Pain in Labor

We’re meant to avoid pain in today’s society. Every ache, every muscle cramp, every bout of soreness can be soothed away by one pharmeceutical or another, and if the over the counter medications don’t touch it, there’s always a prescription to try, presumably.

Laws against direct marketing to consumers were relaxed in 1997, and since we’ve seen an unprecedented marketing strategy, combined with an unprecedented upswing in the number of prescriptions. A popular reply to questions about natural childbirth is a comment about giving birth without an epidural being similar to having a root canal without pain medication.

I don’t think they’re even comparable.

A root canal is a treatment for a pathology. Gallbladder surgery, which necessitates pain relief, is a treatment for a pathology. When I was having gallbladder attacks and accepted pain medication, I was accepting pain medication for a pathology.

Birth is not a pathology.

Again, birth is not a pathology. Birth is a normal, natural process in the course of life, not dissimilar to sex, death, breathing, eating, or using the restroom.

When something hurts beyond reasonable expectations during sex, it’s considered a pathology. Yet it’s accepted that there will be a moderate amount of pain experienced in relationship to sex a moderate amount of the time. It’s when it crosses some threshold point that it’s seen as a pathology.

There are reports of painless childbirth, and while I believe it can happen, that’s not my concern. My concern is a normal childbirth, a biological childbirth. There will, in many cases, be some pain. The muscle tissue of the uterus is contracting massively in order to draw back the cervix and then push the baby out into the world. If a mother did not push at all, her baby would still be born, forced into the world by uterine contractions. That’s what contractions in childbirth are – contractions of the uterine muscle, similar to any other muscle contraction. There’s another parallel in that other muscles will usually hurt when contracting if they are doing an unprecedented or nearly unprecedented amount of work in a short period of time. Additionally, there will typically be pain associated with the perineum when the head is crowning, as these blood-rich tissues stretch and then stretch more around the baby’s head.

This pain associated with labor and birth, however, is pain with a purpose. The body is actively working, of its own accord, to birth the baby, at the appropriate time for that baby and that mother.

Pain that cannot, in fact, be managed adequately is a signal of something wrong. I know someone who experienced an enormous amount of pain as her daughter made her way down through the vagina, which is actually atypical. Once the baby girl’s head was born, the reason was clear – atypical presentation, where one hand was alongside her head. Another atypical presentation that causes back labor and atypical pain is a posterior presentation. Babies can be birthed in these presentations, yes, but the fact of the atypical pain is a clear sign that something is different than expected.

O’Mara states that pain is experienced the same, physiologically, by everyone (116). The unaccounted factor is the psychological response; that is, how each person has decided to respond to the painful stimulus, both consciously and unconsciously (O’Mara, 116). Other factors, not necessarily under the mother’s control, include the environment during labor, baby’s position, mother’s position, who is with the mother, the mother’s energy level, and whether or not the mother has previously given birth (O’Mara, 116).

The crux of the issue is that there is a very large difference between feeling pain, and suffering. The pain that a woman experiences is purposeful. England brings this together when she states, “The sensations [experienced] are part of an ingenious feedback mechanism which is essential to normal labor and birth. The pain and sensation of labor tell [the mother] what position is best… and how to move in labor to get [the] baby out. With an epidural, this feedback is wiped out” (240).

To a large extent, childbirth proceeds best when the mother is unmedicated, because abnormal pain can guide the mother. “Commonly, the positions and activities she chooses for comfort are also those that promote good labor progress or help shift the baby into the right position for birth. Remove the pain, and you kill that feedback mechanism” (Goer, 252) While I don’t know what labor and birth would have been like for me had I not heeded my body’s warning, I certainly experienced ‘abnormal pain’ during the pushing phase, as I attempted to squat. There was a searing, rubbing pain in my pelvis that was decidedly not normal. I stood, and then later, leaned forward, an approximation of a hands and knees type position (though I was not on my knees). That hands and knees position is commonly accepted as a way to resolve shoulder dystocia. Is that why I felt compelled to get into that position? I won’t ever know.

What else can pain, or the nerve stimulation interpreted as pain, provide? The nerves in the cervix, pelvic floor, and vagina transmit signals that tell the pituitary gland to produce more oxytocin. More oxytocin moves labor forward, thereby causing more cervical dilation and later telling the uterus to direct its efforts towards pushing the baby out. If the nerves are numbed – such as with an epidural – this feedback mechanism is completely wiped out.

