Breastmilk Jaundice
October 7, 2016
Your Birth Plan
November 2, 2016

Dealing With Pain

DEALING WITH PAIN

Many women who are pregnant for the first time fear that pain is going to be overpowering.? They may have never experienced pain that tested their inner resources and feel ignorant of the kind of pain that they are likely to face.

The three statements that follow express what many first-time mothers feel:

?I?ve got a very low pain threshold.? I can?t stand going to the dentist, so I can?t think what labour is going to be like!?

?The idea of the pain really worries me.? I?ve never really experienced severe pain, and I can?t imagine what it?s like to be in pain for hours and hours and hours.?

?What is labour pain like?? I mean, is it like breaking your arm or a bad headache or period pains or indigestion ? or what?? If I knew what it was going to be like I could face it better.?

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PUTTING PAIN IN CONTEXT

People often think that pain is just a matter of a ?high? or ?low? pain threshold.? There are very few women who think that they have a high threshold and can bear pain well.? In fact, the idea of a pain threshold being like a wall, with some of us possessing high walls and others low ones, is a myth.

It is now know that the pain sensation threshold is the same in all human beings.? In one research study in the United States, members of Italian, Jewish, Irish and other ethnic groups were given electric shocks ranging from mild to fairly strong, and every single person said pain occurred at exactly the same point.? Yet obviously we do not all react to pain in the same way because it depends on what is going on in our minds.? There are times when a pain, which you once bore easily, becomes too much to take and you cannot stand it any more.? Toothache that you can handle without difficulty when you are busy and preoccupied can be absolutely shattering when you go to bed, lie down and try to sleep.? So you cannot judge the degree of pain simply by watching how an individual reacts in a laboratory situation.

People may see a pain-producing stimulus as a test of their power to endure pain, and may not always be ready to admit to being hurt.? In the Sudan, for instance, a young man who cannot bear pain loses social esteem and is unlikely to find a girl to marry him.? As in many cultures, the ability to bear pain stoically is part of a code of values.? In every society there are cultural stress points, situations that are seen as threatening and thus predispose people to feel pain.? When we know what makes people anxious, we can begin to understand these stress points.? Pain is further complicated by the fact that in many societies some painful stimuli may be linked with pleasure.? In lovemaking, for example, slightly painful stimulation may be sexually exciting.? The borderline between pleasure and pain can be indistinct.

The context within which pain occurs is important.? As an experiment, electric shocks were given to test people first when they were feeling relaxed and cheerful, and then when they had been made to feel anxious.? The electric shocks were felt as much less painful when the subjects were cheerful.? In another study, as many as 35 per cent of a doctor?s patients experienced marked pain relief when given a placebo, an inactive substance that they were told was a painkiller.? It has also been found that the degree of pain tolerated bears a direct relation to the rate of increase in pain, rather than to the level of pain reached.? A person experiencing a pain stimulus that gets worse rapidly feels it more than someone experiencing just as strong a stimulus that takes longer to reach the same point.? It helps to have time to adapt to pain.

This may have particular relevance to very rapid labour, especially an induced labour (see page 334), when the pace is more than a woman can cope with.? We sometimes talk about labour as if a long labour were difficult, and a short one easy.? But speed alone can give no indication at all of how a woman experiences her labour.

Pain perception involves not only a recording of the stimulus by the brain, but also a judgement as to its significance and its place in the scheme of things ? the meaning of the total situation in which the stimulus occurs.? The experience of pain in labour is profoundly influence by the values of the society in which the woman grew up and everything that she learned about birth when she was a child.

So labour pain is partly a product of personal and social values about the meaning of childbirth.? The way we eat, sleep, empty our bowels, make love, have babies and die makes these experiences more than simple biological acts.? They all express ideas about good and evil, beauty and ugliness, the pure and the polluting, what is healthy and what is diseased and what is normal and abnormal.

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SOME PHYSICAL CAUSES OF BIRTH PAIN

As the first stage of labour progresses nerve fibres that record pain are stimulated because the muscles of the uterus are squeezed tightly.? A similar thing happens if you contract a muscle in your leg or arm very tightly and hold it taut for a minute or so.? The uterus is the largest muscle in your body, so it is not surprising that this squeezing hurts.? Pain of this kind is a sign that you are having good, strong contractions.? When the uterus contracts firmly, the flow of oxygenated blood into the muscle and of deoxygenated blood out of it is slowed down until the contraction is over.? So there is a temporary build-up of waste products, which are released again in the interval between the contractions.? Relaxing and taking complete breaths as soon as each contraction is over enables you to provide fresh oxygen for this hard-working muscle so that it can function effectively.

As the cervix is stretched to make space for the baby to pass through, localized pain is felt at the place where the cervix is dilating.? This pain, at the very bottom of your abdomen, is common in straightforward labours and a good sign that your cervix is opening.

When pelvic ligaments and joints are stretched as the bony pelvis spreads wide and the baby descends, nerve fibres that run through them are stimulated, resulting in pain as your body opens up.? This pain from ligaments, through difficult to handle, is a sign that your body is working well.

