Tuesday, January 18, 2011

Off the Shelf: Easy Labor and Ina May’s Guide to Childbirth

This past weekend was a lazy one (though “lazy” implies that I was willingly shirking other duties, and I’m not sure that was the case). I had a backache and was very tired, so I spent most of it napping, reading and watching BBC miniseries. Since it’s been a few years since I did the whole “labor & delivery” thing, I find myself in a position to brush up on my knowledge about the process and consider my current thoughts on pain management.

First, some personal history (TMI? Meh. After 3 deliveries, I defy you to find someone who hasn’t seen me in a hospital gown)…

My first child was delivered after a necessary induction at 39 weeks. After taking a birth class (I suppose it was closer to Lamaze than anything else, but it was more generally informative rather than a particular philosophy, like Bradley classes, for example),  I had a birth plan… no IV (I hate needles), no planned pain meds but an open mind, and I asked that everyone knock before they entered the room and ask before bringing in students (ours is a teaching hospital). But when I was diagnosed with severe preeclampsia and found out that I was going to require continuous IV medication and a catheter, I opted for an epidural. My OB had recommended it since epidurals have a side-effect of lowering blood pressure, and that is the main concern with preeclampsia. The epidural worked like magic… I went from pain-induced vomiting to complete relief. I managed to take a nap, wake up fully dilated and push effectively for 20 minutes until my daughter popped into the world. Overall, the outcome was as good as could be hoped, and the recovery went well.

19 months later, when I was checking into triage for the induction of my second labor for pregnancy-induced hypertension (basically pre-preeclampsia) at 39.5 weeks, I let them know that I was planning to get an epidural at some point. I did not require preeclampsia treatment as I had the first time, but the point did come when I was ready for an epidural. Like the first, it was complete relief… until it wasn’t. I don’t remember everything in stark detail (I was in a lot of pain, after all), but what I do remember is having increased pain with every contraction until I was sure I was getting no relief at all. Unlike the first epidural, this time I had a button to push every so often when I thought I needed a boost for the pain relief, but  I was in a situation where this little boost was not nearly enough to do anything for the pain. I let the nurses know this as it was happening, but I don’t recall anyone taking action to get the anesthesiologist back to fix the situation. I don’t think it lasted very long though, and after some very painful but short-lived pushing, my second daughter was born.

Then, 13 months later (“the lipstick was still on”, as my grandmotherly neighbor would say), I found myself back at the hospital with my third birth experience. This time labor began spontaneously at 38 weeks, and I was admitted by a resident who first lectured that my contractions were probably brought on by being dehydrated before conceding that I was dilating and, in fact, actually in labor. I had meant to do more research about pain options during that pregnancy, but with a baby and a toddler and all the joys of pregnancy, it just hadn't happened. I was hoping that my bad epidural was just a one-time thing, but it happened almost exactly the same with the third as it did with the second. Again, I had a beautiful baby (a boy this time) and an ideal recovery, but the pain was not handled well and my “satisfaction” with pain management by my hospital was nothing to write home about.

So… here I am again! Very excited for baby #4, looking forward to labor with more anticipation that worry, but very interested in knowing all my options for pain relief and a sincere desire to have a better birth experience this time. In discussing it with my OB, he made a good point… some women want to carefully orchestrate all elements of their birth experience, and others just want to get through it. He likened it to vacuuming… some people want to see a pattern in the carpet when they’re done vacuuming, and some people just want the vacuuming done so they can enjoy the tidy room. I’m more of a get-it-done person, and this time, I’d like to be more comfortable as I deliver. My OB agrees that I was probably in the most intense pain but without the advantage of having gotten there more gradually, as would have been the case without an improperly functioning epidural, so my two bad epidural experiences may have essentially been my worst case scenario in terms of pain. I certainly survived without emotional scarring, but this time I’d prefer to save the suffering for the first twelve months of sleep-deprivation and the teenage years, thank you very much.

I don’t think that everyone needs pain medication to get through labor… childbirth is certainly natural and undeniably survivable. But also personal and individual. And pain and suffering are not the same thing, and felt differently by different people. Some pain can be good, and many people think this of labor pain. Personally, I am not afraid of labor. But many are, and justifiably so. It is exquisitely painful. There have been documented cases of painless labors without medication, but no one should have any expectation of completely avoiding pain, no matter what sort of philosophies are employed to mentally and physically prepare. Every labor is different, and any number of unpredictable factors might come into play to change the experience (preeclampsia, dystocia, back labor, issues with the baby’s heart rate, etc). Ultimately, the only things that can be counted upon during labor are confidence that it can be done and trust in the people caring for you.

And since knowledge is power, I picked up a couple books at our local library to explore pain relief and coping mechanisms for labor. I have a few books around already, like the ubiquitous What to Expect When You’re Expecting and The Birth Book, but I wanted a more targeted selection. I wanted books that respected women’s decisions to manage their own births, as well as providing actual data… given my biology degree, I understand the importance of proper research in forming conclusions, and I want real data to back up claims of safety or danger, especially the effect of certain medications on the health of the newborn.

