Some thoughts about a four-letter word

PAIN.

I hesitate to even write this post, because it gives pain a privileged position in childbirth. We all know how pain and birth are talked about: birth as the most excruciating pain a woman will ever endure, pain management in labor (a euphemism for drugs), getting a pain-free labor with hypnosis...

But now that I have been there done that, I feel the need to share my experience of pain. Not because it was awful or excruciating, but because it was one of many, many sensations that made up the entirety of labor.

Before my labor began, even before I became pregnant, I knew that I wanted to experience labor in its fullness. I wanted to feel every sensation, pleasant or not. I firmly believed—and still do—that by numbing myself to the painful parts of labor, I would also miss out on the bliss and the ecstasy as well. I wouldn’t be pain-free by taking drugs or having anesthesia; I would be sensation-free. I didn’t like that idea.

I wasn’t wedded to the idea that labor had to feel a certain way. I didn’t expect pain, but I also didn’t expect its absence. Honestly, I expected to feel a great many sensations as I labored, and I knew that pain might be one of them. I loved reading stories of painless births, ones that take a woman by surprise because she doesn’t realize she is in labor, or the ones where a woman experiences bliss and waves of pleasure. I listened to Marie Mongan’s Hypnobirthing CD and read her book. The CD was incredibly useful for relaxation during pregnancy and helping me sleep when nothing else could, but I resisted her assertion that if you relax the right way, you will not feel pain. I think that often is the case, but I didn’t want to be so dogmatic about my own labor and feel that I somehow failed if I experienced a sensation as painful.

My contractions felt like sharp, intense menstrual cramps, all entirely in the front of my abdomen close to my pubic bone. I can only say they were “like” menstrual cramps because cramps for me don’t come and go like contractions—they are a slow, dull, relentless ache, almost in my pelvic bones. The contractions became more intense and more painful as labor progressed. Pushing brought on a different kind of pain. I think the ferocity of the contractions and the uncontrollable urge to push made the sensations a bit more difficult to integrate. All I had to do during the labor contractions was relax and let everything happen, keeping my body totally loose. During pushing, however, I HAD to actively participate even though I sometimes didn’t want to, because it was so intense.

The funny thing about pain is that it fills any given space. It’s like a gas—no matter how small the amount, it will completely fill the volume it occupies. That’s why I hesitate to say something like “it was the worst pain I have ever felt.” Heck, even a paper cut, at the moment it happens, can be the worst pain ever!

The pain I felt in labor was clean and finite: as soon as it was over, it was over. Completely gone. I calculate that I spent far more time feeling pleasure during the rest periods, than I did feeling pain during the contractions. Except for a few short moments when I became discouraged during pushing, I never felt like I was suffering or in distress. Just very focused on the task ahead of me.

A few times during my labor, I was able to alter the sensations from being painful to pleasurable. During the early morning hours while I was leaning over the kitchen countertop and breathing deeply, I started smiling and making my face look blissful. Another time, soon before I started pushing, I said to myself mentally, “breathe in comfort, breathe in relaxation” (a phrase from the Hypnobirthing CDs). Both times, the pain altered itself instantly into a rushing kind of pleasure, kind of like the dizzy tingly feeling you get before you faint.

One of the best ways I have found to approach labor pain is with this acronym:

Progress
Anticipated
Intermittent
Normal

Labor pain indicates that your body is working. You know it will come and then it will disappear completely (unless you are having back labor because of a posterior presentation, but that is another story). It is not a signal that anything is injured; instead, it comes from muscles working incredibly hard and from tissues stretching and expanding—as they are meant to do.

Pain was one of many sensations I felt during labor. It was strong when it was present, but it did not dominate the experience. Almost all of the time I was able to integrate it without judgment. Instead of thinking oh no this hurts, I am suffering, make it stop, I was able to think this way: another contraction, the pain is building, inhale, exhale, sway my hips, the pain is ending, now I can rest. I had awareness of pain without labeling it as good or bad. It just was.

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Burn the male midwife!

A British midwife and PhD recently submitted an article to Evidence Based Midwifery, a publication of the Royal College of Midwives. Some of his viewpoints were featured in an article in The Observer. Its headline proclaimed: It's good for women to suffer the pain of a natural birth, says medical chief. The midwife argued that epidurals are overused and that having an unmedicated birth can be beneficial to women by helping them bond with their baby, preparing them for the demands of motherhood, and serving as a significant rite of passage. Instead of routinely offering epidurals, the midwife wrote, hospitals should encourage non-pharmaceutical forms of pain relief, such as yoga, hypnosis, and birthing pools. Any article discussing pain relief--whether epidurals are over- or under-utilized--is bound to be controversial. But this midwife's perspective has elicited an outpouring of what can only be described as mass hysteria.

Why? Because the midwife, Dr. Denis Walsh, is a man.

The outcry has been fierce and swift. Newspapers (mostly in the UK, Australia, and New Zealand) and bloggers quickly joined in the debate. Most simply repeated what The Observer reported, but with increasing levels of embellishment, outrage, and indignation. A sampling of headlines from various media reports about Dr. Walsh's paper:

The Mail Online's headline announced: Why mothers should put up with pain of childbirth - by a male expert in midwifery. A companion article in the same publication began with these words: "Obviously, it was a man who said it. A man who will never know the intense fury of a contraction, the hours of desperation or the waves of fear as a baby makes its painful way into the world," wrote Laura Kemp in I dare you to say that to a woman in labour.

Momlogic's headline asserted that "Midwife Says Childbirth SHOULD Be Painful." The first line of the article shouted (emphasis theirs): "When he pushes a baby out of HIS body, maybe we'll give a damn what he has to say!...Of course, this would be A GUY who says this ... a guy who has never had to go through the pain of childbirth himself!"

British midwife calls for end to pain relief during childbirth, says Australia's 3News. `

From the UK's Marie Claire: Male Midwife: Women Should Endure Labor Pains.

Medical News Today announced that More Women Should Endure Labour Pains Says Leading UK Midwife.

This is a classic case of telephone--each article reporting what another article said, each step away from the source becoming more extreme and distorted. For example, you'd think that Dr. Walsh were saying that no one should ever have the option of any pain relief and that all women should just suffer in agonizing pain. However, he did not say that at all. In fact, he strongly advocated the use of other techniques that reduce the pain of labor, including hypnosis, yoga, and water immersion. (Hydrotherapy in labor is the second-most effective form of pain relief, eclipsed only by the epidural, and was rated as the safest form of pain relief by Britain's National Institute for Health and Clinical Excellence.)

Even the original article in The Observer probably distorted Dr. Walsh's intended message. I have been interviewed multiple times for magazines, newspapers, and television. Most of the direct quotes attributed to me were, in fact, inaccurate. I never actually said those things verbatim. Instead, the people interviewing me made up quotations approximating what I said. In addition, the process of writing an article necessitates emphasizing some points and omitting others--further changing the interviewee's original message.

I doubt that any of the authors actually read Dr. Walsh's original article about "Epidural Culture." Why? Because it does not yet exist! If the authors and readers submitting comments had actually taken a moment to do some research, they would have discovered that his paper has not even been published yet! (It is currently undergoing peer review.) Nevertheless, many of the articles assume the article has been published, and that Dr. Walsh's quotes are taken from the article, because of the wording in The Observer:

He has set out his controversial views in an article for the journal Evidence Based Midwifery, which is published by the Royal College of Midwives (RCM). In a sharply worded critique of the rising popularity of pain-free labour, Walsh warns that normal birth is in danger of being "effectively anaesthetised by the epidural epidemic" in the NHS. A widespread "antipathy to childbirth pain" has emerged in the past 20 years and combined with increased patient rights and risk-averse doctors to create a situation where almost all hospitals now offer epidurals on demand, even if that is not in the mother's or baby's interests.

It sure sounds like those quotes are coming from the article, right? But they aren't, and the article doesn't yet exist.

On top of playing telephone, most of the commentary about Dr. Walsh's views suffers from a classic case of killing the messenger. Notice how quickly so many of the authors and bloggers and comments are quick to discredit his viewpoints, simply because he is a man and has therefore not given birth. Because if we can dismiss anything a male midwife says, simply because of his gender, then we surely must also discount any viewpoints on pain relief from male OBs. And we must also dismiss anything from any female midwives or OBs who have not had children. And, for that matter, any female birth attendants who have had a baby by cesarean--since they would not know what giving birth feels like, right? What we have is a reductio ad absurdum argument: if you have not given birth and experienced exactly what I felt, you have no right to have an opinion, research-based or not, about the value of labor pain.

There is a serious case of gender bias going on here. Not only is he male, he is a male midwife. Almost as weird as a male nurse. Note how many of the articles mentioned his gender. However, if the author had been a female midwife, they would not have emphasized her gender and mentioned it alongside her profession. I wonder if the response would have been as dismissive if it had been a male OB, rather than a male midwife, voicing the same ideas.

