Page 4 P H Y S I O T H E R A P Y September, 1969 c o n d u c te d , w hich m ean s th a t la b o u r is a llow ed to progress fo r so m e 8 to 12 h o u rs befo re a decision is m a d e as to d o in g a c a e sa rea n se c tio n o r a llow ing la b o u r to pro ceed a n d achieve vaginal delivery. I f o n the o n e h a n d the p a tie n t is to ld in the last few w eeks o f h e r p re g n an c y th a t she is to h ave a trial la b o u r a n d th a t a se ction m ay be necessary sh e will b e in so m e u n c e rta in ty a n d will n o t e n te r la b o u r w ith full confidence th a t la b o u r will progress in the n o rm al w ay in w hich she h a s been in stru cte d . O n the o th e r h a n d if she is n o t to ld o f th e possibility b e fo re h a n d a n d is then to ld a fte r som e h o u rs o f la b o u r th a t she n ow re q u ire s a se ction she is a p t to im agine th a t so m e serious c o m p lic a tio n h as su d d e n ly arisen a n d h ow ever m u c h she is re a ss u re d she will be a p p reh e n siv e a b o u t the o u tc o m e fo r h e r baby. T h e e m o tio n a l sta te o f la b o u r is n o t c o nducive to h e r being a ble a t th a t stage to a cc ep t a ra tio n a l e x p la n a tio n o f w hat is h a p pening. A re w a rd in g a spect o f a n te n a ta l in stru c tio n is th a t the p a tie n t w ith a definitely c o n tra c te d pelvis fo r w h o m vaginal delivery is n o t safe a n d w ho is to ld a t 38 w eeks th a t a cae sa rea n se ction is definitely necessary will som etim es ask th a t sh e be allo w ed to have som e h o u rs o f la b o u r first. T h ro u g h the m ed iu m o f h e r in stru c tio n she has com e to lo o k fo rw a rd to the experience o f la b o u r a n d the o p p o rtu n ity o f p roving h e rself a n d a lth o u g h she realises th a t se ction is in evitable does n o t w a n t to b e de p riv e d c o m pletely o f the lab o u r. I n som e c en tres in th e U n ite d S ta te s a n d C a n a d a th ere has in re c e n t y e ars b een a s tro n g sw ing to w a rd s n a tu ra l c h ild b irth , so m u c h so th a t o b ste tric ia n s have c o m p la in e d th a t w here c a e sa re a n section becom es necessary they can h ave th e u tm o st difficulty in p e rsu a d in g th e p a tie n t to accept this. T h e answ er to th e p ro b le m m u st lie in in stru c tin g p a tie n ts a t p re n a ta l classes th a t c a e sa re a n se c tio n is n o t u n d e rta k e n as a last d e sp e ra te m ea su re b u t ra th e r as a m ea n s o f fore­ stalling c o m p lic a tio n s a n d a v o id in g tra u m a to m o th e r a n d b a b y . T h ey sh o u ld a lso be m a d e a w a re th a t th e ir p re n a ta l tra in in g w as n o t w asted sh o u ld they n o t be a b le to deliver vaginally b u t th a t la b o u r a n d delivery fo rm b u t o n e p a rt o f the p re n a ta l c o u rse a n d they will still have the ad v an tag e s o f p o stu re , p ro p e rly to n e d u p m uscles, c o rre c t b re a th in g in th e late r m o n th s o f p regnancy a n d a n u n d e rsta n d in g o f m an y a spects o f c h ild b e arin g . T hey s h o u ld also n o t lose sight o f the fact th a t p o stn a ta l exercises a re as im p o rta n t a fte r se c tio n as a fte r vaginal delivery. I f th e p a tie n t h a s th is k n ow ledge a n d .h as confidence th a t h e r d o c to r will c h o o se th e rig h t c o u rse fo r her, little difficulty sh o u ld be e n c o u n te re d in p e rsu a d in g h e r th a t c a e sa rea n se ction is the rig h t c o u rse fo r her. T H E S E X U A L A S P E C T T h ere a re m an y a spects o f p re - a n d p o stn a ta l in stru c tio n w hich a re b e tte r im p a rte d to a g ro u p th a n to a n individual as the p a tie n t will th en feel th a t th e re m a rk s a re n o t being a d d ressed to her pe rso n ally a n d so she is a ble to assim ilate the k n ow legde w ith o u t e m b a rassm en t. T h is is p a rticu la rly tru e o f m a tte rs re la tin g to sexual a d ju stm e n t. T h e delivery o f a h e a d o f som e 4 inches d ia m e te r th ro u g h the uro g e n ital h ia tu s w hich n o rm a lly is o f 1£ in ch diam e te r will in evitably re su lt in stre tc h in g o f th e v a gina a n d o f the m uscles a n d ligam ents s u rro u n d in g it. T h e le v a to r m uscle will n o t sp o n ta n e o u s ly re tu r n to its fo rm e r sta te b u t p ro v id ed th a t it h a s n o t been o v e rstre tc h e d o r to rn it can be re sto re d to n o rm a l by m ea n s o f a ssid u o u sly -p ra ctised p o stn a ta l exercises. D u rin g delivery o f the first in fa n t e p isio to m y is freq u e n tly c a rrie d o u t as a m eans o f av o id in g o v e rstretch in g o f th e m uscle, b u t this leaves a sc a r w hich displays residual ten d e rn ess fo r som e weeks o r e v en m o n th s a fte r delivery. A s sexual sa tisfac tio n a n d o rg a sm in th e fem ale a re largely d e p e n d e n t o n th e in te g rity o f the lev a to r m uscle it is h a rd ly su rp risin g th a t th e p a tie n t w ith a stre tc h ed a n d relatively a to n ic le v a to r a n d a te n d e r sc a r to b o o t will n o t find m u ch jo y fro m the re s u m p tio n o f sexual re la tio n s w hen h e r b a b y is a m o n th o r 6 w eeks old. A d d e d to these difficulties are the fact t h a t h e r in te rest h a s becom e very largely c e n tre d o n th e b a b y a n d th a t she is so m e w h a t e x h a u ste d by the d e m a n d s he m ak e s o n her. It is th e re fo re n o t very su rp risin g th a t even th e p a tie n t w h o h as e n joyed g o o d sexual responsiveness b e fo re her delivery will o ften c o m p la in o f loss o f interest, p a in a nd a bsence o f o rg a sm a fte rw a rd s. F re q u e n tly sh e will b e shy even to m en tio n these difficulties to h e r d o c to r a n d m ay th e n n ever recover th e n o rm a lity she knew befo re in this re g ard . F o r the p a tie n t w ho w as h a v in g difficulties before her pre g n an c y the p ro b le m is a p t to be m agnified ten fo ld . T h e re a re a lso su b tle h o rm o n a l c h anges th a t ta k e place d u rin g pre g n an c y w hich m ay result in loss o f sexual res­ ponsiveness a t th a t tim e a n d th e re is freq u e n tly fear in the u n tu to re d th a t in te rc o u rs e m ay be h a rm fu l to th e baby. T h e e n fo rc e d ab stin e n ce d u rin g the last m o n th o f p regnancy a n d fo r the first m o n th a fte r delivery can also cause a d is ru p tio n in m a rita l re la tio n s w hich is difficult to overcom e. A d d e d to