What's pain got to do with it? (Pregnancy & Birth).

There is no doubt that painful birth has been the experience of thousands, maybe millions, of women. This concept is so prevalent in our society that it is taken as a given that birth must be an excruciating ordeal. Women who have had painless births are dismissed as liars or delusional "naturalists" in books such as Misconceptions by Naomi Wolfe. I've heard young mothers-to-be exclaim, "I just couldn't do it without the epidural!" and "I don't want to feel a single thing!" because they have so much fear over the pain that they assume must be inherent in birth.

Let them cling to the notion that suffering and birthing are two sides of the same coin. I want to explore the possibility of painless birth, without drugs.

Years ago when I first read about painless birth my reaction was also "Yeah, right!"; but I've changed my beliefs regarding birth and pain. I hope I can help alleviate the fear for the reader as well.

Even in my midwifery training I learned that pain in labor is essential for both physiological and psychological reasons. I still believe that in certain instances pain is beneficial. It can be a great communicator, both guiding and warning.

I accepted without question that birth was painful. Still, I felt that it was manageable when weighed against the harm drugs posed. When I gave birth to my own daughter in 1991 labor was definitely not painless. It was bearable.

I've certainly felt worse, before and since. Birth was a breeze compared to pathological pain such as a kidney infection, a ruptured ovarian cyst, or a broken arm.

My own birthing experience, combined with the first hundred or so births I witnessed, reinforced my belief. I did see a couple of women give birth painlessly, one even orgasmically. However, I felt that they were lucky or somehow different from the rest of us. Maybe they had a high tolerance for pain, I reasoned.

I viewed natural birth as an accomplishment to be proud of. I marveled that there were women who trained incessantly to be thin or to climb mountains, surely enduring more pain for longer periods than what labor would require, only to demand elective paraplegia on their first labor twinge. I felt it quite ironic that empowerment seminars with fire walking and river rafting were all the rage, yet women's built opportunity for enlightenment was numbed with drugs. I wondered if a runner would feel pride in winning a race if at the first stitch in the side or muscle cramp she were given drugs to stop the pain and then sped past the other runners in a wheelchair.

What I see now is that my belief colored what I saw, so that what I saw supported my belief. If birth is intrinsically painful, it would be so for everyone. Yet, it isn't. HypnoBirthing[R] (1) mothers give testimonials of two-hour, painless labors. Homebirth mothers often experience labor and birth as comfortable, or at least manageable. There are known variables that contribute to pain in labor including positioning (of both mother and baby), tension, environment, obstetrical management, and a multitude of other things under the control of the mother. Could it be that a mother's choices, in pregnancy and during the labor and birth, had any impact on her experience? Absolutely.

Once I attained certification as a Mongan Method HypnoBirthing[R] practitioner and heard repeated firsthand stories of quick and easy births, I knew for certain what I had hoped was possible. Birth isn't the problem. The obstetrically managed births, known for decades for higher morbidity and mortality rates as well as epidemically high, unnecessary surgical birth rates, are the problem.

It was the second birth of my best friend that left no doubt in my mind that my past ideas about pain in birth had been wrong. I hoped that HypnoBirthing[R] would work for her. Her first birth was "textbook," twelve hours of labor with two hours of pushing. It was hard work, and it was painful. It was emotionally difficult for me because I love her and hated to see her in pain.

When I attended her HypnoBirthing[R] two years later she was radiant. She was calm, relaxed, and retained her keen sense of humor throughout. The time between her water breaking, labor kicking in, and her her ten pound, three ounce son being in her arms, was an hour and a half (with a thirteen-minute second stage). As beautiful as that was, the amazing part was that she had broken her tailbone four days prior to birth. She never once felt pain from her injury. She beamed, "It's over already? It was so easy!"

When I believed it, I saw it. Once I saw it, I felt compelled to understand it better.

Is Pain Inescapable in Labor?

In early attempts to let women in on the secret of comfortable birth, I asked parents in my classes if labor has to hurt. The responses have been consistent, likely thoughts the reader may have, so I will address them.

Labor Must Be Painful, it's Eve's Curse

The belief that labor should be painful is often attributed to the Bible, Genesis 3:16. The word translated as "pain" or "sorrow" is the Hebrew "etzev." This same word is used sixteen times throughout the Bible. Nowhere else is it translated as "pain." In fact, in the very next verse, Genesis 3:17, it is accurately translated as it is in all other instances, as "toil." (2)

Contractions Hurt, Everyone Knows That!

Who is "everyone"? Obviously not HypnoBirthing[R] women! Obviously not blissful homebirth mothers.

The uterus contracts painlessly in its normal functioning at times other than during birth. During menstruation, the uterus contracts the cervix opening to allow the contents of the uterus to pass. Most women will not experience pain during this process.

The uterus contracts painlessly during the Braxton-Hicks contractions of pregnancy.

The uterus contracts painlessly during orgasm.

