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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Comments about To The Contrary

I part ways with Lynn Griesemer over the father's role in unassisted births. We've talked about this, and she has more of a "daddy delivery" philosophy about unassisted birth. I don't think men should be "front and center" in births. Women should be. After all, they are the ones giving birth! It's really not that hard to catch a baby, yet when men (or doctors) do it, they get all sorts of glory and acclamation. My husband's role at the birth was to sit in the other room and wait as I birthed our daughter (and to be errand boy when I needed food & drinks). Now, that was exactly what I wanted and needed him to do, so it's not like I resent that in any way. The most significant thing he did for me--more important than any coaching or catching or delivering--was giving me blessings when I asked for them. (LDS lingo here...let me know if you haven't a clue what I'm talking about.) The blessings gave me absolute certainty that both I and Zari would be perfectly healthy and that the birth would go smoothly. There is no machine, no test, no care provider who could do that!

Even though Lynn would not identify herself as a feminist, I do agree that birth issues are noticeably absent from almost any feminist platform. That's a shame, I think. The National Organization for Women has recently made some statements about birth issues, including a statement against VBAC bans, but otherwise feminism has been oddly silent on the birth side of "reproductive rights." I also think that the almost exclusive focus on abortion has alienated many women who are concerned with the rights of childbearing women. Women need more opportunities to unite, and unfortunately the abortion issue is one really good way to keep women divided.

Dr. Healy claims that she supports patient's rights to refuse treatment, yet she undermines that by her statement that "when you’re making that decision for a child, it’s a very different situation." Is it different? Pregnant women have the same medical and legal rights as non-pregnant people (with the very disturbing exceptions of court-ordered obstetrical interventions). This is the same double-talk that ACOG uses in its statement against home birth: "Although ACOG acknowledges a woman's right to make informed decisions regarding her delivery, ACOG does not support programs or individuals that advocate for or who provide out-of-hospital births" because "the American College of Obstetricians and Gynecologists believes that the hospital...is the safest setting for labor, delivery, and the immediate postpartum period." ACOG's active opposition to out-of-hospital births stands in direct contradiction with its claim to support women's choices in health care.

It's kind of like saying "We support your right to choose any color of car you wish. But you can only have a blue car, because we believe that all other colors are unsafe. In addition, we will actively oppose any car manufacturers who promote, sell, or distribute non-blue cars. We can do this, because we have a monopoly on the $33 billion-a-year business of car manufacturing, sales, and advertising. But remember, we support your right to choose!"

I agree with other commenters that Dr. Healy skimmed over the issue of babies dying in hospitals. Yes, it's true that neonatal deaths are fairly uncommon anywhere in developed countries. But her comments imply that a hospital is the only place that the low death rate can be ensured, and that any infant deaths that occur in hospitals are unavoidable.

The doctor also shows a blatant lack of knowledge about unassisted birth, or home birth in general, with her claim that first-time mothers do not make that choice. What irks me is that her statement will be taken as factual and authoritative, simply because she is a physician.

I am also puzzled by her comment that "you don’t know the health of that baby until that baby arrives." Isn't that one of obstetric's main claims--that it can monitor, assess, and predict the health of babies during pregnancy and birth? Why else all the monitoring during pregnancy (ultrasound, screening tests, etc) and birth (electronic fetal monitoring)? Is her statement an admission that the standard obstetric care really cannot predict outcomes with any accuracy, let alone avert them? Or is her comment meant to mean that women birthing at home cannot know whether or not their baby is healthy while it is in utero? Because certainly women can and do feel their baby kicking and moving, listen to the heartbeat, and keep track of the baby's growth. Read that way, her statement implies that a physician has a better knowledge of the unborn baby than the mother herself.

Of Eleanor's comment--which I find immensely condescending and anti-woman--let me just say that safety, satisfaction, and empowerment are not mutually exclusive. In fact, the factors that bring unassisted birthers pleasure (privacy; security; complete freedom to move about, eat, drink, and vocalize; not feeling observed or monitored or pressured to birth in a certain amount of time; lack of drugs and interventions and their known side effects; absence of stress and fear; optimal hormonal levels that help the mother experience ecstasy and bliss; ability to focus on labor and not on outside distractions) also enhance the safety of both mother and baby. The pitting of fetal safety versus maternal satisfaction is a cornerstone of the obstetric worldview, as Robbie Davis-Floyd notes in Birth as an American Rite of Passage. The midwifery paradigm, in contrast, perceives the mother and baby as an inseparable, mutually dependent unit. What is good for the mother is good for the baby, and vice-versa.

I fear that this discussion of safety is quickly turning into a dissertation itself, but let me briefly add some insights from Sarah J. Buckley. She argues that the safest, easiest, and most ecstatic births are ones that are undisturbed:

"Anything that disturbs a labouring woman’s sense of safety and privacy will disrupt the birthing process. This definition covers most of modern obstetrics, which has created an entire industry around the observation and monitoring of pregnant and birthing women...On top of this is another obstetric layer devoted to correcting the 'dysfunctional labour' that such disruption is likely to produce. The resulting distortion of the process of birth—what we might call 'disturbed birth'—has come to be what women expect when they have a baby and perhaps, in a strange circularity, it works."

