Simple Guide to Having a Baby 2016

Simple Guide 2016

The 2016 edition of Simple Guide to Having a Baby has gone to print, and will be available to the public at the end of July. (We’re hoping to have copies for sale at the DONA conference in Bellevue, WA) It will be available from Amazon, Barnes and Noble, Walmart, and probably Target.

Simple Guide covers essential information about pre-conception, pregnancy, birth, breastfeeding and newborn care at a 6th grade reading level, in a short, accessible format. It is written by the authors of Pregnancy, Childbirth, and the Newborn. Although we are writing at a different literacy level, we do our best to incorporate the same foundation of current, research-based information and our practical experience of working with thousands of birthing parents over many decades.

What’s new in 2016: increased cultural diversity and sensitivity in photographs and writing, incorporation of the visual aid “The Road Map of Labor“, more links to online resources for more information, and more details on baby care. We have also extensively updated all the medical information. I have an extensive post on all the updates we did to Pregnancy, Childbirth and the Newborn – we weren’t able to incorporate all of these details into Simple Guide, but they certainly did inform our revision of this shorter work.

If you would like to write a review of Simple Guide, I do have galley proofs available. Contact me and jdurham at parenttrust dot org, and tell me about yourself and where you publish reviews, and we can make arrangements to get a proof to you.

Pregnancy and Disability

Janelle 32 wks

Someone recently asked me to share my perspectives on how perinatal professionals can provide sensitive, supportive care for people with disabilities. Here are some initial thoughts on that question.

First, a caveat to any advice I offer below: I can only speak to my own experience. The needs of each person are unique and depend on such things as:

  • What is the disability?
  • How long have they had it and how experienced are they at working around it?
  • What is their self-image / identity – if they think of themselves as “disabled” they are likely to have more worries about the perinatal period than someone who doesn’t see their disability as a primary part of their identity or life experience

My experience: I had bone cancer when I was 15 years old, and had my leg amputated above the knee. I wore an artificial leg for a few years, but discovered I can move around faster and easier on crutches than with an artificial leg. I don’t really think of myself as “handicapped” because there’s little I can’t do. I can’t “run” very fast. But, I can ski, swim, roller-blade, ice skate, and ride a tandem bike. I can carry things while walking on crutches, take care of all my household chores, drive, work full-time, and so on.

When I became pregnant with my first, I’d already been an amputee for 11 years, so I was very used to making the physical adaptations I needed to make. So, throughout my pregnancy, I never questioned my ability to handle pregnancy, birth, and caring for a baby. I didn’t know all the exact details of how I would adapt everything, but I had complete confidence I would figure it out. And I did… I’ve now birthed and cared for 3 children – I don’t actually find it that difficult.  (OK, honestly, we all find parenting difficult! I’m just saying that having one leg did not make it particularly more challenging.)

My care providers vs. others:  During my pregnancies, I don’t remember my disability being a big issue for anyone. My care providers never implied that there would be anything especially challenging about my case, which I appreciated.

But that’s not always the case. Once a public health nurse called and asked me to doula for someone delivering at Valley. I told her I didn’t travel that far. But then she told me why she’d called me specifically. The client was a double amputee who used a wheelchair. She had been told that she would need to deliver by cesarean because she was an amputee. I was dumbfounded! It’s not like you need legs to have a vaginal birth. I ended up not assisting that mother because of timing, but I did meet with her and talk to her about her options, and she did end up planning and having a vaginal birth.

