I've started some doula discussions on facebook. If anyone is interested here is what we'll be discussing. If you want to join in go to my facebook page at http://www.facebook.com/pages/The-Beginning-of-Motherhood/175908596269
For these discussions I'll give a research article and some scenarios...then present some discussion questions. I'll usually give a scenario that is based solely off of comfort and another scenario that is more clinical. I would love to hear all your experiences in relation to the research and what you have or have not encountered.
Here's a link to the research article that I'll be discussing....
http://www.ncbi.nlm.nih.gov/pubmed/9892892
For those who want the whole article you can buy it for a price.
From the article's introduction is this quote..."Patterned breathing is a major element of childbirth education. It is applied widely and is considered an effective way of managing pain and stress during labor. Nurses midwives physicians and doulas enourage this breathing to distract the laboring woman from her pain and also to involve the partner in her care....Used correctly patterned breathing is purported to maintain oxygenation of mother and baby...increase relaxation...decrease pain and anxiety...and provide a means of focusing attention...No research studies were found that documented the effectiveness of these techniques but they are part of accepted practices in labor and delivery education...In anecdotal reports many nurses have questioned if patterned breathing techniques tire women when they are begun too early in labor".
"The findings suggest ways to use patterned breathing in managing the first stage of labor. During the latent phase of labor the raw fatigue scores increased as the complexity of the type of breathing pattern increased(Table 1). For the latent phase the differences in scores were statistically significant suggesting that the most appropriate management of women in the first stage of labor is to postpone the patterned breathing until the active phase. The paced type of patterned breathing related to the highest fatigue scores which were found in women in latent labor. This suggested that women should not be encouraged to begin using paced breathing during the latent phase and that traditional breathing should be approached cautioulsy if at all.
During the active phase differences among breathing types were less pronounced and were not statistically significant. Hence it may be appropriate for nurses midwives physicians and doulas to recommend traditional and paced patterned breathing when women shift into active labor".
In this research patterned breathing was both slow breathing and paced(a quicker pace of breathing). For more info on different types of breathing go to this link: http://www.babies.sutterhealth.org/laboranddelivery/labor/ld_breathe.html
1st scenario:
Melissa is a first time mom that started labor at 7pm on a Mon. night. Her contractions started out at a half hour apart and so she paced her house to try and get them closer together. At this point her contractions were mild cramps and very manageable. By 11pm they were 5m apart and stronger. When she went to the hospital however she was only 2cm dilated. At this point her contractions felt like strong menstrual cramps. They were ones that she would call painful but do-able. She had wanted to try a natural labor though and felt ok about going back home for awhile.
Melissa had taken a short childbirth class and she started doing slow deep breathing through her contractions while continuing her pacing. Her contractions remained about 5-7 m apart. The breathing helped her focus on something else for a while but by 2am she was very tired. She decided to take a bath and try and get some sleep. While in the bathtub she noticed that her contractions slowed down to about 10-12 min apart. This made her a little anxious that she wasn't progressing enough but she was so tired that she layed down afterwards anyways. She had a restless night of sleep as she would wake up every so often with a contraction.
At 5am she got up to eat breakfast and noticed her contractions pick up to about 5m appart again. At this point she was using slow breathing and focusing inward to work through contractions. They were getting hard to work through and she was very tired. She remembered that her classes talked about a different kind of breathing that was faster paced. She switched over to that one to see if it would help more.
She found that these helped to distract her more but took more energy out of her. She decided to go to the hospital again at this point. While at the hospital she was 3cm dilated with contractions3-5m apart. She was using the paced breathing as these still seemed to help distract her. While there they had her walk around for an extra hour because she a changed a little bit but was also spotting a little. Two hours after getting to the hospital she was 4cm dilated.
Melissa felt like the contractions were getting very difficult and she could feel her exhaustion pulling her down. After another hour in the hospital and doing the paced breathing she felt like it might be best to get an epidural to help her rest a little bit more. Her baby was born at 12 noon.
Questions:
1. Was the use of patterned breathing here appropriate or inappropriate?(Keeping in mind the research article and also your own experiences)
2. What else might have helped Melissa to cope with this labor?
3. What could have been done to help with her fatigue?
4. How might patterned breathing been used differently?
2nd Scenario:
Sandy was having her second baby and had been admitted to the hospital at 5cm dilated at 3pm. She had brought a doula with her to help her with this labor as she was not wanting to use any medications. While at the hospital she had been using the tub and a birth ball to cope with the contractions.
After an hour in the hospital she wanted to know how far dilated she was. When she got out of the water though she could feel the contractions getting harder to cope with. Her doula could sense the change and started reminding her to try taking some deep abdominal breathes during her contractions. These helped Sandy refocus and continue with her labor even while the nurse was checking her.