A baby who is not curled up, head down, in a neat ball with its chin tucked into its chest, takes longer to pass through the cervix and down the birth canal, and the pressure produced by the back of its head sticking into the small of the mother?s back, or the unflexed head pushing down through soft tissues, causes pain.? This also happens sometimes if the baby is very big.? As contractions become stronger and more frequent they usually have the effect of rolling the baby round and down into a better position.? So this pain may disappear entirely once the way is clear and you can push.? You help your baby to rotate by being upright or on all fours.? Upright positions such as standing, kneeling or squatting enable you to use gravity.? An all-fours position lets the baby drop away from your spine so that it turns more easily against your springy abdominal wall.

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PAIN RELIEF IN OTHER CULTURES

There are two myths about the ways in which women in traditional cultures give birth.? One is that labour is always horrific and dangerous, but that women do not cry out because of strong taboos against showing that they are in pain.? The other is that women all have completely painless births, and just squat down in the fields and have their babies before getting back to work again.? The truth is probably somewhere in between the two extremes.? In many traditional cultures healthy women have straightforward labours while other, malnourished women suffer a great deal.

Most cultures have methods of relieving pain in childbirth, so there is obvious recognition that it exists.? But the ways in which pain is relieved and labour made more comfortable are radically different in the technological Western counties.? We can give complete relief from pain and remove all sensation from the waist down with regional anaesthesia.? This is what an epidural does (see page 319).? We have other forms of pain relief that partially remove pain or that eradicate the memory of it.? We rely on pharmacological substances to do this for us.? Herbal medicines are used in traditional cultures and some of them have narcotic or mood-altering properties, just like modern drugs, although it is much more difficult to prepare the right dose when you are using plants.? There are also other kinds of help that are favoured in these countries and that used to be employed in the West.? They include religious and magic rites, counterstimulation, massage, hot and cold compresses, changes in position and emotional support from others sharing the experience with the woman in labour.? These supporters hold her, stroke her, rock her back and forth and live through the birth with her.

Much of what is done by birth attendants in other cultures provides simple, practical help based on the handed-down experiences of generations of women.? It has a psychosomatic effect, too, helping the baby to be born by positively influencing the mind of the woman in labour.? This kind of practical help is forgotten or misunderstood in our modern hospitals.? Yet there are advantages in coping without drugs, because all powerful drugs have side effects and they all go through the mother?s bloodstream to her baby.

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IMAGINING YOUR LABOUR IN ADVANCE

It is good idea to work out how you might like to be helped to be more comfortable, and how to use your mind to help your body through relaxation, focused concentration and ideas and mental images that produce a harmonious pattern between what is going on inside your uterus and the way you think about it.? You may find that all this is difficult to conceptualize before you have your first baby.

Trying to master your body or run away from sensations can actually produce pain because you become tense and chemical messages are sent instantaneously into your bloodstream which affect your whole metabolism.? This causes changes in skin and muscle tone, blood pressure and heart rate, breathing, and digestion.? Psychosomatic factors can even change the action of the uterus itself in ways we do not yet fully understand.? A woman who is very anxious may have a long labour because her uterus does not work efficiently or stops contracting.

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WHAT LABOUR FEELS LIKE

In normal labour, pain is quite different from the pain of breaking a leg, for example, or being injured.? The physical feelings produced by a strongly contracting uterus are powerful and challenging.? They involve a combination of sensations ? a very tight squeeze, a pulling open of tissues, and the firm, downward pressure of the solid ball of the baby?s head through a passage that is being slowly stretched wide.? In films you sometimes see a pregnant woman suddenly double up, her hands clasped over the top of her abdomen.? Labour has started!? But it never happens like this in reality.? Instead, there is a sensation of being gripped by tightening muscles low down in your abdomen or in the small of your back.? All the sensations are at hip level.? Nor is the feeling a sudden one.? A contraction has a wave-like shape, building up to a crest and then subsiding and disappearing until the next contraction.? There is a rest period between them, often lasting a minute or more, even in the stormy late first stage.? As contractions get stronger, longer and closer together, the tightening may extend right round your body, so that it feels more like a circle of thick, wide elastic across your pelvis which is being steadily drawn in, held firm and then slowly released again.? Or you may be conscious of expansion during contractions and aware of the top of the uterus spreading and rising, tilting forwards in your abdomen, while the great muscle squeezes its lower part open and presses the baby down.

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PAIN WITH A PURPOSE

Feeling during labour may be painful, but it is pain with a purpose and different from the pain of injury.? Contractions are not painful in themselves, and in fact the uterus contracts strongly and rhythmically at intervals in the second half of pregnancy, usually without causing any pain.? It is the peak of the contraction, when the muscle is working hardest and is making most progress, that is most likely to be perceived as painful, and this may last as long as 30 seconds or as little as 15 seconds.

The idea of a pain that is qualitatively different from other kinds of pain is difficult to accept for anyone who has not experienced it.? Yet sheer physical effort, like that involved in running a race or climbing a mountain, produces that kind of ?functional? pain, the ache of muscles that are working very hard.? If the athlete thought only of pain instead of about winning the race, she would give up.? If the mountaineer thought that her aching muscles were the sign of some dreadful physical injury instead of the natural result of working them so hard, she would forget all about her goal and lose the feeling of triumph when she reaches the summit.

Pain in labour is the by-product of the body?s creative activity.? Contractions are not pains.? They are tightenings that may be painful, especially when they are being most effective.? There is an art in approaching each new contraction, in thinking ?Splendid! Here?s another one!? and later, as you approach the end of the first stage, when they are at their strongest, ?Oh, this is a really good one!?? When you are in the thick of labour, your whole self is involved.? It is almost impossible to think about other things or to hold a part of yourself back.? The intensity of labour can be frightening, especially for the unprepared woman who does not know what to expect, or for one who wants to keep it all at the level of a learned skill, doing her exercises in the same way as she might carry out a three-point turn in a driving test.? This is why preparation merely for handling contractions is never enough.? You also need to prepare yourself mentally and emotionally for the overwhelming sensations and feelings of labour.

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MOVEMENT

One of the best ways of handling pain is to move.? Walk about, and when a contraction comes, lean on your partner or against furniture, and rock or circle your pelvis as you ?go with the flow? of the contraction.

Your partner can join you in a slow birth dance.? You lead ? your partner follows.? You may want to place your hands behind your partner?s neck, fingers interlaced, and rest your head against her chest or shoulder.? Or it may feel best to have your arms dropped and relaxed.? Let your partner?s arms encircle you, and her strong hands give counter pressure in the small of your back.

You can move this way in a kneeling position, too.? Or it may feel good to put one foot up on a chair, and move in a lunge position.? It is easy to sway and rock your pelvis when you are on your hands and knees, too.? An all fours position like this often relieves pain.? Explore some of the movements suggested on pages 214-218.

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BREATHING

When we are in pain our breathing usually changes.? We hold our breath, gasp, or breathe in and out rapidly with a cry.? The result is under-breathing or over-breathing, both of which, over time, alter the balance of blood gases and make it harder to cope with pain.

Birth pain comes and goes in waves, gradually building up to the peak of the contraction, then subsiding and disappearing.? In most labours it continues for some hours and comes at regular intervals.

Breathing in panic becomes part of a vicious circle.? The reaction to pain causes more pain, and as a woman gets increasingly tense and tired, the pain gets worse.? Her panicky breathing begins to affect people close by and makes them anxious, too.? She picks up their concern and becomes more and more agitated.? No wonder that the only way out of this circle of pain and distress seems to be an epidural.

Backache, also common in labour, is not rhythmic.? It tends to be there all the time, getting more severe at the height of contractions.? In reaction to back pain, breathing can become constricted or breath is pumped in and out rapidly in gasps, and this makes the pain worse.? Smooth, rhythmic breathing is a way to handle pain.? Focus on the breath out and avoid gulping in air.? Use the greeting breath and the resting breath described on page 208 with each contraction.? As pain peaks, blow out, or give a long, deep groan on the breath out.? Keep the pitch low, as if it were going down into your pelvis.? Rehearse the breathing pattern suggested on pages 208-209 to manage your pain.

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HYPNOSIS

Some women find hypnosis an effective method of relieving pain in labour.? It has the great advantage over chemical anaesthetics of not reducing the baby?s oxygen intake or making the woman feel drugged and drowsy.? In fact, about a quarter of women who have had hypnosis in childbirth say that they experienced no pain, but results vary and most women who have hypnosis choose chemical pain relief as well.

The common belief that hypnosis involves some magic trickery and that you can be made to do anything the hypnotist wishes is very wide of the mark.? Hypnosis is a state of increased suggestibility induced by deep relaxation and concentration.

With hypnosis, some women become immune to pain and may have a forceps delivery or be stitched up after an episiotomy without a local anaesthetic.? Two out of every hundred women can be so deeply hypnotized that they could even have a Caesarean section without feeling any pain.

If you plan to have hypnosis in childbirth you are usually trained in progressive relaxation to remove anxiety and are helped to think positively about childbirth.? You can also be taught to use auto-hypnosis in which the hypnotist suggests that you will be able to put yourself to sleep and wake up when you wish.? After the birth the doctor may suggest that in the future you only be afraid of being put into a trance by anyone using hypnosis for their own purposes, or for fun.

It could be claimed that all good childbirth classes teach auto-hypnosis.? Thinking ahead to labour constructively when you are deeply relaxed is equivalent to using the power of suggestion and positive fantasies about labour and your beautiful baby to prepare yourself for childbirth in the knowledge that this is completely safe.

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ACUPUNCTURE

Another way of reducing pain in childbirth is by acupuncture.? It derives from a completely different system of beliefs about the human body from that of Western medicine.? Hair-fine needles are used to stimulate 12 lines of energy called ?channels? flowing beneath the skin.? This energy keeps the blood circulating, for example to relieve nausea and vomiting, cure constipation, encourage a breech baby to turn, and to start labour.? Acupuncturists sometimes use moxibustion, the burning of a small pellet of mugwort at certain parts of the body, to turn the baby.? In labour, electroacupuncture may be used at points in the ear for analgesia, and with this technique the woman herself can control the degree of stimulation.? In Beijing nowadays acupuncture is performed in preference to epidural anaesthesia for 98 per cent of Caesarean sections.? It is also sometimes combined with small quantities of drugs.

The advantages of acupuncture are that it is non-invasive, easily administered by someone trained in the method, instantly reversible, and babies are in better condition at birth than after pethidine has been given.? Some studies show that acupuncture shortens the first stage for women having a first baby.? Women say that they feel more in control than when they have taken drugs for pain relief.

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TRANSCUTANEOUS ELECTRONIC NERVE STIMULATION (TENS)

With TENS, which is being offered increasingly in hospitals, a pulsed wave of variable intensity is passed through electrodes attached to the skin surface.? This stimulates the production of natural pain-relieving substances in the body (endorphins and enkephalins).? You operate a switch like a push-top pen or two dials as you feel a contraction build up.? There is a tingling sensation when it is switched on.? The electrode pads are usually stuck on your back, but can also be used on the abdomen or in the groin.? The disadvantage of TENS is that it cannot be used in water.

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REFLEXOLOGY

Similar to shiatsu, reflexology is a form of acupressure.? It consists of manual pressure on reflex points in the feet, hands and face to stimulate subcutaneous nerve endings.? The belief is that it causes the brain to release natural endorphins and other chemicals that help to reduce pain.? In childbirth, reflexology involves massage and gentle pressure on the feet.

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AROMATHERAPY

At its simplest level aromatherapy is a matter of breathing in pleasant smells that help you feel good about yourself.? It provides you with a positive sensory environment for birth.? This is useful if you are having your baby in hospital, where it can erase any off-putting hospital smells.? Doctors and midwives can relax and enjoy it, too.? The essences used are highly concentrated and molecules that can cross into the bloodstream may reach the baby.? Since we demand rigorous trials of drugs, most of which are derived from plants anyway, research into the effects of aromatherapy is important, too.? Plant essences stimulate sensory cells in the nose, which send chemical messages to the limbic area of the brain, which cause neurochemicals to be released into the bloodstream.? These essences are energizing-imagine smelling an orange, a lemon, eucalyptus or a sprig of rosemary-or relaxing-imagine breathing in lavender, sweet geranium or the scent of an old-fashioned rose.? Essential oils also stimulate the production of endorphins, the body?s natural analgesics, which are similar to morphine, so that you are less likely to need drugs for pain relief.

You can put drops of essential oil on a pillow, handkerchief or hot, damp flannel and keep it close to you.? Alternatively, they can be mixed with a vegetable or nut oil (soya, jojoba, apricot kernel, wheat germ, sunflower, almond and avocado are all good) and massaged into the skin.? They can also be added in concentrated form, or mixed with a dispersal oil or milk, to the water of a bath or birth pool, so that you are enveloped in their scent.? You can use them in a warm foot bath.? Or they can be burned in a vaporizer.

As you inhale essential oils notice how your face becomes softer and your breathing slower and fuller.? The breathing of fear, anxiety or panic is rapid and jerky.? When you are relaxed and confident, breathing is rhythmic, and each breath is complete, with a slight pause between the breath in and breath out, and another between the breath out and the breath in.? During pregnancy you can experiment with essential oils to discover which ones work best for you and enable you to breathe easily, and which refresh and reinvigorate you and help any tension flow out of your body.

Lavender can be put directly on the skin.? It can be mixed with one or two other essences, such as chamomile, sweet geranium, cedarwood, frankincense, myrrh, jasmine, neroli, rosewood, rosemary, peppermint (but do not use peppermint if you are also taking homeopathic medication), Melissa or mandarin.? Some essential oils are overpowering if you use more than one or two drops, so sniff the bottles first before you concoct your recipe to make sure that it is well balanced.? Some good combinations-all relaxing-are lavender and orange; lemon grass and orange; geranium and orange; ylang ylang, sandalwood and jasmine.? Rose, neroli (very expensive) and sandalwood in jojoba oil can be massaged into your forehead, face and neck.

Clary sage should not be used in pregnancy, since it can stimulate uterine contractions.? This is why it may be helpful if the cervix is dilating very slowly in labour, the introductory phrases of labour are lasting a long time, or you are two weeks past your due date and want to give gentle encouragement to you uterus to start contracting.? Some books about aromatherapy that include reliable sources of oils and advice are listed at the end of this book (see page 426).

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HOMEOPATHY

Unlike conventional medical treatments, homeopathy aims to treat the whole person, including the mental and emotional states that have an adverse effect on physical wellbeing.? There are 2,500 homeopathic remedies, many derived from plants, but others from metal (gold, silver), animal products (cow?s milk, snake venom), allergens (pollen, house dust) and drug extracts (aspirin).? The principle behind the remedies is that like is treated with like, but in minute quantities.? The more diluted a remedy, the more effective it is.

A homeopathic labour pack might consist of 7 g (1/4 oz) bottles of the following remedies:

  • Arnica leopard?s bane at 30c. It helps reduce bleeding and bruising.
  • Hypericum St John?s wort. This promotes healing of the skin and cab be taken with Arnica leopard?s bane, starting when labour begins and continuing for at least five days.
  • Staphisagria stavesacre at 10 ml (2 tsp). This is said to be a remedy for trauma to the urethra, and also a treatment for postnatal ?blues?.
  • Hypericum and calendula pot marigold can be combined in a 10 ml (2 tsp) tincture, which helps to soothe and heal skin that has been bruised or grazed. Mix ten drops with 20 ml (1 ? tbsp.) of sterile, cooled water and stroke it in wherever you feel sore.

When you go to a homeopathic practitioner, the case history will take about an hour.? This readiness to listen may be one element in the success of homeopathy.? On the other hand, there are homeopathic veterinarians, so results cannot all be chalked up to the placebo effect.? Some homeopaths are medically qualified.? Others work closely with GPs, and all will refer to them when necessary.? Homeopathy is available on the NHS and you can ask to be referred through your GP.

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BACH FLOWER REMEDIES

These remedies, another form of homeopathy, treat emotional states, not physical conditions.? They can be used in pregnancy and during labour as antidotes to stress, fear and lack of confidence.? Tinctures are available in homeopathic dilutions, and the plant essences are preserved in brandy.? There are 38 remedies for different emotional states, such as depression, shock, apprehension and irritability, and because emotions are often complicated they are often used in combination.? The general ?rescue remedy? is recommended for those ?distressed by startling experiences?.

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IMMERSION IN WATER

You already know how soaking in a warm bath can relieve pain, whether you have experienced backache, aching muscles from strenuous exercise or a state of physical tension, or menstrual pain.? Being immersed in water can be comforting in labour.? Lying in warm water increases venous pressure so that veins return blood to the heart more efficiently.? It also enhances cardiac action and slows the pulse rate.? Total relaxation in the warmth and comfort of a bath helps the uterus to contract more effectively.? But it does more than this.? Water both counteracts the force of gravity and any pressure a woman may feel against her back and buttocks, and also reduces pressure felt from inside the body, so there is a further pain-relieving effect.

Sometimes pain is so much reduced and dilatation proceeds so fast as a woman surrenders herself to the water that the baby slips out while she is still enjoying the bath.? This is quite safe, since the baby only takes a breath when lifted clear of the water, and for a few minutes after delivery blood is still pulsating through the cord, thus providing the baby with oxygen.? After the baby has left your body, the midwife will rest a finger on the cord so that she can feel the blood pulsating through it.? You may like to do this too.

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WATER BIRTH

If you would like to use water in labour and birth discuss it with your midwife.? Some hospitals are not happy about births taking place under water, but encourage it for labour.? Some obstetricians have expressed concern about cross-infection, particularly with HIV, from using birth pools.? There is no reason why birth in water should make cross-infection more likely than birth on land.? The Department of Health?s expert advisory group on AIDS states that there are no circumstances where it is acceptable to test expectant mothers for HIV as a condition for using a birth pool.? In some hospitals women with high blood pressure, those whose membranes rupture at the start of labour, or who are carrying twins or a breech baby, are not allowed to use water.? But you can stand under a shower and have a powerful jet of water directed against your back.? If you have drugs for pain relief you should not give birth under water because they may affect the baby?s breathing.

Using a birth pool is now well-established practice in hospital and home births.? It is no longer considered an ?alternative?, but is a readily available option.? Half of all the women who use water in labour go on to give birth in the pool, too.? They enjoy the freedom of movement, the way that water relieves pain, and the peaceful atmosphere provided by a birth pool when attendants watch and wait without interfering.? They often believe that water provides a more gentle transition to life for the baby, who has been floating in amniotic fluid for nine months.

In a water birth, the baby should never be left under the water, but should be lifted immediately into the mother?s arms.? You know how cold you can feel after getting out of a bath.? The baby quickly becomes chilled, too, so the room should be warm, and you and the baby should be wrapped immediately in big, warm.? It is probably unwise to decide in advance that you are definitely going to give birth in water.? A woman for whom floating in water feels blissful late in the first stage of labour may want to feet out of the water and have her feet firmly on the found once the second stage starts.? Do whatever feels right at the time.

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THE SAFETY OF WATER BIRTH

A major paediatric study of over 4,000 babies born in water reveals that water birth is not dangerous.? A healthy newborn does not breathe under water.? Babies breathe inside the uterus, although it is fluid rather than air that passes in and out of their lungs.? Before labour starts the baby stops this breathing, probably because of hormone changes and a rise in the level of prostaglandin E2.? This hormonal inhibition of breathing continues while the cord remains untied because blood containing prostaglandins is still flowing through the cord into the baby for several minutes.