In contrast, undisturbed birth and its “optimal hormonal orchestration provides safety, ease, and ecstasy." She explains: “When a mother’s hormonal orchestration is undisturbed, her baby’s safety is also enhanced, not only during labour and delivery, but also in the critical transition from womb to world....[I]interference with this process will also disrupt this delicate hormonal orchestration, making birth more difficult and painful, and potentially less safe.” She uses two analogies to explain the optimal conditions for undisturbed birth: lovemaking and meditation, both of which necessitate privacy, quiet, and freedom from feeling watched. “If we were to consider giving birth as the deepest meditation possible, and accord birthing women the appropriate respect, support, and lack of disturbance, we would provide the best physiological conditions for birth.” [1]

I also want to say that childbirth was definitely something that I embraced and enjoyed in many ways. Some parts were challenging, some were very very exhilarating. Pain was present at times, but so was immense pleasure, experienced in the form of an incredible endorphin rush between every contraction. Five minutes after the birth, I said, "that was hard work, but definitely doable." Distance runners experience this same mixture of pleasure, pain, exertion, and exhilaration. I can say this from personal experience, since I am very close to running a half-marathon. My longest run so far has been 10 miles.

Now, in case you are tempted to dismiss my experience by figuring that I must have an unusually high pain tolerance, let me set the record straight: I was known for my extremely low pain tolerance growing up. I would scream and wail over every little thing, so much that my mom didn't believe me when I broke my wrist and waited 10 days before taking me in to the doctor!

Eleanor's disparaging comment about enjoying labor and birth is destructive and indicates either some very traumatic personal experiences giving birth or very strong cultural programming that birth is inherently and inescapably traumatic.

And the final panelist...where to start? She reiterates that choosing to birth at home unassisted is selfish, yet her own childbirth preferences (using drugs, including general anesthesia) confer no physiological benefits to mother or baby during normal labor, and also pose many significant risks, as Dr. Buckley has thoroughly documented. We could very well argue, with much more substantial evidence than any of the panelists had, that any mother taking drugs for pain relief is selfish--caring more for her own experience than for the baby. (Not saying that I want to use this label, because there is too much woman-hating and guilt spreading out there already).

This concludes tonight's episode of "Rixa writes, raves, and rants whilst remaining reasonably restrained in her responses."

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[1] Gentle Birth, Gentle Mothering 110-114.

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Gloria Lemay classics

Here are two classic articles by Gloria Lemay, a birth attendant in British Colombia:

Pushing for First-Time Moms

Pelvises I Have Known and Loved

In "Pushing for First-Time Moms," Gloria exquisitely describes the stages of pushing. I experienced many of the sensations she discusses. I first had small abdominal pushes that felt exactly like throwing up, except in the opposite direction. I call it "throwing down." I could hear my voice catching in the back of my throat, but I wasn't making any audible sounds.

At that point, I reached inside for the first time to see if I could feel anything. Sure enough, there was the baby's head, still kind of far inside and more backwards than upwards if that makes sense. I felt a small, thin anterior lip of cervix. It felt exactly like the neck of a t-shirt. Because I had read Gloria's article, I knew the lip was nothing to worry about and that I just had a little more dilating left.

I also experienced a sensation of being "stuck" and some frustration that the baby wasn't moving down--especially when my pushing urges changed from mild and slightly pleasant to irresistible bearing down sensations that I had roar through.

Gloria has this to say about the baby's head being "stuck":

I recommend that midwives change their notion of what is happening in the pushing phase with a primip from "descent of the head" to "shaping of the head." Each expulsive sensation shapes the head of the baby to conform to the contours of the mother's pelvis. This can take time and lots of patience especially if the baby is large. This shaping of the baby's skull must be done with the same gentleness and care as that taken by Michelangelo applying plaster and shaping a statue. This shaping work often takes place over time in the midpelvis and is erroneously interpreted as "lack of descent," "arrest" or "failure to progress" by those who do not appreciate art. I tell mothers at this time, "It's normal to feel like the baby is stuck. The baby's head is elongating and getting shaped a little more with each sensation. It will suddenly feel like it has come down." This is exactly what happens.
Given time to mold, the head of the baby suddenly appears. This progression is not linear and does not happen in stations of descent. All those textbook diagrams of a pelvis with little one-centimeter gradations up and down from the ischial spines could only have been put forth by someone who has never felt a baby's forehead passing over his/her rectum!

My full-on pushing urges lasted about two hours, and towards the very end Zari's head descended fairly quickly, exactly as Gloria has described. At this point I was sitting on the toilet and supporting my tissues. Eric says I got very quiet. He thought that labor had stopped. Little did he know that she was starting to crown!

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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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