Psychological birth trauma
Back over on Neonatal Doc, several people commented on the psychological trauma that they experienced when they had a hospital birth. I wonder if these experiences are truly traumatic in the psychological sense, or whether they represent guilt and disappointment at not being able to meet unrealistic ideals of natural childbirth advocacy.
Isn't it unreasonable for the natural childbirth movement to downplay the pain of labor, thereby preventing women from making realistic plans in advance of the birth of a first child? Why, for example, does the natural childbirth movement encourage women to make birth plans refusing pain medication
in advance. In any other setting (prior to having a hysterectomy, for example), you would never ask a person to assess her need for pain medication before she actually feels the pain. Why encourage it in this setting?
Shouldn't the natural childbirth movement (and the people who run the websites and write the books encouraging childbirth without pain relief) bear some of the responsibility for psychological birth trauma?
28 Old Comments:
Women who opt for natural births before they experience labor are usually well-researched about what might happen and what they can expect. Natural is undoubtably the harder choice, and deciding in advance takes conviction and education.
There is a third issue here. What about the women who rely on epidurals, with no other form of preparation for labor (not learning relaxation or other coping techniques), and then are unable to get an epidural in time, or the epidural has little or no effect on them? Who bears responsibility for this situation?
I have known women traumatized by their labor experience when epidurals failed them. They thought they could go in and the doctor would take care of everything, that they would not feel pain once they were in their hospital beds, and then panicked when the pain did not go away.
Laboring women should always have a backup plan, even if they do not plan to use it. This is just good sense.
I think that women bear complete responsibility for their own education and preparation. I think there is nothing wrong with telling women they can birth without medication - the messages "you can do this" and "your body was made for giving birth" are positive ones. Why discourage it?
That some women might feel like they failed if they get an epidural is unfortunate, but should we refrain from setting goals because there is a chance we might not reach them?
The only trauma I really experienced in my first hospital birth was twofold:
1) silly incompetence: nothing criminal, but it made things harder than they had to be. No one could find the birthing bar or ball that I was assured would be available. It is partly due to this I think that I was required to push for over 5 hours; which brings me to:
2) the lying. For five hours, I was told that I was one to two pushes away. I must seem awfully credulous, but I believed this. Finally a vacuum extractor was used after I finally said, "you are full of $hit, aren't you?" and gave up.
My second hospital birth was natural and I was quite happy on my birthing ball. It was six hours soup to nuts from my water breaking. When I was pushing and was told I was 1-2 pushes away, I became very hostile and I did not believe them. It was actually true, and my second son was born quite happily.
I think much lasting psychological trauma, other than the occasional malfeasance, does come from an unreasonable expectation of fulfillment. All I wanted was a healthy baby. I was lucky; my second birth experience was pretty amazing and I got a great kid out of it. My oldest son is great too, but the birth experience itself was not "positive" for me. So what?
Labor is nothing compared to the day in day out raising of a child, both in the pain, guilt, fear, doubt, and of course happiness.
Anonymous:
"Women who opt for natural births before they experience labor are usually well-researched about what might happen and what they can expect."
Yes, but they can't possibly know what level of pain to expect and whether it will be tolerable for them. This is especially true when you consider that the baby's position at the onset of labor can affect the type of pain. For example, if labor starts when the baby is occiput posterior, there could be a considerable amount of back pain, and that could affect a woman's ability to tolerate it.
Furthermore, if you have never had a baby before, you have no idea how long your labor will be. There is a very big difference between being in labor for 6 hours and being in labor for 26 hours. This has an important effect on the ability to tolerate the pain.
Wouldn't it be more appropriate to suggest waiting to experience the pain, and make a decision about pain relief when you actually have some reliable information to base it on?
"Natural is undoubtably the harder choice, and deciding in advance takes conviction and education."
No, it is not the "harder" choice, it is the more painful choice. There is a big difference and it all depends on a woman's cultural perceptions of the value of pain.
"I think there is nothing wrong with telling women they can birth without medication ..."
