Tag: birth

How To Release The Fear Of Labour Before Birth

I wrote this blog post for The Daisy Foundation all about how releasing your fear in labour can help ease your pain. Fear, tension and pain are in a self-fulfilling cycle, find out how to break it.

So you’re pregnant – congratulations! Now you’ve started to share the good news, we’re willing to bet that you’ve started getting the horror stories – the failed inductions, the 3rd degree tears, the days long labour…right? In the words of Chandler Bing could that BE less helpful?

Think about your reaction when you got the last round of grim labour stories. You winced, you grimaced, you clenched your pelvic floor and tensed your knees together? Oh yes, that’s the good old fear factor – fight or flight – setting in. Fear makes your nervous system produce adrenaline, which increases your heart rate, makes your breathing shallower, blood diverts from your non-essential organs and your muscles tense. Perfectly understandable…but now think about where your baby’s going to come from. Uh huh. Your body being tense from your belly button to your knees isn’t going to help your baby on their way, is it? Your fear leads to tension, and tension leads to pain.

When adrenaline is produced in a labouring person, it inhibits the production of two other hormones; oxytocin and endorphins. It’s these two hormones that are responsible for stimulating the contractions of the uterus, and for blocking the feelings of pain. Without these present in sufficient quantities labour will be longer, more stressful, and more painful than if we allow our bodies to limit the production of adrenaline.

So what if you were told that you can help reduce the pain of labour? Hell YEAH. Let’s start by looking at the fear aspect of the cycle. Fear of the unknown is a well-established phenomenon and it holds true in labour too. Just as each birthing person and each pregnancy is different, so too is each birth experience. For a first-time mum with no point of reference, the thought of pushing a baby out of a hole that small can be pretty terrifying. Reduce the unknown, however, and you can reduce the fear. And that’s where antenatal education comes in. A knowledgeable, informed woman is one who no longer fears the unknown. Now – no woman can plan their birth experience entirely, otherwise we’d all be having two-hour labours with no tearing or pooing (am I right?) but by becoming knowledgeable about the birth process, about the options available to you and about how you can influence the birth to be the best possible outcome on the day by playing the hand that’s dealt, then you can make it all a lot less scary. What’s more, by being so well prepared, this knowledge becomes innate and you won’t have to rouse yourself too much from your birth bubble to give consideration to anything that might need a decision from you. Coming out of that internally focussed zone allows adrenaline to creep up – not good for your oxytocin levels.

We’ve looked at how you can reduce your fear by preparing your cortex (your ‘thinking brain’, responsible for knowledge and decision making) ahead of the big day, but you can also prepare your limbic system (or ‘emotional brain’) to release fear. Now your limbic system is responsible for many things, one of which is your fight or flight reflex…yep, that again. And where knowledge and information can affect your cortex, we need a different language to speak to the emotional brain. Something that will help you exercise the part of the brain which switches on – and off – that adrenaline switch. This is where relaxations and visualisations come in. Using guided visualisations such as seeing each contraction as a wave building up in intensity, peaking and gently rippling away while in a state of pain-free relaxation can encourage your body to return to that state when anchoring itself to those visualisations in labour. Your breathing becomes easier and floods the body with oxygen, your muscles are relaxed and free of tension which makes each contraction more effective, you’re disassociated from feelings of pain which keeps oxytocin and endorphin levels high. Pretty impressive, right?

There’s another way to keep adrenaline, fear and tension out of the birthing room with you, and that’s the room itself. Imagine a stark white, brightly lit room that smells slightly of Dettol that hums with the electric lights. Now picture a dimly lit, warm room filled with your favourite scent and music. It’s unlikely you’re going to be feeling very comfortable in room number one. And if you’re not comfortable, if you don’t feel safe and secure, then your adrenaline will rise and your labour might stall. So really think about preparing your birth space to be a place where you can feel comfortable in. Many hospitals and birth centres are really accommodating at letting you take in goodies from home.

Now, I’m not saying that birth can or should be pain free. But we do know that working with our emotional and physical selves, really understanding the physiology of how our bodies work, can reduce the experience of pain. And that’s a bloody good start to giving birth isn’t it?

Birth Positions Which Can Help You Give Birth More Easily

Many women enter pregnancy having only seen labour occur on television, where women are laid on a bed, knees up, chin to chest, ‘purple pushing’ interspersed with screaming. Understandably, this can lead to some nervousness on the pregnant woman’s part!

