Childbirth-easing drugs may affect breastfeeding

11:32 11 December 2006
NewScientist.com news service
Rachel Nowak

Drugs used to ease the pain of childbirth could interfere with breastfeeding, a new study suggests.

Siranda Torvaldsen of the University of Sydney, Australia, found that 416 women who received the opioid drug fentanyl by epidural injection during delivery were twice as likely to have stopped breastfeeding by the time their baby was six months old compared with 312 women who did not receive the drug.

Torvaldsen does not know whether this is because the drug has a direct effect on babies’ ability to suckle or that women who opt for (or need) epidural painkillers are also more likely to stop breastfeeding sooner.

A previous study found that the babies of women who have fentanyl tend to be drowsier at one-day-old, raising the possibility that the drug affects suckling at the critical time when breastfeeding gets established.

"Adverse reaction"

In Australia and the US only around 40% of babies are still receiving at least some breast milk at six months, although the World Health Organization recommends breast feeding exclusively until that age.

“Now we’re aware that painkillers may affect breastfeeding, we need to be sure that women who take them get adequate help,” says Torvaldsen.

Sue Jordan of Swansea University, UK, who is an expert on the effects of labour drugs and mental health, says the effect of opioids and epidurals on breastfeeding should be seen as an "adverse drug reaction".

In an article accompanying Torvaldsen’s study in International Breastfeeding Journal, Jordan calls for extra support for the most vulnerable women "to ensure that their infants are not disadvantaged by this hidden, but far-reaching, adverse drug reaction".

Journal reference: International Breastfeeding Journal (DOI: 10.1186/1746-4358-1-24)

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I am not anti-epidural. I'm becoming more anti-hospital, though I still maintain my belief that women need to be where and with whom they feel safe.

But I wonder how much publicity this little bit of information will receive.

People who are already opposed to the routine use of epidurals for all moms will think it's great.

Those who can't imagine why anyone would do anything other than opt for an epidural as soon as it can be given, will dismiss it as unsubstantiated.

The medical community probably won't even blink.

What does it take to cause change? What needs to happen, what needs to be discovered, for real changes to begin happening?

I want to see women seeking education about birth before they seek escape from it. If they ultimately decide that epidurals are definitely for them, at least it will be an educated choice and not a decision made in a vacuum - "I don't know what to expect and I don't wanna know."

I have heard of childbirth educators telling their classes, "Ninety-five percent of you will be getting epidurals anyway, so I won't go over relaxation techniques."

I have heard of nurses begging laboring moms to get pain relief. Even constantly asking the mom, "Do you want your epidural yet?" without knowing what her preferences are, or continually offering "something to take the edge off the pain" without using the word narcotic...these are all actions hostile to unmedicated birth, and apparently to the breastfeeding relationship, too.

So why doesn't this garner more of a reaction? Why don't mothers care more about it? If mothers cared, they would demand change, and the medical community would have to adapt, and men and sons and daughters would learn to act differently towards birth.

Virginia Woolf believed that if libraries were available to women in her time, that the world would split open. She too thought that knowledge would be enough.

I'm dismayed that women don't seek out their own education on certain things, especially childbirth.

It would be nice if every doctor made time to sit down with a pregnant woman and ask, "So what kind of birth do you want?" ...

It would be great if all doctors had a certain reverence for birth, understanding what is inappropriate to do or say when a woman is giving birth, reacting when needed, but showing restraint and respect when needed...

It would be nice if L&D nurses were trained so thoroughly that no laboring mom or doula would ever suspect that she knew more about birth than the nurse(s)...and if nurses all knew how important it is to support and nurture the connection between mom and baby...

It would be great if all childbirth educators were trained to help women find what kind of birth they want, how to increase their chances of having that experience, what to do if it doesn't happen, and how to recognize if something is going wrong, either during the birth or during the initial postpartum time...

But the reality is that none of these things are common or guaranteed.

So it's up to women, it's up to each woman to educate herself and learn to stand up for herself.

No more assuming that because someone went to nursing or medical school, they must therefore know what they're doing and would NEVER do anything destructive to the health and well-being of mom and baby. No more thinking that taking a single childbirth class covers all the bases and prepares you for anything, especially childbirth.

No more denying responsibility.

There is so much to learn. Do your research. Ask questions. Change care providers. Read everything you can.

It's all up to you.

More on Prodromal Labor

My previous writings on prodromal labor were strictly theoretical. I have never experienced it, and I had never before attended someone who was in prodromal labor. This past weekend, I did. I have much more to say about it now.

Prodromal labor is a term for early labor that lasts for a long while without progressing into active labor. It is a nightmare. This is the labor pattern that lasts for days, causing the mother to lose sleep, disrupt her appetite, and causes exhaustion. It will probably eventually change into an active labor pattern, but even if this happens, the biggest danger is depletion of emotional and physical resources: the mother may not be able to continue with the labor and may need pain relief or even a cesarean. This is not the kind of labor that any woman wants to experience.

The article I wrote before stands out to me now as something written by a person who has read about a topic and knows nothing of it. It strikes me now as profoundly unhelpful.

When a woman is in prodromal labor, also called arrest of the first stage of labor, one of two options should be considered: should active labor be encouraged, or should attempts be made to slow or stop the contractions?

For either option, there are universal precautions: save your energy (no marathon shopping trips), eat as much as you can (even if it's only smoothies and toast - you will need the energy), and sleep if possible.

To encourage labor to progress, stay upright and walking if you can. Sway your hips - sitting on a birth ball or slow-dancing with your sweetie are great ideas. You may want to consider using nipple stimulation.

If you wish to try to halt the contractions, you need to relax. Sleep as much as you can. Take lots of baths or showers. Get a massage. You may not be able to stop the labor from progressing into active labor, but you will increase your chances of being a little more rested, and it will make a difference.

Prodromal labor can last for days. Its cause can be a complex combination of physical and emotional reasons. To avoid physical causes, do not be induced without a medical indication. Emotional work may be needed. Are you afraid of having your baby? Are you scared of what changes it will bring to your life, especially to your relationship? Are you afraid that your partner might leave you? Are you a single mom without a partner? It is time to work through these fears. It may help your labor to do so.

Sometimes new mothers will focus too much on early labor. This is not necessarily the same thing as real prodromal labor, which takes longer than usual to progress - though the same principle applies: the excitement of steady contractions can cause women to become exhausted, if they are focusing on the contractions and spending too much energy when labor is easy. If the contractions are not stopping you in your tracks or preventing you from speaking, you're very likely in early, early labor, and need to conserve your energy. Do not spend too much effort on these contractions.

If you gained nothing else from reading this, I hope that the main point that stands out is this: if you are in prodromal labor, you need to rest.

Going Overdue

By the end of pregnancy, you're probably ready to be done. You're huge, your belly is pendulous, you can barely sleep, and you have to pee every ten - no wait, every seven - minutes. Most women hope to deliver early, and these hopes soar in the last weeks.

Your due date arrives! And...it passes. No changes in your body, or your dilation, but your mood plummets.

Going overdue often makes pregnant women depressed. You are ready to be finished, prepared for labor, perhaps have family arriving to help with the transition, yet you are still pregnant. You might feel like a failure - after all, you aren't doing your job. No baby to show for your forty weeks of effort. If it goes on, you might feel that you will never go into labor.

If this is where you are, take heart. Forty weeks is an estimate, and your actual due date is an estimate too. Your baby will be born soon. Relax, do something fun, like go see a movie. Try to forget that you're pregnant (it doesn't help to dwell on it - thinking about labor will not cause it to occur any sooner - sometimes trying to forget that you're past your due date is good therapy). Your life will change dramatically very soon.

Avoid induction for arbitrary reasons. If you are more than a week overdue, you will need to be monitored by your OB to make sure that the placenta is functioning and the baby is doing fine. As long as everything is going well, do not be induced. There are complications associated with induction, especially in first-time moms, and you and your baby will be better off if you allow labor to start on its own. Your body will be better able to respond to labor, and you will know that your baby is full-term and ready to be born.

If you have family arriving and feel pressured to have a baby while they're in town, please readjust your priorities. Your baby has one chance to be born, and it should be as free from risk and complications as possible.

One word on how labor begins: The baby's lungs are the last organs to complete their development. Once they are mature, they release a protein, and that protein causes the release of other hormones that initiate labor. If you haven't gone into labor yet, it may be because your baby's lungs are not yet entirely ready. Hang in there. You will go into labor.

If you are concerned about the baby gaining weight, there is usually not cause to worry. Ultrasound weight estimates can be inaccurate by 2 lbs either way, on average. Most methods of estimating fetal weight tend to overdiagnose macrosomia (large babies). Do listen to your doctor, but keep in mind that it is ultimately your decision whether to be induced or not.

