Labor Pains- Natural Birth? I Hope Nobody Reads This!

If nobody reads this, maybe we can continue to label those women that say they want to have natural birth as a bunch of hippies and wierdos. Then when we fail to provide them with resources to maximize their chances of achieving what they want, we won't feel as bad. Great idea!
If nobody reads this, maybe we can continue to smile knowingly everytime we meet someone who wants to try labor without an epidural.We can continue to make mental bets on how long they will last. After all, what else is there to offer them?
If nobody reads this, maybe when our patients say they want to try natural birth we can go on telling them, "sure just come in on the day and we'll see how you manage!".
Perhaps many of those that want to have a natural birth like the idea of it but don't want to put much time and effort into preparing for it anyway. I tried this philosophy on running the marathon once. It didn't work out too well!
The question is, who has time for all of this when things seem to be working just fine? How can change happen?

If we really wanted to make a change, we would initially create a sense of urgency. Then we would put together a guiding team that would include patients, physicians, midwives, nurses, hospitals etc. (if you can't tell, I've just read "Our Iceberg is Melting" by John Kotter!). The solutions would be decided upon as a TEAM.
Since no one will hopefully reads this, I can be honest and say that many women who choose a non-pharmacologic approach to pain management are often ill-prepared. Some of the ones that succeed look at the pain as a side-effect of a normal process (labor). They may even say crazy things like they felt "able to transcend their pain and experience a sense of strength and profound psychological and spiritual comfort during labor". Yeah! Whatever!
So what are some of the things that we do know about this option?
In contrast to epidurals, the primary goal is not to make the pain disappear. Instead, the woman is educated and assisted by her caregivers, childbirth educators, and support people to take an active role in decision-making and using self-comforting techniques and nonpharmacologic methods to relieve pain and enhance labor experience. If a woman after a few hours in labor decides to get an epidural it is not a sign of failure. For some, just the ability to walk around for a period of time and feel more in control can be very satisfying.
The birth environment and continuous labor support from the father, family member or doula are very important aspects of this approach. A doula that is familiar with the family and the physician can provide tremendous support. A prior meeting or discussion will make sure that everyone shares the same mental model of what to expect when the time comes.
These are some of the options for non-pharmacologic pain management in labor even with the system that we have in place now;
Water Immersion: Many women find the feeling of being immersed in warm water very comforting and relaxing especially in the beginning phases of labor. It has been shown that in "low risk" pregnancies this is a safe practice.
Sterile Water Injection: Also called a "water block", usually involves four small injections in the skin of the back to primarily relieve pain in that area. The injections can be painful but the relief can last 45 to 120 minutes.
Touch and Massage: Women clearly appreciate these and they appear to reduce pain and enhance feelings of well-being.
Acupuncture and Acupressure: As long as this approach is performed by trained practitioners it seems to be safe and provides a great deal of satisfaction to those that have tried it. It remains to be seen how it can be integrated in healthcare institutions.
Hypnosis: Hypnosis used for childbirth is almost always self-hypnosis; the hypnotherapist teaches the woman to induce the hypnotic state in herself during labor. Sometimes her partner is taught to signal her into the hypnotic state. I have seen the positive effects of this technique in my patients that I have referred to Dr Jay Stone. He makes his materials available on line at http://www.drjaystone.com/ .

There are many techniques that can help decrease the pain of labor and sometimes eliminate the need for epidurals and medications. Not all of them may be available or appropriate depending on the risk level of the pregnancy. Most of these methods need a good deal of preparation and time investment by the woman and everyone involved in her care. Although our current system is not fully set up to support these approaches it doesn't mean that they are completely out of reach.

It does seem like a lot of work though! Like I said I'm glad nobody's gonna read this.

Labor Pains- Epidural, Neither Demon Nor Savior

A knight in shining armor, the anesthesiologist gallops away on his white horse after saving yet another lady from the throes of pain!

When the epidural works as it is supposed to this or a similar scene is what comes to mind. The fact that the anesthesiologist is the hero in this scenario doesn't bother me. Really, I'm not jealous! Even though un-scientific polls (conducted by me) show that most women would prefer to see their dentist rather than their gynecologist. I know that I will never experience a gyne exam but less popular than dental work? When I see my dentist I have what seems like a large and noisy Black & Decker drill excavating my tooth, shaking me to the core while flying debris land on my face and glasses. This all as I'm trying to watch Oprah on the tiny sized TV mounted high in the corner. It may be my only opportunity to learn what she is telling my patients to ask me. I'm not angry. I'm just sayin'!