Every muscle in the body functions by contraction and release. No other healthy muscle going about its normal function hurts. A malnourished or dehydrated muscle hurts. An injured muscle hurts. Normal function such as walking, flexing a bicep, or the beating of a healthy heart does not hurt.

Something Huge Is Coming Through Such a Small Opening!

The uterus is the size of a pear before pregnancy. At term, it has stretched to accommodate the baby. Being pregnant isn't painful. There are normal discomforts as the body adjusts, but most women would not judge them painful.

The cervix has stretch receptors in it that signal the brain to release endorphins. These are the body's own strong painkillers. The cervix thins as it opens over the baby's head, as a turtleneck sweater stretching when being pulled over a head. This means there is "extra material" to work with, so to speak, as it goes from very thick and soft, to paper thin, disappearing as it is taken up as part of the uterus, which it is.

Viewing images of crowning in class invariably causes wincing. Again, we look to the amazing design of women to understand why this part doesn't have to hurt. By childbearing age, the genital area is comprised of many folds of skin. During birth, as with the "extra" thickness of the cervix, these folds are "taken up." They smooth out around the baby's head until they are gone completely, like an accordion. This built in "give" is why episiotomies are so rarely necessary.

Painless Birth: An Old-New Concept

Between the early 1900s and the 1970, three doctors tried to help American women give birth naturally and comfortably.

In 1913, Dr. Grantly Dick-Read asked a woman he'd just attended in birth why she had refused chloroform for the relief of pain. Her reply was "It didn't hurt. It wasn't meant to, was it, Doctor?"

Other similar experiences caused Dick-Read to question what he'd learned about birthing. He concluded that what made these painless labors different was the absence of fear. The idea of the fear/tension/pain cycle was born. By the 1950s Dick-Read had published several books on the subject. (3)

In the 1940s, Dr. Robert Bradley became a natural childbirth proponent, coming to many of the same conclusions that Dr. Grantly Dick-Read had.

From Dr. Bradley's work came his book Husband-Coached Childbirth and Bradley[R] Childbirth classes. Ninety percent of Bradley[R] couples give birth without drugs (4), however the emphasis is often said to be not of comfortable birth, but simply birth without drugs.

Dr. Bradley was very interested in hypnosis and originally promoted his "method" as using hypnosis. However, during the 1950s and 1960s hypnosis was controversial. Eventually, the emphasis on hypnosis was dropped and put on "deep relaxation" instead.

During the 1950s, Dr. Ferdinand Lamaze witnessed painless birth in Russia. He documented what he felt were the essential components for a comfortable birth. In the early years, Lamaze was unabashedly about self-hypnosis, but, perhaps due to the resistance met by Bradley, his "method" was termed "psychoprophylaxis" or "mind prevention." The original intent was painless birth.

Not only has the original intent been abandoned, but Lamaze[TM] International's (5) current objectives are often ignored by practitioners as well, either because they are at the mercy of the institutions in which they work or they simply do not personally agree with those objectives. Not many hospital classes address the safety and value of homebirth or evidence-based guidelines for second stage, for instance. In fact, right or wrong, anything contradicting current obstetrical management (6), much of which is the origin of pain, will be excluded from discussion.

Many nurses, and doctors, object to teaching painless childbirth on the premise that if we say it's possible, women who perceive birth as painful will feel like "failures." This is like saying that if women have painful periods, they should feel like failures for not menstruating painlessly. Pain is a subjective experience. Perceptions differ. There are too many variables in birth, and in the choices that women make, to ensure that every woman will have the exact same experience.

Another obstacle is that in most cases the nurses teaching these classes have only seen obstetrically managed births. They don't know comfortable or painless birth is possible.

A Rose By Any Other Name

One mother of the 1950s who had benefited from Dr. Grantley Dick-Read's work decided it was time for women to take back their births. Her name is Marie Mongan and she is the originator of a program using the necessary components of a gentle birth, HypnoBirthing[R].

As the name implies, HypnoBirthing[R] is about self-hypnosis. Mongan has chosen to educate people about what self-hypnosis actually is instead of cloaking the method in alternative language. Misconception still surrounds the word "hypnosis." It isn't something someone does to you. All hypnosis is self-hypnosis. Anyone can and does access this state several times a day. Falling asleep or waking up, driving, reading, or even watching TV, our brainwave pattern is the same as in "hypnosis."

Advertisers know this and use it to their advantage. Commercials slip information into our subconscious constantly. If we are in a state of hypnosis when a commercial comes on for a flame-broiled burger, why don't we all rush to get one? Because no one will do something against their own values while "in hypnosis." Those whose only exposure to hypnosis has been stage hypnosis have probably seen participants do outrageous things; however, stage hypnotists purposely choose people who might act outrageously anyway.

The Common Thread

In the 1970s, Dr. Herbert Benson studied a state he termed the "relaxation response." He acknowledged that this relaxed state carried many labels, one being hypnosis. If the word hypnosis is objectionable, the physiological state and brainwave pattern characteristic of hypnosis, as well as the relaxation response, have also been called biofeedback, prayer, and meditation. No matter what name it goes by, what's important is how the mind affects the body.