The weight of research[1] shows that upright labouring positions can provide advantages to a birthing mother. In an upright position, gravity can assist the baby within the uterus by bringing it down and out, as well as helping keep it in the optimal foetal position when coupled with leaning forward. Being upright can also reduce the risk of aorto-caval compression which could result in a reduced blood supply to the baby. Upright positioning uses gravity to bring a stronger connection between the baby’s head and the cervix, releasing oxytocin and giving more efficient uterine contractions. In traditional squat and kneeling positions the pelvic dimensions become wider, allowing the baby to pass through with more ease. As well as increasing the comfort of the mother and improving the overall birth experience, the positive impact of these positions on the pace and efficiency of labour tend to make interventions less necessary and therefore less common.

The benefits of upright positioning don’t stop there either. Studies have shown that an upright position during the first stage can both reduce pain in the labouring woman[2] and shorten that stage, reducing the need for pain relief and preventing exhaustion in the woman. Interestingly the physical position a woman is in to give birth can also have a psychological impact: being able to find a comfortable position and knowing that the woman’s own movements are helping the baby be born more easily can give feelings of control and stem any fear and anxiety arising from the situation. By reducing stress and discomfort, these psychological responses to a good birthing position can make the whole experience more positive.

Despite the considerable evidence for the benefits of upright birthing positions, the actual positions that women give birth in do not reflect the evidence or national evidence based practice guidelines and nearly half of deliveries are made in a semi-recumbent position[3]. In developed countries where pregnancy and labour has become medicalized, interventions such as foetal monitoring and different types of analgesia can limit the options for position of a birthing woman[4]. A Cochrane review theorises that women are encouraged to push in supine or semi-recumbent positions simply because it is more convenient for the healthcare professional to gain access to the woman rather than being beneficial to the woman. Women ‘choose’ these positions on the basis that they think it is expected of them when presented with a bed in a hospital setting, coupled with the cultural expectation ingrained in them as seen previously, through the medium of television[5]. It is important that the woman knows what positions will help her and to have the confidence to try these positions without being led by the healthcare practitioner in attendance.

A Cochrane review[6] compared the risk of interventions and birth outcomes for upright birthing positions in comparison to non-upright birthing positions and concluded that upright positions can be associated with a shorter length of first stage of labour; a reduction in the use of epidural analgesia; almost a quarter less likely to have an assisted delivery; 20% less likely to have an episiotomy but 35% more likely to have a second-degree tear; 50% of births are less likely to have an abnormal foetal heartrate and 65% are more likely to have a blood loss of more than 500mL. The review found that there was no difference in birthing positions on the length of the second stage of labour; emergency caesarean rates; third or fourth-degree tears; blood transfusion rates; neonatal admissions or perinatal deaths. As there is only a negative impact on second-degree tear rates and blood loss by being in an upright birthing position, it seems clear that upright birthing positions really are the most beneficial, especially as tears can heal more quickly and neatly than episiotomies and there is no knock-on effect on blood transfusions needed.

The birth position chosen by the labouring woman may have a specific purpose. Different positions can bring relief to different complications. For example, if shoulder dystocia presents then the Gaskin Manoeuvre[7] of turning onto all fours and being on hands and knees will cause changes to the pelvic shape which will allow the shoulder to release and the baby to be born.  All fours positioning will be useful for women whose baby is or has turned occiput posterior in labour. Gravity and rotations can help the baby rotate to anterior position[8] although Balaskas points out that when the baby begins to crown each woman should become as vertical as possible to help it out. The use of these positions and a mother’s existing familiarity with them will help to reduce the need for interventions.

There is not just a physiological impact from birth positions on a woman, but psychological too, and these can prefigure the birth itself. Knowing that she can speed up her labour or slow it down if she feels overwhelmed puts her in a position of power. A woman who feels like she is in control of her birth, who feels as though she has a variety of tools at her fingertips to assist a range of experiences she may encounter, will be more empowered to deal with how her labour goes. In contrast, being in a supine position promotes a vulnerability in a healthcare setting that the woman must shed in order to birth most effectively; being upright will automatically help with that.

Ultimately a woman must birth in the position in which she is most comfortable, and the care providers around her must work with her to help her accomplish that goal.

[1] MIDIRS (2008) Positions in labour and delivery. Informed choice for professionals leaflet Bristol: MIDIRS. See also: Gupta, J et al (2012) Position in the second stage of labour for women without epidural anaesthesiaCochrane Database of Systematic Review

[2] Miquelutti, MA, Cecatti, JG (2009) The vertical position during labour: pain and satisfaction Revista Brasileira de Saude Materno Infantil

[3] Royal College Of Midwives (RCM) 2010 The Royal College of Midwives’ Survey of positions used in labour and birth London : RCM

[4] 2016, W.H.O. (2015) Position in the second stage of labour for women without epidural anaesthesia. Available at: http://apps.who.int/rhl/pregnancy_childbirth/childbirth/2nd_stage/tlacom/en/

[5] The Royal College of Midwives (2012) Evidence Based Guidelines for Midwifery Led Care in Labour: Positions for Labour and Birth

[6] Gupta, J et al (2012) Position in the second stage of labour for women without epidural anaesthesia Cochrane Database of Systematic Review

[7] Gaskin, I.M. (2003) Ina May’s guide to childbirth. New York: Random House Publishing Group.

