Hypno-anesthesiology 101, with Dr. Seuss

Now the news has arrived
From the Valley of Vail
That a Chippendale Mupp has just bitten his tail,
Which he does every night before shutting his eyes
Such nipping sounds silly, but, really, it's wise.
He has no alarm clock. So this is the way
He make sure that he'll wake at the right time of day.
His tail is so long, he won't feel any pain
'Till the nip makes the trip and gets up to his brain.
In exactly eight hours, the Chippendale Mupp
Will, at last, feel the bite, and yell "Ouch!" and wake up.

This passage is from Dr. Seuss's Sleep Book, which I read to my two year old daughter to help her fall asleep. Although the Chippendale Mupp's eight hour lag in pain perception is an exaggeration, the passage illustrates an important fact about pain. Pain signals from the body have to travel along the nervous system to the brain before we actually recognize pain. Therefore, it could be said that pain happens in the brain. The following quote from the article Replacing Painkillers With Hypnosis explains how a pain test performed under hypnosis looks on an fMRI:

New imaging techniques have recently started to reveal what occurs under hypnosis, and why pain that would otherwise lead to severe discomfort becomes bearable. Using functional magnetic resonance imaging (fMRI) scans, Sebastian Schulz-Stubner and his team at Aachen University in Germany measured the brain activity of 12 healthy volunteers who received repeated heat stimulation to their skin. The researchers found that hypnosis interrupted the pain signals that normally travel from the nerve cells to the primary somatosensory cortex, where the sensation of pain is elicited. Instead, the signals fizzled out in the subcortical region, failing to produce the normal ouch effect.

The article also goes into detail describing a dental procedure using hypnosis for pain relief, using a "Special Place" like the one taught in Hypnobabies. One thing I love about the Hypnobabies method is that is uses medical hypnoanesthesia techniques, just like the ones this article is talking about.

What is Hypnoanesthesia?

Hypnoanesthesia is simply the body's own endorphins, which are released by the brain. Endorphins are said to be ten times stronger than morphine. We experience rushes of endorphins in response to pain, but also during exercise and after good sex. Hypnosis allows us to control the release of endorphins with our thoughts. One of my friends was telling me recently about Candace Pert's Molecules Of Emotion, which explains the scientific basis of how our thoughts have physical effects on our bodies. I haven't read it yet, but it's on my list.

But wait, if birth isn't inherently painful, why do I need anesthesia for it?

Birth is not inherently painful, though that may depend on your definition of pain. However, birth can become painful when other factors are introduced. Things like stress, fear, distraction, and not being able to follow to your instincts can create pain.

During natural labor, a woman will usually instinctively disconnect from her surroundings and her conscious thoughts and enter a state of deep focus. This state triggers her brain to bathe her body with endorphins and continues the flow of oxytocin. These hormones promote relaxation in the woman, which allows her body to birth her baby without her resistance.

The problem is that if a woman is unable to enter this state, or is distracted from it and can't get back to it, her birthing will become painful and she may fight her body. Knowing hypnoanesthesia techniques allows women to remove pain that is created by forces outside the birthing process. These forces can stop the flow of endorphins from her brain, resulting in pain caused by a level of endorphins lower than should naturally be present during birth. Hypnosis is a way to enter a state of deep relaxation and calmness quickly, which can get a woman back on track if she is thrown off. Hypnoanesthesia allows women to release endorphins on demand to get them back to the state they should be in during birthing. They are also able to get to this state faster when labor begins.

Distractions are a part of modern birth, even if it is just a quick check on the baby's heart rate. Women who use hypnosis have the advantage of being able to refocus quickly when distractions occur. It is natural for a woman to give birth in a place she feels safe, since giving birth makes her vulnerable to attack (several natural childbirth books discuss this concept, including Ina May's Guide to Childbirth and Birthing from Within). In antiquity, women could give birth in privacy, like animals do. Hypnosis actually allows modern birth, regardless of setting or attendant, to be more natural and instinctive, because it allows women to go within and be in a safe place in their minds. So, whether it's on a train, in the rain, in a house, with a mouse, here or there, or anywhere, you can give birth in comfort and peace.

