The discussions on this page were published in Midwifery Matters No. 85, Summer 2000.
White Coat Hypertension
I’ve found an interesting article on the Journal of American Medical Association, where the researchers tried to differentiate between white-coat hypertension in pregnancy and true high blood pressure.
C/s rates were 12.4% for the women with normal blood pressure, 45.2% for the women with white coat hypertension, and 41.1% for the women with true hypertension…….
The authors conclude that “the increased incidence of caesarean delivery in the WCH group may reflect decision-making processes influenced by office BP”
Prognostic Value of 24-Hour Blood Pressure in Pregnancy Gianni Bellomo et al, JAMA Vol. 282 No. 15, October 20, 1999
An Indication for Home Birth?
Perhaps this could be a way of identifying and `targeting’ women who could benefit from caseload midwifery and/or home birth. I think that a woman who suffers from WCH has far more to lose from labouring in an unnatural environment. Did the authors give reasons for c/s? I’ll bet a fair number were for failure to progress.
Unless the WCH is `treated’ it will impede labour. And the way to treat it is to take away the white coats themselves, and give a woman someone to befriend her during pregnancy whom she will then trust during labour.
(Of course I’d far rather all women had one-to-one midwifery)
maybe they could just take their coats off………
Activating Fight or Flight
I suspect the majority of mothers suffer from some form of WCH (white-coat hypertension) unless they are attended by people with whom they feel totally comfortable. … any intrusion into that birthing environment by any one else will stimulate WCH or fight or flight syndrome.
Many mothers are activated just by arriving at a hospital or birthing center. I have come to the conclusion that the healthy woman who gives birth in a safe and familiar environment, with attendants who she is not restimulated by either consciously or unconsciously, will have a pain-free and enjoyable birth. Many reports that I have received from mothers, midwives and physicians estimate that length of labor once the water bag has broken, can be counted in minutes not hours.
I my opinion we need to pay much more attention to whether or not our presence or anyone else in the environment is causing a fight or flight reaction, quite unwittingly of course. Particularly when a simple and easily applied remedy is at hand.
I have witnessed very painful and distressed labors dramatically reversed once the correct diagnosis was made and treatment was applied. In the healthy mother who has had adequate nutrition and has exercised during her pregnancy, if pain occurs then pathology is present. The pathology may well be an unsafe environment as determined instinctively by the laboring mother.
If steps are not taken to create a safe environment or discharge the adrenaline with strenuous exercise, a long wait may be necessary and in many cases intervention will be needed.
Labour is Painful
Oh, come off it, Rayner! Labour is painful – however ideal the circumstances! It may also be fulfilling and rewarding and exciting and so on and so on – but it’s usually damn painful too.
If we’re not careful, we’ll conjure up yet another thing for women to feel guilty about – daring to find labour painful even when in a “safe and familiar environment”.
All I have to say is RHUBARB, Has this esteemed researcher ever had a baby, even under the best of circumstances?
Under the usual circumstances I agree. But that is what I am trying to convey, the `usual’ circumstances are the `pathology’. Have you considered trying to replicate the circumstances which I have described?
With the belief that pain in labor is inevitable and `normal we have already created a mindset that has made many mothers feel guilty about having a pain-free and enjoyable birth! I really don’t want to make any mothers feel guilty, my goal is I am sure the same as yours. I wish to see mothers have safe births with as little discomfort as possible and without guilt of any kind.
It just so happens that I noticed my wife going into the fight and flight syndrome as soon as others arrived to assist in the birth. I helped her discharge the adrenaline, and as soon as she had done so, her contractions resumed and the birth attendants were able to come back into the room without the fight and flight syndrome being restimulated again. My wife, who is not a Stoic, experienced a pain-free and very enjoyable birth. She very quickly discovered however, that this information could rarely be shared.
I find it disturbing and very surprising that in the midwifery community of all societies, that observations concerning the possibility of a pain and distress free birth are not welcome on the whole, and need to be suppressed. Apart from a minority of midwives and some OBs this subject is not welcome….
Since the birth of my daughter in 1981 I have been observing births here in the States. I have also been studying many other cultures and corresponding with mothers, midwives and physicians world wide on this subject. There is ample evidence that the presence of people that are UNconsciously perceived by the laboring mother as hostile will inhibit labor. This inhibition will then have to be either waited out or medicated in order for labor to proceed. This evidence is anecdotal. …
Incidently, these observations were far more expertly described by Grantley Dick-Read over fifty years ago!
I’ve given birth – myself – three times – under the most ideal of circumstances! And I’ve spoken with many, many mothers who have, likewise, been lucky enough to give birth at home, with loving and skilled supporters. And all, without exception, agree that – yes – it hurts. Yet, at the same time, the experience was fulfilling and rewarding – and, ultimately, enjoyable.
I’ve also cared for labouring women in the developing world, free to move around, make any noise, hide in corners, roam the compound, supported and safe – and (guess what?) – it still hurts!
