Ina May’s Guide to Childbirth – book review

Ina May’s Guide to Childbirth by Ina May Gaskin.

NY; Bantam, 2003.

The physiology of birth is complicated and still not well understood. Our subjective experiences of birth are richly textured. Personal accounts spill over with combinations of intense sensations, strong emotions, vague impressions and fine details. What is astonishing about Ina May’s Guide to Childbirth is how exquisitely she traffics in the language of an internal landscape to describe and explain this complex process. She truly captures the uniqueness and universality of birth. I am adding this book to the list of recommendations I give my clients, as well as suggesting it to other teachers.

Devoting nearly the first third of the book to positive first-hand birth stories provides a substantial grounding. Many times I found myself thinking: Yes! That woman is describing this or that essential bit of wisdom I want to impart to my clients. Let me point out one example.

On pages 24 and 25, one of narrators describes 3 slices of her experience. First, she got advice not to read or learn too much and not to make a plan because the more details she had in mind, the less likely she would get what she wanted. Too much reading would interfere with her ability to go with her body, she was told.

Second, she describes her experience of being in a tub and how she needed a lot of reassurance because she was both scared and aware of the great power in her body. The physiological phenomena occurring in her brain and motor systems indeed would be described as these subjective states of being. She definitely perceived what was happening.

Third, she describes turning from looking at things during a contraction to listening because looking made her think, while listening allowed her to feel and be instinctive, which felt better than thinking and was not so overwhelming. Thus, she was going with her body. We see her process in this narrative.

The stories all got me thinking about whether I am telling my clients too much or too little! One of my teaching goals is to insure that clients distinguish between strategy and tactics. Example:  In the case of the story above, the strategy was to go with her body. The tactics she used were to not get too much information so she did not have too many expectations and to use sound rather than vision as her way of connecting inner and outer reality.

As a teacher, I see my job as insuring that my clients who might hear this story do not think that they must use sound rather than vision in order to go with their bodies, but rather that this was a piece of the process for this woman to reach her objective. It might work, but it might not. To get this across to clients, I tell stories about births in which I have been present when opposite tactics accomplished the same strategy or where the same tactic led to different outcomes.

The multitude of stories she presents in part I allow part II – the textbook part – to come to life. Whether she is discussing stages of labor, pain or release, she calls up stories and because the reader is already receptive to the notion of examples, the illustrations help the reader grasp whatever point she is making about the process.

However, the complex physiologic sequence of birth, including its variation from woman to woman, is less well served – in part because there is still so much to be learned about how birth happens, and in part because the birth community in general (whether having had professional or academic training) is not as well versed in normal physiology as it could be.

Let me focus on two issues: One is pain/pleasure and the other is hormones/behavior. Regarding pain/pleasure, Ina May makes a lot of important points, among them that how we experience an intensely sensational experience depends to a great degree on our preparation and that different women have different pain/pleasure experiences during birth. What she doesn’t tell us, though (and I suspect because it’s not common knowledge), is that some of the factors that control how we experience sensations are beyond our control. We experience pain/pleasure through a series of sensations, mental foci and behaviors such as breathing and muscle release. These nerve impulses are forwarded throughout the brain, some sensations taking on emotional content – some terrifying and others ecstatic – depending on the neural pattern. This is the basis of both the fear/tension/pain syndrome and the orgasmic pattern. But the precise pattern is dependent on genetics, as well as environment and behavioral training.

Some individuals become aware of sensations at a very low neurological threshold; others do not. Some individuals quickly find sensation of which they are aware to be uncomfortable or emotionally intolerable; others do not. Some people need comfort measures for their discomfort soon; some later, or not at all. Tolerance of what finally becomes pain or pleasure (or just a sense of stretching or motion through space) is also variable from person to person. Thus, the point at which we start has both biological and psychosocial determinants within this already variable process. In describing the variation in how women experience pain and pleasure in labor, Ina May is great at giving us examples and identifying psychosocial or cultural variations identified in research, but not so enlightening on the biology of why and how. This may or may not matter to the reader.

The issue of hormones that govern the vicious cycle we call labor is much less well understood. We have a pretty good concept of how prostaglandins, oxytocin and endorphins are stimulated and affect the process, and Ina May describes these in accessible ways. But while adrenaline is thought to inhibit early release of oxytocin, there has been little discussion of its importance in the pushing or ejection phase (she does cite Michel Odent’s notion that adrenaline might play a part in the ejection reflex when a labor is slowing down). But, there is little recognition outside of the physiology field that what happens in transition is our energy system shifting to a sympathetic [adrenal] source to give us more power to push. That’s why contractions change, why some women have a rest period between, and why – back in the day – we used to say to a woman having difficulty culling up her resources to push that she could get mad! Going through the effort and discomfort is key to inducing the rush of beta-endorphins. We know this, in a scientific way, from research that tells us runners who listen to music (relaxing and dissociative) experience lower rates of beta-endorphins at the end of the run than runners who do not listen to music, but work through the effort and discomfort they experience (stress inducing).

One of the things that makes Ina May’s book so valuable, in my mind, is the discussion near the end about midwifery, statistical support for natural birth and enumeration of the risks associated with surgical birth that are often glossed over when a family experiences dystocia. There are many elements within the birthing community striving to create an accessible spectrum of choices for birth. Let’s face it, birthing at home for low risk women, seamless transport alternatives, birthing centers attached to medical facilities, and readily available medical options when emergencies arise, would be a wonderful future. Birth attendants with universal acceptance, variable but rigorous training, and delineated scopes of practice would be ideal. Whether we get there remains to be seen, but I am glad Ina May exists, has her track record and is being listened to in this effort.

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How to Get Pregnant – Coaching Topic #1

Hurrah! We have power at last…a week after hurricane Irene romped through, we have juice! Thanks for bearing with us while we camped out.

So let’s get on with the topic of How to Get Pregnant, starting with why do we need to know this?

In the past few decades, the average age for a first pregnancy in the U.S. has moved from the mid twenties into the mid thirties. In the same time period, the facts of conception – sperm enters egg released in mid cycle, then zygote implants in the uterus, along with how sex allows this to happen and how to prevent it – seems to have disappeared from middle and high school health classes. If that weren’t enough, as women have become more and more essential in the work force, the cost of having children as well as starting later, have driven down the birth rate. Similar conditions exist in most developed nations, although teen pregnancy rates are lower everywhere else.

The birthing population has bifurcated – we see older women (over 35) and teens as the major groups having children. On the one hand we have been working to reduce teen pregnancy while helping older and older women become first time moms. To a certain extent, they need the same information; its just that with teens we use this information to prevent pregnancy and with older women we use information to help them increase their odds of getting pregnant.

Understanding the menstrual cycle, ovulation, charting temperature – all the basic techniques of using the “natural” method of birth control – have become the first steps of the how-to-get-pregnant coaches. Beyond this, a number of sites have their own essential lists to help women be healthy and ready. Sites such as gettingpregnant.com, pregnancy.org/getting-pregnant, and storknet.com/cubbies/preconception/ provide additional information. Many suggestions – things to avoid eating, what proteins are needed for ovulation, how to reduce stress, what to do if there are sperm problems, how to find IVF clinics, donors and surrogates – are addressed.

How effective are these suggestions? Well, research tells us they are somewhat effective. None of the sites I contacted answered my query about how they measure or assess consumer outcomes when following their suggestions.

An interesting article in the NY Times 9/1/2011, entitled Are You as Fertile as You Look? openened with this sentence: “FORTY may be the new 30, but try telling that to your ovaries.” The reality is that being under 35 is still the best predictor of how difficult it may be for you to become pregnant. As the article makes clear, looking 30 and being 30 are not the same thing. Even healthy living does not prevent the loss of good eggs.

So, what conclusions can we draw? First, even if you come from a “fertile family,” it may behoove you to have your children in your late 20s or early 30s. Second, if you are putting off having children beyond that time, ask yourself what extremes you are willing to go to to have your own biological offspring. And, third, consider adoption. Frankly, it would be wonderful if adoption were easier, but in the drive to conceive at later and later ages we see the hand of biology and understand why adoption is not easy:  Our own offspring – our own DNA out there in the world – is a heady motivation.

If you are on the pathway of becoming pregnant, being under 35 is the best ally you have. If not, maybe some of the suggestions on the web will work for you. Whatever you decide, all the best.

One parting comment:  Regular moderate exercise – while it helps you stay young and healthy – will not prevent your eggs from being popped out every month. It will help you have a healthy pregnancy if you conceive, so stay with it!

Pregnancy Pathway, Outcome – Mom & Baby Health Status

This 2/1/2010 entry seems to draw attention consistently, so we decided it was worth re-posting it. The discussion concerns determinants of the health outcome for mom & baby in the Pregnancy Pathway. It reviews the pathway, and then continues to the last stage of the Pathway, the health outcome. Here’s the whole graphic:

So, the big question is: How can we predict the health outcome of mom and baby, given all the variables of preconception, conception, pregnancy, labor and birth?

Well, there are some things for which we can predict or estimate risk/benefit ratios, and there are some for which we cannot. Let’s start by going over the major things that are not very predictable. At the moment, genetics is pretty much unpredictable. Down the road…maybe…but for now, not so much. Some IVF labs claim they can slightly slightly increase the odds for one sex or the other.

Post-conception, chorionic villi sampling and amniocentesis are methods by which the genetic make-up of the fetus can be identified. These are done mainly to give parents a choice about continuing a pregnancy if there is a question about genetically transmitted disorders or conditions, such as Down Syndrome. But, for now, the best way to manipulate the genetic odds of health outcome for your offspring is to mate with someone who is healthy and has health-prone genes!

Once you are pregnant, it is clear that prenatal health care, exercise, healthy nutrition, stress management and adequate sleep play significant roles in increasing the potential for a healthy outcome for mother AND baby. In fact, not only short term, but also long term healthy outcomes are linked to these factors. These are factors within our control.

Risk factors – most of which are within in our control – that can adversely affect outcomes include environmental toxins, risky behaviors (unsafe sex, drinking, smoking or drugs), poor nutrition, sedentary behavior, stress and isolation (lack of social support). These risks, as well as the benefits, are all discussed in the previous posts.

At this point, it is important to note that there is a lot that goes into making a healthy pregnancy, birth and outcome that is within the control of the mother, providing she has family and/or social support to take good care of herself.

The labor process and birth mode can also affect health outcome, but in general the effect is short-lived. For moms who have received regular care and are in excellent health, the occurrence of a truly devastating birth outcome for mother and/or baby is extremely rare. The exception may be mental or emotional turmoil that can accompany a difficult, unexpected and uncomfortable situation, such as an unplanned cesarean birth.

 

Group exercise programs are a source of social support.

Three interesting research outcomes point to the importance of exercise groups. One is that exercise can help prevent some disorders of pregnancy, such as preeclampsia or gestational diabetes. Second is that the health benefits of exercising during pregnancy and the postpartum period are beneficial for both short and long term for mother and infant. Disorders of pregnancy are risk factors for future cardiovascular disease and metabolic disorders. Third is that exercise is most likely to occur when there is good social support.

Moving together is a “muscle bonding” experience that helps bind moms-to-be and new moms into a community of support. Within the group, moms can get help with tips for healthy eating and living, along with the support of others who know what she is experiencing. There are a lot of ways to get adequate exercise. When you are pregnant or a new mom, an exercise group can be one critical path to health and well-being.

Pregnancy Pathway, Outcome – Mom & Baby Health Status

Thank you for your patience while our new website was going up. Also, thanks to those who viewed the site! If you are interested in more research; in taking a class in the U.S. or parts of Europe, South America or South Africa; or, in teaching pre/postnatal fitness, please pop over to the renovated website: www.dancingthrupregnancy. com.

Now, let’s return to our Pregnancy Pathway, take a look where we’ve been, and then continue to the last stage of the Pathway – the health outcome.

Here’s the whole graphic:
So, the big question is:  How can we predict the health outcome of mom and baby, given all the variables of preconception, conception, pregnancy, labor and birth?

Well, there are some things for which we can predict or estimate risk/benefit ratios, and there are some for which we cannot. Let’s start by going over the major things that are not very predictable. At the moment, genetics is pretty much unpredictable. Down the road…maybe…but for now, not so much. Some IVF labs claim they can slightly slightly increase the odds for one sex or the other.

Post-conception, chorionic villi sampling and amniocentesis are methods by which the genetic make-up of the fetus can be identified. These are done mainly to give parents a choice about continuing a pregnancy if there is a question about genetically transmitted disorders or conditions, such as Down Syndrome. But, for now, the best way to manipulate the genetic odds of health outcome for your offspring is to mate with someone who is healthy and has health-prone genes!

Once you are pregnant, it is clear that prenatal health care, exercise, healthy nutrition, stress management and adequate sleep play significant roles in increasing the potential for a healthy outcome for mother AND baby. In fact, not only short term, but also long term healthy outcomes are linked to these factors. These are factors within our control.

Risk factors – most of which are within in our control – that can adversely affect outcomes include environmental toxins, risky behaviors (unsafe sex, drinking, smoking or drugs), poor nutrition, sedentary behavior, stress and isolation (lack of social support). These risks, as well as the benefits, are all discussed in the previous posts.

At this point, it is important to note that there is a lot that goes into making a healthy pregnancy, birth and outcome that is within the control of the mother, providing she has family and/or social support to take good care of herself.

The labor process and birth mode can also affect health outcome, but in general the effect is short-lived. For moms who have received regular care and are in excellent health, the occurrence of a truly devastating birth outcome for mother and/or baby is extremely rare. The exception may be mental or emotional turmoil that can accompany a difficult, unexpected and uncomfortable situation, such as an unplanned cesarean birth.

Pre/postnatal exercise groups provide a community of support

Three interesting research outcomes point to the importance of exercise groups. One is that exercise can help prevent some disorders of pregnancy, such as preeclampsia or gestational diabetes. Second is that the health benefits of exercising during pregnancy and the postpartum period are beneficial for both short and long term for mother and infant. Disorders of pregnancy are risk factors for future cardiovascular disease and metabolic disorders. Third is that exercise is most likely to occur when there is good social support.

Moving together is a “muscle bonding” experience that helps bind moms-to-be and new moms into a community of support. Within the group, moms can get help with tips for healthy eating and living, along with the support of others who know what she is experiencing. There are a lot of ways to get adequate exercise. When you are pregnant or a new mom, an exercise group can be one critical path to health and well-being.


Pregnancy Pathway, Pregnancy – Behavior: Avoiding Risks

Sometimes it seems like pregnancy is a time of restrictions. Avoiding risks can be one thing that makes it seem that way. But, bear with us here in an interesting trip through danger and finding you find ways of enhancing your pregnancy!

Risk Factor #1:

Lack of prenatal care. More than anything else, be sure you have care. Having someone monitor your health and that of your baby during pregnancy is vital to a good outcome.

Exercise! Avoiding it is a risk factor for diabetes and preeclampsia.

Exercise! Avoiding it is a risk factor for diabetes and preeclampsia.

Risk Factor #2:

Not exercising. Sedentary behavior increases the risk for metabolic, cardiovascular and immune disorders.

I know, I know, you don’t have time to exercise. Well, pay now or pay later, as they say. Make time to go to a class (make sure it includes 20 -30 minutes of aerobics) a couple times a week. A class will also provide social support, another factor that enhances your pregnancy. Take a walk at lunch time. Practice relaxation techniques.

Risk Factor #3:

Breathing dangerous fumes. Yes, this includes smoking and second-hand smoke. But, it also means avoiding environments where there is a lot smog (near highways), living with mold or dust, and fancy cleansers that may have dangerous chemicals in them. Stick with vinegar, ammonia or bleach as cleansers.

Smog can endanger your fetus!

Smog can endanger your fetus!

We are learning that combustion exhaust from cars and trucks can negatively affect birth weight and prematurity. If you live or work near a highway or in an area where smog is prevalent, what are your options? Can you transfer or move? Can you wear a mask? Talk to your care provider and figure out the best protection for you and your fetus.

Risk Factor #4:

Poor Nutrition. Yup, just go back one entry and find out how food affects pregnancy. If you don’t eat enough protein and drink enough water, you don’t make sufficient blood volume to nourish your placenta and thus your fetus.

Read labels!

Read labels!

Eat whole foods and learn to read labels when you buy processed foods. What is a “processed” food? Anything with more than one ingredient!

Some processing (ex: homemade soup) takes little nutrition away, but some processing (ex: potato chips) takes everything good away and replaces it with unsafe substances. Look for low sodium, low sugar, high vitamin and mineral content items with no saturated or trans fats.

Read the ingredients; if you don’t know what the words mean, maybe you want to pass it up.

Risk Factor #5:

Alcohol and Drugs. Common items can be as dangerous as street drugs, which

There is plenty of time in life for a glass of wine...later.

There is plenty of time in life for a glass of wine...later.


No. No. No. Only meds from your prenatal care provider are okay.

No. No. No. Only meds from your prenatal care provider are okay.


Caffeine? Only one cup & only if you must.

Caffeine? Only one cup & only if you must.

can severely compromise you baby’s future. If you have a drug or alcohol habit, get help.

Risk Factor #6:

Genetics. You can have genetic predispositions for many pregnancy issues. However, that does not necessarily mean you will develop a given disorder. For example, nutrition and exercise greatly reduce the risk and severity of metabolic issues. Some genetic issues are unavoidable however, and your care provider will alert you to these, if they are relevant.

Risk Factor #7:

Social issues – isolation, lack of support, abuse, poverty. All of these factors can have negative effects.

If isolation is a simple matter of needing to meet other moms-to-be, join an exercise program. That way, you get both support and exercise; just be sure it includes aerobics, along with centering, relaxation and appropriate strength.

If your situation is more dire, seek the help of a care provider or social worker at your local hospital or clinic. Safety and support are critical for you at this time. Get the help you need. There are people who care. And, if you know of someone who needs help, help them.

If you have other risk factors to offer, please post them in the comments. Thanks!

What’s next?  BIRTH!!

Pregnancy Pathway, Pregnancy – Maternal Immunological Response

Today: Maternal Immunological Response…or…the Mother/Fetus Dance!

Maternal Immune Response During Pregnancy

Maternal Immune Response During Pregnancy

Back to work! Thank you for your forebearance while we wrote a chapter for a nursing textbook!

During the course of pregnancy, the mother/fetus dance is ongoing. The maternal immune system and the trophoblast cells continue to influence each other even beyond the implantation.

Because the mother’s immune response modulates near the start of each trimester, the fetus is affected to some degree and mounts a response, as well. For a long time it was thought that maternal and fetal DNA material was not exchanged across the placental membrane, however recent findings indicate that there is some exchange of material. Thus, we all carry some portion of our mother’s DNA and our mother carries some of ours.

What is the impact of this chimeric effect? It depends on how well our DNA gets along!

How does this affect the fetus in utero? The fetus may be affected by clotting issues. Depending on maternal health status s/he may be subject to a stronger or weaker immune system.

How does this affect the mother? Women are more likely than men to develop autoimmune disorders (pregnancy playing a role here), and those who bear male offspring are more likely than those who only have girls to have these disorders.

The maternal/fetal dance goes on….

Be Prepared for Birth!

Be Prepared for Birth!

Pregnancy Pathway, Conception – Prior Sperm Exposure

Today:  Sperm!!!

For complete graphic, see Feb. 5 or 23 post.

The mother's prior sperm exposure can affect her pregnancy.

The mother's prior sperm exposure can affect her pregnancy.

Not every sperm is your friend! Sperm exposure – like so many exposures – affects our immune system. Women who have babies with more than one father may be at risk for disorders of pregnancy because the challenges to their immune system have been extensive. And, very young women who become pregnant are at increased risk of some disorders because they have had very little exposure to sperm.

In addition, women who have primarily and extensively used barrier methods of contraception may be at risk for disorders for reasons similar to young women with little exposure. Unlike women whose immune system has had too much challenge due to pregnancies by several men, women with little exposure may not have a strong defense against foreign DNA. Please do not take this as a reason to not use a condom – one of the barrier methods along with a diaphragm and cervical cap. Rather, if you use a barrier method of contraception, keep in mind that your body’s adjustment to pregnancy may take time.

For more information on barrier methods, to go the American College of Obstetricians and Gynecologists’ online pamphlet: ACOG Pamphlet on Barrier Contracetption.

Another way sperm can affect the pregnancy is that the combination of the mother’s and father’s natural immune responses may be strong against the trophoblast implantation. This is not something  you can know ahead of time. Also, women are eight times more likely than men to develop autoimmune disorders. One reason may be the prenatal exposure to foreign DNA encountered in pregnancy.

Keep in mind that by getting good prenatal care, exercise, sufficient rest, stress managment and healthy nutrition, you do all within your power to have a healthy pregnancy. Your health care provider will determine your risk factors that may affect pregnancy outcome and treat you in an appropriate manner.

Moms and babies enjoy exercise together!

Moms and babies enjoy exercise together!

Once your baby comes, there will be time to maximize health for both of you. Exercising together is great fun!

Getting there may require some patience, but the reward is well worth it.

When you are looking around for sperm, use your head. The same behavior that protects you from infections you never want to get, protects you from sperm you don’t really want to meet. When the time comes to adopt some sperm, find out about it’s credentials!