But that's not exactly a newsflash. It's the default mode, after all. Everyone knows that more than 99.9% of women who have ever labored have done it without medication. So the question is not whether a woman CAN do it, but whether she WANTS to do it.
"should we refrain from setting goals because there is a chance we might not reach them?"
That raises the fundamental question: should we really be encouraging women to think that having a baby without pain relief is a laudable goal?
I guess it all depends on why the woman is choosing to go without meds. If she is choosing to go without meds because she feels that it is the healthiest thing possible for her baby, then I don't see how encountering that pain would be tramatic. She can always change her mind while actually going through labor (birth plan or not). If she chooses to not take any meds, she will make it out the other side of birth. If she is choosing to not use meds because she feels forced by a spouse, well, I can see how that would be tramatic, but still not the fault of the natural childbirth community. I have heard of women who haven't gotten the meds they wanted because of doctors not wanting to come in and I can see that also as quite tramatic for a woman who wants those meds.
My first birth left me with lots of trauma to work through, but that was my heavily medicated one. I first was in panic because it took me FOREVER to get to 4cm with an induced labor in the OP position. I had no idea how to deal with what I was feeling and felt completely unprepared because I had just counted on getting something for the pain right away. Then even after I hit 4cm and I knew that pain relief was not far off, the nurses wouldn't call back in the doc to give me the epidural because he had just been in and had just left for home.... so I had to wait another 2 hours. There were some other nasty things that ended up happening during that birth that left me feeling very traumatized, but it was not the fault of the natural childbirth community.... I went into that labor knowing that I wanted drugs.
My second birth I felt no trauma even though I had no meds at all. I chose to birth the way I did, not to receive some sort of ficticious award, but because I felt it was the safest and healthiest for my family. This made all pain very tolerable. Of course, I was at home too, which made the pain much less as well.
I don't see that women are being bullied by anyone to not use meds, since it is such a minority of women who don't.
From Amy (how do I italicize?): "So the question is not whether a woman CAN do it, but whether she WANTS to do it."
I do agree. But see, Amy, you're wearing your paternalistic doc coat here. Because in the same post you just said she can't possibly know what the pain will be like or what she really wants.
I'm actually a moderate. I think natural childbirth is absolutely healthiest for most moms and babies. I think it is indeed empowering for most women. Women and babies both do SO much better in the first important hours without meds, I strongly believe that.
But I have no problem with moms who want medication or an epidural, as long as it's on their terms. That involves a LOT of talking about it beforehand, how dedicated is a mom to avoiding pain meds, how hard should I work to avoid them with my midwife tricks and both respect her voice in the moment and the personal goal she entrusted to me?
I think pain meds and epidurals can sometimes be very useful tools, which I am grateful to have available on occasion. I like to say, pain meds aren't for pain, they're for problems. We have a 25% hospital birth rate, and some of them plan medication. But we have a 3% incidence of women actually using meds in labor (both in and OOH). Most never even ask for it, it just does not occur to them that something is "wrong" with the work of labor.
Amy I don't think a woman can just assume she'll simply decide in the moment, because it does take preparation to achieve natural birth. I'm not a fan (at all) of directed breathing classes, etc, that's not what I mean. I mean learning about labor and birth (knowlege being power and helping to reduce the fear:tension:pain cycle) and having a plan to create a safe birth space around you.
I actually consider that one of my main intangibles as a midwife: keeping the birth space safe and comfortable so labor can work really well. That means protecting privacy - HUGELY under-rated in hospital birth! I bet the c/section rate would be halved if birth was more private in hospital. I also work to let moms stay in their primal birth zone (rather than dragging them out of it through conversation, questions, small talk, bright lights, etc. Read Michel Odent on this). It means knowing that moans, groans, grunts, noise, smells, nakedness, sweat, poop, leaking down your legs, being naked and shaky and vulnerable -- are NORMAL things in labor. Hospitals are very, very uncomfortable with such things - as institutions they are designed for order. Labor nurses who have seen 10,000 births often still think moaning is bad, it's insanity!!! Most docs, too, are horrified by real primal birthing. Now, not every woman births that way, for sure. But a lot do, and it's healthy and normal and physiologic.
Hmmm, physiologic. That's the thing that makes the tired "why would you have dental work without novocaine" and "what about a kidney stone" arguments so totally useless in relation to labor. Usually in life, pain is a symptom of a problem. Childbirth is hardly a problem. Childbirth is as normal a human event as eating, drinking, peeing, pooping, menstruating, making love, growing old, etc etc. Amy, I'm not saying it's as 'risk-free' as those, but as normal, as physiologic, a human function. The pain of childbirth does not signify a problem. The pain has a purpose.
Childbirth with narcotics and especially epidurals simply does NOT work as well. I'm not completely against them, but I feel that is a non-debatable issue.
amy tuteur said:
"Wouldn't it be more appropriate to suggest waiting to experience the pain, and make a decision about pain relief when you actually have some reliable information to base it on?"
Why would you approach childbirth undecided and unprepared?
"There is a very big difference between being in labor for 6 hours and being in labor for 26 hours. This has an important effect on the ability to tolerate the pain."
Interesting that you should bring this up. My first labor was about 26 hours, my second one was 6, and the first was far easier. Anecdotal, sure, but length of labor isn't the only indicator of difficulty or of the level of pain experienced. Long labors can be gentle, and fast ones can be treacherous.
Of course, I was eating and drinking and moving around the entire time for both.
"should we really be encouraging women to think that having a baby without pain relief is a laudable goal?"
For some women it is a laudable goal. Amy, why are you anxious to take that from them?
"the question is not whether a woman CAN do it, but whether she WANTS to do it."
That's exactly true! So those women who WANT to have a natural birth, let's encourage them and give them support to do it! And those women who CAN but don't want to, they have all the resources they need in their nearest hospital.
It has to go both ways. You can't say that pain medication is the right choice for everybody. You also can't say that home birth is right for everyone. We have to maintain support and resources for both.
I think it's an erroneous assumption that psychological birth trauma is related to failed natural childbirth. I've seen plenty of my doula clients with no desire for natural anything end up traumatized by the events surrounding their births, from episiotomies inflicted by a doctor with his scissors hiding behind his back to vacuum extractions spraying blood across the faces of mother's loved ones witnessing the births of their babies to not getting the epidural she counted on to the doctor/midwife they wanted not being on call to... to ... to ... the list could really go on.
(ps: to italize for a quote put this set of symbols around what you want to highlight: . Same idea to boldit.)
maribeth, CNM said "how do I italicize?"
I can'rt EXACTLY explain, since trying to show an example will probably be invisible.
Right under the "leave your comment" text, it says "you can use some HTML tags, such as..." and then lists the tags.
b is for bold.
i is for italic.
to begin italics or bold, you type two arrows with an "i" in between, just like it shows in the example.
to END your italics or bold, you do the same thing, BUT you insert a "/" before the i. so what is in the arrows looks like this :
i inside arrows (starts italics)
yadda yadda (text which is inside the italics)
/i inside arrows (ends the italics.
I suggest using "preview" until you get used to it.
The arrows I mean are these:
"<"
and ">"
Maribeth:
"I think natural childbirth is absolutely healthiest for most moms and babies."
Of course you think that, otherwise the natural childbirth movement would be nothing more than competitive mothering. (I tolerated the pain; you couldn't).
The only problem is that there is no evidence for that.
For example, there are literally tens of millions of adults and children whose mothers used epidurals during their births. So where are the casualties? What can you point to that differentiates people born to mothers who had epidurals from people born to mothers who didn't? Since there are millions and millions of people involved, surely there must be some concrete medical indication that these people were harmed by epidurals. Yet I don't see any evidence at all.
In order for me to believe that natural childbirth is healthier than childbirth with pain relief you MUST show that the people who were born to women who didn't use pain relief are healthier. I doubt you can do that, and since you can't, it is just your opinion.
Jenna:
"Why would you approach childbirth undecided and unprepared?"
I'm saying that no matter HOW decided and prepared you are, you don't have the most relevant information --- how much pain you personally are going to have, how long your personal labor is going to last and how you personally react to pain based on your physiology and cultural values.
It's beginning to seem to me that having natural childbirth is not the achievement (since any woman can do that and almost all women who ever existed have done it), but rather the "achievement" is in refusing pain relief even though it is available.
Otherwise, why such a big emphasis on deciding before you have enough information to make a decision? The whole point appears to be to resolve not to have pain medication no matter what as opposed to not having pain medication if you don't feel the need for it.
"For some women [having a baby without pain relief] is a laudable goal. Amy, why are you anxious to take that from them?"
No, it is a personal goal and as such, it should be respected. However, I do not see it as a goal that women in general should aspire to, or a goal that people should praise.
Metromidwife:
"I think it's an erroneous assumption that psychological birth trauma is related to failed natural childbirth."
I didn't say ALL psychological birth trauma is related to failed natural childbirth. I am suggesting that women who are depressed and feel like failures because they opted for pain relief also endure psychological trauma. I wonder if there is any psychological research on these women and their experiences.
Amy, you seem to be assuming that physiological pain is the only cause of psychological trauma, and furthermore, that there are no physiological or psychological adverse effconsequences to pain medication as if it were a simple choice between pain and comfort. In fact, women are choosing between temporary pain and the ill side effects of pain management. The degrees and qualities of pain and trauma completely relative to individual experience, and can only thus be weighted against the debilitating effects of pain medications.
Psychological trauma can be caused by a person's sense of having been victimized by professional coercion.
sicocochran:
" you seem to be assuming that physiological pain is the only cause of psychological trauma"
Quite the contrary. I am talking about psychological pain due to failure to meet expectations.
"The degrees and qualities of pain and trauma completely relative to individual experience, and can only thus be weighted against the debilitating effects of pain medications."
Okay. So what are the scientific data on the debilitating effects of pain medications?
Psychological trauma can be caused by almost anything, depending on the person's personal history and previous experiences.
For me, a midwife-assisted homebirth would be my worst nightmare.
There are reasons why I don't trust women, period, and especially when it comes to all things gynecological in nature. With all due respect to Dr. Amy, who I am sure is a both a fine doctor and a lovely person, I wouldn't pick her to attend a birth any more than I'd pick a midwife.
Men make me feel safe. The hospital setting where I know my male doctor is calling the shots makes me feel safe. And if I feel safe, I'm going to be able to let go of my personal psychological stuff and concentrate on the task at hand a lot better than if I had to stay on guard because some female was in charge.
Find me a male mid-"wife", and I might consider a home birth. As it is now, it's driven by women, and, for me, that would be impossible for me to get through.
If I were stuck in a situation where a woman was hassling me during my deliveries, I'd probably resort to something a lot stronger than an epidural. Actually, I'd probably insist on a C-Section just so I could get knocked out and wake up when it was over.
So it's not hospital v. home, doctor v. midwife - it's about where women feel safe and comfortable and being able to focus and concentrate. I think women who feel secure probably require less pain meds. For some, just knowing they're available is enough. For others, they just might need them, and that's okay.
~T
There are a few really great male midwives!
So what are the scientific data on the debilitating effects of pain medications?
Epidurals Can Prolong Labor American Journal of Obstetrics and Gynecology (1998;178:516-520)
Kapp FT, Hornstein S: Some psychological factors of prolonged labor due to inefficient uterine actions; Compr Pschiatry 1963: 4:9
Study suggests epidural lead to more invasive tests for newborns; Liberman E, et. al. Epidural, Maternal fever and neonatal sepsis evaluation, Pediatrics, 1997;99:415-420
Narcotic use during labor (within 10 hours of birth) results in a statistically significant increase in drug abuse and addiction of narcotized fetusus as they become teens and young adults. (Jacobson, et al, 1990, Jacobson, Nyberg, Eklund, Bygdeman & Rydberg, 1988)
thanks for the help on style everyone
Amy, I never said narcotics and epidurals caused long-term harm to people, though Michel Odent does, at http://www.birthworks.org
/primalhealth/databank.phtml. I have not reviewed all that data, but think it an interesting endeavor.
So what are the scientific data on the debilitating effects of pain medications?
From the Cochrane Library: http://www.cochrane.org/
reviews/en/ab000331.html
Epidurals for pain relief in labour
Epidurals are widely used for pain relief in labour. There are various types, but all involve an injection into the lower back. The review of trials showed that epidurals relieve pain better than other types of pain medication, but they can lead to more use of instruments to assist with the birth. There was no difference in caesarean delivery rates, long-term backache, or effects on the baby soon after birth. However, women who used epidurals were more likely to have a longer second stage of labour, need their labour contractions stimulated, experience very low blood pressure, be unable to move for a period of time after the birth, have problems passing urine, and suffer fever. Further research on reducing the adverse outcomes with epidurals would be helpful.
You really think these things are as healthy for moms and babies as a spontaneous birth? How do you figure?
However, I do not see it as a goal that women in general should aspire to, or a goal that people should praise.
Amy, why are you so bitter? Can you show that natural birth is harmful to mother or child? Why do you think it isn't praiseworthy?
Amy Tuteur, MD said...
In order for me to believe that natural childbirth is healthier than childbirth with pain relief you MUST show that the people who were born to women who didn't use pain relief are healthier.
Um, no. You don't "have" to show that at all. For example, he children can be equally healthy, and the mothers can be less healthy.
Alternatively, there could be short terms effects which accrue to children or mothers (pain, to use an obvious example) following an epidural, but no long term effects. This might not be a serious effect, but neither would it be no effect at all.
Sorry to nitpick. It's just my nature.
Anonymous:
"Narcotic use during labor (within 10 hours of birth) results in a statistically significant increase in drug abuse and addiction of narcotized fetusus as they become teens and young adults. (Jacobson, et al, 1990, Jacobson, Nyberg, Eklund, Bygdeman & Rydberg, 1988)"
Aww, c'mon. It is just this kind of citation that makes it hard to take homebirth advocates seriously. This 1988 paper is about the use of NITROUS between 1945 and 1966 in Sweden. The 1990 study is hardly better. It also takes place between 1945 and 1966 and involves the use of opiates, barbiturates and nitrous. Both are ridiculously poorly done studies, but the important point is that they has no relevance to this discussion. Need I remind you that during that time period, women received general anesthesia for labor?
When you don't read the papers before you cite them, it becomes very obvious that you are simply copying something out of someone else's book.
"Need I remind you that during that time period, women received general anesthesia for labor?"
And yet that was considered perfectly safe at the time, and natural birth advocates were scoffed at by the medical community.
I wonder what you'll be saying in 20 years? Perhaps 'need I remind you that during that time period women received epidurals for labor'?
It is just this kind of citation that makes it hard to take homebirth advocates seriously.
It is your unwillingness to have a discussion that makes us homebirthers distrustful of the medical community. You can keep shooting down every argument from the other side and ignoring the ones that make legitimate points, but you're going to lose your authority and eventually your audience.
I have seen many people in these discussions give ground to you and your tenable ideas, and yet you won't reciprocate.
I don't know why we're patiently addressing your hostility to us and our views. We're gaining nothing but exasperation at your stubbornness in return.
Anonymous:
"I have seen many people in these discussions give ground to you and your tenable ideas, and yet you won't reciprocate."
I'm sorry that you feel that way, but I fear that it is the result of misunderstanding. Being polite is, of course, very important, but when we are arguing about scientific data, being polite is not the objective.
You offered a paper to back up your contention that narcotics in labor harm babies. Yet the paper was literally 40 years out of date and was not even on the topic we are discussing. Furthermore, you clearly were not aware of that.
I suppose that politeness might require that I refrain from mentioning that, and if we were having a discussion at a social function, I would probably do just that. However, we are not having a discussion at a social function.
You are asserting that I think is okay to harm babies by giving narcotics to laboring mothers, but you offer as proof something that is no proof at all. Politeness may indeed suggest that I not point this out to you. Yet in a debate, what other choice do I have?
Amy, what is your response to the Cochrane Review data?
And, meant to ask, if you think narcs and blocks are as healthy for moms and babies, if you think natural childbirth is not an achievement, why did you have two natural births, doula assisted and all?
I know you don't like personal stories but bare with me...
40 hours into a posterior labor with my first I was transfered to the hospital. Sure my dreams were shattered but that wasn't the traumatic part...
The traumatic part was the constand invasion of privacy, the contant nagging of the nurses, the fact that things were stuck in every crevice of my body and the fact that 4 doctors and the hospital psych were all called in to scare me into a C/S with "baby is too large" "pelvis is too small" "your putting your baby's life in danger" "labour is too long" "we'll have to go to the courts and have your rights terminated" just because he was posterior and easn't ready to come out yet...
After 50 hours of labor, while the doctors and hospital psych were on the phone with a judge and nurses were all busy elsewhere my baby turned and came out quickly into my own hands without pushing once. The doctors and psych refused to answer questions and the nurses ignored me... I left two hours later...
As for the epidural: "dr" amy asked...
So where are the casualties?
So, do you dismiss the fact that epidurals (and every other med)comes with risks?
Personally the side effects that I had are persistant headaches and nerve damage leading to the loss of feeling in part of my foot.... of course it must be in my head right dr. amy? since medicine and doctors are perfect and no harm could ever be done...
Yes, I could have put all my trust in them and agreed to be sliced open for no reason except to please their "god" complex... and most women would have done so and then told the story of their "emergency" C/S but I know that docs are full of bull and are too slice happy and impatient...
I lost trust in all "doctors" many years ago, way before the birth. I am glad that I did...
One could certainly argue that the pain of laboring and birthing is different from other types of pain because it is something our brains and bodies are evolved to handle in the kind of environment where humans would have birthed for tens of thousands of years (e.g., not in a strange hospital environment, not with strangers touching us). Certainly there are situations that could far exceed what our brains and bodies are "expecting," and certainly our cultural experiences, prior trauma, and other things could change a woman's psychology to tolerate more or less birthing pain prior to experiencing birth as traumatic. But it is important for medical professionals to remember that birth is not a medical event until it becomes a medical event. Capiche? My own two labors at home were of typical duration with nicely positioned, large babies and I did not ever want any painkillers. Had I been in the hospital, maybe I would. Had I had a badly positioned baby or some other problem, maybe I would have. Personally I have not particularly noticed people in the natural childbirth movement giving advice about labor pain that I think is unrealistic. I'm sure it's out there but I don't think it's mainstream. I do hear second hand unrealistic advice about labor pain given out by hospital practitioners and first hand by some mothers, in the other direction.
MM, Georgia
These discussions always amuse me because I get the feeling at times that it isn't truly an exchange of information, it is people defending their opinions. Here is my experience. I had trauma associated with the doctor attendant in my hospital birth. He yelled at me for choosing to take childbirth preparation classes that he didn't approve of. When i expressed the desire to birth without pain meds he started telling me stories about woment that should have had normal births but ended up with C-sections. I had an uneventful, healthy pregnancy. I know, I have gone over my files with my midwife(second child)
Things stand out- I was told by one nurse that I wouldn't get an award for refusing the epidural-during the tour
I asked the doctor not to give me an episiotomy, I got one despite the fact that there was no medical reason.
I was told that I might as well get meds because I couldn't possibly be ready to push, then they found out I was
My doctor tried to schedule an induction because I was overdue- a week before my due date.
Part of this was a doctor problem, some of it was a hospital problem. The result is that I had an unmedicated birth, and the first thing I remember when I think about my sons birth was being confined to a hospital bed, being denied water, and the excruciating pain of having stiches when the lidocaine didn't take.
You can say what you like, the medical establishment seems(I say seems to give the benefit of the doubt) to forget that they are there to serve the patients, not force their personal birth opinions. I know women that were induced for the doctors convenience-inductions can fail due to the woman not being ready.
I know women that have been told they HAD to have the baby right away cause it was a 10 pounder and would never fit, and then the baby is 7 pounds. I also know many many women that have forgone the hospital with incredible positive results.
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