The major goals of childbirth education that were initially promoted by Dick-Read are taught with little modification in formal childbirth preparation classes today ( Box 22.1 ). 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. Some instructors and training manuals claim other benefits of childbirth preparation ( Box 22.2 ), although a 2015 review of the Bradley method and HypnoBirthing methods called for more rigorous study with transparent methods rather than self-reported outcomes. A 2007 systematic review concluded that there is insufficient evidence to evaluate the efficacy of antenatal childbirth education on childbirth and parenting outcomes, although a 2023 scoping review emphasized the need for more rigorous study. Despite the lack of high-quality evidence and variability in teaching quality, childbirth preparation classes are broadly available and often attended.

Socioeconomic disparities exist in childbirth education class attendance. In addition, the effect of childbirth education on attitude and childbirth experience depends, in part, on the social class to which the mother belongs. Although investigators have found that childbirth classes have a positive effect on the attitudes of both parents of all social classes, this effect is more pronounced among “working-class” and indigent women ; 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. Attendance is also associated with improved postpartum practices (e.g., safe newborn sleeping practices, breastfeeding). Contemporary analyses suggest that privately insured women who attend childbirth education classes may benefit from a lower elective cesarean delivery rate.

In the modern era, women and their partners obtain information about childbirth and analgesia from many sources. Social media and other internet sites have become the primary source of information for many patients. However, variability in internet-based information quality may limit pregnant women’s understanding of her options. Knowledge of information sources and biases held by patients facilitates shared decision-making between anesthesia providers and their patients.

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. 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. The method of preparation influences the pregnant woman’s ability to use breathing and relaxation techniques. Bernardini et al. 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 also set false expectations. If a woman does not relate to the “normal” delivery discussed during classes, she may experience a sense of failure or inferiority. Both Stewart and Guzman Sanchez et al. have discussed adverse psychological reactions in 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. In contrast, some evidence exists that antenatal childbirth education courses may help ease the fear of childbirth.

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 anecdotal clinical experiences with an assumption that it offers benefits for the mother and child. Outcome studies often do not include a group of women who were randomly assigned to an untreated or a placebo-controlled group, and statistical analysis is often incomplete. Older studies have reported a decreased use of analgesic medications ^43,44 or regional anesthesia, shorter first stage of labor, and a lower incidence of nonreassuring fetal status and cesarean delivery, whereas others reported no change in the use of analgesics, duration of labor, rate of operative vaginal or cesarean delivery, or incidence of nonreassuring fetal status. A 2013 systematic review found a paradoxical increase in labor epidural analgesia use and induction of labor among those who attended childbirth classes, although benefits included fewer admissions for false labor, decreased anxiety about childbirth, and enhanced partner engagement. A 2020 retrospective review of 197 low-risk, nulliparous women who self-selected to attend or not attend childbirth classes noted that the attendees were less likely to undergo induction of labor and had lower use of analgesic medications during labor. There was no significant difference between groups in maternal satisfaction or perception of control. These diverse findings may reflect different patient populations, poor study design, or researcher bias. Table 22.1 summarizes several studies of childbirth preparation training and their association with labor outcome.

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 by evaluating nonpregnant and nulliparous women in laboratory settings. Studies varied in the stimulus 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 support during labor is essential to the process of a satisfying childbirth experience. Typically, the pregnant woman’s partner, family member, and/or friend provide this support. Research has noted that partner participation is associated with decreased maternal anxiety and medication requirements. Studies evaluating the benefits of emotional support provided by doulas or other unrelated individuals on the mode of delivery, feelings about the birth experience, use of labor analgesia, oxytocin augmentation, duration of labor, perineal trauma, breastfeeding outcomes, and Apgar scores, among other outcomes, suggest that the companionship of another woman who is not part of the medical establishment may reduce a parturient’s anxiety more effectively than the companionship provided by her partner. A patient’s sense of isolation adversely affects her perception of labor. In one study, women randomly assigned to receive intrapartum support from a friend or female relative who was chosen by the parturient and trained as a doula were more likely to have positive feelings about their delivery and had a higher rate of breastfeeding 6 to 8 weeks after delivery than women who were randomly assigned to receive usual care.

A 2017 metaanalysis evaluated results from 26 studies that included 15,858 women who were randomly assigned to receive either continuous childbirth support or usual care ( Table 22.2 ). The pooled data suggest that women who receive one-on-one support during labor are less likely to use any type of analgesia and report negative feelings about the childbirth experience, and are more likely to have a spontaneous vaginal delivery, although evidence was generally of low quality. The benefits were greater when the support person was present in a doula (trained labor companion) role. In addition, the mean duration of labor was slightly shorter (approximately 41 minutes) in the women who received continuous support during labor, and the likelihood of a low 5-minute Apgar score was less.

These results have important implications for obstetric care, although they may not be generalizable. Results from trials in North America do not appear as striking as those from Europe or Africa. The aforementioned systematic review of continuous labor support concluded that the preponderance of evidence suggests that all parturients should have access to emotional support, whether it is provided by the partner, a family member, a labor companion (e.g., doula), or professional hospital staff. Further studies should compare different models of continuous childbirth support and should include longer-term outcomes, including breastfeeding and postpartum depression.

Various touch and massage techniques are discussed with women and their support persons during childbirth preparation classes. These techniques include effleurage (e.g., long, light stroking of the back or abdomen), counterpressure to alleviate back discomfort, and reassuring pats. While a 2018 systematic review found low-quality evidence that massage provided reduced self-reported pain intensity, other outcomes showed no difference based on very low-quality evidence. Touch and massage can provide a comfort that is generally appreciated by women during labor. These measures may be used by the pregnant woman, her support person, or the professional staff members providing intrapartum care. The techniques are easily discontinued. In some cases, touch and massage may reduce discomfort. More often, touch and massage transmit a sense of caring, which fosters a sense of security and well-being.

Another simple technique for alleviating labor pain is the therapeutic use of temperature (hot or cold) applied to various regions of the body. Warm compresses may be placed on localized areas or a warm blanket may cover the entire body. Alternatively, ice packs may be placed on the low back or perineum to decrease pain perception. Studies of the therapeutic use of heat and cold during labor are of low quality. The use of superficial heat and cold for comfort is widespread (if not completely understood), and it has no discernible risk to the mother or the fetus. Cold and heat should not be applied to anesthetized skin as diminished awareness may increase the potential for damage to the skin.

Aromatherapy is the use of essential oils, which are fragrant, volatile organic compounds obtained by distillation of plant material. The oils are commonly combined with a carrier oil and massaged into the skin, inhaled, or mixed in a bath. Two metaanalyses showed pain-reducing benefits for labor with the use of aromatherapy. Another metaanalysis investigating types of aromatherapy showed reduced pain in the first stage of labor with lavender oil, jasmine oil, rose oil, chamomile oil, bosweilla oil, and bitter orange oil. Given the widespread availability and relative affordability of aromatherapy diffusers and oils, they should be included in the childbirth experience if desired by the patient, barring any hypersensitivity to these compounds.