Benson's main concern was relieving stress. He recognized that modern day humans spend far too much time engaged in a "fight or flight response." His contention was that our modern life kept us in this state continually, harming our health. We now know this to be true.

In birth "methods" that actually result in comfortable, shorter, natural birth, the interruption of the fear/tension/pain cycle was integral to the method. What I found interesting when I read Dr. Benson's work (7) was that the essential components in what he termed the "relaxation response," the opposite of the "fight or flight response," were what made up the working methods for painless birth.

The Four Elements

If we look at what is required to elicit the relaxation response, we can see why some methods may have worked when they were developed, but no longer do.

1. A comfortable (and safe) environment.

Dr. Lamaze's concepts did not translate well to American hospitals where the limbic system, the primitive part of the brain that conducts birthing, interpreted strangers and unfamiliar odors as signals to "fight or flee."

Also, husbands and partners were not allowed in the delivery room, as a rule, until Husband-Coached Childbirth. The painless births that Lamaze saw in Russia included labor support. This one component has since been proven to improve outcomes (8) yet it wasn't until recent years that American women had even heard of the terms "doula" or "labor assistant."

2. A mental device--a sound, word, prayer, fixed gaze or focus on breathing.

The counted breath and focal point, which are associated with Lamaze[TM], is one example of this. HypnoBirthing[R] uses deep abdominal breathing, which holds a relaxation trigger in and of itself.

3. A passive attitude--not worrying about performing well and the ability to put aside distracting thoughts.

4. A comfortable position.

When Lamaze's methods were brought over from Europe, this was not even an option in American hospitals--all women were laid on their backs, the most uncomfortable position imaginable for birthing.

Before the routine use of non-medically indicated technology, Lamaze[TM] might have helped many women despite less than ideal conditions. A mother may not have been comfortable in the hospital, but she might be attended by the physician she'd had since childhood. She might not have been allowed a comfortable position, but if she were able to focus intently, she might be able to block uncomfortable sensations.

As birth began to revolve around the convenience of staff and the use of technology, mothers had a harder time adapting. As these mothers experienced painful labors, the mothers and those attending her made the sweeping assumption that Lamaze[TM] "doesn't work," never considering it was the adaptations that rendered it ineffective.

The importance of deep, slow breathing for relaxation is now widely recognized. Bradley[R] parents learn relaxation as well as how to avoid harmful or unnecessary interventions. The success parents experience is due to their dedication to being informed consumers and reducing interventions to only those that are medically indicated. ALACE (9) and BirthWorks[TM], indeed most independent classes, help many women in the same way and most teach techniques that trigger the relaxation response. HypnoBirthing[R] teaches such relaxation techniques along with wise consumerism.

New Choices

If our only choice in labor really was between torture or being numb to the most important event in a woman's life, it would be quite understandable that women would disconnect. The spin that has been put on this normal process is that no drugs equal pain, drugs equal no pain with some serious misrepresentations.

It's human nature not to look very deeply into those misrepresentations if we believe that it will take away our salvation. Now that we know that we don't have to make a choice between suffering in labor or our babies' well-being we truly have options. HypnoBirthing[R] has revived the concept of comfortable birth, now supported by the science of evidence-based care. Those willing to conquer the fear our culture has falsely instilled in us will change the face of what it means to birth safely, gently, and with dignity. We'll see it when we believe it.

References

(1.) Developed by Marie Mongan of the HypnoBirthing[R] Institute, www.hypnobirthing.com.

(2.) From http://answeringislam.org/Index/L/labor.html; http://www.geocities.com/Wellesley/Atrium/51481bible.html.

(3.) Mongan, F. Marie, M. Ed., and M. Hy. 1992. HypnoBirthing[R] A Celebration of Life. Rivertree Publishing.

(4.) The Man Who Changed the Face of Childbirth in the World and Got Husbands Into the Delivery Room, http://www.bradleybirth.com/drbob.htm.

(5.) An Independent Study Continuing Education Program from Lamaze[TM] International, The Lamaze Philosophy of Birth, Judith Lothian, RN, PHD, LCCE, FACCE.

(6.) Enkin, M., M. Keirse, M. Renfrew, and J. Neilson. 1995. A Guide to Effective Care in Pregnancy and Childbirth. Oxford University Press; and Goer, Henci. 1995. Obstetric Myths versus Research Realities, A Guide to Medical Literature. Bergin & Garvey.

(7.) Benson, H. 1975. The Relaxation Response. The Mind/Body Medical Institute, Harvard Medical School. Harpertorch.

(8.) Doulas Can Improve the Health of Both Mother and Newborn, http://www.mercola.com/2000/oct/1/doula.htm, studies cited at end of article.

(9.) ALACE, The Association of Labor Assistants and Childbirth Educators, www.alace.org.

Kim Wildner, CCE, HBCE, CHt; [e-mail]; [e-mail]; [phone]; http://mail.chartermi.net/~mamamojo/