History

The history of modern childbirth preparation began in the first half of the 20th century; however, it is important to review earlier changes in obstetric practice to understand the perceived need for a new approach. Before the mid-19th century, childbirth occurred at home in the company of family and friends. The specialty of obstetrics developed in an effort to decrease maternal mortality. Interventions initially developed for the management of complications became accepted and practiced as routine obstetric care. Physicians first administered anesthesia for childbirth during this period. The 1848 meeting of the American Medical Association included reports of the use of ether and chloroform in approximately 2000 obstetric cases.⁷ The combination of morphine and scopolamine (i.e., twilight sleep) was introduced in the early 20th century. These techniques were widely used, and influential women demanded that they be made available to all parturients.⁸ Together, these developments moved childbirth from the home and family unit to the hospital environment.⁹ Despite their desire for analgesia/anesthesia for labor and delivery, women began to resent the fact that they were not active participants in childbirth.

Beck et al.¹⁰ wrote a detailed history of childbirth preparation. Dick-Read^11,12 reported the earliest method in his books, Natural Childbirth and Childbirth Without Fear. In his original publication, he asserted his belief that childbirth was not inherently painful. He opined that the pain of childbirth results from a “fear-tension-pain syndrome.” He believed—and taught—that antepartum instruction about muscle relaxation and elimination of fear would prevent labor pain. He later established antenatal classes that included groups of mothers and fathers. Some readers incorrectly concluded that he advocated a return to primitive obstetrics, but this was not the case. Review of his practice reveals that he used the available obstetric techniques—including analgesia, anesthesia, episiotomy, forceps, and abdominal delivery—as appropriate for the individual patient. However, he cautioned against the routine use of these procedures, and he encouraged active participation of mothers in the delivery of their infants. Unfortunately, he did not use the scientific method to validate his beliefs.

Although Dick-Read was the earliest proponent of natural childbirth, it was Fernand Lamaze¹³ who introduced the Western world to psychoprophylaxis. His publications were based on techniques that he observed while traveling in Russia. Although his theories ostensibly were translations of teachings later published in the West by Velvovsky et al.,¹⁴ they contained substantial differences and modifications. The “Lamaze method” became popular in the United States after Marjorie Karmel¹⁵ wrote about her childbirth experience under the care of Dr. Lamaze. Within a year of the publication of her book Thank You, Dr. Lamaze: A Mother’s Experiences in Painless Childbirth, the American Society for Psychoprophylaxis in Obstetrics was born. Lamaze and Karmel published their experience at a time when organizations such as the International Childbirth Education Association and the La Leche League were formed.¹⁶ These organizations actively and aggressively encouraged a renewed emphasis on family-centered maternity care, and society was ripe for the ideas and theories promoted by these organizations. Women were ready to actively participate in childbirth and to have input in decisions about obstetric and anesthetic interventions. Childbirth preparation methods were taught and used extensively, despite a lack of scientific validation of their efficacy.

In 1975, Leboyer¹⁷ described a modification of natural childbirth in his book Birth Without Violence. He advocated childbirth in a dark, quiet room; gentle massage of the newborn without routine suctioning; and a warm bath soon after birth. He opined that these maneuvers result in a less shocking first-separation experience and a healthier, happier infancy and childhood. Although there are few controlled studies of this method, published observations do not support his claim of superiority.^18,19

Physicians were the initial advocates of the various natural childbirth methods. Obstetricians had become increasingly aware that analgesic and anesthetic techniques were not harmless, and they supported the use of natural childbirth methods.¹⁰ Subsequently, natural childbirth, like the methods of obstetric analgesia introduced earlier in the century, was actively promoted by lay groups rather than physicians.²⁰ Lay publications, national advocacy groups, and formal instruction of patients accounted for the greater interest in psychoprophylaxis and other techniques associated with natural childbirth.

Goals and Advantages

The major goals of childbirth education that were initially promoted by Dick-Read are taught with little modification in formal childbirth preparation classes today. Most current classes credit Lamaze with the major components of childbirth preparation, even though Dick-Read was the first to promote patient education, relaxation training, breathing exercises, and paternal participation.¹⁰ Box 21-1 describes the goals of current childbirth preparation classes. In addition, some instructors and training manuals claim other benefits of childbirth preparation (Box 21-2). Reviews by Beck and Hall²¹ and Lindell²² concluded that much of the research on the efficacy of childbirth education does not meet the fundamental requirements of the scientific method. Despite these shortcomings, childbirth preparation classes are widely available and attended.

