (J. B. Allan, personal communication, May 5, 2016). As a doula counselor I have personally observed times when a mother’s culture spurred her to be full of movement- often these are women who love dance or are Goddess worshipers. I have also seen FLDS midwifes think less of women who are loud and full of movement.

 

Relaxation during pregnancy and birth can have positive effects on the outcomes for both mothers and infants. According to Gedde-Dahl and Fors (2012, p. 62) mothers have an increased sense of wellbeing postpartum having practiced relaxation with a guided relaxation cd 24 times prior to labor (2.7 vs. 4.2; t = 2.14, df = 46), p < .05 on an independent t-test), though they could not rule out a placebo effect. A study that randomized pregnant mothers into control and experimental groups, where the experimental group was taught relaxation techniques found positive outcomes for infants. The infants whose mothers were in the experiment group had statistically significant increases in height and in infant reflexes (Toosi, Akbarzadeh, Zare, & Sharif, 2013). A study that used relaxation techniques for women who were a risk for preterm labor- dilated to a 3 or higher between 20 and 30 weeks- found benefits to both the mother and the infant. The mothers in the experimental group had longer pregnancies than those in the control group. Less experimental group infants required any NICU stay and those that did require the NICU, their stays were shorter (Chuang et al., 2012).  One surprising find is that neither Toosi et al. (2013) nor Chuang et al. (2012) found any statistical difference in the apgar scores at 1 or 5 minutes for those whose mothers did, or did not, use relaxation during pregnancy and labor. My person hypothesis would assume increases in oxygen from controlled breathing would increase apgar scores.

 

I have been using relaxation with pregnant and laboring women to good effect. I will continue to use these CBT skills with future clients. With the science supporting what I have personally observed, I feel more confident in my continued use of these techniques.

 

 

References

Autonomic Nervous System. (2014). Retrieved from https://faculty.washington.edu/chudler/auto.html

Chuang, L., Lin, L., Cheng, P., Chen, C., Wu, S., & Chang, C. (2012, March). The effectiveness of a relaxation training program for women with preterm labour on pregnancy outcomes: A controlled clinical trial. International Journal of Nursing Studies, 48(48), 257-264. http://dx.doi.org/10.1016/j.ijnurstu.2011.09.007

Chuang, L., Liu, S., Chen, Y., & Lin, L. (2015, September). Predictors of Adherence to Relaxation Guided Imagery During Pregnancy in Women with Preterm Labor. Journal of Alternative & Complementary Medicine, 21, 563-568. http://dx.doi.org/10.1089/acm.2013.0381

Gedde-Dahl, M., & Fors, E. A. (2012, February). Impact of self-administered relaxation and guided imagery techniques during final trimester and birth. Complementary Therapies in Clinical Practice, 18, 60-65. http://dx.doi.org/http://dx.doi.org/10.1016/j.ctcp.2011.08.008

Ivey, A. E., Ivey, M. B., & Zalaquett, C. P. (2010). Intentional interviewing & Counseling (7th ed.). Belmont, CA: Brooks/Cole.

Mongan, M. F. (2005). Hypnobirthing- The Mongan method (3rd ed.). [Nook]. Retrieved from

O’Donohue, W. T., & Fisher, J. E. (2009). General principles empirically supported techniques of cognitive behavior therapy. [Kindle DX].

 Bartholomew, P. (n.d.). Paul Bartholomew Production. Retrieved May 19, 2016, from http://www.paulbartholomewproductions.com/#videoproduction-1 

Shilling, T., Romano, A. M., & DiFranco, J. T. (2007, Summer). Care Practice #2: Freedom of Movement Throughout Labor. Journal of Perinatal Education, 16, 21-24. http://dx.doi.org/10.1624/105812407X217101

Simkin, P., Bolding, A., Keppler, A., Durham, J., & Whalley, J. (2010). Pregnancy, childbirth, and the newborn: The Complete guide (4th ed.). [Kindle DX]. Retrieved from

Toosi, M., Akbarzadeh, M., Zare, N., & Sharif, F. (2013, Spring). The role of relaxation training in health index of infants in pregnant mothers. Journal of Jahrom University of Medical