BIRTH PAIN – FROM FEARFUL TO POWERFUL

By Mariette Snyman

The uncertainty surrounding birth is an age-old concern. The question has always been: Will mom – and baby – survive? Today mothers are more inclined to ask: Will it hurt? This article seeks to shed light on the topic of birth pain.

“What do you prefer: a vaginal birth, or a caesarean section? Do you want an epidural?” These are two questions expectant women often hear. The answer is determined by factors such as medical aid cover, the desire to minimalise the risks involved, concern about baby’s wellbeing – and the fear associated with vaginal birth. In the times we live in, avoiding and numbing pain is a common occurrence. Previous generations had to face birth pain, whether they wanted to or not. Today, we have options. However, let’s look at the birth process in context before deciding to cast pain as the enemy.

“Women’s experience of birth pain varies,” says Cozette Laubser, Childbirth Educator and Paramana doula from Johannesburg.

“Some describe giving birth as painless. Others say it was bearable, while others recall excruciating levels of pain. Strangely enough, the level of pain a labouring woman experiences is not necessarily determined by factors such as the mom’s build or the baby’s size.

“Let’s look at pain within the context of a birth that is progressing smoothly on a physical and emotional level. The goal of childbirth is not only to bring a baby into the world, but to forge bonds: between mom and baby or between mom, dad and baby. Birth is the first meeting of individuals who will spend many years together, and the atmosphere and emotional experience surrounding birth leaves a lasting impression on all involved.

“A mother’s state of mind and her experience of birth pain are strongly interwoven. Pain registers in the brain, and some hormones can intensify the pain while others dampen or even numb it.

Desired hormones that assist the process of birth include:

• Oxytocin, also known as the love hormone and birth accelerator. This hormone is associated with emotions such as empathy and trust.
• Endorphins, which can dampen the experience of pain or erase it all together.
• Melatonin, which is known to work most effectively when the sun goes down – in the absence of electrical light – and teams up with oxytocin to strengthen contractions and ease the progress of birth.

“In contrast to these advantageous hormones, adrenalin – a stress hormone – suppresses the working of oxytocin. Our bodies secrete adrenalin when we are cold, afraid, anxious or rigid. Fear makes our muscles tense; this includes the largest and strongest muscle in the female body – the uterus. Adrenalin also affects the circular muscles of the cervix. These muscles can constrict and close the cervix altogether, bringing the progress of labour to a screeching halt. Prolonged muscle tension will heighten nerve impulses, which the brain can interpret as pain. The presence of adrenalin can in other words not only intensify pain during labour, but stall labour or stop it altogether.

“Ideally, oxytocin, endorphins and melatonin should secrete abundantly, while the secretion of adrenalin should be limited. For this to happen it is pivotal that we look at the physiology of birth, and understand the roles played by the birth environment and birth team.”

Factors that pave the way

The functioning of the labour hormones is strongly directed by the mom’s emotional state. French obstetrician Michel Odent points to the importance of a birthing environment that is both physically and emotionally safe and comfortable. According to Odent, mammals choose a birthing environment that

• Is safe, both physically and emotionally
• Is private, and prevents them from being observed
• Is warm and dark
• Allows freedom to change position and move around.

Think of a mommy cat about to give birth. She will seek out a dark, private and warm spot to give birth to her kittens. A space where she won’t be disturbed.

“Does the ideal birthing environment for mammals apply to humans? The human ability to speak and rationalize is what sets us apart from other mammals, and it is precisely this difference that often becomes a major stumbling block during labour and birth. American midwife and author Ina May Gaskin says: “We are the only species that can doubt its capacity to give birth, think about that …” and as we now know, fear stimulates the secretion of adrenalin.

“Labour progresses better when a mom moves from her critical thinking brain to her more instinctive mammalian brain, a part of the brain where feeling leads stronger than thinking. Birth is a natural process, and here, instinct is a much wiser guide than the intellect.