Socioeconomic disparities exist in childbirth education class attendance.²³ In addition, the effect of childbirth education on attitude and childbirth experience depends in part on the social class to which the mother belongs. Most investigators have found that childbirth classes have a positive effect on the attitudes of both parents in all social classes, but this effect is more pronounced among “working class”²⁴ and indigent women²⁵; this latter finding probably reflects the greater availability and use of other educational materials by middle- and upper-class women. Childbirth classes often are the only—or at least the primary—source of information for working class and indigent women.

Limitations

Limitations of the widespread application of psychoprophylaxis and other childbirth preparation methods remain. Proponents assume that these techniques are easily used during labor and delivery; however, Copstick et al.²⁶ concluded that this assumption is not valid. They found that patients were able to use the coping techniques in the early first stage of labor but that the successful use of the coping skills became less and less common as labor progressed. By the onset of the second stage, less than one third of mothers were able to use any of the breathing or postural techniques taught during their childbirth classes.²⁶ The method of preparation influences the ability of the pregnant woman to use the breathing and relaxation techniques. Bernardini et al.²⁷ observed that self-taught pregnant women are less likely to practice the techniques during the prenatal period or to use the techniques during labor.

Childbirth preparation classes may create false expectations. If a woman does not enjoy the “normal” delivery discussed during classes, she may experience a sense of failure or inferiority. Both Stewart²⁸ and Guzman Sanchez et al.²⁹ have discussed the psychological reactions of women who were unable to use psychoprophylaxis successfully during labor and delivery. In addition, several women have written about their disappointment with the dogmatic approach of their childbirth instructors; these women described instructors who rigidly defined the “correct” way to have a “proper” birth experience.^30,31

Effects on Labor Pain and Use of Analgesics

Little scientific evidence supports the efficacy of childbirth preparation in mitigating labor pain. Psychology, nursing, obstetric, anesthesia, and lay journals provide extensive discussions of childbirth preparation, but most articles describe uncontrolled clinical experiences. Outcome studies often do not include a group of women who were randomly assigned to an untreated or a placebo-control group, and statistical analysis is often incomplete. Despite these shortcomings, supporters of childbirth preparation assume that it offers benefits for mother and child. Table 21-1 summarizes a few of the studies of Lamaze and other childbirth preparation techniques and their association with labor outcomes. The findings are not consistent. Some researchers have reported a decreased use of analgesics^32–35 or regional anesthesia,^32–36 shorter labor,³⁷ reduced performance of instrumental^32,34,36 and cesarean delivery,³⁶ and a lower incidence of nonreassuring fetal status,³⁶ whereas others have reported no change in the use of analgesics^36–40 or neuraxial analgesia,^38,39 length of labor,^{34–36,38–41} performance of instrumental^38–40 and cesarean delivery,^34,38–40 or incidence of nonreassuring fetal status.^33,34,37,39 These diverse findings may reflect different patient populations, poor study design, or researcher bias.

To elucidate the effect of the coping techniques taught in childbirth classes, several investigators have attempted to quantify changes in pain threshold, pain perception, anxiety levels, and physiologic responses to standardized stimuli. Several studies have evaluated nonpregnant and nulliparous women in laboratory settings,^42–45 and another study evaluated pregnant women in the antepartum, intrapartum, and postpartum periods.⁴⁶ Conclusions varied according to the stimuli applied, the coping techniques studied, and the parameters analyzed. Together, these studies suggest that practicing these techniques facilitates their efficacy and that newer cognitive techniques (e.g., systematic desensitization, sensory transformation) may be more effective than traditional Lamaze techniques of varied breathing patterns and relaxation. Further studies may help refine childbirth preparation to maximize the positive psychophysiologic effects.

Continuous Labor Support

Some techniques that require minimum equipment and specialized training are taught as integral components of childbirth preparation classes. Continuous support during labor is essential to the process of a satisfying childbirth experience; typically, the parturient’s husband or friend provides this support.^50,51 This support appears most helpful for the parturient who lives in a stable family unit. At least one study noted that husband participation was associated with decreased maternal anxiety and medication requirements.⁵¹ Others have found that emotional support provided by unfamiliar trained individuals (e.g., doulas) also has a positive effect.^52–55 Several studies have evaluated the benefits of emotional support provided by doulas or other unrelated individuals on the length of labor,^52,53,55 oxytocin use,⁵³ requirements for analgesia and/or anesthesia,^52,53 incidence of operative delivery,⁵³ and maternal morbidity.^53,54