THERAPEUTIC TOUCH IN LABOUR AND BIRTH
By C. Stark, R.N.

Childbirth. Mention this to anyone who has experienced giving birth, regardless of age, and the response will be a strong one. It may have been the most exciting moment in a woman's life and its memory can last a lifetime.

Descriptive words I've heard include - *incredible, unbelievable, amazing, terrifying, exhausting, painful, nerve-wracking, awesome, wow!* As a labour and birth nurse at St. Michael's Hospital in Toronto, the challenges of my working day are many. Birth becomes the long-awaited event and the pregnant woman arrives on the unit with both emotional and physical needs.

Issues may exist that may have an impact on the patient's labour experience and its outcome. Is she alone or with family support, married or single? Are there unemployment or housing difficulties? Is there evidence of abuse, alcohol or drug use? Is she a recent immigrant or refugee with limited understanding of English or Canadian culture? Is this an unwanted pregnancy?

Is the sex of the baby a factor? Some issues may not have been addressed during pre-natal visits - often due to the patient's hesitancy to say anything - so the labour nurse may be the first care-giver to notice behavioural "cues" such as unusual fear, anxiety, silence or excessive talking.

The patient is usually young and in good health. When in labour, she will show signs of coping with pain that may range from quiet, restrained internalization to high intolerance and near hysteria.Where does Therapeutic Touch (TT) fit into all this? I think it is the comfort and support given to the labouring patient that ultimately affect her feelings towards childbirth and I believe TT to be a key element in providing such care in a positive, reassuring, calm and gentle way.Before I enter a room, I centre and focus on calmness in myself to help me accomplish whatever is required. I discuss with the patient and husband their expectations of labour e.g. if they wish for a natural childbirth. The patient may know of some comfort measures that we can help her with, however, I always explain and demonstrate some simple techniques.

Breathing and Relaxation.

During a contraction, have the patient breath gently in through the nose and out through the mouth, to visualize oxygen going into the lungs to nourish and give energy to herself and the baby. For relaxation, as the contraction subsides, she should return to normal breathing, physically relax the shoulders and allow her body to sink into the bed, close her eyes and think of quietness and rest. When relaxing, I will gently touch her ankle, knee, wrist, elbow and/or shoulder and suggest she visualizes all her joints relaxing and letting go of tension. Breathing and relaxation allow the patient to participate, to keep control for herself and perhaps, to lessen her anxiety and fear of the process of labour. The support person can help her continue this should the nurse not be available.

Visualization.

During labour, a patient may have a visual point to focus on (her husband, a photograph, something pleasant in the room) or she may choose to close her eyes to visualize an "image" for herself, or listen to music.Visualization can be very helpful. M. A. Alexander RN, who also works on the unit, finds that an idea often needs to be given to the anxious, tense patient in active labour and suggests this type of imagery: "imagine the baby being out and in your arms/during a contraction, breathe the baby down . . . completely relax and see the discomfort drain out of the body and into the floor.

Giving Therapeutic Touch.

Labouring patients are very sensitive to touch; it may be urgently called for or refused, all within minutes. By explaining that TT is like a light "massage-without-touching" and that it may help towards relaxation, the idea of TT is introduced as a gentle option and/or complement to physical touch. The patient may not wish to know about TT at this time; she may want immediate pain relief and only an epidural will do. This is to be respected. While waiting for assessment, for blood results prior to getting an epidural, or to "locate a vein" for IV therapy, she may be willing to receive some TT and thus verbal permission is given. Often by *giving it a try*, the patient will want TT continued.

Centering.

It only takes a breath but one may need to re-centre frequently as there are many interruptions. While coaching the patient with breathing, I will often breathe along with her and so centre myself as we breathe together. When I notice the stress level rising in the room, I will say "O.K. everyone, let's all now take in a big breath and let it out slowly" and I visualize those in the room being calmer.

Assessment.

I scan the patient's field from time to time, not to identify "specifics" but to have a sense of her energy level. This is an acute care situation: every contraction requires attention and if they occur every 2/3/4 minutes, there is little time for incorporating all the phases of TT. Away from the bedside, I will assess the energy field in the room. Often the energy level will greet me as I open the patient's door and I will visualize myself unruffling the whole room, asking for gentle soothing light to enter and calm the atmosphere within.

Unruffling.

When a contraction starts and the patient begins her visualization and breathing, I unruffle, starting at the forehead and gently sweeping down without stopping until well past the feet. I may unruffle once or up to three times during each contraction and my intention is that the patient's energy field will clear to allow the process of labour to continue its path to a healthy, safe outcome. I also envision the patient being calm, relaxed and able to manage her pain without anxiety or fear. As the contraction subsides, I ground the patient by gently touching her feet or by envisioning the energy flowing from her feet. I may unruffle again if there is high anxiety. A times I talk quietly with the patient while unruffling.

Evaluation.

During relaxation (between contractions) I will stop and we "take a moment's rest". It is during this time that the nursing work takes priority (nursing care, assessments, monitoring, documentation), questions can be answered, drinks and nourishment offered etc. However, I have noticed that during relaxation a sense of peace and quiet permeates the room.

Partnering for TT.

Although most labour units support one-on-one nursing, this is not always possible due to unexpected emergencies. To give TT to a patient who wishes it continued and the RN is called away, a "mini-course" in TT can be given to the support person. The husband is often willing to learn as it allows him more opportunity to support his wife. We try a few imagery ideas so they can both feel comfortable with a specific one or come up with one of their own.I demonstrate unruffling, let the husband unruffle while his wife breathes though a contraction and during relaxation, have him sit by the bed, close to his wife, holding her hand or massaging her. We also unruffle together. Regarding intent, I suggest he visualize a soft mist or gentle sunshine all around them, that everything is calm and peaceful and his wife is managing beautifully.When I leave the room, the husband may help his wife with visualization, breathing, physical massage and/or unruffling. As long as there is sincere intent in the participation between the two, then TT is being continued.

Effects and Benefits.

Relaxation is the most obvious effect. The patient's awareness of relaxation may come within a few minutes of receiving TT or after some time when she realizes she has been coping better with the contractions (even at their most intense) and is able to fully relax and rest between contractions.

From the relaxation effect, there come a number of benefits - decreased anxiety and fear, a sense of peace and calm, and being able to co-operate with the process of labour by no longer fighting against it. The atmosphere in the room noticeably changes from high stress/tension to relaxed quietness. After an epidural, giving TT will reduce anxiety and allow a relaxed sleep.Does TT reduce pain, speed up the process and/or reduce complications? Only research studies will provide affirmation to those questions. As 'TT nurses' however, we have seen that through the relaxation effect in labouring patients, the process of labour is allowed to travel its journey and pain does not appear as intolerable. The progress does seem faster in many cases and perhaps there are fewer complications.

L. Wilkinson RN, who works at the Hamilton Health Sciences Centre, McMaster site, has gained valuable insight from using TT with her patients over several years. Here are some of her observations: "In my practice, I find the use of touch and visualization very important. Even the most active patient will benefit from a compassionate hand, stroking her arm and having the intent to relax her. A simple visualization such as watching her breath will help her take control and enhance the relaxation. It is not expected that all pain will be taken away but if the patient is in control of what she is doing and can manage her labour, then TT has been successful."Wilkinson suggests the writing of Carl Jones The Labouring Mind Response may help understand the psychological, emotional and behavioural changes that occur as labour progresses and how the left-brain orientation of logic/reasoning shifts to right-brain functioning of creativity/intuition/instinct and the patient becomes more open to suggestion, like touching, imagery, TT etc.It is a privilege to be a part of childbirth! It is intensely private and personal, the physical effort and emotional releases are intimately shared by all involved and the experience is truly profound. To hear the cry of a lusty, healthy newborn baby is indescribable and to see the joy in the parents' eyes is reward indeed. A TT nurse can share in the knowledge that Therapeutic Touch contributes towards this accomplishment.

C. Stark RN is a labour and birth nurse at St. Michael's Hospital in Toronto. Originally from Essex, England, where she trained as a midwife, Stark has been enthusiastically practising Therapeutic Touch since 1995.She is currently investigating the effects of Therapeutic Touch in the post partum phase.

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