How do you breathe through contractions?

Hi, everyone. In today’s video, we’re going to talk about using breathing for pain relief during labor.

Hi, my name is Rebecca Dekker and I’m a nurse with my Ph.D. and the founder of Evidence Based Birth. We’ve been doing a YouTube pain management series all about the effects of different comfort measures on pain during labor, and today we’re going to focus on the effects of using breathing for pain relief during labor. Breathing techniques are one of the focuses of something called psychoprophylaxis, which refers to teaching parents how to respond to contractions with relaxation and breathing exercises.

Lamaze

Breathing was first brought into focus by Lamaze, and Lamaze was originally known as the American Society for Psychoprophylaxis in Obstetrics. In the 1960s, Lamaze taught women how to use strict, controlled breathing patterns to cope with labor sensations. However, Lamaze actually stopped teaching these strict breathing patterns in the 1980s.

There’s a really great article on this topic by Judith Lothian that was published in 2011 called “Lamaze Breathing: What Every Pregnant Woman Needs to Know.” In this article, she describes how as research grew and we learned more about comfort measures during labor, that Lamaze shifted to encouraging women to use slow, controlled breathing. And this became just one of many non-drug comfort measures that they taught in Lamaze classes. They now say that the right way to breathe is whatever way feels best – no rules – and breathing patterns should be individualized to the birthing person. Now, the key to using breathing for pain relief during labor is that breathing should be conscious, not automatic. So in other words, it’s a behavioral, or voluntary thing to focus on your breathing.

Breathing, however, is usually not used by itself. It’s typically combined with other relaxation methods such as guided imagery, visualization, hypnosis, continuous labor support, or progressive muscle relaxation. And one of the problems you’ll find when we talk about the research is that because breathing is usually combined with a variety of other comfort measures, it’s nearly impossible to tell the effects of breathing by itself on pain levels during labor.

How might breathing patterns during labor work to help manage pain or promote comfort?

Researchers think there are a couple of different ways that breathing might work for pain relief during labor. Focused breathing might work by interrupting the transmission of pain signals to your brain by giving you something positive to focus on. It may also work by stimulating the release of endorphins, which are natural pain relieving hormones,  and by helping you reframe your thinking about labor so that you view it as positive, productive and manageable.

The theory by which this would work is called the Central Nervous System Control (CNSC) mechanism. Using breathing techniques and focusing your attention on your breath may activate mental processes in your brain that make labor sensations seem less unpleasant. Now, breathing techniques are a body-mind training mechanism that are used by people around the world for stress relief.

Abdominal breathing

There has been a lot of research around the world especially on something called abdominal breathing, or diaphragmatic breathing. With this method, as you inhale or breathe in, your abdomen goes out, and as you exhale, your abdomen goes back in, and this is a slow, controlled type of breathing. Abdominal breathing is a core component of things like yoga, tai chi, and meditation. Even musicians incorporate this type of abdominal breathing into their daily lives. Electroencephalography (EEG) studies on this type of abdominal breathing have found that even just a few minutes of using this type of breathing alters your brainwaves in a positive way, increases your relaxation response, decreases your stress hormones, decreases your blood pressure, and increases your oxygen levels.

How many people use breathing for pain relief during labor?

The ‘Listening to Mothers III’ survey study looked at 2,400 mothers who gave birth in the United States in the years 2011 and 2012 in hospitals. They found that breathing techniques were the most common non-drug comfort measure used by pregnant people with 48% of people saying that they used breathing for pain relief during labor. However, an earlier study by those same researchers, published in 2006, asked mothers about the effectiveness of the different pain relief methods that they used. Out of all of the methods that mothers said that they used, breathing was actually rated as the least helpful.

So what’s the evidence on using breathing for pain relief during labor? Is it even effective?

Well, there have been four recent randomized, controlled trials that looked at breathing either by itself or as a package deal with other comfort measures and its effects on pain or other outcomes.

Boaviagem et al. (2017) RCT from Brazil

There’s only been one recent study that looked at breathing techniques by themselves and compared them to not using breathing techniques. This study took place in Brazil, was published in 2017, and included 140 people giving birth. Participants were randomly assigned to either receive instruction in breathing for pain relief during labor or were not encouraged to use breathing techniques. In this study, during the first stage of labor, the breathing group was instructed to inhale slowly, counting from one to five, and then to breathe out gradually, counting down from five to one. They were instructed not to inhale all the way full. When contractions were strong, participants were instructed to take an extended inhalation pushing their lips forward, called pursed lip breathing. A physiotherapist demonstrated the breathing patterns to each woman. When they looked at pain, anxiety, tiredness and maternal satisfaction, they did not find any differences between the people who received the breathing instruction and those who did not. Pain scores were high in both of the groups, an average of 8.8 on a scale of 0 to 10. And all of these women were having unmedicated births, so without pain medication.