these fa c to rs th ere m ay be th e fe a r th a t a n o th e r pre g n an c y m ay e n su e so o n e r th a n is desired. F o r these v a rio u s re a so n s loss o f lib id o (n o rm a l sexual desire) is one o f th e c o m m o n e st a n d m o s t try in g o f p o stn a ta l c o m p li­ catio n s. P a rt o f th e answ er lies in p ro p e r p re n a ta l in s tru c tio n as to the harm lessness o f in te rco u rse d u rin g pregnancy, e m p h a sis o n pelvic flo o r exercises p re- a n d p o stn a ta lly , a h e alth y division o f in te rest betw een h u s b a n d a n d b a b y a fte r c on fin e m e n t a n d p ro p e r c o n tra c e p tiv e advice. T h e re s p o n ­ sibility fo r th ese m ea su re s lies jo in tly w ith th e d o c to r a n d th e p h y sio th era p ist. T hese m easures a lo n e m ay be in a d e q u a te a n d th e n m o re de ta ile d h elp m u st be given a n d p e rh a p s the help o f a psychologist so u g h t. Psychological Principles A p p lie d to Antenatal Training By A L M A E. H A N N O N , (M .A .) Psychology D ivergence o f o p in io n exists a m o n g s t th e p ro p o n e n ts o f a n te n a ta l tra in in g as to w h a t c o n stitu te s a com pletely sa tisfa c to ry p ro g ra m m e fo r th e p re p a ra tio n o f c h ild b irth . Successful p e rfo rm a n c e d u rin g la b o u r is co n sid ere d th e c rite rio n fo r “ sa tis fa c to rin e ss” . U n til a c o n tro lle d in vestiga­ tio n is u n d e rta k e n w here th e re su lts d e m o n s tra te a definitive re la tio n s h ip b etw een m e th o d o f tra in in g a n d p e rfo rm a n ce d u rin g la b o u r no claim s fo r th e su p e rio rity o f o n e m e th o d o ver a n o th e r c a n b e m ade. R e se arc h in th e efficacy o f these different p ro c ed u re s w o u ld p ro v e extrem ely la b o rio u s a n d a lm o st since c o n tro l o f all th e v ariab les re la te d to successful p a rtu ritio n w o uld b e difficult. H o w th e n c a n we assess th e in trin sic value o f a n y o n e o f th e tra in in g p ro c e d u re s? W e m ay be p re p a re d t o a sse rt t h a t if it w orks, th e n it is successful. T h is is p u re em piricism . S u ch a n .a p p r o a c h is p e rm itte d in a scientific discipline b u t it c a n p ro v e sterile w h e re th e g e n e ra tio n o f new co n ce p ts, h y p o th esis o r a th eo re tic al m odel a re c o n ce rn ed . T h e q u e stio n sh o u ld be “ w h a t m ak es it w o rk ? ” T h is becom es a q u e st fo r th e a n te ce d e n ts o f the o b se rv ed b e h av io u r. “ H o w d oes it w o rk ” o n th e o th e r h a n d im plies a q u e st fo r law s g o v e rn in g b e h a v io u r. I f such a n a p p ro a c h is a d o p te d , we n eed e x p lo re n o fu rth e r, as the p rin cip les g o v erning b e h a v io u r a re a lre a d y k n o w n to us. W h a t we need to d e te rm in e is h o w a d eq u a te ly th ey are a p p lie d to th e a r e a o f a n te n a ta l c a re o r train in g . A n te n a ta l tra in in g c a n be divided in to th re e categ o rie s: P hysical tra in in g th ro u g h exercise a n d b re a th in g ; re la x a tio n ; a n d e d u c a tio n in th e p h y siology a n d m echanics o f c h ild b irth a n d la b o u r. A ll th re e categ o rie s sh o u ld be c overed in th e p re p a ra tio n fo r c h ild b irth . T h e ra tio n a le fo r any a n te n a ta l p ro c e d u re sh o u ld be to eq u ip th e w o m a n w ith responses 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. ) September, 1969 P H Y S I O T H E R A P Y Page 5 w hich she will be a b le to use d u rin g her con fin e m e n t to c o n tro l a n d fa cilitate b irth o f th e child. L e t u s no w exam ine e ach o f th ese categ o rie s in tu rn . P H Y S IC A L T R A IN IN G T H R O U G H E X E R C IS E S A N D B R E A T H IN G A w aren ess o f th e b o d y in space d e p en d s o n c o n s ta n t in p u t fro m th e so m a tic n e rv o u s system . O u r p e rc e p tio n o f a n a rm e x te n d ed a b o v e th e h e ad d e p en d s o n th e c o -o rd in a tio n o f ta c tile a n d visual se n sa tio n s ; acc u rac y o f m ovem ents is th e re su lt o f a sso c iatin g differential m u sc u la r ten sio n s w ith different visual se n sa tio n s as th e a rm is m oved th ro u g h space. S ensory d e p riv a tio n o r th e re d u c tio n o f sensory in p u t re su lts in d is o rie n ta tio n o f th e bod y in space. H a l­ lu c in a tio n s w ere e x perienced by s tu d e n t v o lu n te e rs in a sensory d e p riv a tio n e x p erim e n t c a rrie d o u t a t M cG ill U niversity by B e x to n e t a l1. Im p a irm e n t o f in tellectual p e rfo rm a n c e w as sh o w n a fte r o n ly s h o rt p e rio d s o f iso latio n . T h e c o n sta n c y o f o u r psychological b e h a v io u r is d e te rm in e d , th e n , by th e c o n tin u o u s in te ra c tio n o f th e b o d y w ith its e n v iro n m e n t. I f we wish to e stab lish a p e rc e p tio n o r a w a re ­ ness, we m u st first in v o k e b e h av io u r. T o q u o te S perry: “ T h e lay m a n n a tu ra lly assum es th e m a jo r w o rk o f th e b ra in to be th e m a n u fa c tu re o f ideas, se n sa tio n s, im ages, a n d feelings, th e sto ra g e o f m em ories, a n d th e like, a n d o fte n e x p ects th e c o rre la te s o f th ese to be som e k in d o f a u ral e n d -p ro d u c t p h o sp h o re sc in g w ith in th e c o rte x o r e m a n a tin g fro m its co n v o lu tio n s. T hese su bjective p h e n o m e n a m ay, how ever, be re g a rd e d as p h a se s o f b ra in fu n c tio n itself, n o t p ro d u c ts o f it. Scientific a nalysis h a s failed to disclose any o u tp u t a t th e c erebral level o th e r th a n th e m iscellaneous b y -p ro d u c ts m e n tio n e d a bove. E x cepting these, th e e n tire a ctivity o f th e b ra in so fa r as science c a n de te rm in e , yields n o th in g b u t m o to r a d ju s tm e n t.” 10. E w ert, w h en try in g to re p lica te S tr a tto n ’s re sea rc h o n th e in v ersio n a n d reversal o f th e visual field p ro d u c e d by p rism a tic lenses w o rn in sp ectacle fram es, fo u n d th a t his visual field re m a in e d u p sid e d o w n a n d reversed w hilst S tr a tto n h a d re p o rte d th e sp o n ta n e o u s c o rre c tio n o f th e visual field a fte r p ro lo n g e d a n d c o n tin u o u s w earing o f th e in v ertin g spectacles. T h e difference in th e ir findings is e x p lained by th e e x te n t o f th e ir m o to r b e h av io u r. E w e rt3 sa t a t his la b o ra to ry desk w ritin g re