Tag Archives: doula

Pain Medications for Labor

This episode offers an overview of medications for labor pain and childbirth – nitrous oxide, IV opioids, and epidural analgesia. For each it covers how it’s administered, the benefits – how it helps with labor pain, and the possible side effects. There is also a detailed discussion of labor support for a person using epidural analgesia.

A full transcription with links to more information is available at https://transitiontoparenthood.wordpress.com/for-parents/labor-and-birth/pain-medication-for-labor/

Labor Support

Continuous labor support, which can be provided by a partner or spouse, other family or friends, a professional doula or by medical caregivers has been shown to reduce interventions, improve outcomes, and improve satisfaction with the birth. This episode is all about how to provide effective labor support: by learning about childbirth, learning about what best comforts the person you will support in labor, creating an environment where she is comfortable and feels able to do what she needs to do to cope without being judged, watching for Relaxation, Rhythm, and Ritual and reinforcing those, and – most importantly – helping her to feel safe, loved and protected. When someone feels safe, loved and protected, oxytocin and endorphins flow, and labor progresses faster and hurts less. [Transcript of episode.]

Understanding Labor Pain

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.]

Labor Hormones in under 10 minutes

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, click here.

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

Hormone What Does It Do What doesn’t help What does help
Oxytocin Causes labor contractions that dilate cervix Anxiety, bright lights, feeling observed, feeling judged

Pitocin – if have synthetic oxytocin, make less hormonal oxytocin

To increase oxytocin: Skin-to-skin contact.
Nipple stimulation, making love.To increase endorphins: social contact and support from loved ones.To increase oxytocin and endorphins and to reduce adrenaline: create an environment where we feel private, safe, not judged, loved, respected, protected, free to move about.(So, partners, if you remember nothing else about labor support, remember that if she feels safe, loved and protected her labor will be faster, and less painful)
Endorphins Relieve pain, reduce stress (cause euphoria and feelings of dependency) 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)

Catecholamines (adrenaline, etc.) 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.)

Stress / anxiety / fear

Lack of control

Feeling trapped

Hunger, cold

 

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.]

Picture2

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.)

Picture3

“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…]

Picture4

[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.]

Picture5

“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.”

More Info

* 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/.

To read more of my blog for childbirth educators and doulas, click here. For lots of ideas for interactive activities for childbirth education classes, click here. To learn more about any topic related to the perinatal period, check out our book Pregnancy, Childbirth, and the Newborn: The Complete Guide.

Phantom Pain Doulas

After a recent experience with phantom pain, I was thinking about how helpful it could be to have phantom pain doulas.

What is phantom pain? Phantom limb sensation is something that is experienced by amputees where it feels like the missing limb is still there.

It can be just sensation. For example, any time I talk about or write about phantom pain or about my missing leg, I feel a tingling throughout my “right leg”, even though my right leg was amputated 35 years ago – back in 1982. The tingling is similar to what you feel if your leg falls _really_ asleep, then you change position and you get that tingling / stinging sensation as the blood flow returns. It is very defined as to its location in the “limb”. I can feel the outline of all 5 toes, my heel, my calf and so on, as if my leg was still there.

Sometimes it’s discomfort – maybe in one very specific place – like the outside of “my pinkie toe”, or “my Achilles tendon”, might feel like someone’s pricking it with pins or thumbtacks.

It can also be pain. From mild to awful. Like someone is taking a sharp knife and stabbing it into my knee over and over again.

You may see articles that compare levels of pain, and they typically say that childbirth and phantom pain are at the top of the list, above broken bones, kidney stones, and tooth abscess. Having had three babies, I can definitely say that the intensity of phantom pain can be as overwhelming as labor pain.

It’s usually not that bad! For me, I’d say it only gets that bad maybe once or twice a year. (Usually when I have a fever.) But, I do have times, maybe once a month or every other month, where it’s bad enough that I have a hard time concentrating on my work or enjoying my leisure, or getting to sleep.

