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Words for Pain

Mar8

May 2015 146I recently purchased a new educational DVD about natural birth called It’s My Body, My Baby, My Birth. A childbirth educator interviewed during the film briefly discusses pain and says that we need more words for pain, because it is ridiculous that we have only one word that is used to describe a hangnail, a broken leg, being hit by a car, and labor. I had already been musing about pain during labor and how we perceive it, talk about it, and so forth and this comment was additional food for thought for me. I’m thinking that there are many other words used to describe women’s experiences of labor and birth other than pain–a word that is limited in scope and that for some women may well not even apply to the experiences in birth (I’m thinking of the intriguing “comfortable, easy birthing” philosophy of programs such as Hypnobabies).

I reflected on my own birth experiences and how I would describe them, especially my second birth, which was very quick. I would describe it as:

Powerful

Intense

Triumphant

Empowering

Major (this is a word I kept repeating during labor…”This is MAJOR!”)

Beautiful

Special

Amazing

Awesome

If someone then asked me, “yes, but was it painful.” I would have to think a minute and then say, “oh yeah. I guess it was painful.” However, pain is very far from my dominant interpretation, impression, or experience of this birth. It does not make my “top ten” list of descriptors. I’m interested by that. I’m also interested to know about the other words women use to describe their births and where “pain” falls on their lists (feel free to leave a comment sharing your words for your birth experiences! If pain is at the top of your personal list, that is okay! I’m fascinated by women’s experiences of all kinds.)

I have heard people scoff at this kind of language to describe birth–triumphant, empowering, etc.–saying that it is just natural birth “rhetoric” trying to lie to women or that if giving birth is so wonderful why do we use “euphemisms” to describe it, but the words I chose above are truthfully my experience. Why would describe my births as painful, if that truly is NOT the best word to describe them? If I had to pick the best word, I’d probably say triumphant. Or, I might choose intense (particularly with that second, fast labor and birth).

As I said, I’ve been reflecting a great deal about pain and the word pain and how to address the issue of pain during birth classes. I hope to share some more of these thoughts soon.

Benefits of Active Birth

Feb29

From Janet Balaskas’ classic book, Active Birth:

“When birth is active–

  • There is less need for drugs.
  • Discomfort and pain are less.
  • The uterus functions better, so artificial stimulants are not usually necessary.
  • Labors are shorter.
  • The supply of oxygen to the baby is improved.
  • There is less need for forceps or vacuum extraction.
  • The secretion of hormones that regulate the whole process is not disrupted.”

Make sure to talk to your care provider about your plan for an active birth. You may have to introduce your attendant to the concept and be assertive about your right to have an active, normal birth.

Will I need an episiotomy?

Feb5

The short answer is no, you do not “need” an episiotomy. Women rarely (if EVER) actually “need” an episiotomy. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening as the baby’s head is being born. This procedure is rarely necessary and you should ask your care provider how often they perform episiotomies. A good answer is, “almost never” or “I’ve done 3 or 4 in my career.” Answers that are NOT good and that should encourage you to question further are, “only if you need it” or, “many first time moms need one” or, “a clean cut is easier to repair than a nasty, jagged tear!” or, “don’t worry about it. I’ll make the decision when the time comes.” These are not good answers, because there has no study has ever shown any benefit to routine use of episiotomy! There is no scientific evidence supporting the practice.

A commonly used analogy to explain why a cut is NOT better than a tear is to imagine a piece of fabric–when you try to tear it, it resists. But, when you make a small cut in the top of the fabric and then then try to tear it, it easily rips all the way down. The same is true of your skin! (and your muscles–an episiotomy cuts through your muscle as well as your skin. Many naturally occurring tears are very small and occur only on the surface of your skin).

Here is some more explanation from an issue of Midwifery Today e-news issue number 8:23:

“Ironically, one of the biggest contributors to perineal tearing is episiotomy, which has long been heralded as the great preventer of tearing. One recent study, which only assessed the effects of episiotomy on third and fourth degree tearing, found a definite correlation between episiotomy and tearing. The risk of severe tearing was found to be nearly four times higher with episiotomy than without. Another study involving thousands of women found that the number one risk factor for perineal tearing was episiotomy.”