Amniotic fluid is warm.? In fact, the baby?s temperature is slightly higher than the mother?s.? Very hot water may reduce oxygen in the blood flowing to the baby.? Water in the pool should therefore be at body temperature.? A healthy baby born into water at approximately blood heat does not breathe it in.

The effort, hard work and all the squeezing and activity of labour bring about a normal reduction of oxygen in the baby? blood (hypoxaemia).? The result is that the baby makes no attempt to inhale water. ?Only if a baby is very short of oxygen (hypoxia) is gasping stimulated.? These are powerful chemoreceptors at the entrance to the baby?s larynx that enable it to taste and discriminate between things that should be breathed and things that should be swallowed.? A baby born into water is much more likely to swallow water than breathe it in.? On the other hand, one born into salt water may breathe it in, because saline is similar to amniotic fluid.? We do not know if this is harmful or beneficial, and research needs to be done.

A baby?s head should not be delivered above the level of the water then dunked.? This might happen if there is insufficient water in the pool to cover your pelvis or if you grip the sides of the pool with your arms and push your pelvis up.? If you give birth in water, ensure it covers your tummy, and keep your shoulders and upper arms relaxed so that you do not tilt your perineum up out of the water.

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DRUGS FOR PAIN RELIEF

A variety of pain-relieving drugs is available, and different drugs suit different women.? It is important to understand what can be used and how each type works so that you can make an informed decision as to whether you want a drug and, if so, which kind.? Whether or not you have drugs ? and how much you have ? is up to you.? As one obstetric anaesthetist has stated: ?The only arbiter of pain is ? or should be ? the patient.? A stereotyped prescription cannot cope with individual variations in response to pain.?

All drugs for pain relief pass through the mother?s bloodstream to the baby.? They all affect the baby ? some more than others.? None of them does the baby any good.? When considering whether to accept drugs, bear in mind that some forms of anaesthesia and analgesia can interfere with your first meeting with the baby.

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ANALGESICS

OPIOIDS Drugs most widely used for analgesia (taking the edge off pain) in labour are opioids, such as pethidine.? They are usually given by intramuscular injection.? They take effect in two to fifteen minutes and last two to four hours.? Some women like them and say they helped them cope with painful contractions by making them feel relaxed and slightly drunk.? Others hate opioid drugs and call them ?stupefying?.? They say they were woozy and out of control.? Some women even hallucinate.? Blood pressure may plummet, producing pins and needles, faintness and disorientation.

A common side effect of opioids is nausea.? One or two women out of every ten vomit when they are given pethidine.? It is sometimes combined with an antihistamine to prevent sickness, but this tends to make you even sleepier.? Opioids can sometimes depress respiration, and it is wise to avoid them if you are giving birth to preterm baby.

Pethidine drugs the baby too, who may be knocked out at birth.? Large amounts will be present in the baby if injected within five hours before the birth, and especially if it is given three hours before delivery.? This is when contractions are strongest and you may want drugs for pain relief.? If injected within 45 minutes of the birth, however, pethidine is unlikely to have built up in the baby?s tissues.? The snag is that you will probably not want pethidine in the second stage because you will be working hard to get the baby out.? Some hospitals provide patient-controlled analgesia by a computerized syringe, allowing you to pump in the drug as you need it.? Women tend to use less pethidine when giving it to themselves than when it is injected by caregivers.

Some research suggests that opiate or barbiturate drugs used in childbirth may be imprinted on the baby, increasing the risk of addiction later in life.? Diamorphine (heroin), for example, is used routinely for pain relief in hospitals.? An addictive drug, it passes through the mother?s bloodstream to the baby.? Swedish researchers recommend that methods of pain relief that avoid passage of large amounts of drugs across the placenta should be preferred.

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MEPTAZINOL? This sometimes offered in place of pethidine, and it is claimed that it relieves pain more effectively.? It is given in doses of 100mg.? It has similar side effects to pethidine ? drowsiness, nausea, lightheadedness, dizziness, shivering, restlessness and sweating.? It may also affect the baby.

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PHENERGAN? This is a drug given in combination with pethidine so that less pethidine is necessary and nausea is combatted.

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GAS AND OXYGEN (Entonox) is mixture of 50 per cent nitrous oxygen and 50 per cent oxygen, from a machine that you use yourself.? If you only use it through the first half of each contraction it gives pain relief over the peak of the contraction.? It is cleared from the baby?s system with the first breaths it takes at birth.

The analgesic effects, which are not enough for some women, occur within 15 to 30 seconds and last for up to a minute.? Timing is important.? In the words of one woman: ?As I felt the very start of the contraction I took three full breaths of gas and oxygen in and out through my open mouth.? I remembered to make them really slow? Then as the contraction got bigger I dropped the mask and went into quick breathing.? It was fantastic??

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LOCAL AND REGIONAL ANAESTHETICS

Local anaesthetics can also cross the placenta.? They are least likely to affect the baby when injected into the area around the vagina and the perineum.? This is done before an episiotomy (see page 331) and before a forceps delivery (see page 346) if other anaesthesia has not been given.? When local? anaesthetics are used to bathe nerves that cover a large area of the body, they called regional anaesthetics.