But, that frequency (once a month of needing attention, once a year of being overwhelming) is what I experience after 35 years as an amputee. It has become much less frequent over the years. For a NEW amputee, they can experience this pain far more often. It could be a huge help for them to have doula style support managing that pain.

What could a doula or other support person do to help with phantom pain?

Validation: Like with labor pain, one of the first steps is validation – “I hear that you’re hurting. I know it’s hard. I know you feel like you should be able to cope with it on your own, but I know it’s challenging and I’d like to help.”

Knowing about self-help techniques that help with phantom pain

  • Counter-irritants: One thing amputees may do to manage the phantom limb pain is to cause another pain somewhere “real” to distract them from this pain. This might be biting their lip, pounding their fist on the remaining limb, or squeezing their fingernails into their hands. Counter-irritants can be helpful for many pain sources, but especially for phantom pain, it can give the sufferer a sense of being in control of that pain even though they can’t control the phantom pain. An effective tool for creating this discomfort that doesn’t harm them is reflexology combs. Learn more about them and counter-irritants here. Learn more about the theory of diffuse noxious inhibitory control here.
  • Heat and massage: I find often, but not always, the cause of my phantom pain in my leg is actually tight muscles in my lower back, near my sacrum. (This usually happens when I’ve had some days of bad posture – like sitting on a soft bed and reading, which is hard on my sacral muscles.) So, heating pads and a good sacral massage can often relieve the phantom pain.
  • Other amputees find other self-help techniques helpful, such as acupressure, exercise, putting pressure on the stump – I discuss them in this post I wrote years ago: www.transitiontoparenthood.com/janelle/energy/PhantomPain.htm
  • Many of the other coping techniques doulas use in labor, such as breathing, attention focus, movement, baths, and so on can help. Phantom pain is often intermittent, coming in waves (like contractions), so support could look like labor support in early labor: sitting and watching TV or playing games for ten minutes, then helping the amputee manage a 30 second surge of pain, then returning to the movie / game.

Knowing about alternative medicine that can help with phantom pain

Knowing about medication

In MY EXPERIENCE (others may vary), here are things that didn’t help with phantom pain: Tylenol on its own, Tylenol with codeine, ibuprofen on its own, other NSAID’s, and alcohol. None of it did anything, really, so the self-help, acupressure, and energy medicine were essential to me for years.

What does help? What’s my best magic cure for phantom pain? One Tylenol and one Ibuprofen. Taken together. It’s gotta be both, or it doesn’t work. But together, it’s fabulous. No matter how bad my pain is, it’s gone in 15 minutes after I take this.

I LOVE that I discovered this about ten years ago. It gives me so much more of a sense of control over my phantom pain. I don’t take medication for mild pain – I want to go easy on my liver and taking large amounts of medication is NOT good for your liver. But it helps to know that whenever it gets too much to handle, or when I need to go to sleep or need to be at my best to teach, all I need to do is take a Tylenol and ibuprofen and it will be better in about 15 minutes and will stay better for about 6 hours. I never travel without my emergency stash of one of each pill (ever since that day in Disneyland where I had to buy one whole bottle of each at theme park prices!)

What you could do

As a doula, you know a lot about pain coping in general, and how to sit with someone who is in pain, and now I’ve given you some tips specific to phantom pain. For an “old amputee” like me, we’ve learned coping techniques that work, and we can take the occasional Tylenol/ibuprofen cocktail to manage it.

But a new amputee needs to learn those coping techniques, and they can’t be popping medications every day (because of impact on liver), so they need extra support. If you know any new amputees who are struggling with phantom pain, consider offering your support, even just a conversation about things that might help.

 

 

Update on Transgender Families

I’m working now on an update of Pregnancy, Childbirth, and the Newborn: The Complete Guide. It was originally not intended to be a full revision – it was just intended to be a limited update on new trends in maternity care, current statistics, and updated medical guidelines. But, I wanted to add in something to acknowledge parents who identify as men and are pregnant, and other expectant families who are genderqueer, gender non-binary, and so on. It started as inserting a few paragraphs on the topic, but I’m now also working to make more of the language in the book gender-neutral. It will not be fully gender-neutral, nor will it fully reflect the experience of these parents, because that level of change is simply beyond the scope of what I can do at this time with our publisher’s deadlines days away. But, I’m glad we’re making baby steps, and hope I don’t make too many mis-steps along the way.

In this process, people have kindly shared resources with me. I will share them here for reference by other birth professionals. If I mis-state anything here, feel free to comment – but be nice, OK? I’m still learning…

Understanding Gender Identity

First, if you know your knowledge of transgender issues is limited, a great place to begin is “Guide to Being a Trans Ally” on straightforequality.org. It’s long, but well worth the read. For example, it defines sex, sexual orientation, gender, gender identity and gender expression, and all the ways terms are used. It also talks about how all these things can be a spectrum. (A side note: If you think biological sex is totally binary, not a spectrum, you’ll find this a fascinating post about in-utero development of sexual characteristics.)

For example, I am a cisgender woman, because I was assigned female at birth, and I identify as female, and my gender expression is female though not exactly “extremely feminine” (you’ll never see me in high heels or makeup!)

A transgender man is someone who was assigned female at birth because of their biological sex characteristics, but internally identifies as male. Some transgender men are not “out of the closet” and don’t disclose their transgender status in their public life – they think of themselves as male and may ask those close to them to refer to them as male, but their gender expression in public is female or sometimes androgynous. Some transgender men express themselves as male – they dress in “male” clothing, may use mannerisms and speech patterns associated with men, and may have a male name but may disclose their history and transgender status. Some express themselves as completely male – as the Guide says, they “just want to be seen as their gender-affirmed selves (sometimes referred to as being stealth or private)” In your practice, you may have encountered these men as partners to a female-identified expectant mother.

Estimates on what percentage of the popular is gender variant range widely. The Williams Institute says 0.3% of Americans are transgender. The Transgender Law and Policy Institute says 2 – 5% of the population experience some gender dysphoria (an emotional / mental health condition that arises when someone’s gender expression and how other people refer to them and react to them does not align with their internal sense of who they are.)

It is very likely that younger people are more likely to identify as transgender than older people. When asked whether they identify as lesbian, gay, bi or transgender, 1.9% of those over 65 say yes, but 6.4% of those 18 – 29 do. (Source) This is likely not due to a change in actual incidence of homosexual orientation or transgender identity but more on social attitudes that make it more acceptable to acknowledge those feelings. This will mean that in the future, you will be more likely to knowingly encounter gender variant families than you were in the past.

Transgender people in America experience very high rates of harassment, discrimination, and assault. They have high rates of homelessness, unemployment, and lack of health insurance. (see http://www.transgenderlaw.org/resources/transfactsheet.pdf and Gender Not Listed Here.)

Transgender Men and Pregnancy

A pregnant father would be someone who was assigned female at birth (and has a uterus, ovaries, and so on) but his internal sense of gender identity is male. There are also people across the gender spectrum who carry and birth babies.

Some of those expectant parents will have an outward gender expression that is obvious to birth professionals, and they may also have a conversation with the professional about their gender identity, preferred pronouns, and preferred terms (e.g. father vs. mother). Other transgender people might not reveal their gender identity to their caregivers, and may be cautious in how they dress and present themselves when coming for appointments. However, this may increase their gender dysphoria. Dysphoria is often intense during pregnancy, but having your caregiver use ‘she’, ‘her’, ‘mother’ and other gendered terms frequently can increase that.

When birth professionals encounter clients who express themselves as gender variant, we  need to know how to treat them with respect and honor their identity. And, because we will also quite possibly encounter other gender non-conforming people without knowing it, we should work on adapting our language at all times to welcome them in. And that includes language on websites and advertising where potential clients may look before coming in to determine whether they would be welcomed by your practice.

Health Care Experiences of Transgender People

Many transgender people have a history of bad encounters with health care providers: As many as one-fourth of gender variant people avoid health care services due to concerns about discrimination and harassment. (Source)  “FTM youth said they frequently encountered verbal abuse and condescension from frontline health care staff such as receptionists: ‘I can’t even make it through the front door without staff staring at me, laughing at me, or whispering about my gender presentation.’ In the FTM youth group, all participants agreed that they did not feel safe receiving health care.” (Source) “One FTM youth found experiences with gynecological care especially upsetting:’There is a lack of sensitivity… The doctor was not sensitive to the fact that I experience myself as male and that this experience was overwhelming for me.’ Said one FTM adult,“I think for me it is respect and a willingness to respect your pronoun.I found that to be a huge problem.As somebody that hasn’t done any body alterations,it’s hard for people to switch pronouns and accept the pronoun [that I prefer].” (Source)

This page http://transequality.org/Issues/health.html offers brief, but helpful, recommendations for trans* people about accessing effective health care in general, and things they should consider, and talk to a supportive caregiver about.

Health Professionals Advancing LGBT Equality (previously known as the Gay & Lesbian Medical Association) has an excellent resource for health care providers on Guidelines for Care of LGBT Patients. It talks about how LGBT clients might “scan” a practice to see how friendly it is: they might look for gender-neutral language (pregnant parent, partner, and so on – not mother and father), non-discrimination statements, gender-neutral restroom signs, pride flags, intake forms that ask for relationship status not marital status, offer a check box for transgender, a line for preferred pronoun, and so on. Check it out for ideas that might apply to your practice.

Birth Professionals and Gender Variant Families

The Science and Sensibility blog hosted a post by Simon Adriane Ellis on Working with Gender Variant (Transgendered) Families which is an excellent summary for birth professionals (OB’s, midwives, doulas, childbirth educators, and so on) about how to work with gender variant people successfully. Some tips are:

  • Offer accommodations such as one-on-one classes, appointments at the beginning or end of the day, if you need to refer to another provider, you call ahead to provide the patient’s background.
  • Plan to offer additional emotional support – they may feel very isolated and may be struggling with gender dysphoria. [Note: Ellis also co-authored a journal article titled “Conception, Pregnancy, and Birth Experiences of Male and Gender Variant Gestational Parents: It’s How We Could Have a Family” which explores this parenting experience and says the over-arching theme was loneliness.]
  • Use sensitive language. It’s important to ask them what name, pronoun, and parenting term they would like to be addressed by.
  • “Don’t let your curiosity get the best of you” – it may be tempting to ask the whole history of their gender identity… only ask what you need to know to care for them
  • I think a really important sentence from the article is “The urge to refer clients/patients to “someone who has more experience” is strong; often, it is grounded in sincere concern for the client’s well-being. But the truth is: with very few exceptions, there is no one with more experience.”

ACNM has a position statement on Transgender/Transsexual/Gender Variant Health Care which includes some pointers to additional research.

Inclusive Language in Childbirth Classes

I attended an in-service by Kristin Kali, from Maia Midwifery on how language matters for LGBT students in childbirth classes. Here are some of my takeaway notes from that:

  • Using very gendered language like “mom” and “dad” can be very alienating for many families: single parents, gay or lesbian couples, surrogates, donor fathers, polyamorous families where there will be more than two parents, or a transgendered dad who is carrying the baby.
  • On intros, could ask “who is in this baby’s family?” Or “who will support you in birth and in the early weeks as a parent?” “Who is in your family? You and your child? You and a partner and child? Uncles and aunties?”
  • In class, refer to pregnant parent rather than “mom”, people in labor rather than “women in labor”, the uterus rather than “her uterus”, parents instead of “mothers.”
  • Don’t wait till you have someone in class who you know is transgender before you adapt your language. It’s hard to remember it in that one class! Consider just changing your language  long-term for ALL classes to be as inclusive as possible so that it flows naturally when you do have that parent.

Resources for Finding Supportive Caregivers

Here are some directories that may aid a gender variant expectant parent in finding a caregiver: