Preparation for childbirth

INTRODUCTION — A woman's childbirth experience is vitally important, and her birthing memories endure [1,2]. Major factors that influence the quality of this experience include personal expectations, the quality and amount of support she receives, the quality of the caregiver-patient relationship (eg, communication, continuity of care, empathy, respect), her involvement in decision making, her clinical risk, and pregnancy outcome [3,4].

Much of the preparation for labor and birth happens naturally as pregnancy progresses. Physical changes occur: her breasts and abdomen enlarge and contractions become noticeable. She becomes attached to her baby as the baby makes his or her presence known with kicks and movement. She begins to tire of being pregnant and often gets a burst of energy to prepare the home for the upcoming newborn before going into labor ("nesting") [5].

Although women have always prepared for childbirth, the process has become more formal. The development of structured educational programs in preparation for childbirth came about when the location of the birth moved from the home to the hospital. Birth became a medical event; mothers, sisters, and other lay women knowledgeable about birth were no longer in attendance, and cultural and family rituals associated with birthing were lost [6,7]. In the early years of formal childbirth education, the focus was on the basic anatomy, the physiology of labor and birth, and simple strategies to cope with the pain of contractions, such as relaxation techniques and controlled breathing. Childbirth education has evolved from this initial curriculum as we now know more about the role of pain [8], the hormonal physiology [9], the wide and ever increasing number of ways that women can find comfort [10-14], and the importance of continuous emotional and physical support [15-17] during labor and birth. Contemporary curricula highlight additional care practices that facilitate the physiologic process of birth, including waiting for the spontaneous onset of labor start [18] and keeping the mother and newborn together [19].

This topic will review goals and activities that can help prepare women for an optimal childbirth experience. Other issues related to this experience, such as doula support, obstetric management, and nonhospital sites for delivery are discussed in more detail separately.

●(See "Continuous labor support by a doula".)

●(See "Labor and delivery: Management of the normal first stage".)

●(See "Nonpharmacologic approaches to management of labor pain" and "Pharmacologic management of pain during labor and delivery".)

●(See "Birth centers".)

●(See "Planned home birth".)

●(See "Prenatal care: Initial assessment", section on 'Care provider'.)

GOALS — The major goals of childbirth preparation are to provide women with [20,21]:

●Confidence in their own ability to give birth

●The knowledge and support needed to make informed decisions aligned with their values and preferences

●The ability to find comfort as labor progresses

●The ability to be supported by family, friends, and professionals

Good preparation can optimize the experience of childbirth, even if complications develop and medical interventions are needed [21,22].

Birth preparation helps women achieve some degree of comfort during labor by addressing modifiable factors that help alleviate labor pain. Such factors include controlling the labor and birth environment, learning coping strategies, and discussing expectations and anxiety about the birth experience [21]. Although most pregnant women are concerned about the pain associated with childbirth, they often report that pain and its relief do not play a major role in their satisfaction with their childbirth experience [3,23]. In part, this is because birth preparation helps women understand the role pain plays in normal labor and birth [8,9].

CHILDBIRTH PREPARATION CLASSES

Benefits — Prepregnancy or early pregnancy childbirth preparation classes can provide information that helps women to make the initial decisions of choosing a health care provider and place of birth and to learn about common issues of the first and second trimesters. In the third trimester, childbirth preparation classes provide an opportunity to meet with other pregnant women; share stories; obtain knowledge about pregnancy, labor, birth, and postpartum issues; devote time to focusing on preparation for birth; and address fears, anxieties, and concerns. Fear of childbirth has been associated with longer labor duration, need for psychiatric care, and presence of symptoms of traumatic stress [24].

Formal childbirth preparation, both hospital and community based, not only helps women know what to expect during labor and birth, but provides a forum for ultimately making choices within the context of contemporary maternity care and developing a personal plan for birth. In addition, hearing birth stories and talking with other women helps foster feelings of connection and provides valuable information about ways that women manage the challenges of labor, birth, and early parenting [25].

High-quality data on the outcomes of women who participate in childbirth education classes are limited, but increasing. (See 'Outcome data' below.)

Components — The components of childbirth preparation classes include discussion of:

●The normal physiologic process of birth including the role of hormones during pregnancy, birth, and breastfeeding.