If you are overdue and there is no evidence of complications:

• Do not be induced. Labor will begin on its own when both you and your baby are physically ready.
• Do not dwell on your pregnancy. Do something fun. Try to forget you are pregnant.
• It is OK to take yourself off the radar for a while. Do not answer the phone or accept visitors, if you are feeling antisocial. You might want to change your voicemail message to say that you are still pregnant and doing fine. Take care of your emotional needs.
• Use the time to finish up any projects or arrangements you haven't yet completed. Make sure the baby's space is ready. Pack your birth bag. Do some cleaning (getting on your hands and knees to scrub a floor is especially helpful to get the baby in the right position for birth!). Or get some much-needed rest.

You WILL go into labor. This is a tough time for you, but no one is pregnant forever. And you won't be the first, I promise!

Updated to include this press release, dated 21 February 2008:

Lamaze International recommends that a woman allow her body to go into labor on its own, unless there is a true medical reason to induce. Allowing labor to start on its own reduces the possibility of complications, including a vacuum or forceps-assisted birth, fetal heart rate changes, babies with low birth weight or jaundice, and cesarean surgery. Studies consistently show that inducing labor almost doubles a woman's chance of having cesarean surgery.

— Lamaze International Press Release

The State of Birth Around the World

This is by no means a complete list. These are just some of the issues brought up in recent news feeds.

Japan. The current situation is that a low birth rate is driving many obstetricians out of business, leaving many women without needed health care. Maternity wards are closing. This is a sad dilemma. Japanese women have a low fertility rate, which means their needs for obstetrical care are limited. They are also having children later in life, raising the risks for a complicated birth, which has historically produced more lawsuits. Not many obstetricians are willing to work long hours in a highly-litigious career for average pay, and who can blame them?

Asia. The mortality rate for babies is dismal in southeast Asia, where fully one third of all neonatal deaths (that's death occurring within 28 days of birth) occur. "South Asia has the highest rates of newborn deaths in the world, next to Africa. In Afghanistan and Pakistan, for example, up to six percent of infants die in their first month." Probably the most helpful thing for these areas would be government emphasis on and funding for better health care systems.

India. Here, "a woman dies in childbirth every five minutes." From the UNICEF website: "The reasons for this high mortality are that few women have access to skilled birth attendants and fewer still to quality emergency obstetric care." Infant mortality is as high as 63 per 1000 births (for comparison, in the US, infant mortality is about 7 in 1000).

Scandinavian countries. Sweden and Denmark are the top two countries for maternal and infant health. More on Swedish maternity leave policies here.

Poland. With the high cost of health care in Poland, many pregnant women have been giving birth in border clinics in Germany, citing better health care. And, by the way, under the EU agreement, Germany pays for it. But not anymore.

Ireland. The cesarean rate has climbed drastically over the past 10 years, from 7.5% of c-sections being elective, to 45% last year.

No Alcohol is Safe During Pregnancy

Pregnant women told no alcohol at all in new guidelines

When I first saw this, I thought it was a new WHO or national guideline. Well, it is a new national policy, but it's new for New Zealand, not the US. Too bad.

I remember being pregnant with my first baby and attending a work function where alcohol was served. I asked for a root beer instead, and someone near me misunderstood me. "You can't drink!" she said, pointing at my swollen belly. I said, "I'm not! I ordered a root beer."

"One drink is ok during pregnancy," another girl said.

"No, it isn't," I said. "I don't think any alcohol is ok during pregnancy."

The first girl suddenly got defensive. "Well, then, you shouldn't be drinking that soda either, for that matter."

Well said, ex-coworker. Sodas should be taboo during pregnancy also, especially caffeinated ones.

I know one pregnant woman who wanted her Pepsi so bad that she changed OBs until she found one who told her that it was ok to drink as much Pepsi as she wanted during pregnancy.

No matter its source, caffeine has been linked to low birth weight, prematurity, and fetal death.

Ingesting high levels of sugar while pregnant may cause gestational diabetes or birth defects.

Pregnant ladies, stick with your vegetables, fruit, and whole grains. Drink only water. Move your body. Take good care of yourself and your growing baby. Everything you do, everything that happens to you, affects your baby, just as everything you do affects you.

What the WHO Thinks of Midwives

Selections from this article:

Evidence shows that midwives are vital to preventing the estimated 529,000 maternal deaths and 8 million illnesses that occur each year during pregnancy and childbirth. In countries as diverse as Malaysia, Sri Lanka, and Tunisia, investments in training, recruiting and retaining midwives, as well as in emergency obstetric care, have reduced maternal death rates. The lives and health of many millions more would be saved with greater investments in midwives.

UNFPA (United Nations Population Fund) and ICM (International Confederation of Midwives) call for urgent action to address the shortage of midwives if the world is to achieve the international development goals of improving maternal health and reducing child death. The World Health Organization estimates that at least 700,000 more midwives are needed to curb maternal death and illness.

"A strong midwifery profession is the key to achieving safer childbirth, and all women should have access to a midwife," said Kathy Herschderfer, the Secretary-General of the ICM.

"Midwives...transcend the levels of care within health systems, and are essential to the continuum of care during the childbearing cycle."

UNFPA and ICM are working together to strengthen midwifery capacity worldwide to reduce the high levels of deaths and disability among mothers and babies. They are cooperating to promote the professionalization of the midwifery practice, to improve national midwifery standards and to help countries scale up community-based midwifery practice.

ICM, the heart and voice of midwives across the world, was founded in 1919. It is a Confederation of 88 midwifery associations from 75 countries. Its mission is to advance worldwide the aims and aspirations of midwives in attaining improved outcomes for women in their childbearing years, their babies and their families, wherever they reside.

UNFPA is an international development agency that promotes the right of every woman, man and child to enjoy a life of health and equal opportunity. UNFPA supports countries in using population data for policies and programmes to reduce poverty and to ensure that every pregnancy is wanted, every birth is safe, every young person is free of HIV/AIDS, and every girl and woman is treated with dignity and respect.

Should men be banned from the delivery room?

This article is from a survey taken by The Royal College of Midwives (love that name!) in the UK. I know, it's trying to be inflammatory. Most of the article ("research") is anecdotal - meaning it's based on a few experiences and not on much actual reliable research - and isn't worth much. But it raises a good question.

I don't think men should be banned from the delivery room. I think, though, that it should be up to the couple to decide, and that men should face no social (or family) stigma if they determine that the man will not attend the birth.

The only problem with my theory: it's anecdotal. It's based on two experiences. OK, maybe three.

The first is my own. My husband, after being by my side throughout twenty hours during my first labor, didn't feel the need to be present for the second one.

I objected to this idea, until I attended a birth as a doula where the husband didn't want to be there at all. It was their third child. He sat in a chair and looked green for most of the labor, and during the delivery he was detached and sickly. I realized that he was not contributing anything, and if anything his reaction detracted from the loveliness of the atmosphere. To me birth is sacred, but if anyone in the room disagrees with that premise, the entire birth team is affected. He wanted to stay at home, and he probably should have.

My husband did attend the birth of our second child, and I am glad he did. Though after that doula experience I didn't think that his presence was required, I felt more supported by him than anyone else, whereas at the first birth I wasn't able to really distinguish one person's support from another's.

But if he truly had not wanted to be there, I would not have demanded it of him.

In another birth situation I witnessed as a doula, the husband watched TV the entire time. His wife, rendered speechless by the strength of her contractions, reached for his hand but he didn't notice. This went on for a few hours.

"Birth is a fundamentally female event." It is difficult to argue with that statement.

If men are required by their women or by society to be there during labor and delivery, well, why should that be the case? What benefit does it give to women if the man is not going to be supportive? Certainly if he's going to turn green and wish the entire time that he didn't have to be there, it would be better to let him be somewhere else.

"A woman who says she prefers not having her partner in the delivery room is doing so to protect him, because she thinks he can't handle it. Why oh why do women keep on treating men like children? And why oh why do men keep on acting as if they were?"

Not all men are the same. Some can handle nearly anything, while others get nauseous by the sounds and smells of childbirth.

"Conception, reception - if you're there for one, you should be there for the other."

Not so! Bad logic! Bad! That's the "you-did-this-to-me-and-you-must-be-made-to-suffer" mindset.

"I think men should be allowed in the delivery room if they want to be - it is an experience not to be missed: very emotional. Unlike watching it on film, you don't tend to notice the blood and mess when it is actually happning before your eyes. However I do think they should stay in a corner out of the way and should not be made to feel guilty if they change their mind and want to go out. The best person to be present is a woman who has been through it.

The best place for a man is actually right outside the door within earshot. That way they don't get in the way but will still know how much the woman has gone through and will be more sympathetic afterwards.

I had my first in hospital and my husband was at home. He expected me to be up and about and cooking the meals immediately afterwards. I had my second at home and he heard everything despite not being in the room and he looked after me better."

