Last night I was teaching a refresher childbirth education class to a couple. The father is a physician and the mother is an occupational therapist - so when I started talking about non-pharmacological methods of pain relief, specifically those related to the Gate Control Theory, they knew exactly what I was referring to. They added to the conversation by sharing that this method of pain relief can really help a mother during her first labor. This particular mom labored submerged in a warm birth tub up to the time she was ready to push. She explained that the water really helped relieve a lot of the pain she was experiencing.
You may be asking how something as simple as a warm bath could act as a pain reliever. This is explained by the Gate Control Theory of Pain, which was developed in 1962 by Ron Melzack and Patrick Wall and details the role of the mind and brain in pain perception. They explain that before pain messages reach the brain, those messages encounter “nerve gates” in the spinal cord that open or close depending upon a number of factors (possibly including instructions coming from the brain). When the gates are open, pain messages “get through” more or less easily and pain can be intense. When the gates close, pain messages are prevented from reaching the brain and may not even be experienced. There are two types of nerve fibers that descend from the brain through the spinal cord: C-fibers, or slow/small neural fibers; and A-delta nerve fibers, or fast or large pain fibers. If impulses along the slow pain fibers outnumber impulses along the fast pain fibers, the gate is opened and pain impulses are transmitted to, and perceived by, the brain. However, the same holds true that if there is more stimulation of the fast fibers the gate closes, inhibiting transmission of pain impulses, reducing pain perception, and stimulating the release of endorphins. To put it in REALLY simple terms, the brain can only process so many signals at a time.
For relief of pain during childbirth, the “gate” is the dorsal horn of the lumbar, a horn-shaped projection of gray matter in the posterior region of the spinal cord. It relays information related to touch and pressure from muscles as well as regulating precise movement and unconscious proprioception. So when we apply sensory stimulation - such as heat, cold, water in a bath/shower, firm pressure, intradermal water blocks, Transcutaneous electrical Nerve Stimulation (TENS) and massage - the fast fibers are activated, endorphins are released, and the transmission and perception of pain never reaches the brain. All of these methods are so accessible and can be used by the laboring mother or offered by a partner or doula.
I find it interesting that the Gate Control Theory and these nonpharmcological methods produce an outcome similar to the relief of an epidural. Ok, granted, an epidural takes much less effort to sustain pain relief, offers a chance for the laboring mother to sleep and has a very high rate of success. (Although it is important to note that the epidural does not offer total pain relief. For some women, it offers none at all.) Here is a very simplified explanation of how the epidural works: a hollow needle is inserted into the epidural space below the spinal cord, and the epidural anaesthesia passes through a catheter that remains in the back for the remainder of labor. The anaesthesia blocks the A-delta and C-fibers from transmitting pain to the brain, offering relief and numbness from the waist down.
It is comforting to know that there are several options for pain relief during childbirth. Even for those choosing to have an unmedicated birth, there are still plenty of ways to relieve the innate pains of labor. Prepare in advance, arranging for a birth tub if you are birthing at home or investigating whether your birth center or hospital has a tub/shower. Purchase a hot water bottle, get an ice pack, and have a rice sock or massage tools available.
May 26th, 2009
I love when childbirth related articles fall into mainstream media. The Sunday, LA Times published an article, “Childbirth: Can the U.S. improve?”. It highlights some of the biggest issues facing expectant parents now a days; high cesarean and induction rates, the growing strain on health care, and the refusal to allow for VBACs (Vaginal Births After Cesareans). I highly recommend spending a moment to read this eye opening article.
Childbirth: Can the U.S. improve?
By Lisa Girion
May 17, 2009
Ruby Wales holds her newborn, Carson. Her first doctor worried more about the risks of vaginal delivery than of cesarean, so she found a different one. C-sections are expensive. Doctors ask if we are doing too many.
After an emergency cesarean with her first baby, Ruby Wales was holding out for a vaginal birth with her second one.
With a toddler underfoot, the 33-year-old Mission Viejo woman wanted a faster recovery. But finding a physician to deliver her second child wasn’t easy. Her first obstetrician turned her down flat. “She said, ‘No — no way,’ ” Wales recalled.
Once reserved for cases in which the life of the baby or mother was in danger, the cesarean is now routine. The most common operation in the U.S., it is performed in 31% of births, up from 4.5% in 1965.
With that surge has come an explosion in medical bills, an increase in complications — and a reconsideration of the cesarean as a sometimes unnecessary risk.
It is a big reason childbirth often is held up in healthcare reform debates as an example of how the intensive and expensive U.S. brand of medicine has failed to deliver better results and may, in fact, be doing more harm than good.
“We’re going in the wrong direction,” said Dr. Roger A. Rosenblatt, a University of Washington professor of family medicine who has written about what he calls the “perinatal paradox,” in which more intervention, such as cesareans, is linked with declining outcomes, such as neonatal intensive care admissions. Maternity care, he said, “is a microcosm of the entire medical enterprise.”
