Fundamentals of Relaxation Part 5 - Breathing

In spite of the new technology associated with labor and birth, women are still fearful.  Fear may come from hearing stories, reading articles, or simply by not knowing the full truth about the events of the birthing process.  An important aspect of relaxation for fear is breathing.

Any source that addresses fear, stress or anxiety will also address breathing.  Breathing is an effective and easy way to reduce stress and fear by decreasing the body’s reaction to the stress.  Slow, rhythmic breathing has been shown to lower blood pressure, reduce heart rate, and reduce the secretion of stress hormones such as cortisol. Relaxed breathing also balances O₂ and CO₂ levels and decrease muscle tension.

Behaviors for coping with severe fear of childbirth or SFOC were related to six domains of childbirth education relaxation: concentration or focusing, support from family or doula, breathing, relaxation and perception of control.  Since breathing helps to maintain focus and relaxation and hence perception of control, breathing seems to be a foundational skill to learn.

For decades, Lamaze has taught patterned breathing to offset the intensity of the contractions. Since Lamaze has become as synonymous to breathing as Kleenex is to tissues, many expectant parents come to childbirth class, regardless of the method, to learning breathing.  While Lamaze still offers instruction on breathing, it is not so much how one breathes as that one does breathing effectively.

In a 2011 article in the Journal of Perinatal Education, author Judith Lothian gives these guidelines for using breathing in labor:

• Breathing is easily subject to conscious control. Therefore, controlled breathing is easy to learn.
• Slow, deep breathing is particularly effective. The “right” way to breathe is whatever feels right. There are no rules related to how many breaths per minute, whether to breathe through the mouth or nose, or whether to make sounds. The key here is that the breathing is conscious, not automatic.
• As labor contractions get stronger and the work of labor gets harder, speeding up the breathing and making it shallower is sometimes, but not always, more effective.
• Focusing on something, either with eyes closed \or open, can help maintain the rhythm of the breathing.
• Using conscious breathing in everyday life, either to relieve stress or to increase body awareness and mindfulness, is excellent practice for labor. It is an excellent life skill.
• Conscious breathing works best in combination with many other comfort strategies. In Lamaze classes, women no longer spend large amounts of time practicing breathing. Women move, change position, slow dance, sway on birth balls, learn massage, and identify the countless other ways they normally relax and find comfort. Each of these comfort strategies can be used in combination with breathing.
• In restrictive environments, breathing may be one of very few comfort strategies available for women in labor. It is one coping strategy that cannot be taken away.

References:

Lothian, J. (2011) Lamaze Breathing: What Every Pregnant Woman Needs to Know.  Journal of Perinatal Education.  20(2), 118-120.

Salomonsson, B.  (2013). Self-efficacy in pregnant women with severe fear of childbirth.  Journal of Obstetrics, Gynecologic and Neonatal Nursing. 42(2): 191-202.

Turankar, A. et al (2013) Effects of slow breathing exercise on cardiovascular functions, pulmonary functions and galvanic skin resistance in healthy human volunteers – a pilot study.  The Indian Journal of Medical Research.  May 137(5): 916-21. 

FEAR - contributing to labor interventions and PTSD

It is called tocophobia .  

It affects 1 in 10 women.

And it seems to be ignored by maternity care literature.

Yet, an amazing study done between 2006 and 2007 in Sweden's Karolinska Institutet, shows that psychoprophylaxis does help in some cases.

What is tocophobia?  From the Greek word tokos meaning childbirth and phobos, meaning fear, tocophobia is the fear (irrational) of childbirth.  Women and men can experience tocophobia and can experience a fear of dying, fear of pain, fear of lack of pain relief and fear of deformity of the newborn.  Occasionally tocophobia is culturally associated, such as when negative feelings toward childbirth are passed from mother to daughter or after seeing a film depicting childbirth early in life with no support or educational explanation.