First of all, it is a very different experience to watch someone give birth and to give birth yourself. When you are delivering a baby, you don't notice the blood and mess, but when you are watching another person, you certainly do, along with all the smells and unusual sights. That is one of the main objections that the husband of my client had: birth is gross. Sometimes it is. If the man wants to be involved, he should be, and not "put in a corner" to stay out of the way. I doubt there is ever reason to worry about giving too much support to a laboring woman.

"The best person to be present is a woman who has been through it." Amen, amen.

I didn't agree with having men hear the labor so they can understand what their women are going through, but based on her experience, it sounds like it was a good thing. Each man is different. I think that most wouldn't assume that women are exaggerating about the ordeal of birth, but maybe I'm wrong about that. It is work. Sometimes it is very painful. And women tend to want all the sympathy they can get.

And that right there is why men should not ever be banned from the delivery room.

Absence of Tens

...as in ten centimeters

This may be anecdotal, but I have witnessed and heard of a number of women who do not progress beyond nine centimeters. I'm not sure why. I have heard of first-time and experienced moms who stay dilated to 9 for hours. One client of mine was at 9 cm for 10 hours before she ended up having a c-section (there were other complications at this birth).

I have a number of theories, but I'm not sure how to find out if there truly is a common cause:

• lack of movement/activity: too much laying in bed prostrate doesn't help the baby's head apply pressure to the cervix and aid dilation;
• posterior baby: wrong birthing position and the baby is unable to rotate because of mom's failure to be upright and moving around (see above);
• interventions (like epidurals) given too early, interrupting labor's progress, and dilation doesn't occur because of uterine exhaustion.

I don't know what the reason is, but I have heard of more and more moms who don't progress past 9 cm and never feel the urge to push.

...as in TENS unit

In many childbirth books and resources, references to TENS units abound. TENS stands for Transcutaneous Electrical Nerve Stimulation. It is a small machine that delivers electrical currents through wires to specific places on the back, and the sensation tends to block the perception of deeper pain (like a labor contraction) and causes the body to release endorphins (natural painkillers). It does not alleviate all of the discomfort, but usually helps to significantly reduce the sensation of pain.

There is no documentation of side effects, and the machines can be small enough to carry in your palm. As far as I can tell, there is also no restriction of movement, though the unit would of course need to be removed for labor tubs or shower use. They are often used for physical therapy and to alleviate the pain of arthritis and fibromyalgia.

However, I have never heard of a US hospital employing the TENS unit for labor. I have never seen one, nor have I heard of anyone personally who has used this method.

Why not??

No side effects, freedom of movement, pain relief...why not?

Hypnobirthing might be dangerous, but we aren't sure why...

Article here.
The New York Times on Thursday examined hypnobirth, a childbirth technique that does not use drugs to control pain but instead uses a combination of relaxation, breathing and visualization techniques to control pain, according to Linette Landa, a hypnobirth teacher. According to the Times, "hypnobirthing" is meant to relax women through contractions so "that there is no screaming to tire the mother or alarm the baby, and labor is shorter." The American College of Obstetricians and Gynecologists allows physicians to decide whether they will permit hypnobirth, and, although many hospitals permit the technique, some physicians have concerns about the process, the Times reports (Olson, New York Times, 4/27).

Very strange. I wonder what the concerns are? Why not "permit" hypnobirthing? I checked out the New York Times article, and it became stranger, and scarier:

While many hospitals now permit hypnobirth, doctors are wary because they fear litigation. The American College of Obstetricians and Gynecologists leaves it up to the individual doctor's judgment.

Oh, of course. Because they might get sued for something.

Such techniques are not a surefire way to avoid pain, but rather "adjuncts and not the end-all to birth," said Dr. Jeffrey M. Segil, an obstetrician who offers the HypnoBirthing option to every patient in his practice in Dover, N.H.
"Women should not be set up to feel that they've failed if they can't follow through to a totally natural delivery," he said.

Don't even bother to set goals, pregnant ladies, if you aren't completely sure that you can reach them.

It doesn't work for everyone: Jennifer Richards, 29, said she gained self-confidence from hypnobirth methods, but had an epidural because of the intense back pain during her 30-hour labor.

I have said many times before that with back labor, all bets are off. But that might just be me.

I have so many questions about this that I don't know where to begin.

• What's wrong with learning relaxation techniques? Why does that have to be equivalent to setting oneself up for failure? What about women for whom epidurals have no effect - aren't they also in danger of relying on "adjuncts and not the end-all to birth" by planning on using methods that might not work?
• Why isn't this decision left up to the mother instead of the "individual doctor's judgment"?
• What potential litigation are the doctors really worried about?

Seems like we could do more good helping the childbearing women in other countries than worrying about whether or not hypnobirthing is going to mysteriously make something go wrong.

I Swear I Am Not Making This Up

Obstetricians are using a pregnant robot to practice attending births.













Named Noelle, the gestating automaton, hooks up to a laptop and can approximate breech births and failure to progress. It can be given IV fluids. The baby robot can be programmed to be born healthy and pink or blue and not breathing.











With this amazing innovation, doctors can practice cesareans, instrument delivery, suturing...

...and they never have to see the natural pattern of undisturbed birth, progressing on its own.

When I heard about this, my first thought was, Why? Is any obstetrician lacking in human births to attend? Is any OB short of practice regarding medical interventions?

We are getting farther and farther from knowing what normal birth looks like. Whatever situations our plastic-and-metal friend Noelle can imitate, undisturbed childbirth allowed to progress on its own, remains a mystery to those in medical training.

No one is asking me. But I think that obstetrical training should involve rotation through a homebirth practice. Just so they know that birth can be left alone and turn out well, so they know that women can give birth without medical assistance.

Reading Recommendations

General Pregnancy Information:

Pregnancy, Childbirth, and the Newborn by Penny Simkin : Not divided by month, as pregnancy books usually are. This book goes through pregnancy issues by subject. Very detailed and informative.

The Complete Book of Pregnancy and Childbirth by Sheila Kitzinger : Anything byKitzinger is fantastic - in this thorough guide she presents childbirth as a normal, natural process. She talks at length about prenatal exercises and water birth. She also has one of the best descriptions of labor I've ever read.

Psychology of Labor:

Ina May's Guide to Childbirth by Ina May Gaskin : I consider this book necessary reading for pregnant women. The first half is empowering birth stories, and the second half addresses the psychological issues in labor. She talks at length about how your mindset can affect your labor.

Childbirth Without Fear by Dr. Grantly Dick-Read : The first book to discuss the fear-tension-pain cycle. It's a bit outdated (it was written in the 50's), but the principles are still true. It was out of print until recently and is now available on Amazon - the old editions can be found at most libraries.

Birthing From Within by Pam England : A wonderful workbook for pregnant women. This book takes women on a creative journey to deal with their fears of labor and birth and find out what birthing method would work best. It is written with the perspective that a woman is the expert of her own body and birth.

Birth Practices:

Natural Childbirth the Bradley Way by Susan McCutcheon : An excellent book about using the Bradley (husband-coached) method during labor and birth. She discusses techniques for early and active labor and pushing. As with all Bradley teachings, prenatal nutrition and non-intervention during labor and birth are emphasized.

Active Birth by Janet Balaskas : All about how listening to your body during labor can help ease pain and tension and help labor progress. She talks at length about strengthening squatting muscles during pregnancy to prepare them - and you - for delivery.

HypnoBirthing: The Mongan Method by Marie Mongan : A great overview of HypnoBirthing philosophies, including dealing with fears, visualizations and positioning, and nutrition. The new version includes a practice CD with a relaxation and imagery script.

Doulas:

The Doula Book by Marshall Klaus : Written simply and clearly, this book is an introduction to what a doula can do for laboring women. By the end of it you'll understand why we say "don't give birth without one!"

The Birth Partner by Penny Simkin : A very thorough guide on supporting women in childbirth. Though not specifically about doulas, it can give women an idea of how a dedicated support person like a doula can help them. Women also read this to find out what to expect of their own bodies and needs during birth.

More Information:

The Thinking Woman's Guide to a Better Birth by Henci Goer : A detailed investigation into each of the medical interventions imposed on laboring women, including all risks and benefits. Required reading for women who wish to be informed about what hospital staff might not tell you about the actions they routinely take to alter labor and birth.


Birth Reborn by Dr. Michel Odent : This is an introduction to Dr. Odent's understanding of birth as a natural process that works best when it's left alone. A short but wonderful book about the birth practice he created at Pithiviers in France, where midwives allowed mothers to labor with privacy and did nothing to interfere.

Breastfeeding:

The Womanly Art of Breastfeeding by Gwen Gotsch, et al : Among the most reassuring books on the subject. This flagship publication of the La Leche League is encouraging and discusses some of the most common breastfeeding difficulties. However, it is not a very complete resource about problems...