I also sense a lot of defensiveness about the use of pain relief, as if people feel threatened or personally attacked because this particular midwife feels epidurals are used too commonly and that there is value to feeling the sensations of labor. If having an epidural was the right choice for a woman, why the need to be defensive about it? (Besides the obvious reasons--1) he is a man and 2) most authors and readers were reacting to someone else's perception and interpretation of Dr. Walsh's message.)

More posts about Dr. Denis Walsh, Male Midwife:

• Village Midwife of Australia remarks that labor IS a rite of passage
• Lisa Barrett, another Australian midwife, writes about Denis Walsh and Andrew Lavender at Homebirth: Midwifery Mutiny.
• Bellies and Babies writes about Pain in Labor
• MedGuru reports that It’s good for women to undergo labour pain: Professor Denis Walsh
• The Times says: Pain in Childbirth. Professor says endure it!
• 'Embrace the pain' of birth, mums told, reports Northern Territory News of Australia

If you only have time to read one link, be sure to visit the commentary at Feminist Philosophers: A Brief Defense of My Current Hero, Denis Walsh. Here is an excerpt:

SO, big dumb MALE midwife versus women just trying to do the best they can to cope with horrible pain, right? No. Not at all. Denis Walsh has made it his mission to write about and try to put into practice good, well-designed midwifery and obstetric research, with a particular emphasis on respect for the woman as a dignified person in a highly vulnerable and difficult circumstance. I know this because–in preparation for a second delivery, of which I was formerly shitless on account of a *terrible* first–I happen to have recently read Walsh’s midwifery text Evidence-Based Care for Normal Labour and Birth. Here is a brief run-down of what I took from his text wrt epidurals:

* epidurals interfere with, slow, and generally throw off the body’s efforts at expelling the fetus, thus greatly increasing the instance of assisted delivery. (For those not in the know, “assisted delivery” means they slice into your genitals with a sharp knife and then shove heavy metal tongs up your vagina to yank the baby out. It is not fun, and even if it’s “simple” (as you’ll hear in the interview linked below), it is certainly not nice–nor are the lasting pain and disfigurement caused by it. And charmingly, in many instances of use (take my experience, for example) it doesn’t even seem to be medically indicated.)
* Midwives (a) have in some delivery ward contexts become so accustomed to routine intervention and pain relief that they’ve simply lost the ability to accurately judge ‘how it’s going’: they see a woman screaming in labour pain and think something’s gone wrong, when in fact she’s simply in labour. Because of this, midwives are quite often quick to try to “fix” the situation by offering epidural; (b) are sometimes simply not willing to take part in helping women to manage pain; in a nutshell, they simply don’t like putting up with screaming patients; and so they like for their patients to receive epidural as quickly as possible.
* Childbirth is a frightening experience, especially for women who aren’t well-educated about it, and as such, midwives tend to influence very heavily what decisions women make for themselves in childbirth.

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Let's talk about pain

With some of the buzz around this recent article Epidurals: Time to stop labouring over 'natural' childbirth, I thought I would add a few thoughts and mention some older blog posts worth revisiting.

Okay, first thing: the obstetric anesthesiologist quoted in the article discusses the "lucrative natural childbirth industry" and claims that "Natural childbirth has become a multimillion-dollar industry." First, we have to put this into perspective. He gave no sources for those figures, but I suspect he is referring to childbirth educators who work for organizations such as Bradley or Lamaze. Thing is, childbirth educators make no more or no less money if women take drugs during labor; their work occurs prenatally. If a woman declines pain medications during labor, no one profits. But if she accepts an epidural, a lot of people do: in particular, the hospital, the pharmaceutical company, and the anesthesiologist. I sense some anxiety from the author of Enjoy Your Labor over the viability of his profession if women choose natural childbirth. He has a very vested interest in encouraging as many women as possible to accept epidurals, because that, after all, is what pays his mortgage.

Second, he claims that "much of the information that women receive is incomplete or inaccurate." This phrase implies that natural childbirth advocates--whoever they might be--are the ones doing the withholding. I would argue that the opposite is more often the case; those with a vested interest (monetary or otherwise) in promoting or administering epidurals have an obligation to share all of the possible risks and side-effects of epidural anesthesia. (By the way, Dr. Sarah J. Buckley has written an excellent article reviewing the risks in Epidurals: Real Risks For Mother and Baby.) How often do women receive full informed consent about this procedure, meaning a thorough discussion of all risks, benefits, and alternatives? I do not know, and I would appreciate input on this.

Third, there's all this talk about the "natural childbirth industry" as if it is one unified conglomerate. Who exactly makes up this "industry?" Childbirth educators? Certainly childbirth educators discuss the risks and benefits of pain medications, as well as non-pharmaceutical alternatives, but that is only a small part of their job. Doulas? Not really, since doulas attend births in all settings and encourage the mother to make her own decisions. I really don't know who else might be part of this "lucrative industry" that he claims is profiting heavily from women's non-use of epidurals.

Last, the article itself was poorly written and poorly organized. The sections do not flow well together, and the transitions from one point of view to another were totally lacking. The article relied almost entirely on quotes or paraphrases from other authors, with little explanation or discussion of the ideas. The university rhetoric teacher in me gives it a thumbs-down.

Now, on to some of my old blog posts:

In a different approach to pain relief, I linked to Britain's National Institute for Health and Clinical Excellence, which recommended that "all expectant mothers should be offered a water birth for the safest form of pain relief." NICE found that birthing pools were the most effective non-pharmacological form of pain relief and second-most effective overall (with epidural anesthesia being the most effective but having more risks than water immersion).

In my Comments on To The Contrary, I briefly mentioned some of my own experiences of pain during labor. I wrote a long post about pain two weeks after Zari's birth called Some thoughts about a four-letter word.

In my review of Jennifer Block's Pushed, I ended with two quotes about the role that hospital policies play in creating pain. On the same topic, it's worth reading this recent blog post on NYC Moms about how epidurals are for tolerating the hospital; labor is the easy part.

Food for thought had some discussion about pain medications and whether or not they were pushed/encouraged by hospital staff. Several comments from blog readers on this topic.

In Labor and marathons, I examined the similarities between the two events and how attitude and beliefs greatly influence the way we experience and interpret them.

Speaking of marathons, I want to end with a plug for Elemental Mom's post Only One Word. She argued that we just don't have language adequate to describe the sensations of labor, so we use the word "pain" as a distant runner-up. I love how Laureen described labor pain as purchasing an endorphin rush! A quote from her post:

What we’re lacking is the linguistic differentiation, in two syllables or less, to say "pain that is the sign of pathology and illness and needs to be obliterated by any means possible" and "pain that is your body’s way of kicking in an endorphin payoff down the road."

Got that? I’m not enduring labor pain. I’m purchasing my endorphin rush, one sensation at a time.

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TENS and cesarean recovery

I checked out physical therapist Elizabeth Noble's Essential Exercises for the Childbearing Year last month. She wrote about using TENS for post-cesarean pain relief (p. 203):

TENS (Transcutaenous Electrical Nerve Stimulation)
This physical therapy modality works on the same principle as scratching an itch. Another message gets to your brain before the pain, traveling over nerves with faster transmission speed. Electrodes are taped above and below your incision. These electrodes are then connected to a hand-held unit with adjustable controls. You can choose the type and speed of electrical current to meet your needs. Patients who use TENS after any kind of abdominal surgery require less or no pain medication, an important advantage to breastfeeding mothers. The stimulation also reduces the incidence of paralytic ileus (intestinal distention and symptoms of obstruction). I also believe it helps to prevent the formation of a dead zone around the scar. A dead zone occurs from pain, disuse, and the mother’s reluctance to examine or palpate this area. The tissues are like dough, many women feel “cut off” from that part of the body, and nerves to the skin may indeed be injured and take many months to recover.

Another (older) book also mentioned TENS for post-cesarean recovery and pain relief. In Adrienne B. Lieberman's Easing Labor Pain, she wrote:

Transcutaneous electrical nerve stimulation (TENS), occasionally used to alleviate labor pain, also offers many benefits to the woman who is recovering from a cesarean delivery. Russsel Foley, TENS expert, comments, “Taking patients’ pain away with TENS gives them better mobility, and that’s important because the most traumatic thing to the body after an operation is immobilization. The longer a person is immobilized, the harder it is to recover.”

Using TENS can mean you’ll need fewer narcotic painkillers after your surgery. Indeed, a study published in Physical Therapy in 1986 showed that women who used TENS following cesarean birth used significantly less Demerol for pain relief. Narcotics such as Demerol, says Russel Foley, “suppress gastrointestinal motility, change respiration, and alter heart rate. If you remove the need for medication by using TENS, you can also remove the side effects of medications.”

If you use TENS for your post-cesarean recovery, the electrodes can be positioned immediately after suturing, and taped to your abdomen under the dressing. You’ll be taught to use the monitor in order to control the amount of electrical stimulation you receive. The monitor can be detached so that you can shower normally. TENS is usually used just for the first two post-cesarean days. (237)

A quick search about TENS and cesarean recovery led me to this small but promising study done last year in Iran: The Analgesic Effect of Transcutaneous Electrical Nerve Stimulation (TENS) on Caesarean Under Spinal Anaesthesia. The authors concluded that "TENS may be used as an effective, non invasive and non pharmacological approach for reducing post caesarian section pain with reduced use of analgesics. This might lead to better outcomes in pain control and facilitating development of bonding between mother and baby."

If you are planning to give birth in a hospital (or even if you aren't, in the event that you end up transferring), you might want to inquire beforehand about the availability of a TENS unit for either laboring or post-cesarean recovery. Ask the staff if they have ever used TENS for post-cesarean pain relief and if they would be willing to try it if you have a surgical birth.

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Sour grapes?

Another article about Gisele Bundchen's birth gives a few more details. From Supermodel Gisele Bundchen claims son Benjamin's birth 'didn't hurt in the slightest':

Four months after giving birth to son Benjamin, she has opened up about the eight-hour birth - saying it 'didn't hurt in the slightest'. Gisele gave birth in her bathtub at home in Boston with no pain relief with her mother, sports star husband Tom Brady and a midwife by her side.

"My delivery was in a bath tub, in water," said the 29-year-old. "I wanted to have a home birth. I wanted to be very aware and present during the birth...I didn't want to be drugged up. So I did a lot of preparation, I did yoga and meditation, so I managed to have a very tranquil birth at home."

Speaking to Brazilian TV channel Fantastico, she said: "It didn't hurt in the slightest. The whole time my mind was focused in each contraction on the thought 'my baby is closer to coming out.' It wasn’t like 'this is so painful.' So I transformed that intense feeling into a hope of seeing him."

Bundchen says her son didn't cry after being born and rested in her lap for a long time. "It's wonderful," she said. "Never in my life I thought I could love like this. You hear people talking about it, but you don't know until it happens to you. I couldn't be happier."

Poor Gisele. She had a lovely birth, one that she planned and prepared carefully for--and she gets ripped apart for talking about it. Commenters to this article call her a liar, an android, a robot. They call her brainless and dumb, or deceitful, or selfish and shallow, or overly competitive. All because giving birth was not a painful experience for her. Sour grapes, anyone?

Now I love my birth experiences. Pain was definitely a part of the experience, although not the dominant or defining aspect. I've written earlier about how I view pain and what giving birth feels like (great stuff in the comments sections, too!). I don't at all begrudge Gisele her painless birth, nor do I doubt that she is telling the truth. I know several women who have had births where pain really wasn't present at all (I'm not talking about painless births due to early epidurals--but unmedicated or "natural" births). Often they were using some form of hypnosis, such as Hypnobirthing or Hypnobabies. Several gave birth in out-of-hospital settings, but not all. The fact that I experienced moments of pain as part of giving birth doesn't make me doubt that Gisele didn't, nor does her experience evoke feelings of hostility, defensiveness, or anger in me.

Gisele's description of focusing the power and intensity of birth--"I transformed that intense feeling into a hope of seeing him," she remarked--reminds me of the video Birth Day. Naoli Vinaver Lopez, herself a midwife and mother of three, transformed the sensation of pain into one of "love bursting out of my womb" by focusing on her husband as she labored. I also recall an essay by Ingrid Bauer about "Birth as sheer pleasure" (from Midwifery Today Issue 68). Some excerpts:

With this second birth, I went into active labour very suddenly and without warning just after 3:00 a.m. I was taken aback by the intensity of the contractions. For some bizarre reason (fear!), I decided to time the contractions even though I hadn’t planned that and had no idea what the timing actually meant! They were five minutes, five minutes, then three minutes, three minutes, then two minutes, two minutes, progressing rapidly.

I didn’t realise how fast things were going and sank into fear mode. If these first six contractions were already this intense, how would I ever stand 10 more hours? After all I was an older mom, hadn’t had a baby in 12 years, and this was going to be hard! Immediately, my abdomen was gripped with incredible pain. I couldn’t stand straight. I bent over, grasped the sink and rolled and rocked and moaned with every contraction. Despite the intense pain, I was “coping” well.

But all of a sudden, I remembered. I realised that even as I was rocking and moaning with the contractions, part of me was actively resisting and holding back against the powerful life energy that was coursing through me. I was still split, hadn’t fully embraced or committed to that energy, and was being painfully pulled between the two choices. It became crystal clear to me in that moment that the only thing that was causing pain was not the strength of the birthing energy, but my fear and resistance to it. The more I resisted, the more it hurt.

I decided to completely move into that energy, as part of it, rather than against it or bravely alongside it. I had a good look at the next contraction. The words, “This is only sensation” came very clearly, out of nowhere, into my awareness. I decided I wanted to feel this sensation, not resist it, no matter what it was, no matter what it felt like. I wanted to be and feel alive, no matter what that might mean! I consciously opened my arms, heart, sex and body to it. I was willing to experience the very centre of it, now, in this very moment. And wow!

Forget about pain-free! In that moment, literally within seconds, the overwhelming pain was transformed into the most intense orgasmic pleasure. And I mean intense. Those contractions were powerful. Contractions came one upon the other with rarely more than 5-10 seconds between, and often less (not like my first birth where I slept between contractions!). I felt sometimes close to the edge of being overwhelmed and falling back into fear (have you ever been so happy that you’re afraid you can’t take any more and it’s going to end? It’s a bit like being at that edge).

But then I opened my mouth to sing and didn’t stop. I just melted right into that life force, flowing like an open channel through my body, out my mouth, out my sex, out my heart. I wish I had a tape recording because apparently I sang some incredibly beautiful melodies (“not like any birthing sounds I’ve ever heard,” said my good friend, who caught the last bit and has been to several home/unassisted births). I don’t remember what it sounded like (except one note); I just remember the feeling of the energy.

I felt everything within my body: the cervix opening, the baby moving down, the bones cracking apart slightly, his head emerging. No pain, no burning, just oh-so luscious, sexy, sensual, wet, alive, moving fullness. There was absolutely no pushing at all. I just kept breathing and singing and wasn’t aware of any contracting or bearing down in my uterus, just smooth movement. Just before he emerged, I instinctively arched way up and then lay forward again (I was on hands and knees), as it felt almost like he was moving “around a corner.”

Exactly two hours and 10 minutes after the very first twinge, he came out to the waist into his papa’s and my hands and paused there between contractions, opened his eyes, looked around and sang “Oh” on the exact same note I was toning. Then he whooshed out on the next contraction and I took him in my arms.

That birth changed so many things in me, showed me the true beauty and pleasure of Nature and birth, cracked my heart wide open. I can hardly read a single book on birth now — even the most progressive, alternative natural birth kind — and not think that somehow, something utterly vital is missing. Something nobody ever told me about. So much emphasis is on how to handle the physical pain. Nobody ever prepared me to simply fully embrace the sheer sensual pleasure of birth.

My parting thoughts? "It is an unfortunate part of human nature to envy those who climb above us and to pull them down literally or verbally or at least within our own critical and judgmental minds," Richard and Linda Eyre commented in an essay about motivating children through praise and positive reinforcement. Let's move beyond our impulse to deny other women's experiences when they are different from our own. Let's stop tearing each other down and instead celebrate those moments of intense joy and fulfillment.

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My experiences with birth hypnosis

Birth hypnosis, HypnoBirthing, Hypnobabies, Hypbirth, the Birth Relaxation Kit...

If you're at all part of the birth world, you've probably heard of one or more of these terms. I've had four pregnancies, four labors, and four babies all using some kind of hypnosis.

Basic idea of hypnosis for childbirth (in my words): the mind is extremely powerful and malleable. Through deep relaxation, conscious breathing, and visualization, you can reprogram yourself to respond positively to the sensations of labor.

How and when I listened to the hypnosis recordings:

For my first baby, I listened to the two hypnosis tracks provided with Marie Mongan's  Hypnobirthing book. I listened to one track every day for the last two months of pregnancy. I didn't have an mp3 player at the time, so I listened on my stereo system. I turned the track on early in my labor when I started having contractions. Once I was up and moving around the house, I turned it off.

For babies #2 and #3, I used the Hypnobabies Self-Study Program. You're supposed to listen to one of the hypnosis tracks, along with the birth affirmations track, daily starting at around 30 weeks. I ended up skipping the affirmations most days. I was busy enough with little children that I didn't have time for two sessions. I put the tracks on my mp3 player when I lay down in bed at night and usually "slept" through most of them, waking up at the end of the track. I listened for a few hours early on in both labors. But once things really started cooking, I was no longer interested. Well, more like I was too occupied with labor to focus on anything else!

For baby #4, I used the Birth Relaxation Kit, a complete birth hypnosis program. Like with my last two babies, I listened at night when going to bed. I listened a bit during early labor, but not once the work started in earnest.

I'd consider using hypnosis in labor a small added bonus. For me, the real value of hypnosis came during pregnancy. The daily deep relaxation was priceless, especially when I was dealing with severe sleep issues and the typical worries of pregnancy (will the baby be okay? what if _____ happens?). 

Does birth hypnosis work?

I'd answer with a qualified yes. Some hypnosis programs emphasize having a comfortable, pain-free birth. I was always a bit hesitant with those promises. I totally believe that some women do have pain-free, comfortable births through hypnosis. But I was also wary of trying to force my experience into a box (and then being disappointed when it didn't fit).

Rather than aiming for being pain-free or even comfortable, I wanted to embrace all the sensations of labor without judgement, to work through the process without fear, to feel everything and to fight nothing.

I don't know why some poeple can do hypnosis programs and feel no pain ("I only felt pressure," they often say, "really intense pressure but no pain"). Or why others like me feel all the sensations--good and bad, pain and pleasure, pressure and power. I theorize that it depends on where the hypnosis affects the nervous system.

Some women truly can "anesthetize" themselves and eliminate feelings of pain entirely. (I still wonder how they can do it, honestly, since there is no way I can imagine feeling the sensations of labor without pain being one of them.) But for them, hypnosis works here to filter, or perhaps the better word is "alter," the sensations of labor so that they are not experienced as pain or discomfort once they reach the brain. Like this:

For me, hypnosis doesn't control the sensations going into the brain. I feel and experience everything. The hypnosis kicks in at the other end, where the brain reacts and sends out signals. The hypnosis helps me experience labor without fighting or struggling against it. So instead of controlling what I feel, hypnosis helps me control how I react and interpret what I'm feeling. Like this:

Mothers using birth hypnosis are often, but not always, outwardly calm. I tend to remain quiet and focused during active labor, although I'm more vocal when I'm pushing. I don't think you need to act calm or quiet to be effectively hypnotized. Remember that hypnosis is really just very deep relaxation and meditation.You can be up, moving, and talking and still be in a hypnotic state.

Stay tuned for my thoughts on the Birth Relaxation Kit...

In the meantime, I want to hear about your experiences using birth hypnosis. Please share!
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Thoughts on birth plans

Desiree of Hitting My Stride recently asked about birth plans--should she write one? If so, what to put in it? Is it too presumptuous to plan for an event that includes a lot of unknowns and uncontrollable factors? (She has two rare blood clotting factors that make hospital birth a necessity and induction fairly likely if the baby doesn't come by 38-40 weeks.)

I was thinking about what I'd say in response, and my first thought was: let's back up a bit first. Before even thinking of writing a birth plan, or list of birth preferences, or whatever else you want to call it, you need to know what is routine practice at your specific hospital. The last thing you want to do is write up a birth plan full of things that are totally irrelevant at your hospital. That will make the staff laugh or roll their eyes or label you as a control freak.

So first off, before you even think of writing up a birth plan, head to your hospital and talk specifics with the L&D nurses. For example, if you really want immediate, uninterrupted skin-to-skin contact after the birth, ask the nurses how likely it is to happen. What about skin-to-skin after a cesarean? If the mom or baby needs additional attention after the birth? If something is not routine practice, ask them what you need to say or do to make it happen. Go through all of the things that really matter to you. Ask the nurses which things won't be an issue and which you'll need to clearly communicate ahead of time.

Some things will need advance planning, such as wireless and/or waterproof telemetry. Some hospitals have telemetry, while others do not. If you know you'll be having constant monitoring (for example, for an induction) but want to have more freedom of movement, ask about wireless monitoring now, while you're still pregnant. If they don't have it, insist they order it! Ask to speak to the person who is in charge of ordering equipment and see what you can do to ensure they have the proper equipment in time for your birth. Or let's say you want to have access to nitrous oxide (aka gas & air or laughing gas) or TENS units for pain relief. These are both rare in the United States, although quite common in other countries such as Great Britain. You'd definitely need to inquire about them in advance.

My next advice--which Desiree seems to have down already--is don't worry about including any of the little things that you shouldn't even be asking permission for. The don't ask, just do kind of things. Eating and drinking if you're hungry, moving and changing positions, music, lighting, unhooking yourself from the monitors to move/go to the bathroom/etc (especially if, like most women, you have no specific reason to be on constant monitoring). Just do these things and don't take any flak from the nursing staff. Make sure your birth partner knows about these things and can buffer you from the nursing staff if you deviate from their policies or routines.

A third suggestion would be having two separate plans: one for the hospital staff with your most important preferences, and a longer, more detailed one for your partner, husband, or support person. Write down all of the things you want your support person to remember for you, so you don't have to remind them when you're in the middle of labor. Things like keeping the room lighting low, keeping you hydrated, helping you into different positions, asking you if you've had enough time to make X or Y decision, reminding both you and the staff of your preferences.

Now let's get back to the birth plan for hospital staff. Once you've eliminated all of the things that are irrelevant to your specific hospital and/or provider, write down the most important things in the briefest possible way. Keep it short and easy to read. Use lots of bulleted points, rather than long, wordy sentences. Don't go into any long-winded preambles. When I say short, I mean short. If you can make it fit onto an index card, all the better. Here's an example of how to communicate your pain relief preferences:

Pain relief:
~ Do not offer or suggest pain medications. If I want something, I will ask.
~ Do not ask me to rate my level of pain; please make up a number if required for your charting.
~ Please offer or assist with non-pharmaceutical comfort measures (showers, warm baths, birth balls, movement, changing positions, etc).

Instead of going into detail over every separate procedure, think of writing a general directive to ensure you are giving full informed consent. Something like this:

Please ask for my permission before every procedure, examination, medication, or intervention (including vaginal exams, AROM, episiotomy, routine infant procedures, etc).  If it is not an emergency situation, ask if I have had enough time to consider my options and review the alternatives before consenting to the procedure. 

When you arrive at the hospital, you can request a nurse who has experience with unmedicated labors (if, like Desiree, this is important to you). Have your birth partner talk to the admitting nurse and say something like "She really wants to labor without pain medications and labor and push in upright positions. Could you assign us a nurse who would be excited to help make this happen?" They might be too overstaffed to meet your request, but they might also be able to arrange nursing assignments to give you a nurse who loves working with unmedicated moms. This doesn't mean you are locked into having a "natural birth," just that you'll have more support for your initial desire to labor without pain medications.

My final thought is that planning for birth is like preparing proactively for breastfeeding. There are the individual choices you make and have control over during pregnancy, such as provider or place of birth. There are the institutional protocols and provider preferences that will influence what happens to you during labor and birth. And then there are the unpredictable, uncontrollable events that may throw you a curveball during labor. Birth plans are primarily for the second category of events--navigating institutional routines and employee protocols that may or may not be what you want, and may or not be beneficial for your or your baby.

Birth plans also help ensure that you remain more in control over your individual, personal choices. Because if you really want an unmedicated birth, but the hospital staff and routines all push you towards having an epidural, you're going to have a hard time accomplishing your goal. Or if you want lots of uninterrupted skin-to-skin contact, but the hospital routinely takes babies to the warmer and only returns them after examining, weighing, bathing and swaddling, you'll probably find your arms empty after the birth. The birth plan itself does not ensure that your wishes will be followed. But it is a starting point for communicating what is most important to you. 

Labor and birth have unpredictable, uncontrollable elements. We cannot make these magically disappear simply by waving a birth plan around. But a lot of what happens to women during labor doesn't occur because of Mother Nature, but rather because of hospital routines, employee protocols, liability protection, and providers' preferences and training. This is where planning and preparation can make a difference.

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Delivery room wrestling match

In an article in the Omaha World-Herald about using alternative positions for labor and birth--aptly titled Stand and Deliver--one physician literally wrested an ambulating woman onto the delivery bed. Dr. Maureen Fleming is director of general obstetrics and gynecology at the Creighton University School of Medicine. Here's the story:

As for obstetricians preferring a more convenient position, Fleming said they, like midwives, are accustomed to strange positions and situations. She recalled a woman in so much pain that she angrily started to walk out of the hospital room. Fleming had to wrestle her back. “I almost fell on the bed with her because I had to throw her on the bed.”

The midwives interviewed for this article tended to be more supportive of alternate birth positions, including kneeling, standing, and squatting.

Alternative positions are by no means sweeping maternity units. The majority of births are done with epidural injections, which numb the lower body and make it virtually impossible for the woman to stand or squat. Nevertheless, some midwives and other delivery experts suggest that expectant mothers are more frequently considering delivering from some position other than the back. “I recommend women get out of bed all the time,” said Heather Ramsey, a certified nurse midwife at the Med Center.

Ramsey and other proponents of alternative positions say the benefits can include decreased pain, better blood circulation for the mother and baby and easier downward descent for the baby. Pain medications, they say, can make the mother and baby drowsy, which may impede the infant's ability to immediately breast-feed.

The two physicians interviewed for the article, on the other hand, viewed analgesics and epidural anesthesia as overwhelmingly positive:

Fleming and Pankratz, a board member with the Nebraska Medical Association, said pain medication and epidurals are fine. “We don't believe there's anything unnatural about alleviating pain in labor,” Fleming said. “My philosophy,” Pankratz said, “is technology is present to make our lives better.”

The article began with a woman who gave birth in a hospital standing up, one knee propped up on the bed. Rosalina Romero tried several different positions, finally finding one that alleviated the intensity:

Finally, she stood with her fists on the bed. The horrible pain dissipated and became more of a burning sensation, far more tolerable. “It's just what felt natural,” she said. She lifted one leg and her husband, Brent Vignery, held the leg up. The baby's head began to come out. She put a knee on the bed and kept one foot on the ground. Their baby, Dexter, emerged. “Gravity helped a lot,” she said.

In contrast, Dr. Fleming expressed her doubts that gravity helps the birth process:

Fleming said she doubted gravity played a role in delivery, as some proponents of standing or squatting believe. The opening of the cervix, or cervical os, holds the baby in, she said. “Babies don't just fall out,” she said.

My commentary:
Delivery room wrestling match = assault and battery
Does gravity cease to exist if you don't "believe" in it?

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Labor and marathons

Disclaimer: In case anyone feels inclined to post a huffy comment about how childbirth and marathon running are NOT the same in every respect, please read this. Of course they are not identical. Of course the analogy breaks down at a certain point. I think the biggest difference between birth and marathons is that birth is something within every woman's capability, while marathon running is admittedly an extreme endurance sport.

I’ve often wondered why we don’t approach pregnancy, labor, and birth like we do marathon running. Pregnant women encounter so much negativity and fear: your baby might be too big or too small. You might develop toxemia. You are gaining too much or too little weight. You might hemorrhage and die. Your pelvis might be too small. Your baby’s head might become trapped. Your baby might go into distress. You probably won’t be able to handle the pain so you should consider an epidural. You don’t get a medal for having an unmedicated birth. All that matters is a healthy baby anyway.

What if we were as pessimistic about marathon running as we are about childbirth? Here’s my imagined scenario for a hopeful marathon runner, Ann:

Ann was in reasonably good shape and could run several miles, although at a fairly slow pace. She ran cross-country in high school and enjoyed it, even though she was usually one of the last to finish. She was inspired by several friends who had recently run marathons and decided she’d prepare for one.

Ann started researching how to run a successful marathon. She wanted to find training schedules, nutritional requirements for runners, and advice on good running shoes. She went to her local public library, which had a shelf of books that focused on the risks of marathons. Most discussed in great detail the various injuries common to marathon runners and only included short segments about success stories. They warned that although marathons can be empowering, most people cannot successfully train for or complete them. The books also emphasized the tremendous amount of pain that marathon runners experience. Ann knew that certain injuries were possible and although she appreciated the information, she preferred to have more information about how to prevent the injuries in the first place through proper training, stretching, and nutrition. She also wanted to read books that motivated her and assumed success rather than failure.

She knew that there must be more useful information out there, so she pulled up a chair to the library’s computer. She waded through pages of results, but she finally stumbled upon a small but vocal community of marathon runners who had successfully completed the race and who raved about the experience. Their stories were generally ones of triumph, confidence, and exhilaration. They talked about the hours of mental and physical preparation, the extensive research they did into ensuring they were in top physical condition, and the ways to prevent common injuries such as shin splints or knee problems. They supported each other when a runner didn’t reach her desired time, or when physical problems forced her to drop out of the race. They cheered each other on as race day grew nearer.

Ann posted her training schedule around the house so she would see it every day. She decided to maintain a positive outlook, knowing that top athletes considered mental preparation as important as their physical training. She dedicated time every day to meditation and visualization. She imagined what it would feel like to line up, waiting for the gun to signal the beginning of the race. She visualized her heart beating strongly, her blood supplying oxygen to her muscles, her breath even and steady. She repeated positive affirmations to herself, such as “It will be exciting and hard at times but I know I can do it.”

A few weeks later, Ann’s training was going well. She had missed a few days, but usually accomplished her daily goals. While the running itself was sometimes tedious and uncomfortable, she loved how she felt afterwards. Ann mentioned to a friend that she was training for a marathon and was surprised when her friend told several horror stories of marathon runners who suffered lifelong injuries—even one about a runner who drank so much water that he died during the race. Ann replied that she had carefully researched both common and rare injuries and that she was sure that she could either prevent them, treat them herself, or seek help if something serious arose. Her friend said, “But how can you be sure? You might die of a heart attack while you are running—you’d have no way to know it’s going to happen until it is too late. It’s just not worth the risk.”

Ann’s family thought she was crazy. Shouldn’t she be doing something more useful with her time? What if something went wrong? What if during the race she is in too much pain and can’t finish—then how would she feel? Anne told her family that she had done her research and that it was an important goal. She asked that they either speak positively about her upcoming race, or that they refrain from saying anything at all.

Ann noticed that the media always focused on the sensational stories of marathon running turned ugly. When TV crews covered races, they showed runners limping along, looking like death warmed over. They usually interviewed runners who had to drop out, giving them several minutes to tell their stories. Then, almost as an afterthought, they would give 30 seconds to a successful runner who looked exhilarated, if a bit tired and sweaty. Of course, after that runner was done speaking, the TV host would remind the audience that most people cannot complete marathons and that it was best not to get your hopes up. Good grief, Ann thought. I know plenty of people who have completed the race without dying or breaking a leg or permanently injuring themselves.

Somehow—maybe it was when she ordered a few pairs of her favorite running shoes—marathon support companies got hold of Ann’s address. Almost every day her mailbox had a new glossy ad for “pain-free, effortless marathons.” One company’s slogan was: We do all the work—you just come along for the ridetm. Inside the brochure, Ann learned that:

Marathons are a lot of work. The pain is excruciating. The risks of running so many miles are numerous. Why suffer when you can do it the Pain-Fretm way? For only 12 monthly installments of $199 each, you can finish your marathon in comfort and style in our patented Pain-Fre(tm) motorized vehicle. Our chauffeur will personally pick you up as soon as you feel too much pain. Once you are settled in your EZE-Ridetm seat, you will enjoy the view in comfort and luxury as you are driven to the finish line. You will receive a complimentary photo of you crossing the finish line on foot. Beverages not included. Runners will be assessed a $10/mile fee for any miles they run themselves. The fee is waived if you take the EZE-Ridetm in the first 5 miles. Due to liability concerns, rides are not available the first 4 miles or after mile 23.

Ann stacked these fliers beside her fireplace. After her long runs on Saturday, she’d run a hot bath, start a fire, and toss the fliers into the flames, watching the edges curl and twist. She imagined all of her fears melting away with those glossy advertisements.

Ann’s training continued. She enjoyed her changing body—seeing her leg muscles become more toned, noticing the articulations of each muscle group. Preparing for the race also gave Ann a heightened appreciation for good, nutritious food. Her body craved proteins, fresh fruits and vegetables, and complex carbohydrates. She ate sweets every once in a while but no longer enjoyed them.

Several months into her training, Ann heard of a disturbing new trend in marathon running: elective bone breaking or EBB. She knew that stress fractures were a common injury among runners, not to mention the rare but drastic broken bones from accidental falls. Apparently some people were advocating a new “preventive treatment,” which consisted of wearing bone fracture monitors while running. The monitors were touted for being able to predict bone fractures. Using information from the monitors, surgeons could then carefully finish breaking the bone (to ensure a clean, even break) and repair it in a controlled setting. The monitors were quite heavy and occasionally caused runners to fall and suffer extensive injuries. However, they were the hot new thing in running, touted as “every runner’s safety net.” One surgeon promoted the new technology as making the leg bones “better than new.” Has the world gone mad? Ann wondered. Why anyone would choose to have their bones broken before a serious problem even developed was beyond her. Fliers started arriving in her mailbox describing EBB. Ann had to smile when one company named itself EBB—Even Better Bones.

As race day grew near, Ann experienced a mixture of confidence and trepidation. She knew she had prepared thoroughly for the race, but she had never run 26 miles before. She decided that if something “went wrong” during the race and kept her from finishing, she would accept it calmly, knowing that she had done everything to ensure success. She continued her daily visualizations, imagining how empowering it would be to finish. The race would end in a beautiful river valley. Ann often swam in the river and knew that the cool water would feel incredible after the race. She kept this image in her mind: lying on her back floating in the clear water, her body suspended between water and sky.

On race day, Ann was surprised how crowded it was around the registration tents. There were almost as many marathon support companies as there were runners. She talked to a seasoned runner who warned her that it was just as bad even when the running began. Motorcyclists would drive alongside runners, asking them how much pain they were in, if they would like to drop out. Bystanders would hold signs saying “It’s never too late to give up.” “Drop out or drop dead.” “You don’t get a medal for finishing.”

One of Ann’s running partners, who had finished her first marathon a year ago, handed Ann a package while they were standing in line to register. It was a t-shirt with the slogan Drug-Free Zone. “You’ll need it,” her friend said, “especially around mile 22 where the race’s sponsors are handing out morphine pills. They know better to stay away from people with these shirts on, otherwise they’ll get an earful and the occasional well-aimed punch.” Ann grinned.

While she stretched, she turned inward, visualizing the stages of the race and repeating her affirmations. I can do it. I am strong. I am ready.

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Alternative Modalities For Turning the Breech Baby: Heads Up! Breech Conference

Day 3 

Alternative Modalities for turning the breech baby

Marie Julia Guittier: Hypnosis for pain control during ECV
Marie Julia, a midwife & PhD candidate from Switzerland, led a study looking at hypnosis for controlling pain associated with ECV. From an earlier study, they found most women would recommend ECV, but many found the pain to be severe (27%) or excruciating (4%). She and her research partners wanted to know if hypnosis can reduce pain during ECV. They compared 122 standard care women with 63 having hypnosis during the ECV. They didn’t observe any statistically significant differences in women’s perceptions of pain. Success rates did not improve with the hypnosis group. Physicians had mixed evaluations of hypnosis; most (72%) thought hypnosis facilitated the ECV, although some did not.

Lindsey Vick: Hypnosis to turn breech babies
Lindsey Vick is a hypnotherapist and Reiki practitioner from Virginia. She referred to a study by L.E. Mehl examining using hypnosis to turn breech babies. There were 100 women in the hypnosis group and 100 women in the control group, matched for obstetrical & sociodemographic characteristics. Women in the study were between 37-40 weeks gestation. 81% of breech babies in the hypnosis group turned, vs 48% of comparison group. She started collecting data on women whose breech babies she was encouraging to turn using hypnosis. For more information, see Mehl LE. Hypnosis and conversion of the breech to the vertex presentation. Arch Fam Med. 3.10 (Oct 1994): 881-7.

JoseLo Gutierrez: Moxibustion
JoseLo is an acupuncturist in the DC area. He spoke about moxibustion for turning a breech baby. It can be used on all toes, but the little toe is the most effective. It can also be combined with massage, essential oils, and hypnosis.

Nancy Salgueiro: Chiropractic to prevent & turn breech presentations
Nancy is a prenatal and pediatric chiropractor in Ontario and is Webster’s certified. She briefly explained the main approach & goals of chiropractic care: to ensure that the brain is communicating effectively with the body via the nervous system. She then discussed the bio-mechanical connections (ligaments) between the uterus and the pelvis. If there are misalignments in the pelvis, the ligaments will pull on the uterus and not give the baby as much space to grow, develop, and maneuver. Webster’s Technique is a chiropractic technique that can be used for anyone. For pregnant women, it’s often used for helping a breech baby turn by adjusting the sacrum and by relaxing the round ligaments in the front of the uterus. It involves no direct manipulation on the baby.

She referred to a retrospective study in the Journal of Manipulative and Physiological Therapeutics that found Webster's technique effective in helping breech presentations turn. (I think that this study has a lot of methodological flaws; I'd like to see a better designed prospective study with matched control groups. On the other hand, chiropractic care is unlikely to cause harm, so the only real downfalls of trying Webster's during pregnancy is the cost.)

Nancy recommends starting Webster’s as early as 34 weeks to have time to get the pelvis balanced. Don’t put it off till the last minute. You can also do this before an ECV to keep the baby from flipping back to breech after it’s turned.

Adrienne Caldwell, Massage Therapy
Adrienne is a bodyworker and massage therapist certified to work with pregnant and postpartum women. After her first baby was breech, she started focusing on helping women with malpositioned babies. She agrees with Nancy to start early and ensure you have a balanced, dynamic body.

My thoughts on this session: 
Women with breech babies are highly motivated--often desperate--to encourage their babies to turn. I've heard numerous stories of women who tried everything to turn their breech baby: inversions, handstands or flips in a pool, ice packs on the abdomen, music played near the pubic bone, knee-chest positioning, chiropractic, hypnosis, moxibustion, ECV, and more. The evidence for some of these modalities is weak. On the other hand, these techniques are unlikely to cause harm. I'd love to see vaginal breech birth a real option for all women, but in the meantime I'd also like to see more quality research on what really works to turn breech babies. With vaginal breech birth being out of reach of most North American women, turning the breech baby is often the last chance to have a vaginal birth.

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Birth Around the World: A Tale of Two Births in Canada

Joanne is a software engineer in Ontario, Canada. Her first child was born in 2007 at Kitchener Ontario's Grand River Hospital, which sees about 4,000 births per year. She chose a midwife-attended homebirth in 2010. This post is lengthy, but it’s really two birth stories in one! It shows two contrasting styles of maternity care available in present-day Canada.

When I became pregnant with my first child in 2007, I had no reasons to distrust the latest technology and knowledge of the Western medical establishment. My family doctor referred me to an obstetrician, who are in short supply in my area, so I “got who I got.” My pregnancy was highly normal and my care was fine (sparse but sufficient) up until the time my due date came and passed, and I waited... waited... waited to go into labour. My OB scheduled me for an induction at +10 days (a Friday--coincidence?) without discussion. I was worried about how I’d be able to handle an induced labour and thus mentally felt increasingly desperate as the fateful day approached.

The night before, I awoke with increasingly strong and regular contractions which I was pretty sure was finally it. When I arrived at hospital the next morning on schedule, the nurses confirmed I was 4 cm dilated and cleared me for continuing since I was in labour already. At noon my OB showed up and was quite annoyed with the nurses (and me) for not following his induction orders.

"We've got to get this baby out now."

"Why?"

"Because it's been long enough."

"I'm concerned about the pain with Pitocin contractions."

"It's called LABOUR for a reason; it's going to be painful. Look, you don't have to do it but I highly recommend it."

Seeing as I was contracting strongly, in pain, I wasn't expecting this, and I didn't have experience going against my primary care provider, I reluctantly agreed to let him break my water and start the Pitocin drip. Of course then I required continuous fetal monitoring, which made every little movement quite an event. The contractions quickly grew stronger, stronger, and more painful. I lasted another 4 hours and with such pain, the tension in my body hadn't actually let me progress past 4 cm. Discouraged, I agreed to an epidural. Admittedly it was a tremendous relief and I wanted to hug the anesthesiologist. Now that I could relax some, I actually progressed to 10 cm in a couple of hours. I also found out something I didn't know about epidurals--i.e. they don't provide total pain relief, at least not for me. Much of the time I could feel most of one side of my body, and the nurse would regularly have to call for permission to top it up.

Naturally I was confined to the bed, so I couldn't move around to deal with the pain. So pushing HURT. I was a good pusher and the baby descended steadily. At some point, the head nurse came in to say "she's got to stop pushing." It turns out (since it was now Friday evening) there was only one OB on the floor and she was busy performing an emergency C-section. And of course, my baby couldn't be born without a doc present. So they turned the Pitocin and lights off and rolled me on my side. What utter agony--I thought my body was going to push out the baby whether we were ready or not!!

There was some meconium in the fluid by this point (likely from the stress) although we could "hear" on the fetal monitor that baby's heartbeat was still reacting well. I was whimpering and at this point my partner secretly believed I was headed for a C-section too. He whispered to me "think of the other family" and I tried to. But eventually the OB and staff appeared, and another 2 pushes, and Alice was out. What relief--I simply cried tears of joy and relief.

The pediatrics team pumped the meconium out of baby’s stomach and luckily she was fine to stay in the room with me. So, in the end, despite all the "help" from the medical establishment, my body did what it was supposed to and I pushed my baby out. Looking back now, I realize I was probably lucky: this combination of Pitocin, epidural, and baby-stress can doom many a woman to an unwanted C-section.

I learned a few more things. I bled heavily after this birth and became anemic.... I learned later this can be a side effect of all the interventions. My tear/episiotomy site became infected, and I can’t rule out the possibility that the cause was from being in a hospital. But: my birth went well, didn't it? I had a healthy 8 lb. 10 oz. baby, delivered vaginally, no NICU visit, and all the nurses were really nice and helpful with breastfeeding. So, I should be satisfied, right? Right?? I had myself convinced for a while.

When I became pregnant with my second child I knew I wanted to try something different for care, so I called a local office of registered midwives. At first, I assumed I would go to the hospital again for delivery because that was just what people did. After processing some of the materials in the lending library, to our surprise, my partner and I independently came to the conclusion that we wanted to try a homebirth. Some of the stories about actively-managed labour with OBs in a hospital setting were simply eye-opening--this is exactly what had happened to us!! I don't know if we would have believed them had we not gone through the experience, but we had. So all of a sudden we were committed to a different kind of birth.

homebirth by reading what natural childbirth subjectively feels like. All these stories, including Rixa’s own birth stories, helped me overcome the knowledge deficit and gain confidence in my body's own ability to give birth naturally. I drank these up in my quest to "reverse" society's notion that childbirth is necessarily a medical event to be managed medically.

So, my second due date came and went with no baby in sight. Even with a midwife supportive of natural birth at home, her guidelines dictate repeated non-stress tests and ultrasounds to check on an overdue baby, as well as a "plan" for what would happen should two weeks past due date come and go. I was starting to feel increasingly desperate again as I saw my dream for a simple homebirth, at risk.

But, eventually at +10 days (again) those pesky prodromal labour contractions finally (finally!) became strong and regular enough to push out my baby. I laboured quietly at night in my bed from 2:00-6:00 a.m. which was nice actually--I could relax sleepily between contractions, which I knew was important for dilation. It was just so great knowing I didn't have to deal with going anywhere. By 6:00 am contractions were too difficult to lay through so I woke up my partner and told him it was time to call our midwife. She took her time getting ready and arrived at 8:30 am to find me 6-7 cm dilated ("and your body did it all on its own," she encouraged me). I was anxiously awaiting her arrival so I could get in the bath tub, post cervix check, for a change of pace.

I laboured alone as the others got the bed ready and brought in all the midwife's equipment. I got on all fours for each contraction (couldn't have done that in the hospital!) and actually found a semi-sitting position that was comfortable for relaxing in between. (I found that was key for me in both labours--I felt a lot of pain in between contractions if I couldn't find a good resting position, and those were elusive.)

I was off in labourland when Nicole came rushing in with "do you feel like you need to push?" Apparently my vocalizations had changed to what they often sound like when the baby is descending during second stage. It was all involuntary, which was awesome--my body was doing it all and I was just along for the ride!! My water spontaneously broke with thankfully only a bit of vernix to see. After 2-3 pushes on my hands and knees (still in the tub--not my midwife's idea of a convenient position but I wasn't willing to move anywhere!), Claire was born, nuchal hand and all. Finally I understood what I had read about it being a relief to push--on my hands and knees, it did feel better to push, almost like applying counterpressure to the contraction. (This was a definite contrast from being confined on my back in the hospital.) I didn't feel a ring of fire or any tearing, although I did receive a second-degree tear again. In fact, comparing the two births, I would say the pain levels were similar, although the first one was with an epidural and the second was obviously much shorter in duration.

It was 9:30 a.m. by this point--all the birthing and emergency equipment was barely in from the car and the backup midwives hadn't even had time to arrive yet. The tub had had to be drained (since it wasn't deep enough for a water birth, unplanned anyway) so I knelt on the floor of the empty wet tub, clutching my slippery newborn. I couldn't believe it had really happened!! A birth at home, just the way we had planned. I cut the cord myself.

Out of the tub and back to the bed for the delivery of the placenta, stitches, and initiating breastfeeding. Another healthy girl, 8 lbs 11 oz. So THAT is what birth is supposed to be like! What a privilege to have been able to experience a safe, natural childbirth at home. This is an experience I would wish for more women. It was so perfect and meaningful and to this day it’s still hard to believe it actually happened all the way we planned!! It was an empowering achievement in the way that my first birth, amazing in its own way since it was my first, just wasn't.

So yes, I join the ranks of moms who had one undesirable hospital birth experience and, as a result, experienced a beautiful homebirth subsequently. 2-5+ years ago, I would have never believed I’d be one of these women!! I try to not be judgmental of other people's birth choices, but now I encourage others to at least call a midwife early in their pregnancy to give themselves some birth choices. I remember my grad school supervisor telling me that if you knew at the beginning what you had learned by the end, it wouldn’t have been a learning and growing journey.... It’s not an end by any means, but the beginning to parenting my two girls!

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Birth Relaxation Kit: a complete birth hypnosis program

On last month's post about my experiences using birth hypnosis, I mentioned that I used the Birth Relaxation Kit during Ivy's pregnancy and birth. The company's founders, a husband-wife team of certified hypnotherapists, generously donated the program for me to test out and review.

Dr. Mavi Gupta, a board-certified physician and hypnotherapist, created the Birth Relaxation Kit along with her husband Jeremy Dyen, a musician and hypnotherapist. They combined their medical, musical, and hypnosis training to create an effective, affordable birth hypnosis program.

When Mavi was pregnant with her first baby, she had originally planned a hospital birth with an epidural. However, exposure to birth hynposis helped her and Jeremy look into other options, and they ultimately decided to have a home birth with a midwife. She writes:

On February 7th, in the middle of winter, our daughter Anjali was born at home with our midwives and doula in attendance. The birth of our daughter turned out to be a beautiful, blissful and amazing experience.  It was the most intense experience of my life, yet I did not experience pain. I birthed Anjali on the day I envisioned and labored at the time I had envisioned as well, in the peacefulness and privacy of my own home. We felt truly blessed.

After the birth, my husband Jeremy and I became inspired to train in hypnosis so that we could develop our own hypnobirthing methods and empower women who want to have a natural birth process without fear.  We each became certified in hypnosis, accredited by the International Certification Board Of Clinical Hypnotherapy (ICBCH).  Our continued work in this field combined with the feedback we have received over the years help us continually refine our program.

Unlike most other hypnobirthing programs, we offer extensive experience in medicine and music in addition to hypnotherapy. I am a board certified physician with extensive pain training and Jeremy has over 20 years experience composing music for meditation and yoga. We have blended this experience along with our personal experience using these techniques to bring you a quality program that will change your life.

The Birth Relaxation Kit is a complete birth hypnosis program and comes in three different packages: Basic ($49), Plus ($79), and Deluxe ($499).

The Basic package has everything you need to learn and practice hypnosis techniques for your labor and birth.

If you'd like personalized one-on-one support, you can order the Deluxe package ($499). It includes all the materials from the Plus package, as well as a personalized hypnosis mp3, 2 phone consultations, and 2 phone or Skype hypnosis sessions.

I reviewed the Plus package while it was in the final stages of development, so I received everything except the sleep and postpartum mp3s.

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I highly recommend the Birth Relaxation Kit. Mavi narrated all of the hypnosis tracks, and her voice was soothing and calming. (Sometimes the narrator of the Hypnobabies program got on my nerves, so I was really picky when testing out the BRK).

Jeremy composed all of the music for the BRK. I'm a trained musician, and I cannot focus on anything else if the background music is too loud. Fortunately, the Birth Relaxation Kit's music was at the perfect volume: audible but never dominant or distracting. I sensed rather than heard the music when Mavi was speaking. Exactly how it should be.

I found the Birth Relaxation Kit incredibly relaxing during pregnancy. I've used hypnosis for all my labors during the early stages. However, the main value of hypnosis, for me, came in the daily deep relaxation during the final months of pregnancy. Hypnosis pulled me through the normal worries of pregnancy, terrible bouts of sleeplessness, and anxiety over various concerns (Dio's breech presentation, possible GD during Inga's pregnancy, etc.).

If you are looking for an affordable alternative to hypnosis classes or self-study programs such as Hypnobabies, the Birth Relaxation Kit is exactly what you need. 

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I've been reflecting on Ivy's birth. Every new detail I remember leads me to suspect that she was posterior the entire labor and for most of pushing. I never felt the amazing, pleasurable high between contractions that I was used to experiencing from my three previous labors. I could tell that the endorphins and other hormones were still there, but they manifested as dizziness rather than as "la-la-ahhhhhh" goodness. I never felt a complete break between contractions. The intensity and pain lessened, but never faded away entirely. I also had constant rectal pressure for most of my labor.

Ivy's labor was definitely my most challenging, although not the longest or the shortest. I wonder how much more intense the birth might have been, had I not done daily hypnosis sessions with the Birth Relaxation Kit.

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To end the review, I want to include some of my correspondence with Jeremy. We were discussing our motivations for using hypnosis. I mentioned that my main goal wasn't to avoid pain; it was to embrace every sensation without judgment. He responded:

That you touch on the fact that your goal was not to avoid pain or have a "comfortable" birth, and that those goals are contrived, is so honest....I love that you want to "let birth be what it will be" and "to accept every sensation without judgment, fear or anxiety." I think undoing the fear and anxiety are the most important elements of our program (and, if I may speak for Madhavi, my wife, her birth experience). But to say you "accept every sensation without judgment, fear or anxiety," is so eloquent and speaks directly to birthing itself, not just the fear and anxiety that is felt during pregnancy.

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The Birth Relaxation Kit is available as an instant download here.

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Get off your back: references

This is a collection of references about maternal positioning during labor and birth. It's from the endnotes of Jock Doubleday's book Spontaneous Creation. Bold text is the original body text, and the plain text are his references.

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"Except for being hanged by the feet, the supine position is the worst conceivable position for labor and delivery." (Dr. Roberto Caldeyro-Barcia, The Family Practice News, 1975:11) in Laura Kaplan Shanley, Unassisted Childbirth, 15)

Being hanged by the feet may in fact present considerable advantages over lying on one's back. No studies have been performed. But a number of trials do suggest that upright positions give greater advantages in childbirth than do backlying positions. See, for instance, Allahbadia, G.N., and P.R. Vaidya, "Why deliver in the supine position?" Aust NZ J Obstet Gynaecol 32(2) (1992):104-106; Bhardwaj, N., J.A. Kukade, S. Patil, and S. Bhardwaj, "Randomised controlled trial on modified squatting position of delivery," Indian J Maternal and Child Health 6(2) (1995):33-39; Chen, S.Z., K. Aisaka, H. Mori, and T. Kigawa, "Effects of sitting position on uterine activity during labor," Obstet Gynecol 79 (1987):67-73; Liddell, H.S. and P.R. Fisher, "The birthing chair in the second stage of labour," Aus NZ J Obstet Gynaecol 25 (1985):65-68; Gardosi, J., S. Sylvester, and C.B. Lynch, "Alternative positions in the second stage of labour: a randomized controlled trial," Br J Obstet Gynaecol 96 (1989a):1290-1296; Gardosi, J., N. Hutson, and C.B. Lynch, "Randomised, controlled trial of squatting in the second stage of labour," Lancet 2 (1989b):74-77. See also Golay, J., et al., "The squatting position for the second stage of labor: effects on labor and maternal ad fetal well-being," Birth 20(2) (June 1993):73-78.

Pam England and Rob Horowitz write: "When a mother having back labor lies on her back, the pain becomes unbearable as the [back of the] baby's head pushes hard against her sacrum during contractions. Lying flat on her back will not only slow (or stop) cervical dilation, but may also prevent the rotation of the baby's head to a face-down position. This is one cause of "posterior arrest," which doctors may try to correct with pitocin, epidurals, forceps or a Cesarean birth. . . . Avoid the lithotomy position. This unnatural position is advantageous only to the doctor. . . . Stirrups also may cause painful cramping, numbness, or blood clots in the legs. In addition, some women experience this position as degrading, vulnerable and powerless." (Birthing from Within, 143, 145)

Janet Isaacs Ashford writes: "According to the controlled clinical trials surveyed by Enkin, Keirse, and Chalmers, lying down on the back and sitting during labor are associated with reduced blood flow to the uterus, resulting in contractions that are less effective and more frequent. Lying on the side or standing up improves blood flow and the efficiency of contractions. In addition, women who are upright or lying on their sides have shorter labors and use less narcotic analgesia, epidural anesthesia, and oxytocin augmentation than those who are supine (Roberts, 1989). Many hospitals now allow women to walk and assume comfortable positions during labor, though the use of continuous electronic fetal monitoring can restrict the mother's mobility. . . . Enkin, Keirse, and Chalmers also found that use of an upright posture when the mother is pushing shortens the length of second-stage labor. . . . Babies born to women in upright postures have fewer abnormal hear rate patterns and less chance of low Apgar scores (Sleep, Roberts, and Chalmers, 1989). Women prefer the upright posture for birth and report less pain and backache than in the supine posture. . . . The use of a squatting posture for birth has been shown to increase intra-abdominal pressure and also increase the sagittal diameter of the pelvic outlet (Davies and Renning, 1964; Borell and Fernstrom, 1967; Russell, 1982). Both factors can contribute to a shorter, more effective labor. However, researchers note that Western women are not accustomed to assuming a squatting posture (for defecation or resting, for example) and many find it difficult to assume this position for birth. Conventional maternity wards are often equipped with labor beds and delivery tables that encourage or enforce the supine posture." ("Posture for Labor and Birth," The Encyclopedia of Childbearing, Barbara K. Rothman, ed., 314). See also Golay, J., et al., "The squatting position for the second stage of labor: effects on labor and maternal ad fetal well-being," Birth 20(2) (June 1993):73-78.

For information on the squatting position for birth, see Russell, J.G., "The rationale of primitive delivery positions," Br J Obstet Gynaecol 89 (September 1982):712-715; McKay, S., "Squatting: an alternate position for the second stage of labor," The American Journal of Maternal/Child Nursing 9 (May/June 1984):181-183. See also Golay, J., et al., "The squatting position for the second stage of labor: effects on labor and maternal ad fetal well-being," Birth 20(2) (June 1993):73-78. See also Robbie E. Davis-Floyd, Birth as an American Rite of Passage, 86-87.

When you endeavor to give birth on your back, your heavy uterus compresses the major maternal blood vessels (Bienarz, J., et al., "Aortocaval compression by the uterus in late human pregnancy: II. An arteriographic study," Am J Obstet Gynecol, 100 (1968):203; Goodlin, R.C., "Aortocaval compression during cesarean section: a cause of newborn depression," Obstet Gynecol 37 (1971):702; Humphrey, M., et al., "The influence of maternal posture at birth on the fetus," J Obstet Gynaecol Br Commonwealth 80 (9173):1075 in Yvonne Brackbill, et al., Birth Trap, 13)

...interfering with circulation and decreasing blood pressure (Bienarz, J., et al., "Aortocaval compression by the uterus in late human pregnancy: II. An arteriographic study," Am J Obstet Gynecol, 100 (1968):203; Goodlin, R.C., "Aortocaval compression during cesarean section: a cause of newborn depression," Obstet Gynecol 37 (1971):702; Humphrey, M., et al., "The influence of maternal posture at birth on the fetus," J Obstet Gynaecol Br Commonwealth 80 (9173):1075 in Yvonne Brackbill, et al., Birth Trap, 13; see also Flowers, C., Obstetric Analgesia and Anesthesia (New York: Hoeber, Harper & Row, 1967); James, L.S., "The effects of pain relief for labor and delivery on the fetus and newborn," Anesthesiology 21 (1960):405-430; Blankfield, A., "The optimum position for childbirth," Med J Aust 2 (1965):666-668 in Doris Haire, The Cultural Warping of Childbirth, 17)

...increases the possibility of fetal distress (Flynn, A.M. et al., "Ambulation in labour," Br Med J 26 (1978):591; Humphrey, M., et al., "The influence of maternal posture at birth on the fetus," J Obstet Gynaecol Br Commonwealth 80 (1973):1075 in Yvonne Brackbill, et al., Birth Trap, 13. See also Laura Kaplan Shanley, Unassisted Childbirth, 24. See also Lumley, J., "Antepartum fetal heart rate tests and induction of labour," in Young, D., ed., "Obstetrical intervention and technology in the 1980s," Women's Health 7 (1982):9.)

Upright birthing positions are associated with more intense and more efficient contractions (See Marjorie Tew, Safer Childbirth? A Critical History of Maternity Care, 33; Chan, D.P.C., "Positions during labour," Br Med J 1 (1963):100-102; Flynn, A.M. et al., "Ambulation in labour," Br Med J 26 (1978):591; McManus, T.J. and A.A. Calder, "Upright posture and the efficiency of labour," Lancet 1 (1978):72-74; Diaz, A.G., R. Schwarcz, R. Fescina, and R. Caldeyro-Barcia, "Vertical position during the first stage of the course of labor, and neonatal outcome," Eur J Obstet Gynecol Reprod Biol 11 (1980):1-7; Williams, R.M., M.H. Thorn, J.W.W. Studd, "A study of the benefits and acceptability of ambulation in spontaneous labour," Br J Obstet Gynaecol 87 (1980):122-126; Hemminki, E. and S. Saarikoski, "Ambulation and delayed amniotomy in the first stage of labor," Eur J Obstet Gynecol Reprod Biol 15 (1983):129-139; Melzack, R., E. Belanger, and R. Lacroix, "Labor pain, effect of maternal position on front and back pain," J Pain symptom Manegem 6 (1991):476-480 in World Health Organization, Care in Normal Birth, 1999)

Elizabeth Noble writes: "Squatting, while uncomfortable for most people without prior practice, offers one of the most functional positions for birth. According to studies in Sweden by Dr. Christian Ehrstrom, when a mother squats the pelvic outlet is at its widest, increased by one to two centimeters. The pelvis is completely tilted to align with the spine, making the most curved passage for the baby's descent. The contraction of the abdominal muscles is very efficient in squatting as they are in a shortened, middle position of their range. Not only does gravity provide additional force from above, but there is no counterforce from below. The vagina becomes shorter and wider, and less effort is required by the mother to open up and let the baby out at her own pace. During crowning of the baby's head, there is an equal stretch all around the perineum, so that this muscular membranous "cuff" is least likely to tear . . . Women who squat for birth can generally deliver their babies without any manual assistance at all. Gravity and the free space around the perineum allow the baby's rotation maneuvers to be accomplished spontaneously." (Childbirth with Insight, 78). See also Golay, J., et al., "The squatting position for the second stage of labor: effects on labor and maternal ad fetal well-being," Birth 20(2) (June 1993):73-78.

"It was established in 1976 than an increase of 30 to 40 mmHg pressure is exerted by the fetal head on the cervix as a result of the effects of gravity, that is, standing instead of lying down. This means that, although the frequency of the contractions is the same, the effectiveness of the contractions is much greater, and hence the efficiency and rate of the dilatation of the cervix is improved. . . . In order to prove the superiority of the upright position in practice, the 1976 study alternated the posture of women volunteers every half-hour from the dorsal to the standing position. There was an abrupt fall in the intensity of the contractions when the women lay down, and the effectiveness of contractions in dilating the cervix was doubled when they stood up. The mothers also found the standing half-hour much less uncomfortable or painful; it was often difficult to persuade them to lie down again."
Sally Inch, Birthrights, 31; see Schwarcz, R., A.G. Diaz, R. Fescina, and R. Caldeyro-Barcia, Latin American Collaborative Study on Maternal Posture in Labor (1977); reported in Birth and the Family Journal 6(1)1979.

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