“Michel Odent refers to the fetal ejection reflex that can occur in the final stages of labour if a mom feels safe and unobserved; typically, in the absence of bright lights, noise and other disturbances. A cocktail of hormones triggers incredibly strong and fast contractions which involuntarily propel the baby down the birth canal without any active pushing from the mother.

“The fetal ejection reflex can occur suddenly and is associated with irrational talk and behaviour by the labouring woman. She may insist on leaving the birthing room, scream that she would rather die, or close herself off in the toilet. She may be upright or leaning forward while the involuntary contractions move the baby out. Under these circumstances the baby is often born in the caul, there is very seldom any vaginal tearing, and the placenta separates from the uterus within minutes – minimalizing blood loss.”

Why is it that we so rarely hear of such safe, straight-forward births?

“The main reason is the fact that the birthing environment has changed radically during the last 100 years. Most births now take place in hospital. The advantage of this is that, should a real emergency arise, the necessary technology and skill are at hand to save lives using surgery. The disadvantage of in-hospital medical care is that the focus always falls on managing risk, thus controlling a process. This style of care applies to high risk as well as low risk mothers. The World Health Organisation recommends that only 10% to 15% of all births take place by caesarean section. However, in South Africa the reality is that the number of caesarean sections done in private hospitals is four to six times higher than the recommendation of the WHO.

“A clinical hospital environment includes bright lights, constant observation, stringent protocols, etc. These are all in place for very good reason, but when we are looking at a birth environment, the environment described here is at odds with the natural, instinctive preferences characteristic of our species. For example, when we induce labour without sound medical reasons, we force labour to start before mom and baby are ready. Protocols such as routine vaginal examinations or instructing a woman to push – instead of encouraging her to work with her own natural urge to push – will interfere with the working of the fetal ejection reflex. Protocols of this nature stimulate the neo-cortex of the labouring woman, activate her critical thinking brain, and undermine the working of her instinctive mammalian brain.

“Labouring on the back on a bed is counterproductive. It closes up the pelvic outlet by as much as 20 to 30 percent, compared to positions such as squatting. Also, it quite literally means pushing uphill. The birth canal curves upwards when laying down, so the labouring woman is required to push against gravity. Laying on the back also constricts blood vessels, meaning baby and mother won’t receive the optimum levels of blood and oxygen. This also means baby runs a bigger risk of bradycardia, a low heartbeat.

“Birthing on the back not only increases the risk of pelvic, spinal and nerve injuries or prolonged pain after birth, but can also stall labour and make it more painful. When hospital personnel observe that labour isn’t progressing as it should, further interventions such as forceps or a vacuum extraction is required. Ironically, such births reinforce the idea that vaginal births are risky and unpredictable and, in the end, will require surgery anyway.

“In many first world countries such as Britain, Denmark and the Netherlands there is a system of midwifery led care. In these countries the vast majority of healthy mothers and babies receive care by midwives, both during pregnancy and birth. The midwifery route is slowly gaining more ground in South Africa.

“Once it is certain that the expectant mother is healthy and that the pregnancy is progressing normally, a natural birth with a midwife becomes an option. Midwives attend births at home, in birth centres, and – where there is a standing agreement – in hospital. When a midwife and gynaecologist work closely together, a home birth becomes a very safe option. In the unlikely event that the homebirth is not progressing as expected, the birthing mother and baby can be transferred to the nearest hospital with a gynaecologist on standby, to assist with surgery.

What tips can Cozette offer expectant couples who want to consider a natural birth?

“The first step is to get in contact with a gynaecologist who is known for delivering babies naturally, to ascertain whether the mother and baby are good candidates for a natural birth. This will be determined by factors such as the mom’s health history, the growth and development of the baby, the position of the placenta, and so forth.

“Secondly, it is important to choose a place of birth and a birth team. A homebirth is an appropriate option for a healthy mother and baby who want to experience a completely natural birth and all its benefits. If a homebirth is chosen, it is important to know that only non-pharmaceutical pain relief options will be available during the birth.