Now, there are various ways of dealing with pain. Previously, I discussed the use of epidurals. However, there are a multitude of non-pharmological means of pain relief which are not commonly considered and may even be ridiculed. First, if a woman is in a situation where she is able to follow her body’s guidance, the amount of pain to be relieved is going to be less, as mentioned above. Another method of “pain prevention” would be paying attention to fetal positioning. The website Spinning Babies has information on this subject, as well as the now out of print books Sit Up and Take Notice! and Optimal Foetal Positioning.

During labor, many women find that their pain is lessened through movement. This movement may be walking, or may be a form of ‘dancing’ that involves moving the hips, rotating the body, and swaying. Bellydancing was originally a form of preparation for childbirth, and moves reminiscent of bellydancing often arise spontaneously in the unmedicated woman. Other women find some relief in the form of sitting on or leaning on a birth ball, which is really another name for an exercise ball. Massage and other forms of touch therapy can provide pain relief, while other mothers swear by acupuncture, acupressure, or reflexology. A number of women swear by hydrotherapy, whether in the form of a shower or immersion. Relaxation and visualization are often mentioned as tools to employ in the service of pain relief. Hypnosis for childbirth, espoused by programs such as Hypnobirthing, Hypbirth, and Hypnobabies, is in some respect an “extreme relaxation” brought on through conditioning.

All of these methods of pain relief are worth using. All of these methods have had considerable success, though some may not work for some people, while others do not work for other people. All of them are valuable to have in a “toolbox” for relief and coping.

Finally, I would be remiss not to mention the idea of painless childbirth. Grantly Dick-Read first brought this idea to the attention of the modernized Western world with the publication of his work commonly known as Childbirth Without Fear. Throughout the sixty years since he first brought the idea to the attention of large numbers of people, other writers have discussed painless childbirth, while others have decried it as an impossibility, or suggesting that to imply it is possible is to set women up for failure. While I agree that the majority of women in North American society are not going to experience painless birth, it does not mean that we should deny that the possibility does exist. Similarly, the possibility of orgasmic birth also exists, and is potentially more common than painless birth, since the orgasmic portion does not necessitate painlessness. Pain and pleasure are both experienced by the same nerves, just different signals are sent to the brain.

Pain is the major thing discussed in American birthing today. How to avoid pain, what causes the pain, and ways to get rid of the pain are all major concerns of the majority of pregnant women in today’s society. The idea of not avoiding pain and instead embracing it is both strange and revolutionary.

originally written 10 January 2007

The Moment of Birth

A liminal state is one dealing with the limen, or the threshold of a physiological or psychological response. Robbie Davis-Floyd recognizes pregnancy as a whole as a liminal state, encompassing physiology and psychology. Even more so than pregnancy, childbirth is a liminal state, and the moment of birth is a powerful limen for both woman and fetus. The woman goes from pregnant woman to a newly born mother, and the fetus, in the act of being born, becomes an infant or neonate. All the complex physiological changes in the baby that occur to transition s/he from womb life to extrauterine life start then. The mother’s body is likewise about to undergo tremendous physical changes as she goes from a pregnant state to a non pregnant state. We don’t know what kind of psychological changes the baby has, but the woman’s transformation to Mother (or Mother Again) is, if not completed, brought in huge leaps towards completion.

Beyond the intellectual knowing of these facts, the moments just before, during, and just after the birth can be otherworldly for the laboring woman. Many women cite feeling as if they were going to die, combined with a calm acceptance of the fact! Birth and death are intimately connected mysteries and with that in mind it does not seem so strange to imagine that the feeling of giving life also can bring the sense of leaving life. Other women feel as if they are going to literally split in two. While some part of them rationally knows that this will not happen, other parts of them remain convinced that this will happen at any moment. There is a transcendent and nebulous quality to perception in these moments that underlines the liminality of the event.

Physically, as the baby moves down and out of the woman, contraction patterns change. In most births, the woman does not even need to consciously push at all, though of course there is no harm in self-directed pushing if she feels she must. The uterus and the baby, working together, will bring the baby to the brink of being born, and then onwards. This has been termed the fetal ejection reflex and has been written about extensively by Michel Odent among other. Vertical positions tend to assist this reflex – standing, standing supported squat, and a full squat are some of the possible variations. The all-fours position also opens up the pelvis for the baby’s passage. The common positions used in the hospital, woman on her back with legs in stirrups or otherwise up in the air, or even in a semi-sitting position, actually lead to sacral compression and a narrowing of the pelvic outlet.