As the No. 1 cause of hospital admissions, childbirth is a huge part of the nation’s $2.4-trillion annual healthcare expenditure, accounting in hospital charges alone for more than $79 billion.
Because spending on the average uncomplicated cesarean for all patients runs about $4,500, nearly twice as much as a comparable vaginal birth, cesareans account for a disproportionate amount (45%) of delivery costs. (Among privately insured patients, uncomplicated cesareans run about $13,000.)
Pregnancy is the most expensive condition for both private insurers and Medicaid, according to a 2008 report by the Childbirth Connection, a New York think tank.
“The financial toll of maternity care on private [insurers]/employers and Medicaid/taxpayers is especially large,” the report said. “Maternity care thus plays a considerable role in escalating healthcare costs, which increasingly threaten the financial stability of families, employers, and federal and state budgets.”
The cesarean rate in the U.S. is higher than in most other developed nations. And in spite of a standing government goal of reducing such deliveries, the U.S. has set a new record every year for more than a decade.
Click here to continue to read this article
May 19th, 2009
I was really struck by a quote from Diana Korte and Roberta Scaer, authors of A Good Birth, A Safe Birth, who said: “If you don’t know your options, you don’t have any.” From what I have encountered in my years of teaching, many women really do not know how many choices they have with respect to their own childbirth. For example, I was quite dismayed to hear from a student that her former OB/GYN said to her “You don’t need to take childbirth education classes or buy the books; I will tell you what you need to know.” (She had the good sense to switch away from that doctor!)
Here are a few areas I review with my doula clients to help them better understand their choices and preferences for the upcoming birth.
Once you have a clear idea of your choices and options, it will help you communicate your wishes with your care provider to assure you are both on the same page.
Labor and Delivery
Labor at home as long a possible- Most of the time the doctor does not want you coming to the hospital too early. In general, go by the 4-1-1 or 3-1-1 rule. This means that the contractions should be 4 or 3 minutes apart, lasting one minute for one hour. Especially if the mother is intending to do a no or minimal intervention birth, it is best to labor at home as long as possible.
Food/ Drinking- While many hospitals have a no food or “clear liquids” only rule, you can decide if you want to continue to eat and drink at home or eat and drink in your labor room. Small meals with plenty of complex carbs are recommended. In fact, the Lamaze Organization, in their Care Practice Paper, “No Routine Interventions,” stresses the importance of continuing to eat lightly through out labor.
Hep lock and IV- The hep lock is a portal for a continuous IV drip. Some doctors and hospitals require the full-time IV while others are ok with just the hep lock. Unless you are in a birth center, you will most likely have the hep lock, but can perhaps negotiate the IV. According to the Cochrane Pregnancy and Childbirth Group, a respected worldwide source of information about evidence-based care, routine use of IVs is not likely to be beneficial. No studies demonstrate that routinely placing an IV in low-risk laboring women prevents poor outcomes.
Vaginal exams- Some women really want to hear regular updates of how they are doing. This can be very encouraging. However, if the water has been broken it is important not to do too many vaginal examines, in order to prevent infection. It is also recommended to have the same person check you so you do not hear too many opinions. The mother also has the right to request minimal vaginal exams. As one midwife explained to me, she does not have to do an internal to see what is happening with the mom. She can watch and listen. If the mother is unmedicated, the mother will let the midwife know when she is ready to push.
Fetal monitoring- Some care providers are comfortable doing intermittent external fetal monitoring with low-risk mothers. There is plenty of research that supports this. In fact, ACOG suggests using intermittent auscultation instead of EFM as a way to safely decrease the cesarean rate.
Labor augmentation- There are many ways to naturally move labor along: nipple stimulation, sex, acupuncture, and castor oil, just to name a few. If you are facing an induction date, check with your care provider to see if these ideas are an option. Once you’re in labor, and if things are not moving along as the care provider wants, consider castor oil as an option before moving on to pitocin.
Epidural and other pain medications- The most common anesthesia during childbirth is the epidural. However, other options are demerol and stadol. These narcotics promote relaxation and reduce the sensation of pain. Many women report that IV medication makes you feel sleepy or as if you’ve had a drink of an alcoholic beverage.
Many students have asked me about the “walking epidural”. They say they like the idea of the pain relief but want to stay active and move around. This epidural is different then the traditional type because it is a combination of spinal and epidural analgesia. However, there is no walking around. This is mainly for legal reasons, but with the epidural the mother is also hooked up to a fetal monitor (external or internal), contraction monitor, IV, epidural catheter, blood pressure cuff and urinary catheter.
Episiotomy- While the use of routine episiotomy has decreased, there are still many doctors that strongly believe it is better to cut than tear. Again, the Lamaze Organization has commented on this subject: “There is no evidence that an episiotomy reduces the risk of perineal injury, improves perineal healing, prevents birth injury in babies, or reduces the risk of future incontinence (involuntary loss of urine or feces).” You can ask your care provider to apply warm compresses to the perineum to encourage the muscle tissue to become more malleable.