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PUDENDAL BLOCK is an injection numbing the nerves in the perineum given at any time after full dilatation, and is often used before an episiotomy or a forceps or vacuum extraction.

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EPIDURAL ANAESTHESIA is injected into the space just outside the dura, the outer membrane around the spinal cord.? Top-up injections or a continuous drip of anaesthetic are given through a fine, plastic tube, which is left in place.? The continuous drip allows the anaesthetist to use a lower concentration of the drug, which reduces undesirable side effects.? An epidural may be given with you sitting up and curled forwards or lying on your left side curled into a ball ? a difficult position when you are in strong labour.? An epidural takes about half an hour to set up.

An epidural can provide complete pain relief and is used as an anaesthetic for Caesarean section.? It removes sensation from the waist, or sometimes from you navel, down, either completely or partially, while allowing you to stay conscious.? For a painful, prolonged labour it can seem to be the perfect answer.? Many women say how marvelous the epidural was, but it is important that it is your own choice ? no-one should be put under pressure to have one.

An epidural should not be given if you have low blood pressure, are taking anticoagulants such warfarin to avoid blood clots, or have a skin infection when the needle is to be introduced, or if you have severe pre-eclampsia.? An epidural tends to prolong labour, so stimulation of the uterus with an oxytocin intravenous drip is often necessary.? It is also important to remember that epidurals do not always work.? It may be difficult to inject into the right place, or the anesthetic may take on one side only, so that you feel contractions occurring in only half your body, which can be disconcerting.? The anaesthetist can try to adjust the placement of the epidural so that finally you can get good pain relief.

The anaesthetic is similar to that used by dentists, and you feel it like liquid ice numbing you tummy, bottom and legs.? Even though it anesthetizes only part of you, it must be given by a skilled anaesthetist, and under sterile conditions.? If by mistake the anaesthetist punctures the dura, you may end up getting a complete spinal.? You are more heavily anaesthetized and a common side effect is a bad headache that can last a week or more after the birth.

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SHOULD YOU HAVE AN EPIDURAL?

An epidural lowers blood pressure, sometimes drastically, so that other drugs may have to be given to raise your blood pressure again.? This happens to one woman in eight, although the drop may be slight.? Because of this, an epidural is sometimes offered to a woman whose blood pressure is already high, even though she may not be having a painful labour.? If your blood pressure suddenly drops, you feel sick and faint and may vomit.? This sudden lowering of blood pressure affects the baby too, since the oxygen-bearing blood supply is pumping more weakly and slowly through the placenta.? If your blood pressure drops and causes fetal distress, you will be given an oxygen mask to get more oxygen to the baby.

Epidural techniques and drug dosages vary in different countries.? In many countries, a continuous infusion pump is almost always used and the dose of bupivacaine is kept low, to reduce side effects.? But because drug cocktails are often given, there are new side effects from these other drugs.

To reduce the risk of a sudden drop in blood pressure, intravenous fluids are given very fast before the epidural.? This increases your blood volume.? If blood pressure drops significantly another drug is given to raise the blood pressure.? Excessive intravenous fluids cause water intoxication.? This means that the body becomes overloaded with fluids.

Having an epidural may start a train of procedures that you did not bargain for.? Because an epidural makes labour last longer, you may have oxytocin to augment labour and you will have continuous fetal monitoring.? There is an increased risk of finishing up with a Caesarean section.? This appears to be greatest if a woman has the epidural before she has reached 5 cm dilatation.? Because you have no feeling in your bladder, it needs to be emptied by catheter.? And because you may not feel any urge to push, the obstetrician may need to rotate the fetal head with forceps or manually.? Since there is an increased chance of instrumental delivery, you may want to refuse a top-up and let the anaesthetic wear off as you reach the end of the first stage.? But if you have not felt first-stage contractions and then suddenly have to cope with long, hefty ones as you approach full dilatation, you may find the experience completely overpowering.

Do not push just because you are fully dilated.? Always breathe your way through contractions, which you can feel as waves of pressure, until the baby?s head is well down on your perineum.? If you push just because you think that you ought to be pushing, you are more likely to have deep transverse arrest of the baby?s head, because when the local anaesthetic is very concentrated, the natural tone of the pelvic floor muscles is lost.? These muscles help the baby?s head to rotate as it descends against them.? If you have deep transverse arrest, you will need a forceps or vacuum extractor delivery.

An epidural multiplies the chance that your baby will get stuck in an occipito-posterior position (see page 270) or in a transverse position.? Obstetricians often tackle this problem by setting up an oxytocin intravenous drip to make the uterus work harder, with a view to avoiding the need for an assisted delivery.? You can, however, do something about this yourself, and will reduce the risk of deep transverse arrest by more than half if you wait until the baby?s head can be seen before starting to push.? It may take two hours or longer from when you are fully dilated for this to happen.

