Why is PAIN a Four-Letter Word?

Pain

I taught a class recently that was a little different. It only meets once and focuses on the brain-body connection, the practice of comfort measures, and how to stay in a coping mindset throughout birth. There’s no discussion about the stages of labor or when to go to the hospital. This class is like “extra” practice for the uninitiated, or in the case of one of the Mommas in this particular class, a “refresher.”

Karen* introduced herself as a “veteran.” She went on to say that she’d chosen to have an unmedicated birth with her first, but it had been “really painful!” She needed more tools to help her cope with labor this time around.

She added quickly, “Don’t worry, ladies. You’ll forget all about the pain.”

Although I appreciated her attempts to not frighten the group of newbies assembled, I’m not sure if I completely agree with her statement. Some women don’t forget the pain of their labors – at least not entirely. And I’m not sure that encouraging women that they’ll forget their pain is necessarily helpful as a preparation technique.

However, her statement did end up being the perfect segue to talking about the “P-word.”

In our culture, pain has become a nasty, four-letter word that we want to avoid at all costs. There’s a thriving multi-billion dollar industry counting on the fact that people want only to take a pill to make their pain, physical or emotional, go away.

When we talk about labor, women don’t want to even think about the pain, let alone focus on it. I’ve found that most women fall into one of three approaches when it comes to labor pain and how to cope with it:

1) “The At-Home, DIY Epidural Kit Approach,” which of course, doesn’t exist. These are women who believe that there is no way they’ll ever be able to get through labor without drugs.

2) “The Grin and Bear It Approach,” which translates to women saying no to drugs, even if it becomes truly unbearable.

3) “The Just Breathe the Right Way Approach” which some women believe will not only allow you to experience birth without the use of pain medications, but also without any pain at all!

None of these approaches sound right to me. All of them have unrealistic expectations built in. And you know, I’m not a fan of unrealistic expectations. So, I’ve come up with my own approach to labor pain and how to cope with it. I’m calling it, “The Why Don’t You Wait and See Approach.”

There is a difference between pain and suffering. Pain is a physical sensation that occurs in the body, most often associated with illness or injury. (In the case of labor, it’s important to note, there is no illness or injury – barring any complications, you are healthy, and labor and birth are normal, biological events.) Suffering represents the emotional reaction to that pain.

In, “The At-Home, DIY Epidural Kit Approach,” too many women decide long before birth ever begins, that they will never be able to handle their contractions without pain medication. Why? Because they’ve bought into Hollywood Birth. Think of the last birth you saw on TV or in a movie. What about that scene would ever make you feel like you could give birth without drugs? Actually, what about that scene would ever make you want to get pregnant?

When women only see this dramatic and intensified Hollywood version of birth, it’s hard to imagine they could ever find labor to be tolerable, let alone something to look forward to. In this mindset, women often start their labors in fear – which actually increases their sensations of pain with each and every contraction. It’s a self-fulfilling prophecy. Making assumptions about your pain tolerance and ability to cope with contractions before labor ever begins is the surest way to undermine your real ability to remain in a coping mindset from start to finish.

But what about “The Grin and Bear It Approach?” Women adopting this approach have equated that they can only have an empowered birth experience if they don’t have any drugs – no matter what. No matter that their labor is extremely long and their baby is in a unfavorable position. No matter that there was a death in the family the same week they’re giving birth. No matter that this labor is kicking their behind and they stopped coping with contractions hours ago. They’re no longer just feeling pain with their contractions, they’ve crossed the line into suffering. These women believe that they’ll feel accomplishment after their births – and are completely shocked when instead they feel overwhelmed and like they were barely hanging on.

Many of the proponents of natural, unmedicated birth talk about enjoying contractions, finding bliss or even having orgasms while giving birth. In “The Just Breathe the Right Way Approach,” women might think they’re doing something wrong when they discover that their birth actually hurts. Maybe it hurts a lot. Talk about disappointment! They thought they’d be blissed out, having orgasms left and right, but that’s not what they’re experiencing at all

(Don’t get me wrong! I’ve actually met two women who did, in fact, have the most massive orgasm of their lives while giving birth! So, it can happen. But when I asked them how they did it, both of them essentially said, “I don’t know. It just sorta happened.” Have you ever gone in search of an orgasm while having sex? It goes into hiding – like witness protection program hiding! This might be one reason why orgasms during birth are not super common.)