What care providers can do:

  • First and foremost: Assume she is capable of pregnancy, birth and baby care. (You may be one of the few who treat her this way.)
  • If you see accommodations that you think could be made, ask her if she would like your help brainstorming how to handle something. If she’s had her handicap for more than a few months, she probably knows a great deal more about her needs than you do. Respect that.
    • For example, I happened to have a dad who was an arm amputee attend a newborn care class I was teaching. I approached him on break, and said “I am wondering if you have any specific questions that are unique to your situation. I don’t know anything about having one arm, but I know a lot about baby care, so if you have things you’re wondering about, maybe you and I can put our knowledge and experience together and brainstorm some kind of solution together.”
    • Once when I attended a prenatal yoga class, the instructor approached me before class, and said “let me know if there’s anything I can do to help you with the exercises.” I told her: “I can usually do a better job than you can of figuring out how to adapt things, but it helps me to know what my goals are. So, when you teach a position, if you can tell me whether the goal is to stretch my hamstring, or stretch my calf muscles, or strengthen my glutes or whatever, that helps me adapt the exercise in a way that reaches that goal.”
  • Don’t “other” someone.  Don’t do things that imply that they are a weird aberration from a normal human being. Examples from my experience:
    • When a caregiver is going to a pelvic exam on me, they always pull out both stirrups as per their usual habit. I like it if they then calmly put one away instead of getting all flustered and awkward when they realize that I don’t have a foot to put in the right side stirrup.
    • When a nurse opened a package of non-slippy socks, I liked that she calmly set one aside on the table, saying “here’s an extra for later”
    • If you make a “mistake”, calmly apologize and move on. Don’t make a big deal of it.
    • If someone gushes over me like “wow! You’re so brave to take this on. If I were handicapped, I would be too afraid to try this,” they may think that’s supportive, but it’s easy for that to come off as “something’s wrong with you. You’re less capable of parenting than other people are.”
  • Be sensitive about their “appliances”. Their wheelchair, hearing aids, glasses – whatever – should be treated with the same respect with which you treat their body.
    • My crutches may seem like inanimate objects to you, but they are an essential part of my independence and mobility. It is VERY important to me that no one take my crutches and move them across the room without my permission. Although I can hop short distances, I can feel “trapped” in place the second my crutches are out of my reach, which can be anxiety inducing.
    • I also wear glasses as I am very near-sighted. I need to know where they are at all times, because when I don’t have them on, I can’t find them! And I feel mentally competent with my glasses on, and severely limited without them.
  • A person with a disability also often has a long history with health care providers and medical institutions. Her experiences may be positive, negative, or a very complex mix.
    • If you sense any defensiveness or animosity toward you, or if she “over-reacts” to a situation, realize there may be a very good reason for her reaction.
    • Respect that she may have some expertise that a non-disabled layperson might not have. For example, I can tell you that I’ve had many I.V’s in my life, and been told by many health care providers that my veins are tiny and tend to roll, and it’s hard to get an I.V. into me. If a patient tells you something like that, respect that. I appreciate when care providers have said “Oh, thanks for letting me know. I’m actually going to ask X to come in and start this I.V. because she’s a wizard at finding a vein.”
    • Ask her: “I’m guessing you’ve had some experience with medical care – tell me what kinds of things you find most helpful or let me know if what I’m doing is not helpful.”
  • Don’t assume that their handicap defines them. Although the fact that I have one leg is certainly the first thing people notice about me, it is only a very small part of all the things that I am.
    • Someone once asked me: “Wouldn’t you have loved to take a childbirth class that was specifically aimed at people with disabilities and that could really focus on your unique needs?” I answered “not really.” Not that I have anything against the idea, but it also didn’t feel like something I needed. When I was pregnant for the first time, my disability was old news. I didn’t need peer support with it. Becoming a parent for the first time was new… I needed support from other expectant parents. Whether they had a disability like me, or liked Broadway musicals like I do, or enjoy Indian food like I do didn’t matter. The key was that they were other first-time parents like me.
    • If there are support services in the community that are unique to specific populations, learn about them! When you have a client that fits that demographic, let them know the resource is out there. But also tell them about all the other support services that might be a good match for them. Don’t assume you know which are the best match. Let them choose the support services that they feel best meet their needs.