●Care practices that promote, protect, and support normal birth (eg, awaiting spontaneous labor when appropriate, delaying hospital admission until the active phase, continuous labor support, avoiding routine amniotomy and other routine interventions, frequent position changes, pushing in response to the urge to push, passive descent [delayed pushing]). The World Health Organization provides guidelines for promoting, protecting, and supporting physiologic birth and ultimately women's satisfaction with their childbirth experience [26].

●The signs of labor and distinguishing prodromal from active labor.

●When and how to call the health care provider.

●What to expect in the hospital (eg, policies, resources).

●The role of pain, including using pain as a guide to finding comfort in labor.

●A wide variety of comfort measures, including simple relaxation and breathing techniques, position changes including walking and rocking, massage, hydrotherapy, aromatherapy, music, meditation, yoga, acupressure, application of hot or cold, facilitated partner support, as well as pharmacologic methods of pain control.

●The importance of support, including a discussion of the role of the partner and the potential value of professional labor support, which can affect the course and outcome of labor.

●Complications of the normal, physiologic process of labor and birth, as well as prevention and management of complications.

●Indications for and types of medical interventions, the effect of interventions on the normal course of labor and birth, and strategies to minimize the influence of interventions. The American College of Obstetricians and Gynecologists (ACOG) committee opinion "Approaches to Limit Interventions in Labor and Birth" suggests a number of such strategies [27].

●Induction and augmentation of labor, assisted vaginal and cesarean birth

●Positions for birthing.

●Newborn issues (eg, circumcision, choosing a pediatrician, the importance of keeping mother and baby together, rooming-in).

●The importance of breastfeeding for both mother and baby; how to prepare for, initiate, and continue breastfeeding, including strategies for women planning to return to work.

●What to expect when the baby is brought home, including ongoing care, infant needs and capabilities, and planning for parental support.

●Other postnatal issues, such as recovery from childbirth, sleep, mood and emotions, relationships, parenting, sex and contraception, pelvic floor and other exercises.

Outcome data — There continues to be a lack of high-quality evidence to assess the results of childbirth preparation or to determine the best approach, especially since few women are willing to enroll in a randomized trial that includes no formal birth preparation [28,29]. While ACOG and others have espoused the value of childbirth preparation in both reducing the primary cesarean rate and limiting interventions in labor [27,30-32], further research is required to determine the optimum content of these classes for parent satisfaction and their effect on important labor, delivery, and newborn outcomes. In the last few years there has been an increase in research across countries related to the outcomes of childbirth education.

In the few limited randomized trials, comprehensive childbirth preparation reduced the number of visits to the labor unit that resulted in the patient being discharged undelivered [33] and use of epidural anesthesia and oxytocin augmentation [34,35], and increased rates of vaginal birth [36] and breastfeeding [37], along with some other benefits [38]. An observational study reported lower rates of labor induction after standardized content about the potential risks of labor induction was added to childbirth classes [39].

Certified childbirth educator — Formal childbirth preparation classes should be taught by a certified childbirth educator [40]. There are several organizations that provide education and/or certification for childbirth education, although Lamaze is the only program accredited by the National Commission for Certifying Agencies (NCCA), the national accreditation body for certifying agencies. The requirements of each organization's program vary dramatically.

The childbirth educator should be knowledgeable about the normal, natural process of birth, including strategies to facilitate labor and birth. They should be up to date with research about birth and maternity care practices and their effect on the physiologic process of birth [41-43]. In addition, they should be a skilled teacher and group facilitator who does not just present data but helps the woman make informed choices before, during, and after her delivery.

Class size, duration, and location — Childbirth classes should be small, with no more than 8 to 10 couples, to facilitate discussion and allow for individualized instruction [44].

In general, classes should involve at least 12 hours of instruction. Traditionally, they are held over a period of weeks in the last trimester, although this model is being questioned [45,46]. Covering all of the necessary material throughout the stages of pregnancy and birth takes time; therefore, it is critical that adequate time is available for practice and discussion regardless of whether classes start early in pregnancy, are taught over a period of weeks or months, or during one long day [21].

As a result of the COVID-19 pandemic, many childbirth classes are being held virtually or online.

WRITING A BIRTH PLAN

Rationale — For some families, preparing for labor and birth involves creating a written birth plan [20,21]. Ideally, written birth plans reduce conflicts and misunderstandings between women and their providers surrounding the birth by making agreements in advance about what will be done in a normal delivery and what might be necessary if an emergency arises.

In general, the written birth plan:

●Provides an opportunity for discussion between the woman and her partner or support team, as well as between the health care provider and the woman, to ensure that all important issues are addressed. The provider and the support team learn what is personally important to the woman and what she needs to feel safe, supported, and confident in labor.