There have been three other recent randomized controlled trials where researchers have combined breathing for pain relief during labor with other comfort measures and then compared that to standard care.

Levett et al. (2016) RCT from Australia

We’ve already talked about the Levett et al. (2016) study in several of our other videos – our video about acupressure and our video about childbirth education. This study took place in Australia and randomly assigned 176 low-risk, first-time mothers to either a complete childbirth course or standard care which included a typical childbirth course. The complete childbirth course took place over two full days and included six complementary and alternative medicine techniques – breathing, acupressure, visualization, massage, yoga techniques, and facilitated partner support.

The complete childbirth course in this study introduced four breathing techniques to birthing people and their partners: “Soft sleep breaths” that they could use for relaxation between contractions; “Blissful belly breaths” used during contractions for pain relief; “Cleansing calming breaths” used between contractions during the transition phase of labor, so right at the very end of labor; and then “Gentle birthing breaths” were used during the second stage to encourage fetal descent and help the mother avoid pushing, to help protect the pelvic floor.

The study found a significantly lower rate of epidural use in the participants who took the complete childbirth course. When the participants in the complete childbirth course group were asked about which specific techniques they used during labor, they found that the “Blissful belly breath” breathing technique was used most frequently (60%) and 35% ended up using the “Gentle birthing breaths” during labor. This study provides evidence that we’ve talked about before that childbirth education that incorporates complementary medicine techniques including breathing techniques is an effective and viable way of managing pain and avoiding interventions. Of course, because the breathing techniques were combined with a variety of other comfort measures, it’s not possible to tell how much of the beneficial effects were related to the breathing techniques.

Bahadoran (2010) RCT from Iran

There was another study published in 2010 in which 117 mothers from Iran were randomly assigned to either a comprehensive childbirth class that took place over eight weeks or to standard care. In this study, the childbirth education group received instruction in relaxation, massage, and breathing techniques. The paper doesn’t specify which breathing techniques were taught. Instead of pain scores, these researchers measured something called ‘vitality’ which they defined as a person’s reported sense of energy and life. They say that it’s the opposite of depression. The researchers did find a significant difference in the childbirth class’s average vitality score compared to the standard care groups’ score. The difference was seen immediately after taking the course and again after the labor.

Yildirim and Sahin (2004) RCT from Turkey

Finally, one small study from Turkey randomly assigned 40 women to either usual care or to an intervention that included progressive muscle relaxation, breathing techniques, position changes, additional support from nurses, and massage. In this study, they encouraged slow, deep breathing in the early phase of labor and more rapid, shallow breathing during the active phase of labor. In the second stage of labor, participants were encouraged to use a “pant-blow” abdominal breathing technique while they were pushing. They found that this multicomponent relaxation intervention significantly lowered women’s perceived pain intensity at two centimeters as well as at four, six, eight and ten centimeters. They also found that people who were assigned the multicomponent relaxation intervention reported greater satisfaction with their pain relief during birth.

Conclusion

So in conclusion, we only have one recent study that looks at breathing techniques alone and compares it to the usual care, and they did not find any differences between groups. However, we have three other recent randomized, controlled trials where breathing was used as part of a more packaged deal, where parents were taught a variety of non-drug comfort measures and they used breathing in combination with those other methods. All three of those studies found benefits from the combination of non-drug comfort measures that included breathing. This suggests that non-drug pain relief approaches work best in combination. Just simply using breathing by itself is probably not going to be effective unless you combine it with other methods such as hypnosis, relaxation, guided imagery, continuous support, or a variety of other comfort measures.

Breathing for pain relief during labor can be made widely accessible to pregnant people through childbirth education. And if you haven’t yet, I encourage you to watch our YouTube video all about the effects of childbirth education on pain relief during labor. Many different childbirth classes include components of breathing in their class curriculum. The techniques may vary but many classes today teach that breathing should be slow, deep, controlled and conscious or voluntary, not automatic.

I hope you found this video helpful. If you enjoyed this video, please hit subscribe to get notifications when our other videos come out. Also, please make sure to check out the rest of the videos in our pain management series. Thanks for watching. Bye.

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