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The first book, Ina May’s Guide to Childbirth, was written by a very well respected American midwife, Ina May Gaskin. It was published in 2003. She has delivered thousands of babies with amazing statistics in terms of minimal interventions, cesareans, etc. Her goal is to educate women about their bodies and the amazing things they do during labor and delivery, to replace fear and ignorance with knowledge and to encourage them to have faith that they can do it, successfully and satisfactorily. I found the book to be very reassuring, but possibly not the very best resource for first time moms. Since I’ve had 3 labors already, I know what level of pain to expect. Her book discusses the concept of “orgasmic birth” in addition to outlining many, many alternative pain coping options. I think that presenting the possibility of a natural yet pain-free birth could set some women up for unrealistic expectations which will not serve them well when they find themselves facing the worst of labor pain. I know several wonderful women who had very difficult, prolonged labors, whose pre-labor plans certainly didn’t help them have a “satisfying” labor experience and, truly, made their deliveries and recoveries more difficult than would have been had there been more medical “interventions”. Ina May’s Guide to Childbirth aims to empower women to be in control of their labor decisions rather than succumbing to the whims of the medical community at large, and I think that is a good thing, especially given the turbulent history of obstetrics. She has a lot of good advice for laboring without interventions, in a manner that provides emotional comfort and physical support… again, this information is incredibly valuable and makes this book a very worthwhile read, even if you’re planning to get an epidural the minute you’re admitted. But pregnant women should also be well informed of medical pain relief options and be made aware of potential complications in addition to coping mechanisms, and this book does not cover those thoroughly or in a very positive way. Some of the data she provides seems at odds with the research documented in the second book (below), and I can’t help but be suspicious that the studies she cites regarding medical interventions, an area of care she does not provide, were presented in a way that supports her personal view that pain relief is not necessary in a normal delivery and could cause guilt, disappointment and possibly fear to women who ultimately choose medical pain relief in the course of their normal delivery.51QyQyG--gL__BO2,204,203,200_PIsitb-sticker-arrow-click,TopRight,35,-76_AA300_SH20_OU01_

The second book I read is Easy Labor: Every Woman’s Guide to Choosing Less Pain and More Joy During Childbirth. Written by William Camann, MD, the director of obstetric anesthesia at a large Boston Hospital, it was published in 2006. This book is much more “medical” than Ina May’s Guide, but offers a very thorough look at all the analgesic and anesthetic pain relief options currently available, as well as many alternative methods (water immersion, birth ball, doulas, etc.). I immediately felt that this book had a bit less of an agenda than Ina May’s Guide, but, being written by an anesthesiologist, was not shy to describe and tout the pain eliminating powers of modern medicine. Perhaps I only felt that way because most American women currently choose medical pain relief so Ina May had to be defensive… the jury is still out. I found it very interesting though, and I appreciated the regular inclusion and citation of research studies that described neonatal outcomes as well as overall patient satisfaction with their labor and delivery experiences. It was interesting to read what decisions doctors and midwives chose for their own labors, and seeing data I felt I could trust about the relative safety of pain medications. I was surprised to learn that there are several types of epidurals, and this might have led to my differing experiences with my 3 labors. I will certainly be more informed when I talk to the anesthesiologist this time around, and I have formed some opinions that will hopefully help me make the right decisions to get satisfactory pain relief when the time is right. This book stressed the ultimate goals of healthy baby and healthy mom, satisfying birth experience and the concept of flexibility when it comes to envisioning your perfect birth, regardless of your pain preferences and initial labor expectations.

After all this educational reading, I am feeling more confident about delivery. I think one of the most interesting new things that caught my attention (from Ina May) was the fact that privacy is a key factor in keeping labor progressing smoothly. During labor, your body is working hard to get a chubby baby out a small space, and this requires concentration and hard work. This feat of womankind is generally accomplished faster and easier without an endless stream of strangers parading through and observing your discomfort. Food for thought…

2 comments:

Betsy said...

Hurray! I know you're 1 kid ahead of me, but I think we have similar mindsets for our upcoming births. I must admit, I'm pretty excited this time around and feel much more confident in myself and my mothering abilities. I'd love to add a book to the list: A Guide to Effective Care In Pregnancy and Childbirth (3rd ed). It's written for medical professionals, but it's easy to read. It's basically summaries of the latest research (in 2000) in pregnancy, childbirth and postpartum care . It's pretty awesome to have my hands on the same info that my doctor has, and understand the "whys and hows" behind some recommendations, etc. It's one of the books we used in nursing school and I'd love a more current ed, but I don't think one has been published, yet. It's my bathroom reading and I think I've read through the whole think, piecemeal, at least 15 times.

Mom said...

It's been more than a decade for me since childbirth, but water is wonderful for pain relief. Have you considered a water birth or laboring in the shower? Positive thoughts for your labor and delivery!