Plan Schman?

I recently came across a blog post on the subject of birth plans and whether it’s worth writing them. (Full disclosure: I now can’t find the original post, or I would link to it here…). As a doula, I have always encouraged my clients to write birth plans and I believe that there are very real benefits and little to no risk, as long as you recognize why you’re writing it and acknowledge both your hopes and your fears while doing so. Continue reading

FAQ Friday: Pain in Induced vs. Spontaneous Labours

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Following up on last week’s inaugural FAQ Friday post, in which I responded to the question, “how is a doula different from a midwife?“, this week I will be addressing a question that was posed to me by a reader: “what is the difference between pain experienced during a natural childbirth and during… an induction?”

A little background to start us off, in case you aren’t familiar with the term “induction”. An induction is when, instead of waiting for labour to begin on its own (or, ‘spontaneously’), measures are undertaken to force the body to go into labour. Usually when we refer to an induction we mean a medical induction, where various steps are taken by medical practitioners in order to cause labour onset.

The word induce is a verb meaning “to bring about or give rise to”. While a medical induction is certainly the most aggressive and surefire way to make labour start, there are many non-medical techniques that women have traditionally used when they want to hurry things along a little. These may include acupuncture, eating certain foods (such as spicy things or pineapple), having sexual intercourse involving both female and male orgasm, or taking homeopathic and/or herbal remedies. Castor oil is also commonly ingested to bring on labour, though many women report unpleasant side effects, so this should only be tried as a last resort (i.e. to avoid a medical induction) and with the blessing of your healthcare practitioner. A medical induction may involve three steps:

  • if the cervix is not yet ‘ripe’ (i.e. it is not yet softening, shortening or opening) a synthetic prostaglandin gel is applied to the cervix directly in order to encourage it to soften and dilate (one of the reasons that sex involving male orgasm is helpful is that semen contains prostaglandins)
  • once the cervix has dilated a little bit, an amniotomy is performed. This is more commonly known as when a doctor or midwife “breaks your water” (aka AROM – artificial rupture of membranes). This is done using an amnio-hook, which looks a little bit like a crochet hook. The hook is inserted into the opening of the cervix and the bag of waters is punctured.
  • sometimes immediately following AROM, but sometimes after a period of waiting (in which labour may start on its own), Pitocin is administered. Pitocin is the brand name for synthetic oxytocin. Oxytocin is the hormone that is secreted during labour, which causes uterine contractions (here is where the female orgasm is handy – our brains also release significant amounts of oxytocin when we have orgasms…also when we kiss, hold hands, sing in chorus…). Pitocin is administered by an IV and the amount is increased gradually until contractions are happening frequently and with enough intensity to cause the cervix to open fully.

As you can probably gather from the above description, a medical induction is a way of simulating the natural processes that typically cause spontaneous labour onset. As with almost any intervention, each stage has some risks or drawbacks, including increased likelihood of a Caesarean section, in the event that the induction fails (a Bishop’s score is a means of assessing the likelihood that an induction will succeed in advance).

One of the biggest drawbacks to inducing labour is what the original question alludes to, that is, increased contraction pain. While every birth is different and some women experience more or less pain than others (indeed, many women experience no pain at all in labour), it can be said in general that an induced labour is significantly more painful than labour that begins on its own and proceeds without augmentation (augmentation is the use of Pitocin in 1st stage labour when it is felt that labour is not progressing rapidly enough).

Why is this? There are a couple of reasons. First, because Pitocin is not your body’s naturally produced oxytocin, but a synthesized form, it affects different people (and their uteri) differently. This makes it difficult to know how much to administer from woman to woman in order to get labour going gradually they way it most often does when it occurs spontaneously. One of the reasons that women who are induced are required to wear continuous electronic foetal monitors is because of this. One monitor shows how strong the contractions are (though not always accurately) and the other shows the baby’s heart rate (again, not always accurately). This is important because babies are affected by the contractions of the uterus and if they are too intense, this can cause foetal distress.

In addition to dosage issues, Pitocin is a substance that is being introduced to the body from outside, rather than being released from within the body as a part of a complete system. Oxytocin is only one of the hormones produced in the body during childbirth. When labour happens on its own the body is responding to prior hormonal secretions (such as melatonin) and subsequently causing others to be released (such as endorphins). When labour begins spontaneously, it usually does so somewhat gradually. The most definite sign of ‘true’ labour is contractions that progress – that is, they become stronger, longer and closer together over time. As they become more intense, longer and more frequent, the body begins to release increasing quantities of endorphins, which allow the woman in labour to cope more easily with the contractions themselves. Endorphins can reach a potency that is significantly stronger than morphine. These hormones (melatonin, oxytocin, endorphins) have a synergistic relationship to one another – that is, they enhance each other’s effectiveness in the body. Because Pitocin is synthesized and administered artificially, the body’s ability to respond with appropriate amounts of endorphins is compromised. It can’t keep up. It is important to note, that the release of endorphins can also be compromised by the release of stress hormones – catecholamines – such as adrenaline. This means that any interruption that causes stress, fear, humiliation, etc. in a woman has a direct impact on her physiologic ability to cope with the sensations of labour. These stress hormones can also interfere with the release of oxytocin, which then may lead to augmentation with Pitocin because contractions are slowing or stalling. For many people, simply being in a hospital is a stressful thing, which may be one reason why statistically speaking, hospital labours tend to be longer and tend to lead to a greater number of interventions, such as augmentation or pain medication, even when they begin naturally.