p o rts w hilst S tr a tto n 11 ■moved a b o u t m a n ip u la tin g his physical e n v iro n m e n t d u rin g th e c o u rse o f his daily ro u tin e . A s th e responses to his e n v iro n m e n t w o uld re m a in th e sam e since his p o sitio n in space w as u n a lte re d , th e new p a tte rn o f visual se n sa tio n s e v oked by th e in v ertin g a n d reversing spectacles w ould becom e fu n c tio n ally e q u iv a le n t to th e fo rm e r one, a n d he w o u ld perceive th e w orld th e rig h t w ay up a n d a ro u n d w hilst w earing th e lenses, w hich is w h a t h a p p en e d . I n o u r se d e n ta ry lives o u r p e rce p tio n s a re being c o n sta n tly “ b lu n te d ” because o f re d u ce d p e rip h e ral in p u t. T h e d im i­ n ish e d aw aren ess o f o u r bodies a c c o u n ts fo r o u r c o n sta n tly b u m p in g in to objects, o u r in ab ility to ju d g e spaces th ro u g h w hich th e b ody c a n pass a n d th e slu m p in g p o stu re s th a t m o st o f us a d o p t, in tim e. I t seem s a re a so n a b le a ssu m p tio n to a ttr ib u te th e differences o b se rv ed betw een p e a s a n t w om en a n d in active w om en in c h ild b irth to th e differences in th eir c u sto m a ry m o to r activity. G ra n tly D ic k -R e a d h a s o b s e rv e d : “ T h e re is g re a te r d isc o m fo rt in c h ild b irth a m o n g s t w om en w ho h a v e led se d e n ta ry lives th a n a m o n g s t th o se w ho live a n d w o rk o u t-o f-d o o rs . . . . T h e re a re still m an y w om en w ho ra re ly exercise e ith e r th e ir m in d s o r th e ir bodies a n d b e ar th e ir c h ild ren w ith g re a te r difficulty a n d m o re freq u e n t inte rfere n c e th a n th e p e a s a n t w o m a n a t th e p lo u g h . T he office w o rk e r ten d s to have m o re tro u b le th a n th e fisher-girl, th e fa rm h a n d o r th e riv e r-b o a t w o m a n . I n all fo rm s o f hig h er an im a l life r e p ro d u c tio n ta k e s place in th e e n v iro n ­ m e n t th a t en su res th e fem ale m ay be as fit as possible to give b irth to , a n d n u rtu re , h e r young. T h e survival o f a species d e p en d s largely u p o n th e bodily a n d m en ta l sta te o f its in d iv id u a ls— it is w om en o f low g ra d e h e a lth w h o p rofit m o st fro m a ju d ic io u s use o f p h y sio h te ra p y .” (p. ,2 1 5 s). I n th is passage, G ra n tly D ic k -R e a d a ttrib u te d th e easier la b o u rs o f th e p e a s a n t w om en to th eir physical fitness. U n d o u b te d ly , physical fitness c re a te s a sta te o f w ell-being, b u t th e im p o rta n t c o n sid e ra tio n fo r pre g n an c y a n d p a r tu r i­ tio n is th a t exercises tea ch th e iso la tio n o f a n d differe n tia tio n betw een g ro u p s o f m uscles. T ra in in g in th e use o f m uscles involved in l a b o u r will e n a b le a w o m a n to use these effectively a n d adap tiv ely d u rin g la b o u r. A n te n a ta l exercises sh o u ld be designed to d u p lic a te all th e re sp o n se s re q u ire d d u rin g la b o u r, th e g re a te r th e sim u la tio n betw een exercises a n d b e h a v io u r d u rin g p a rtu ritio n th e b e tte r will be th e p re p a ra ­ tio n . “ T h e w o m a n le a rn s how to hold th e s e m uscles in a s ta te o f re la x a tio n ; a n d she e n d e a v o u rs to o b ta in th e best possible m otor co-ordination. She rehearses u seful m ovem ents, fa v o u ra b le p o sitio n s a n d p o stu re s th a t a re a n a d v a n ta g e a t c e rta in tim es. W e try to im p a rt to th e w o m a n d u rin g her p re g n an c y so m e fo rm o f discipline. T h is discipline a m o u n ts to th e fo rm a tio n o f c en tres o f e x c ita tio n a n d o f new c o n n ec ­ tio n s a t b ra in level. A t the very m om ent w hen th e first c o n tra c tio n a p p e a rs th e w o m a n g ets th e m a x im u m fu n c tio n al efficiency o u t o f h e r b ra in , a n d raises th e th re s h o ld o f p a in fu l p e rc e p tio n by p ra ctisin g all th e reflexes she a cq u ired d u rin g h e r p r e p a r a tio n .” (p. 130s). T h is re p re se n ts the p sy c h o p ro p h y la c tic a p p ro a c h to exercise, essentially a tra in in g in aw areness. P e rc e p tio n o f bodily se n sa tio n s c a n be heig h te n ed d u rin g differential tra in in g in w hich c o n tra c tio n s a n d re la x a tio n in g ro u p s o f m uscles a re p e rfo rm e d a lte r­ natively. S uch a p ro c e d u re e n a b le s a w o m a n “ first to differentiate, a n d n e x t t o d issociate, a n y th in g t h a t h a s a p o sitive effect fro m a n y th in g th a t has a n egative o n e as far as th e m o to r system is c o n ce rn ed . So m u ch so th a t by th e tim e la b o u r is re a c h e d th e w o m a n c a n in d u c e a m uscle to w ork o n its own, while th e o th e rs w hich d o n o t need to w ork a re m aintained in a sta te o f re la x atio n . D u rin g delivery, for exam ple, her a p p ren tic e sh ip will have ta u g h t h e r h ow to c o n tra c t h e r a b d o m in a l m uscles w hile she k eep s th e m uscles o f h e r pelvic flo o r relaxed. T h e re will be n o o b s tru c tio n to o vercom e fo rcib ly ; h ence th e d u r a tio n o f delivery will be sh o rte n e d a cc o rd in g ly .” (p. 1318). K itz in g e r5 m ak e s th e follow ing c o m m e n t o n d is a s s o c ia tio n : “ ‘D isa ss o c ia tio n ’, a te c h n iq u e ta u g h t as p a r t o f th e p sy c h o p ro p h y lac tic m eth o d , is very different, (th a t is fro m her m e th o d o f sim ulated c o n tra c tio n s) is n o t in te n d e d to sim u la te in a ny w ay tru e u te rin e c o n tra c tio n s, a n d su b stitu te s a delib e ra te, co n scio u s a c t fo r a n experience w hich essentially is o n e o f sm o o th , c o -o rd in a te d activ ity o f involuntary m uscles— ones w hich th e m o th e r c a n n o t will to fu n c tio n effectively an d which no am ount o f intellectual inform ation or p h y sica l exercise can help to control, (p. 17, italics m ine). T h is la tte r sta te m e n t is c o n tra d ic te d by a w e alth o f e x p erim e n tal evidence o n c o n d itio n in g o f a u to n o m ic fu n c tio n in g . I n sum m ing up som e o f th is evidence F ra n k s 4 sta te s: “ U n d e r c e rta in c ir­ cu m sta n ce s v erbal stim u li c a n b rin g a b o u t o r m odify a wide variety o f physiological re a c tio n , som e sim ple, o th e r com plex, som e a t th e level o f aw areness, o th e r o f w hich th e subject is n o rm a lly q u ite u n a w