As the baby crowns, I feel that it truly is in one of the most threshold situations possible, matched only by the threshold at the end of life. In the mother, now feeling air, now back a bit. The baby crowns and the head is born. Partly outside the body – an infant – and partly inside the body – a fetus – the baby may start to breathe outside air, beginning the change in the circulatory system, even as the umbilical cord continues to function and provide oxygen. Not yet born, not still a fetus in the womb: babies could almost define “transitional state.”

The moment of birth, then, is one in which both the mother and the baby experience tremendous changes. Emotional impressions wash over the body even as immense physiological changes are triggered, but the reactions to this fact will vary. The fact remains, however, that this moment of birth is special, isolated from all others. The moment of birth is when one starts the process of becoming two.

Birth Safety as a Binary Condition

“Your baby is healthy and that’s all that really matters.”

How many times have you heard it or some variation of it? How many times have you said it or something like it? A new mom is struggling to make sense of a traumatic or confusing birth experience, to come to terms with unplanned interventions, perhaps an instrumental vaginal delivery or cesarean section that she’d never imagined she’d have. When she expresses her sorrow over the loss of the birth she had hoped for, the beautiful event she’d imagined, too often the response is, “At least you have a healthy baby.” Christy Fiscer’s essay, “A Healthy Baby Isn’t All That Matters”, addresses this troubling tendency to trivialize a woman’s birth experience by implying she isn’t grateful enough that her baby is “healthy” (which really equates to “not dead or noticeably damaged”) or that she’s selfish for wanting, let alone expecting, more from birth than to be treated like an insignificant baby-bearing vessel. Seeking meaning in birth outside of a “healthy” newborn is viewed as frivolous, and women seeking empowering birth experiences are portrayed as solely being out to prove something or expecting to “get a medal for going without drugs.” There’s no need for me to rehash in great detail something that Christy has already addressed so passionately and eloquently. The “healthy baby is all that matters” attitude is merely one facet of a larger flaw in how our culture views birth outcomes.

The other day, someone left a comment [which was deleted due to the comment's author, not the comment's content] on my essay about “bravery” not really being a factor in choosing a homebirth to the effect that, if maternal and neonatal mortality outcomes of homebirths and hospital are nearly identical, that neither hospital birth nor home birth was more or less dangerous. I found this to be an interesting interpretation of the Johnson & Daviss study. While it’s true that outcomes in terms of mortality rates were nearly identical, what made the study relevant to my essay was NOT that it showed a difference in the number of deaths, but that the low rate of mortality in the homebirth group was achieved with significantly fewer interventions than that of the hospital birthing group. If safety is measured by number of deaths alone, I suppose this would indicate that neither hospital nor home is more “dangerous” than the other, but is “not a lot of people died” really all that we’re going for?

When did “didn’t die” become our only barometer for success in childbirth? Baby was born/extracted from womb, both mother and child survived, therefor all is well, regardless of whatever other steps may have been involved in that birth/extraction process, regardless of any long-term harm (or increase in risk) to the mother or child, and regardless of the way anyone feels about the experience. Mom and baby lived; most studies would consider that a positive outcome. From a purely statistical standpoint, the birth was a success. This is certainly how birth is judged in this country from an obstetrical standpoint, but are we really satisfied as individuals with this binary notion of birth wherein “bad” is defined only as “dead” and “good” is defined only as “not dead”?

If a living mother and child are all that is required for birth success (or if, indeed, a healthy baby is the only thing that matters) then yes, hospital birth is “just as safe” (or “equally dangerous” or “no more dangerous,” choose whichever language you prefer). If you start measuring safety and success by something more than a binary “live or die” condition, however, then you find disparity in outcomes.

What do many homebirth advocates view hospital birth as dangerous? It’s not because more women die in hospitals, or because more babies die in hospitals, but because the interventions performed in ever increasing numbers in hospitals can have a devastating effect on long-term physical and mental health. The increased likelihood of cesarean section for women giving birth in hospitals is a good example of what is perceived by homebirth advocates as a danger of hospital birth. Cesarean section is a major abdominal surgery. While some care providers like to present surgical delivery as “just another way to give birth,” the reality is that the procedure introduces a host of new risks to mother, child, and future pregnancies. These risks are worthwhile if the cesarean section is necessary, as the World Health Organization says the procedure is for less than 15% of births, but the procedure is grossly overperformed in the United States. Can a woman who did not need a cesarean, but who was manipulated/pressured, legally forced, misled by care providers about the necessity of the procedure, or who experienced iatrogenic health complications (for herself or her baby) due to mismanagement or over-management of her birth, be said to have had a “safe” or “successful” birth experience, even if the immediate outcome of the surgery is that mother and child live?