One side effect of having an epidural is that your temperature rises which makes you feel uncomfortable.? Being over-heated can be bad for baby too.? Moreover, when a woman has a fever in labour, investigations are made to find out if she and the newborn baby are suffering from an infection.? She and the baby may be treated with antibiotics ?just in case? there is an infection and the baby goes to the special care nursery.

Epidurals may have long-term side effects for you, too.? A small proportion of women have problems with backache, migraine, neckache or numb areas of skin, bladder dysfunction and faecal incontinence.

An epidural anaesthetic passes into the baby within ten minutes.? Studies are still being carried out on the possible effects of an epidural on the newborn.? Some suggest that the baby becomes nervous and jittery, while others show that the baby is very drowsy.? This may vary according to the drug and the dosage, how long the epidural is in place and the condition of the fetus before it is given.? If you decide to have an epidural, bear in mind that some of the difficulty you might have in coping with the baby in the week or so after the birth could be connected with the effect of the anaesthetic on the baby.? It does not mean that you are an incompetent mother.? You will soon be over this difficult period and everything will get much easier.

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SPINAL EPIDURAL?? With a combined spinal epidural (C.S.E.) analgesic can be self-administered as and when you need it.? Used this way, there is no evidence of harm to the baby.

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MOBILE OR ?WALKING? EPIDURALS? To achieve an epidural so that you retain some feeling in your legs and can move a little, bupivacaine is given in smaller doses and combined with an opiate drug.

  1. The first dose of anaesthetic ? half as much as usual ? is injected into the subarachnoid space where cerebrospinal fluid circulates. A very fine spinal needle is used.? This reduces the risk of you suffering a post-dural puncture headache.
  1. Opioids and local anaesthetics are injected into both the subarachnoid and epidural spaces. When a drug cocktail that includes opioids is given, bupivacaine can be cut by more than half.
  1. Epidural top-ups are injected when needed, and you may have a continuous infusion pump. Having top-ups reduces the drug dose by 35 per cent compared with an epidural infusion.

Advantages of lower drug doses are that you can move around in bed, and possibly walk.? But mobile epidurals can make you dizzy, and your legs may feel rubbery so you are unable to walk.? There is less need to catheterize the bladder, and a mobile epidural reduces the risk of long-term backache.? The problem is that there is still a high chance of a forceps or ventouse delivery.

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SPINAL BLOCK? This is used for Caesarean sections.? Local anaesthetic is given by injection into the cerebrospinal fluid in the lower spine, in more or less the same way as for an epidural.? The effect is to numb you from the mid-chest down.? Nowadays anaesthetists use ultra-thin needles to inject the anaesthetic, with the result that post-spinal headache (which used to be a major problem) is rare.? This technique works well, and has the major advantage of speed.

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WHAT WOMEN THINK ABOUT EPIDURALS

My own research into epidurals reveals that women are sharply divided in their opinions about them.? In my study of women?s experiences, many were very happy with their epidurals and said things like ?It was a miracle!? and ?It was pure magic?.? But 18 per cent of women very much regretted having had the epidural and said, in effect, ?Never again!?

Women praise epidurals when: it was their own decision, and theirs alone, to have one; they felt that they were among friends in the delivery room; the epidural provided them with effective pain relief; there was minimal other intervention; and they managed to push the baby out unaided.

Women are highly critical of epidurals when: they were not given a free choice about having one; they were not in an emotionally supportive environment; the epidural was not effective; delivery was by forceps; and there were side effects ? they felt sick and giddy, suffered headaches or had problems after, such as pain or numbness, which they attributed to the epidural.

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THE FUTURE OF DRUGS IN CHILDBIRTH

Hospitals should provide an environment and the kind of personal care in which each woman is free to accept or reject pain-relieving drugs as and when she wishes to do so.? Whatever drugs are given, their effects and possible side effects on you and the baby should be fully explained, and your consent should always be obtained beforehand.

Unfortunately, drugs are often used in place of loving emotional support and encouragement and one-to-one care.? Fear, anxiety, loneliness and the feeling that you are part of a factory for producing babies all increase the experience of pain.? Understanding what is happening inside you and what is being done to help you and you baby, being able to move freely, having non-pharmacological ways of handling pain, knowing that you can do to help yourself, feeling you are among friends and having someone you love with you all make pain much easier to bear.

Pain-relieving drugs almost invariably have an effect on the progress of labour, and often prolong it or make an operative delivery more likely.? This may be a price worth paying.? It is up to you to decide.? Nobody else should make the decision for you.? Modern obstetric anaesthesia, used only when necessary, is fairly safe for the baby, but little is really known about the effects, short- and long-term, on the child.? One consultant anaesthetist warns that ?numerous questions about the effects of drugs given to the mother on mother-baby interaction and future child development require an answer?, and stresses that long-term studies should be carried out to assess exactly what risks are being taken.? For the present this remains a largely unexplored field of research.

Text copyright ??Book: The New Pregnancy & Childbirth choices and challenges by Sheila Kitzinger

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