are . I t is claim ed t h a t in th is w ay it is possible to influence m eta b o lism , th e secretio n s in th e g a stro in te stin a l tra c t, v a so -m o to r activity . . .” (p. I I 4). H e re in v o lu n ta ry o r a u to n o m ic b e h a v io u r is b ro u g h t u n d e r verbal c o n tro l by th e ju d ic io u s p a irin g o f a verbal stim u lu s w ith a n u n c o n d itio n e d stim u lu s, t h a t is o n e th a t p ro d u c es th e a u to n o m ic re sp o n se , fo r a critical n u m b e r o f tria ls a n d in sp a tia l a n d te m p o ra l con tig u ity . A g a in q u o tin g from F ra n k s : “ W o rk in g w ith a v ariety o f visceral responses B ykov has sh o w n th a t th ese responses obey th e sa m e law s as d oes th e C R (c o n d itio n e d response) se c re tio n o f saliva. E specially im p o rta n t is his w o rk w ith th e k idneys in w hich th e m echanism o f th e u rin a ry C R w as sh o w n to involve b o th th e p itu ita ry g lan d a n d th e n e rv o u s system . I n a sim ilar m a n n e r, B ykov a n d h is associates have been a b le to e stab lish a n d m a n ip u la te C R o f bile, h e at re g u la tio n o f th e b ody, b lo o d su g a r . . .” (p. 104). A n a sso c iatio n fo rm e d betw een tw o events, u sually a stim u lu s ev en t a n d a re sp o n se e vent, is te rm e d c o n d itio n in g . I t w as P a v lo v w h o discovered th e c o n d itio n e d reflex (as o p p o se d to th e in n a te o r u n c o n d itio n a l reflex) a n d u sed it 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 6 P H Y S I O T H E R A P Y September, 1969 as a n in stru m e n t fo r stu d y in g th e processes a n d principles g o verning h ig h er n e rv o u s a ctivity. C o n d itio n in g applies n ot o n ly to reflex b e h a v io u r, a s was d e m o n s tra te d by th e R u ssia n s, b u t a lso to o p e ra n t (w h a t th e lay m a n refers to as v o lu n ta ry b e h a v io u r itself p ro d u c es c o n sequences fo r the in d iv id u a l; th e e n v iro n m e n t is “ o p e ra te d ” u p o n . W h at m a n ip u la tio n s o r o p e ra tio n s will be lea rn ed o r c o n d itio n e d in a n in d ividual d e p en d s o n th e co n tin g en cies p re sen t in th e en v iro n m en t. If, fo r e xam ple, a n org a n ism is se a rc h in g fo r fo o d a n d finds it, th e b e h a v io u r p receding the a c tu a l e a tin g o f th e food, will be w h a t is asso c iated w ith fo o d . O n su b seq u e n t o c casions th e o rg a n ism will a tte m p t to find fo o d by d o ing e x actly the sam e thing. S uch b e h a v io u r will becom e p e r­ m a n e n t if it is re p e a te d ly successful. “ F o o d alw ays p re se n t” will be th e c o n tin g e n cy w hich will m a in ta in th e o rg a n is m ’s re sp o n se ; food is th e re in fo rc em e n t o f th e b e h a v io u r; absence o f fo o d w ould be n o n -re in fo rc e m e n t. R e in fo rc e m e n t, th e n , is th a t event w hich increases th e p ro b a b ility o f th e occu rre n ce o f a response. Irre g u la r re in fo rc em e n t slow s d ow n c o n d itio n in g w hilst the a b se n ce o f re in fo rc e m e n t will w eaken a n d finally extinguish a n asso c iativ e link. D iffere n tia l responses o ccur to stim uli w hen differential re in fo rc em e n t effects a re present in th e e n v iro n m en t. A gain, b e h a v io u r w hich is n o t reinforced will be w eakened, a n d if sim ilar, b u t n o t id entical b e h a v io u r is re in fo rc ed , th e n th e ind iv id u a l will le a rn to d iscrim inate b etw een th e stim uli o n th e basis o f th e re sp o n se effects. G e nerally, th e d e finition o f re in fo rc em e n t is ta u to lo g o u s fo r it is described as “ th a t sta te o f affairs th a t m ain tain s b e h a v io u r” . I n th e la b o ra to ry re in fo rc em e n t is d e term ined b y th e ex p erim e n ter, b u t in a free -re sp o n se se ttin g w h a t will be re inforcing fo r b e h a v io u r is n o t necessarily k n ow n. R e in fo rc em e n ts o f everyday life a re social in o rig in ra th e r t h a n e m a n a tin g fro m a biological c o n d itio n . I n o u r early tra in in g p ro c ed u re s fo r th e y o u n g we re in fo rc e a n y form o f b e h a v io u r th a t a p p ro x im a te s th e re q u ire d p e rfo rm a n ce , b u t th e re in fo rc em e n t shifts in th e d irec tio n o f fo rm s w hich ap p ro x im a te m o re closely n o rm a l c u ltu ra l practices. T h e re in fo rc em e n ts th a t a re m a n ip u la te d in th e social c o n te x t include p a ying a tte n tio n , show ing affection, love, e n c o u ra g e ­ m en t, a p p ro v a l; w hilst n o n -rein fo rc em en t (o r negative re in fo rc em e n t as it is also called) includes d isa p p ro v al, in attentiveness, im patience, reje ctio n , criticism a n d derision. O n e c a n sh a rp e n th e stim u lu s c o n tro l o f b e h a v io u r by m an ip u la tin g re in fo rc em e n t, th a t is o n e stre n g th e n s th e ten d e n cy fo r b e h a v io u r to o c c u r w hen re le v an t a spects are p re sen t a n d w eakens th e d isp o sitio n to re sp o n d w hen irrelev a n t asp e cts occur. T h e w om an a tte n d in g a n te n a ta l classes is essentially in a social c o n te x t a n d h e r b e h a v io u r c a n be b ro u g h t u n d e r the c o n tro l o f specific stim uli. H e r p a rtic ip a tio n in exercises is c o n sta n tly b e ing re in fo rc ed by th e te a c h e r th ro u g h praise a n d e n co u ra g em e n t. F u rth e r, th e know ledge th a t she is eq u ip p in g herself a d e q u a te ly fo r a n e vent will lessen any a n x ie ty she m ay experience a n d th is will re in fo rc e her a tte n d a n c e a n d p a rtic ip a tio n in th e pro c ed u re s. H e r be­ h a v io u r will e v o k e social a p p ro v a l fro m o th e r so u rces as well, h e r h u sb a n d th ro u g h his in te rest w ould also b e p ro viding re in fo rc em e n t; h e r d o c to r by sa n c tio n in g such b e h av io u r is also re in fo rc in g it; frien d s by sho w in g w illingness to discuss th e a n te n a ta l p ro g ra m m e also p ro v id e w hat is ta n ta m o u n t to a p p ro v a l. T h e so u rces o f re in fo rc em e n t in such a c o n te x t a re n u m e ro u s a n d th e re sh o u ld be no difficulty in m a in ta in in g th e desired b e h a v io u r a t a n o p tim a l level. T h e real p ro b lem is how to bu ild u p th e b e h av io u r. D e sc rip ­ tio n s o f w hat is re q u ire d a re n o t w holly sa tisfac to ry , as the tr a n s itio n be