Maybe – just maybe – there is some physiological point to the pain of labour?
Please note! I said “pain” – not “pain and distress” (as in your reply).
Distress in labour is pathological.
I quite agree with all you say about the negative effects of adrenaline in labour, Rayner. I can’t speak for UK midwives in general, but recognition and dealing with this has long been an integral and basic part of my own practice. In my experience, a warm, private bath, a good cry, or an angry outburst can all help discharge the “fight or flight” reaction. I don’t think a RCT is needed to prove the validity of this approach – how on earth could one humanely randomise?!
My two labours at home (one of which ended with transfer and a caesarean, and one with birth at home) were pain free. My contractions were intense, but not what I would describe as painful. Of course, I know that many women’s labours are very painful, and I don’t for one minute think that mine weren’t because I’m somehow superior or did anything better than them. I never felt any Braxton Hicks contractions either, so perhaps I just have a very insensitive uterus!
All I wanted to say was that it is possible to have a pain-free labour and delivery. I’m sure it’s rare, and I consider myself very lucky, but it does happen.
I just wanted to add my 2p that I agree in part with Mel. I wouldn’t describe the contractions as painful. Having said that when it gets to the bit where the baby’s head crowns is b*** painful – but then over with quite quickly. Lots of people don’t believe this, but I quite genuinely think that having my bikini line waxed was more painful than childbirth.
It Hurts in Hospital
… my wife’s paternal grandmother had her first two children by herself in Hawaii. Her labor according to her was painless, and took about 20 minutes from her waters breaking to birth. It was a different matter when she had her last birth in the hospital. Her labor was extremely painful and arduous, and took many hours. She was also humiliated and felt dominated and without any power. It was the recounting of her experiences that convinced my wife to have a home birth.
An Israeli MD who had read an article by me, had been in the desert during the Gulf war. He noticed a woman obviously pregnant leaving her tent and squatting behind some bushes. Thinking she was going to the bathroom, he turned away. After some minutes he heard the unmistakable keening of a newborn. Turning he saw the woman bending over and biting through the cord. He rushed up to her and offered to help. She was offended and couldn’t understand why he was concerned. She had by then wiped her infant with her djellaba, the voluminous cloak which ensures modesty, and tucked her infant inside. She returned to her tent without further ado.
This MD made some enquiries and found that the women of some tribes quite routinely would give birth either by themselves or with a close relative, never with a relative stranger. It was not considered to be unusual for these births to be painless and fast. Some tribes who practised genital mutilation would on occasion permit a mother to be attended by a relative stranger or go to hospital when a gross infection was present. These births were of course usually hideously painful and life- threatening.
I have many such anecdotes from people in a variety of cultures. Painless birth is certainly not a rarity. The key factor seems to be in that all these instances the mother was either alone or with midwives, relatives, fathers or friends that she had known for a long time and was totally comfortable with on all levels.
I am not suggesting, or recommending at all, unassisted birth. Most mothers in this culture need assisted births with loving, kindly and very competent midwives in attendance. All I am suggesting is for midwives to closely observe for signs of fight or flight and help the birthing mother to discharge the adrenaline with strenuous exercise, or strategise so that the mother is not stimulated in the first place. This last would require an overhaul of the present system or the further use of technology to avoid stimulation.
I would like to see midwives having a far greater role in educating mothers, being with them for long periods of time so that familiarisation can minimise or eliminate such primitive reactions. To be able to go into the schools possibly to start the long process of changing the mindset that pain is inevitable. To create a dialogue that does not suggest that a mother is somehow at fault because she has pain or that a mother who does not is boasting and/or lying!
… There have been a number of teenagers here in the States who have given birth in public bathrooms or at home without parents of friends being aware of the pregnancy or birth. One notorious and very tragic case of a young girl at her prom dance, gave birth in the bathroom, left her newborn in a trash can and resumed her dancing. The trail of blood she left led to the discovery of her infant. There was also a girl of fourteen who gave birth at home, kept her infant in a closet, breast fed her, and changed her diapers and cared for her infant physically very well under those circumstances for some weeks. Her mother at last heard the infant crying in the closet.
Did the fear of discovery mute the pain or did they deny it was painful? Where they on drugs or drinking, etc., or was it that the absence of stimulators enabled their bodies to give birth easily and quickly. Now I don’t think that a speedy labor is necessarily desirable except that from a primitive point of view, it was obviously optimum that a birthing mother would cease being vulnerable as soon as feasible.
There may well be some physiological reason for pain in labour but so far no one has told me what that point is. All my training has led me to the point of regarding pain during a natural process as an anomaly or pathology. I am very open to learning otherwise.
In my experience it takes quite a sustained session of strenuous fighting a pillow or mattress to fully discharge the toxins. The F & F syndrome is an ancient one, and very powerful. It is after all designed to save lives and ensure the survival of the species.