“Choosing your birth team with care is critically important. They will ultimately determine whether the birth environment is one where you feel safe, heard and respected, or not. Remember, the emotional atmosphere directly influences the progress of labour. The birth team can include a doula, a non-medical companion during pregnancy, birth, and the postpartum period. A doula has the mammoth task of facilitating the communication and decision-making process regarding all things related to birth. During the birth she also makes sure the labouring woman’s wishes are heard and respected as far as possible. Because a doula is no stranger to the birth environment, she brings calm to the birthing mother and her partner. Remember, adrenalin can be counterproductive to the progress of labour, and because it is contagious, it should be kept at bay. Recent research shows that the presence of a doula can lower the likelihood of a caesarean section by 60%.

“Confidence in the natural birth process is strengthened when we understand that pain does not always equal suffering.

American author and midwife Penny Simkin points out the difference between pain associated with physical exertion, like running a marathon, and pain associated with damage and trauma. Birth pain does not have to overwhelm a labouring woman. Her muscles work exceptionally hard, but her hormones help her to function from her more instinctive mammalian brain and facilitate the progress of labour and birth.

“Birth can be a joyous and utterly empowering experience if the labouring woman is supported. Should birth pain become unbearable, the labouring woman should reserve the right to choose pain relief options. Whatever happens, responsible and informed care should always ensure the wellbeing of both mother and baby.”

Pain relief during birth

Cozette Laubser, Childbirth Educator and Paramana doula from Johannesburg, discusses various pain relief options:

In my mind natural birth refers to the spontaneous onset of labour and ends with the birth of the placenta, without the use of any intervention, whether pharmaceutical or instrumental. The process is lead by the labouring woman and baby. She can move freely, eat and drink as desired, make noises if so inclined – in short, she can do whatever feels right to find her own rhythm in labour. As soon as there is medical intervention, vaginal birth is no longer completely natural.

 Natural pain relief

• The most natural pain relief readily available in the body is endorphins, the body’s natural morphine. It is included in the ‘Cocktail of Hormones’ the body secretes if the birthing environment allows it.
• A birthing pool, filled with water at body temperature, offers great pain relief for most labouring women. Babies birthed in water also seem to be calmer and more relaxed as the environment they are birthed into is similar to the in utero conditions they know.
• Certain labour positions can also bring pain relief. If, for example, the baby lies with its back against mom’s back, standing on all-fours can alleviate the pain as baby doesn’t rest so heavily on mom’s spine in this position. Most labouring women will instinctively choose this position without necessarily knowing why.
• Rhythmic breathing, sounds and movement can also alleviate pain.
• Some labouring women repeat a mantra with every contraction, sometimes out loud and sometimes internally.

Pharmaceutical pain relief

• Regarding vaginal birth the most common pain relief option is an epidural and, in the case of a caesarean section, a spinal block. The difference mainly lies in where they are administered in the spine.
• Other pharmaceutical options can be administered via
  • an injection,
  • an intravenous fluid (IV) administered directly into a vein,
  • or inhaled.

It is important to note that these options can alleviate pain, but do not necessarily nullify it. Expectant couples should thoroughly research the pros and cons of every option and be aware of the impact drugs will have on their baby’s ability to adjust, breathe, feed, bond, and so forth. Their choice of pain relief can also determine whether their baby will routinely be required to spend the night in the NICU or not. Medical intervention steers birth in a certain direction; for example, the use of pain relief via IV automatically restricts the labouring woman’s movement. Similarly, requesting an epidural means you are confined to labouring on your back on a bed. One intervention can necessitate the next. This is called the cascade of intervention.

Cozette Laubser – Childbirth Educator, Paramana doula, Advanced BabyGym Instructor and Play Learn Grow Facilitator: cozette@sensiblebirth.co.za, www.sensiblebirth.co.za, Sensible Birth on facebook and www.theartofcocreating.co.za

Cozette offers quarterly free talks on these topics and more.

 

*This article originally appeared in Afrikaans in rooi rose magazine.

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