A Dice Game to Explore Normal Variations in Labor

There are two different versions of this game described here: a ten-minute small group activity which reviews information about stages of labor, and helps students to think about normal variations in the range of labor, and another version of the game which can be used to structure either a presentation on variations and interventions, or to structure a labor rehearsal.

The ten-minute small group version

Supplies: three sheets of paper, 12 dice, 3 coins, 3 markers to write with

Time: 10 minutes, or more, depending on how much optional discussion you allow time for.

Goals: Small group interaction, illustrate the range of normal labor, and get students to put themselves into a role, and imagine how they might cope with a specific course of labor. Comparing the three scenarios at the end allows them to consider other scenarios than just the textbook average.

Divide class up into three teams (or four for really large classes). If you have multips in the class, put them in a separate group from the first-time moms.

Each makes up an imaginary woman’s name (I like Daisy Mae, Wilma Flintstone, etc.) Each team gets a marker, four dice, 1 coin, and a big piece of paper, which says:

Mom’s name: ________________

Labor Begins at ___________ a.m. or p.m.

Length of Early Labor ____________ hours

Shift to active labor, go to hospital at __________

Length of Active Labor and Transition ___________ hours

Pushing begins at ____________

Length of 2^nd Stage Pushing ____________ hours

Baby is Born at ____________

Total Length of Labor _____________

At the beginning of each section, give the students instructions, then leave them to discuss for a few minutes before moving on to next section. Then instructor wraps up that segment of labor with a brief review of important points, then goes on to next game action.

Game Action	Group Discusses	Instructor Could Add
Labor begins: Each team rolls 2 dice and add them together to figure out what time labor starts, then flip coin to decide if it’s a.m. or p.m.	Have each small group discuss amongst themselves where the mom might be at this time of day, where the partner might be, and how they should respond to labor beginning at that time. (i.e. call partner, try to rest if it’s night-time, be active if it’s morning, etc.)	A review of signs of the onset of labor.
Length of early labor: Then, roll 4 dice to figure out how long early labor lasts (from 4-24 hours). [Multips get to roll just two dice]	Teams then discuss how they would cope with that length of early labor, what moms should do to take care of themselves, and what partners should do to take care of themselves.	Instructor reinforces early labor coping: resting, eating, natural augmentation.
Shift to active labor: tell them to “do the math to figure out: if labor started at x time, add the length of early labor to figure out what time of day you shift into active labor, and go to the hospital.”	They discuss what it might feel like to go to the hospital at that time of day. Would traffic be an issue? Would they know how to get into hospital in the middle of the night?	Instructor could review recommendations for when to go to hospital. Could talk about hospital procedures, like where to park, and what to expect in triage.
Length of active labor: roll 2 dice to figure out how long active labor and transition are (2-12 hours) [Multips roll one die]	They discuss coping skills for active labor and transition.	Optional: tell everyone higher than 6 hours that dr. recommends Pitocin and/or AROM. Could review risks/benefits/alternatives. Could address pain med options if prolonged.
Pushing Begins: “Do the math. If active labor started at x time, then add the length of active labor. What time is it?”		Could touch on staffing. Is doctor likely to be in-house / nearby?
Length of pushing: roll one die, divide in half to get number of hours of pushing. [Multips use one die, divide by 3]	Discuss how they would cope, what they could do in terms of positions, comfort, etc.	Optional. If someone rolls a one, tell them their dr. didn’t make it in time, another doctor delivered baby. If they roll a 6 (3 hours), dr. recommends vacuum or forceps. (If desired, you could then flip a coin to see if that’s successful, or if cesarean is necessary.)
Time of Birth: Do the math.	Where are friends/family members? Who will you call?	Instructor could touch on the importance of spending some time in skin-to-skin contact with baby and bonding with baby in first hour…. Maybe waiting a little while to make those phone calls.
Total Length of Labor	Discuss: How would that be for you?	Point out that it probably didn’t HURT the whole time… but built up gradually, as contractions got longer, stronger, and closer together.

After this, tape all three sheets of paper up together in the front of the room for comparison sake, and give some more feedback on what the emotional and physical experiences might be for women who experienced this sort of labor.

The instructor-led version:

I have also used this effectively as a guide for my presentation on labor variations and interventions, and as a guide for labor rehearsals.

For this, instead of giving teams their own papers, I divide the white board up into three columns, and we write the stories on the board as we go along.