We seem hell-bent on trying to avoid pain in labor and I’m not exactly sure why. 

To me, pain and pleasure are two sides of the same coin. We can’t really understand pleasure, if we don’t have something to compare it to. And while I would never classify my contractions as pleasurable, I definitely would describe the breaks in between as pure bliss. I would work hard through each contraction, pushing myself to my own personal limits, and then blessedly, there would be sweet relief on the other side of every single one of them.

It’s true that each contraction grew longer, stronger and closer together. And the breaks in between definitely got shorter. But if I was able to maintain that coping mindset, I knew this meant I was getting closer to holding my baby in my arms.

“The Why Don’t You Wait and See Approach,” allows women to stop preemptively deciding what they’ll be feeling when they go into labor. No one knows what their pain tolerance is for labor, because the pain you feel with contractions is so very different than any other kind of pain you’ve experienced before.

If you’re able to stay in a coping mindset, it’s completely possible that you can get through your entire labor experience without any need for pain medications.

Most likely, you’ll experience at least some level of discomfort in the middle of a contraction. You might describe your contractions as really painful, but tolerable. You might feel like your contractions are too intense for you to continue to handle them on your own. Who knows? You might win the labor lottery and have a big ol’ orgasm!

The point is – you have no idea what to expect. So, stop trying to predict how your labor will unfold and how you’ll respond before you’re ever in labor. Be open. Remain flexible. Wait and see. Then, make your best decision about how to cope with your contractions as they are actually happening, so you can look back on this experience and feel strong, empowered and confident that you participated fully in your birth.

What was your personal approach to your birth experience? Was it spot on from before birth, or did you have to switch gears in the middle of your labor? How does “The Why Don’t You Wait and See Approach” resonate with you? Please leave me a comment. I love to hear from you!

*Not her real name.

Empty Nest

It takes a torrential rain or windstorm to blow the last remaining leaves off the trees revealing what was so well-hidden in the uppermost branches throughout Spring and Summer: one, two, sometimes up to three bird’s nests. They vary in size and shape, and I have no idea if these nests were constructed just last year for a whole community of birds to share some space together, or if they’ve been there for years and yet are so sturdy as to withstand several winters. But one morning, after dropping my kids off at school I looked up from my parked car and this is what I saw:EmptyNest

Instantly, I thought of all the families who’ve been preparing in excited anticipation for their babies arrival only to end up with an empty nest. Whether it be through miscarriage, infertility or infant death, these families don’t get to celebrate all they’d hoped for when they began their parenting journey.

Truthfully, I’ve been sitting on this post since early Fall, wondering if I’m the “right” person to talk about this. After all, my husband and I have been extremely lucky in our personal parenting journey. But, despite writing dozens of other posts, this image of the empty nest and what it represents won’t quit me. And since I first made that connection I know several people who have experienced miscarriage and infant death personally. While I may not have experienced these things directly, I do know something about the pain of it – at least, vicariously.

Working in this field, miscarriage, infertility and infant death are realities. And after 17+ years and thousands of couples, I know families I work with who have experienced all of these things. Sometimes I’m privy to this information – a family will choose to share the details of their parenting journey with me. But oftentimes, I’m not.

As their Childbirth Educator, they might not feel comfortable sharing with me (or anyone else in class) their history of miscarriage as we’re just getting to know one another. So they remain silent about any struggles they might be having with their current pregnancy. Despite feeling especially vulnerable about the health and welfare of their baby, they might not be willing or able to reach out for support.

And even if I might have played an important role in their preparation to become parents, if a family has experienced infant death, this might be just too painful to share with anyone outside their immediate circle of support.

I respect a family’s desire to maintain their boundaries and privacy around such intensely personal events. Families should never feel pressured to share their parenting journey with anyone other than whom they choose.

I’m dedicating this poem/post to all of the families I’ve known, personally and professionally over the years who have suffered through miscarriage, infertility, or infant death as a part of their parenting journey. I’m not sure how often these realities are acknowledged. But I think they should be.

