Wednesday, November 4, 2009

A Response to Hypnobirthing by Marie Mongan

I just finished reading Hypnobirthing by Marie Mongan last night, and I thought it was a great, very helpful book. It is a very positive, encouraging approach to childbirth with some wonderful specifics on achieving relaxation during labor. It was a good refresher to get me started on preparation for my next birth. There were, however, a couple of things that I was either concerned about or found myself questioning a bit. I'll share those in a second.

The best part about the book is it's positive message - that childbirth can be a comfortable and enjoyable experience without pain medication. (Hurray!) It also emphasized the need to avoid unnecessary medical intervention (which is so prevalent in this country). Mongan points out the importance of choosing your care provider very carefully. She expresses the importance of communicating respectfully with your doctors/midwives/nurses on your birth wishes in order to create a positive atmosphere in prenatal visits and in the birthing location. She even puts forth alternative language for birthing couples to use in order to keep the mindset of childbirth family, rather than medically, oriented. I found these all impressive and very encouraging.

There were a few concerns for me, though. First of all, Mongan is SO positive about her descriptions of the right birth that I fear it can raise unreasonable expectations about childbirth. For example, when she refers to the birthing stage known in the medical community as "transition," she avoids pointing out that the uterine surges or contractions reach a new level of intensity and that it requires the deepest focus and relaxation of all. She works so hard to avoid any reference to pain that I could imagine it might be an alarming stage for a hypnobirthing mom to reach if she starts to feel like she has some pain. For some women, the transition stage isn't a big deal. But for many more, it really is the point when the contractions totally peak, and it can start to feel painful - not unbearable and not even extremely painful - but they're strong enough that you have to focus intensely through each one and you might even vocalize a bit. She does acknowledge that it is a point when moms might start to doubt themselves, and she turns it around very positively by saying that this is an exciting sign - a sign that the birthing stage is near. This is great, but moms deserve to know that if you start to feel like the contractions are painful, it's okay. It is short-lived, and this is when your partner/coach should offer reassurance and praise to the birthing mom. Indeed, the end is near, and it's so awesome.

Mongan doesn't like the word "coach." It makes it sound like birth is an athletic event to her. I get that. But "coaches" aren't necessary yelling at their wives. They are encouraging, comforting, soothing - and I don't think there is anything wrong with the word. (Besides, I'm a Bradley mom, and you're kind of picking on my lingo, Lady.) :)

There was an overall sense in the book that childbirth shouldn't seem exhausting. I wholeheartedly agree with this in that it shouldn't involve intense huffing and puffing (which can lead to hyperventilation anyway), and pushing should not be some Herculean task that breaks blood vessels. But labor does require some stamina, especially if any stage of it is prolonged or if it begins at the end of a long day and goes into the night (which often happens). This is okay, and it provides good reasoning for consistent exercise during pregnancy. Mongan touched on exercise, but more lightly than the Bradley method does (to which I'm so obviously biased).

I was intrigued by her thoughts on stage 2 of labor, typically referred to as the pushing stage. She strongly criticizes the idea of pushing a baby out and points out that it can not only make the baby's experience more violent, but that it can increase damage to the pelvic floor as it can cause the perineal muscles to constrict. She encourages instead "gentle birthing" and "breathing" the baby down. This is a terrific concept, don't get me wrong. I love the idea of gentle birthing, and I've noticed that in my own experience with my second baby and in many birthing experiences, the final "pushes" in crowning are best if they're not really pushes. A nurse or midwife might say with that last contraction, "Okay, don't push on this one. Just breath deeply." This can be great, because a baby on the threshold of birth who is "breathed out" can have a more gentle birth, the body will be more relaxed, and it can/will minimize or eliminate tearing.

Here are my concerns with the "breathing them out is best" principle: First of all, if your baby is in an awkward position or is particularly large, breathing down your baby might not be possible or could take much longer than everyone expects it to. It might require you putting some pushing behind it. In Bradley training, we're not taught to push with all of our might. We're taught to push as much as we comfortably can, but we're a very active part of it. We're also taught the signs of appropriate pushing - that is, the best sign is that the perineum (the muscle between the vagina and the anus) is bulging. This is not constriction of the perineum - it encourages the perineum to unfold.

Also, Mongan's description of "breathing your baby down" makes it sound like crowning shouldn't involve any pain. Again, we're back to my unreasonable expectations issue. What if it does hurt at that point? I've noticed in my births (with my reasonably large babies - 9'4" and 8'1" with knots and tangles) that once the dilation stage is over, pushing is really comfortable (and cool), but crowning stings a bit - it even hurts at some point. Does this mean I've done it all wrong? I don't think so. First of all, you can't really practice this stage much during pregnancy except when you're having a bowel movement, and even then you need to take it easy. So I'd honestly be curious to poll hypnobirthing moms about crowning and how it felt to them. Did it hurt? Sting? Burn? Did they push? How was their pushing?

Of course, these concerns and speculations might be answered if I took a hypnobirthing class. Perhaps in the class the teachers give a more realistic view of the experience. Also, the "breathing down" might make more sense to me if I saw a woman do it. But I think it would be advisable for any woman to prepare for the possibility that if her baby is not progressing much with the "breathing down" method, more active pushing might be needed and shouldn't be feared.

Another thing that concerned me was Mongan's use of the words "needing an episiotomy" (in case baby isn't being born quickly or easily enough). Mongan clearly wrote this in the age when the medical community still saw tears as something to seriously avoid. I'm not saying tears are swell, but as I've already pointed out, tearing is not a big deal. It's so much better to let mom tear than to cut her unless there is an urgent need to get the baby out now. If a mom is afraid to really push her baby out and she has this fear of tearing, then a practitioner might feel the need to perform an episiotomy - and you know how I feel about episiotomies (and the tears they sometimes bring along with them). So, basically, I'm just allergic to the word "episiotomy" and it makes me sad when I hear those words...

As a word of advice to hypnobirthing moms, really work on your breathing down. But if baby isn't coming out with that, don't be afraid to push. Get those knees back, and try to pee on someone! :)

Another thing that frustrated me a little when reading the book was, again, her extreme optimism - only this time about the medical community. She repeated here and there that there were "many" practitioners who would support birthing requests, etc. I don't know how obstetrics is in New Hampshire, but here it's another story. If you want a practitioner who is supportive of natural birth and routinely avoids unnecessary intervention, it is like looking for a needle in a haystack. They are hard to come by. For one thing, there are laws which make it difficult for them. For example, Utah law basically states that doctors and midwives have to induce you by a certain time past the due date. They are required to do so. These laws must be based on some of the challenges that can come with overdue babies (especially in epidural births), and they are pretty apprehensive of big babies. (Believe me, I know.) Another thing is that birthing in a tub (which she mentions lightly but advocates) is illegal in Utah (I believe). It happens in certain home-births but never in hospitals out here. You may labor in a tub, but not birth in one. (You are welcome to contradict me on this, by the way. This is based on my understanding of the laws and has no legal references to back it up).

It's a big challenge out here to find a doctor or midwife who routinely holds back unnecessary intervention. It's also difficult to know how a doctor will handle your labor. They don't fess up easily on their routines. I didn't know until I was in the hospital with my oldest that continuous fetal monitoring and IV's were non-negotiable with my doctors, but no one would say this upfront. You have to know exactly what to ask about when seeking a practitioner, know what signs to look for, and you have to tread very lightly while asking your questions. Also, their answers to a less experienced mom might be deceiving. For example:

Me: So do you encourage your patients to have epidurals, or can they choose not have one?

Evil Dr. J (aka - Cervix Assaulter): No, if you don't want one, you don't have to have one. My wife didn't want one, because she didn't think the contractions were that big a deal. Her dad was a drill sergeant, you see. She actually broke her arm once, and no one realized it because she didn't mention it to anyone for a whole day.

On the surface it sounds like he's saying that epidurals aren't forced on you and they totally respect your wishes. But he's also saying that you'd have to have a ridiculously high pain tolerance to endure unmedicated childbirth. Well, I don't have a high pain tolerance. If I stub my toe unexpectedly I curse, and I try to not curse. So if you express a desire to go natural and your practitioner tells a story like this, switch doctors NOW.

Here's another dialogue, because that last one was so fun:

Me: So do you routinely perform episiotomies? (I worded this badly. The word "routinely" is a red-flag to doctors...)

Evil Dr. J: Hey, if your bottom's big enough, then I won't cut you.

This was a favorite exchange of mine. Since I'm rather gifted with languages, I'll translate: "I don't believe in the perineum's ability to stretch, and I don't like tears. It takes too long to sew them up. If your baby isn't coming out as easily and as fast as I like, then I'll cut you." I know, can you believe that much was said in just those few words???!!!! Some languages are just weird!

What you want to know is not whether or not they like epidurals. It's whether they are happy to hold back intervention in your low-risk labor. Unnecessary intervention could make your labor less manageable, and hence you might end up choosing an epidural. When you're looking for a provider, you want to know some of the following: When do they use IV's? Are they comfortable with intermittent fetal monitoring when mom and baby are doing well? Are they comfortable allowing a mom to tear (or not tear) instead of performing an episiotomy as long as the baby is well? Do they mind sharing their cesarean rates with you? Do they use vacuum or forceps frequently in births? Do they get uncomfortable with moms having large babies if the mom is no petite lady (not necessarily a problem, by the way)? Would they allow eating or drinking in labor? Are they comfortable with a "birth contract" or a "labor wish list?" Would they mind if you hired a doula? Will they always consult with you to discuss interventions and allow you veto power unless it's an emergency? Do they attend a lot of unmedicated births?

I can't tell you exactly how to ask these questions. It's important to be respectful, but you don't have to be sheepish either. It's your birth. If you start asking these questions and the doctor or midwife is enthusiastic or plainly states something like, "Labor, when issues don't arise, should be a natural as possible," you've found yourself a winner. You can reassure them that you are prepared for the possibility that some things might go wrong, and you're glad you're in good hands. (Of course, that doesn't mean to skip the "wish list.") If, however, you start asking these questions and the practitioner gets uncomfortable or makes a joke about having to catch a baby on the ground or something (happened to a family member), then you have a red flag. Switch practitioners NOW. And if you're 32 weeks along when it hits you that it's time to change, don't beat yourself up. Take control of your birth.

Mongan isn't wrong to be optimistic and positive about the medical community, but when she uses the word "many" in referring to supportive doctors/midwives/hospitals, it feels overly optimistic. Hypnobirthing moms would do well to take extra care in choosing their providers and should not feel abashed about asking a lot questions. Most of us don't have a ton of babies, and you have a right to have say in how your care is handled. It's your baby and your body.

How about nutrition and medical interventions and their risks and benefits? What if things go wrong? Well, that's my final concern with the hypnobirthing book. Well, it's not really a concern with the book itself. The book is great for preparing you for an uncomplicated delivery with a good low-risk pregnancy, but I felt that it touched only very lightly on the more comprehensive parts of childbirth education - the medical and nutritional side of childbirth. It's good to keep the language positive and gentle, but when you're birthing in a hospital, they use terms like "transition," "contractions," "water rupturing," instead of gentler hypnobirthing terms. Hearing the more common medical terms shouldn't frustrate couples. Knowing what they mean should be comforting.

Again, I haven't taken a class, and it's very possible that the class fills in some of these gaps. The book is definitely not meant to stand alone, though, as Mongan repeatedly refers the reader to their Hypnobirthing teacher and specific handouts. Couples considering a class might want to ask if these extra topics are covered and, if not, what books or websites might be a good supplement to the class.

For someone only reading the book, I'd definitely encourage hypnobirthing couples to supplement their education with other materials, like a friend's Bradley class workbook (and a few hours doing research on the internet) or Childbirth the Bradley Way by Susan McCutcheon. It's a little dated, and there are tons of nudy shots (so sorry for that!! I suggest post-it notes to cover the photos), but the book not only gives some great detail on childbirth, but it helps you educate yourself comprehensively on nutrition, medical interventions, and what is best when some things can go wrong. This might sound a little negative (which Mongan is anxious to avoid), but if a complication arises and you understand what it is and what care is best, then you can still feel good about the good parts of your labor. And you can feel great about being a couple that understands what is going on and what care is best for the situation.

Much of this might sound negative about the book, but I really do think it's a great book, especially as part of preparation for the deep relaxation necessary for comfortable childbirth. In Marie Mongan fashion, I want to end on a positive note and point out two of my favorite parts in the book.

First of all, I love Ms. Mongan's descriptions of her own birth experiences and the genesis of hypnobirthing based on them. In her first two experiences, she labored comfortably, completely unassisted and unmedicated, despite the derision of the nurses, and was crowning before she was forcibly put-under and her baby was birthed with her unconscious. By her third labor, she stood up for herself and made firm requests about birthing her baby consciously and about having her husband in the room. This was so unorthodox and extremely brave. She is such an amazing woman to have been able, at such a time, to stand her ground and have relatively positive birth experiences. And all of it started with her reading Childbirth Without Fear by Grantly Dick-Read. Her own experiences and her courage are very inspiring. She also takes some time to outline the history of viewpoints on childbirth, and you can see how the emotional atmosphere in our society has really fostered pain in childbirth. Women are scared to pieces and dread labor, and then they have traumatic experiences that pave the way for other women. And these are great, amazing women who are being terrified into fearing a very important event in their lives. Mongan is an amazing pioneer in natural childbirth, as was Dr. Dick-Read and Dr. Bradley (and even Dr. Lamaze, I'm sure).

The other part I loved - my favorite part - was a chapter that I really needed on releasing fear. I am so grateful to the friend who suggested this section to me. I realized that I had been getting very caught up in the negative aspects of my previous labors and was stressing myself out everyday replaying the experiences in my head. It was very distracting. Mongan warns that fear from any source - abuse, previous birth experiences, others' birth experiences, the opinions of others, etc - can become self-fulfilling prophecy in a bad way. Every woman, every pregnancy, and every labor is different. There is no need to assume that because something went wrong once, it will happen with every labor. There is no need to fear complications in a healthy labor. Things can happen, but they usually don't - and moms don't need to stress themselves, their partners, or their babies out with anxiety. What a blessing to be reminded of this and to be advised that I have to let go of the disappointments of the past and have faith that it'll be okay!

Hypnobirthing is a great book and an excellent resource for any mom preparing to birth naturally. I wouldn't use it as my only resource for preparation and education, but it would be a valuable staple in the natural birthing mom's library. Borrow, buy, or steal it (no, don't do that, I'm just joking). Just get it and read it often!!

1 comment:

  1. I have really enjoyed reading some of your posts. I think you are right about a lot of what you said about Hypnobithing. I am glad to hear your thoughts on the book.
    I was not able to "breath" my baby down. I tried for a while but things were going so slow and so my midwife asked if I wanted to try pushing. So I did and things move so much faster and I forgot all about birth breathing.
    And yes, it did BURN like CRAZY when I was crowing! My sister said it is sometimes called the ring of fire!
    You have convinced me to look into Bradley for our next baby (IF there is a next baby :)!