Childbirth Education

Then and Now

by Marcia A. Pugh, DNP MBA HCM RN

Abstract: A common adage is that women

have been giving birth since the beginning of time. Although babies today are
physiologically born in the same manner
as they have been for generations, there
have been changes over the years. These
changes have been most dramatic in what
women expect in relation to their pregnancy and the total childbirth experience
and aftercare. This includes the type of
delivery women envision and the degree
of pain they expect to endure. These
expectations have required changes in
childbirth education. This article discusses the changes that have occurred in the
expectations of pregnant women today in
relation to the pregnancy experience and
the total childbirth experience. Subsequently, childbirth educators must evolve
and make the necessary changes to meet
the needs of this new generation.
Keywords: childbirth education, history, prenatal

Education is a primary function of nursing practice. This

is especially important in the childbearing community. Formal childbirth classes did not exist prior to 1940. Before this
time, childbirth education was managed by word of mouth
from an experienced woman to the novice. With formalization of childbirth education classes, pregnant women were
provided information about their pregnancy, delivery, and
post-delivery care. This information about their pregnancy
and what to expect during a normal delivery was anticipated
to allay their fears and prevent delivery stress. Going to

childbirth classes became the norm. Attendance at childbirth

education classes continues to be the expectation of the
healthcare provider and many pregnant women. Gaining
knowledge, however, has meant changes in expectations. The
purpose of this article is to draw attention to the changes
that have occurred in the expectations of pregnant women
today in relation to pregnancy and the childbirth experience.
It will present information for childbirth educators needed
to make the necessary changes to meet the desires of a new
generation including information on expectations of women
related to childbirth, pain management and technology used
during pregnancy and childbirth.

Delivery Then and Now

Teaching women about pregnancy and the expectations
of giving birth prior to the 17th century were the responsibility of the grandmother and female family members. Women
were expected to have uneventful deliveries, and this
delivery would occur at home. The birth was often attended
by the community midwife or the eldest female family member. Before giving birth, experiences of the family matriarch
were readily relayed to the expectant mother. This teaching
oftentimes occurred while cooking, caring for younger family
members, or working in the household or garden. There
were no formal sessions and no formal settings.

Women were expected to have

uneventful deliveries home deliveries.
The only time a medical professional was expected
to attend a delivery was if there were expected complications or these occurred unexpectedly during the birthing
process itself. In practice, complications meant the need for
instrumentation for delivery assistance. The invention of the
obstetrical forceps by Peter Chamberlen meant a physician
(usually male) would attend deliveries that required more
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Childbirth Education Then and Now

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expertise than the community and family assister could
provide (Dunn, 1999). Because a forceps-assisted delivery
was uncommon, the pregnant woman was provided no prior
education. Lack of knowledge could make this joyous childbearing event a traumatic experience.
Prior to the 1900s childbirth was expected to occur at
home (Cox Jones, 2010). Even the sick sought to receive
medical care at home. Medical technology was very primitive, so care by the physician was provided using an arsenal
of instruments, equipment, and supplies the physician
could carry in a medical bag. Hospitals were little more than
houses where the sick who could not be cared for at home
were sent for medical intervention. This was considered to
be no place for a pregnant woman, not just because of its intended use, but because pregnancy was considered a natural
phenomenon. The expectation was that delivery would be
a natural occurrence. This natural phenomenon meant no
need for formal education.
Attention to cleanliness, the identification of its
importance to the education of healthcare providers, and
the advancement of medical technology transformed the
community house for the sick into a healthcare organization.
This transformation included wards where pregnant women
were expected to engage in communal labor with limited or

no family in attendance. Once delivery was imminent, the

woman was moved to a delivery room where only she and
the healthcare providers were allowed. The birthing event
was sterile and more focused on procedures than working
with the mother to have a holistic, natural event.
Childbirth education consisted of self-learning modules with prenatal care booklets and paper information.
These were followed by question and answer sessions in the
prenatal care providers office. There was little to no available
contact times nor an alternate contact format for questions
that arose outside this venue. Oftentimes, hospitals did not
conduct formalized classes.

Pain Management
The 20th century saw a need to address infant mortality rates and preterm births (Wegman, 2001). The need to
decrease infant mortality rates and pre-term births was met
with the need to meet changed expectations of the pregnant
woman. These expectations included more information and
less labor discomfort. With hospital delivery came the expectation of pain management options that reduced mother
and infant complications. Women and childbirth facilities
expected childbirth educators to teach the pregnant woman
information regarding pain options, which included holistic
methods such as breathing and relaxation techniques to assist in labor comfort (Jones et al., 2012; Reidman, 2008).
continued on next page

Table 1. Selective Anesthesia Used in Childbirth

Type Indications
Local
Provides pain relief during the first

and second stages of labor
Opiates
Pain reduction and ease anxiety
Pudental Nerve Block
Injection to numb the vaginal area


Epidural
Relieves pain while allowing the

pregnant woman to participate

in the delivery.

Spinal Block
Provides pain relief in the lower

half of the body. Oftentimes does

not last more than a couple of hours.

Combined Spinal-Epidural
Provides pain relief throughout labor.
(CSE) or Walking Epidural Some women are able to walk with

this type of anesthesia.

