A few years ago I listened to a really useful InJoy webinar given by CRNA Amy Wehrman on Oral Intake During Labor which is still available for review as part of their ‘Classic Injoy’ series.  In the webinar, Amy recommends eating from the BRAT (bananas, rice, applesauce, toast) diet since these foods are gentle on the stomach and less likely to cause vomiting. Of course, she also points out the lack of evidence-based research for denying people food in the hospital but many educator posts, as well as the release of the Lamaze Infographic (No Food, No Drink During Labor? No Way!), have highlighted this - as well as the need for change. Besides the BRAT diet foods, I have come upon a few studies that highlight some food for thought (excuse the pun) in labor.

Baking Soda (SODIUM BICARBONATE) in Early Labor?

Athletes employ many different food theories and diets to enhance or improve their performance. One of those methods, referred to as a 'buffer', is the use of baking soda (aka sodium bicarbonate). Dissolved in water (0.3g sodium bicarb/kg body weight) and taken roughly an hour before the event allows resistance against muscle exhaustion caused by changes in acid-base balance. Sodium bicarbonate has a proven neutralizing effect on the lactic acid that forms during muscle exertion and improves performance.

In a fascinating study in 2016 out of Sweden and the UK, Wiberg-Itzel, et al, worked together to study the effect of sodium bicarbonate on laboring women whose contractions had become weaker and consequently less effective (dystocic). Two randomized groups of 200 primiparous women in active labor were studied. The first group received no sodium bicarbonate and oxytocin/Pitocin was started immediately (adhering to local clinical guidelines). The second group was each given 4.26g of sodium bicarbonate (using an over the counter aid for indigestion called Samarin which is readily available in Sweden) mixed with 200ml of water an hour before starting oxytocin if no progress in labor was identified.

The results were quite astonishing. 84% of the sodium bicarbonate group went on to have spontaneous deliveries versus 67% of the non-bicarb group. 6.7% of the sodium bicarb group was assisted by vacuum whereas 24.2% of the other group needed vacuum assistance. Newborns from the sodium bicarb group of mothers had overall better outcomes including no APGARS <7. It is quite clear that the sodium bicarb helped the uterus recover from the muscular changes associated with labor exhaustion.

The question remains whether people should consider using sodium bicarb without further studies and if so, how much. The only known downsides of sodium bicarbonate are that it can contribute to stomach upset and water retention and so some may not tolerate it well. Will people be using a sodium bicarbonate product in early labor routinely in future? Do you have any experience using it?

Yogurt, etc.

Over the last few years, the aforementioned BRAT diet has evolved into the BRATY diet with the Y standing for yogurt. One of the reasons I encourage people to eat yogurt during pregnancy is that it may help reduce Group B Strep colonization. Although the evidence is not strong, a small study (Hanson et al, 2014) by) concluded that foods that increase lactobacilli in the pregnant person's diet (i.e. yogurt that contains probiotics like lactobacillus or acidophilus) may decrease the chance of GBS infection. In addition, some of the commonly prescribed practices in pregnancy (laxatives for constipation resulting from iron pills and calcium carbonate antacids to reduce heartburn) and the general stress pregnant women experience put them at far higher risk of killing off their 'good bacteria'.

In labor, any antibiotics received by the pregnant person can deplete their good bacteria. The death of good bacteria also decreases the parent's immunity and increases the likelihood of food allergies in the baby (Love B, et al, 2016) so eating yogurt both during and after labor may help (re)build good bacteria. Yogurt is a super source of protein and calcium and is usually well tolerated, even in people who are lactose intolerant.  There also a small observational study that suggests high serum zinc levels can lower the odds of testing positive for GBS in pregnancy.  Zinc-rich foods include oysters, red meat, shell-fish and fortified cereals. 

Protein Shakes

The 2019 ACOG Committee Opinion on limiting interventions during labor and the 2024 ACOG Clinical Practice Guideline on labor management both statethat oral hydration can be encouraged to “meet hydration and caloric needs, and that routine continuous IV fluids may not be necessary for spontaneously progressing labor”.  Oral hydration includes black coffee, fruit juices without pulp, clear tea, carbonated beverages and sports drinks.

What about a protein shake in labor? After all, protein shakes are used by professional athletes to help increase endurance. In 2013, researchers at the University of Pittsburgh evaluated people who drank a 325ml protein shake (Premier Nutrition) within 15 minutes of receiving an epidural. Their hope was that the protein shake would reduce the incidence of nausea, vomiting, and gastric emptying. Sadly the results did not support their theory as the outcomes were statistically insignificant. The lead researcher Manuel Vallejo Jr, MD did, however, state 'Physicians should feel comfortable replacing ice chips or water with a high-protein liquid supplement when vaginal delivery is expected.'

What the study did highlight, however, was the overall increase in satisfaction from the people allowed the protein shake. Isn't anything that increases a person's satisfaction in labor without increasing adverse consequences worth pursuing?

Xylitol-based chewing gum

This last item is one I recommend people have in their hospital bag 'just in case'. While I hope that the people in my class don't experience a cesarean section, I'm well aware that the cesarean section rate in our local hospitals - more than half of which are unplanned mimic the national average at approximately 32%. After a cesarean section, people in our area are not generally released until they have produced a bowel movement. This can be a particularly stressful thought at a time when healing is paramount. In a 2017 study in the Journal of Maternal-Fetal Neonatal Medicine, researchers Ciardulli, et al reviewed seventeen randomized control trials (representing over 3000 people) to examine the effect of people using chewing gum after a cesarean section. They concluded that: 'Gum chewing starting right after cesarean delivery three times a day for about 30 min (until the first flatus) is associated with early recovery of bowel motility. As this is a simple, generally inexpensive intervention, providers should consider implementing cesarean postoperative care with gum chewing.'

Of course, the next question would undoubtedly be what kind of gum? A recent study from Taiwan (Lee, et al, 2016) specifically examined the effect of the natural sweetener Xylitol in gum. The study used three control groups (gum containing Xylitol, Xylitol-free gum or no gum) to determine whether Xylitol-based gum should be recommended. They concluded 'After cesarean section, chewing gum increased participants' return of bowel activity, as measured by the appearance of bowel sounds and the passage of flatus. In this context, xylitol-containing gum may be superior to xylitol-free gum.' Not only is Xylitol billed as helping to prevent tooth decay, it prompts the mouth to produce more saliva which in turn would start involuntary peristalsis.

Although the studies I read did not talk about specific guidelines for xylitol dosage, I came across a few brands (Pur, Epic Xylitol, Xlyoburst) which carried roughly one gram per serving (serving = one piece of gum) and could be ordered online or found in health food stores. Interestingly, one of the warning labels I read mentioned the possible side effects of exceeding 40-50g of xylitol: diarrhea, borborygmi (rumbling sounds of gas moving through the intestine) colic and increased bowel movements. Of course, these side effects (in moderation) are exactly the reason xylitol based gum can be useful after a cesarean section or any surgery which could impair the intestinal tract.

Food for thought?

Would you feel comfortable sharing the science behind ingesting baking soda and yogurt in labor? How about a protein shake? Would it be useful to discuss xylitol chewing gum for faster recovery of bowel motility following a cesarean section? What do you recommend that people eat in labor? Have you found any foods or fluids that worked well for you or the families you educate?

References:

Ciardulli, Saccone G, Di Mascio D, Caissutti C, Berghella. Chewing gum improves postoperative recovery of gastrointestinal function after cesarean delivery: a systematic review and meta-analysis of randomized trials. J Matern Fetal Neonatal Med. 2018; 31(14):1924-1932.

Hanson L, Vandevusse L, Duster M, Warrack S, Safdar N. Feasibility of oral prenatal probiotics against maternal group B Streptococcus vaginal and rectal colonization. J Obstet Gynecol Neonatal Nurs. 2014 May-Jun;43(3):294-304. doi: 10.1111/1552-6909.12308. Epub 2014 Apr 22. PMID: 24754328.

Jian Tao Lee, RN, PhD, Mei-Hui Hsieh, MS, Po-Jen Cheng, MD, and Jr-Rung Lin, PhD. The Role of Xylitol Gum Chewing in Restoring Postoperative Bowel Activity After Cesarean Section. Biological Research For Nursing. 2015; Vol 18, Issue 2, pp. 167 - 172

Love BL, Mann JR, Hardin JW, Lu ZK, Cox C, Amrol DJ. Antibiotic prescription and food allergy in young children. Allergy, Asthma, and Clinical Immunology: Official Journal of the Canadian Society of Allergy and Clinical Immunology. 2016;12:41. doi:10.1186/s13223-016-0148-7.