I agree with Hannah – I have also had three homebirths, with hand picked family and midwifery support, and in each case it was BLOODY painful. In the case of the last one, it appeared to be so relaxed and `easy’ that the attending midwives (good friends of mine) found it hard to believe that I had experienced it as being excruciating in places (although ultimately, after the event, highly satisfying – maybe even because of the pain, and consequent endorphin levels, and etc???)
I think Trisha Anderson’s work is interesting here – she asked women who had had, to the eye of the observer, apparently calm, peaceful, un-stressed births what it had felt like to them, and she was astonished at the intensity of the responses and, specifically, the reports of the pain experienced. I think that we need to accept that sometimes, things in life are hard, and that the pay offs for dealing with the hard stuff and coming through with dignity are: self-respect, self-esteem and a certain added inner strength [and] may in fact be essential (or at least very useful) prerequisites for parenting.
This doesn’t mean scary out of control stuff, but strong, hard, dealing with it stuff. As an anecdote I am ABSOLUTELY CONVINCED that the sense of immense fulfilment I got from successfully birthing my first child at home after a long, difficult, and painful labour carried me through the first year of her life when she was found to have a rare and profoundly disabling chromosomal abnormality, with a lot of associated problems. I never got the blues, and I felt great about the experience for months.
Pain in labour is an absolutely fascinating topic – another one for disentangling women’s and midwives’ knowledge from that of obstetricians. Thanks for your thoughts Rayner – they are a valuable addition to the debate. However, it seems to me that there are many aspects to this topic, and it’s about time we started exploring them.
I Enjoyed Labour
I’ve had four children and thoroughly enjoyed everyone of them. The only analgesia I had was entonox and although the pain was sore it was perfectly bearable. I would rather have a baby than go to the dentist – which I find more unbearable.
So did I …at home
Marie T O’Connor’s 1992 study of intentional home births in Ireland found the women reporting “little or no pain” in 20% of cases. Marie was inclined to disbelieve them when she first heard a woman state this, but found it hard to stay incredulous, the more women who reported it.
Personally speaking, my augmented labour was dreadfully painful (begging for drugs after two hours); my caesarean was also dreadful, in terms of post-operative pain, but my home birth was BLISS – yes, the crowning was very sore, but during my long labour (waters breaking at 2.30 am – to baby born at 8.55 pm) pain was never an issue except for the crowning.
This was largely (not entirely) my experience too, with my first labour at home. Still waiting to find out about the second! Personally I didn’t find the first stage painful at all – uncomfortable, and intense muscular effort like weightlifting (which I used to do), but not painful. But then I was at home, free to move, and very confident. There was nothing sharp about the sensation – contractions sometimes overwhelming, like retching, but I just went with the flow.
What I did experience was excruciating joint pain in second stage, in my pelvis and lower back… my husband said he could see my bones bulging out and this really was pain in the joints; my uterus and cervix were no problem! I think that was probably because my son was 9lb 6oz and very wide (it took a big shove to get his shoulders out too, and then after the shoulders he was still stuck at the tummy!). Probably also connected to my having some spinal deformities in the lower back and pelvis which mean that area is always a little inflamed. Crowning burnt, but I didn’t care about that – the `ring of fire’ was really no problem, and I wasn’t afraid of pushing the baby out.
Talking to other women, I get the impression that there are many variables involved and I doubt that painless childbirth is possible for everyone, but can imagine that it could be completely painless for some. Except crowning of course!
What was bizarre for me was talking to my best friend who had her baby a week later. When we spoke immediately after the birth, she later said she was sure I was, “holding something back,” from her, and that I’d been through something awful. She was having her baby at home too but, unfortunately, had a less supportive team of midwives and started with a hindwater leak and irregular contractions. She had to fight off transfer all the way through, and agreed to have her forewaters broken just to take the pressure to transfer off. After that she had eight hours of agonising first stage, followed by a second stage which she describes as no problem at all and pain-free apart from crowning! So… I had been avoiding telling her about all the joint pain I experienced in the second stage, but when it came down to it, her second stage was absolutely fine, and her first was awful.
I am not the sort of person who is generally oblivious to pain, although I can deal with it well. I used to have all my dental treatment, including deep drilling, done without anaesthetic as I had a phobia of needles, and I can assure you that I did feel a lot of pain, I just knew how to handle it. First stage of labour was different. I was not denying or managing pain. On the other hand, the reason I used to avoid [dental] anaesthesia was that my phobia would often cause me to faint and feel excruciating pain throughout my body, and that feeling was far worse than the drilling. Part of that pain may have been oxygen deprivation, but most of it tension and psychosomatic. I feel sick and a bit faint nowadays when in hospitals at all, and I’m much better now… so can imagine that if I’d been having my baby in a hospital I would have found it very hard as I would have been in a state of nervous tension.
I too experienced two pain free labours and the deliveries were gently controlled (by the soothing words of a midwife who empowered me) and therefore no panic induced trauma to the perineum. I would sooner give birth than endure the attentions of a dentist!
Comfort Measures to reduce Labour Pain – from US Midwife Archives
AH updated 8 July 2000