Contraindications
Severe preeclampsia
Sensitivity to narcotics and analgesics
Coagulation disorders
Infection in the ischiorectal space or adjacent structures
Sensitivity to local anesthetics
Hemorrhage or shock
Pregnant woman is taking anti-coagulants
Infection is present in the back or blood
Pregnant woman unusual atomic condition or spinal abnormality
Hemorrhage or shock
Pregnant woman is taking anti-coagulants
Infection is present in the back or blood
Pregnant woman unusual atomic condition or spinal abnormality
Hemorrhage or shock
Pregnant woman is taking anti-coagulants
Infection is present in the back or blood
Pregnant woman unusual atomic condition or spinal abnormality

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Because each womans pain tolerance is different, the
expectation for the use of analgesia and anesthesia is different. Analgesia and anesthesia are expected to relieve pain as
well as allow the pregnant woman to participate in the delivery. This meant the use of other forms of anesthesia than
general anesthesia (see Table 1). The childbirth educator was
expected to know various types of pain relief, their actions,
and contraindications to their use. These were to be correlated to patient self-reported pain tolerance and past history
of medical conditions that may contraindicate the use of
specific types (e.g., report of prior spinal fusion surgery).
Medication during labor and delivery has an impact on
infant and mother. The popularity of unmedicated childbirth
evolved during the 1950s and 1960s with awareness of infant
mortality related to use of anesthesia. Use of alternative holistic mechanisms for pain management included patterned
breathing exercises, relaxation, and water immersion (Tournaire & Theau-Yonneau, 2007). This work was pioneered
by early proponents such as Lamaze in the 1960s (Kushner,
2005), Leboyer in 1975, and Bradley (2008) in 1978. New
advances in medications have evolved that result in less disruption to the birthing process and are safer for mother and
baby. Mothers are still aware of the fact that no medication
is without risk, but many know that these new medications
have fewer side effects than those of earlier decades.

Tips for Organizing and Delivering Child

Birth Education
Remember, the birth of a baby represents the birth
of the family. There will be changes in the dynamics
of family relationships.
Recognize that there is family diversity outside of
the traditional family structure. The traditional image of the family is not to be discursively reinforced.
Family centered maternity care involves more than
the healthcare team. The pregnant woman, her
family, and community resources form the circle of
care for the team.
The rights of the pregnant woman are to be recognized, supported, and upheld. Her needs are to be
identified and addressed. Teaching should revolve
around these needs and not those of the significant
other or caregiver.
Keep childbirth education information current and
provide evidence-based educational information
affixed to the most current research.
Childbirth education is not the panacea for poor
pregnancy outcomes. It is only one of many interrelated factors that affect the outcome of the birth.
Putting the information into perspective with the
physiological, sociological and psychological factors
will produce pregnant women and families that are
better prepared.

Technology and Childbirth Education

Traditional education meant intensive planning and
advertising to promote attendance by the educator (International Childbirth Education Association, n.d.). Pregnant
women and their significant others were all gathered in a
classroom setting. They were expected to bring pillows,
blankets, and whatever they used to focus for pain relief
education. These large groups meant a set agenda with little
individualized instruction (Lothian, 2008). With a set time
and place, accommodations into their daily schedule had to
be made by those planning to attend. The classes were expected to be attended by those desiring natural childbirth as
well as those planning to use anesthesia or even a Cesarean
Section in an effort to learn as much about the pregnancy,
body changes, and the delivery process as possible.
Technology has changed the face of childbirth education. Intermittent stethoscope evaluation has been replaced
by continuous fetal heart rate monitoring. The purpose of

this monitoring is to allow evaluation and intervention in

order to prevent complications that may result from delayed
intervention. Electronic fetal monitoring (EFM) is now
routinely used to evaluate both the infants heart rate as well
as the pregnant womans contractions. Infant complications
associated with lack of oxygenation can be detected early for
necessary medical intervention. Education involves teaching
the pregnant woman about both intermittent as well as continuous EFM. According to Dekker (2012), no differences in
perinatal mortality, cerebral palsy, Apgar scores, cord blood
gasses, admission rates to neonatal intensive care unit admissions, or low-oxygen brain damage were found in women
receiving intermittent auscultation and continuous EFM.
Heartbeat guidelines and protocols have been developed by
the American College of Obstetricians and Gynecologists for
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fetal heart rate monitoring and intervention that promote
consistent use and reduced variability that can result from
individual interpretation. Although these monitors do not
replace vigilance and nursing assessment, they have been
shown to reduce infant mortality (Chen, Chauhan, Ananth,
Vinizileos, & Abuhamad, 2011).

Teaching for New Moms in the 21st Century

Childbirth education is critical to the best outcomes for
both mother and baby. It can also have a positive effect on
health behaviors and self-care (Koehn, 2002). It is imperative
that nurses update their knowledge in order to address current expectations and promote the best possible outcomes.
This is also necessary to include mothers with disabilities and
those of various ethnic backgrounds who may have differing
expectations based on their heritage and exposure (Blackford, Richardson & Grieve, 2000).

References
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Bradley, R. (2008). The husband-coached childbirth: The Bradley method of
natural childbirth (5th ed.). New York, NY: Random House.
Chen, H.-Y., Chauhan, S. P., Ananth, C. V., Vinizileos, A. M., & Abuhamad,
A. Z. (2011). Electronic fetal heart rate monitoring and its relationship to
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Tiffany Panas, Call it Love Photography

Reidmann, G. (2008). Education for childbirth [Electronic chapter]. Global

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http://jn.nutrition.org/content/131/2/401S.full

Dr. Marcia Pugh is Division Director for Grants, Research and

Outreach of West AL (GROWestAL) of the Tombigbee Healthcare Authority in Demopolis, AL. She has a Doctor of Nursing
Practice degree from The University of Alabama. Prior nursing
experience includes Program Director of a Maternity Care Program and Director of Nursing of an acute care facility inclusive
of a Maternity Care Unit.
classroombobb.com
classroombobb.com

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