In the medical literature, tocophobia or severe fear of childbirth (SFOC) is seen addressed more in

psychological journals or those from Europe than in the North American continent.  Maternal confidence and self efficacy are common threads in discussions of tocophobia or SFOC.  From the Nethersole School of Nursing in Hong Kong, the author writes that the efficacy-enhancing educational intervention should be further developed and integrated into childbirth education interventions for promoting women's copying ability during childbirth. Not only did the educational intervention promote a woman's self-efficacy but also reduced their perceived pain and anxiety in the first two stages of labour.

Further research in the literature demonstrates that prenatal anxiety was significantly related to self-efficacy for childbirth in late pregnancy, labor pain, number of hours at home in labor and admitting cervical dilation, and interventions used during the labor.


Kathy McGrath demonstrates that fear has its place in birth and new mothers can benefit from it:

Giving birth is meant to shake us right down to our roots so that we come out of it changed and ready to take on the daunting tasks of mothering a new baby. When birth goes well, from an emotional as well as a physical perspective, we come out of it empowered, awed, and humbled. When it does not go well, we can enter motherhood feeling disappointed, disillusioned, and disempowered. The stakes are high.

As childbirth educators and doulas, we need to approach this fear with caution and respect.  Not only does fear of childbirth result in extended length of labor, arrested labors, increased using of induction or augmentation, cesarean delivery, instrumental delivery but SFOC can affect mothers during the postpartum period as well with an increased risk of post-traumatic stress disorder (PTSD).  Fear and lack of control are elements contributing to PTSD.

SFOC is not addressed in the typical office visit.  Childbirth education classes are often discouraged.  Why are women's fears being ignored?  Why do we send new mothers, traumatized by a difficult birth that validated their prenatal feelings of fear, home alone with little or no support?

Give expectant mothers an atmosphere where they can feel safe in sharing their fear(s), where they feel they are heard and not judged.  Acknowledge the fear and share with them psychoprophylaxis!

What is psychoprophylaxis?  Based on a method of preparing women for childbirth with education, psychological and physical conditioning and breathing, psychoprophylaxis soon became synonymous with Lamaze, after Dr. Fernand Lamaze brought the Russian style of childbirth preparation to the West in the mid 1950s.  Quite simply, psychoprophylaxsis (psycho means mind and prophylaxsis means prevention) gives expectant mothers the educational and practical techniques to understand the careful hormonal orchestration of birth and be empowered to use simple techniques to produce effects that are not only healthy for both mother and baby but truly define self-efficacy for birth and the postpartum period.

As Barbara Hotelling so brilliantly put it: 
We once lost touch with a caring model of birth, and we are fortunate to have that knowledge and the availability of that model again. Childbirth education must evolve from the technological curriculum to a physiologic study of how well women's bodies are created, not for being delivered, but for giving birth.

With physiologic birth as our guide, we can reduce or eliminate tocophobia.


References:

Bergstrom M. et al.  Fear of childbirth in expectant fathers, subsequent childbirth experience and impact of antenatal education: subanalysis of results from a RCT.  Acta Obstetricia et Gynecologia Scandinavica 2013 Apr 16.

Harris, R., Ayers S. What makes labour and birth traumatic? A survey of intrapartum 'Hotspots'. Psychology and Health 2012; 27(10): 1166-77.

Hotelling, B. Considerations when using videos in Lamaze Classes.  Journal of Perinatal Education 2012 Summer; 21(3): 189-92.

Hotelling, B.  From Psychoprophylactic to Orgasmic Birth.  Journal of Perinatal Education 2009 Fall; 18(4): 45-48.

Ip, W et al. An educational intervention to improve women's ability to cope with childbirth.  Journal of Clinical Nursing 2009 Aug; 18(15): 2125-35.

McGrath, K. The Courage to Birth.  Journal of Perinatal Education 2012 Spring; 21(2): 72-79.

Rouhe H. et al. Obstetric outcome after intervention for severe fear of childbirth in nulliparous women, a randomized trial.  British Journal of Obstetrics and Gynecology.  2013 Jan; 120(1): 75-84. 

Saisto T., Halmesmäki E. Fear of childbirth: A neglected dilemma. Acta Obstetricia et Gynecologica Scandinavica, 2003 82(3), 201–208