Though it often is presented as a choice–i.e. “would you rather tear or be cut?” I offer that there is a third option….Neither! A perineal wound is NOT an inevitable part of giving birth (even with your first baby). Though it is not abnormal to tear, it is also perfectly possible to not tear or need stitches. One way to work with your body to avoid tearing is to give birth on your hands and knees, kneeling, or squatting. Another way is to stop pushing when you feel a burning sensation or “ring of fire” and let the baby’s head naturally ease out. Your uterus will push the baby out without sustained, breath holding, high exertion pushing from you–you can rest and let your uterus do the work! When you are doing forceful or directed pushing you are more likely to tear than if you follow your own body’s pushing urges and signals. Some people also advocate perineal massage prior to birth to help the tissues stretch. While it does not hurt to become more familiar with this part of your body and how your muscles feel when they are relaxed or tense, perineal massage has not been shown to have very much effect on your chance of tearing during birth.

Why “Woman-Centered” Childbirth?

Jan15

I refer to my approach to childbirth education as “woman-centered.” Why? I believe woman-centered birth supports normal birth. The two are inextricably linked. According to the Association of Labor Assistants and Childbirth Educators, “woman-centered childbirth recognizes the primary role of the mother, and allows labor to progress according to the mother’s natural rhythms.” As an ALACE trained educator, I stress the importance of respecting the mother’s instincts and choices about how to give birth, including positions for labor and birth,  comfort measures, and choice of caregivers and support. My goal is to help women reclaim trust in their bodies inherent abilities to give birth in a safe and unhindered manner.

This does not mean there is not a role for the father in birth or that I do not value the role of fathers. A father most definitely goes through a “birth” of his own–into fatherhood–and the psychological growth he experiences is significant. He also experiences fears and changes as he prepares to meet his baby and is of significant importance during labor and birth in his irreplaceable role of loving and supporting the mother of his baby. My beliefs about birth are underscored by the feeling that the mother is of central importance in the process of birth and that respecting birth as a woman-centered and woman-directed passage is the healthiest, safest, and best way for babies (and therefore, families!) to be born.

Pushing the issue of pushing in labor…

Jan14

Coping with the second stage (pushing) of labor can involve several different approaches. There are many benefits to pushing according to your own body’s urging and natural rhythms. Your uterus will actually push the baby out for you without any straining from you if you are in a gravity utilizing position–upright–and following your body’s spontaneous pushing urges! Some care providers and nurses instead encourage “purple pushing”–this is often the kind of pushing you see on television portrayals of birth, prolonged breath holding and bearing down, red straining face, and directed efforts (often with loud counting to 10).

The benefits of spontaneous bearing down instead of controlled, prolonged, directed pushing, and straining include:

  • less strain on your perineum and consequently less chance of tearing
  • less incontinence later
  • better oxygenation for your baby (less breath holding–>more breathing–>more oxygen for baby)
  • less wasted effort since you are working in harmony with your uterus

If you have an epidural, delaying pushing until you feel an urge or the baby’s head is visible on your perineum is preferred as well and reduces your chance of tearing and of trying to push out a malpositioned baby.

How can your labor support person “push the issue of pushing” during labor? (i.e. support you in spontaneous pushing instead of the controlled, directed pushing common on labor & delivery units). Your labor support person–husband, partner, friend, mother, sister, doula, or other person offering you their nonmedical companionship during labor–can remind provider and nurses of your birth plan (which should specify spontaneous pushing).  If directed pushing is being used anyway–i.e. loud counting–your labor support can try the counting as well once or twice and then ask you in an audible voice: “does it help you when I count like that while you push?” You can then say, “no”–this is not directly offensive to nurses, but clearly states what is helping and what isn’t and getting pushing back into your “court” which is absolutely where it belongs!

Thanks to the fabulous publication International Doula for getting me thinking about this topic (and for the catchy title)!

What about fetal monitoring?

