Page 2 P H Y S I O T H E R A P Y June, 1970 A Survey of Breathing Exercises and Natural Childbirth Methods. ADELE BLANKFIELD, B.Sc., M.B., B.Ch.(Rand) Honorary Research Associate in Obstetrics, Monash University, Melbourne Reprinted by courtesy o f the Editor o f Physiotherapy, Journal o f the Chartered Society o f Physiotherapy August, 1969. At the turn o f the century the opinion was held that the pregnant woman must breathe for two. For this reason she was advised to avoid stuffy atmospheres and move only in well-ventilated places. G ood posture, linked with correct breathing, was considered essential for good health. Failure to follow these dicta would have meant that the pulmonary function o f the expectant mother would have readily been rendered inadequate11- 17’ 20' 21 • 26. These ideas influenced the breathing exercises which have been taught by the childbirth preparation methods. They form a part o f the curriculum o f pre-natal classes and are intended to be o f benefit both in pregnancy and labour. An outline o f breathing exercises will be given in this article and the rationale for them considered. Physical exercises in the obstetric patient have been discussed elsewhere2. THE NATURAL CHILDBIRTH METHOD Grantly Dick Read21 prescribed breathing exercises during pregnancy as the basic essential for good health. He con­ sidered maternal oxygen intake to be dependent upon the correctness o f this function. He stated that, with labour, “In the first stage respiration is naturally free and, as dilation progresses, increases in rate and depth. From 24 to 28 full breaths in a minute is normal at this time, followed by one or two deep breaths as the uterus relaxes . . . ” He recom­ mended that the patient pant with delivery o f the head to help preserve the perineum. English physiotherapists combined his ideas, with their own to produce the exercises taught by this method, and their use in labour is not very clearly described. Heardman11 elaborated on the use o f deep breathing o f the abdominal or diaphragmatic type. In this the abdominal wall is made to rise up with inspiration to permit maximum use o f the diaphragm. This breathing is meant to be practised daily during pregnancy at varied speeds and depths and is to be utilised with labour contractions. It is also to be combined with relaxation, for “To displace disturbing or worrying thoughts some positive idea must be given to the mind. Rhythm is a mental release, and the natural breathing rhythm serves the purpose”.10. In addition, rapid “thoracic” type breathing with sternal elevation is suggested for use in late first stage. Rehearsal o f bearing down is included in classes. THE RUSSIAN PSYCHOPROPHYLACTIC METHOD This method o f painless childbirth originated in Russia in about 1950 and appears now to have waned8. Breathing exercises were incorporated into it as part o f the pain- prevention technique in labour27. When the pain became very intense, effleurage or abdominal stroking was added to these. Deep, rhythmic respirations at the rate o f 16 to 18 breaths per minute were suggested for use with contractions. The importance attached to this was twofold. Firstly, propeiv breathing could meet the increased oxygen requirement uterine activity and improve the course o f the contraction and eliminate distressing sensations. Secondly, the foetus was supposed to be favourably affected. A t the birth o f the head, the patient was instructed to change from long straining to a short, rapid-type respiration. THE FRENCH PSYCHOPROPHYLACTIC METHOD Lamaze introduced this method into France in 195211. He completely modified the breathing exercises and explained precisely what manoeuvres had to be done for each phase o f labour. The benefits derived from the exercises o f the Lamaze method practised during pregnancy are supposed to be as follows. Firstly, the maternal oxygen requirements are increased, but the lordosis o f pregnancy hampers ventilation and leads to fatigue, strain, and general trouble, which is overcome by exercise. Secondly, the patient is made con­ scious o f the anatomical relation o f organs directly or indirectly connected with parturition. This gives her better control over her diaphragm in labour. Thirdly, it is physical training for an event with a physical aspect. In labour, psychoprophylaxis patients are cautioned to breathe