●Encourages the family to be actively involved in making decisions, which is an important component of childbirth satisfaction.

●Provides a framework for developing a collaborative relationship between the health care provider and the woman. In some instances, it helps to resolve inconsistencies between the woman's expectations and what is considered best practice (for instance, if she has an epidural anesthetic, she will need an intravenous line). It helps care providers (including nurses) get to know the woman in a more personal way.

●Serves as documentation of the agreement between the provider and woman. It changes as circumstances change, acknowledging that medical interventions based on best evidence may be necessary if complications ensue.

The effect of the birth plan on pregnancy outcome has not been well-studied. Some studies reported no difference between women with and without a birth plan in their overall birth experiences (control, fear, pain), some report women with birth plans had improved childbirth experiences, and some report women with birth plans were less satisfied with their birth experience than those without birth plans [47-50].

Items covered — The strategies the pregnant woman develops in the birth plan to meet her goals will be different depending on her personal preferences and where she will give birth (eg, hospital, birthing center, home). Typically, the written birth plan covers the items listed in the table (table 1). The birth plan and the woman's personal preferences should be honored, unless there is a serious medical necessity for a change in the plan.

CHOOSING SUPPORT PEOPLE — Choosing one or more individuals for support during childbirth appears to have both psychological and medical benefits. In a meta-analysis of 27 trials including over 15,500 women, the continuous presence of a support person reduced the likelihood of medication for pain relief, assisted vaginal birth, cesarean birth, and dissatisfaction with the birth experience [17]. Continuous support was also associated with a slight reduction in the length of labor and improvement in maternal satisfaction (eg, coping during labor, level of personal control during childbirth). These data are reviewed in detail separately. (See "Continuous labor support by a doula".)

CHOOSING THE SITE FOR DELIVERY — As an alternative to a conventional hospital birth, healthy women with low-risk pregnancies may choose to give birth in a birth center or in a home-like environment that has been created in some hospitals. Giving birth at home is another alternative [51]. (See "Birth centers" and "Planned home birth".)

Choosing to give birth in a home-like birth environment appears to have beneficial effects. In a meta-analysis of randomized trials of alternative versus conventional institutional settings for birth, low-risk women giving birth in a bedroom-like, ambient, or Snoezelen room used less analgesia, had fewer operative deliveries, and were more satisfied with their birth experience and more likely to be breastfeeding two months postpartum [51,52]. They also were less likely to request epidural anesthesia and undergo oxytocin augmentation and episiotomy. However, increased support from caregivers typical of this setting may be an important confounding factor affecting these outcomes.

CHOOSING A NATURAL CHILDBIRTH METHOD — The term "natural childbirth" is sometimes used to describe a method of childbirth where medical intervention for management of pain or labor is minimized. Various methods of natural childbirth are available. Some of the more common approaches are summarized below. The distinctions between these methods have blurred over time.

●Grantly Dick-Read believed that childbirth is not an inherently painful event. He described a "fear-tension-pain" syndrome in which fear produced tension in the myometrium leading to pain [53]. The educational program that he designed attempts to minimize fear and thus diminish the fear-tension-pain cycle. It also includes an exercise regimen to prepare women for the exertion of labor.

●Lamaze originated in France. Fernand Lamaze combined the concepts of preparation/education to reduce fear and conditioning to diminish the pain reflex (psychoprophylaxis) [54]. The key features of the original Lamaze method were controlled deep breathing, light massage, concentrating on a focal point, active support by a labor coach, and the woman's control over her body and labor management.

Contemporary Lamaze is quite different. The cornerstone of Lamaze preparation is a philosophy that affirms that birth is normal and natural, women have the inherent ability to give birth, birth is important in women's lives, and the health care provider and place of birth affect women's birth experiences [21]. Breathing is only one of many comfort strategies taught in contemporary Lamaze classes. Women are now encouraged to work with their labors, find comfort in response to their contractions, and push in response to the urge to push, rather than letting the labor control their bodies [55,56].

●Robert Bradley gave the woman's partner an active, major role (ie, husband-coached childbirth) and emphasized an extremely natural approach, with few or no drugs and minimal medical intervention during labor and delivery.