Oral intake during labor. ACOG Committee Opinion No. 441. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:714.

Vallejo Jr M. American Society of Anesthesiologists (ASA) 2013 Annual Meeting. Abstract #1066. Presented October 12, 2013.

Wiberg-Itzel E, Wray S, Akerud H. A randomized controlled trial of a new treatment for labor dystocia. The Journal of Maternal-Fetal & Neonatal Medicine. DOI: 10.1080/14767058.2017.133268.

About Mindy Cockeram, LCCE, IBCLC

Mindy Cockeram is a Certified Lamaze Childbirth Educator and IBCLC working with a large hospital chain in Southern California where she's been teaching for 15 years. She trained initially through the UK's National Childbirth Trust in Wimbledon, England. She graduated from Villanova University in 1986 with a bachelor's degree in Communications and a minor in Business Studies. Mindy is the author of four books: Cut Your Labor in Half: 19 Secrets to a Faster and Easier Birth, Pregnant Again? A Childbirth & Breastfeeding Refresher, Breastfeeding Doesn't Have to Suck: Tips, Tricks and Knowledge for a Great Experience and Pump It Up! A Practical Guide to Confident & Efficient Breast Pumping, ". She resides in Redlands, California with her British husband and two children.

People cannot choose an option they do not know exists. This is often true of pushing during childbirth in the United States and many other parts of the world. Birthers are commonly encouraged to hold their breath and bear down for ten seconds, repeating this at least three times with each contraction. Current evidence; however, suggests that breathing while pushing may better protect the pelvic floor. Childbirth educators can support pregnant families by explaining the benefits of breathing during pushing, including:

• Less pain
• Reduced risk of pelvic floor muscle tears
• Less fatigue after birth
• Lower risk of urinary incontinence after birth

Childbirth educators can also teach advocacy skills for breathing during pushing and encourage class participants to choose a healthcare provider who supports physiological birth.

Lamaze Healthy Birth Practice #5: Avoid Giving Birth on Your Back and Follow Your Body’s Urge to Push encourages birthers to listen to their body when it comes to pushing, breathing during pushing, intuitively during the pushing stage (also known as the second stage of labor). This article presents three breathing techniques to avoid pelvic floor trauma during the second stage of labor

Technique 1: Push with an open glottis

The glottis contains the vocal cords and the space between them in the throat. When the glottis is open during pushing, that means air is still flowing past the vocal cords. Accordingly, the birthing person can be heard making a sustained exhale or hum. Compare this to closed glottis pushing (also sometimes called Valsalva or “purple pushing” as the persons face may get purple during pushing), where the vocal cords come together to stop airflow and no sound is made.

One research study compared birthing people who were randomly assigned either to hold their breath during pushing or to avoid holding their breath. Researchers found that those who did not hold their breath had less pelvic floor trauma and were more likely to have an intact perineum without tearing. A systematic review found the same results. A narrative review of the evidence also found that birthing people were consistently encouraged to exhale while bearing down, which helped protect the perineum from trauma and supported vaginal opening as the baby was born.

How long should someone push while breathing out? Recent studies indicate that pushing efforts of five seconds result in less pelvic floor injury than traditional pushing recommendations (which typically uses a closed glottis technique, pushing for ten seconds, repeated three times per contraction). Furthermore, another study involving 1710 people giving birth to their first child and using an epidural found that the direction to push two times per contraction versus three times per contraction resulted in lower rates of episiotomies, with no increased impact on neonatal morbidity or postpartum hemorrhage in the birther.

In 2019–and reaffirmed in 2021–the American College of Obstetricians and Gynecologists (ACOG), in cooperation with the American College of Nurse Midwives (ACNM), stated in Approaches to Limit Labor Interventions, “When not coached to breathe in a specific way, [birthing people] push with an open glottis. In consideration of the limited data regarding superiority of spontaneous versus Valsalva pushing, each [birthing person] should be encouraged to use [their] preferred and most effective technique” (ACOG, 2019).

Technique 2: Make some noise

When a birther is having trouble remembering to breathe during labor or pushing, that person might have better success with the instruction to make sounds. Vocalizing keeps air flowing through the glottis. There isn’t a lot of research on exactly which sounds to make; however, commonplace sounds for pushing include:

• Grrr
• Growling or groaning
• Sustained A, O, and U sounds

One study stated that the best sounds to make were “low and slow” to assist with birthing, while high pitch and fast sounds impede birthing.

In one small study in Brazil, making sounds decreased the risk of a perineal tear longer than two centimeters by 68%. Likewise, another study found that saying positive affirmations helped to decrease stress, pain perception and increase a connection with the baby being born.

Sometimes people giving birth feel self-conscious about the sounds they are making. If that’s the case, the birthing person may feel more at ease if their support people also make the same sounds as them during pushing.

Technique 3: Blow out during crowning

During crowning, “blowing out” breaths refer to puffing breaths or soft “ahhh” sounds as the baby’s head emerges, rather than continuing to bear down. A birth attendant typically introduces this technique after observing crowning and encourages the birthing person to “puff” or “blow” instead of push. This can help the birthing person resist the urge to push forcefully, reducing pressure that could injure the pelvic floor.

In a study, open glottis pushing combined with blowing during crowning resulted in no perineal tearing for 41% of birthing people, compared with 19% in the closed glottis (Valsalva) pushing group without blowing. Tears that did occur were also less severe than those in the closed glottis group.

Are there times when closed glottis pushing should be performed?

If there are medical complications that warrant a speedy delivery, closed glottis pushing might be suggested to shorten the time to birth. However, when looking at the evidence, studies show mixed results with some showing shorter times for open glottis pushing and others for closed glottis pushing. In 2024, a systematic review and meta-analysis showed that when the data was pooled between studies, the result was that there was no significant difference between time of second stage labor between the two methods of breathing.

Several studies suggest that holding the breath during pushing can have harmful effects. It may alter acid-base balance and contribute to fetal distress, while also increasing postpartum fatigue for the birthing person. Encouraging breathing during pushing has been associated with positive fetal and neonatal outcomes, including comparable Apgar scores.

Conclusion

Pregnant people benefit from clear, evidence-based guidance on pushing and breathing during the second stage of labor. Techniques such as keeping the glottis open, vocalizing, and easing the baby’s emergence during crowning may help reduce pelvic floor injury and support long-term quality of life. Childbirth educators can ensure their instruction reflects current evidence, while perinatal professionals can help families understand the value of physiological, parent-led pushing and choose a care team that supports this.

References

American College of Obstetricians and Gynecologists (2019). ACOG committee opinion No. 766: Approaches to limit intervention during labor and birth. Obstetrics and Gynecology, 133(2), e164-e173. https://doi.org/10.1097/aog.0000000000003074

Ahmadi, Z., Torkzahrani, S., Roosta, F., Shakeri, N., & Mhmoodi, Z. (2017). Effect of breathing technique of blowing on the extent of damage to the perineum at the moment of delivery: A randomized clinical trial. Iranian Journal of Nursing and Midwifery Research, 22(1), 62-66. https://doi.org/10.4103/1735-9066.202071

Heim, M. A., & Makuch, M. Y. (2023). Breathing techniques during labor: A multinational narrative review of efficacy. The Journal of Perinatal Education, 32(1), 23-34. https://doi.org/10.1891/jpe-2021-0029

Kownaklia, J., Phanwichatkul, T., Chaichan, A., & Lee, A. (2024). Effectiveness of spontaneous pushing versus Valsalva pushing in the second stage of labor on maternal and neonatal outcomes: A systematic review and meta-analysis. Pacific Rim International Journal of Nursing Research, 28(2), 407-420. https://doi.org/10.60099/prijnr.2024.264145

Le Ray, C., Rozenberg, P., Kayem, G., Harvey, T., Sibiude, J., Doret, M., et al. (2022). Alternative to intensive management of the active phase of the second stage of labor: A multicenter randomized trial (Phase Active du Second STade trial) among nulliparous women with an epidural. American Journal of Obstetrics and Gynecology, 227(4), P639. E36-E15. https://doi.org/10.1016/j.ajog.2022.07.025

Neta, J. N., Amorim, M. M., Guendler, J., Delgado, A., Lemos, A., & Katz, L. (2022). Vocalization during the second stage of labor to prevent perineal trauma: A randomized controlled trial. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 275, 46-53. https://doi.org/10.1016/j.ejogrb.2022.06.007

Roosevelt, L., Danford, K., & Zielinski, R. (2025). Impolite birth: Provider perspectives on vocalization during childbirth. Birth, 52, 627-633. https://doi.org/10.1111/birt.12907