Please ignore my digression. This post is not about exulting the virtues of epidurals but hopefully giving you an idea of what we know of it's benefits and disadvantages and perhaps dispelling some myths.


Lets start with benefits:

Epidurals have been shown to be more effective in relieving pain and have less of an effect on the baby than some of the intravenous medications. Their placement is usually easy and despite some women's fears not very painful. Depending on availability some may be able to walk with the epidural in place but in practice most women rest in bed. There is also the possibility of patient controlled epidurals where you control the amount of medication flowing through the pump.


Now disadvantages:

You may have heard that epidurals slow down the process of labor. This indeed appears to be true. Studies show that it can prolong labor by 40-90 minutes. There are also some conflicting data about the fact that it may increase the need for instrumental (vacuum or forceps) delivery.
A more common but usually minor risk is that epidurals can cause a headache. This commonly resolves within days and rarely requires an intervention called a "blood patch".

There are times that epidurals are ineffective or only partially effective. This does not happen very often but understandably can create a great deal of anxiety and panic. Some of my patients say that they want to be "drugged up" so they won't feel any pain. It is important to emphasize the other options for pain relief and provide tremendous coaching and support in case the epidural is unavailable or is ineffective.


How about myths:

Some of my patients make their minds up very early on that they will not consider an epidural under any circumstances. Unfortunately many times this is not a choice based on accurate information but rather myths perpetuated by friends and family members. One of the most prevalent is that epidurals cause chronic back pain. This has been shown not to be the case. The risk of developing back pain is the same whether you receive an epidural or not.

Another common but erroneous perception is that an epidural may not be placed until cervical dilatation has reached four centimeters. The view of ACOG (American College of Obstetricians and Gynecologists) is that "women in labor should not be required to reach 4–5 cm of cervical dilatation before receiving epidural analgesia".



Epidural analgesia is a safe and effective option for pain relief in labor. You need to approach this choice as you would any other medical procedure. Ask questions, discuss with your physician or midwife and consider the risks, benefits and other alternatives. This post is certainly not meant to be comprehensive but only to provide an overview and a starting point for discussion. In subsequent posts we will look at some other options to consider and they probably will not involve anesthesiologists or dentists!

To look at the ACOG patient education pamphlet on "Pain Relief During Labor and Delivery" go to:
http://www.acog.org/publications/patient_education/bp086.cfm

Labor Pains-Regain Control

"A large number of women want to avoid pain. Some just don't fancy the pain [of childbirth]. More women should be prepared to withstand pain… pain in labour is a purposeful, useful thing…such as preparing a mother for the responsibility of nurturing a newborn baby," (Dr Denis Walsh-Associate Professor of Midwifery, United Kingdom, July 2009).
OMG! (Oh my god!) WITRMBSATITDAA?! (Who in their right mind believes such a thing in this day and age?)
I feel a little nervous starting a series of blogs about labor pain management. The discussion many times becomes overwhelmed by extremes of beliefs that accuse each other of often untrue and imagined practices. On one side are those that passionately advocate for natural, unmedicated labor and on the other those that believe medicalized pain relief is often the best choice for most women. The former at its extremes paints a picture of scalpel wielding, episiotomy cutting physicians who want to expedite delivery in time for the first “tee-off”. The latter on the other hand portrays an image of incense burning, oil rubbing midwives who would go beyond the boundaries of safety to achieve natural birth.
In my experience neither of these portrayals is anywhere near accurate. However it’s the extremes that grab the headlines and leave pregnant women confused and sometimes forced to choose sides.
Forgive my slight detour but this is very similar to our current debate on healthcare reform. If one listens to the loudest voices the choices are either granny killing death panels on one side or gun toting poor people haters on the other. The majority of us want to hear a reasonable mature discussion where all sides are heard and acknowledged, (I know people tell me I’m naive!).
Over the next couple of blogs I will discuss what options may be available to manage pain during labor. From medications and epidurals to meditation and guided imagery. Whatever pain management technique you may be drawn to, knowledge is empowering.
Some of my patients tell me that they are used to being in control and are fearful that they have none when it comes to pain in childbirth. In my opinion, control is a function of knowledge and together with your readings (but not googling at random!) and discussions with your healthcare provider team you will feel in charge. It is important for you and your healthcare provider team to have a “shared mental model”. This means that all of you agree on a common goal: a healthy baby with a healthy and happy mom.