A Natural Third Stage?

The idea of active management of the third stage has never sat right with me. Even before I developed my interest in natural childbirth. When I was pregnant with my daughter, I was taking one of the hospital classes I talk about that are not so great. The nurse who was teaching the class told us that after our babies were born, we would be getting pitocin in our IVs to help the placenta come out and help the uterus clamp down to put pressure on the placenta site to prevent too much bleeding. I asked if you can decline it and she acted like that would be a stupid thing to do, because why would you want to risk bleeding too much and before we had it a lot of women died from hemorrhage.

It just didn't seem right to me. I didn't like the idea of having a medication to prevent a complication that only might happen. This was part of my reasoning behind changing providers and hospitals. My CNMs told me that with an unmedicated birth, third stage pitocin is often unnecessary, so my birth plan said I didn't want it unless I started to hemorrhage. I ended up being induced with pitocin for that birth anyway, so it didn't matter.

When I moved to a new area while 3 months pregnant with my son, I called the hospital where I was planning on birthing for a recommendation for a provider who would be supportive of natural birth (they recommended Dr. I., who was awesome) and the nurse and I talked about the policies. She said that if I really didn't want an IV, they could do the postpartum pitocin as an IM injection instead and told me that in her 10 years as a nurse, she had never seen a woman not get pitocin after giving birth. When I met with Dr. I., I talked to her about this, and she brought up that breastfeeding really should work just as well as pitocin. She said she would support trying breastfeeding first.

So, then, I had an unmedicated birth, but they had to take my baby to the warmer to give him oxygen. Dr. I. waited until the placenta was out to see how much I bled, but it was too much, so I got both pitocin and methergine--I think it is possible that doing it later is why I needed both.

I wondered if perhaps I'm just a "bleeder" and will need pitocin for all of my births. I don't have a problem with it if it is actually necessary. Then Gloira Lemay shared with me an Australian article called Optimising psychophysiology in third stage of labour: theory applied to practice. I read the full article (link is to the abstract). I believe these authors are on to something, and I would love to see more research on this topic. You can read an interview with one of the article's authors at the Science and Sensibility blog.

The basic idea is that studies of "active management" and "expectant management" haven't really studied truly physiological third stages. The authors theorize that in order to produce the oxytocin surge necessary to help her uterus contract sufficiently to avoid hemorrhage, the mother needs to focus on her baby, holding him skin to skin, in a calm environment with little distraction. This is certainly different than how my 3rd stage was with my son, and I think it is likely pretty rare in a hospital setting.

In natural childbirth education, and especially with hypnosis, we try to help women produce the right natural chemicals in their bodies to promote smooth (and even comfortable) birthing in the first and second stages (though the second seems to be more difficult for some of us). There is scientific evidence that the mind and body are connected and our thoughts and feelings have direct effects in our bodies (the research of Dr. Candace Pert on neuropeptides is one example). We strive for a relaxed, comfortable state of mind to promote oxytocin and endorphins in the first two stages--it makes sense that the same sort of mental state would be necessary for a natural third stage. Third stage is still part of birth, and it's important for both women and their caregivers to recognize this.

The belief of the L&D nurses I have spoken with seems to be that an unmedicated third stage with a small amount of bleeding would be an exception. It seems to me that under the right conditions, a gentle, hands-off approach could make postpartum hemorrhage the exception rather than the rule. According to Gloria Lemay, it works.

In order to accomplish a natural third stage, separation of mother and baby must be avoided whenever possible. This is easy if you don't cut the cord right away. Check out Navelgazing Midwife's recent post on the gross practice of using shoestrings to clamp the cord in unplanned out-out-of-hospital births. And for more on keeping mother and baby together, check out the recently posted Healthy Birth Blog Carnival #6: MotherBaby Edition

be sure to check out my new follow up to this post: Physiological Third Stage, without the "as long as"