This episode covers second stage labor – the birth of a baby, third stage – the delivery of the placenta, and the first hour of baby’s life. Addresses when to push, how to push, and positions to aid labor progress. Talks about “the Golden Hour” of bonding with a new baby. [A full transcription of this episode is available at: https://transitiontoparenthood.wordpress.com/for-parents/labor-and-birth/birth-and-babys-first-hour/]
I discuss the physiology of pain and ways that people who have been through birth describe how contractions feel. Given all of the physical changes and challenges of labor, it’s not surprising it is painful for many people. The acronym P.A.I.N. can remind us that labor pain is Purposeful, Anticipated, Intermittent, and Normal. However, understanding what factors make that pain worse than it has to be helps us learn how to reduce it. The Fear Tension Pain Triangle theory tells us that when we’re fearful, we tense up. As we tense, the pain increases, which frightens us more…. the fear increases, and so on. Instead, we want to explore ways to shift this to the Confidence Relaxation Comfort Triangle to make labor more manageable. [Transcript of podcast episode.]
Podcast Episode 1: The most common question from people preparing for labor is ‘how will we handle the pain’? This episode provides an overview of all the tools that we can stock in a Toolbox for Coping with Labor Pain. It introduces both non-drug comfort techniques and pain medications, explores how the choice of pain coping techniques influences the whole experience of labor, and discusses the Pain Medication Preference Scale, a helpful tool for clarifying and summarizing priorities related to pain medication. Knowing someone’s preference helps to guide the labor support team in how to support them through the challenges of labor. Learn about all these tools by listening to more episodes of this podcast, or by reading Pregnancy, Childbirth, and the Newborn.
I’ve created so many resources over the years that I sometimes forget about some. I got an email today reminding me about this one I wrote back in 2003, with two other educators (Tawnya Ostrer and Jamie Olson)… I looked back and, you know, it’s pretty good! So, I updated it, and will share it here.
This is a handout to be used in a childbirth education class or with doula clients, which encourages expectant parents to plan ahead for practical support, emotional support, and peer support. It also includes a letter that they can give to friends or family members who ask how they can help.
Postpartum Support and Sanity Savers – Word (you are welcome to edit the document to substitute your local resources for the Seattle area resources I list. Otherwise, please use as written, with copyright info intact.)
And here’s a related handout to help them plan for a division of labor after birth: Baby Care Plan
Note: this page is about how professionals can TEACH this concept to expectant parents. If you’re an expectant parent looking for info on labor hormones, their effect on labor pain, and what your partner can do to help you have a shorter and less painful labor, read Hormones and Labor Pain or listen to episode 5 of my podcast – Labor Support.
In my childbirth classes, and with doula clients, I want them to understand that our emotions, and the support we receive, absolutely affect labor on a physiological basis, by influencing our hormones. The big message is that fear and anxiety slow labor down and make it more painful. Support and feeling safe make labor faster and easier. I have simplified the complex details into a simple stick figure drawing that takes 5-10 minutes.
Before I talk about my teaching method, let’s start with…
A basic summary* of hormones
- What it does: Causes labor contractions that dilate cervix (i.e. helps labor progress)
- What hinders oxytocin production: Anxiety, bright light, feeling observed or judged. Pitocin (if you’re given synthetic oxytocin, you make less hormonal oxytocin)
- What increases oxytocin: Skin-to-skin contact. Nipple stimulation, making love.
- What they do: Relieve pain, reduce stress (cause euphoria and feelings of interdependency)
- What hinders endorphin production: Stress, lack of support. Narcotics (if you have an external opiate, your body will start producing less internal opiate… even after the narcotics wear off, you’ll have less endorphins)
- What increases endorphins: social contact and support from loved ones.
- What does it do: In early / active labor: slow labor down(Imagine a rabbit in a field. If it doesn’t feel safe, it wants to keep baby inside to protect it) In pushing stage: Make you and baby alert and ready for birth, give you energy to push quickly. (If the rabbit is about to have a baby, and something frightens it, it wants to get the baby out as quickly as possible so it can pick it up and run with it.)
- What increases adrenaline: Stress / anxiety / fear; Lack of control; Feeling trapped; Hunger, cold
- What increases oxytocin and endorphins and reduces adrenaline: creating an environment where the birthing parent feels private, safe, not judged, loved, respected, protected, free to move about.
Teaching about Hormones
So, in class how do I convey these ideas in just a few minutes, so it’s easy to understand and to remember?
First, I say: “In labor, our emotions and our environment effect our hormones. Our hormones have a huge effect on labor. Let’s look at a couple scenarios for labor.” [I draw two stick figures on the board.] “This one is awash in stress hormones which will make labor longer and more painful. Let’s label it adrenaline. This one is under the influence of oxytocin and endorphins. These help the laboring person shift into an altered state where labor pain is milder (less intense and less unpleasant) and also help labor progress more quickly.” [Add labels to drawings, add sad face and smiley face.]
Then I say “So, you are all probably familiar with adrenaline. What do we call it? Yes, the fight or flight hormone. This is the idea that if an individual ran into a tiger in the woods, they would choose either to fight it or to run away. Do you know what we call oxytocin? Many call it “collect and protect” or “tend and befriend.” If a tiger is coming into our village, we gather everyone together, because we are safest together.” [I add these labels to my drawing.] (I sometimes throw in the tidbit here that men who are not dads are more likely to release adrenaline during stressful situations; women and dads are more likely to release oxytocin – it’s the “gather the babies and protect them” response.)
“So, what effect do these hormones have?”
“With adrenaline, all your muscles tighten. All your energy goes to your limbs in case you need to fight or run away. So, oxytocin production drops and labor slows down. (It’s hard for your cervix to open when you feel scared…) You are also more sensitive to pain – this is useful if you’re at risk of injury – your body tells you what to move away from. But, in labor it’s not helpful – it just means labor hurts more!”
“With oxytocin and endorphins all your muscles relax. Energy is sent to the uterus and oxytocin increases. (Oxytocin is often called the love hormone, because it increases when we feel loved, and its peak levels are when we orgasm, when we birth, and when we breastfeed. It’s all about making babies, birthing babies, and feeding babies.) We also get an increased endorphin flow, which makes us less sensitive to pain, can cause euphoria, and can cause feelings of love and dependency in us… “I love you man….””
[As you talk, write the notes, and draw on the figures like this to show effects…]
[If you teach the 3R’s method for coping with labor pain – relaxation, rhythm, and ritual, you can also add in here: If you’ve got oxytocin and endorphins flowing, you may also have more rhythm – you may rock, moan or sway rhythmically. If your partner helps to reinforce your ritual, it will help build your oxytocin and endorphins.]
“So, what causes adrenaline rushes? Fear, anxiety, feeling watched or judged, feeling like you have no control over your situation, being hungry or cold.”
“How can we tell a person in labor is rushing adrenaline? They act vigilant or panicky, have lots of muscle tension, and a high pitched voice.”
“What causes oxytocin and endorphins to flow? Feeling safe, loved, protected, having privacy, having support, eye contact, skin-to-skin contact, and love making.”
“How can we tell if someone is in an endorphin / oxytocin high? They seem open and trusting, their muscles are relaxed, and their voices are low-pitched and husky.”
[Add notes about causes and signs to your picture.]
“So, partners, what’s the big picture summary?”
“If you remember nothing else from this class, remember this: If a person in labor feels safe, loved, and supported, her labor will be faster and less painful. If in doubt about what to do, always return to this! Anything that helps her relax, gain her rhythm and feel cared for will help her.”
* If you want a great overview of hormones in labor, read Pathways to Birth. If you want all the details on hormones in labor, read Hormonal Physiology of Childbearing. You can find them both at: http://transform.childbirthconnection.org/reports/physiology/.
Find more thoughts about teaching on my blog for childbirth educators. Check out ideas for interactive activities for childbirth classes. To learn more about any topic related to the perinatal period, check out our book Pregnancy, Childbirth, and the Newborn: The Complete Guide
In classes, we talk about the Pain Medication Preference Scale from Pregnancy, Childbirth, and the Newborn. We have the expectant parents look at it together, and then encourage the pregnant parent to choose the number that best represents their preferences, and the support partner to choose what they WISH the pregnant parent would choose.
Then we have them discuss. Often they align, but not always. Sometimes there is a pregnant parent who is hoping for an un-medicated labor who has a partner who can’t bear the idea of seeing them in pain. Sometimes a pregnant parent wants medication, but the partner has concerns about side effects on them or the baby. I would much rather this issue come up during pregnancy when they can resolve it rather than arising without warning in labor.
I have designed a new worksheet that asks more questions about labor coping preferences that they can fill out separately, then discuss, to further illuminate these issues and enhance the discussion they can have about goals and preferences before labor begins. You can see the Pain Preferences Worksheet here – feel free to print and use in class.
In my last post, I talked about 4 steps of teaching informed decision-making: Values Clarification, Communicating Values with Birth Plan, Key Questions to Ask, and Informed Decision Making. This post is all about that last step.
Note: we prefer the term Informed Decision Making to Informed Choice for a few reasons: 1) Choice sounds like there was a clear black and white list of options, and we check a box… decision-making is often murkier than that. 2) Choice sounds a little entitled (my four-year-old likes to shout “It’s my choice so I get to do this!” I tell him that’s not really the case…) Decision-making sounds more like a discussion between the parents and the caregiver and a careful evaluation of the options.
So, how do we teach informed decision-making?
Teaching Method 1: The Five Finger Method
I say “Before your caregiver made the recommendation to you, they already did a risk-benefit analysis. They already thought of what the options were, and thought about the balance between which would be most effective and which would be lowest risk. Let’s say they considered 5 options. [Hold up one hand, five fingers spread.] This option [touch pinkie] would definitely work – it’s very effective, but it’s too high risk – your health situation is not dire enough to need that level of intervention. This option [touch thumb] is really low risk, but it’s not clear if would be effective… it’s benefits are not good enough to offer. This option [touch middle finger] is the best compromise – that’s why your caregiver offered it. But remember, it’s the best compromise for any non-specific person in your situation. That doesn’t mean that it’s the best compromise for you! When you look at those options, you might find that this one [touch index finger] feels like the best answer to you. You understand it might not be effective, and that you might then have to escalate to one of these, but you’d like to try it first. Or, you might be exhausted and done with labor, and ask to do this one [touch ring finger] because you just want to do something you KNOW will work to solve the problem.”
I then give an example: I start with a non-birth-related example. I want to take them out of the realm of birth (where some may feel like this is all complicated and only experts understand it) into some different field where they feel like they have all the info they need.
Two examples I have used: the air conditioner and the loose shelf. I kind of like the air conditioner example better because it brings up the idea that maybe before we ask an expert for an intervention, we should think about whether something is really a problem. But if I’m working with mostly low income clients, it could come from a place of privilege to be able to consider all five options there…
The air conditioner example. “So, the air conditioner broke in my friend’s car last August. Now she knows even before she asks someone what her options are likely to be – she could do nothing and just live with it [touch thumb]- after all, this is Seattle – how many days do you need A/C? she could repair it [touch middle finger], or she could replace it [touch pinkie]. Now, if she goes to the mechanic and says ‘what should I do’, is the mechanic going to offer ‘do nothing’ [thumb]?? No! He figures that if you came to him asking for help, you want him to do something! He might say ‘well, I could repair it. That’s cheaper than replacing (lower cost = lower “risk”) but it might break again. Or I could replace it. Higher cost, but we know it’s effective.
“So, she’s asked her key questions. She’s gathered all the data from the mechanic’s point of view. Now she needs to look at her values and also at her budget, which the mechanic knows nothing about. If she’s trying to save money for something that’s much more important to her, she may decide either never to fix the A/C [thumb] or to tough it out through August, and save money between now and next summer to repair it then [index finger]. If she’s tight for money but can afford it she may start with a low level repair [middle finger]. If she can afford it and she REALLY hates being hot she might try a more comprehensive repair [ring finger.] If she’s got plenty of money, she might go straight to replacement so she doesn’t have to deal with it again.”
The loose shelf example: I won’t detail it here, because i include it as the example in the quadrants tool I describe below.
Now that I’ve taught the five finger theory and given a quick example, now I want to apply this to birth. AND I want them to practice decision-making. I present a scenario, and tell them they have to ask me questions about benefits, risks, and what other options I considered. Then they have to think about their own values and priorities and what choice they would make
Slow Labor Progress example (you’re past 6 cm, but have gone 4 hours with no progress). Recommendation: Try Pitocin and position changes for an hour or two to see if we can speed it up. [Point to your middle finger to show that is the middle-of-the road recommendation that caregiver made. Note: it’s important that you hold up all five fingers and point to the middle one. Don’t just hold up your middle finger. 🙂 ] Parents can ask: what are the other options: pinkie – we could do a cesarean now – that would get the baby out, but there’s risks to a cesarean, and your situation is not that big of a problem. Ring finger – could also break your bag of water. Index – could start with really low dose Pit. Thumb – Could just try position changes and maybe some nipple stimulation, but I’m not convinced that’s going to do anything. So, now parents have all the info. They need to reflect on their goals and values. Let’s imagine one family who had originally planned a home birth and wanted as low of interventions as possible. They might say to the caregiver: “Thank you for all that information. We understand that your recommendation is the most likely to be effective with the least risks. But, our original hope was to be as low intervention as possible, so let’s start with a low dose Pit [index finger] and see if that’s enough.” Another family, who has always been open to whatever interventions were needed to help labor progress well, and who are now very tired and just wanting to hold their baby might say “Let’s move this along – let’s do the Pitocin and break my bag of waters… I’m ready to rock.”
Teaching Method 2: The Quadrants
In this PDF: Decision Making Quadrants, I describe the full process of this method. But basically, you’re asking people first to consider their
- intervention style: are they quick to intervene or are they willing to let something be a problem for a while before they intervene?
- Self-Help or Expert Help: Do they like to solve things with their own skills, or do they prefer to turn it over to an expert?
- Benefits vs. Risk: Do they choose the most effective thing even if it comes with more possible risks? Or are they very cautious about risks and more likely to try lots of less effective options first?
- In a particular decision-making moment, how do they balance their normal decision-making style with the urgency/severity of the current situation while taking their values into account.
- Examples include: the loose shelf, pain medication preferences
Teaching Method 3: The Values Clarification / Decision-Making worksheet
Teaching Method 4: Help Students Learn More about their Decision Making Style