December 3
Volume 10, Issue 25
Midwifery Today E-News
“Pain in Childbirth”
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In This Week’s Issue:

Quote of the Week

"Doubt is a pain too lonely to know that faith is his twin brother."

Kahlil Gibran

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The Art of Midwifery

One of the most emotionally challenging tasks of giving birth for the mother is the necessity of separating from the baby. The baby is perceived by the woman both as an individual and as a part of her. In some ways he is still imaginary, yet he is becoming increasingly real to the mother. Separating from a part of ourselves or from someone very close to us is always a difficult and painful process.

In childbirth, this separation is often partly desired and partly feared. The unknown of the "real" baby contributes to such mixed feelings. The less the mother familiarises herself with her unborn baby during pregnancy, in fact, the more difficult the separation process will be.

In this context, pain has a double function. On one hand, it forces the woman toward a necessary separation, leaving no room for hesitation. Since many women would probably never undertake this separation process voluntarily, pain helps them to acknowledge the unavoidable necessity of giving birth, by concentrating all their attention on the parts of the body most involved in the process. On the other hand, physiological pain becomes the expression of the emotional pain of separation. Intermittent pain, the rhythm of labour with its accelerations and slow transitions, marks the time. In separation processes, time is important and individual.

[T]he midwife can have an important role in facilitating this process. Encouraging a good mother-baby bond even before the birth and encouraging a process that makes the baby more real and less imaginary to the mother will help make the separation process more fluid, the birth faster and the pain of birth less intense.

Verena Schmid
Excerpted from "The Meaning and Functions of Labor Pain," Midwifery Today, Issue 75
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A 2002 Taiwan study investigating the association between demographic-obstetric factors and perceived labor pain in 90 primiparas having normal births found that their perceived level of pain was related to their expected level of pain. The researchers found no significant association between the pain and newborn birth weight, maternal age, body mass index, confidence in labor or duration of labor. They concluded that the "findings suggest that primiparas' perceived labor pain is correlated with psychogenic rather than physical factors."

Kaohsiung J Med Sci, 18(12):604–09, 2002

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Pain-free Birth?

Inevitably, in discussions about unassisted or natural birth, the topic of pain-free birth rolls around. When it does, I wonder if striving for a "pain-free birth" doesn't inadvertently miss the potential beauty of natural birth itself. I don't believe birth is meant to be pain-free, in fact, I believe it's far more than that! I believe, and have experienced, birth to be downright ecstatically, blissfully pleasurable.

"Pain-free" doesn't even come close to describing that experience. That's like calling a high sexual union with your mate "pain-free," or the most breathtaking sunset you've ever seen "ugly-free." I think that as long as we're focusing on getting rid of or avoiding pain, we're focusing on the wrong area and we're completely missing the point.

There's also the idea that birth is painful but simultaneously pleasurable. Which is it? I just can't buy into the whole "no pain, no gain" paradigm, or the description of the "joy pain," or sacrificing to experience joy. How is pain joyful? How is joy painful? Given the opportunity and knowing it was natural and healthy, wouldn't we all forgo the pain each and every time? I think the folks who believe that no woman should have to suffer through childbirth have the right root but, through fear and ignorance (and perhaps greed, in the case of the pharmaceutical industry), have climbed up the wrong tree.

I don't deny at all that these things get very mixed up in our cultural conditioning, and most of us have confused and enmeshed the two. Most of us, unfortunately, have instances in our upbringing and lives where pleasure and hurt were closely connected and became entwined. For some people this goes as far as masochism, where no pleasure can be experienced unless there is pain (or a lot of intense therapy).

But is this natural? Does this happen in nature when there is no interference? Would undomesticated animals raised in a natural environment really endure a painful situation willingly because they also somehow convinced themselves it was pleasurable? I wonder.

Prolonged pain is, in my opinion, a sign of blocked energy, whether physical, emotional, environmental or other. I don't deny at all that pain arises (and denial is just a symptom of another kind of pain I think). I understand that there are millions of women for whom birth is extraordinarily difficult and painful, and I don't discount or question the reality of their experience. I'm not talking about denying feelings or striving obsessively for some ideal and judging ourselves if it is not reached. Both physical and emotional pain is still a regular, even frequent, companion on my life journey, especially in those areas where I am still learning what my natural expression is or where I am reluctant to make certain changes. But I no longer believe that this pain is inherently necessary or natural, as in "birth (or menses) is painful," or "burns/cuts hurt while they heal," or "teething hurts" or "rejection is devastating."

Ingrid Bauer
Excerpted from "Birth as Sheer Pleasure," Midwifery Today, Issue 68
To read about the birth experiences that shaped Ingrid Bauer's thinking, purchase the back issue.

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The rate of births in which an epidural was used has increased over time. CDC birth statistics for 2005 showed that 2/3 of women giving birth have an epidural.

— Centers for Disease Control, Wonder (Wide-ranging Online Data for Epidemiologic Research),

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Question of the Week

Q: I am a Lamaze Certified Childbirth Educator and had learned many years ago that pain in childbirth is caused by the muscular contractions of the uterus. The theory: When the uterus contracts, a percentage of oxygen is cut off. When this is accompanied by fear, tension and holding one's breath, there is less oxygen for the uterus. I was told that a hard-working uterus needs all the oxygen it can get to help minimize pain.

However, I recently read a brief article in Fit Pregnancy (Oct/Nov 2008) that states: "Labor pain evidently comes mainly from the cervix, not the uterus, a Swedish researcher says. In non-pregnant women, the uterus contains pain-sensitive fibers, but for reasons unknown, those fibers disappear almost completely during pregnancy. Experts' best guess is that this is an evolutionary adaptation; if the nerve fibers remained, birth would be too painful—as would pregnancy. The findings could lead to more effective labor pain treatment."—From S.R. Karolinska Institute

I'd appreciate any input you might have on this subject and, if possible, referral to another possible source.

— Elly Rakowitz, LCCE

SEND YOUR RESPONSE to with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.

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Question of the Week Responses

Q: I'm looking for information on giving birth again with an existing rectocele. I want to have more children and have read that it's pointless to have surgery on a rectocele if you're planning to have more children. Are you aware of any articles, books or information from midwives who have had clients give birth with this condition? I'd really like to hear from other women who have continued on with childbearing in spite of this condition. Or maybe some midwives who've had some clients with many children who are continuing to have more children.

I've had eight children. My first was born in the hospital and I had a terrible tear (all the way through to the rectum). I'm thinking that's when the damage was done. I've had one more in the hospital and six at home, all vaginal deliveries. Now I have a rectocele.

— Jennifer

A: I also have a rectocele and had symptoms prior to having children, although it was not diagnosed at the time. It has gotten worse and has now been diagnosed, since having my kids. One was 9 lb 8 oz and the other was 11 lb 2 oz; both were born quickly at home with midwives.

I am pretty sure I had this problem prior to having kids and most definitely before having my second. It is difficult to answer though because there are degrees of difficulty with rectoceles and mine was not as bad prior to having kids as it is now. So I'm not sure I can offer much reassurance. Personally I won't be having more kids. But no one had ever suggested that I shouldn't because of the rectocele, either.

My doctor suggested putting off surgery until the rectocele became a big problem, which is hasn't yet. She estimated that I will probably need surgery within 10 years. I am 33. Good luck!

— Shire

A: I have a cystocele, which is when the bladder is hanging down too low. I continue to have children, although it is uncomfortable at times and I have to void frequently and experience incontinence of urine in late pregnancy. But I have had no trouble with vaginal delivery.

— Cindy Pinson

Q: I am currently a labor and delivery nurse at my local hospital and am preparing to enter school to become a midwife. One of the most common questions/concerns I'm confronted with is the issue of meconium-stained amniotic fluid in a homebirth. I usually have answers for other concerns, but this one is always a little hazy. Do midwives who help moms deliver at home bring suction of some sort with them? Do they automatically transport to a hospital at the sight of meconium? Is it all dependent on the situation and the midwife?

Thanks for your help in understanding!

— Stephanie

A: In my homebirth practice I always bring a DeLee suction device in case there is thick meconium at the birth. Since I very rarely break the waters and often the waters break only in second stage, there is always the possibility of surprise meconium. If the water breaks spontaneously in first stage and there is heavy meconium then I would transport to hospital, unless it is a multip whose water breaks late in first stage, and the probability of birthing en route is likely.

We had always been taught that the thickness of the meconium is an indication of severity and of the likelihood of fetal distress and meconium aspiration. I understand now that studies show that this may not be so, and that light meconium can be just as dangerous. From my personal experience with 26 years of midwifery and thousands of births, I have seen very few problems with meconium aspiration syndrome (MAS). Most babies are fine regardless of meconium. Also we know that MAS can happen in utero as well as at birth, and that deep suctioning is not always a preventive and may cause more harm than benefit.

When I do see meconium at birth, I will be listening more frequently to the fetal heart tones and will certainly not rush to get the shoulders out and will let the chest be naturally "squeezed" and watch the meconium pouring out of the mouth and nose. I also don't feel comfortable about doing waterbirth with meconium-stained fluid. One thing that experience has taught me is that if you see really thick meconium suddenly pouring out of a woman's vagina during labor, check that a breech is not presenting! Israeli homebirth protocols call for transfer to hospital with meconium in first stage.

— Ilana Shemesh, nurse-midwife

Responses to any Question of the Week may be sent to E-News at any time. Write to Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.

Think about It

Laura Milligan, on the USPharmD+ blog posted a neat list called "100+ Essential Online Resources for Midwives" (, which advocates homebirth and puts in one place a large number of resources.

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As a project about fertility, a student midwife took photos of her cervix everyday for an entire cycle—check out the Web site she made:


I have spent about a year-and-a-half developing and opening the Childbirth Resource Center of Grenada here in the West Indies. We officially opened the doors on August 8, 2008, but I was serving clients prior to that date. The Center offers resources, classes and individual counseling to women who are pregnant or breastfeeding. All services are free of charge and I, along with my assistant director volunteer.

So far, 18 women and teens have attended childbirth education classes, borrowed books and been supported in early labor and during the early weeks after delivery. We get about one new referral per week. The need for our services is great. Clients have limited resources and support. Many live in small, crowded houses (shacks) with no running water (outhouses and a public pipe in the street serve a neighborhood), no power—which means no refrigeration, and no transportation, beyond the bus system here. Yet, they come to classes to get information, support and encouragement during their pregnancies.

The Center hasn't paid the rent for November yet. Although many of my friends and family members helped launch the Center, and local businesses donated the furnishings for the facility, the ongoing operations budget is $360 US each month. We were able to cover three months' rent and security, but funds have run out and November's rent is unpaid! I cannot support the center financially. I can only give it my time. The government here has no money.

I realize that times are extremely hard right now and almost everyone has been affected by the current economic crisis. But if you could give even $5 or $10, then we won't have to close the doors! $20 and December's rent, which is now due, could also be paid. I am pursuing other sources all the time, but business donors take longer to process requests and budget their annual giving. If you go to the link below and donate online, your donation will be tax-deductible through Open Arms Perinatal Services in Seattle, which is acting as our fiscal agent. They are a 501(c)(3) organization and they send all the money to Grenada.

Thank you for considering supporting my efforts here! I appreciate your much needed help. In the spirit of this year's holidays, please give what you can! Thank you!

Peace and Love,
Heather Struckman

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