When you look at naturally occurring contractions on a monitor, they look like hills that have a slow incline, a rounded peak and a slow decline. As labour intensifies, the slopes on either side become more extreme and the peaks get higher. Contractions caused by Pitocin on the other hand, tend not to have very gradual slopes and have much higher peaks, earlier on. They look spiky, rather than hilly. In other words, induced labour hits women much harder, faster, instead of allowing for a gradual ‘easing in’. Add to that the fact that your body’s pain ‘medications’ – endorphins – don’t work as effectively when the system is circumvented, and it’s no wonder that women who have experienced both induced labours and spontaneously occurring labours say that the former are much more painful than the latter.

Do you have a question you’d like me to answer? Maybe you’d like to know more about induction, or maybe your question is on another topic altogether. Anything goes! Leave it in the comments and I’ll be happy to tackle it next week.

photo credit: Fire Engine Red via photopin cc

Don’t Believe the Hype

This article from The Wall Street Journal provides some great historical information that connects meaningfully with my previous post (Home)Birth is Safe.

The author, Nathaniel Johnson notes that,

In 1923, Mary Breckinridge started the Frontier Nursing Service in rural Appalachia….Within a decade, the astonishing impact of that care was apparent. The women the Frontier Nursing Service cared for, who were desperately poor and usually gave birth at home, were 10 times less likely to die in childbirth than the average American at the time. The nation as a whole wouldn’t catch up until the 1950s, after the widespread acceptance of antiseptic and the discovery of antibiotics.

Given that antiseptic practices and the use of antibiotics are available and in use in midwife-attended home births today, it makes sense that, as Sheila Kitzinger has argued, it is not a high level of medicalization that makes birth safer – it is overall health: access to good pre-conception, prenatal and postpartum healthcare, good quality nutrition, access to clean water and access to skilled birth attendants. This has been borne out the world over, regardless of whether women are typically birthing at home or in hospitals. Access to medical interventions for the few women who actually need them is important, which is why midwives are thoroughly trained to detect possible complications before they become problematic and why they only support home births for women who are not at risk. Obstetricians are trained to deal with problems when they arise, but midwives are far more likely to be able to prevent them in the first place. Continue reading

Education is key! Next prenatal course begins March 5th.

I have another upcoming prenatal series starting at the Centre for Social Innovation, in the Annex, on March 5th. This course will run Tuesday evenings from 6:30-9 pm for six weeks.

If you are expecting a baby between late April and early June, this is the class for you! I cap my courses at six couples, so that my students can get to know one another and start building those new parent networks early. This course will give you and your partner the information and skills you need to cope with labour and birth; self-advocate effectively with your healthcare providers; know how breastfeeding should look and feel; know what to expect of a newborn; and make decisions about parenting that will work for you and your family.

The course is $240 per couple. Discounts are available for doula clients. Email me for more information, or to register.

Topics for the series include (but are not limited to):

-pain management and coping strategies for labour

-the physiology of labour and birth

-positioning for labour and birth

-risks and benefits of common interventions

-breastfeeding

-newborn care, characteristics and abilities

-parenting options

Education is the key to having a birth experience in which you feel confident, calm and in control.

You Can’t Beat Mother Nature

I’m always excited to read about good hard science that reveals more about the awesome power of women’s and babies’ bodies. Check out this article about the hundreds of different bacterial microorganisms that have been identified in breast milk through DNA sequencing.

In addition to the further confirmation that a mother’s milk can’t be duplicated in its richness and complexity, this article also lends support for minimizing interventions in labour where possible:

The type of labour also affects the microbiome within the breast milk: that of mothers who underwent a planned caesarean is different and not as rich in microorganisms as that of mothers who had a vaginal birth. However, when the caesarean is unplanned (intrapartum), milk composition is very similar to that of mothers who have a vaginal birth.

These results suggest that the hormonal state of the mother at the time of labour also plays a role: “The lack of signals of physiological stress, as well as hormonal signals specific to labour, could influence the microbial composition and diversity of breast milk,” state the authors.

Our bodies truly are amazing.

Two Prenatal Series Options!

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I will have two new prenatal education series’ starting in the new year for those expecting a baby between late February and early April, 2013. Classes at the Centre for Social Innovation (Annex) will be on Tuesday evenings, from 6:30 – 9pm, beginning January 8th. Classes at Women’s College Hospital will be on Wednesday evenings, from 6:30 – 9pm, beginning January 9th. Both courses are six weeks in length. You can choose the series that best suits you in terms of day and location.

In taking the role of prenatal instructor at Women’s College, one of my top priorities was that I would be able to use my own curriculum and that there would be no imposition of a hospital agenda upon my prenatal course content. In other words, these two courses will be identical in content and will focus on preparing for birth as a normal, healthy experience that can be anticipated and experienced without fear and in a calm an relaxed manner. We will also cover topics related to the postpartum phase and parenting.

To register for the course at CSI Annex (Tuesdays), email me at heather@socialinnovation.ca. To register for the WCH course (Wednesdays), email janelle.noel@wchospital.ca or call 416-323-6494.

For more info on topics that will be covered, hit the jump! Continue reading

What is a ‘good’ birth?

I am one of the very lucky people in Toronto who gets to work out of the Centre for Social Innovation. This shared workspace is teeming with brilliant, engaged minds belonging to individuals who all want to make the world a better place. Every day I am surrounded by people working in social justice, the environment, food politics, public spaces and other important fields. With such a committed group of people come a lot of shared values and the interest that is fostered between members here is really motivating; everyone truly seems to care about each others’ projects, even when they seem to have very little in common with one’s own. As the only (I think!) doula in the space, people know when they see me packing up and rushing out the door mid-day, or when they don’t see me at all for a couple of days, that I am more than likely supporting a woman in labour. Upon my return I am often warmly greeted with questions like, “Were you at a birth?”, “Did somebody have a baby?”, and sometimes the hardest to answer, “Was it good?”. Continue reading