[8] Balaskas, J (1989) New Active Birth: A Concise Guide to Childbirth,London: HarperCollins

What Is The LOA, The OFP, And Other Acronyms.

The presentation of baby in labour is extremely important for how that labour progresses. Most women know, or come to know, through their pregnancy that their baby should be head down in preparation for birth: but even a head-down baby can be in an optimal or suboptimal position depending on where their spine aligns. The baby’s position is important as it affects their ease of rotation and descent as they travel through the birth canal.

The occiput anterior position is the most effective way for the baby to travel down through the pelvis and make its way into the world. The baby is head down, facing the maternal spine which gives space for the chin to be easily tucked in onto their chest allowing the smallest part of their head to fit through the cervix first. The soft bones at the fontanelle fold to make their head smaller still. This position allows the baby to travel through the pelvis as easily as possible. There is less likelihood of a baby in an occiput anterior position needing medical assistance in being born.

The occiput posterior position, while head down, is not so effective at helping the baby on its way through the pelvis. The baby’s spine is aligned with the mother’s such that the baby is facing towards the mother’s naval. As the baby descends they have to rotate all the way around so they’re facing the back, often making the labour longer and more painful, with the pain being felt at the woman’s back caused by the hard surface of the baby’s skull pressing on the mother’s back. It is more difficult for the baby to tuck their chin down, meaning that the diameter of the presenting part of the head is bigger (approximately 11.5cm) than if presenting in an anterior position (approximately 9.5cm).

There needs to be a good connection between the baby’s presenting part and the cervix in labour in order for oxytocin to be released – oxytocin being the stimulus to the uterus contracting. An occiput anterior position allows the best fit of the baby’s head into the cervix, resulting in good contact and hence causing a good flow of oxytocin to be released. When in labour, kneeling positions can encourage this contact by allowing gravity to assist in putting pressure between the baby’s head and cervix. If the baby is in an occiput posterior position, these movements will not be working as effectively for the baby or mother. This can result in a long latent phase of labour for the mother or having a stop-start pattern to contractions.

It was Jean Sutton and Pauline Scott in 1996 who coined the phrase ‘optimal foetal positioning’[1]. Through their work they showed the importance of the mother’s posture and position in pregnancy and labour. They showed that babies who start labour from a left occiput anterior position seem to birth easier. Babies in that position tend to curl the crown of their head into the mother’s pelvis better, allowing a flexed vertex presentation of the skull with a diameter of approximately 9.5cm.

Sutton and Scott noted that the number of left occiput anterior presenting babies are decreasing in recent decades, and attributed this to the change in lifestyle of women. Women are less likely to spend substantial time in active physical housework (often leaning forwards or on all fours) and more likely to spend their time relaxing on laid back sofas. Gravity does the rest in pulling the heaviest part of the baby – its spine – down towards the mother’s spine. By paying particular attention to the encouragement of a left occiput anterior position during the stage of pregnancy where the baby is beginning to start engaging (around 36 weeks for a first time mother and slightly later for biparous or multiparous women) women can help themselves have the most efficient labour possible.

There are ways for women to help position their baby optimally by building in things to their everyday lives. These include: changing their sitting style to ensure their knees are lower than their hips; not crossing their legs; kneel over a birthing ball while watching television; not putting their feet up; sitting on a birth ball not a sofa and swimming using breaststroke or front crawl.

Babies who are right occiput anterior may rotate away from that position as they travel through the pelvis and become posterior during labour. Indeed, Gardberg (1998) states that the majority of occiput posterior babies in labour start off as occiput anterior[2] – likewise the majority of posterior babies will turn in labour too. This, then, would lead to the conclusion that while there is an optimal position to begin labour in, it really isn’t a defining moment for the mother if baby turns away from this position.

[1] Sutton, J. and Scott, P. (1996) Understanding and teaching optimal foetal positioning. 2nd edn. Tauranga, New Zealand: Birth Concepts.

[2] Gardberg, M. (1998) Intrapartum sonography and persistent occiput posterior position: a study of 408 deliveries.

Antenatal Education: Why Is It Important?