Empty Arms

“We’re pregnant!”
We want to scream it from the rooftops
But, we’ve done that before
And remember what happened last time
Parents and siblings trying on their new identities:
Grammie and Pops, Auntie Jen and Uncle Matt
Friends joking, “You’ll never sleep again!”

So,

Instead we check the test results over and over again
Like a nervous tic
“Is that a plus sign?”
“Do you see one line or two?”
And we keep the news to ourselves
Locked away
Silent, mute, anxiety-excitement
Heavy in our hearts
We won’t tell anyone

Until…

Morning sickness becomes all-day sickness
The baby starts moving –
A lot
We’re past that day, that week, that month

Because…

We need to feel the weight of the baby in our arms
The emptiness has been almost too much to bear
We can’t go through it again
Everyone else’s excitement crashing down
Heavy, crippling us under their collective grief

So,

We wait
With the breath of hope caught in our throats
We wait
For the right moment to whisper
Only to a select few
“shhhhh – we’re pregnant.”
Please keep our secret – don’t tell anyone
Don’t get excited – don’t believe it
We don’t – we can’t

Not yet

~~~~~~~~~~~~~

Every time I see a baby
My heart somersaults in my chest
And I wonder

“Why can’t that be me?”

If her baby is crying and she is frustrated, or angry, or too slow to respond
I wonder
How much better I would be at this:

Mothering

Because –
Why, exactly?
Because – I want it more
Because – I deserve it more

These are not rational thoughts
I’m not proud of these thoughts
But it is completely irrational that I’m not a mother
That we’re not parents

We’ve made the decision to stop trying
But we never decided that we didn’t want to have a baby
That was decided by someone – or something – else

And no matter what bargain we tried to strike
No matter what promises or prayers
We whispered long into the dark nights
Our arms remain

Empty

We still long to be parents
That desire doesn’t just go away –
That desire to be a family
Never goes away

Not ever

~~~~~~~~~~~~~

When I came into this place I was a mother
Because my baby was still alive
Not of this world, yet
But alive in the world created inside me

I could feel my baby’s every movement
Stretching my belly skin taut like a drum
Pushing my ribs out of place
Tap dancing on my bladder
Beautiful pain and exquisite discomfort
Now only a ghost memory

How can we leave this place now?
Arms empty
Breasts full

We have a car seat, a stroller, a bouncy seat
And there is a room in our home
A room with a dresser, a crib, a changing table, a diaper pail
All of the trappings of what was supposed to be
Our new little family

Intolerable cruelty
How will we ever get through this?

The pain is hot and sharp
It pierces and stabs
The pain is cold and dull
It throbs and aches

A constant reminder of how much
We were willing to love

How will we
How can we
Ever allow our hearts to love this way again?

Know that I grieve deeply with you if you’ve ever experienced miscarriage, infertility or infant death. And while these are such painful realities of many parenting journeys, they deserve to be shared and talked about – if and when you are ready to do so. These experiences are important chapters of your parenting story.

One national resource that might help you process is Share: Pregnancy and Infant Loss Support.

I’d also encourage families to consider individual and couples counseling. There are many therapists who specialize in working with families who have experienced pregnancy and infant loss.

Lastly, I’d like to remind all those who work with families to be aware that the parenting journey may include these painful issues and our families deserve our full support and compassion wherever they are in telling their stories.

Either/Or? How About Yes/And?

Yes:And

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.

Pain and Pleasure?

Enjoy

Have you listened to the podcast The Longest Shortest Time? Episode #28, The Missing Chapter to Ina May’s Guide is so worth the listen. Please pop over there and do yourself a favor – then come back to me here. The interviewer, Hilary speaks to Ina May Gaskin – yes, the Ina May Gaskin, the grandmother of the natural birth movement, and basically tells her how she felt betrayed by both her and the NBM when her birth ended up not being at all what she expected after reading all the “right” books and doing all the “right” preparation for what she hoped would be an “ecstatic experience.”

I might be in the minority on this one, but I think it’s totally okay to say to pregnant women, “Birth is probably going to be painful.” Now what level of pain a woman experiences during her birth depends on tons of different things: Is she tired and hungry going into labor? Has she taken a class that’s really emphasized how to cope with contractions? Are there a lot of tried and true tools coming into the labor and delivery unit with her? Is she feeling confident or fearful of the birth process? What’s her labor support team look like? What’s her personal pain threshold? Is her birth slow and steady, or fast and furious?