both in a shallow and fast manner from the time when they have attained approximately 3 cms. o f dilation until the second stage is reached. They are trained to punc-{ tuate their breathing patterns with blows to overcome any premature urge to bear down. The second stage is rehearsed with gentle pushing efforts and panting for delivery o f the head. Vellay28 believed that with training, women in the future would produce strenuous efforts whilst breathing. Most psychoprophylactic method authors advocated the use o f supplementary oxygen in late labour. The importance attached to correct breathing in labour by psychoprophylaxis has two aspects. “ ■ 2“. Firstly, the increased maternal and foetal oxygen demands o f labour are met with by fast breathing (and not slow). The responsibility to ensure good oxygenation falls mostly on the mother, and if her respiratory response is inadequate, both she and her baby could be adversely affected. Secondly, shallow breathing prevents irritation o f the uterus as this organ is thought to feel every bit o f pressure increase, but the significance o f this statement is never explained. The way to avoid this apparently undesirable state is to relax the abdominal and pelvic-floor muscles as well as to exert control over the diaphragm. The diaphragm is credited with a piston-like pushing action, and thus its movement must be minimised by the application o f shallow breathing. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) June, 1 9 7 0 P H Y S I O T H E R A P Y Page 3 PATIENT REACTION Patients and midwives have been questioned about the value o f breathing exercises performed in labour and a diversity o f views have emerged. However, adequate ques­ tionnaire study and evaluation have still to be completed on this aspect. Many consider them to be a good distraction, and provide something on which to concentrate9. Others find them helpful, particularly in the early stages o f labour. Some patients discover that in late labour they are difficult to perform or are o f no assistance1' 10. Certain midwives have commented on the Lamaze type o f breathing. Some find that the patients can become very tired from its performance and also emotionally distressed if they are unable to remember the details to follow all their instructions. The frequency o f these occurrences is unknown. The majority o f trained patients co-operate well during the second stage and can push or restrain themselves as (requested. DISCUSSIO N Many o f the breathing exercises, and the purposes given for their practice, are common to the different methods. The major variation between methods occurs in the recom­ mended rates o f respiration3. Three main issues are raised by the childbirth methods and their use o f breathing exercises in pregnancy and labour. Firstly, the physiological question is posed about the adequacy o f maternal oxygen uptake and the subsequent transfer to the foetus. Secondly, importance is attached to the patient’s knowledge and control o f her anatomical mechanisms o f breathing. Thirdly, the psychological values and effects merit consideration. (a) Physiological Considerations Pregnancy gives rise to an increased ventilatory demand which the woman meets with a “physiological hyper­ ventilation” 18' 23. Cugell et al (1953)7 studied pulmonary function in pregnant women and found no defect in gaseous distribution. In another study, only patients with very severe respiratory disease did not produce the associated respirator .changes o f pregnancy18. Another survey showed that certain (severe scoliotic patients could cope with pregnancy without the development o f cardio-respiratory complications18. Respiratory ventilation studies in labour are scanty, but information has recently emerged about normal patients. Some o f the aspects o f maternal gas exchange have been measured and have not demonstrated any ill effects to the foetus from spontaneous maternal respiration15- 25. Supplementary oxygen can be transferred from the mother to the foetus, but this depends on the concentration and method o f administration8- 22. However, the indications for oxygen administration, the optimum concentration required, and the circumstances under which benefits can accrue, have still to be more fully assessed. (b) Anatomical Mechanisms The mechanisms o f respiration as described by the childbirth