She was 7cm after that check and Sandy could feel the contractions getting stronger. She started to panic at one point but then found that it was helpful to do more of a patterned breathing as she had been taught in her childbirth class. The rhythm of the breathing helped her to cope better. At 4:30 Sandy felt the urge to push and a little boy was born a half hour later.
Questions:
5. As labor support how can we help a woman find her own pattern of breathing that helps her cope?
6. Is it appropriate to make them breath with you when you feel they are not coping?
7. If this woman had not previously taken any childbirth classes and did not know about patterned breathing how would you help teach her this while in labor?
For these next two scenarios I wanted to add a little bit more information that will help with decision making...
When a practitioner is watching the babies heart rate they will be looking for signs that the baby is coping well. One trend that they will look for is if the heart rate is having late decelerations. This is where the heart rate is having dips after a contraction. This is indicative that the baby is not being well oxygenated during the contractions. If you would like to see a more detailed description of this you can go to by blog at this site: http://thebeginningofmotherhood.blogspot.com/search/label/fhr.
If you are only acting as labor support it is not your job to treat this but there are some things you can do to help if you notice this happening.
Deep Breathing
“Some benefits of abdominal breathing include
1.Increased oxygen supply to the brain and musculature.
2.Stimulation of the parasympathetic nervous system. This branch of your autonomic nervous system promotes a state of calmness and quiescence. It works in a fashion exactly opposit to the sympathetic branch of your nervous system which stimulates a state of emotional arousal and the very physiological reactions underlying a panic attack.
3.Greater feelings of connectedness between mind and body. Anxiety and worry tend to keep you “up in your head”. A few minutes of deep abdominal breathing will help bring you down into your whole body.
4.More efficient excretion of bodily toxins. Many toxic substances in the body are excreted thorugh the lungs.
5.Improved concentration. If your mind is racing it's difficult to focus your attention. Abdominal breathing will help to quiet your mind.
6.Abdominal breathing by itself can trigger a relaxation response.
Bourne Edmund J. The Anxiety and Phobia Workbook Fourth Edition
Abdominal Breathing Exercise
Slow inhale...Pause...Slow exhale (“Ten”)...allow body to relax
Slow inhale...Pause...Slow exhale (“Nine”)...allow body to relax
See also...http://thebeginningofmotherhood.blogspot.com/2010/01/effects-of-stress.html
Also from The Anxiety and Phoebe Workbook
"Studies have found differences in the breathing patterns of anxious and shy people as opposed to those who are more relaxed and outgoing. People who are fearful and shy tend to breathe in a shallow fashion from their chest while those who are extroverted and relaxed breathe more slowly..deeply and from their abdomens....
If you breathe from your chest you may overbreathe...exhaling carbon dioxide in relation to the amount of oxygen in your bloodstream. You may also tend to breathe through your mouth. The result is a cluster of symptoms..including rapid heartbeat...dizziness...and tingly sensations that are so similar to the symptoms of panic that they can be indistinguishable. Some of the physiologic changes brought on by hyperventilation include:
Increased alkalinity of nerve cells...which causes them to be more excitable. The result is that you feel nervous and jittery.
Decreased carbon dioxide in the blood..which can cause your heart to pump harder and faster as well as making lights seem brighter and sounds louder.
Increased constriction of blood vessels in your brain...which can cause feelings of dizziness...disorientation and even a sense of unreality or separateness from your body".
3rd Scenario: Dawn had been in labor for about 4 hours and she knew she was know in transition. She was using visualization and paced breathing to help her cope. Both of these were working well for her at this point.
Soon though a nurse came rushing into the room and told her her baby was having a more difficult time with her contractions and that the heart rate was having late decelerations. Dawn became a little more frightened at this point and was trying to do what the nurse asked while working through her contractions. They were noticeably harder at this point and she was no longer able to keep up with the deep focus and visualizations. Though she did keep up with the pace breathing.
She noticed that she was feeling a little dizzy and the nurse was now getting nervous that her blood pressure was getting a little too high. When Dawn mentioned to the nurse that her fingers where also feeling tingly the nurse wasn't quite sure why. The nurse also asked that she lie down to help decrease her blood pressure. These made the contractions even more uncomfortable and difficult to work through. The babies heart rate was still having late decelerations and Dawn was starting to get a feeling of panic.
Questions:
8. In this situation how would you change the focus of your labor support?
9. Would you still continue to use patterned breathing?
10. How might patterned breathing help or not help in this situation?
11. How do you differentiate between latent and active phase and how would you apply the research article to women in your definitions?( see this web site for other ideas...http://midwifethinking.com/2010/12/22/stages-of-labour-and-collusion/
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