There’s lots of extenuating factors that will have an impact on her ability to cope with contractions and manage them effectively without any pain medication. There are some women who really feel that the pain of labor and delivery is negligible! One of my students actually said, “I’ve had paper cuts that were harder to deal with!” In my experience, she is the exception to the rule. But having a painful birth doesn’t mean it has to be a negative experience.

When I hear that a woman felt like her birth was not painful, I’m thrilled! And so is the woman who’s telling me her birth story! But she’s happily surprised by this turn of events. In my classes, women are prepared to work hard through contractions and know they will most likely experience some level of pain and discomfort as they’re going through labor.

I don’t ever want a woman to be angry and disappointed that she actually had pain with her contractions. I want her to have realistic expectations that birth, for most women, is painful. I don’t emphasize that point, and I don’t dwell on it, but I think they should be prepared.

If they have the expectation that there will probably be pain in their labor – no matter how well they breathed with their partner in the classroom, no matter how often they change positions, no matter how they’re using the “doula’s epidural” of getting in and out of the tub for pain relief – then a laboring woman can work with her pain and not be overcome by it. Rather than making pain the star of the show, she can give it a minor supporting role and move on. Maybe this will allow her to actually enjoy the experience of giving birth.

It might seem like I’m talking out of both sides of my mouth.

“Birth is going to be painful.”

“Birth is something you can enjoy.”

But I think both statements are true. I try and have my couples imagine something that they’ve done, a physical challenge of some sort, that was painful to get through, but still left them feeling positive, happy, satisfied, proud of themselves, and accomplished once it was over. Then I’ll ask them, “At any point, did you feel like you were suffering?” If they feel it was a positive experience, the answer will almost always be “No.” If I press and ask if it was painful,  they might respond with – “It was one of the most painful things I’ve ever gone through – but it was so worth it!”

They would not be able to respond this way had they experienced suffering. It’s so important to make that distinction between pain and suffering. They’re two very different things. Pain is something we feel, suffering is our overwhelming and negative perception of that pain.

No woman should ever suffer through her birth. If she ever reaches the line that separates pain from suffering, then we’d better be doing everything we can to keep her on the side of continued coping. If she has crossed that line and moved into suffering, then we need to do something immediately or she can be traumatized by this experience – even if it goes according to her “natural birth” plan.

What about the woman who hopes for an unmedicated birth, but goes into the experience thinking, “If the pain gets to be too much, if I think an epidural has become medically necessary, I’ll ask for some relief.” She may not end up needing this relief. But identifying a tool to help her if she’s beginning to suffer is what counts here. An epidural as a medically necessary choice allows her to care for herself during birth without feeling like she somehow failed, like she wasn’t strong enough to get through without drugs.

More than anything, I want women to enjoy their births so that they are able to move into parenting from a place of peace and confidence, feeling proud and accomplished by what they’ve just done. I might sound like a broken record, but a birthing woman – despite mode of delivery – has co-created a new human being, grown her baby in the perfect environment and then on the day of birth, she either opens and pushes her baby through her body into this world, or she goes through major abdominal surgery to bring her baby into this world. She has already done an amazing job. She has already done more than enough.

Feeling guilty about needing to use interventions like medication or surgical delivery to birth her baby has no place in the postpartum experience. When a woman is feeling betrayed by her body, by the medical establishment, by the natural birth movement, she cannot fully enjoy her experience of pregnancy, birth or new parenting. There’s not enough room for enjoyment – there is only room for anger, blame, and shame. How does this benefit a woman in her new identity as mother? How does this benefit the couples relationship?

I think it’s entirely possible for a woman to enjoy birth, no matter what the circumstances, but we need to provide the birthing woman with realistic expectations about labor and delivery first. We need to encourage her to find her voice and participate fully in the experience. She needs to surround herself with the right people as members of her support team. And then she needs to be prepared to make the hard choices that weren’t a part of the original plan if they become necessary. In this way, she might experience pain, but she can also enjoy the pleasure of giving birth.

When you gave birth were their moments of pain? How were you able to tolerate the pain? Did you enjoy giving birth? What made that possible for you?