tw ee n ve rb aliz in g a n d e n ac tin g c a n o n ly be achieved if th e re q u ire d b e h a v io u r is a lre a d y p a r t o f an in d iv id u a l’s re p e rto ire . A u dio-visual a id s will m erely c o n ­ so lid ate ex iste n t b e h a v io u r a n d d o n o t necessarily give rise to th e stim uli o r se n sa tio n s w hich a re th e an te ce d e n ts fo r responses. T h e se quence o f b e h a v io u r necessary fo r p a r­ tu ritio n will have to b e “ sh a p e d ” by successive steps, e ach involving sets o f m uscles. T h e feed-back fro m e ac h set o f m uscles p rovides th e stim u lu s fo r th e n ext re sp o n se in the c h ain . I t is o n ly b y th e m a n ip u la tio n o f b o th th e stim u lu s a n d re sp o n se v ariab les th a t c o n d itio n in g c a n be established. A successful tra in in g p ro g ra m m e fo r la b o u r w o uld be one th a t sim u la tes as closely as possible th e la b o u r itself, thus ge n era tin g a n d c o n d itio n in g to ta l p a rtic ip a tio n o n th e p a rt o f th e w om an. Im ag e ry a n d v e rb a liz a tio n s a re b o th inte rn alise d m ed ia to rs o f b e h a v io u r, th ey c a n n o t e voke th e b e h a v io u r itself unless th e b e h a v io u r has b een experienced. T ry in g to im agine a c o n tra c tio n is im possible w ith o u t hav in g experienced som e m u sc u la r te n s io n ; th e in ju n c tio n to c o n tra c t a m uscle is im possible in th e a b s tra c t. U sin g generalized im agery has v alue o nly if th e re is som e c o m m u n a lity betw een experiences, fo r th e n g e n era liz atio n s o f b e h a v io u r c a n occur. T h e d anger in usin g such a p ro c e d u re is th a t th e stim u lu s o r se nsations o n e is try in g to e v o k e becom e so m e w h a t b lu rred and non-specific. F o r exam ple, q u o tin g fro m K itz in g e r: “ U te rin e c o n tra c tio n s are felt by m a n y w om en to sw eep to w a rd s th em , rise in cresc e n d o a n d th e n fade aw ay like w aves o f th e sea, so th a t w ave im agery is very useful w h e n describing th e se n sa tio n s o f c o n tra c tio n . T h is w ave im agery is closely associated w ith th e id ea o f rh y th m , w hich is all im p o rta n t in h a rm o n io u s p sy c h o so m a tic a d a p ta tio n to la b o u r. O n e can e x p la in how a w o m a n m u st sw im o v e r th e w ave a n d n o t allow it to envelop her, a n d to d o th is she m u st go fo rw a rd to m eet it w ith her b re a th in g instead o f w a iting u n til it is a lre a d y o n her. So she m u st ju d g e its size— a n alyze it— a nd keep o n to p o f it w ith h e r b re a th in g , a d a p tin g th e rh y th m a n d d e p th o f her b re a th in g to th e c urve o f th e wave. A s it a p p ro a c h e s its crest, h e r b re a th in g is a t its m o st light a nd ra p id . H e r b re a th in g is alw ays in re la tio n , n o t to a c h a r t on a wall o r a n illu stra tio n in a b o o k , b u t to th a t p a rtic u la r c o n tra c tio n o f h e r o w n u te ru s a n d to its rh y th m and in te n sity .” (p. 165). T h is a n alo g y elicits so m e w h a t a m o rp h o u s se n sa tio n s a n d so fails in its p u rp o se o f id en tify in g the a n te c e n d e n ts o f b e h a v io u r; fo r b e h a v io u r to c o m e u n d e r stim u lu s c o n tro l th e stim u lu s m u st be u n a m b ig u o u s. A n o th e r difficulty c a n arise fro m th e use o f im agery in a tra in in g p ro g ra m m e b ecause differences in th e ease w ith w hich p e o p le c a n h a n d le im a g in ativ e s itu a tio n s a re k n o w n to exist, so th o se a ble to elicit im agery w o uld be b e tte r p re p a re d th a n th o se w h o c o u ld n o t. T h e type o f in s tru c tio n th a t w ould succeed a d m ira b ly because o f its specificity is also given b y K itzin g e r, h e re fo r b re a th in g fo r b e arin g dow n . “ T o p ractise, b re a th e in, blow o u t ; th e n ta k e a deep b re a th in th ro u g h th e m o u th , fixing th e rib s a n d d ia p h ra g m , a n d , h o ld in g y o u r b re a th , w ith y o u r c h in tu ck e d in a g ain st y o u r chest, a n d arm s relaxed by y o u r side a n d slightly flexed a t th e elbow s, lean o n th e c u sh io n o f in tra -a b d o m in a l p re ssu re y o u c a n feel b e n e a th th e d ia p h ra g m a n d press d o w n firm ly a n d slightly o u tw a rd s, feeling th e m uscles w hich will h elp y ou to squeeze y o u r b a b y gently a n d evenly d o w n th e b irth c a n a l, a t th e sa m e tim e delib e ra tely releasing the m uscles o f the pelvic flo o r ." (p. 1096). H e re is a highly stru c tu re d se quence o f re sp o n se s w here th e feed-back fro m e ac h segm ent o f b e h a v io u r will b e co m e th e stim u lu s fo r th e next re sp o n se , th e w hole sequence involves k in ae sth etic se n sa tio n s. T he sug g e stio n : “ I t m a y help you to th in k o f a tu b e o f to o th p a s te w h ic h y o u a re ro lling u p fro m th e e n d w ith ste ad y p re ssu re ” (p. 1106) im m ediately b re a k s d o w n th e stru c tu re d m o to r re sp o n se s b ecause it involves o n ly visual se n sa tio n s ; th e re is n o m o v em e n t o f th e b o d y a k in to ro llin g up a tu b e o f to o th p a s te . In ste a d o f c o n so lid a tin g b e a rin g d o w n b e h av io u r, such a n in stru c tio n w ould in te rru p t a n d in h ib it it as the sensory m o d alitie s o f k en aesth esis a n d vision have n o t been fu n c tio n a lly re la te d in th is exam ple. I n su m m ary , th e v alu e o f exercises fo r la b o u r lies in the d e v elo p m en t o f c o n tro l o f v o lu n ta ry m uscles a n d th e m o d ific atio n o f a u to n o m ic re sp o n se s to g e th e r w ith a sh a rp e n e d aw aren ess o f b o d ily sensations. R E L A X A T IO N T h e re la x a tio n p ro c ed u re s used in a n te n a ta l tra in in g are all b ased o n J a c o b s o n ’s P rogressive R e la x a tio n . T h e essence o f J a c o b s o n ’s m e th o d is to p ro v id e p ro lo n g ed a n d intensive 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. ) S e p t e m b e r , 1969 train in g in re la x a tio n fo r th e p u rp o se o f achieving differential re la x atio n , w here all m uscles n o t in use a re relaxed a n d so n e u ro m u s c u la r ten sio n s a re d im inished. T o q u o te . . . an excess o f slight o r in cipient ten sio n s o r m o v em e n ts, som e c o -o rd in a te d a n d w ith well m ark e d fu n c tio n a n d som e n o t, involving in m a n y in stances sm all b u t in o th e rs great c alo ric e x p e n d itu re , seem s fro m o n e s ta n d p o in t to c o n stitu te th e very essence o f w h a t is c o m m o n ly called n e rv o u s d iso rd e r. F ro m th is sta n d p o in t, th e effect o f differential re la x a tio n is to e lim in a te such e lem ents o f m o to r d iso rd e r.” (pp. 99-100’). T he effect o f re la x a tio n is to raise th e th re s h o ld o f anxiety- e v o k in g o r te n s io n -e v o k in g stim uli. M u sc u la r re la x a tio n is a n ta g o n istic to th e e x p ressio n o f anxiety. G ra n tly D ic k -R ea d asse rts “ . . • re la x a tio n is em ployed as a n a n tid o te to a b n o rm a l te n s io n a n d th e re fo re a n a d ju v a n t to th e p h y sio ­ logical p rocess.— 1 suggest, how ever, th a t fo r th e p u rp o se o f its a p p lic a tio n in o b ste tric s, we c o n sid er re la x a tio n to be a c o n d itio n in w hich th e m uscle to n e th ro u g h o u t th e b o d y is reduced to a m in im u m .— F o r it we a re a ble to re d u ce th e to n e o f o u r m u sc u la r system we k n o w fro m ex p erim e n t a nd clinical o b se rv a tio n , th a t th e reflexes o f the b o d y are d im i­ nished in pow er. W e also k n o w th a t th e influence o f the 1 m ec h an ism th a t re co rd s se n sa tio n s arisin g w ith in the b o d y is m u ch less p ro n o u n c e d in a sta te o f m u sc u la r re la x atio n th a n in a sta te o f m u sc u la r ten sio n . S tim uli a rising from th e e m o tio n a l system p ro d u c e less violent re a c tio n w hen th e re is a n absence o f ten sio n in th e m u sc u la r system . . . . in a p p ly in g th is to o b ste tric s we c a n say th a t if th e b o d y is c o m pletely relaxed, it is im possible to e n te rta in th e e m o tio n o f fe a r.” (pp. 199-2002). T h e physiological usefulness o f re la x a tio n lies in th e te m p o ra ry asc en d a n cy o f th e p a ra sy m p a th e tic n e rv o u s system w hich will in h ib it sy m p a th e tic fu n c tio n s w hilst psychological benefit com es fro m th e in h ib itio n o f fear. R e la x a tio n w ould n o t e lim in a te a n xiety o r fear fo r these responses a re u n d e r specific stim u lu s c o n tro l, w h a t it achieves, how ever, is th e te m p o ra ry in h ib itio n o f such responses. T h e e lim in a tio n o f a n x ie ty o r fear c o uld o nly be effected th ro u g h d e c o n d itio n in g , w here th e a sso c iatio n b etw een stim uli a n d responses is extinguished o r w eakened. D e co n d itio n in g o r d e se n sitiz atio n o f a nxiety-evoking stim uli h as b e en used extensively by W olpe a n d o th e rs in th e tre a tm e n t o f n e u ro tic b e h av io u r. E sse n tia lly th e d e c o n ­ d itio n in g p ro c e d u re b re a k s d o w n th e associative link b etw een a stim u lu s a n d a re sp o n se by estab lish in g an a lte rn a tiv e re sp o n se to th e sa m e stim ulus. A b rie f d e sc rip tio n o f th is p ro c e d u re is given by W o lp e in th e follow ing passage, w here e a tin g w as used as a n a lte rn a tiv e re sp o n se ra th e r th a n re la x atio n . “ S om e y ears ago, stu d ies o n th e in d u c tio n a n d e lim in a tio n o f ex p erim e n tal n e u ro ses in a n im als show ed t h a t these c o n d itio n s w ere p e rsisten t h a b its o f u n a d ap tiv e b e h a v io u r a cq u ired by lea rn in g (c o n d itio n in g ); a n d th a t th e ir th e ra p y w as a m a tte r o f un lea rn in g . T h e c en tral c o n s titu e n t o f th e n e u ro tic b e h a v io u r w as anxiety, a n d the m o st effective w ay o f p ro c u rin g u n lea rn in g w as re p ea te d ly to feed th e an im a l w hile it w as re sp o n d in g w ith , a w eak d egree o f a nxiety to a “ w e ak ” c o n d itio n e d stim u lu s. T h e effect o f this w as to dim inish progressively th e s tre n g th o f th e a n xiety re sp o n se to th e p a rtic u la r stim u lu s so th a t it e ven tu ally declined to zero. Inc re a sin g ly “ s tro n g ” stim u lu s s itu a tio n s w ere successively d ealt w ith in th e sam e w ay; and finally, th e an im a l show ed n o a n x ie ty to a n y o f th e s itu a tio n s to w hich a n xiety h a d b een c o n d itio n e d . T h e basis o f the g ra d u a l e lim in a tio n o f th e a n x ie ty re sp o n se h a b it a p p e a re d to be a n exam ple, a t a m o re c o m plex level, o f th e p h e n o m e n o n o f recip ro ca l in h ib itio n described o riginally by S h e rrin g to n . E ac h tim e th e a n im a l fed, th e a n xiety re sp o n se w as to som e e x te n t in h ib ite d ; a n d e ach o c ca sio n o f in h ib itio n w eakened so m e w h a t th e stre n g th o f th e a n xiety h a b it. T h e e x perim ents suggested th e general p ro p o s itio n th a t i f a response inhibitory to a n x ie ty can be m ade to occur in the presence o f a n x ie ty- evoking stim uli so that it is accom panied b y a com plete or p a rtia l suppression o f the a n x ie ty response, the bond between these stim uli and th e a n x ie ty re sp o n se will b e w e ak e n e d ” . T h e b e h av io u ral re sp o n se as a n a lte rn a tiv e to anxiety Page 7 m o st w idely used is re la x a tio n ; re la x a tio n is as m uch a p a rt o f b e h a v io u r as a n y m o re obviously “ activ e ” response. D e co n d itio n in g o r de se n sitiz atio n to anxiety-evoking stim uli in th e ra p e u tic p ra ctic e involves th e p re se n ta tio n o f stim uli in a n ascending h ie ra rc h y o f in te n sity w hilst the p a tie n t is c o m pletely relaxed. T h e p ro b a b ility o f these stim uli e v o king a n xiety is dim inished b ecause th e stim uli a re c o n tig u o u s to a new response, a n d o n e th a t is a n xiety in h ibiting. By using differential re la x a tio n in a n te n a ta l tra in in g it is q u ite possible fo r th e effects o f anxiety-evoking stim uli to be re ciprocally in h ib ited by th e a d a p tiv e v e rb aliz a tio n s o f the trainee. T h e re p ea te d o ccurrence o f such in h ib itio n s w ould e n a b le c o n d itio n ed in h ib itio n o f th e a n x ie ty responses to develop. E ffective d e co n d itio n in g o f a nxiety, how ever, d e p en d s u p o n th e system atic m a n ip u la tio n o f th o se stim u lu s events which in itia te a n d m a in ta in the anxiety. W h a t the critical stim u lu s c o n stellatio n s are d e p en d s u p o n the in d iv id u a l’s life 'h isto ry . A s they w o uld v a ry fro m individual to in d ividual it w ould n o t be possible to d e c o n d itio n anxiety in the g ro u p situ a tio n , unless th e a n te ce d e n ts for b e h a v io u r were c o m m o n to all m em bers o f th e g ro u p . L a z a ru s9 has c o n d u c te d a stu d y in w hich his g ro u p s w ere hom ogeneously com posed. T he m o re restricted use o f re la x a tio n fo r the c o n tro l o f m u sc u la r ten sio n is th e o n e th a t c a n be successfully ex p lo ited in a n te n a ta l tra in in g . T ra in in g in re la x a tio n will e n a b le a w o m a n to id entify te n sio n in m uscles a n d e q u ip s h e r with th e responses fo r d e aling w ith it. Som e in d iv id u a ls are in ca p ab le o f deep re la x atio n . I n such in stan c es, o n e can tra in th e m to perceive differences in te n s io n by increasing a n d re d u cin g th e te n s io n in a ny o n e set o f m uscles, until th e y c a n achieve c o m p le te re la x atio n . T h is usually applies in cases o f h y p e rte n sio n w here th e ind iv id u a l has never experienced a sta te free fro m ten sio n , even in sleep th e re are re sid u al tensions. (In such cases th e use o f c h lo rp ro m az in e, m e p ro b a m a te o r c o d ein c o uld be used to c re a te th e experience o f re la x atio n , w here indicated). R e la x a tio n sh o u ld n o t b e a passive p a rt o f tra in in g w here th e w o m a n m erely flops in to a sta te o f o b livion, b u t ra th e r a delib e ra te m an ip u la tio n o f m uscles to h e ig h te n th e aw areness o f feed-back fro m the m uscles. By experiencing the differential m u sc u la r ten sio n s a w o m a n will th e n be a ble to e voke th em o n c o m m a n d a n d so c o n tro l a w hole se quence o f b e h av io u r. O n e c a n n o t necessarily relax aw ay p a in b u t o n e c a n relax aw ay re sistan c e w hich induces pain. E D U C A T IO N IN T H E P H Y S IO L O G Y A N D M E C H A N IC S O F C H IL D B IR T H A N D L A B O U R E d u c a tio n is th e p re p a ra tio n o f th e ind iv id u a l to m eet d e m a n d s m ad e b y th e e n v iro n m e n t, b o th physical a n d social. I t is th ro u g h in s tru c tio n th a t we p rovide th e m odels for b e h av io u r. D e sc rip tio n s o f th e physiology a n d m echanics o f la b o u r will highlight a n d identify th e a p p ro p ria te b eh av io u rs involved a n d so estab lish th e g o als o f re sp o n se th a t each ind iv id u a l sh o u ld strive to achieve. A n o th e r a sp e ct o f fo rm al tra in in g is th a t it p rovides o p p o rtu n itie s fo r th e c o u n te r-c o n d itio n in g o f un d e sirab le a ttitu d e s to w a rd s o r beliefs o f pregnancy. E x p o su re to scientific in fo rm a tio n will in itia te m o re c o n stru ctiv e verbal b e h a v io u r a n d th o u g h t, su p e rstitio u s beliefs and m isco n ­ c ep tio n s will b e extinguished as they a re replaced by s itu a tio n a p p ro p ria te responses. T h e c o n tingencies fo r in itiating, m a in ta in in g a nd e x tinguishing b e h a v io u r are in h ere n t in a n y social g ro u p . Q u e stio n s a n d sta te m e n ts w hich a p p ro x im a te th e scientific m odel o r b o d y o f facts, will be positively re in fo rc ed by th e tea ch e r th ro u g h a p p ro v al, h e r w illingness to listen a nd e x p la in fu rth e r, o r m erely by tim e sp e n t in c o n sid e ra tio n . C onversely, q u e stio n s o r s ta te ­ m e n ts o p p o site to th e scientific d ictates will b e d iscouraged o r n o n -rein fo rc ed by co m m e n ts such as “ T h a t is n o t q u ite w h a t h a p p e n s ” o r “ Y o u do n o t fully u n d e rsta n d th is ” or, so m e w h a t m o re forcibly, “ T h a t’s w ro n g ” . T h ese c o n tin g e n ­ cies have a cq u ired th e ir p o ten c y th ro u g h th e e v o lu tio n o f c u ltu ra l p a tte rn s . S u b tle a n d com plex p ro p e rtie s o f b e h a v io u r c a n be traced to su b tle and com plex fe a tu re s o f th e c o n ­ P H Y S I O T H E R A P Y 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 8 P H Y S I O T H E R A P Y September, 1969 tingencies o f re in fo rc em e n t w hich p revail in th e e n v iro n m e n t. C o m m u n ic a tio n a n d d iscussion a re b e h a v io u rs e n c o u ra g ed by th e clim ate o f a social g ro u p . W h ere th e p u rp o se is to in s tru c t, p a rtic ip a tio n by m em bers o f th e g ro u p s h o u ld be e n c o u ra g e d ; th e ir u n d e rsta n d in g o r k n ow ledge being shaped in a p p ro x im a te step s to c o m p le te b e h av io u r. T h e re aliz a tio n th a t facts a re being m aste red a n d th a t m ean in g fu l p a rtic i­ p a tio n in d iscussion is possible, will in itself be re in fo rc em e n t for in d iv id u a l in te ra c tio n . T h e a cq u ired p o sitiv e a ttitu d e s a n d c o n stru c tiv e b e h a v io u r will e n g en d e r a n o p tim istic b u t in fo rm e d a p p ro a c h to la b o u r. T h e g ro u p s itu a tio n c a n also be used as a p la tfo rm to disse m in a te facts o n c h ild -rea rin g p ra ctic e s w hich c o n fo rm to th e c u ltu ra l n o rm s. A g a in , th e con tin g e n cies in g ro u p in te ra c tio n s c o uld initiate , m odify o r e x tinguish in d ividual a ttitu d e s. Since th e a cq u isitio n o f com plex social b e h av io u r is lon g te rm , c o m p le te re g u la riz a tio n o r c o n fo rm ity o f c h ild -rea rin g b e h a v io u r c o u ld n o t be achieved in th e s h o rt tim e dev o ted to a n te n a ta l train in g . T h e guide-lines, how ever, c o uld be e stab lish e d . W h a t develops la te r w o uld be d e te r­ m ined by th e m o th e r’s social m ilieu. R E F E R E N C E S 1. B exton, W . H ., H e ro n , W ., a n d S c o tt, T . H . 1954. E ffects o f decreased v a ria tio n in th e sensory e n v iro n ­ m ent. Canadian Journal o f psychology, 8, 70-76. 2. D ic k -R e a d , G ra n tly , 1958. Childbirth w ithout fe a r . 3rd ed. L o n d o n , H e in em an n M edical Books. 3. E w ert, P. H ., 1930. A stu d y o f th e effect o f inverted re tin a l s tim u la tio n u p o n sp a tia lly c o -o rd in a te d b e h a ­ v io u r. G enetic P sychol. M onogr., 8. 4. F ra n k s , C. M ., 1965. Conditioning techniques in clinical practice a nd research. L o n d o n , T a v isto c k P u b lica tio n s L im ited. 5. K itzin g e r, S. A n approach to antenatal teaching. T h e N a tio n a l C h ild b irth T ru s t. N .C .T . T .A .2. 6. K itzin g e r, S., 1967. The experience o f childbirth. Rev. ed. G re a t B rita in , P e lic a n B ooks. 7. Ja c o b so n , E ., 1938. P rogressive relaxation. C hicago, U n iv e rsity o f C h ica g o Press. 