In labor variations presentation, each time we get to a situation where an intervention might be recommended, we leave our stories behind for a moment, and I do the presentation on induction, then we move on. (Note, if none of our “laboring moms” have a reason to need an intervention, I still need to cover it. So, even if none of the characters need to be induced, I cover induction anyway before moving on.)

In rehearsals, we take a break at each section where it talks about “coping with” that stage, and we discuss and practice techniques.

Here is a sample of what the board might look like at the end of class (probably with a less detail J)

In the chart below, italicized text is what you do; not written on board! For some things, instead of rolling dice, I just ask them to make up what happened. (in the chart below, a * indicates that I just ask a group member for this answer, a # indicates they roll dice (number of dice listed above)

	Wilma Flintstone	Marge Simpson	Ginger (from Gilligan’s island)
Birth plan prior to labor? *	Hospital with OB. Partner. Planning epidural	Hospital w/ midwife. Partner and doula Wants unmedicated birth	Hospital w/ family practice doc. Mom and sister supporting. Prefer no meds, but OK w/epidural
What week does labor begin?*	38	42	40
When does labor begin? #	2 pm	9 am	2 am
How does labor begin?*	ROM at the mall Later, back pain.	Induction (tried natural, got prostaglandins / Pit)	Contractions, 8 minutes apart
In a variations presentation, here’s where you would take a break in the birth stories, and cover induction (even if none of the moms in the stories needed an induction.
Length of early labor? #	14	20	6
When will early labor last till	4 am	5 am	8 am
In variations presentation, here’s where you cover precipitous labor (even in none of the women in our stories are having it)
What do she and partner do?* (If using this as labor rehearsal, you could stop and practice techniques now.)	Shopped, then went home, watched movie, back pain techniques, warm bath, tried to sleep.	In hospital: frequent monitoring made it harder to relax, move around. Listen to music.	Rested, then “snuggling” with partner in bed, then walk, shower, breakfast
Shift to active labor / go to birthplace: how know it’s time to go? What is trip like? *	Came in thru ER	Already at hospital.	morning rush hour!
Length of active labor #	8	3 hard hours if stay on Pitocin. 6 hours if off Pit. They decide stay on Pit.	4
Variations: cover prolonged labor and augmentation here. Can talk about all the things that might cause prolonged labor (dehydration, immobility, full bladder, fear, tension, uterine inertia) and have them think about how to prevent / treat
Coping with Active Labor* (In labor rehearsal, could spend time practicing here. Could cover back labor techs)	Tried walking, bath, massage.	Tried hot packs, ice packs, movement in bed.	Walking, birth ball, bath for 3 hours, moaning, rocking, chanting
Considering pain meds?? # Halfway through her active labor, she debates about pain meds. Her cervix is at __ cm. (roll dice, add 4 (for early labor dilation))	At 8 am, 6cm. (Pitocin recommended because 18 hours post ROM)	At 7 am (22 hours into labor), 7 cm	At 10 am (8 hours into labor), 8 cm
Pain Med Choices *	Light epidural	Narcotics, then epidural.	No meds
Variations: could cover pain medications here, if not covered elsewhere in series. This dice game gives a great opportunity to explore with the group what effects our pain med choices: prenatal preference, PLUS how our labor progresses and what other things happen, PLUS what kind of support we receive, and care provider’s influence (e.g. since Marge has been in hospital for hours, the nurse may have hinted several times that pain meds would be good option for her)
Pushing Begins	12 pm	8 am	12 pm
Length of pushing. # (roll die, divide by 2. Could choose to add 30 minutes to dice results for those who have epidural)	30 minutes	3 hours	2 hours
Coping with Pushing	Pushed lying on side	Labored down – delayed pushing for first 2.5 hours Pushed on side, semi-sitting, and with towel around squat bar	Sat on toilet for a while, pushed in squatting position, hands and knees. Delivered in a kneeling position, with perineal massage
Cover second stage variations here (again, even if none of the moms in the stories have one.) Cover episiotomies, vacuum, forceps, and possibility of cesarean. I have “offered” cesarean to the moms in these stories, but I always end the stories with all three having successful vaginal births. I cover cesarean in detail later on in the class, not as part of this exercise.
Time of Birth	12:30 pm	11 am with vacuum,	2 pm
Total Length of Labor	21.5 hours	26 hours	12 hours

The nature of doing an interactive exercise, and especially one involving random dice rolls, is that you can’t necessarily “control” it and end up with the perfect balance of stories, and with three great birth stories. Something may “happen” that you didn’t intend, or something you wanted to cover doesn’t happen – you cover it anyway. This randomness helps to illustrate that birth is unpredictable, and it’s important to stay flexible!