Shamekh Taman, A. H., & Elaziz Hassen, H. A. E. A., & Mahmoud Shoukhba, N. S. (2024). Effect of breathing technique of blowing versus perineal warm compresses during second stage of labor on birth outcomes among primipara. Egyptian Journal of Health Care, 15(3), 249-262. https://doi.org/10.21608/ejhc.2024.372632

Shinozaki, K., Suto, M., Ota, E., Eto, H., & Horiuchi, S. (2022). Postpartum urinary incontinence and birth outcomes as a result of the pushing technique: A systematic review and meta-analysis. International Urogynecology Journal, 33(6), 1435-1449. https://doi.org/10.1007/s00192-021-05058-5

Talasz, H., Kremser, C., Talasz, H. J., Kofler, M., & Rudisch, A. (2022). Breathing, (s)training and the pelvic floor: A basic concept. Healthcare, 10, 1035. https://doi.org/10.3390/healthcare10061035

Vila Pouca, M .C. P., Ferreira, J. P. S., Parente, M. P. L., Natal Jorge, R. M., & Ashton-Miller, J. A. (2022). On the management of maternal pushing during the second stage of labor: A biomechanical study considering passive tissue fatigue damage accumulation. American Journal of Obstetrics and Gynecology, 227(2), 267.e1-267.e20. https://doi.org/10.1016/j.ajog.2022.01.023

When to conduct the icebreaker

Using an icebreaker when the class comes together for the first time helps to calm the nerves and jitters that some people may feel when their birth class begins. Start off your class with one of the fun icebreakers below to put everyone at ease. If you are offering a series, consider starting each week with a different icebreaker, so the community continues to grow and become more relaxed during class.

How long to allow for this activity

Icebreakers should be short and sweet, so the facilitator can move on to the learning content. Plan for no longer than 10 minutes at the beginning of class to move through the icebreaker topic you have selected.

How to conduct this activity

Introduce the icebreaker topic to the class. You can have it written on the white board or a sheet of poster paper, or in your slide deck or just verbally share. Ask for a volunteer to go first. After they have answered, invite them to select another person/family to speak. If appropriate and depending on the question, each person in attendance can answer for themselves, or the family can answer as a unit.

If the icebreaker also serves the purpose of collecting resources, consider jotting down the answers to share back with the group after class. If you have a large group, and cycling through everyone will take more time than you feel you can allocate to this activity, break them into subgroups and have them share responses within their smaller circles.

Potential topic questions for your icebreakers

• How did you choose your doctor or midwife and birth location?
• What was the last question you asked your health care provider?
• What qualities do you possess that will make you a great parent?
• What qualities does your partner possess that will make them a great parent (if everyone is partnered in the class)?
• What was your favorite childhood book that you look forward to reading to your own child?
• How do you want to feel after you give birth?
• What is one word or phrase to describe the pregnancy experience so far?
• What is one thing you have done/changed so far because of being pregnant or your partner being pregnant?
• What is the last thing you read about pregnancy, birth or parenting?
• What is the best (or hardest) part of this pregnancy so far?
• Share the wackiest advice you have received on the topic of pregnancy, birth or parenting?
• After sharing with a partner (if partnered), who was the second person you told that you were pregnant?
• Invite everyone to share their name and the details they know about how/why they received that specific name.
• Ask each person (or family) to share two truths and a lie and the others in the class have to guess which is the lie.
• Share the last item purchased or acquired in preparation for the baby’s arrival.

How you can modify this activity

These questions can be asked for both in-person and virtual classes with opportunities to build community in either format. A modification to this activity might be to invite each family to “sponsor” the icebreaker each week by choosing the question for the week from a list of questions you share, providing structure to their selection.

What do families say about starting their childbirth class with an icebreaker?

Many people choose to take a childbirth class not only to receive information to help them feel prepared and confident for what’s ahead, but also to meet and connect with others who are going through shared experiences. Families have shared they appreciate the opportunity to meet and learn about others in the class, and even identify a commonality upon which to potentially build a friendship. They also appreciate something light-hearted when many of the topics discussed can feel big, important and serious.

Conclusion

Do you use icebreakers in your childbirth classes? If you do not, what would make you reconsider this? If you do, what are some of your perennial favorites? Please share in the comments section below so we can all gain some new ideas to start our classes. Also check out these other previous Brilliant Activities for Birth Educator icebreaker ideas.

• Solve the Puzzle of Virtual Teaching
• An Anatomy Icebreaker

Dates contain folate (Vitamin B9), riboflavin (Vitamin B2), biotin (Vitamin B7), thiamin (Vitamin B1), commonly known as part of the B-complex vitamins, and ascorbic acid or Vitamin C. They also contain Vitamin K. Dates contain various minerals, such as calcium, potassium, magnesium, and iron. In addition, studies have shown that eating dates along with taking iron supplements raises hemoglobin levels more than taking iron alone. So simply as a fruit they are rich in nutrients.

Many studies have explored the benefits of date consumption during pregnancy, labor, and postpartum. Eating dates in early pregnancy may be beneficial, as the high fiber content may aid normal bowel function. There are some cautions to be aware of when eating dates which include allergic reactions, because of the sulfite content in dates. People with diabetes of any form, either gestational, or preexisting, should consult with their healthcare team prior to adding dates to their diet. Date fruit is a significant source of dietary sugar, fructose and glucose, so its use needs to be part of a nutritional plan to avoid high blood sugar levels. Though there is some evidence that carefully added date fruit can help to stabilize blood sugar levels if added to a diet plan under the guidance of the healthcare team.

It appears that the most consistent dosing of date fruit is 6-7 pieces per day starting at 36 weeks gestation for prenatal use. A study conducted in Indonesia with women at risk for preeclampsia, showed that the mean arterial pressure was significantly lower in women that ate 7 dates a day. This lower pressure was thought to be due to the high content of potassium, magnesium, and flavonoid within date fruit. So, there is potential benefit for those at risk for preeclampsia. Yet more research on this topic needs to be undertaken.

Prenatal consumption of 6-7 dates starting a month before the due date has benefits for labor including higher Bishop scores, less need for induction of labor with slightly shorter gestation period, and greater cervical dilation on admission to the birth location. There is at least one randomized controlled trial that shows that the membranes are less likely to rupture prior to labor onset. A systematic review and meta-analysis showed shorter length of early labor by an average of approximately 3.5 hours and a shorter length of active labor by an average of approximately 1.3 hours in pregnant people that ate dates in late pregnancy. There was no significant difference in the lengths of second and third stage labor. The fatty acids that are contained in date fruit are thought to aid in the production of prostaglandins, which contributes to cervical ripening, while potassium and magnesium are thought to promote uterine contractions. Both mechanisms, increased prostaglandin production and increased uterine contractions, will in turn promote labor progression. Mode of birth across the studies was inconsistent, but one systematic review found a significant increase in spontaneous vaginal birth in women that ate date fruit in late pregnancy.

Likewise, eating dates during labor provides energy owing to the high carbohydrate content of dates. The dosing quantity that has been studied was 6 dates when admitted into the birthing unit. Like eating dates prenatally, a systematic review and meta-analysis determined that eating dates during labor also shortened the length of the active phase, shortened the total length of first stage labor and shortened second-stage labor, as well. Again, the mechanism of action is thought to be the presence of fatty acids, potassium, and magnesium within the dates.

The postpartum benefits of eating date palm fruit include decreased lochia and increased milk production have been studied. For postpartum consumption, the dosing was 10 dates or 100 grams within one hour after birth. This dosing was shown to significantly decrease the occurrence of postpartum hemorrhage. Studies looking at breast milk production postpartum used various dosing regimens, of 8, 10, and 30 dates consumed per day. Overall, the pooled results showed a significant increase in milk production over birthers with standard care who did not eat dates postpartum.

Studies of date consumption also looked at newborn outcomes, including APGAR scores, birthweight, weight gain after birth, admission to neonatal intensive care units, and meconium or blood stained amniotic fluid. When compared with non-consumers, infants of birthers who ate date fruit during pregnancy or labor did not show any significant differences in any of these outcomes. The findings of these studies are that there are no direct benefits or harms to the infants.

Implications for childbirth classes include talking about date intake during antenatal nutrition sessions or spiraling content through the topics of antepartum, intrapartum, and postpartum care. These discussions should include benefits for each part of pregnancy and childbirth, as well as risks of allergic reactions and increased blood sugar levels with gestational or preexisting diabetes. Likewise, lessons for childbirth class participants should include the dosing methods that have been studied and are known to be safe.

