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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Pregnancy Exercise and Home Birth

The web is abuzz with news of the rising rate of home births. Increasingly women are electing to stay home for three major reasons: perceived safety, a desire to avoid medical interventions, and a previous negative hospital experience. There is also a lot of discussion about the need for more trained midwives, qualified to attend home births in low risk situations, as well as more midwives to attend in-hospital births. Some physicians are even complaining that the current insurance and liability situation forces them to practice defensive medicine, executing procedures and recording them to maintain a legal paper trail rather than care for their patients.

What is at the core of this issue? Several things leap to mind…

Defensive medicine is certainly a major component. Mandated medical procedures and frequent measurements during labor tend to interfere with the natural process. For example, in first stage labor, interruptions force women out of the parasympathetic state (brain alpha rhythm associated with the relaxation response) that helps promote the release of oxytocin and progress in labor.

Allowing the body to work is a very different kind of experience from what many women discover about birth in a hospital setting. In my experience, women who are aerobically fit do well in any labor setting. Women from my fitness classes have a very low rate of cesareans. Having your vitals checked and your contractions and fetal heart beat measured every hour or sometimes continuously cannot promote labor, although fitness seems to protect women to some degree. Of course, the argument for measurement is that if anything goes wrong that could have been detected through measurement, the practitioner will be blamed for malpractice. Thus, if 3 out of 4 cases of late decels leading to cesareans result from false positives in fetal monitoring, that has been seen as an acceptable rate within the medical community.

But, clearly, it is less acceptable to women, fit or not. Attempts are being made to alter the amount of monitoring in hospitals. The fact that it is perceived as an interference speaks to the problems with the method of measuring. In home births and even some midwife-attended hospital births, attendants listen to the fetal heart, a skill that – while it produces more accurate assessment – is rarely taught in medical schools any more.

Additional elements of defensive medicine are suspect, as well:  induction, denial of food and adequate fluid intake, poor communication to patients about the risks of procedures, and a system that views the mother as merely the medium through which the fetus is produced.

Another component is surely the psychological safety that women associate with their home environment over a hospital setting. Hospitals have attempted to circumvent this by creating labor and birth rooms that mimic a home environment and by offering tours of the labor and birth floor to help acclimate parents-to-be. But, it is also factors like not wanting medications that may flatten their emotional response to the birth experience, and the perception that drugs will be pushed on them in a hospital setting, that cause women to simply stay out of the hospital. Obs and midwives will even tell their patients to stay out of the hospital as long as possible if they want to avoid drugs and interventions. Certainly, in my work as a childbirth educator, I see a large part of my task as providing all the information they are requesting to couples in their decision-making process about their approach to the hospital.

One component I find particularly difficult is the standard approach to second stage labor in a hospital setting. To be clear, the notion of using the valsalva maneuver to push out a baby was invented by a man. It speeds up the process (which strikes me as a particularly male goal – apologies to the anti-sexist contingent), but creates more damage than following the body’s urges (reference here). During transition, the body shifts from the parasympathetic state to the sympathetic state. Pushing is aggressive; urges allow a woman to summon strength and direct her efforts. At the end of a long endurance event lasting many hours, a strength test is required. It is very different from the quiet stamina needed during dilation.

As information to this effect gets disseminated, I think women have come to recognize that they have greater trust in a female-based approach. More and more, we are hearing that educated women prefer laboring in water, movement, upright positions, drinking water, eating, gentle monitoring and being around people they trust, to what they have heard about or learned in previous births at the hospital.

Which brings me to a point:  Being present and enjoying birth requires not only a safe setting, but also body trust. Body trust is something one gains by having successful experiences with one’s body. I wonder if women who choose to birth at home tend to have positive self-images? And, most of all, I would be curious to know about the exercise practices of women who choose to birth at home. Any thoughts?

Safe Pregnancy, Safe Labor, Safe Motherhood

The challenges to safe motherhood vary depending where in the world you live. In some areas the challenge may be to get adequate nutrition or clean water; in other areas, it may be to prevent infection; and in still other locations it may be trying to avoid pregnancy before your body is ready or getting access to prenatal care. In the U.S., it may mean avoiding being sedentary and making poor food choices, or having to deal with the high technology environment of medical birth that can sabotage the innate physiological process of labor and birth.

Birth begins the bonding or unique love between mother and child.

The biology of birth is a complex series of cause-effect processes…baby’s brain releases chemical signals to the mother and the placenta begins to manifest the maternal immune system’s rejection of the fetus.

To help the ball get rolling, relaxation (the trophotropic response) helps promote the release of oxytocin. With the help of gravity, the head presses on the cervix, amplifying the uterine contractions. After an ultra-distance aerobic endurance test, the cervix opens enough to let the baby move into the vagina and the mother’s discomfort moves from sharp cramping into the bony structure as she transitions to the strength test of pushing. She transitions. Relaxation modulates into an ergotropic – adrenal – response to gather her power.

Pushing is an interesting term…more masculine, I think, than the one I prefer:  Releasing. Releasing or letting go of the baby. It’s a catharsis. In this portion of the labor another set of important processes help the baby clear its lungs of amniotic fluid, stimulate its adrenal system and challenge its immune system, as the contractions drive the baby downward. The mother’s deep transverse abdominal muscles – if strong enough – squeeze the uterus like a tube of tooth paste, to aid this expulsion. In the meantime, the labor is helping set up the mother to fall in love and produce milk. When the baby emerges and moves onto the mother’s chest, s/he smells and tastes the mother, recognizing her mother’s flavor and setting up the potential for bonding.

Any way you slice it, there are two parts to safe motherhood. One is a safe pregnancy…healthy nutrition, physical fitness, safe water, infection prevention, support and a safe environment. The other is a safe labor. In a safe labor, there is both an environment that promotes the natural process of labor and the means necessary for medical assistance when needed. Women die at an alarming rate from pregnancy or birth-related problems. Despite some progress made in recent years, women continue to die every minute as a result of being pregnant or giving birth.

What keeps us from having a better record on motherhood is often lack of care in the developing world and too much intervention in the U.S.. They are two sides of a coin. Mothers’ experience and health needs are not on equal footing with other cultural values. In places where basic prenatal care or family planning are low priorities, at-risk women are vulnerable to the physical stresses of pregnancy and birth. In the U.S., machine-measured data is paramount, even if it produces high rates of false positives, unnecessary interventions or counterproductive procedures. We are learning that obesity and sedentary lifestyles have detrimental effects, but fewer pregnant women than their non-pregnant counterparts exercise.

Despite the money spent to support the technological model of pregnancy and birth in the U.S., there are parts of the world – especially Scandinavia, Northern Europe and parts of the Mediterranean and Middle East (Greece, the United Arab Emirates, Israel, Italy and Croatia) – with lower rates of maternal deaths. In fact, in the U.S., maternal deaths are on the rise.

It’s a tricky business. Clearly Western medicine has a lot to offer the developing world when there are medical concerns. On the other hand, importing the U.S. model could create more problems than it solves. Instead, the micro-solutions now being developed in many locations will be observed and evidence collected by organizations such as the White Ribbon Alliance and UNICEF.

There is an effective international midwives model adopted by JHPIEGO, the Johns Hopkins NGO working toward improved birthing outcomes. It assesses the local power structure, social connections, potential for trained birth assistants, and location of available transportation to create a network so that locals will know when a labor is in trouble and who can get the woman to the nearest hospital.

In the U.S., there are in-hospital birth centers that allow low-risk mothers the opportunity to labor and birth in a setting designed to encourage the innate processes. Women are beginning to vote with their feet…staying home for birth. Women are going abroad to give birth. At the same time, women are coming to this country to give birth, believing it is safer than where they are. There are several ways these scenes could play out.

But, I’ll wager, improving outcomes will involve compromise:  Watchfulness and support in most births, plus better ways to assess danger and provide technology. No matter where you live in the world, the solution may be essentially the same.

Labor Pain…or Labor Sensations?

There is no sensation known as pain. Sensations are nerve impulses that travel from the body toward the brain. Touch, sight, hearing, taste and smell are the major physical sense categories. Pain is a combination of sensations and emotional content supplied when the brain notices sensations and routes them through parts of the brain that determine emotion, or feeling.

Sensations include touch subcategories such as pressure, temperature, stretch, speed and acceleration, spatial orientation and movement direction, texture and so on.

There are nociceptors – receptors of touch perception that tell us when the body is being damaged, as when we are burned or struck. If you have ever had these things happen to you, you will recall that any pain associated with these experiences is not immediate, but develops as we create our response to the sensations AND feelings involved.

I have written more extensively on this phenomenon in my textbook, Women’s Fitness Program Development (Cowlin, AF. Human Kinetics Publishers, 2002, pages 192-3). But, my point here is that as we embark on the discussion of how to bring birth back to a mother & baby centered experience, we must examine the evidence concerning the physiology of birth. Solid knowledge about the nature of sensation and how it becomes something we call pain is key in our ability to educate and train women to be fully present – that is, to control – their experience of labor and birth.

Our perception of pain is partly genetic, partly training and partly culture. Birth educators work hard to help women understand they have choice within their experience of the sensations of labor. But, changing women’s experience of labor to a more positive and purposive set of sensations requires a large contribution from the culture. Why is sensation sometimes NOT to be avoided so that it gives us information about what is happening to our bodies?

Most of us spend large portions of our day disconnected from our bodily sensations. When we sense our bodies, we take pain-killers. One of the most common things new dance students say when learning to dance is: “That hurts.” Often, I find when I query them further, what they are actually saying is: “I have never had a sensation of that part of my body and it is strange.” Getting in touch with our bodies these days often requires breaking the digital connection, the altered virtual reality in which we now so often live.

How will we do this? If you have suggestions, please post them. Thank you!!

Pregnancy Pathway, Birth – Labor

The First Stage of Childbirth is the long, hard labor. It is the slow process that produces dilation, or opening, of the cervix – the “neck” or outlet at the bottom of the uterus. Once the baby’s head can fit through the open cervix, it is time for the Second Stage, but that is another topic for another post.

Labor is generally a long, slow process...there is no "enter" button for dilation!

Labor is generally a long, slow process...there is no "enter" button for dilation!

Before the baby can leave the mother’s body, s/he must leave the uterus. The opening of the cervix to let the baby out of the uterus generally takes up the most time. For a first time mom it can be 10 or 12 hours…or, yes, a couple of days. Of course, for some moms, this time is difficult and for others it only becomes difficult in the last few hours.

But, you know all this, right? What you want to know is:  Why do I have to go through this? And, if I must, how can I make it the least painful?

Why labor is important. Let’s go to another question:  How important would your offspring be if it was no big deal to drop one out? If you were walking along the sidewalk and you could simply drop a newborn on the pavement, would you even stop to pick it up if you could do it again in a few days, when, of course, it will be much more convenient?

Frankly, pregnancy and labor remind us to pay attention. A newborn cannot survive on its own for at least two years. If we don’t pay attention, it will die.

Okay, now that labor has your attention, what else does it do that is beneficial? It stimulates the baby’s stress response and teaches the newborn to be alert during situations of duress. Each contraction is pulling the cervix, helping it slowly open. If you are upright, each contraction is also alerting the baby to the influence of gravity.

Why is labor painful? So, you need to go through this because it is the bridge from pregnancy to parenthood. Why does it have to be painful?

The first thing to keep in mind about pain is that pain is a combination of sensations and emotion, mainly fear. Fear makes you tense; tension reduces blood flow. Reduced blood flow to the uterus makes the contractions less effective. In addition, cortisol is released, making sensations stronger and evoking greater fear.

Fear is the emotion of fight or flight. Interestingly, the opposite response, the relaxation response, is very effective in promoting labor. So, relax. Breathe deeply and slowly, focus, move through the center of your experience. You don’t have to be in fear if you know what is happening and if you are physically fit and prepared. Both childbirth education and physical fitness teach your body to work with discomfort. By including them in your preparation, you give yourself a tremendous advantage.

Does this mean you will never feel like you want to stop in the middle of labor? No, but it does mean you can do it. It is finite. The notion that the baby will not do well is also tied to your physical fitness…babies of fit mothers less often experience fetal distress. Your care providers will let you know if there is some factor beyond your control that requires medical intervention.

Birth is an empowering event. But, before the baby can be born, it must escape the uterus. It is a classic conflict and the mother’s body is the venue. Give yourself over; go with it. Only women can do this.