Jan9

Another area in which common practice or hospital policy often diverges from evidence based pratice. Women in hospitals commonly experience electronic fetal monitoring as a matter of course, particularly an “admission strip” on the baby and then at least 15 minutes of monitoring throughout labor. ACOG itself has recommended that routine continuous fetal monitoring be dropped from the standard of care for low-risk pregnant women and instead recommends intermittent fetal heart tone listening (which can be done with a hand held doppler instead of a fetal monitoring belt). Still, at least 85% of women giving birth in the US have electronic fetal monitoring even thought their practitioners own trade union (ACOG) does not specifically recommend it. Additionally, “electronic fetal monitoring without access to fetal scalp sampling” is on A Guide to Effective Care in Pregnancy and Childbirth table of forms of care likely to be ineffective or harmful. This exhaustive research summary of evidence based care practices for pregnant women also nots that there is insufficient data to support or to disprove the use of short periods of electronic fetal monitoring upon admission to the hospital.

Continuous electronic fetal monitoring with scalp sampling vs. intermittent ascultation (listening) during labor is included on the table of tradeoffs between benefits and harm. the book suggests that women and caregivers weigh the effects of those practices according to circumstances, priorities, and preferences  (this is the same table under which epidural analgesia is classified).

More about normal birth

Dec28

I recently read on the Passion for Birth blog that the Maternity Care Working Party in the UK has a new consensus statement called Making Normal Birth a Reality. It is difficult to arrive at a concise definition of normal birth (which I define as “physiological birth”). They describe it as a women whose labor “starts spontaneously, progresses spontaneously without drugs, and who give birth spontaneously.” There is a lot of room in each of these for some interventions (such as electronic fetal monitoring) that many activists would argue impede the progress of normal, physiological, naturally progressing birth. However, it is nice to see the emphasis on spontaneity and also to see what other countries are doing/saying about protecting and promoting normal birth.

What About Routine Suctioning?

Dec18

Another instance in which hospital policy may not match the evidence is with regard to suctioning the baby’s nose and mouth immediately after birth. Some doctors may suction all babies routinely. Others have a policy to only suction if meconium (baby’s first bowel movement) is present. 

However, the newest protocols from the American Academy of Pediatrics say not to suction while the baby is on the perineum at all–whether or not meconium is present. A fellow independent childbirth educator, Jeanne Anderson, was certified in neonatal resuscitation by the American Academy of Pediatrics this year and shared the following information about the AAP’s 2007  guidelines:

“Their latest research indicates that the baby will spit up the meconium on its own, and if it is one that will develop respiratory problems, they will happen regardless of perineal suctioning. The newest protocols are to birth the baby and only wipe any visible mucous from the mouth/nose with a towel as you are handing the baby to the mom and
visually evaluating him/her. If the baby needs more resuscitation it will show up as poor respiratory effort, lowered heart rate or poor color, which can then be addressed. Normal infants will only need help less than 10% of the time.”

Can I Eat During Labor?

Dec14

A woman in labor is working harder and longer than she may ever have done before. Eating is important to maintain her energy, strength, stamina, and good health. Many women choose light, easily digested foods–whatever appeals to them most at the time. However, many hospitals and care providers have a policy in which laboring women can only have ice chips to “eat” during labor. Others permit water and sometimes clear liquids. This is an example of a situation in which common policy and routine is NOT in accordance with evidence based care.

A large recent study from the UK confirms what birth professionals have long felt to be true–that light eating during labor does NOT raise the risk of complications.

Policies denying women solid foods during labor are often explained with the reasoning that there is a risk of “aspiration pneumonia” if you eat during labor (and then end up having a cesarean under general anesthesia). The researcher, Dr. Liu, says that this problem “did not occur.” He also stated that the UK Department of Health’s records show only one case of aspiration in two million births (the risk of complications of cesarean is considerably higher than that and that doesn’t stop US doctors from having a 31% national rate of cesareans!). 

Policies against eating during labor originated during the 1950’s and things have changed a good deal since then. As an ICAN representative stated,  “This new study will allow doctors to rest assured that eating helps rather than hinders the birth experience.”

 The excellent exhaustive research summary and review A Guide to Effective Care in Pregnancy & Childbirth (available for free download from Childbirth Connection), also supports light eating during labor, pointing out that not doing so leads to a risk of dehydration and/or ketosis. Withholding food or drink from women in labor is included in the Effective Care book’s table, “Forms of care unlikely to be beneficial.”