The Ultimate Breastfeeding Book of Answers by Jack Newman : Recommended because it talks more thoroughly about breastfeeding difficulties not mentioned in the LLL book. For example, this book has a section on recognizing dehydration, something not mentioned at all in The Womanly Art of Breastfeeding. However, it has been criticized for being arrogant and difficult to read. But together, these two books make an excellent addition to a breastfeeding library.

Common Mistakes at the Beginning of Labor

Here are some things many women do that can set them up for a high-intervention birth (vacuum/forceps, c-section) from the beginning of labor (please keep in mind that this has nothing to do with whether you want a natural or a medicated birth - absolutely nothing):

• Being induced with no medical indication - Many doctors will not induce if there is no medical reason, but many will if the woman goes even one day past her due date. They have forgotten that the due date is a rough estimate, and that the average gestation time for first-time mothers is 42 weeks. I know it's hard being pregnant for longer than you think you will be. But so long as everything is fine, labor will begin when it's best for the baby and for your body. (I've known people who have scheduled early inductions because their family was visiting and they want to have a baby to show to them).

• Going to the hospital too early - There is a balance between going to the hospital too late and the discouragement of being sent home because you aren't dilated enough to be admitted. There is wisdom in trying to stay at home as long as possible - at home you can eat, drink, and move freely. Labor progresses more quickly here than it will at the hospital (see below). And don't put too much weight on timing the contractions. The general rule of thumb is to wait until contractions are 5 minutes apart in a regular pattern before going to the hospital. I have found, through my experience and hearing the stories of other women, that the times of contractions has little to do with the amount of work being done. You can have contractions two minutes apart and still be dilated to 1 cm. Adhering to the 5-minutes-apart rule is not as helpful as using the amount of focus required from the laboring woman as a gauge.

• Staying in bed on your back - This position is the worst for laboring women. With an epidural in place you don't have much choice, and even then most hospitals encourage laboring on your side rather than on your back. The weight of the baby cuts off the oxygen supply to the uterus, decreasing contractions and possibly putting the baby at risk. Also, remaining upright causes gravity to pull the weight of the baby down against the cervix, helping it to dilate more quickly. When laboring moms walk around and move, they respond to the contractions in ways that encourage progression of labor.

• Spending too much energy when labor is easy - Many times women are so excited for the onset of labor that they stop their regular activities and concentrate very hard on contractions that are not difficult to handle. If they expend too much energy early on, they will not have the strength they need when labor gets tougher, and are setting themselves up for fatigue. If you can speak and walk through contractions, then keep going about your usual business; when it is time to pay attention, you will know.

The Best Laid Plans

A Suggestion for Birth Plans

Have you seen those really long questionnaires that are supposed to help you write your birth plan? While those can be helpful in finding out what options you may have during different stages and if complications should occur, most of what they say is not necessary to include on your birth plan.

Suppose you put a lot of thought into how you want your birth experience to go. You type up your birth plan, and it ends up being three pages long. When you're in labor, you go to the hospital and hand the nurse a copy of your birth plan. S/he might glance at it. But s/he likely won't have the time to go through it. And with so many items listed, s/he won't know what is most important to you.

One suggestion: keep it short and succinct.

My favorite way to lay out a birth plan is to divide it into the stages of labor and then put only one or two items in each section. These should be the things that are crucial to you, that apply to normal labor and birth, and things that are a departure from the hospital's normal routine. Don't put down "I would like to play music during labor" if the hospital allows it - just bring your music along and set it up when you get there.

Here's an example:

FIRST-STAGE LABOR

• I would like to be free of time limits. No artificial augmentation of labor so long as the baby and I are fine.
• I do not want any pain medication offered to me. I will request it if needed.

SECOND-STAGE LABOR

• I would like to allow the baby to descend using breathing-down techniques until the crowning takes place.
• I would like to push instinctively and not be told when or how to push.

POST BIRTH

• I would like to delay ointment in the baby's eyes for one hour after birth to allow for sight bonding.

That's it. One page long. But it's very clear and only lists the things that matter most to the mother or that depart from normal procedures. Many of the things you might want - "I'd like to breastfeed", "I'd like to take pictures" - probably do not need to be written down on your birth plan and only take up space. Keep it simple. Keep it realistic.

Also keep in mind that I'm talking about the piece of paper that will be handed to the nurses and doctor/midwife. When you're thinking about what you want and don't want, yes, be as lengthy and comprehensive as you can. But realize that your caretakers will pay more attention to a short, easy-to-read list of the most important parts, so pare down the list you give to your care providers.

This will require you to talk to your caretaker about what is and is not allowed according to hospital protocol. Writing "I want to eat and drink freely" on your birth plan won't do you a lick of good if the hospital doesn't allow laboring women food and liquids by mouth.

As far as complications (the specifics of what you want to do in case of emergency c-section, if the baby is not breathing, etc.), your options are important to understand. I would write that list and keep it separately. But know that your options will likely be limited and the hospital will make as many accomodations for you and your partner as they can.

Sick Infant
Choose as many as you would like.

• Breast feeding as possible
• Unlimited visitation for parents
• Handling the baby (holding, care of, etc.)
• If baby is transported to another facility, move us as soon as possible

This seems a bit unnecessary to write on a birth plan. You're not going to say, "If my baby is sick, I want my visitation to be limited" or "I want to stay in a separate location from my sick baby". But things like wanting the screen lowered during a c-section or having the baby stay with one parent at all times after a section, or if you have something like a lotus birth planned (I'm not holding my breath that anyone in this audience does), those things should probably be on your "complications" list.

Some people say that birth plans are silly, unimportant, and you can't plan what will happen during labor anyway. I think that, though they probably won't change the kind of labor one has, they are valuable, at the very least because they make the pregnant woman find out what matters to her. When labor begins it is too late to do research or make preferences.

Pro-o-dro-o-mal Labor

This might be one of the biggest fears of all pregnant women: slow, inefficient labor that has the potential of going on for days and days with little or no real progress. Contractions come, but they do little to dilate the cervix. The mother gets more and more exhausted and discouraged.
It's called "false labor" and "early labor" and can seem endless. Eventually - in a few hours or as long as 3 days sometimes - labor does intensify, and the cervix dilates, and the baby will be born.

Occasionally the condition of the baby might require some medical intervention. Babies might not be able to tolerate the long labor well, and augmentation with pitocin, breaking the waters to encourage labor, or even a cesarean may be necessary. Often, though, the most critical part is keeping the mother comfortable and making sure she has enough energy to continue.

"Exhaustion is the enemy of labor." How many times women have labored for a day, had their energy depleted, and asked for an epidural, just so they could get some sleep! There is no way to predict who will have prodromal labor, no way to make completely sure it won't happen. Pitocin might not be effective. And the cervix may not be dilated enough to consider breaking the bag of waters. This is a difficult time, and it feels like it lasts forever.

Here are some suggestions for prodromal labor:

• Try to relinquish control of the labor and accept what is happening. Much of what's going on is not in your control. Dismiss any ideas about what is normal or not, and accept this as part of your labor.
• Spend as little energy as possible. You will deliver a baby soon, and you will do best if you are well-rested for the hard work to come.
• Being active (walking or other light exercise) might increase contractions, but it might also just wear you down without helping labor to progress. Doing your usual routine will distract you without spending all your energy. Or, do something entertaining like going to the movies. Take care of any last-minute baby preparations, like washing or hanging baby clothes, packing your birth bag, or preparing birth announcements.
• Get plenty of sleep. Take a bath, get a massage, stay relaxed.
• Keep eating. Small, light, frequent meals will help you keep up your strength.

Coping with Fears of Labor

This full article is published here (commentary is mine).

In order to resolve fear and prepare actively for your childbirth consider the following guidelines:

• Realistic coping skills and education to the normal process of birth. (Read lots and lots of books until you get bored with the topic because you know it so well. It will help you, to understand what is actually happening in labor and birth.) Take classes that teach the normal process of birth and read books that emphasize what goes right and why, rather than focusing on what can go wrong.
• Read stories of births that went well (Ina May's Guide to Childbirth!!!), women who coped with the intensity of contractions and were supported in the labor process, by a doula and/or their partners. Allow yourself to take in the positive experiences women have to balance the messages you heard growing up. This is an important part of the healing from [other's] emotional pain around childbirth. But do not stop there.
• Use a body centered hypnosis and visualization tape for resolving your fears. Create a birth visualization on tape that you can use in preparation for labor. Address your fears, rather than run away them. (I would have thought before I gave birth that this kind of thing is really pretty hokey, but this is essentially what I did during Hypnobirthing classes, and it's what helped more than anything. Imagine beginning labor with calmness and confidence!!) Embedding a new story about birth in your nervous system must take place experientially to be effective. Doing so, will calm your mind and ready you for labor, rather than leave you a victim of your fear. This preparation allows you to replace the negative messages embedded experientially through the limbic system, which holds the emotional charge of [other's] stories about childbirth. The experiential process is critical to allowing you to separate from [other's] negative experience and be ready for your own positive labor and childbirth.
• Create a birth plan and assemble your birth team. (Get a doula! GET A DOULA!!) Allow yourself to be supported during this significant life event. Choose a birth practitioner that supports the way you want to give birth, whether you do so with an epidural or not. Consider having a doula present who is experienced in helping women cope with the normal and healthy intensity of labor. Prepare with your partner for this pivotal family life event. Some of the best anesthesia is the soothing that comes from genuine, supportive encouragement! (Absolutely true!!!)

Research shows that respect for the woman during the process of labor and childbirth, and a woman's active participation in the experience, are key contributing factors to positive feelings of self-esteem in birthing women. Addressing your fears about the birth through active education and preparation is what will allow you to enjoy the rest of your pregnancy.

* Get educated. * Face your fears. * Hire a doula.

More articles here and here.

The Unkindest Cut

The primary reason I became involved in childbirth was because I wanted to avoid a cesarean for my first delivery. Newly-pregnant women hear everyone else's birth stories, and I came to realize that most of the women around me had had c-sections, usually for their first births. The more I learned, the more I wanted to protect myself from having a surgical birth (more on this in a little bit).

And now there's news that the c-section rate in the US has climbed to almost 30% (read about it here). That's up from 24% from just a couple of years ago. So more and more women are having major surgery to deliver their children, are being sliced open with a scalpel and having their babies tugged from their wombs. One of the things the above link references is the belief that cesareans are actually safer than vaginal births. Now, I could list all the risks and difficulties from cesareans (and there are lots of them), and make another list comparing the same regarding vaginal deliveries, but that's essentially not why I chose to make c-sections my first birth battle.

I wanted to participate in my birth. I wanted to find out what it was like, to really have the experience. And I wanted to breastfeed. And I didn't want to be recovering from major surgery just as I was beginning motherhood.

Myths about cesareans:

• Cesareans are safer than vaginal birth - Actually, cesareans carry increased risks of everything from jaundice, respiratory problems in newborns, maternal death, and breastfeeding difficulties - there should be no doubt that they do cause increased harm to the mother, by their very surgical nature.
• Cesareans prevent incontinence, sexual difficulties, and pelvic damage - In truth, cesareans are far more likely to cause problems with bowel obstructions; sexual difficulties and pelvic damage are related to vaginal 'assisted' birth involving forceps or vacuums, because of the episiotomy, and are not inherent to the birth process. (ACOG support for this here.)
• Cesareans are just another birth option, and women should have choices in deciding how they want to birth - This is a misleading idea disguised as a compassionate outlook. Education shows that elective cesareans pose a hazard to women; having them available does not 'help' women at all, but puts them - unnecessarily - in harm's way. Medicine and surgery ought not be practiced with dangerous procedures being implemented through lack of education - in no other circumstance would we even consider that major surgery on this scale should be performed without medical necessity.
• It is more convenient to schedule a birth than be surprised by labor beginning spontaneously - I suppose everyone must decide what their priorities are.

I reaffirm what I said before. Doctors don't care whether you have a cesarean. They get paid more and they get to practice their surgical training, so if anything, they are likely to be predisposed towards the idea of women having cesareans rather than vaginal births. Ever heard of the famous paper in which a group of doctors gave their opinion that all births should be by c-section? Does that sound like it has women's best interests in mind?

More on Pain

Babies are the biggest things that pass through any of our orifices. Ever.

- Ina May Gaskin

I wouldn't have a root canal done without novocaine. Why would any woman give birth without an epidural?

- Husband on A Baby Story

The most common thing I hear pregnant women say is, "I'm going to try and go natural, but we'll see. I don't know how bad it will get." Fear of pain - rather than the actual amount of pain experienced during labor - seems to be the foremost reason women opt for an epidural. It's rarely because the pain is intolerable; the women are almost always afraid that it will get worse and if they don't get an epidural now, they will have lost their chance and will suffer more than they want to.

I can only speak of my own experiences here, though I have seen and heard enough accounts from other women that I believe mine are at least typical if not representative. The pain I felt during labor progressed to a point, and then the only change was that the contractions came closer together. The pain itself was not the issue; the frequency of the contractions was what bothered me, and that only psychologically, especially in my second labor. I had a trapped feeling, a sense of loss of control over my circumstances, that was far worse than the physical pain.

There are two things I want to say about pain. First, there are different kinds of pain. I have said before that I think it's more painful to stub my toe than have a baby, and I mean it sincerely. There are so many varieties of pain. Sometimes it is intolerable when I bite my lip or crash my shin into a table, but I can function relatively well through a migraine headache or menstrual cramps. And occasionally a tiny paper cut produces all-consuming agony. Some pain is harder to bear than other kinds. I think that labor is entirely bearable.

I think that when women (and from time to time, men too) think about what happens during labor, they find it hard to imagine that pushing an entire baby out of their vaginas could be anything other than traumatically painful. They think it is like pushing a bowling ball through nonelastic tissue, not realizing how much we can stretch and open up during birth:

Even though I had been attending births and respecting women's bottoms for their amazing powers for twenty years, Judy showed me something new and exciting. A first-time mother, she came to our birth center because her baby was in breech position. Several people tried to scare her into having a cesarean by warning her that her baby's head could be caught inside at birth. I told her that in my experience, her baby's large bottom was actually going to prepare the way for his head. Holding my hands in a corcle to indicate the size to which her vagina would open gradually (about the size of a large grapefruit), I told her, "You're going to get huge."

One week later, her son's bottom was just coming into view after seventeen hours of labor. Before his butt pushed directly against her perineum, her vagina enlarged and opened to an extent that astounded me. I had seen this phenomenon in women who had already had seven or eight children, but never before in a first-time mother. Judy's vagina would easily have allowed the passage of a baby considerably bigger than her seven-pound eight-ounce son without a tear.

Some days later when Judy and I were talking about her birth, I told her how surprised I had been to see how open her vagina became without direct pressure on her perineum. (I was still amazed.) Judy said, "I used that mantra you gave me."

"Mantra?" I repeated, uncertain of what she meant.

"I kept thinking while I was pushing, I'm going to get huge. I'm going to get huge!"

(This is from Ina May's Guide to Childbirth, chapter 8.)

Giving birth is not like pushing a watermelon out of your butt or having a root canal without anesthesia (incidentally I don't recommend trying either of those). Women are powerful in birth when they work with their bodies, and women's bodies can do amazing things. Birth is not meant to cause injury or be unbearable.

When I hear women describe their labors as the worst pain they ever felt, I always assume that they either had painful complications or did not know how to relax during contractions. It is also interesting to find that American women rate their labors as more painful than do women of other cultures. Indeed, every media portrayal of labor is of the woman in unbearable agony, twisting about, yelling, maybe cursing at her husband; every discussion is about how much it hurrrts. And while I don't wish to downplay the intensity of childbirth, I want to emphasize that the intensity and the pain are not equal in labor.

The greatest collective obstacle before laboring women is to face their fear of pain. Both Ina May Gaskin and Dr. Grantly Dick-Read (author of Childbirth Without Fear) have excellent perspectives on the fear-tension-pain cycle, and both of their books are part of my must-read list for pregnant women. Basically fear produces tension, and tension increases pain, which then feeds our fear, and we are headed down a frightening path. The most practical advice I can give pregnant women is to find a way to be present, to stop thinking about "What ifs" (especially "what if it gets worse?" or "what if what I'm doing, doesn't work?" or "what if this goes on for (x) hours?"), and deal with labor as it's happening right now. Don't anticipate the next contraction; get through the current one and then be happy for the break. There are more breaks during labor than there are contractions. Your focus is needed on relaxing your body, so that it can do the hard work it's doing with as little resistance as possible. For that to happen, you need to not be afraid of the process. "Embrace the water", as joyful_mommy said (that's a great analogy, by the way! Read her comment here). Use your prenatal time to deal with your fears and learn effective relaxation techniques. I can't promise pain-free labors, but having those tools will significantly reduce the pain experienced.

All About Induction

I am opposed to inducing labor. I think it's a very bad idea, especially for first-time moms. I was going to try and write as if I'm neutral about it, but I just can't do it.

Let me start my saying that there are some valid reasons for inducing labor. These include preeclampsia, placental age, and illnesses like high blood pressure and kidney disease.

Most women, though, will not have these problems. Most induction candidates are women who induce electively, for reasons like this:

• They're impatient and weary of being pregnant;
  
• They have gone one day to one week past their due date (the arbitrary cut-off point between waiting for labor and inducing, depends on the care provider);
  
• They want their baby to be smaller than he or she would be full-term;
  
• They want to have their baby at a specific, scheduled day and time.

The other most common induction group is mothers who are convinced by their doctors that it is a good idea, in the absence of any medical reason for being induced. This is simply bad practice. Mothers can be easily monitored for signs of distress or to be certain that the placenta is functioning and that all is well. There is no need to induce simply for being overdue, and being induced without medical cause opens up the route for complications, and very rarely avoids them. Mothers should carefully research their options, but arbitrary induction of labor is a route that should be avoided.

To expecting mothers: During your last weeks, you may be recommended to participate in a 'non-stress test' to ensure that the baby is responding to contractions well and that your placenta is functioning - on these days, make sure you eat a meal before you go in for the test. Not eating enough may cause you to exhibit signs of distress and illness that may be misinterpreted and end up in a completely unnecessary induction (high blood pressure, protein in the urine, lack of responsiveness of the baby, all of which will be completely resolved if you simply eat a meal). And, even though you have to pee every few minutes, drink lots of water.

As I have previously mentioned, my first baby was almost 3 weeks overdue (most women, even first-timers, don't go that long). I chose not to be induced because of one reason: I wanted to avoid a c-section. Induction is notorious for being a slippery slope, meaning that if it goes on for a while and doesn't work, the woman will likely be sectioned.

The main reason I am opposed to induction is because it leads to so many interventions and can easily culminate in a preventable c-section. Especially for first-time mothers, I believe that having major surgery is a traumatic entrance to parenthood. I had a natural birth with my first baby, and it was hard enough, getting accustomed to the new and entirely different world of motherhood; I can't imagine what additional hardships I would have had if I had also been healing from a giant surgical cut in my abdomen. Inductions are linked to an increase in the incidence of shoulder dystocia and a higher rate of instrument delivery (here). I hope for better for all mothers, and wish to help mothers avoid unnecessary trauma. Labor is much more gentle for mother and baby, and faster too, when it begins on its own.

I am also worried about the welfare of the babies. Babies born too early, even by a few days, can have trouble breathing, nursing, or sustain injuries. They are much safer in the womb until they are ready to come out and their mothers' bodies are ready to birth them.

The method of induction depends on how ready the mother's body appears to be. If the cervix is effaced and dilating, she will likely have pitocin. If the cervix is not prepared, she will probably have prostaglandin gel applied to her cervix to ripen it. Other methods are stripping or sweeping the membranes (the practitioner uses his or her fingers to manually lift the bag of waters from the lower part of the uterus, trying to stimulate contractions - labor may take a day or two to start, if it's going to at all), and breaking the bag of waters (increases the chance for infection and c-section if the woman's body doesn't start labor within a certain period of time).

Most likely, if the induction has been scheduled, a combination of these methods will be used. (Just as a side note, I found this sentence on a popular baby/pregnancy website: "Some women say that Pitocin causes more intense contractions, but if this is your first baby, you won't know the difference." You won't know if your contractions are unnaturally difficult and intense? Of course you will be able to tell! You just won't know that labor can also be gentle and manageable.)

If the mother is in a hospital and her bag of waters has been broken, she will stay until she has delivered the baby. This means that if the care provider breaks the membranes in an attempt to start labor and it doesn't give the desired results, after a period of time a cesarean will be considered necessary. With the membranes broken, the woman is at risk for infection, and once infection begins, the doctors cannot be certain that the baby is not in trouble also. Maternal fever is considered a problem for both laboring mother and the unborn baby.

If your doctor wants to induce labor by way of cytotec (also called misoprostol or prostaglandin E1, and is in pill form), refuse it and get a new doctor. At the very least don't take it. Cytotec is not approved by the FDA for use on pregnant women; it was originally intended to be used on ulcer patients. It was found to also cause strong uterine contractions. Sometimes it can cause hyperstimulation of the uterus, increasing the chances of uterine rupture and overstressing the baby. One of the problems of using cytotec is that because it is administered in pill form (either swallowed or vaginally inserted), its effects cannot be interrupted once it has been taken. I find the risks far too great for both mothers and babies, and it is unconscionable that cytotec is still being used to induce labor.

It's hard to be pregnant. It feels like forever. Towards the end, when you're as big as a house and it's hard to move around or sleep or eat or sit because your body is half baby, you really long for the relief of labor and birth, just so you can be comfortable again. Both of my babies have been overdue, and I completely understand how difficult the last weeks are.

My midwife assured me, "You will go into labor. Everything is fine, and eventually, when your baby is ready, you will go into labor." It helped to know that I was not defective, that I would not be pregnant forever. The average length of pregnancy for first-time mothers is 42 weeks. That means that some are shorter, and some are longer. Just because the pregnancy lasts 40 weeks and two days does not by itself mean something is wrong. Due dates are estimates. Women who have their labors induced are taking their babies out of the womb before the babies are ready, no matter what the reason. For some situations the risks of remaining in the womb outweigh the risks of being taken from it early. I do not believe, for the sake of mothers or their babies, that inductions should be done electively, as a matter of course, with no medical indication.

Alternatives to Epidurals

Epidurals are popular, but they are not the only means of pain relief during labor. Here are other effective methods, sorted roughly by my own preference:

• Hire a doula! Doulas know many strategies for dealing with labor. They can massage arms and legs and backs and help with breathing, movement and positioning, and emotional support. Their presence reduces the need for additional help.
• Get in the water. My doula trainer said that for fussy children and laboring moms, water always helps. Baths, showers, anything that's available, is usually helpful. Labor pools are sometimes called "wet epidurals" because of the pain relief they can provide.
• Change positions. Sometimes women find a position during labor that feels better than others. While in labor almost anything feels better than laying flat on a bed! Some women prefer to squat or sway or be on all fours, or sit on a birth ball, or a rocking chair...

Apart from getting medication injected into one's spine, there are other pharmacological approaches. I hesitate to mention them, because to me their side effects are unacceptable.
Narcotics (such as Demerol, Sublimaze, Stadol, Nubain, meperidine, Narcan; also called opioids), given by injection to the mother during labor. They do not provide complete pain relief; many people say they take the edge off the pain. They are also relatively short-lived. A quick web search found these results from a study on the effects of narcotics on newborns: "opioids are associated with neonatal respiratory depression, decreased alertness, inhibition of sucking, lower neurobehavioral scores, and a delay in effective feeding." Mothers have also reported feeling groggy, delirious, or goofy, as a result of narcotics during labor. (Note: if, when you are in labor, you are offered a shot to 'take the edge off the pain', it is a narcotic.)

Paracervical block: an injection of Lidocaine directly into the cervix, to numb the cervix and adjoining tissues during the first stage of labor. Its effects are short, but it doesn't require the presence of an anesthesiologist. Its use is associated with infant bradycardia (slow heart rate).

Though I know many women prefer medical management of labor, I feel safer with psychological and emotional support.

The Psychology of Labor

Most of what I have written about labor involves the physiological progression and can be found in any book on pregnancy. I think it is important to know what is happening and what it might feel like to be in those phases. But there is more to labor than phases. What I'm going to write about here is mostly based on my experience, and I hope it will give insight and alleviate any fears and feelings of being overwhelmed that all the information of the previous entries may have caused.

The first thing I want to say is going to sound strange. I want to tell pregnant women to not be afraid of the pain. Women in labor are not being injured. The only thing that is happening - the only thing - is that the uterus is contracting to open up the cervix. This does not cause injury; barring malposition, the only pain felt is due to the hard work of the uterus, that it is working up to and sometimes past the point of muscle fatigue that we feel when we lift weights. It feels like menstrual cramps at first because it is the same mechanism: during menstruation, our uterus contracts to get rid of the blood-rich uterine lining, so much so that the muscle rapidly uses up a lot of oxygen, causing cramps. The same thing is happening during labor.

This is why it is so important to find ways to relax during contractions. If we can relax our bodies, we are not using up oxygen anywhere extra to maintain tense muscles, and we are also not fighting against the hard work our bodies are doing. When we tense up during a contraction, we are counteracting the uterine contraction, as if we are trying to stop it from happening, and this results in serious pain.

Let me use an example from my first labor. With the help of a doula, I was doing great, not feeling the need for anything else. I had a difficult time progressing from 4 to 7 centimeters. Around the end of this time, I was getting weary of dealing with contractions, of having to stay so focused, and I decided I didn't want to do it anymore. Unfortunately I made that decision in the middle of a contraction. I panicked and tensed up, fighting against the contraction. Suddenly the manageable amount of pain I was experiencing, increased by about 100 or more, and it instantly became more than I could handle. I learned my lesson and tried hard to stay relaxed during the rest of the labor; it went back to being well within what I could take.

From that I learned that relaxation is tied to how much pain we feel during labor. With the help of my doula and several family members, I had enough support that I never even considered asking for drugs. (I remember in the few minutes after my baby was born, I had the thought, I wonder if I'll need pain medication? It took me a moment to realize, Oh my goodness, I did it already!)

Do not be afraid of the pain. The pain is temporary, it comes and goes, and you just need to get from one contraction to the next. It is well within your ability to manage, especially if you have a support person who is dedicated to making you comfortable during labor. The bodies of laboring women are doing the work all by themselves, and all the women need to do is let it happen. If you get to the point where you don't feel like you want to do this anymore, try hard to regain your composure. If you're exhausted but your contractions are still going strong, try to let it keep going; if you're overworked, have had a long labor, have been restricted from eating and drinking for a long time, or your contractions are weakening instead of progressing, you may need something like an epidural just so you can get some rest. This is not failure; this is dealing with the labor as it has happened. Labor is not intended to be a path into the depths of hell, and I hope that women never experience it as this.

I was never sure I could have a drug-free natural birth, not until it happened. I was worried during the last parts of both of my pregnancies about needing medication, mostly because I didn't know what to expect. I didn't know how much I could handle, and I didn't know what labor would be like. It was different from how I imagined. It was a much more psychological, introspective experience. Hours flew by without me being aware of how much time had passed (my first labor was 20+ hours but felt like 3-4 hours to me).

In the fantastic book Birth Reborn, Dr. Michel Odent talks about the need for laboring women to be able to get in touch with their natural instincts, that they already know what to do during labor and birth. He says that birth is in the primal realm, not the cerebral, intellectual world we usually live in, and to get in touch with that part of ourselves, we should ideally be in an environment with little or no interruption, low light, a place where we feel comfortable being uninhibited.

I want to say two things about this. First, a word about our intellects. This part of our minds, makes lists and organizes calendars, plans and arranges, and works logically and rationally through decisions. This is not the part of our minds we want to listen to during labor. Here is one example of why: It might take us fourteen hours to dilate to a 7, and our minds will tell us that we cannot endure another (quick math: one centimeter every 2 hours, means 6 more hours of labor) 6 hours of labor before the baby is born! While that is mathematically reasonable, labor does not follow that pattern. After 6 or 7 centimeters, the woman enters transition, labor speeds up, and by 7 centimeters she might have less than one hour before she is holding her baby. It should be clear that if we listen to this voice, we will be misled, feel discouraged, and might make decisions we will regret. A better gauge is something like, How am I doing? Is this bearable right now?

The second thing I wanted to address is the need for the laboring woman to feel comfortable using her coping techniques. My favorite during my first labor was low moaning - the low tone keeps the body relaxed, while making noise helped me to feel like I was doing something other than just sitting there. I could moan as loudly as I needed to, so long as I kept the tone low. Sometimes I roared and yelled, lowly of course. I can't imagine what I would have done if I hadn't been allowed to make noise or if I had been worried about disturbing other people. I believe that women should feel free to do whatever it is that helps them during labor, whether that's walking around, being completely naked, on all fours, moaning, chanting, wiggling, making horse noises, or anything else. There are so many techniques that have helped laboring women, and while pregnant women might look into those things and be familiar with them, there is a chance that they will not know what the most effective one(s) will be until they are in labor.
To read about some of those, and for lots of knowledge and confidence in the power of women in childbirth, read Ina May's Guide to Childbirth by Ina May Gaskin. This is a great book, and essential reading for pregnant women.

More about Labor

The previous entry detailed the basics. There is, of course, so much more to say about labor and birth.

Back Labor

I have never experienced back labor, but I have heard plenty of times that it is excruciating. Back labor is most often caused by the baby being in the wrong position for birth. The normal position is head down with the baby turned towards the mother's back and the baby's back facing outwards towards the mother's abdomen. If the baby is reversed - that is, with the baby's spine facing the mother's spine - the bony part of the baby's skull presses down on the mother's tender nerves, causing pain that shouldn't be there. Sometimes this can be remedied with walking and rotating the hips, or swaying on a birth ball. The pain can be partly relieved by getting on all fours and taking the pressure of the baby's head off of the mother's nerves. Counter-pressure - having an assistant press hard on the lower back - usually helps. If the baby does not rotate to the favorable anterior position, the baby will be born "sunny side up", and this might extend the pushing phase.

Epidurals

Epidurals are an extremely common form of pain relief for labor. They are typically administered between 4 and 7 centimeters of dilation. The mixture of drugs used is unique to every woman, and epidurals must be given by an anesthesiologist. The process usually takes about 45 minutes to an hour and a half to complete. The epidural is given directly to the spine. The procedure is basically as follows: an area on the mother's lower back is cleansed and a thin catheter is threaded between two spinal vertebrae into the column of fluid surrounding the spinal cord. The anesthesiologist gives a test dose to ensure the placement is correct, then tapes the catheter cord to the mother's skin. The epidural mixture is either given in doses by the anesthesiologist as needed, or it is given in a drip that can be controlled by the mother.
I am not altogether opposed to epidurals. I think they are overused, and I am stunned to hear of women who want epidurals before they have ever felt a single contraction. It seems to me that these women would be better served in facing their fears of childbirth instead of beginning motherhood in a drugged-up state. I believe that epidurals ought to be administered when the mother is overtired and her exhaustion is affecting the progress of labor, or if she suffers from back labor. I wish they were not given as a matter of course, giving women the impression that they are unable to endure labor and need drugs to help them through it. For the women for whom this is true, they should be available, but I refuse to believe that this is the case for most pregnant women.

Effectiveness of Epidurals

For most people epidurals are a very effective way to obtain pain relief during labor. The epidural numbs the mother from the top of her uterus all the way down to her feet, and often the mother will feel pressure during contractions but no pain.

Potential Risks and Side Effects

Epidurals dramatically lower the mother's blood pressure, so an IV is given at the same time to counteract this effect. Because she is numb, the mother will no longer be able to walk or change positions unassisted. Epidurals tend to slow down the progression of labor, and so they are associated with an increased use of pitocin, an artificial oxytocin used to increase the rate and strength of contractions. Occasionally the mother will not be able to feel her pelvic muscles well enough to assist with pushing the baby out (another reason to practice those Kegels!), and forceps or a vacuum extractor will be required; at worst, she will need a cesarean.The rate of complications with epidurals is estimated to be 23%. Most complications are problems with administration and are not inherent to epidurals in general. Some are life-threatening, but those of course are extremely rare. In truth no medical procedure is free of risks.One of the common complications is punctured dura, meaning the spinal cord itself may be punctured during the administration of an epidural. Spinal headaches will result, which are extremely painful and can last for a very long time - I have heard of spinal headaches persisting for as long as a year after delivery.

Some medical practitioners tell women that the epidural does not pass to the baby and therefore cannot affect the baby, which is an outright lie. Epidurals given too close to the delivery of the baby tend to depress the baby's respiratory system, requiring some level of resuscitation. Having a drowsy, uninterested baby is not ideal during the crucial first hours after birth, when bonding between mother and child is so important and can be so beautiful.

Occasionally the epidural has no effect on the mother, which means she faces both the disappointment of not being able to obtain relief and the daunting task of having to deliver a baby naturally. I believe that it is in the mother's best interest to mentally prepare herself for a labor without pain medication, even if she plans to get an epidural, just in case the epidural has no effect on her. The judicious use of epidurals can make the difference between a mildly disappointing event during an otherwise joyous occasion, and a traumatic birth experience.

Labor!

On any pregnancy website you can find a list of the signs of impending labor: spotting, nesting, crampy regular contractions, bag of waters breaking, etc. First-time moms anticipate labor beginning hourly during their last weeks of pregnancy, thinking it could happen at any moment. This is an exciting time, especially since it is nearly a universal sentiment by this stage of pregnancy that the woman is ready to be done with being pregnant and move on to the next phase. And it could happen at any time, whenever the baby is done developing, that mysterious and unknowable timetable.

Most first-timers go beyond the 40 week mark. Some, like me, go way beyond it. Tests and ultrasounds can monitor the placenta and make sure it's still functioning, since one of the risks of being overdue is that the placenta will fail - it is, after all, only a temporary organ (amazing! the body grows this wondrous organ, only to dispose of it a few months later when it is no longer needed!). I haven't seen statistics on this occurrence, but with my first baby I was 18 days overdue. Everything was fine, and I chose not to be induced. When my baby was born, she was just fine, not huge, not peely and leathery like babies who have overstayed their time in the womb - just perfect. I think a lot of women, who are tired and feel huge and just want to meet their babies, go in for inductions before their babies are ready to be born... but more on inductions later.

The truth is that unless you are one of those very rare women who has a completely painless, unfeeling labor, you will know when labor starts. You will likely have been feeling contractions all through the third trimester, but there will probably be a distinct change in sensation when the real work begins. Labor carries an intensity with it, and a regularity, that is obvious to those who experience it. From that point, the issue becomes, how much longer will it last, and how much worse will it get?

I don't believe that most people can, even through relaxation techniques, experience a painless labor. I think that relaxation is important in helping the work to progress, and in making the pain manageable, but I believe the majority of women will still have pain during labor. So long as I was relaxed, every one of my labor contractions hurt less than, say, a stubbed toe. People endure stubbed toes without getting analgesics injected into their spines; so too can people endure labor, with the proper support and understanding of what's going on, without needing medical help.

The first phase, early labor, begins with the onset of regular contractions. This is usually the easiest part, as the contractions are far apart (a few minutes) and the woman can talk and interact even while experiencing contractions. She will probably be very excited, knowing that "this is it" - but that excitement can lead to one of the most common major missteps that first-time moms are especially vulnerable to: using too much energy during this phase, when labor is easiest! The mother-to-be might decide that this is the time to clean the baby's space or cook a big dinner or even focus too deeply on the contractions when she doesn't really need to - any one of these things can lead to exhaustion. Labor probably won't feel very difficult at this point, but it is crucial that the mother get plenty of rest and not burn herself out.

The contractions will continue to get stronger and closer together. The uterus is working hard, and the sensation of cramping might turn into something that feels more painful and harder to handle. This is because the uterus, the strongest (and at this point largest) muscle in the body is being exercised, contracting and releasing, for several hours. Any muscle that is worked this much will begin to feel sore, and the same pain one gets from using an arm or leg muscle to its limits is the same as what the woman experiences - only to a larger degree. She will experience the unusual and uncomfortable sensation of moving beyond that. The uterus has a long way to go. What is happening physically is that the uterine contractions are pulling the cervix open. The cervix needs to be dilated to about 10 centimeters, or approximately the width of a human hand (this of course varies, as does the actual measurement of full dilation for each woman). When the cervix has reached 4 centimeters, the woman has entered the next phase of labor, the second stage. Contractions are typically demanding all her attention now, and usually are about 3 minutes apart and last about one minute. What this means to the woman is that she is going between contractions and rest at a rather fast pace! One minute of contractions, two minutes of rest, one minute, two minutes...it will be more challenging to stay atop the contractions. Most women cannot help but remain focused on their labor at this point, and do not want to be distracted, which is essential to getting through it.The last phase of this part of labor is transition. If women are going to panic, this is often where it happens. Here labor tends to be the most dramatic and requires the most from the woman. The good news is that it is also the shortest phase, lasting less than an hour and often only about 15 or 20 minutes, maybe 10 to 20 contractions long. The uterus is finishing its work of dilating the cervix, and contractions are hardest and closest together. Women often become overwhelmed during transition - they may decide they can no longer handle labor, or they might insult their partners or caretakers, or become nauseous and shaky. (During my first labor, transition was quite easy - it was getting from 4 centimeters dilated to 7 cm that was the tough part!)Fortunately this phase typically ends peacefully, with a period of quiet, where contractions stop completely. Sheila Kitzinger calls this the "rest and be thankful phase". With the cervix completely dilated and effaced, the body is resting in preparation for pushing the baby out. The kinds of contractions the woman endured before have ended, and the work the uterus does now to birth the baby are of a different sort and usually not painful. This restful period can last several minutes before the second stage of labor begins.

Pushing

Now the hard work begins! Up to this point, labor was characterized by endurance alone, by just getting through it, and allowing the body to do its work by not interfering. But with the second stage of labor, the woman can finally actively participate in the birth of her baby. This is the pushing stage, where the cervix is dilated and the body is ready for the passage and delivery of the baby. Even though labor may have been exhausting up to this point, a welcome surge of energy comes, and women again get excited to meet their babies.How this stage is experienced depends greatly on the woman's caretakers and environment. Some hospitals coach women through pushing, telling them how and when to push. But it is becoming more acceptable to let women push spontaneously, when they feel the urge. Most women will experience a deep primal and irresistable need to bear down as the baby descends. The uterus is still contracting, and the baby will be born whether she actively pushes it out or not, but she will probably not be able to control her desire to push. The baby makes a two-steps-forward-one-step-back progression. This is a natural way of reducing damage, to stretch out the tissues of the birth canal. Left to descend on their own, the movement of the baby down and out often prevents much damage and results in a gentler birthing than constant pushing from the moment of dilation.The head of the baby is the largest part of its body. Once it has stretched the perineal tissues to their maximum (often called the "ring of fire" because of the burning sensation this produces - to get a small idea of what this is like, place a finger at each corner of your mouth and pull hard), and is born, it will no longer retract and the baby will be born within moments. The head turns - the body is maneuvering itself down the birth canal, down the path of least resistance - and the shoulders emerge, often followed very quickly by the rest of the body. For first-time mothers, the second stage can last several hours, but for subsequent births it may be only minutes.All the hard work of labor has accomplished the most amazing thing, the birth of a baby. This time is crucial for bonding with the baby, for beginning breastfeeding, and welcoming the little one into the world.

A Second Birth

However, the woman's body isn't yet finished with its work. The third stage of labor is the expulsion of the placenta and the continuing contracting of the uterus to its prepregnancy size. The detachment and birth of the placenta is painless, and some women often do not even realize it has happened.With the detachment and delivery of the placenta and the uterus returning to its original state, labor is finally at an end, and motherhood is just beginning.

Choosing a Prenatal Care Provider

The type of care the pregnant woman wants should be reflected in who she chooses to provide her care. Unfortunately, though, not all varieties of care are found in all areas. Most women in the US go to an obstetrician for the duration of their pregnancies, and the highest number of patients admitted to hospitals in this country are women about to have a baby.

When I was pregnant for the first time, I signed up with an OB just like everyone else I knew. I picked a female because I had heard so many other women say that they felt more comfortable with female doctors, especially in this situation. Women are more sympathetic because we're all on the same side, right? I'm sure that's true for many female MDs. I can't say whether it was true for mine or not because I barely saw her. Halfway into my pregnancy, after I had done some research and decided that I wanted to try to have a natural birth, I was also considering a home birth. I spoke to another woman who had brought up the issue of home birth with our shared OB, whose reply was, "What, do you want your baby to die?"

I never went back to that OB, because I found a perfect combination of support for natural birth and quick medical attention if necessary. In a suburb of my community was a small hospital which had the ideal arrangement. The prenatal clinic was run by midwives in conjunction with OBs, but the doctors only saw the high-risk pregnant women; all "normal" (low-risk) pregnancies were directed to the midwives. The hospital had a birthing center attached, run by the midwives, and was equipped with labor pools, a doula program, and comfortable, single-patient labor rooms and a separate postpartum wing. If anything went wrong, the doctors were around the corner, and an emergency surgery room was not far. The emphasis, though, was on non-interference with the natural rhythms of labor and birth. Both of my babies were born there, the second in a warm pool of water.

This is an extremely rare arrangement. I don't believe many places like this clinic and hospital exist throughout the country. Most women will have to choose between doctors and midwives, between hospitals and home birth (or a freestanding birth center). Most of the time, that decision is between two different worlds.

My experience with obstetricians was rough, and I found mine to be cold and clinical, emphasizing the pathological side of birth. She stressed interventions (she tried to convince me to get an amniocentesis for my first pregnancy, even though I was young and wouldn't terminate even if the results showed anything) and rooted my fears that somehow birth is unnatural and needs to be carefully watched and managed. I believe that there is a place for obstetricians, and it is not with normal birth. Not many OBs have ever even seen a normal birth. Midwives specialize in this area, and their personalized support and desire to educate spreads enthusiasm instead of fear. I understand that this is an oversimplification, because of the polarization of doctors and midwives. In my current community, if a woman wants a natural birth without interventions but not a home birth, her best option is to see the only local OB who is sympathetic to this point of view. One local doula says that if you don't want a c-section here, you need to arrive at the hospital while you're pushing.

My point in telling all of this is that the person a pregnant woman chooses to give her care, does matter, especially for first-time mothers. As a society we keep believing that doctors always have our best interests in mind and always know the best things to do, and women having their first babies have been taught to be scared and to doubt their ability to handle giving birth. In some cases doctors do have expertise, but I don't believe as a whole that doctors should have so much jurisdiction in the area of normal birth. Doctors are trained to interfere, not to stand by and let nature take its course. Doctors are impatient and have schedules and many patients. They give stimulating or inhibiting drugs so that labor follows a prescribed course, an action especially dangerous for first-time mothers, who usually need more time to give birth. If a woman's OB disagrees with her about what kind of birth she wants, she will probably not get what she wants. I have very rarely seen or heard of anything that contradicts these statements.

I wish all communities had both doctors and midwives, but at least doulas can be found in most areas now. Doulas are a step towards filling the void in personalized care, but the same rule applies to them as applies to both doctors and midwives: the most important thing is that the pregnant woman feels comfortable in their presence, secure in the knowledge that her care provider will give her the kind of care she desires and will support her in her reasonable decisions.

Still more to come!