Maternal Satisfaction and Pain

If I were to do a poll about labor concerns, most people would say what they fear(ed) most about childbirth was the pain. What’s more, when most people just think of a word they associate with childbirth, the first to come to mind is pain.

(As a side note: how sad is it that joy, family, or wonder are not the first words. Instead it is pain, epidural, loss of control…)

I digress – pain and its management are very central in childbirth education models (especially in Western thought). There are many different theories of pain – all worth studying.

But the research that surprised me the most indicated that pain is not chief when it comes to satisfaction in childbirth.

Are you surprised too?

Then, of course, since its good research, it didn’t surprise me so much and it even began to make a lot of sense.

It didn’t matter so much as far as pain and its management. Women with epidurals were just as likely as women without medical pain management (drugs) to feel dissatisfied with their birth over these points – information provided, concerns recognized, and support received.

Let me break that down again – women with epidurals were dissatisfied with their birth if they felt the doctor and nurses didn’t give them enough information, didn’t address their concerns, and/or didn’t give enough support.

In fact, research seems to indicate that patients are more likely to sue if they feel they are not being communicated with and included in decision making. (see below for citation)

Can we all collectively say “Wow”?

This totally knocks the old “all that matters is a healthy baby” out of the picture. Also out the door is the idea that an epidural is the “Cadillac” of pain management.

Insurance companies, doctors, nurses, hospitals, clinics, politicians, feminists, women, and men should all be jumping all over this.

Why is it not happening?

Because this model of care in addressing all concerns, providing all information, and giving all levels of support requires a lot of time. If I were better with numbers, I’d run them to see if it confirms my suspicions – it’s cheaper to pay high malpractice premiums than it is to take fewer clients in order to spend more time with each one.

I’ve said it before, but it bears repeating – OBs (and some midwives as well as general practitioners for regular health matters) do not spend enough time counseling patients on preventative medicine and healthy lifestyle choices. How many of us were asked about our eating during our pregnancy, unless we were “gaining too much weight”? How many heard that exercise could be continued but to take it easy, without regard for our current level of fitness?

I’m getting off track – pain, however central in our minds before labor, appears to take a lower position of importance during labor.

Yes, it’s still painful.

Yes, we still want to know how to deal with it – either with coping techniques or drugs.

But for women with or without epidurals, even those with absence or pain or sensation, still have a greater need for this – information and the support it gives.

Once we recognize that and true informed consent happens, it will change everything about birthing in America.

The article that is the main focus of this: http://www.ajog.org/article/S0002-9378%2802%2970189-0/abstract Results: Four factors—personal expectations, the amount of support from caregivers, the quality of the caregiver-patient relationship, and involvement in decision making—appear to be so important that they override the influences of age, socioeconomic status, ethnicity, childbirth preparation, the physical birth environment, pain, immobility, medical interventions, and continuity of care, when women evaluate their childbirth experiences. Conclusion: The influences of pain, pain relief, and intrapartum medical interventions on subsequent satisfaction are neither as obvious, as direct, nor as powerful as the influences of the attitudes and behaviors of the caregivers.

Article concerning likelihood of lawsuit: Communication gaffes: the root cause of malpractice claims. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1201002/

Another article regarding pain management and maternal satisfaction:
Abstract – Maternal Satisfaction and Pain Control in Women Electing Natural Birth – I think this one comes to the wrong conclusion that “survey results suggest that concerns about epidurals and their effect on the baby, greater than anticipated labor pain, perceived failure of requesting an epidural, and longer duration of labor may have accounted for these findings [of being less satisfied with birth].” I think further study is needed, but that it is good to point out what the study did certainly find: “88% of women who requested an epidural for pain reported being less satisfied with their childbirth experience than those who did not, despite lower pain intensity.” http://journals.lww.com/rapm/Abstract/2001/09000/Maternal_Satisfaction_and_Pain_Control_in_Women.14.aspx

Hypnobabies Sale!

Hypnobabies sale! 

Friday, October 29th to Friday, November 5th. 

All products at www.Hypnobabies.com website store are 20% off, (excluding MP3s). 

Use the "Shop Online" menu in the top right corner of the site's home page and use the ordering code FB-FALL

Breech Birth?

What options do you really have for breech birth? And will your doctor tell you about them?

I consider myself educated about birth and research-based practices. I studied all I could before I was pregnant and while I was pregnant.

So why did I agree to an elective c-section?

I thought I had no other option.

It frustrates me, angers me, saddens me to learn now what options I did have, but at the time had no way of finding out.

I feel lied to, mislead, coerced even.

It hurts that I feel so taken advantage of.

The situation: I made my doctor very aware throughout my pregnancy of my intention for a drug-free natural birth. This was usually met with a well-meaning but slightly condescending comment that I “really had no idea of how my labor might go, that it might be as long as 12 hours and I may change my mind.”

This should have been my first clue – a doctor should always support any healthy practice. This includes encouragement and even giving further resources. A doctor should never discourage a healthy practice. (How many of us would go to a doctor who told us starting an exercise program or diet was really hard and that we might want to change our mind once we started?!)

Late in pregnancy when he was stubbornly breech, I wish my doctor would have given me other options rather than a scheduled cesarean before my due date. Yes, I should have looked into options on my own as well. However, ethically, a doctor should give you all information. Period.

What could these options have been?