methods are open to doubt. Two types o f breathing are traditionally described. There are the abdominal or diaphragmatic form and the thoracic type. This classification is debatable and stems from observations made in the Victorian era. Women wore tightly laced stays and were unable to move their abdomens, thus their respiratory movements were only visible in the thorax. This was classified as thoracic breathing. However men, unhampered by wearing apparel, moved their abdomens freely with respiration13 20. Kellogg (1902)12 studied the body movements o f respiration and presented penumo- graphic tracings o f two male and five female subejcts (Fig. 1). One female subject was an habitual corset-wearer, and one male wore a corset for the purpose o f the experiment. He recorded expansion over the thorax and abdomen and showed that abdominal movement predominated over thoracic, except in the corset-wearers, where the reverse occurred. Combined radiological and spirometric studies have been performed in relation to movements o f the chest and diaphragm28. Wade (1954)28 concluded that there is a close co-ordination between the movements o f the diaphragm and the chest. He found no evidence that a person can have direct voluntary control over the diaphragm, but trained subjects could inhibit changes in chest expansion. The direct relationship o f abdominal movement as a reflection o f diaphragmatic movement can be queried. Measurements were taken o f the vital capacity o f physio­ therapy students with normal chest movement. These were compared with the capacity found in the same students when they attempted diaphragmatic breathing. A 25 per cent reduction was found with the latter type o f respiration30. THE DIAPHRAGM AND INTRA-ABDOMINAL PRESSURE The action o f the diaphragm in respiration is thought by the French psychoprophylactic school to increase intra­ abdominal pressure. For this reason they recommend shallow respiration in first-stage labour. This concern with the danger o f pressure increase might stem from the pos­ sibility o f production o f cervical oedema in first-stage labour when bearing down (i.e. a state o f increased intra-abdominal pressure) occurs. Measurements o f intra-uterine pressures were recorded during the labours o f over 300 women. These were mainly untrained patients who'did not try to regulate their breathing patterns or mechanisms. Changes due to respiration were rarely observed. In a few cases respiratory deflections appeared in patients who snored, but they were o f an insignificant order o f magnitude21. ' Measurements o f intra-abdominal pressures taken in healthy males during normal breathing showed little variation (3-5 cms. water). With hyperventilation, the pressure changes rarely exceeded 10 cms. water at the upper limits6. The role o f the diaphragm in bearing down is primarily one o f fixation o f the thorax when the glottis is closed and the intra-abdominal pressure is increased. The piston-like pushing action attributed to it could be incorrect1. (c) Psychological Consideration The psychological aspects, as yet, are almost unexplored, but on preliminary survey both favourable and undesirable effects emerge. The performance o f breathing exercises gives the patient something to concentrate on and occupy herself with in labour9. Distraction—in this instance breathing exercise— apparently can elevate the pain threshold to a limited extent. If the pain intensity increases far beyond this elevated threshold, the patient may then find them o f no further assistance. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 4 P H Y S I O T H E R A P Y June, 1970 Difficulty in performing breathing exercises in labour can occur for two reasons. Firstly, the patient might be in severe pain and/or drugged. Secondly, some o f the exercises are unrelated to spontaneous respiratory rhythms which occur in labour, and this can create problems in their execution3. Inability to carry out these exercises as instructed can occasionally cause the patient distress, but this depends on the personalities o f patient and teacher. CONCLUSION The ventilatory response o f the normal woman to preg­ nancy appears to be adequate. Breathing exercises are thus unlikely to improve gaseous exchange or prevent ill health. The division o f breathing into abdominal and thoracic types appears to be based on trick movements. The dia­ phragm and the thorax largely co-ordinate their action, and direct voluntary control o f the former cannot be realistically achieved. Instruction in trick movement may cause confusion and upset to the patient in labour. In normal spontaneous respiration, the movement o f the diaphragm does not increase intra-abdominal or intra­ uterine pressure to a level which can irritate the uterus. The diaphragm is a fixative muscle, and this function is utilised in bearing down. Needless responsibility is placed on the patient if she is taught to perform precise respiratory actions in labour for unproven benefits to the baby and herself. If any problems arise in labour, the treatment and correction o f these depend on the.obstetrician and not on the patient. Nevertheless, if .the patient concentrates on her natural respiratory rhythm in labour, as proposed by Read, this can be o f variable assistance. It is a good distractive measure and keeps the woman occupied. Patients should be told that in early labour they will find themselves breathing slowly, and in later labour they might breathe much faster with their contractions. They should be cautioned that this might not be o f help in late labour, but safe m odem drugs can then assist them. Training can increase the ability o f the patient to co operate with bearing down in second stage and to pant to the negative command o f “D on ’t push” . SUMMARY \ Some o f the reasons given by childbirth preparation methods for the use o f breathing exercises in pregnancy and labour are in doubt; the patient can be taught to concen­ trate on her natural respiratory rhythm in labour, and should do this only when she finds it to be a helpful dis­ traction and occupation. ACKNOW LEDGEMENTS The author would like to thank Professor Carl Wood, Dr. W. Newman, and others o f the Department o f Obstet­ rics and Gynaecology, Monash University, Melbourne, for discussion and criticism o f the manuscript; and Dr. I. Johnston and Dr. B. Ritchie for their suggestions. REFERENCES 1. Blankfield, A. (1965). Med. J. Aust. 2, 666. 2. Idem (1967). Med. J. Aust., 1, 163. 3. Idem (1969). Aus. and New Z . J. Obst. Gynaec., 9, 118. 4. Buxton, R. St.J. (1965). Nursing Mirror, June 18. 5. Campbell, E. J. M. and Green, J. H. (1953). J. Physiol., 122, 282. 6. Chertok, L. (1967). Am. J. Obst. Gynaec., 98, 698. 7. Cugell, D . W., Frank, N . R ., Gaensler, E. A; and Badger, T. L. (1953). Am. Rev. Tuberc., 67, 568. 8. Davey, D . A ., Du Toit, H. J., Farrel, A . G. W., Rorke, M. and Trezise, R. (1967). Proc. Fifth World Congress o f Obstetrics and Gynaecology, Butterworths, Australia. 9. Earn, A. A. (1962). Am. J. Obst. Gynaec., 83, 29. 10. Heardman, H. (1948). A Way to Natural Childbirth, E. & S. Livingstone, Edinburgh. 11. Idem (1951). Physiotherapy in Obstetrics and Gynaeco­ logy, E. & S. Livingstone, Edinburgh. 12. Kellogg, J. H. (1902). Ladies' Guide in Health and Disease, Pacific Press, London. 13. Ker, Alice (1891). Motherhood: A Book fo r Every Woman, John Heywood, London. 14. Lamaze, F. (1958). Painless Childbirth (Part 3), BurkeJ London. 15. Lumley, J., Renou, P., Newman, W. and Wood, C. Am. J. Obst. Gynaec., 103, 847. 16. MacRae, D . J. and Palavradji, D . (1967). J. Obst. Gynaec. Brit. Comm., 74, 11. 17. McKenzie, W. C. (1928). Brit. med. J. 2, 534. 18. Manning, C. W., Prime, F. J. and Zorab, P. A. (1967). Lancet, ii, 792. 19. Midwives Questionnaire: unpublished data. 20. Morris, M. (1936). Maternity and Post-operative Exercises. Wm. Heinemann, London. 21. Newman, W. (1968): personal communication. 22. Newman, W., McKinnon, L., Phillips, L., Patterson, P. and Wood, C. (1967). Am. J. Obst. Gynaec., 99, 61. 23. Novy, M. J. and Miles, J. E. (1967). Am. J. Obst. Gynaec., 99, 1024. 24. Read, G. D . (1963). Childbirth Without Fear (4th edition, revised). Wm. Heinemann, London. 25. Reid, D . H. S. (1967). Lancet, i, 782. 26. Vellay, P., (1963). Childbirth Without Pain (2nd impres­ sion), Hutchinson of London with Allen and Unwin. 27. Velvovsky, I., Platinov, K., Ploticher, V. and Shugom, E. (1960). Painless Childbirth through Psychoprophylaxis, Foreign Languages Publishing House, Moscow. 28. Wade, O. L. and Gilson, J. C. (1951). Thorax, 6, 103. 29. Wade, O. L. (1954). J. Physiol., 124, 193. 30. Wines, B., Nicol, L., Nicolson, R., Court, D . and Korsch, H. (1967). Aust. J. Physiother,., 13, 72. 13 th February, 1970. The Editor, Thank you for asking me for my appraisal, o f Dr. Adele Blankfield’s article on “A Survey o f Breathing Exercises and Natural Childbirth Methods”, which appeared in the Journal o f the Chartered Society o f Physiotherapy in August, 1969. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) June, 1 9 7 0 T have read this article carefully and agree with it entirely. T firmly believe that the pulmonary ventilation o f the normal pregnant woman is adequately served by normal snontaneous breathing and cannot accept that any special patterns of breathing will really improve on this state of affairs. The only possible advantage, that might accrue to the nreenant woman who has received special breathing exer­ cises is a psychological one. It may give her something to concentrate on in early labour and this may give her the feeling that she can do something active “to help” during the first stage of labour. Conversely, this may result in a feeling o f guilt towards her baby if in the later stages of labour she finds herself unable to maintain the pattern of breathing that she has been taught. In the second stage I agree that training does increase the ability o f the patient to co-operate with bearing down efforts—especially at the point o f crowning o f the foetal head. In my opinion Dr. Blankfield’s article is a well balanced and clear assessment o f the subject o f breathing in pregnancy and labour. It is an article that must be welcomed and is long overdue. It will help clarify a field that has, in recent years, become clouded and confused with unscientific methods and claims bordering on witchcraft. I am, Yours sincerely, L. van D on gen Professor o f Obstetrics and Gynaecology, University o f Witwatersrand. Page 5P H Y S I O T H E R A P Y C R O N IC L O W B A C K A C H E in the M ID D L E -A G E D W O M A N MICHAEL ADLER, M.B.Ch.B., F.R.C.S. (Ed.), F.R.C.S. (Glasgow) Department o f Orthopaedic Surgery and W ULF. H. U TIAN , M.B.B.Ch., M.R.C.O.G., Department o f Obstetrics and Gynaecology, Groote Schuur Hospital and University o f Cape Town Back pain may be described as a universal symptom. Almost everyone suffers from backache at one time or another in their lives, and some have it more or less con­ tinuously, but only a proportion o f those who suffer from it, complain o f it. Women are more prone to the condition than men because o f hormonal influences, changes o f posture during pregnancy and because gynaecological disturbances may cause backache. The complaint is often suffered in silence. Many people believe it is a normal sequel to childbirth or a natural accompaniment o f the menopause. It is a subject which is often dismissed lightly, but much discomfort and disability can be ameliorated. fre.quency w*th which long standing symptoms in the . a neurotic personality coincide is notorious, what u a Psych°somatic disturbance, and inevitably, ,„mi u , cause, it is very likely that sooner or later there w be psychological implications. ofTup treatment o f backache demands the time and patience e practitioner. Backache is seen in equal numbers by the gynaecologist and the orthopaedic surgeon. There is in fact an organic cause to nearly every complaint in the back. The assessment o f the severity o f pain, the cause o f it and the treatment best fitted to the individual patient remains one o f the more difficult problems in clinical medicine. It is by no means possible to arrive at a precise diagnosis, but the attempt must be made, for it is unusual to identify the specific structure causing pain in the back, even when X-ray changes are present. N ot many years ago, the concept o f the slipped disc came into vogue. Doctors jumped at this notion as a gift from heaven and the diagnosis was exploited so that slipped disc became the diagnosis for almost every backache. The subject is complex. Almost any structure in the spine can in fact cause pain. Furthermore, many abdominal or pelvic organs can cause pain referred to the back, that is, seeming as if it were coming from the back. Backache is a symptom and not a diagnosis. It presents frequently as an entity (as does headache). To simplify the matter therefore, it is useful to classify backache into a number o f clinical syndromes, since every R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )