During introductions on the first night of class, Janet* sat up, told us her name, and added: “I’m planning on getting the epidural – and you can’t talk me out of it!” She pointed straight at me when she said this and I threw up my hands in mock defense replying, “I’m not going to try and talk you into or out of anything! That’s not my job! My job is to provide you with as much evidence-based information as I can, so you can make the most informed decisions for yourself.”
Her statement was not a surprise to me – most women come into a Childbirth Preparation class thinking that every decision they make about birth is “Either/Or.” Never is this more true than in the case of pain medication and birth. Most women believe that it’s either “Get the drugs!” or “Go without!” I try, when I’m able, to coax them away from this Either/Or thinking toward a more Yes/And approach to how they’ll give birth.
I’m not always successful.
We form opinions in almost every aspect of our lives. Some are based on past experiences, or what friends and family have to say, and sometimes our opinions are based on actual facts and evidence. We tend to read, listen, watch and agree with information that supports what we think we already know. This is called confirmation bias. It makes sense, then, that we might go to a Childbirth Preparation Class unconsciously seeking out the information that already supports our established point of view, while ignoring the information which does not.
This happens all the time with different couples in the same class. As a Childbirth Educator, it’s important to teach from an evidence-based, benefit/risk stance in order to speak to everyone in the room from a place of non-bias. This allows me to hope that when challenging topics are discussed, my couples are better able to take in all of the information – even if it challenges their established point of view – so they can make the most informed decisions for themselves.
I have evaluations from the same class that read: “Appreciated the support of an unmedicated birth” and “Felt supported in my decision to have an epidural.” Every time this happens, I have two reactions: I’m glad that my presentation seems to be well-balanced, but I’m also a bit puzzled. I’ve shown the same movies, cited the same studies, shared the same stories – yet these two different people have walked away with their two very different perspectives validated. It’s fascinating to me!
It’s also the reason why I encourage my students to have realistic expectations about the birth they’re hoping to have, as well as the actual birth they might end up having. I want to discourage them from ignoring any information presented in class just because it doesn’t line up with their established point of view about birth. If they end up shutting out information that doesn’t support their personal views, there is the possibility for great disappointment as their birth unfolds. This is what happened to Janet.
Janet wanted a very controlled birth experience and was planning on getting an epidural the instant she started to feel uncomfortable. This is not conjecture on my part – she was very vocal about this in class. While I applauded her ability to know herself so well and to be willing to voice her opinion in a class where many others had reported wanting to try for an unmedicated birth, I was also concerned about her hardline stance on this subject.
There are many different ways to increase comfort and the ability to cope with contractions in labor: breathing, position changes, hydrotherapy, birth balls, heat/cold, massage, encouragement, etc. We spend time practicing these techniques. I want every woman in my class to recognize these good self-care practices and learn to use them outside of birth. I also emphasize the need to rely on these methods in the early phase of labor when medication is not a realistic option.
Janet wasn’t very keen on practicing any of these comfort measures – especially the breathing. She would laugh, roll her eyes or talk through every practice contraction. I was concerned that she’d put up a wall and wasn’t letting any other information in. She saw no need to practice any other labor coping tools – she was going to get an epidural, after all. Eventually, I called her on it. “Janet, if you or anyone else in here is choosing an epidural for pain relief, I want it to be the best epidural that’s ever been given to anyone, anytime, anywhere!” And I meant it! “But, sometimes, the epidural is not all it’s cracked up to be and you might really need these tools as back up to continue to cope with your contractions.” I’m pretty sure she rolled her eyes at me.
Fast forward to our reunion together many months later. When I asked Janet to share her birth story, she wasn’t happy. She’d gone in for an induction and was put on a Pitocin drip to try and get her labor to start. Her contractions began soon after and she was making good progress. Her L&D nurse asked if she was ready for an epidural. Janet had shared her desire to get an epidural as soon as she felt uncomfortable, but she decided to hold off for a bit longer. Soon after, her contractions kicked in and she was in hard labor. Janet called the nurse back so she could get the epidural, but unfortunately, the anesthesiologist had been called into a Cesarean and wouldn’t be available for at least the next hour.
Janet’s labor was on the fast track and she ended up progressing from 4 cm to 10 cm in about an hour – all without the medication that she’d been counting on. Because of the induction and epidural, she was confined to bed and on continuous monitoring, so position changes were limited and using the tub or shower for pain relief was out. And because she never practiced the breathing – in or outside of class – this incredibly useful comfort and coping tool was of no help to her.
Janet suffered through her labor feeling helpless as this especially fast and challenging labor overtook her. Because she saw this as an Either/Or decision, she felt like there was no other way to cope with her contractions when the epidural “failed to deliver.”
I really want women to have positive birth stories – experiences where they feel confident and a sense of pride at what they’ve just accomplished. This doesn’t have to be an Either/Or experience. She can feel this way with or without medication and intervention, through a vaginal or a Cesarean birth. But Janet had suffered through most of her birth because she had placed all of her trust in the promise of a perfect epidural. She paid very little attention to practicing the other non-medicated coping techniques because they seemed to be in opposition to her plan of getting an epidural.
Women feel they need to “make the decision” about medication before labor even begins. When it comes to medication in birth, thinking about this as an Either/Or proposition is setting women up for disappointment.
Women wishing for an unmedicated birth, might find that after a particularly challenging and long labor, they need to make a different decision. In the retelling of their birth stories, these women will say something like, “And then I caved and got the epidural.” Like they somehow failed birth by asking for pain relief when it became necessary.
On the other hand, there are women who joke about the other coping techniques practiced in class, thinking to themselves, “As soon as I feel real pain, I’m getting the epidural. I won’t need any of this stuff.” Their disappointment is very real when the epidural doesn’t provide them the relief they were counting on. Now they feel forced to endure contractions without access to other tools to help them cope.
In both cases, the ideal birth story has gotten in the way of being able to adequately prepare for the actual birth story. One is disappointed that she “wasn’t as strong as she thought” while the other “never wanted to be a hero”.
Birth is something that very rarely goes “according to plan.” Preparing for birth means going into the experience willing to be open to all of the information provided (as long as it’s evidence-based!) Especially the information that might challenge you and your established point of view about birth. Women need to realize the importance and appropriate use of coping techniques – medicated and non-medicated – as valid and useful tools that can help them have a more positive birth story to tell for years to come.
So in birth, it’s very rarely an Either/Or proposition as much as it is a Yes/And proposition. “Yes, I have an established point of view about the use of medications in birth. And I realize that I might need to shift my point of view on the day I give birth to reflect what is happening in real time. I will try to remain open to all comfort and coping techniques available to me – medicated and non-medicated – so that I feel best prepared to cope with my labor however it unfolds.”
Did you have an established view about medication and birth? Were your beliefs challenged at all during your pregnancy and birth? When you gave birth, did you have to make a different decision around this particular birth choice?
*not her real name.