8. L am az e , F ., 1958. P ainless childbirth. L o n d o n , B urke P u b lish in g C o m p an y . 9. L az aru s, A . A ., 1961. G ro u p th e ra p y o f p h o b ic d iso rd e rs by system atic de se n sitiz atio n . J. A bnorm . Soc. P sychol., 63, 504-510. 10. S perry, R . W ., 1952. N e u ro lo g y a n d th e m in d -b ra in p ro b le m . A m erican Scientist, 40, 291-312. 11. S tra tto n , G . M ., 1897. V isio n w ith o u t in v ersio n o f th e re tin a l im age. Psychol. R ev., 4, 341-60, 463-81. 12. W olpe, J., 1961. T h e system atic d e se n sitiz atio n tr e a t­ m e n t o f neuroses. Jnl. o f N ervous a n d M e n ta l Disease, 132, 189-203. Treatment Notes Physiotherapy in Ante and Postnatal Field B y M rs. P . U N IA C K E P h y s io th e ra p y in o b ste tric s has c o m e very m u ch to the fore in th e p a st 20 years, especially in th e a n te n a ta l field. “ N a tu ra l C h ild b irth ” . T h is is a tta in e d “ w hen on the physical p la n e la b o u r is p h y siological a n d u n o b stru c te d a n d o n th e m e n ta l p la n e th e m o th e r-to -b e is u n a fra id ” . T h is w as th e p rin c ip a l to be p u t in to pra ctic e a n d , w ith th e in v alu a b le h elp o f th e late H e le n H e a rd m a n ’s tw o b ooks, The W a y to N a tu ra l Childbirth a n d P hysiotherapy in O bstet­ rics a nd G ynaecology, th is h a s b ecom e q u ite sim ple. T h e p a tie n ts m u st n a tu ra lly have th eir d o c to r’s perm ission to a tte n d classes a n d sh o u ld s ta rt a n y tim e fro m 4J- to 5 m o n th s . T h e first tim e th e y a tte n d th e y co m e 15 m inutes e arly a n d we sit a n d h ave a q u iet d iscussion a b o u t re la x atio n . I t is im p o rta n t fo r th e m to realise w hy they a re d o in g all th e exercises. A sm all d ia g ra m o f th e c o n te n ts o f th e pelvis is show n to th em a n d th e n a n e x p la n a tio n o f the m u sc u la r m ov em e n ts o f th e u te ru s d u rin g th e first stage o f la b o u r. D u rin g a n u terin e c o n tra c tio n the p a ra sy m p a th e tic in n erv a te s th e lo n g itu d in a l fibres o f the u teru s, w hich sh o rte n , c ausing the u te ru s to c o n tra c t a n d re tr a c t; the c irc u la r fibres, m eanw hile, relaxing. I f the w o m a n s ta rts to tense th ro u g h fear, th e sy m p a th e tic is called in to pro tec tiv e a c tio n cau sin g sp a sm o f the low er segm ent a n d th e longi­ tu d in a l fibres now have to ov e rco m e the re sistan c e o f the c irc u la r ones. T h e re is no w w a rfare betw een th e tw o o p p o sin g forces a n d tru e p a in results. All th is is exp la in ed to th e p a tie n t in sim plified te rm s to b rin g h e r to th e re a lis a tio n th a t fear cau ses ten sio n , tension c au ses th e n eck o f th e cervix to tig h te n , w h ich cau ses p ain w hich leads to m o re fear th u s estab lish in g a vicious circle. T h e p a tie n t is n ow re a d y to jo in th e class. T h e follow ing e q u ip m e n t is used: (a) F o a m m a ts ; th ree p a tie n ts to a m at. T hese c a n be ro lle d u p a fte r use a n d easily sto re d . (b) Sm all pillow s fo r th e h e ad c o v ere d by sm all tow els w hich a re easily la u n d e re d . (c) A g ra m o p h o n e . P a tie n ts p e rfo rm the a b d o m in a l a n d leg exercises fa r b e tte r w ith m usic th a n w ith o u t a n d it also a d d s in te rest fo r th em . E xercises a re given in th e follow ing o rd e r: (a) A b d o m in a l a n d c hest b re ath in g . (b) Pelvic rocking. (c) Pelvic floor c o n tra c tio n s. T h e im p o rta n c e o f these exercises being stressed fo r c o n tro l o f th e b lad d e r b e fo re a n d a fte r b irth . (d ) F iv e a b d o m in a l exercises c a rrie d o u t to m usic. (e) Pelvic flo o r stre tc h in g exercises. ( / ) B re ast exercises, im p o rta n c e being stressed th a t these exercises m u st be d o n e by th e p a tie n t a fte r th e b irth o f the child, fro m th e first day. A p a rt fro m p ro m o tin g th e flow o f m ilk it helps to c o n tro l th e sw elling, lu m p s a n d d isc o m fo rt as th e b re a sts enlarge. (g ) R e la x a tio n w ith c o n tro lle d slow bre ath in g . P a tie n ts a re ta u g h t to re la x o n e ac h side. D u rin g th e first stage o f la b o u r o n e side is usually m o re c o m fo rta b le b u t b o th sides s h o u ld b e p ra c tis e d a t classes as it is to o early to tell w hich side will be used. T h re e types o f b re a th in g a re ta u g h t: (a) Slow b re a th in g . T h is is sta rte d low d o w n in the d ia p h ra g m g ra d u a lly c om ing up to in te rc o sta l w ith a c o u n t o f 15 in a n d 15 o u t. F o u r to five c o u n ts o f 15 last fo r 60 seconds w hich is ro u g h ly th e len g th o f one c o n tra c tio n . S om e p a tie n ts c a n p ro b a b ly b re a th e far slow er b u t in a class it is b e tte r to ta k e a n a verage th a t c a n be m an a g ed by all. T h is m u s t be pra ctised a t h o m e every day. (b) W h en th e c o n tra c tio n s a re to o s tro n g fo r th e p a tie n t to m an a g e 15 c o u n t they can c o u n t 10. (c) A t th e e n d o f th e first stage, d eep b re a th in g th ro u g h th e m o u th to a c o u n t o f 3. T h is c o m pletes th e first stage o f lab o u r. I f th e p a tie n t w ishes h e r h u s b a n d to be p re sen t a t the b irth sh e is a sk e d e a rlie r o n to te a c h h e r h u s b a n d h o w to c o u n t. T h is h a s been fo u n d to be a g re a t help. S E C O N D S T A G E O F L A B O U R P a tie n ts d u e in 6 to 7 weeks tim e c om e 20 m in u te s e arlie r th a n th e re st o f the class a n d sta rt exercises fo r th e second stage. T h e b e a rin g d o w n se n sa tio n , i.e. th e desire to e m p ty the bow els, h e ra ld s th e be g in n in g o f th e second stage. T he p a tie n t, o n feeling this, is to ld to rin g th e bell a n d in fo rm th e m idw ife th a t sh e desires to p u sh . (a) C ro o k lying. W ith e ach c o n tra c tio n ra ise th e legs, h o ld in g th em u n d e r th e k n e e w ith the k n ees a p a rt. T a k e a deep b re a th in, low er th e sh o u ld e rs in a g ain st th e b e d a n d p u sh w ith th e re c tu m fro m the w aist d ow n, low ering th e legs a t th e e n d o f e ac h c o n tra c tio n . (b) A s th e h e ad s ta rts to descend th e v a gina th e p a tie n t m ay experience a terrific sp littin g se n sa tio n . S he m u st 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. )