●Hypnobirthing is based on the belief that when a woman is prepared physically, mentally, and spiritually, she can experience the joy of birth in an easier, more relaxed, and potentially pain-free manner [57]. Self-hypnosis and deep relaxation are important components of this method, but it, like other approaches, is eclectic and incorporates many other ways to find comfort and be confident in labor.

●Mindful Birthing, developed by Nancy Bardacke, is an adaptation of mindfulness-based stress reduction and incorporates meditation, yoga, and mindfulness into childbirth education [58].

PLANNING COMFORT MEASURES AND PAIN MANAGEMENT — Before labor begins, women should think about their goals and options regarding pain management. There are many measures that they can use to cope with pain during labor and increase their level of comfort. Childbirth preparation classes provide information about these measures and additional information is readily available from other resources.

●(See "Continuous labor support by a doula".)

●(See "Nonpharmacologic approaches to management of labor pain".)

●(See "Pharmacologic management of pain during labor and delivery".)

RESOURCES

●Being present at another woman's labor and birth or viewing videos of birth also helps to prepare women for their own births. There are a number of excellent videos available in which women give birth confidently in a variety of settings. Everyday Miracles is an example that can be viewed at no cost on the Lamaze International website [59].

●There are literally hundreds of books about pregnancy and birth and an ever increasing number of websites that contain information about pregnancy, labor, birth, and early parenting. However, in spite of the wealth of information that is available, many resources contain inaccuracies and increase women's fears about labor and birth. Some resources that this author recommends include:

Books:

•Giving Birth with Confidence [21]

•Ina May's Guide to Childbirth [60]

•Our Bodies, Ourselves: Pregnancy and Birth Book [61]

•The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Labor Companions [62]

•Labor Progress Handbook [63]

•Mindful Birthing: Training the Mind, Body and Heart for Childbirth and Beyond [64]

•Gentle Birth, Gentle Mothering [65]

Online resources:

•Lamaze International

•Childbirth Connection

•American College of Nurse-Midwives

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General prenatal care".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Labor and childbirth (The Basics)" and "Patient education: How to tell when labor starts (The Basics)" and "Patient education: Managing pain during labor and childbirth (The Basics)")

PATIENT PERSPECTIVE TOPIC — Patient perspectives are provided for selected disorders to help clinicians better understand the patient experience and patient concerns. These narratives may offer insights into patient values and preferences not included in other UpToDate topics. (See "Patient perspective: Managing pain during labor and delivery".)

SUMMARY AND RECOMMENDATIONS

●Goals of childbirth preparation – The primary goal of childbirth preparation is to reduce fear and anxiety of a potentially stressful and life-changing event. Classes early in pregnancy can help women make decisions about choosing a health care provider and place of birth. Other goals are to enable women to labor and give birth confidently, comfortably, and supported by the people around them. (See 'Goals' above.)

●Quality of the childbirth experience – Major factors that influence the quality of the mother's childbirth experience include personal expectations, the quality and amount of support she receives, the quality of the caregiver-patient relationship (eg, communication, continuity of care, empathy, respect), her involvement in decision making, and her clinical risk. (See 'Introduction' above.)

●Components of childbirth preparation

•Childbirth education – Childbirth preparation classes provide an opportunity to meet with other pregnant women/couples; share stories; obtain knowledge about pregnancy, labor, birth, postpartum, newborn, and parenting issues; address fears and concerns; and devote time to focus on preparing for birth. This information helps women/couples know what to expect during labor and birth and provides a forum for ultimately making choices within the context of modern maternity care and developing a personal plan for birth. (See 'Childbirth preparation classes' above.)

•Birth plan – Written birth plans reduce conflicts and misunderstandings between women and their providers surrounding the birth by making agreements in advance about what will be done in a normal delivery and what might be necessary if an emergency arises. Typically, a written birth plan covers items listed in the table (table 1). (See 'Writing a birth plan' above.)

•Support persons – Choosing one or more individuals for continuous support during childbirth appears to have both psychological and medical benefits. (See 'Choosing support people' above.)

•Birth location – Choosing to give birth in a home-like birth environment appears to have beneficial effects. In addition to the home, home-like environments for giving birth are available for low-risk women in birth centers and in many hospitals. (See 'Choosing the site for delivery' above.)

•Consideration of natural childbirth – The term "natural childbirth" is sometimes used to describe a method of childbirth where medical intervention for management of pain or labor is minimized with the intent to interfere as little as possible with the natural, physiologic process of labor and birth. Various methods of natural childbirth are available. (See 'Choosing a natural childbirth method' above.)