1. Switch to a practitioner trained in vaginal breech birth. There is at least one in the area (I know this now and with I had known then). Research says that vaginal breech birth is just as safe as cesarean breech for the baby and presents fewer complications for the mother. I believe it is unethical not to provide this information.
2. Wait until I went into labor to do a cesarean. It seems that we are so focused on the pain of labor (next post will discuss a bit of this) that we forget that labor is beneficial for both mother and baby. Babies benefit from the contractions of labor; they help push fluid from the lungs in preparation for breathing. Both mother and baby benefit from the natural hormonal cocktail (which is very different from the unnatural Pitocin many get) – lactation is facilitated and the baby is better prepared for the sudden environment change. Bonding is initiated. These benefits cannot be overlooked or ignored – they equate fewer NICU stays and better lactation success. Additionally, there is some, however slim, chance that a breech baby may turn during labor. Again, it is unethical for a practitioner to neglect to mention these facts.

I’m starting very much to question going back to my current OB/GYN for future pregnancies – even though I have heard he will attend VBACs. I feel he neglected to tell me so much that I wonder what he might leave out of his VBAC “standard of care.”

I’m always looking for VBAC and breech birth information in the area, and would love to hear about VBAC and breech supportive providers – even homebirth midwives. (which, judging from the research I found for my last post, is looking to be more and more of an option)

A little end note: I would love to get my hands on this film – A Breech in the System.

Research regarding heparin in pregnancy

Had to do a quick post on this because I am very excited!

As you all know, I had a stroke at 20. In the following months, I underwent a lot of bloodwork and tests to attempt to determine the cause. In the absence of any other risk factors, it appears that chronic migraines and birth control pills were the cause. (Did you know that chronic migraines in women increase the stroke risk? I didn’t.) I tested negative for every single known clotting disorder.

However, I was still on prophylactic heparin during pregnancy and post-partum. I don’t mind the shots; you get used to them. I mind that it forced me into OB care. (Prophylactic – giving a medication or treatment as a preventative or just in case. It’s not treating any problems already there; it’s simply trying to prevent them.)

I just found a slew of articles against prophylactic heparin therapy during pregnancy!

I’m not pregnant again (yet), but I am so excited to have these at my disposal. I wonder where they were two years ago when I needed them and searched and searched. But I’m sure glad to have them now.

Links:
Thrombophilia and pregnancy complications: cause or association? http://www.ncbi.nlm.nih.gov/pubmed/17635737

Anticoagulant therapy for deep venous thrombosis during pregnancy http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD007801/frame.html

Aspirin plus heparin or Aspirin Alone in Women with Recurrent Miscarriage (http://www.nejm.org/doi/full/10.1056/NEJMoa1000641)

Safety of Withholding Heparin in Women With a History of Venous Thromboembolism http://www.nejm.org/doi/full/10.1056/NEJM200011163432002

A Beginner's Guide to Charting, Part 4 - Putting it all together

Let’s review some things first. The part of your cycle where estrogen is dominant is the first part – the part before ovulation. Progesterone is dominant after ovulation – the last part of your cycle. Estrogen causes lower BBT and higher fertile quality cervical fluid. Progesterone causes a temperature shift to higher temps and a drier (non-fertile) cervical fluid.

During one’s period at the beginning of the cycle, you cannot get pregnant. When we talk about your period, I mean true bleeding and shedding of the uterine lining that is built up during the progesterone phase. You may have heard, however, of women getting pregnant during “their period” – however, this is not a true period with shedding of the lining. Rather, it is an episode of “break-through” bleeding after a long estrogen period. Anytime you are charting and have not had a temperature shift to confirm ovulation, you should assume you are still fertile – even if it has been thirty or more days of a low pattern.

How can this happen? Many times stress is the culprit here. My cycle around my wedding was 43 days long; I didn’t ovulate until a week and a half after the wedding on cycle day 25. Job stress can contribute; as can sudden increases in exercise training (exercise on its own should not inhibit ovulation and fertility, unless you are training for the Olympics and not giving yourself enough rest time. Let’s just go ahead and bust that myth).

Additionally, you can have an annovulatory cycle, a cycle without ovulation. My wedding cycle was simply a very long cycle, but you can have cycles where it seems like your body simply starts over. This is ok if it happens every once in a while, and is quite normal. However, if you only have annovulatory cycles, or have many more of them than fertile/true cycles, you should check with a doctor or midwife. Just like with really long cycles, you should use protection (if trying to avoid pregnancy) or keeping going (if trying achieve pregnancy) until you have that temperature shift. It can be hard to tell when your body will go ahead and ovulate on super long cycles or annovulatory cycles. 

Here’s one of my pregnancy charts – Elias chart. You can see how we achieved pregnancy. Any time we made love before the fertile period was just for fun; same for any time after the fertile period. That fertile window is what you want to focus on. This is especially important for anyone who naturally has short cycles or long cycles. If you don’t ovulate on day 14 (again, many of us don’t), you’ll want to analyze your cycles to understand the best time to try.

What about if you are trying to avoid getting pregnant? This is one of the things that I really loved about charting when I first started. Traditional birth control – shots, pills, barriers, spermicides – require that you use them throughout the cycle because they don’t tell you when you are fertile. By knowing when you are fertile, you can limit the use of these methods. (Of course, taking birth control pills 5 days out of your cycle is not going to work!) My husband is not a fan of condoms – many of us aren’t. Knowing my fertile days allowed us to only use condoms during those days; we were free to go without any other time of my cycle. 

If you are trying to avoid, there are a few rules/guidelines to follow. You are free during a true period (see above!). You are free three days after a temperature shift with dry-up of cervical fluid (they have to go together). You are free anytime you do not have fertile quality cervical fluid, though the closer you get to expected ovulation, the more careful you will want to be. The best advice – chart for at least three cycles before relying totally on this method to avoid pregnancy.

There are so many other things we could discuss about the finer points of charting, but it would take a great deal of time. I suggest that everyone own a copy of Taking Charge of Your Fertility, or at least check out a copy from the library. It’s an invaluable resource and well worth it.

Again – I have no affiliation with Ovusoft, etc. I simply like and use the software. Thanks.