References

Al-Kuran, O., Al-Mehaisen, L., Bawadi, H., Beitawi, S., & Amarin, Z. (2011). The effect of late pregnancy consumption of date fruit on labour and delivery. Journal of Obstetrics and Gynaecology, 31(1), 29-31. https://doi.org/10.3109/01443615.2010.522267

Bagherzadeh Karimi, A., Elmi, A., Mirghafourvand, M. & Baghervand Navid, R. (2020). Effects of date fruit (Phoenix dactylifera L.) on labor and delivery outcomes: A systematic review and meta-analysis. BMC Pregnancy and Childbirth, 20, 210. https://doi.org/10.1186/s12884-020-02915-x

Kharizmatika, Soediono, M. R. (2026). The effect of date fruit consumption on delivery outcomes: A systematic review. Majalah Obstetrics and Ginekologi (Journal of Obstetrics and Gynecology Science), 34(1), 61-69. https://doi.org/10.20473/mog.v34i12026.61-69

McGee, A. J.,  Malam, N., & Spencer, E. (2025). Does eating dates decrease duration of the first stage of labor? Evidence-based Practice, 28(6), 22-23. https://doi.org/10.1097/ebp.0000000000002380

Murray, B., & Parsh, B. (2023). Date fruit consumption for childbirth. Nursing, 53(2), 10-11. https://doi.org/10.1097/01.nurse.0000905688.20852.49

Royani, I., As’ad, S., Mappaware, N. A., Hatta, M., & Rabia (2019). Effect of Ajwa date consumption to inhibit the progression of preeclampsia threats on mean arterial pressure and roll-over test. BioMed Research International, 2019, 2917895, 1-5. https://doi.org/10.1155/2019/2917895

Salajegheh, Z., Nasiri, M., Imanipour, M, Zamanifard, M., Sadeghi, O. et al. (2024). Is oral consumption of dates (Phoenix dactylifera L. fruit) in the peripartum period effective and safe integrative care to facilitate childbirth and improve perinatal outcomes: A comprehensive revised systematic review and dose-response meta-analysis. BMC Pregnancy and Childbirth, 24, 12. https://doi.org/10.1186/s12884-023-06196-y

But what about those more significant tears? It is true that large tears do happen. Fortunately, research has shown us that there are ways to reduce the risk of tearing during a vaginal birth. Some of these ways of preventing tears can be done before childbirth, while others are done during birth.

Before childbirth

1. Perform perineal massage.

Perineal massage is a type of stretching for the vagina to prepare for childbirth. Typically, a pregnant person does the stretching on themselves by using one or two thumbs to widen the opening of the vagina, although sometimes a partner helps. Here’s a link to directions on how to perform perineal massage. 

Research done between 2022 and 2024 on perineal massage done prior to birth compared with birthers that did not do any prenatal perineal massage found that it:

• Reduced the risk of any tearing, but specifically reduced tearing that needed stitches by 9%
• Reduced the risk of needing an episiotomy (an incision to widen the vaginal opening) by 17%
• Reduced the risk of perineal tears that reached the anus (grade 3 and 4) by 64%.
• Reduced pain in and around the vagina after birth for 3 months after birth
• Reduced swelling in the perineal area in the first 10 days after birth
• Reduced the involuntary loss of gas in the 45 days after birth.

How much perineal stretching should you do? Perineal massage is often started eight to four weeks prior to the expected due date. It can be done daily for 5-10 minutes per day. It can be done sitting or lying down.

Pregnant people should check with their medical provider before starting perineal massage. Frequently, people on pelvic rest or at risk of early delivery may be instructed not to perform perineal stretching. 

2. Consider Kegels

Kegel exercises are also known as Pelvic Floor Muscle Training (PFMT). Some studies show decreased frequency of episiotomy, and less tears that reach the anus (grade 3 and 4) when Kegels are performed. However, a systematic review shows that after urinary incontinence develops in pregnancy Kegel exercises don’t improve incontinence before birth or in the year after birth. The same systematic review also looked at preventing urinary incontinence in pregnancy and results were a decrease in developing urinary incontinence of 62% with performing Kegels. Therefore, the recommendation is that Kegels be considered by women as a potential aid to prevent urinary incontinence.

How many Kegels should I do? One study prescribed 5 to 8 second Kegels, then 8 seconds of rest, repeated for 10 minutes, three times per day. However, the Mayo Clinic recommends sets of 10-15 Kegels three times per day. A systematic review found wide variation in dosing and determined that there were no recommendations for maximum benefit. When to start is also widely variable. Some recommend starting as early as 12 weeks gestation, while other studies looked at starting near term. 

3. Practice birthing positions ahead of time.

Certain positions are more likely to lead to larger perineal tears. These positions are ones where the sacrum (part of the low back) is pressed against another surface, such as a bed or chair. Research has shown that perineal trauma is reduced when giving birth on one’s side or kneeling out of a bed. Pushing in a squatting position has been shown to decrease overall time of pushing but has a slightly higher risk of tearing than the other two. Squatting with a grab bar or something for the birther to hold on to is more comfortable. Often, it is easier to remember what TO DO when it comes to birthing, versus what not to do. For this reason, I encourage birthing people to practice positions that will be less likely to cause tears (sacrum is freer to move). Here are some things to practice before going into labor:

• Side-lying
• Kneeling
• Squatting

Recent research suggests that upright positions in general are less likely to lead to tears while horizontal positions are more likely to lead to a birthing person having an episiotomy performed. Use of an epidural has not been found to increase the risk of severe perineal tearing.

4. Make a perineal tear prevention plan.

A study in 2026 compared individualized prevention plans with standard care. The results of the study showed that those with individualized plans had significantly lower rates of episiotomy, 15% shorter second stage labor, and significantly less pain in the postpartum period. So, make a visit to the midwife or obstetrician to talk about ways they can reduce the risk of perineal tearing during birth. It is much easier to include perineal tear prevention strategies in the birth process if they have been agreed upon before labor starts.

Here are some of the common ways a midwife or obstetrician might try to reduce the risk of perineal tearing:

• Controlled birth of the baby’s head
• Individualized positioning to optimize the pelvic outlet
• No routine episiotomy
• Warm compress on the perineum with pushing
• Continuous communication between the birther and the medical and nursing staff.

Warm compresses with pushing can be created from clean washcloths that are soaked in warm water, changing as they become cool. A systematic review showed that there were more of intact perineum, tears that didn’t need to be stitched, less overall tears, less rate of episiotomy, and less pain in the birthers who had warm compresses than in those that didn’t.

During childbirth

5. Consider fewer vaginal examinations during labor.

Having five or more vaginal examinations is associated with a higher risk of a severe perineal tear, even when other factors are controlled for. A birthing person might consider requesting the medical team to only perform medically necessary examinations, so that the exams are limited to as few as possible.

6. Get in the water for pushing.

Waterbirth has been associated with having no perineal tears at birth, at a rate which is significate when compared to those not in water. First time birthers were also significantly less likely to have an episiotomy. Being in water also decreases pain in labor and at the time of birth. If a birthing person is interested in a water birth, they should be sure to check (a) that they have a provider who will honor their wish to birth in the water and (b) that a tub will be available. A tub may need to be rented or purchased depending on the birthing location.

7. Push with an urge and breathe through pushes.

Some birthing people are instructed to push right when they reach 10 centimeters of dilation, while others wait until they feel the urge to push. Delaying pushing does lead to a slightly longer second stage of labor; however, the time of active pushing by the birther is shorter. To spontaneously push the birther should push without holding one’s breath. One technique is to inhale over a second or two, then exhale over 4-5 seconds. Benefits of delayed pushing are slightly more spontaneous vaginal births, and perhaps less fatigue as active pushing is less. Studies show mixed results as to whether delayed pushing prevents lacerations. If someone plans on doing delayed pushing without breath holding, it can be helpful to discuss this decision with the midwife or obstetrician ahead of time, so that the birthing person does not receive unwanted coaching.

Conclusion

Keep in mind that regardless of the amount or type of tearing, the human body has a tremendous capacity for healing. This includes the ability to heal from tears and episiotomies. If a perineal tear does occur, with or without preventative measures being taken, it is not the birthing person’s fault. There are many forms of support for recovering from a perineal tear, from medical treatments to support groups. Regardless of the outcome, birthing people have options for feeling restored. These days, there are many specialists from pelvic floor physical therapists to medical doctors who are board-certified in female pelvic medicine and reconstructive surgery (FPMRS), also known as a urogynecologist, as well as colorectal surgery. No one should suffer alone. If you have a student, client or patient with a significant tear who needs support, please share the resource Life after Fourth Degree Tears.

References

Ahmar, H., Sofyana, S., Suciati, S., Ernawati, & Liantanty, F. (2025). Labor position and its impact on the birth process: A literature review. Journal of Current Health Sciences, 5(2), 97-108. https://doi.org/10.47679/jchs.2025115

Burns, E., Feeley, C., Hall, P. J., & Vanderlaan, J. (2022). Systematic review and meta-analysis to examine intrapartum interventions, and maternal and neonatal outcomes following immersion in water during labour and waterbirth. BMJ Open, 12, e056517. https://doi.org/10.1136/bmjopen-2021-056517

Chen., Q., Qui, X., Fu, A., & Han, Y. (2022). Effect of prenatal perineal massage on postpartum perineal injury and postpartum complications: A meta-analysis. Computational and Mathematical Methods in Medicine, 2022, 3315638, 1-10. https://doi.org/10.1155/2022/3315638

Cohen, W. R. & Friedman, E. A. (2024). The second stage labor. American Journal of Obstetrics and Gynecology, 230, S865-S875. https://doi.org/10.1016/j.ajog.2022.06.014

da Costa Monguilhott, J. J., Bruggemann, O. M., Velho, M. B., Knobel, R., & Costa, R. (2022). Antenatal perineal massage for trauma prevention: A pilot randomized clinical trial. Acta Paulista de Enfermagem, 35, eAPE0381345. http://dx.doi.org/10.37689/acta-ape/2022AOO3813459

Delusa-Lopez, P., Cuenca-Martinez, F., Sanchez-Martinez, V., & Sempere-Rubio, N. (2024). Maternal outcomes using delayed pushing versus immediate pushing in the second stage of labour: An umbrella review. International Journal of Nursing Studies, 152, 104693.

Gluck, O., Herman, H. G., Tal, O., Grinstein, E., Bar, J., Kovo, M. et al. (2020). The association between the number of vaginal examinations during labor and perineal trauma: A retrospective cohort study. Archives of Gynecology and Obstetrics, 301(6), 1405-1410. https://doi.org/10.1007/s00404-020-05552-z

Halfdansdottir, B., Ellinger-Kaya, K., Fjosne, K., Lindgren, H., Hegaard, H., & Blix, E. (2024). The association between waterbirth and perineal injury or other adverse outcomes among low-risk women with physiological birth: Result from the Nordic Home Birth Cohort Study. Women and Birth, 37, 101625. https://doi.org/10.1016/j.wombi.2024.101625

He, R., Wang, X. X., Nian, S., Wang, X. Q., Zhang, L., & Lu, Y. (2023). The effect of pelvic floor muscle training and perineal massage in late pregnancy on postpartum pelvic floor function in nulliparas: A randomized controlled clinical trial. Complementary Therapies in Medicine, 77, 102982. https://doi.org/10.1016/j.ctim.2023.102982

Jissa Donel, & Anuchitra, S. (2025). Evidence based comparison of merits and demerits of different birthing positions and practices: Narrative review. International Journal of Developmental Research, 15(1), 67589-67593. https://doi.org/10.37118/ijdr.29196.01.2025

Kunkel, M. E., Picanco, C. P., Santos, M. V., Schor, P., & Zanetti, M. R. D. (2024). Preventative approaches to perineal trauma in vaginal delivery: Systematic literature review. Brazilian Journal of Motor Behavior, 18(1), 1-11. https://doi.org/10.20338/bjmb.v18i1.407

Mayo Clinic Staff (2024, October 8). Kegel exercises: A how-to guide for women. https://www.mayoclinic.org/healthy-lifestyle/womens-health/in-depth/kegel-exercises/art-20045283

Nguyen, N. T., Lam, Q. M., & Do, H. T. (2024). The effectiveness of warm perineal compresses during the second stage of labor on perineal trauma and labor pain: A systematic review. Journal of Research Development in Nursing and Midwifery, 21(2), 16-21. https://doi.org/10.61186/jgbfnm.21.2.16 1

Okeahialam, N. A., Sultan, A. H., & Thakar, R. (2024). The prevention of perineal trauma during vaginal birth. American Journal of Obstetrics and Gynecology, 203. https://doi.org/10.1016/j.ajog.2022.06.021

Waller-Wise, R., Lewis, S., & Williams, B. (2020). A quality improvement project utilizing a clinical practice guideline in women during second-stage labor. The Journal of Perinatal Education, 29, 72-82. http://dx.doi.org/10.1891/J-PE-D-19-00014

Woodley, S. J., Lawrenson, P., Boyle, R., Cody, J., Morkved, S., Kernohan, A. et al. (2020). Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews, 5, CD007471. https://doi.org/10.1002/14651858.cd007471.pub4

Zafarovna, B. Z. (2026). Individualized labor management strategy for the prevention of soft tissue birth canal trauma: A clinical and prognostic analysis. Medical Research Journal, 2(3), 1-8. https://mrjedu.com/index.php/mrjedu/article/view/330/225

Zhang, D., Bo, K., Montejo, R., Sanchez-Polan, M., Silva-Jose, C., Palacio, M. et al. (2024). Influence of pelvic floor muscle training alone or as apart of a general physical activity program during pregnancy on urinary incontinence, episiotomy and third- or fourth-degree perineal tear: Systemaic review and meta-analysis of randomized clinical trials. Acta Obstetricia et Gynecologica Scandinavica, 103, 1015-1027. https://doi.org/10.1111/aogs.14744

It has been over ten years since the American College of Obstetricians and Gynecologists (ACOG) changed the definition of the start of active labor from 4 cm to 6 cm of dilation (Caughey, 2014).  While most Educators updated their teaching curriculum to account for the change, some may still need to adapt the emotions and expectations of the previous definition of early labor.  The definition of active labor beginning at 6 cms requires different thinking about the phases of labor and how we teach parents to recognize and cope with each phase.  If we do not explore the changes from cm 4 to 6 with future parents, we are not adequately preparing them for the skills and techniques needed to avoid going in too soon.  

For most laboring parents, their experience of intense contraction pain and the need for comfort measures and emotional support starts well before 6 cm of dilation.

Katie Rohs CD(DONA), LCCE teaches a 4^th phase in early labor: "In addition to the traditional "early", "active", and "transition" phases of the first stage, I teach a 4th 'phase' of labor called 'Early Getting Into Active' which is approximately 3 or 4 to 6 cm. There are such clear emotional & physical changes that happen in this phase that I find it to be critical to teaching realistic expectations."

Janelle Durham LCCE reiterates the work needed from centimeters 4 to 6 : "The important message is that laboring parents have to do really hard work to get from 4 - 6 cm, and they shouldn't be discouraged if that phase is really challenging and it takes a while - that's normal. I think it's almost as if we're adding a fourth phase to 1st stage: early labor is the warmup - then there's the intense-but-slow-progress of "getting into active" - the intense-but-at-least-there's progress of active labor - and then transition."

Here are a few tips for teaching about the laboring woman’s needs from cm 4 to 6:

Use AV aids that realistically show what parents experience in each phase of labor.  One of the best teaching graphics may still be Penny Simkin's Road Map of Labor depicting parents' coping at all phases of labor. (Please note, the Road Map of Labor also appears on page 498 of the latest edition of Pregnancy, Childbirth and the Newborn, 2024.)

Teach parents that the ability to cope is independent of cervical dilation.  Ability to cope varies depending on numerous factors, including pain intensity, speed of labor progress, knowledge of comfort measures, understanding what is going on with the baby and cervix, having good support and patient caregivers and companions.

Teach realistic expectations about when to arrive at the birth location.  Most hospitals prefer admitting laboring parents at 4 cms dilation or beyond and parents need to understand reaching the active labor threshold for most first-time parents will take between 15 - 24 hours. The greatest areas of influence childbirth educators have is teaching parents to cope confidently with a long early labor, recognize the signs of labor progress, and understand the signs and signals of when to appropriately leave for the birth place. Many hospitals recommend that laboring parents arrive at the hospital when contractions are 3 minutes apart or if the bag of waters breaks. Additionally, hospitals may recommends discharge home if:

• Cervix 4-5 cm without change x 2 - 4 hours
• Less than 80% effacement
• Membranes intact
• Reactive NST/FHR category I (if uterine contractions present)
• Contractions less than 3 in 10 minutes

Tracy McPhillips PCD(DONA), LCCE: "The instructor is key to helping parents understand what it's like to progress from early labor into active and when it's time to leave for the birth place or call the midwives to come. Ideally, class members develop patience for how labor unfolds and appreciate the need to learn and use skills to cope with a longer early phase of labor.

Focus on teaching coping skills and comfort techniques to increase parents' ability to confidently cope with labor pain intensity, regardless of the phase of labor.  Instead of creating false expectations that the latent phase of labor will be the easiest phase of labor and last until 6 cm, childbirth educators must prepare parents to confidently cope with whatever intensity they feel whenever they feel it.

Penny Simkin – known as the  ‘Mother of the Doula Movement’ once said:

"If we don't prepare people to cope with early-to-active labor, we are not doing our job."  She further recommended that "We should go into detail about the emotional and physical challenges that come with getting into active labor, and tie them in with cervical changes and the 6 Ways to Progress, which we have already covered in class. (i.e. the contractions intensify before the cervix responds with dilation, as it continues thinning, moving forward, and ripening). The cervix tends to resist dilation until it becomes very thin. This causes an emotional struggle for the laboring person, who may feel overwhelmed and anxious, especially if they think the contractions are very intense and doing nothing”.

They struggle with "control," and may decide it's too hard and request an epidural, or they may release control ("I can't do this. It's too hard. My body will have to do it!"). (I've wondered if the well supported laboring person releases control about the same time that the cervix lets go -- just a thought!) When she does release control, she often becomes more instinctual and discovers her own spontaneous ritual.

From my experience, I've learned that when in this instinctual state, "coping" seems to consist of spontaneous behavior, which includes the "Three Rs:" 1) Relaxation between contractions (if not during contractions); 2) Rhythmic behavior (breathing, vocalizing, moving; or rhythmic mental activity, such as counting, a mantra, a song); and 3) Ritual, which is the repetition of these rhythmic behaviors for many contractions in a row. After that, labor becomes more manageable, not because the contractions are less intense, but because the laboring person has discovered how to work with the contractions. A key point is that in order to get through this challenge, the laboring person really benefits from freedom to move around to seek comfort, and "emotional safety," which I define as unconditional acceptance by others of the way they discover to cope -- sounds, movements, etc.

The laboring person shouldn't be criticized (even though the intention of the criticism to be helpful: "You're breathing too fast" "Try to stay still during your contractions or you'll exhaust yourself" "Those high-pitched sounds aren't doing any good. Try to lower your pitch." This translates to the laboring person as, "I'm doing it wrong. They disapprove." The laboring person is likely to remember, "I was awful in labor. I did it all wrong," rather than, "I found a way to cope!" We should teach that these 3 Rs (Relaxation, Rhythm, and Ritual) indicate that the laboring person is coping, and teach the partners to match the laboring person's rhythm in some way (head or hand movements; stroking the laboring person's arm or back, vocalizing with them, etc.)"

‘PAIN’ and The Other 3 R’s

In addition to Penny Simkin's 3 R's, Audrey Miles Cherney, Great Starts Program Manager and Childbirth Educator, talks about "labor P.A.I.N." and really emphasizes the need to relax during the contractions, releasing any muscles not needed to support oneself during a labor contraction, as well as the "other 3 R's" that are important during the "resting time" between contractions.

Audrey explains, "As many educators do, I teach families about the acronym for labor P.A.I.N. as a way to transform a word with which we otherwise have negative associations. "Pain" is a word that is often assumed as meaning "suffering" or that something is wrong that has to be put right and healed, but there are many ways to experience pain and the sensations of labor without suffering and to work with it, instead of fighting or resisting it. When I explain the acronym, I talk specifically about how labor is "Powerful" as well as "Purposeful". It is the laboring person's inner power and strength at work signaling what we need and when we need it when birthing the baby. In one such way, it is a signal to be in their "safe place" and to be surrounded by the people who make them feel safe, if not also loved and respected, and help them be comfortable during this process. Early on, their safe place may be in their neighborhood going for a stroll, then a little later at home actively coping with partner and/or doula. And then even later still, either at the hospital with their medical team, or at the birth center or at home with their midwife. And while we can "Anticipate" what will work for coping, such as with Penny Simkin's "3 R's", we can also anticipate that the strong sensations of labor are "Intermittent"--that there will be a peak with each powerful surge and then it subsides and allows time for the "other 3 R's" to happen: Rest, Rehydration/Refuel, and Reconnect as a couple (or Regroup as a team, and ask questions, or Re-strategize if something is not working).

These elements between contractions work in compliment to what is happening during contractions since the resting time is at least as important to the support happening during the contractions when it comes to maintaining one's ability to reasonably cope and achieve better outcomes overall. And, of course, barring any medical complications, the sensations of pure labor are "Normal." Our bodies are designed to give birth, just as it is designed to breathe and digest food. We certainly do not give birth every day, but it is still a normal physiological process we are designed to do. According to WHO estimates, every second there are 4-5 babies born, so literally, there are hundreds of people worldwide giving birth to babies any given minute. As has been noted by many others before, the human race would not have survived this long, or been so successful breeding if our ability to birth was inherently flawed."

Building parents' confidence in their ability to cope takes time. There is no way around it: Mastering self-comfort coping skills is reached through repetition and practice. Educators should aim for 35% - 50% of their class time teaching and practicing physical and emotional/mental coping skills for labor and self-advocacy skills for shared medical decision-making.

Conclusion

The new guidelines, "6 is the New 4" will lower cesarean rates for failure to progress, but they require laboring persons to be able to endure longer labors, and potentially more emotional distress if they have not found ways to cope. Even those with an epidural find the longer duration of labor until they are eligible to receive and epidural to be stressful. Labor is as much an emotional experience as a physical one for the laboring person and their team. Our job as childbirth educators is to present them with accurate information, help them develop realistic expectations and practice the skills they will need to cope successfully with this challenge.

References

Caughey, A. B., Cahill, A. G., Guise, J. M., Rouse, D. J., & American College of Obstetricians and Gynecologists. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology, 210(3), 179-193.

Simpkin P, Whalley J, Keppler A, Durham J & Bolding A. (2024). Pregnancy, Childbirth and the Newborn: The Complete Guide.

Wagner, C., Zabari, M., Handel, S., & Director, I. C. (2015). Best Practice Recommendations for Labor and Delivery Care.

Originally Published 06/14/2016
Revised 06/17/2027

In 2026, the Lamaze Six Healthy Birth Practices continue to be strongly supported by international research and clinical guidance. Many recommendations now considered standard were introduced years ago, yet they are not always consistently reflected across curricula or teaching materials.

This reflection offers a moment to pause and take stock. It brings together key evidence-aligned updates that reinforce the Six Healthy Birth Practices and support educators in keeping curricula current, credible, and responsive to the realities families face today.

Our goal is to ensure Lamaze Childbirth Education continues to reflect the clarity, confidence, and depth that current evidence offers.

Birth Practice 1 — Let Labor Begin on Its Own

International research and clinical guidance increasingly recognize that labor often unfolds more slowly than previously taught. Active labor is now widely understood to begin closer to 6 cm dilation rather than 4 cm. This reframing helps normalize longer early labor and reduces unnecessary concern when progress does not follow outdated timelines.

Guidance from multiple countries emphasizes patience with early labor when there are no clinical concerns and encourages thoughtful timing of admission based on the full clinical picture.

Teaching Reflection
This evidence supports deepening conversations about patience in early labor and helping families understand that longer early labor is a normal and healthy variation. Reinforcing how time and patience support physiologic birth strengthens alignment with this Birth Practice.

Sources

• World Health Organization – Intrapartum Care for a Positive Childbirth Experience
  https://www.who.int/publications/i/item/WHO-RHR-18.12
• National Institute for Health and Care Excellence (NICE) – Intrapartum Care Guidelines
  https://www.nice.org.uk/guidance/cg190
• American College of Obstetricians and Gynecologists (ACOG) – First and Second Stage Labor Management
  https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2024/01/first-and-second-stage-labor-management

Birth Practice 2 — Walk, Move Around, and Change Positions Throughout Labor

Freedom of movement during labor remains one of the most consistently supported practices in maternity care. Research continues to associate movement with improved comfort, coping, and overall satisfaction with the birth experience.

More recent evidence has helped clarify why movement is so supportive. As labor unfolds, movement allows the pelvis, soft tissues, and fetus to respond dynamically to contractions. Changing positions can support fetal rotation and descent, reduce discomfort from sustained pressure, and help regulate sensation and fatigue.

The emphasis remains on movement itself: changing positions, adjusting posture, and avoiding prolonged immobility. For individuals using epidural analgesia, supported position changes continue to offer benefits related to comfort and pressure relief, guided by safety and individual needs.

Teaching reflection
This evidence reinforces movement as a foundational labor support practice. Teaching can focus on responsiveness to sensation, fatigue, and comfort; normalizing frequent position changes; and affirming that movement supports physiologic labor.

Sources

• World Health Organization – Intrapartum Care for a Positive Childbirth Experience
  https://www.who.int/publications/i/item/WHO-RHR-18.12
• Cochrane Database of Systematic Reviews – Maternal position and mobility in labor
  https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003934.pub4/full
• American College of Obstetricians and Gynecologists – First and Second Stage Labor Management
  https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2024/01/first-and-second-stage-labor-management

Birth Practice 3 — Bring a Loved One, Friend, or Doula for Continuous Support

Few practices in maternity care have as strong and consistent an evidence base as continuous labor support. Across diverse settings, continuous support is associated with improved birth outcomes and more positive birth experiences.

This practice remains central to Lamaze philosophy. Support may come from partners, chosen family, doulas, or a combination that reflects each family’s needs and circumstances.

Teaching reflection
Teaching can reinforce the value of continuous presence and help families think intentionally about who will provide support, how roles may shift during labor, and what support looks like for them.

Sources

• Cochrane Database of Systematic Reviews – Continuous support for women during childbirth
  https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003766.pub6/full
• World Health Organization – Intrapartum Care for a Positive Childbirth Experience
  https://www.who.int/publications/i/item/WHO-RHR-18.12

Birth Practice 4 — Avoid Unnecessary Interventions

The Healthy Birth Practice, Avoid Unnecessary Interventions, reflects evidence showing that interventions are most beneficial when used thoughtfully and for clear clinical reasons. Guidance across maternity care systems supports distinguishing between interventions that are medically indicated and those that may be applied routinely without clear benefit.

Current evidence continues to clarify how this plays out in practice:

• Induction of labor: Recommendations vary internationally and depend on individual clinical factors such as maternal age, pregnancy type, blood pressure, diabetes status, fetal growth, and overall pregnancy health.
• Second-stage pushing: For many first-time birthing parents using epidural analgesia, routine delayed pushing does not improve vaginal birth rates and is associated with increased risks, including infection and postpartum hemorrhage. Timing is best guided by maternal and fetal status.

Across care settings, guidance emphasizes shared decision-making, clear communication of benefits and trade-offs, and flexibility in clinical management.

Teaching reflection
This evidence supports focusing on how decisions are made, as well as which options may be offered. Teaching can help families understand why recommendations may differ, normalize appropriate use of interventions, and build confidence in shared decision-making. 

Sources

• World Health Organization – Intrapartum Care for a Positive Childbirth Experience
  https://www.who.int/publications/i/item/WHO-RHR-18.12
• National Institute for Health and Care Excellence (NICE) – Intrapartum Care Guidelines
  https://www.nice.org.uk/guidance/cg190

Birth Practice 5 — Avoid Giving Birth on the Back and Follow the Body’s Urges to Push

Upright and lateral positions continue to be supported for comfort and pelvic mechanics. Guidance increasingly reflects the value of physiologic pushing, particularly when epidural anesthesia is not in use, while recognizing that clinical context and individual needs shape how pushing unfolds.

Teaching reflection
Encouraging body awareness, flexibility, and responsiveness remains well aligned with evidence and supports this Birth Practice across a wide range of birth settings.

Sources

• World Health Organization
  WHO Recommendations: Intrapartum Care for a Positive Childbirth Experience
  https://www.who.int/publications/i/item/WHO-RHR-18.12
• Cochrane Database of Systematic Reviews
  Maternal position during the second stage of labor for women without epidural anesthesia
  https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002006.pub4/full
• Cochrane Database of Systematic Reviews
  https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009124.pub2/full

Birth Practice 6  —  Keep Parent and Baby Together: It’s Best for Both

This practice is increasingly supported by evidence that extends well beyond the immediate hours after birth. Current guidance emphasizes postpartum care as a continuum, with planned follow-up and support in the days and weeks following discharge.

Evidence highlights that early postpartum contact and continued assessment support feeding, bonding, emotional well-being, and early identification of concerns for both parent and baby. Skin-to-skin contact, rooming-in, and responsive feeding practices are most effective when supported after discharge through lactation care, newborn follow-up, and attention to parental mental health.

Teaching reflection
This evidence supports weaving postpartum care directly into teaching about Birth Practice 6. Helping families anticipate continued support, understand the connections between feeding, bonding, and mental health, and recognize postpartum care as part of caring for both parent and baby strengthens confidence and continuity.

Sources

• National Institute for Health and Care Excellence (NICE) – Postnatal Care Guidelines
  https://www.nice.org.uk/guidance/ng194
• World Health Organization
  https://www.who.int/publications/i/item/WHO-MCA-17.06

Final thoughts

The Lamaze Six Healthy Birth Practices continue to endure because the evidence continues to support them, often with greater clarity and nuance than when they were first articulated. Keeping curricula reflects respect for families, confidence in science, and trust in educators’ ability to translate evidence into learning that truly matters.

When teaching is grounded in both long-standing principles and updated guidance, families receive education that feels steady, credible, and relevant to their real lives. In 2026, Lamaze childbirth education remains powerful because it grows alongside the evidence, stays rooted in physiologic birth, and continues to center informed, supported families at every step.

Your health and the development of your baby may be significantly impacted by everything you eat during this time. When you’re pregnant, the food you eat feeds both you and your growing baby. Eating nutritious food isn’t just good for you and your baby, but it can also ease some of the discomforts you can encounter during pregnancy. So, it’s essential to keep a close eye on your daily food intake and ensure that it meets all the necessary aspects of health and nutrition.

With this Complete Guide, you’ll find simple and easy-to-understand information about pregnancy nutrition. You’ll learn which nutrients matter most, how much you need, and ways to get them through food. Whether you just found out that you’re pregnant or you’re already in your third trimester, you’ll discover new approaches that will benefit you and your baby.

Remember, good pregnancy nutrition is a gift you give to yourself and your baby.

Get ready for birth with confidence — Join a Lamaze online class today!  Empower yourself with evidence-based knowledge and support every step of the way.

This toolkit was created with one goal in mind: to make it easier for you to connect with parents, fill your classes, and show the world the power of Lamaze.

Why This Matters

Today’s parents turn to social media first for answers, ideas, and connection. When Lamaze shows up consistently online, through our educators’ voices and classes, more families discover evidence-based childbirth education. That increased visibility means more filled classes for you and stronger recognition of your Lamaze certification.

The truth is, every post helps. Whether it’s a myth-busting tip, a gentle reminder to register for an upcoming class, or a warm message about what makes Lamaze unique, your voice makes a difference. When parents see Lamaze educators regularly sharing clear, confident messages, it builds trust and sparks curiosity.

What’s Inside

The toolkit includes customizable Canva templates for infographics, class promotions, banners, and educator profiles — everything you need to make your posts shine. You’ll also find:

• Sample captions and post ideas you can copy, paste, and personalize
• Posting tips to keep your content engaging and consistent
• A suggested posting calendar to help you plan ahead
• Easy resizing tools so your graphics look perfect on Instagram, Facebook, LinkedIn, and Stories

Every element is designed to be simple, flexible, and uniquely you. Add your photo, class details, and contact information, then share with confidence.

Imagine the Possibilities

Imagine sharing a myth-busting post on Monday (“You don’t have to stay in bed during labor, movement helps!”) and a class promotion by Friday, all predesigned, branded, and ready to go. In just a few clicks, you can post something that looks professional, reflects your certification, and reaches the parents who need you most.

Want to highlight your upcoming series? Use one of the bright promotional templates. Want to engage parents between classes? Try a “Did you know?” graphic with a quick comfort measure tip. And when you post about your next session, you can easily add your logo or the Lamaze seal to help families recognize your professionalism and credibility.

These small, consistent touches make a big impact. They keep your name, and Lamaze, front and center in the spaces where parents are already looking for help and community.

How to Access the Toolkit

You can open, customize, and download the templates directly through Canva, no design experience required. Once you’ve updated your graphics, post them to your favorite social platforms and invite parents to learn more or register for your next class.

Together, We Grow the Lamaze Movement

Every time an educator posts, shares, or promotes their class, it strengthens the Lamaze brand and helps more families find trusted, evidence-based childbirth education. This toolkit is one way we’re investing in your success and helping Lamaze educators worldwide grow their reach.

Explore the toolkit and start sharing today, and don’t forget to tag @LamazeInternational in your posts so we can celebrate and amplify your work. Your stories and creativity are what bring Lamaze to life for families everywhere. Let’s fill every feed with confidence, connection, and the spirit of Lamaze.

Access the Lamaze LCCE Social Media Toolkit through your member portal today!

For childbirth educators, keeping up with these changes is both professional growth and a meaningful way to serve families. Current, evidence-based content builds trust, reduces anxiety, and makes classes more effective and empowering.

The Challenge of Keeping Pace

Tradition is strong in childbirth education, but medical science and family needs change quickly. Many educators make small, thoughtful updates, such as revising a handout or adding a new comfort measure. While these changes are valuable, reviewing the curriculum as a whole from time to time ensures that families receive information that is both consistent and fully up to date.

A full curriculum review is time intensive, but tools such as curated handouts, professional webinars, updated textbooks, and organizational resources can help you keep your content accurate and effective.

Demographic and Social Shifts Shaping Education

Declining Birth Rates and Changing Families
Fewer people are having children, and many who do have limited experience with babies. Classes often serve as both educational spaces and sources of community. More parents are giving birth over age 35, with higher risks of hypertension or gestational diabetes. Family structures are also more varied, including unmarried partners, polyamorous families, and multi caregiver households.

Increasing Diversity and Inclusion Needs
Parents represent a wider range of racial, cultural, and gender identities. Disparities in outcomes for families of color persist, making culturally sensitive teaching essential. LGBTQIA+ visibility is expanding, particularly among younger generations, making inclusive language such as “birthing parent,” “chest feeding,” and “human milk” important for ensuring families feel seen and respected.

Rural Obstetric Deserts and Policy Shifts
More than one third of U.S. counties lack local birthing facilities, leaving many families without accessible care. Online education and tele-support are critical lifelines in these regions. Changing Medicaid coverage and state level reproductive policies also affect how families plan their care and where educators must focus attention.

Teaching Families to Navigate Information

Parents are inundated with information, much of it contradictory or commercially influenced. Educators play a key role in teaching families how to assess sources.

Encourage them to ask:
- Who is providing this information, and what are their qualifications?
- Is there a financial or ideological agenda?
- Does the content use fear based language or lack citations?

By building critical thinking, families gain confidence not only in pregnancy and birth but also in early parenting decisions.

Shifting the Emphasis: Risks to Protective Factors

Traditional education often emphasizes risks, which can heighten anxiety. A protective factor approach shifts the focus to what families can do to improve outcomes, such as balanced nutrition, safe physical activity, consistent prenatal care, and strong social supports.

This resilience- based model strengthens self-efficacy, helping families feel capable and prepared while still acknowledging individual risks. It mirrors public health trends showing positive, strength-based education is more effective than fear-based messaging.

Key Updates in Pregnancy Care

Pelvic Floor Health
Pelvic floor care includes both strengthening and relaxation. Awareness, breath, and tension release alongside Kegels can improve comfort in labor and recovery.

Nutrition and Choline
Alongside folate, iron, iodine, and DHA, choline has emerged as essential for fetal brain development. ACOG recommends 450 mg per day during pregnancy, though many prenatal supplements lack it.

Weight and Gestational Health
Gestational weight gain targets are now individualized. For people with obesity, the Institute of Medicine range is typically 11 to 20 pounds, with shared decision making to balance maternal and fetal health. Screening for gestational diabetes is recommended for all between 24 and 28 weeks, with earlier testing for those at risk. Low dose aspirin, 81 mg daily, is recommended for individuals at high risk of preeclampsia, starting ideally before 16 weeks.

Labor and Birth Practices

Admission Guidelines
Policies increasingly aim to delay hospital admission until active labor when safe. ACOG defines active labor as beginning at 6 cm dilation. Educators can help parents understand labor patterns and when to call their clinician.

Comfort and Positioning
Mobility and a variety of labor positions, including upright and side lying, are encouraged to support comfort and physiologic birth. Peanut balls and similar tools may also facilitate progress, but the emphasis is on movement and individualized choice.

Pushing and Third Stage
Routine delayed pushing with epidurals is no longer recommended, as evidence shows limited benefit and possible risks. Coached pushing at full dilation is supported for many nulliparas with epidurals. In the third stage, prophylactic oxytocin and uterine tone assessment are standard. Routine sustained uterine massage is not recommended when Pitocin is given.

Continuous emotional and physical support during labor, whether from a partner, friend, or doula, is consistently linked with better outcomes. This reinforces the Lamaze practice of encouraging families to bring a supportive companion into the birth space. Lamaze also encourages upright positions and working with the body’s natural urges whenever possible, even when epidurals are used.

Labor Practices: Past vs. Current This aligns with the Lamaze practice of letting labor begin on its own and avoiding unnecessary interventions. This reflects the Lamaze practice of moving and changing positions in labor, supporting both comfort and progress.

Induction of Labor

Induction rates are increasing. For some conditions, timing depends on age and health status. Many with well controlled diabetes deliver at 39 weeks. People aged 40 or older may be offered delivery at 39 weeks. For twin gestations, timing is based on chorionicity and clinical factors, often between 37 and 38 weeks.

Educators can prepare families to ask about cervical readiness, expected length of induction, and the support needed for longer processes.

Newborn Care and Feeding

Immediate Care
Delaying the first bath at least 24 hours protects the skin barrier and helps with temperature regulation. Pulse oximetry screening for critical congenital heart disease is now standard.

Feeding Practices
Inclusive language such as “chest feeding” and “human milk” is recommended. Breastfeeding education emphasizes laid back positioning and self-attachment. For bottle feeding, paced feeding supports healthy feeding behaviors.

Lactation Science
Blocked ducts are now reframed as inflammatory processes. Best practice is gentle care, cold compresses, NSAIDs when appropriate, and avoiding deep massage. 

In the past, nipple pain during breastfeeding was often assumed to be caused by yeast, and antifungal medication was prescribed as a first response. Current evidence shows that many cases of nipple pain resolve on their own or are related to other causes such as positioning, latch, or inflammation rather than fungal infection.

Observation and gentle supportive care are now recommended before turning to antifungals. This approach reduces unnecessary medication, avoids potential side effects, and helps families focus on practical strategies such as improving latch, ensuring frequent effective feeds, and using comfort measures.

Postpartum Care and Mental Health

ACOG now recommends contact with a provider within 3 weeks postpartum and a comprehensive visit no later than 12 weeks. Those with hypertensive disorders or gestational diabetes may need earlier or more frequent visits.

Educators can normalize the wide range of postpartum experiences, including physical recovery, changes in intimacy, and mental health challenges. Encouraging open communication and self-compassion helps families build resilience. Awareness of resources gives families confidence to navigate this complex period.

Practical Teaching Tips

- Provide handouts highlighting what is new compared to what is well established.
- Use activities to compare induction methods or labor positions.
- Show diverse video demonstrations of labor and infant care.
- Offer hybrid or online formats for underserved families.
- Stay current through webinars, journals, and organizational updates.

Conclusion

Excellence in childbirth education comes from keeping curricula current and evidence based while staying rooted in what matters most to families. Childbirth education must continue to evolve with new research, shifting demographics, and the realities of diverse families. By embedding critical thinking, highlighting protective factors, and presenting inclusive, evidence-based updates, Lamaze Certified Childbirth Educators can ensure their teaching remains both relevant and impactful.

The true goal is to provide the latest science backed information and to walk alongside families in ways that leave them feeling capable, supported, and confident as they step into birth and parenting.

Update your curriculum with the latest evidence-based information right HERE.

References

ACOG. (2024). First and Second Stage Labor Management Clinical Practice Guideline. https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2024/01/first-and-second-stage-labor-management

ACOG. (2023). Nutrition During Pregnancy. https://www.acog.org/womens-health/faqs/nutrition-during-pregnancy

ACOG. (2020). Gestational Diabetes Mellitus. Practice Bulletin. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/02/gestational-diabetes-mellitus

ACOG. (2018). Optimizing Postpartum Care. Committee Opinion. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care

ACOG. (2018). Physical Activity and Exercise During Pregnancy. Committee Opinion. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/04/physical-activity-and-exercise-during-pregnancy-and-the-postpartum-period

ABM Protocol #36. (2022). The Mastitis Spectrum. Academy of Breastfeeding Medicine. https://www.bfmed.org/protocols

AAP. (2024). Delaying Newborn Bathing. HealthyChildren.org. https://www.healthychildren.org/English/ages-stages/baby/bathing-skin-care/Pages/Delay-Newborns-First-Bath.aspx

AAP/CDC. (2018). Critical Congenital Heart Disease Screening Using Pulse Oximetry. https://www.cdc.gov/ncbddd/heartdefects/cchd-facts.html

March of Dimes. (2023). Nowhere to Go: Maternity Care Deserts Across the U.S. https://www.marchofdimes.org/research/maternity-care-deserts-report.aspx

Discover the six simple steps to a safe and healthy birth. Enroll in Lamaze’s Safe and Healthy Birth online class and take charge of your birth experience.