 

New Ways to Talk about Labor Pain V: Research on Effectiveness of 3 Mechanisms

table

In 2012, a new Cochrane review of pain management for women in labor was released. Although it had positive things to say about the non-pharmacological techniques, it also said that research into their efficacy was unclear due to limited evidence…

“WHAT WORKS: Evidence suggests that epidural, combined spinal epidural (CSE) and inhaled analgesia effectively manage pain in labour, but may give rise to adverse effects. … WHAT MAY WORK: There is some evidence to suggest that immersion in water, relaxation, acupuncture, massage and local anaesthetic nerve blocks or non-opioid drugs may improve management of labour pain, with few adverse effects.  Evidence was mainly limited to single trials. …INSUFFICIENT EVIDENCE: There is insufficient evidence to make judgements on whether or not hypnosis, biofeedback, sterile water injection, aromatherapy, TENS, or parenteral opioids are more effective than placebo… Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby, however, their efficacy is unclear, due to limited high quality evidence.”

A 2014 review by Chaillet, et al (Chaillet, et al. (2014) Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2): 122-37. http://www.ncbi.nlm.nih.gov/pubmed/24761801) is a significant addition to the research about non-drug approaches.

Chaillet, et al pooled techniques into three categories. If you’ve read my posts from the past few days, you’ll be familiar with these concepts. Also, see the chart at the top of this post for more information.

  • Gate Control mechanism = apply non-painful stimuli on the painful area. Methods included massage, bath, positions, walking, and birth ball. The theory is that this will block some of the intensity of the pain.
  • Diffuse Noxious Inhibitory Control (counter-irritant) = create pain or discomfort anywhere on the body. Methods included acupressure, acupuncture, TENS, sterile water injections. The theory is that this discomfort causes the body to release endorphins which reduce pain intensity.
  • Central Nervous System Control (cognitive/support techniques). Methods included  attention focus, education, relaxation, hypnosis, continuous labor support.

By pooling studies together, you get larger sample sizes which increases the statistical significance of the results. Note, all techniques were compared to “usual care” which might have ranged broadly depending on the preparation of the laboring family and the support they were given by caregivers. It is possible that some in the “usual care” groups were also using a variety of coping techniques. So, the true difference between people who use some coping techniques and those who use none may be even greater than these results indicate.

The results of this review were:

  • Gate Control mechanism. Those who used these techniques had lower pain intensity (as predicted), were less likely to use epidural, and needed less Pitocin.
  • Diffuse Noxious Inhibitory Control (counter-irritant). Those who used these techniques had lower pain intensity, were less likely to use epidural, and more satisfied with birth. (Two trials found women felt safer, more relaxed, and more in control.)
  • Central Nervous System Control (cognitive/support techniques) Those who used these techniques were less likely to use epidural, Pitocin, less likely to need instrumental delivery or cesarean, and had a higher satisfaction with birth. The CNSC did not reduce the intensity of the pain so much as they reduced the unpleasantness of the pain. (See more on intensity and unpleasantness here.) So, although labor still hurt a lot, women felt better able to cope – more like they were working with labor pain.

The most effective technique overall was continuous labor support, such as that offered by a doula. The effectiveness of support was already demonstrated in a Cochrane review by Hodnett et al, (Hodnett E, Gates S, et al.. Continuous support for women during in childbirth. Cochrane Database Syst Rev. 2013. CD003766)

The best results in pain coping were from combining the labor support and education which reduce the unpleasantness of pain with gate control or DNIC techniques that reduce the intensity of the pain.

Recommended: be sure to also check out Henci Goer’s discussion of this study on Science and Sensibility.

New Ways to Talk about Labor Pain, IV: Bonapace Method

The Bonapace Method for reducing pain during childbirth can be used instead of, or in conjunction with, a traditional childbirth education class.

This method does not just teach pain coping techniques, but also teaches about the role of labor pain, how pain messages are transmitted in the body, and three mechanisms that help moderate the perception of pain. Those mechanisms are:

Cognitive structuring / central nervous system control (CNSC). Understanding labor pain and progression – what’s happening and why – enhances a sense of self-control. Focusing on something positive (like a self-affirmation) helps with labor pain.

Gate ControlTheory. Non-painful stimulation blocks part of the pain message transmitted by the spinal cord. Note: Bonapace interprets this differently than I have see elsewhere, saying specifically that it is pleasant sensation applied where the pain is located. The description on their website says “To activate this mechanism during childbirth, the fingers must be run lightly over the painful area, particularly during contractions.”

Diffuse Noxious Inhibitory Control (DNIC). (I call this counter-irritation) Creating a second pain elsewhere on the body (i.e. not where you’re already hurting). The brain wants to reduce the pain’s effect on the body as a whole, so releases endorphins to do so. But the sensations near the second pain are still felt because the body is assessing them. (So, under this theory, holding a birth comb tightly causes a release of endorphins which helps with the labor pain, but the user is still aware of the pressure points from the comb on their palm.) In the Bonapace method, sensitive points on the body (trigger areas) are massaged by the partner, causing pain.

In a journal article (“Evaluation of the Bonapace Method: a specific educational intervention to reduce pain during childbirth”, J Pain Res 6: 653-661 at http://www.dovepress.com/articles.php?article_id=14256), Bonapace et al, compare the results of a “traditional childbirth training program” (TCTP) with the Bonapace method. Study participants chose which class to take from these options.

The TCTP was a 4 week class, with a total of 8 hours of class time, started around the 23rd week of pregnancy. It covered A&P of childbirth, exercises, stages of labor, variations, pain meds and newborn care. Relaxation, visualization, massage, and labor positions were not taught. Only breathing techniques were practiced.

The Bonapace class was 4 weeks, 8 hours, starting in the 30th week. The entire program was dedicated to pain management and partner participation. It covered 1) CNSC through breathing, relaxation, and cognitive understanding of labor pain and endorphins, 2) Gate control – non-painful stimuli such as walking and light back massage between contractions, and 3) DNIC where the partner did painful massage of acupuncture triggers points in the lower back, hands, and buttocks.

39 women participated in the full study. In labor, every 15 minutes, participants were asked to rate their pain on two scales: intensity and unpleasantness. (If pain medications were given, they stopped assessing pain after the medication. If that participant had pain scores for two phases of labor, they were kept in the study, if not, they were dropped.

Those who had learned the Bonapace method had an average of 45% less pain intensity and 47% less unpleasantness than those who had received the “traditional” childbirth education. No difference was found in the use of pain medication.

The reduction in intensity of pain was consistent for nulliparous and multiparous parents. On the “unpleasant” ratings, there was a larger reduction in scores for nulliparous than multiparous. This is likely due to anxiety… a nulliparous woman with no birth experience and no training / childbirth preparation is likely to be anxious about labor pain (and, of course, anxiety increases pain). With the TCTP, her anxiety may have been somewhat reduced and thus her pain unpleasantness would be reduced, but with the Bonapace method, her anxiety and thus unpleasantness were much more reduced.

This study indicates that being given information about the physiology of pain, and plenty of education in clear, simple techniques to manage it, has a significant impact on pain intensity and pain coping.

New Ways to Talk about Labor Pain III: Diffuse Noxious Inhibitory Control

Diffuse Noxious Inhibitory Control (DNIC) is one of the mechanisms we can use for managing pain. That name is a mouthful, so I call these counter-irritants. (Read my post on birth combs as a DNIC tool here.) The principle is that if a laboring mom adds a pain or discomfort on her body during a contraction (like biting her lip, pressing her fingernails into her palm, or putting ice on her back), that helps to distract her brain from the pain. TENS, sterile water injections, acupressure, and birth combs are all DNIC tools for labor.

One theory for why these are effective is that the pain from these sensations causes a release of endorphins, endogenous opiates that help to reduce our perception of pain.

Another has to do with how the brain processes stimuli coming in on various pathways. (This is similar to the Gate Control mechanism of pain, which says that when we provide stimuli on fast-moving nerve pathways – like through sound, smell, touch with our sensitive fingers and toes – then those block some of the pain coming in on slower pathways – like labor pain.)

Chaillet, et al says that DNIC primarily reduce the intensity of pain. I believe that they can also help to reduce the unpleasantness of the pain. (see my post here for the difference between the intensity of pain and the unpleasantness of pain.) If mom is in control of the counter-irritant, it may give her more of a sense of control over the labor pain. She may feel like she can’t escape the labor pain (it’s highly “unpleasant”) but that she could stop biting her lip anytime she wants… being in control of something is better than feeling totally out of control. It’s one way of “working with labor pain.”

In childbirth classes, we can talk about counter-irritants by suggesting options to the pregnant parent (ice, squeezing something, TENS). We can use the concept to better explain sterile water injections (some parents are mis-educated in advance, and think that the injections themselves relieve pain… they’re shocked at how much the injections hurt! So, we want to explain in advance that they do hurt… like a bee sting… and that’s the idea, because they trigger an endorphin release.

In classes, we can also let the support person know that some people in labor develop a spontaneous ritual where they are causing pain to themselves (like pulling their hair)… help the partner understand that the person in labor is looking for counter-irritant – an uncomfortable sensation to distract her from the pain, and they can help her find one that gives that counter-stimulation but doesn’t harm her (like squeezing birth combs).

In the Bonapace method (I’ll post on that tomorrow), the DNIC mechanism that is taught is for the partner to do painful pressure on acupuncture trigger points. I personally prefer using only counter-irritant techniques that the person in labor applies and controls. I personally don’t like to teach partners to do anything painful to a woman, even if it might have benefit for labor pain. (A licensed massage therapist who has been clearly trained in safe high pressure massage I have no concerns about.) If I were to teach this in a class, I would set clear expectations that the laboring woman controls this firm massage – she asks for it to be done, and if she doesn’t like it, she tells her partner to stop, and her partner should stop.

New Ways to Talk About Pain II – Working with Labor Pain

Many years ago, I created a class I called Working with Labor Pain. I had realized that if women were expecting non-drug comfort techniques to take away their pain like an epidural can, then they would be disappointed. If they imagined that if they used a few deep breathing techniques and some visualization, then labor would be “easy”, they were in for a shock. But, if they understood that the techniques we taught could help them feel like they were working with their pain,  then the pain would feel more manageable. Coping with labor would be hard work, but it didn’t have to be suffering. (See my last post for more on this distinction.)

Nicky Leap, a professor of midwifery at the University of Technology, Sydney, Australia, has done some great writing on this subject.

For her dissertation (Leap N 1996a A Midwifery Perspective on Pain in Labour – described here) she did a literature search on labor pain, including novels, poetry, short stories, plays, biographies, oral history and books on childbirth aimed at pregnant women, and she interviewed 10 midwives. “The midwives described two distinct approaches to pain in labour. I named these the dominant paradigm (or ‘mind set’) of ‘pain relief’ and the paradigm of ‘working with pain.'” The pain relief approach has the goal of reducing pain through medication. It assumes that not offering pain relief in labor is cruel in the days of modern analgesia. Working with pain is based on an understanding that normal pain is part of the process of labor.

Nonpharmacologic should be first method: labor support combined with Gate Control or counter-irritant. If not enough, and woman is suffering, then combine pain meds with nonpharmocologic, especially support.

The midwives felt that in normal labor, pain triggers endorphins that help the women to cope. Pain is an ally which tells women to summon support and find a safe place to give birth. Pain is a signal of labor progress. If a woman is supported through the pain by people who are confident in her ability to cope with it (to work with it), then she has heightened joy at the end of the process from the triumph of walking through that pain. In a normal labor, with safety and support, women aren’t sent more pain than they can handle. (Abnormal pain is associated with abnormal labor that might require intervention and might require pain relief.)

The midwives were concerned that when we offer the full menu of pain relief choices, with the benefits and risks of each method, that we create “a culture where both women and their attendants end up seeing some form of ‘pain relief’ … as a necessary part of the process of giving birth.”

In “Journey to Confidence: women’s experiences of pain in labour and relational continuity of care” (Leap, et al, JMWH 2010), Leap documents interviews with ten women who had midwifery care. They linked their confidence about pain coping to the way their midwives talked about labor pain openly, candidly, and calmly, explaining that it’s not like other pain, and that it’s manageable pain. During labor, when they were feeling overwhelmed, it was helpful reassured by the midwife that although labor was painful, the contractions were bringing the baby down, and being reassured that they could manage the pain. After labor, “women consistently linked their pride about coping with pain to feeling strong and confident and to a positive start to new motherhood.”

In Working with Pain in Labor (Leap, et al. New Digest, 2010) she says that if the pain relief paradigm is applied, then even when women say they hope for a drug-free labor, they may still begin labor with the expectation that they’ll need some form of pain relief. If they have unrealistic expectations about pain, they are not prepared for labor, and if “a woman experiencing normal labour is offered pharmacological pain relief, she will find it irresistible.”

On the other hand, if the caregivers have a philosophy where pain as seen as a normal physiological process, and mothers are given privacy and protection from disturbances, they can go into an altered state where oxytocin and endorphins help them cope.

In childbirth classes, we should think more about how we talk about working with labor pain for a normal labor that’s intense but not unbearably unpleasant versus how we talk about pain relief as a useful tool for any abnormal labor or any point where the pain has become suffering.

In the last edition of Pregnancy, Childbirth, and the Newborn, we added a chart comparing what labor is like without pain medications versus with pain meds. For the 2016 edition, I’m working on a clearer description that the role of pain meds is pain relief and the role of non-pharmacological options is to help us feel like we are working with labor pain and it is manageable and we can triumph over it.

New Ways to Talk about Labor Pain, 1: Intensity &Unpleasantness

scales

Melzack and Casey* described multiple components of pain:

  • Intensity (they called it sensory-discriminitive): how intense it is, the quality of pain and where it is located – more objective
  • Unpleasantness (motivational-affective): are you suffering and how badly do you want to escape from the pain – more subjective
  • Interpretation (cognitive-evaluation): how intense and unpleasant a pain seems to us is influenced by things like our cultural beliefs and whether we believe the pain to be a sign that “something must be really wrong”

In our book, Pregnancy, Childbirth, and the Newborn, we discuss the difference between pain and suffering. You can have pain without suffering – ask anyone who has run a marathon or climbed a mountain…. it’s hard, grueling effort, but they feel utterly exhilarated when they reach their goal. You can have suffering without physical pain, such as that experienced with grief over a loss or betrayal by someone you had trusted. Suffering can be eased with support or worsened through isolation.

So, some women in labor have very intense pain, but it’s low in “unpleasantness” – they’re not suffering if they feel like they are working with their labor pain and they have the support they need to meet the challenge.

We offer in our book the illustrations shown at the top of this page. The pain intensity scale is often used in hospitals for post-operative patients to determine whether they have sufficient pain medications or need more. We encourage women that if they are asked to rate pain intensity, they do so. But then they can offer a second rating – on unpleasantness – how hard they are struggling vs. how well are they coping. A rating of 0 would mean they were really suffering and felt desperate to escape. But a rating of 7 or 8 acknowledges “yeah, sure it’s unpleasant… but I’m doing OK.”

So a person in labor might rate their intensity very high, but also be high on the pain coping scale. They are working with their labor pain. Another person might not be as high on intensity, but might be very low on the coping scale – they’re suffering, and might choose pain medication to reduce their pain intensity.

Using these terms in our childbirth classes gives people in labor other ways to talk about their pain, and it can also offer reassurance to partners: their support may not be able to reduce the intensity of labor pain, but it can make it much more bearable… much less unpleasant.

* Melzack R, Casey KL. Sensory, motivational, and central control determinants of pain. In: Kenshalo DR, editor. The skin senses. Springfield, IL: Charles C. Thomas; 1968. pp. 423–443.