Maternal mortality rates do not tell us if the mother who had a unneeded cesarean section went on to have more children (as cesareans can cause fertility problems). Maternal mortality rates do not tell us if she had other cesarean deliveries as a result of her primary c-section (as fewer and fewer doctors/midwives will attend VBACs and many insurance providers will not cover them), or what complications or outcomes came from that birth (as each additional cesarean section has increased risks over the previous cesareans). They do not tell us if she experienced uterine rupture during her VBAC or repeat cesarean as a result of scar tissue from the primary surgery (the risk of rupture for VBAC and repeat cesarean is nearly identical, at slightly less than 1%). They do not tell us if she experienced placental previa or accreta in later pregnancies as a result of her prior c-section (the risk of both is increased in women who had have c-sections). They do not tell us if additional surgeries had to be performed after birth to correct iatrogenic health conditions, such as damage to the bowels or bladder (rare, but possible). They do not tell us if she experienced post-traumatic stress disorder, postpartum depression, or sexual dysfunction (all more common among women who had unplanned c-section than women who had planned vaginal births or planned c-sections) as a result of the unexpected surgery. Maternal mortality rates don’t tell us if the mother had difficulty breastfeeding (women who have c-section are less likely to breastfeed). The only thing that maternal mortality rates tell us is whether or not a woman died during or shortly after giving birth as a result of that birth. These rates say nothing about the dangers to a woman’s long-term health, either physical or mental, that resulted from the cesarean section. These rates say nothing about the feelings of disappointment, guilt, confusion, anger, or fear experienced during or after the birth.

I could list every intervention more common in hospital births than homebirths and tell you exactly why I, as a homebirth advocate, feel the overuse and misuse of these interventions make hospitals a dangerous place for low risk women to give birth, but why beleaguer that point? The heart of the issue, for me, isn’t to examine the individual interventions, or even the cumulative risks of the whole cascade of interventions, but to bring attention to how little a binary notion of birth location safety actually tells us about the safety of giving birth.

When a child is born, a new mother is made. The process of her making, the experience of her birthing, is a meaningful one. Statements like “a healthy baby is all that matters” marginalize the mother by implying that the she doesn’t matter, that she is lacking in worth (either by comparison to her child or in general). Though every mother’s primary concern is a healthy baby, the mother’s own experiences are not suddenly made worthless or unimportant if that goal of a healthy child is attained. Defining birth outcome by whether or not the mother and her child lived is equally marginalizing of the mother, because this narrow definition doesn’t allow for variations in personal experience, physical or mental health, non-mortal birth crises. This definition of birth success says that only life or death, not the process, has meaning, and that even if you were poked, prodded, injected, cut, dehumanized — if you didn’t die, well, you were actually “safe” the whole time. You were in no danger, because the end justified all the means.

I don’t know about you, but I want more than that particular binary view of safety.

Copyright 2009 by Morgan A. McLaughlin McFarland

“Brave” has nothing to do with it

When hearing the news that I had my last baby at home and am planning to have this one at home as well, the first response from most people is, “You’re so brave.”

This has to be one of the most irritating things that people say to homebirthers. The implication is that birth is dangerous and that we are willing to take on a tremendous risk to do it anywhere but a hospital. It negates the research and planning that we’ve done to come to this decision. It makes the choice about balls, not brains. After all, homebirth is “dangerous.” Hospital birth is “safe.” Therefor, it must be bravado alone that would lead a woman to choosing such an option. Right?

In 2003, over 20% of women had their labors induced, with a rate closer to 40% in many hospitals, while that rate should not exceed 10% (and has remained at 10% in most industrialized nations). Inductions are approximately 5 times more likely among planned hospital births than planned homebirths. An 1999 American Journal of Obstetrics and Gynecology “Green Journal” review of 7000 inductions found that 3 out of 4 of the inductions were not medically necessary. Inductions are performed unnecessarily for estimated size of the baby (too large or too small), going past the estimated due date, amniotic fluid levels that are low but not critically low (correctable in nearly all cases by rehydration of the mother), rupture of membranes without immediate start of labor, the mother being dilated/effaced but not in active labor, or scheduling reasons on the part of the mother or care provider. Approximately 40-50% of inductions fail (depending on the induction method used and the mother’s Bishop score), and most failed inductions end in cesarean section. Inductions increase labor pain and length, and create, among other problems, an increased risk of fetal distress, uterine rupture, and cesarean section.

But homebirth is “dangerous.” Hospital birth is “safe.”

Over 30% of women in the US have cesarean sections, while overwhelming research has led the World Health Organization to set an ideal standard rate of cesarean sections at 10-12%, with 15% being the rate where more harm is being done instead of good. Cesareans are performed at a similar rate across all risk groups, low to high. The cesarean rate for planned births at home or in an independent birthing center is approximately 4%. Cesarean sections increase the likelihood of maternal death by as much as 4 times, and have other immediate and long-term heath risks for mothers that include, but are not limited to, infection, bowel or bladder perforation, hysterectomy, future infertility, and increased risk of uterine rupture for future pregnancies. Risks for the baby include respiratory distress, fetal injury, prematurity (if result of schedule section or failed induction), and breastfeeding difficulties. Four of the greatest causes for the increase in cesarean section are overuse of interventions during labor, concern for malpractice/liability on the part of care providers, failed labor inductions, and “failure to progress” (labor not progressing fast enough or regularly enough for care providers).

But homebirth is “dangerous” and hospital birth is “safe.”

The ACOG and AMA have both come out against homebirthing, calling it a dangerous trend and referring to it as a “fashionable, trendy, [...] the latest cause célèbre,” and they paint a horrible picture of complications arising in low-risk pregnancies with no warning that cannot be handled anywhere but the hospital. Despite that, the most thorough study ever done on homebirth safety, Kenneth C Johnson and Betty-Anne Daviss’s Outcomes of planned home births with certified professional midwives: large prospective study in North America, BMJ 2005;330:1416 (18 June), found that the outcomes of planned homebirths for low risk mothers were the same as the outcomes of planned hospital births for low risk mothers, with a significantly lower incident of interventions in the homebirth group. The Lewis Mehl Study of home and hospital births, which matched couples in each group for age, parity, education, race, and pregnancy/birth risk factors, found the hospital group had 9 times the rate of episiotomies and tearing, 3 times the cesarean rate, 6 times the fetal distress, 2 times the use of oxytocin for induction/augmentation, 9 times the use of analgesia/anesthesia, 5 times the rate of maternal blood pressure increase, 3 times the rate of maternal hemorrhage, 4 times the rate of infection, 20 times the rate of forceps use, and 30 times the rate of birth injuries (including skull fractures and nerve damage). Breastfeeding success rates are higher and postpartum depression rates are lower for planned homebirths.

But homebirth is “dangerous” and hospital birth is “safe.”

The United States spends more per pregnancy/birth than any other country, the vast majority of women in the US give birth in hospitals, and yet the US’s maternal death rate is the worst among 28 industrialized nations and the neonatal mortality rate is the second worst. The Netherlands, where 36% of babies are born at home, has lower maternal and neonatal mortality rates than the US. Denmark, where all women have access to the option for a safe and legal home birth, has one of the lowest maternal and neonatal mortality rates.

But homebirth is “dangerous,” hospital birth is “safe,” and Brutus is an honorable man.

I didn’t choose a homebirth because I am brave. Bravery has little to do with it. If anything, I believe women who choose to give birth in US hospitals are the brave ones, because knowing what I know about our technocratic obstetrical system, I can’t imagine voluntarily choosing an obstetrician and a hospital for anything but absolute medical necessity. My decision to homebirth wasn’t made in a void, but based upon years of research. I wonder how much research the average woman puts into her hospital birth? Considering how many times I’ve heard someone say “I’m glad I was in the hospital because…” and then given as her reason a non-emergent situation (such as fetal size or nuchal cords), I’d say not that much.

Call me stubborn, because I wasn’t willing to accept out of hand the culturally held belief that hospitals are safer. Call me an idealist, because I believe that birth can be a positive, safe, and empowering experience for child and mother. Call me a nonconformist, because I choose to birth at home in defiance of a powerful technocratic system. Call me outspoken, because I can’t keep my mouth shut when I hear about yet another iatrogenic birth calamity. Call me a “birth nazi,” because I believe it’s the right and responsibility of every woman to educate herself about birth and take ownership of her birth experience.

But brave? Don’t call me brave. “Brave” has nothing to do with it.

Copyright 2009 by Morgan A. McLaughlin McFarland

North Metro Birth and Breastfeeding Coalition

Our mission statement: “To normalize physiological birth and breastfeeding, for both individuals and the community, through education and advocacy.”

We are woman-centered advocacy and education group, helping women become empowered to advocate for themselves, working with them to identify what they are looking for in maternity and postpartum care, assisting them in researching their birth options (including safety, legal, and social ramifications of those options), supporting them throughout breastfeeding, and providing them with educational resources.