The pregnancy and perinatal period is one of immense change for a woman as she gets to grips with becoming a mother, both physically and emotionally. In many regards, particularly for first-time mothers, pregnancy is a threshold which separates the known world from one that will be radically different. In this context, emotional balance is likely to be disturbed readily and substantially. Antenatal classes provide a safe space for women to explore this change and empower themselves with knowledge and confidence, while reflecting in an informed manner on the change that awaits them. As will be elucidated here, this provision of balance is achieved through the careful consideration of and respect for the relevant social, hormonal and bonding factors, as well as each mother’s own belief structures and anxieties.

A big consideration when thinking about a woman’s changing emotional state while pregnant is that of her adaptation to her new role, either as a first-time mother or when changing the family dynamic to include more children. Both parents are understandably nervous about that which they don’t yet know and this can cause extreme challenges within the family unit and for the parent’s mental health. Cowan and Cowan argue that there is a “conspiracy of silence[1]” around the pregnancy and newborn period that can make parents feel that they’re the only ones that are struggling. One only needs to take a quick glance at the multitude of mother forums online to see a glut of ‘am I the only one…’ and ‘is this normal…’ postings by mothers who suffer from a lack of support around them. One of the big reasons that women seek out antenatal classes is to make friends with other like-minded people in a similar situation to them, and a key role for the antenatal teacher is to help facilitate friendships within the groups they teach. Having a support network of people going through similar experiences will help de-mystify their journey and ease many worries of each woman.

Classes where a woman can take some time to focus and centre herself will be beneficial to those who are dealing with pregnancy difficulties bigger than those ‘normal’ feelings and worries. Helping mothers to use techniques to have control of their own labour can help to counteract the negative impacts of health concerns that the mother may have about her own body or that of the baby. Antenatal classes help to empower women to make genuine change over their pregnancy and to benefit from the confidence this gives them. Antenatal teachers help a woman take charge of her body, filling her with self-belief by empowering her with knowledge and therefore control of her pregnancy and birth, the definition of antenatal classes according to Dick-Read who champion antenatal education to remove anxiety and dread, inhibiting fear and replacing it with confidence and increase normal labours and pregnancies[2].

There have been studies which link the level of a mother’s bonding with her child after birth to the amount of engagement with her pregnancy and the thoughts she has around it and what the baby will be like once born[3]. Benoit, Parker and Zeanah[4] linked this to the security of attachment the baby has to its parents in the first year of life. Antenatal classes encourage the mother to focus on her baby, creating a peaceful bond between them and soothing anxieties that they may not develop a strong bond. Antenatal teachers aim to anchor these bonding moments through techniques used in pregnancy which baby will recognise and be soothed by once born. Classes are spaces within which mothers can reflect on their pregnancy and learn to prepare for the future; this has substantial benefits for her emotional balance.

It is not unusual for a pregnant woman to experience feelings of stress, anxiety or depression; often this is from the usual worries and concerns a woman has when embarking on a pregnancy as seen previously, and it is important that we encourage women to let these worries go. Creating balance and harmony in her mind has a knock-on effect on her body; there are a number of studies which show various physical responses to anxiety and stress hormones in the pregnant body including reducing oxygen and calorie intake to the baby, maternal cortisol crossing the placenta and restricting foetal brain growth, growth delays, reduced levels of serotonin, reduced ‘quiet and active alert states’ when born and increased risk of hyperactivity in the long-term[7]. As Gaskin alludes to, when the mind is steadied the body can open for birth[8] and it is our aim to equip each mother with the tools to help balance her mind as well as her body.

[1] Cowan, C.P.P. and Cowan, P.A. (1993) When partners become parents: The big life change for couples. New York: Basic Books.

[2] Grantly, D.-R. (2006) Childbirth without fear the principles and practice of natural childbirth. London: Pollinger in Print, United Kingdom.

[3] http://www.refuge.org.uk/get-help-now/what-is-domestic-violence/domestic-violence-and-pregnancy/

[4] Dex, S and Joshi, H (2005) Children of the 21st Century: From Birth to Nine Months. Bristol: Policy Press

[5] Stern D (1985) The Interpersonal World of the Infant. London: Karnac Books

[6] Benoit D, Parker K and Zeanah C (1997) Mother’s representations of their infants assessed pre-natally: Stability and association with infants’ attachment classifications. Journal of Child Psychology, Psychiatry, and Allied Disciplines

[7]https://www.rc.org.uk/sites/default/files/Emotional%Wellbeng_Guide_WEB.pdf

[8] Gaskin, I.M. (2003) Ina May’s guide to childbirth. New York: Random House Publishing Group.