Laboring positions/ Freedom of movement- Excerpt from “Care Practice Papers” from the Lamaze Institute for Normal Birth: When you walk or move around in labor, your uterus, a muscle, works more efficiently. Changing position frequently moves the bones of the pelvis to help the baby find the best fit through your birth canal, while upright positions use gravity to help bring the baby down. When labor slows, a change in position often will help you “find your rhythm” again. If your baby is in a posterior position (with the back of the baby’s head toward your spine), getting on your hands and knees helps the baby rotate and decreases back pain. If your baby is posterior, labor may be very long and difficult until the baby rotates to an anterior position, with the back of the head toward your front.
Pushing positions- There are so many options for second stage of labor, the pushing stage. The laboring mom could be on all 4’s, side lying, standing, squatting, sitting on a birthing stool, and of course, the most traditional and common, in a reclined or semi- reclined position. This is a really important subject to discus with your care provider! It is not that they may be against alternative positions; they just may not know how to guide the baby out in any other positions besides a supine position.
Students- Here is one that many people don’t think about. You have every right to ask that there be a minimum of people interacting with you and/or in the room while you birth. You or your partner can request not to have students present during your birth experience.
Pushing- Directed or spontaneous pushing? Directed is when the nurse, partner, doctor or doula instructs the mother when to push and for how long. This is what is often portrayed in the movies with the whole counting while pushing scenario. Spontaneous pushing is the mother pushing when she feels the urge to and pushing on her own.
After delivery
Cord blood collection- There are private companies that offer cord blood collection as well as public banking.
Skin to skin- You can request to have your baby placed directly on your stomach or chest immediately after delivery before they are weighed, foot-printed or given the vitamin K shot and eye ointment if all is medically sound with your baby. The Cochrane Review, an authority on evidence-based maternity care, concluded in a study that involved 1,925 mothers, that “Skin-to-skin contact between mother and baby at birth reduces crying, improves mother-baby interaction, keeps the baby warmer, and helps women breastfeed successfully.”
Cutting of the cord- You do not need to have the cord cut immediately. This excerpt from an article on cord clamping explains why. “Late vs. Early Clamping of the Umbilical Cord in Full-Term Neonates: Systematic Review and Meta-Analysis of Controlled Trials” by Eileen K. Hutton, PhD, Eman S. Hassan, MBBCh:
“Earlier physiological studies have shown that, of the total blood volume in the combined fetal-placental circulation at full gestation, approximately 25% to 60% (54-160 mL) is found in the placental circulation and that as many as 60% of the fetal red blood cells are found therein. This blood is also known to be rich in hematopoietic stem cells.
Previous research has suggested that early clamping of the cord (within the first 5 to 10 seconds of birth), compared with later clamping, results in a decrease to the neonate of 20 to 40 mL of blood per kilogram of bodyweight, which would provide the equivalent of 30 to 35 mg of iron. It has been argued that early cord clamping puts the newborn at increased risk of hypovolemic damage and iron loss, as well as of several blood disorders and type 2 diabetes, as a consequence of loss of hematopoietic stem cells.”
Newborn procedures- Unless it is medically necessary, you can request to postpone newborn procedures for up to one hour or until after initial breastfeeding.
Placenta delivery- When to deliver the placenta. This is called the third stage of labor and it could take anywhere from 5 minutes to an hour. The uterus will continue to contract, which helps expel the placenta from the uterine wall. Often, the doctor may add a little pressure to help bring it out. Some care providers allow the placenta to detach and birth on its own.
I found this great antidote by Roberta Gehrke, CNM from Midwifery Today E-News (Vol 2 Issue 2, Jan 14, 2000) about placenta delivery. “Placenta delivery techniques were taught to me when I was studying basic midwifery in London many years ago. I recall the demonstration with a smile every time my hand goes to a uterus after the birth of a babe and before the placenta comes out. The Sister asked one of my classmates to stand up and put her arms out; she threw a sheet over her and said, ‘This is the uterus, tubes and ovaries.’ She then jabbed the student moderately firmly in the sides, making her jump and quickly bring down her arms. Sister then said, ‘When you are getting impatient waiting for the placenta to let loose, the first rule is to never fiddle with the fundus! It makes the uterus jumpy, and it clamps down, keeping the placenta trapped for longer than it needs to be. It can lead to hidden hemorrhage between the placenta and uterine wall. So it may be a wise idea to ask your care provider to allow the placenta to release naturally instead of helping it along.
Breastfeeding - If you are planning on breastfeeding exclusively, you should make it clear to the hospital staff not to give your newborn a bottle or pacifier.
Now you may have a clearer idea of the choices that are in front of you. Education is empowerment. You will certainly make clear choices with how you wish to raise your child, shouldn’t you do the same with how you choice to birth your child?
May 7th, 2009
