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.

Painless Childbirth, revisited

Lately, my Understanding "Painless" Childbirth post has gotten a lot of attention. I'm so glad, because much of what is in it is so important for women to know. I have gotten a few comments from women who experienced painless childbirth without hypnosis. I think these stories are awesome and they fit right in with the ideology that birth doesn't have to be painful. Here is one of the comments, explaining the various degrees of comfort for her five births.

[. . . ]I experienced almost painless childbirth with and without drugs and never used hypnosis. I think it is different for everyone..[. . . ]In five births, number one and two were painless with drugs. Number three was painful. Number four was not painful until the last ten seconds and number five was painless

I just started focusing on reassuring the baby and the surges never got painful with four and five. The crowning was not painful on number three and number five.

The contractions hurt on number three (possibly because I was panting to keep the baby in on the dash to the hospital.)

Notice her theory that fighting against what her body wanted to do in order to get to the hospital before giving birth may have caused more pain that was necessary. I have been meaning to write about why I feel my second birth became uncomfortable during second stage, after I was almost completely comfortable for first stage, including transition.

My birth plan said "limit vaginal exams to those I request, unless necessary for a medical decision." This request was ignored soon after my OB started to tell I was getting pushy. She had me get into a good position to be checked (big mistake #1 was getting into that position in the first place, big mistake #2 was not getting out of it) and when I was found to have just a lip of cervix left, she continued to check periodically without saying anything. I didn't really mind much at the time since I was really focused on relaxing through the waves, but I do understand why some women feel violated by things like that. I had read about the flaws of the rule of 10 and wanted to be able to push a little if I felt like it even though I was not "10 centimeters." At first, my OB's advice supported this, and she encouraged me to push only as much as I felt I had to. The waves felt different and I began to vocalize through them, because it felt better to, but I was still using my hypnosis and staying comfortable. I don't know how much time passed, but she must have gotten impatient, so she wanted to try holding back the lip of cervix and having me push, which was extremely uncomfortable.

All of you who work with birthing women, this is important, during birthing, our brains sometimes don't clearly interpret what you mean when you say things to us. When trying to hold back the lip of cervix didn't make it go away, my OB told me to try not to push, though I think now she must have meant to only push as much as I had to, but in my confused birth-brain, I read it as "don't push at all" which was very different from what my body was telling me to do, and I think greatly increased the discomfort and, I dare say, pain that I experienced. It is likely that the fighting my body and the confusion caused the pain, not necessarily the pressure waves. When she started telling me I could push, obviously that implied the lip was gone, but again, I had birth-brain. This (and not getting out of that bed) is why I think I ended up needing to be coached to push him out. Once I started really pushing, it wasn't really painful anymore. Crowning didn't really hurt to me either, just felt like really intense stinging.

Here is another comment from a woman who experienced a painless birth:

I had a painless birth with my fifth baby. It was so painless that I didn't realize it was real until he was crowing. (Luckily my husband recognized subtle changes in my mood and called the midwife, who arrived just in time.)

I did not do hypnosis. I just practiced relaxing my perineum with each braxton hicks. When I was lying in bed, in active labor, I thought I was having BH contractions so I just kept relaxing my perineum.

It didn't even hurt when he was crowning. I tore a little and that stung but not bad at all.

For the record: My son was 10lb 6oz and I have a ridiculously low pain threshold

That is pretty amazing. Her comments illustrate beautifully that women do not have to have an unusually strong ability to endure pain to have enjoyable natural birth experiences--it is not an issue of how much pain you can take, but how you choose to think about the sensation you're experiencing.

In both this story and the previous, the moms did not have the painless experience until they had already been through birth before. These women have probably found a solution to the fear problem by experiencing birth. Since they have done it before, they don't need to fear the unknown. Thinking you're not really in labor would probably reduce the fear, too.

Here is another one, from a midwife

[. . .] I had painless childbirth with all my babies. I think it was because I did unassisted births and no one talked to me or touched me while in active labor. I was able to go into the zone and time seemed to stand still. But every time I looked at the clock an hour had gone by. When it was over I felt like I had just had the best sex ever. I was 17 and had a 5 and 1/2 hour labor with my first.

As a midwife, I try to allow my moms to go to that zone, but I also have to listen to the baby, give drinks of water, etc. I tell my apprentices not to talk to her, just support as they see a need and be aware of the mom's response.

I have discussed unassisted birth before. I do think that women are likely to have more comfortable birth experiences if they can be undisturbed. Undisturbed birth does not necessarily have to be unattended. If a doctor or midwife can act as a lifeguard, then a "best of both worlds" birth is possible. The benefits being able to stay focused and follow your instincts while still having a knowledgeable expert available to step in if they are needed. This appears to be how this midwife practices and teaches her apprentices to practice.

The Fear Problem

Fear of the Unknown

It is normal to fear the unknown. For most first time pregnant women, birth is a huge unknown. Not only have we never done it, we may not even have ever seen it done. In North America today, I think it's highly unlikely that the average woman has ever been at a birth before giving birth. She also won't see uncensored images of vaginal birth in any public media. So, unless her school showed birth films in health class (mine didn't) or she takes a childbirth education class, seeks out birth videos on the internet, or watches a birth documentary such as The Business of Being Born, she may not even have seen a baby birthed before she is expected to do it. As I discussed in a prior post, some women seem to think that viewing a birth would disturb them, so they don't seek out any birth videos.

Add this that the fact that virtually every pregnant woman reaches a point in her pregnancy where, looking at her much-changed body, she realizes her baby is going to have to come out, but to her it just seems impossible that it could. It really is an unbelievable thing, even for those who have seen it and done it. That's kind of the miracle of it. Much of the medical system, however, seems to believe that it really is impossible without their help, and they are also afraid of the rare and very scary things they've seen or heard of going wrong, and they pass that fear on to women to add to their fear of never having done it and thinking there is no way her body can do something that seems impossible. Medicalization of birth also increases the "unknown" factor--it is something for educated doctors and nurses to know about, not average women.

Fear of Pain

It is also normal to fear pain, because pain is usually an indication that something is wrong, and we find it unpleasant. Our young pregnant women has heard others talk about how birth was painful for them and that they would never think about doing it without medication (or they did and it was a bad experience), and this just compounds the fear. She has probably seen birth shows on cable TV, which edit birth footage in ways that focus on the dramatic, because they are in the business of making exciting television, not of educating women about what birth is and can be. She probably has also heard a few stories of births where there were complications--maybe a vacuum delivery or an unplanned cesarean. She may fear something going wrong or having something strange done to her. Many women also feel fearful when they are in an unfamiliar place, surrounded by strangers, as is often the case with birth today.

Effects of Fear on Birth

We know that fear causes the body to release chemicals that can stop the birth process. This makes sense from an evolutionary perspective--a tribal woman wouldn't want to give birth if a tiger was chasing her, but as is explained in the book Birthing From Within (not a hypno-friendly book, by the way), the body doesn't know how to distinguish between real and imaginary tigers, it only knows fear. Fear also increases our perception of pain and prevents us from enjoying birth.

So, what is our average (and now thoroughly terrified) first-time pregnant woman to do?

Most likely, she'll figure that she has a highly-skilled doctor and well-equipped hospital that will keep her and her baby safe because they're the experts, and she'll decide she will get an epidural, so she won't need to worry about pain. It is likely that her preparation won't go much beyond this. She will still have other fears to deal with, though. For example, what if she's afraid of needles?

Fear of Needles

Fear of needles is pretty common. I see nothing unreasonable about having a fear about a sharp object penetrating one's skin to introduce foreign substances into one's body. I realize that needles do a lot of good in medicine, but the idea of them is just disturbing to me. It is sometimes fear of needles that leads women to seek out natural childbirth.

My Answer?

The best answer to the fear problem is childbirth education. And by childbirth education I don't mean most hospital-sponsored classes where the woman learns a little (but usually not enough) about what is going on in her body, what routine medical procedures to expect (without letting her know she has the right to refuse all of them), and that epidurals are usually safe and not anything to worry about. I mean childbirth education that is free to tell you what the hospital doesn't want you to know.

Most natural childbirth classes address fear in two ways. They tell women that they can give birth without medication, just like women did before medication existed, and teach them pain coping techniques which helps increase their confidence and overcome their fears about pain. Some of these techniques rely on freedom of movement, so these classes usually encourage women to consider declining unnecessary routine medical procedures that interfere with movement (such as IV fluids and continuous monitoring). They also address fear of the unknown by teaching about the natural process of birth, as well as explaining how medical interventions might affect the process and giving information about the risks and benefits of these procedures and encouraging women to choose for themselves whether to accept them or not. Feeling like they are involved in decisions about birth helps women feel less afraid.

Fear of Medical Interventions

However, the downside to teaching about medical interventions (both in classes and other places such as books/films/internet groups) is that sometimes this education has the unfortunate side effect of creating fear of medical interventions. So, fear of pain, birth, and the unknown, are replaced by fear of hospitals, pitocin, and iatrogenic complications. Remember, fear interferes with birth, no matter what the source or intention. Going into birthing with any kind of fear is not healthy. And there is always a possibility that a woman will need medical intervention in her birth, and if that happens, we don't want her to be afraid of it. I recognize that fear of pitocin had negative effects in my own first birth.

I want women to be able to make birth decisions without fear. The presence of fear makes it difficult to use the other things we need to make decisions--our logic and our intuition. Sometimes natural childbirth sources are guilty of some of the same fallacies as the medical side of things. Those who believe in liberal use of medical technology in birth will focus on a few rare complications as reason why a woman shouldn't choose a homebirth, a VBAC, minimal monitoring, no IV or heplock, etc, while ignoring the majority of births that go right. Natural birth advocates sometimes focus on the rare scary complications of epidurals and cesareans, without mentioning that the majority of women who choose an epidural or need a cesarean have no major problems. It is important for women to understand the risks of interventions, while at the same time understanding that there are times when the benefits of these interventions clearly outweigh the risks.

Overcoming Fear

I feel that the best type of childbirth education would present information in a way that doesn't scare women, but provides them with unbiased information that allows them to make informed, and not fearful, choices. Good childbirth education also has ways of helping women overcome their fears. Hypnobabies includes a fear-clearing exercise that works very well for this. Some other ideas can be found in this post by Felice at The Gift of Giving Life.

Understanding "Painless" Childbirth

This post is inspired by a recent conversation on my natural childbirth forum, as well as a few birth stories I have read from Hypnobabies moms who were surprised to find that their pressure waves felt "painful" to them. It also is a response to something I stumbled upon while browsing the archives of a natural childbirth blog, in which the author said she would not want to have a painless birth.

So, what is up with "painless" childbirth?

A few women are rumored to have "painless" births without special preparation. I think this is probably pretty rare, but the fact that it happens is notable. The majority of women who refer to their births ans "painless" or "pain-free" are women who used hypnosis.

I think this is something that is commonly misunderstood, and I admit I didn't understand it when I was preparing for my first birth. I read the book Hypnobirthing by Marie Mongan, and listened to the CD that came with it a few times. As I understood it, Mongan was teaching that all "pain" in childbirth was a result of the fear/tension/pain cycle, meaning birth will not be painful if you are not afraid of it. I believed that what we experience in birth is a direct result of what we expect, so I chose not to expect pain. I was really oversimplifying things, and I was in for a rude awakening.

When I started having contractions (I refer to them as "contractions" here because that is what I called them at the time--I didn't buy into the idea of changing the words then) I admitted that "they hurt," but it was very manageable. They went on for quite a long time, going away and coming back, and then I was given a very low dose of pitocin, and those contractions really hurt. I was still able to cope using movement and deep breathing for a while, but I was really miserable. I do recognize that there was a psychological element to this pain. In my mind, something external (pitocin) was inflicting pain upon me, instead of it being caused by my own uterine muscles contracting. This, as well as exhaustion and pressure to dilate due to risk of infection, made it much harder for me to cope.

I think that I, as a first timer, espoused a common misconception about painless birth: believing that your birth will be painless just because you've heard of it and believe it's possible. I didn't think I needed to do anything to have a painless birth; I thought it would just happen because birth is not "meant" to be painful (right, Dr. Dick-Read?)

My understanding of this changed when I did the Hypnobabies program for my second birth. I don't know if there is really a difference in the two programs' views or if my experiences caused me to have this new understanding. I don't know if birth is really "meant" to be painful or not, but I do know that it involves a stimulus that the majority (at least in our culture) of women's brains interpret as "pain," which is generally experienced as a negative thing. Good hypnosis for childbirth provides a system for changing your mind so that the stimulus is interpreted as not painful, so that it can be experienced more positively. For me, with my second birth, experiencing it positively involved a conscious choice on my part.

Both Hypnobirthing and Hypnobabies use a technique of renaming some of the words commonly used in childbirth. This is a strange practice and, I admit, it's a little cumbersome at times, but many women find it helpful to avoid negative associations their subconscious may have with the words. One example is avoiding use of the word "pain" and using "discomfort" instead, because it is not as negative of a word. Some could argue that "painless childbirth" is about semantics, but it's really about what you choose to believe.

I believe that most women who have unmedicated births are able to find a way to experience the stimulus of the sensations of childbirth as not a bad thing, even if they do experience them as painful. In embracing a "pain with a purpose" ideology, women are choosing to tweak their understanding of the word "pain" (which is usually a negative word to describe a sensation that occurs when the body is being harmed) to include a kind of pain that is good. This essentially means changing the negative connotation of the word "pain" to be positive in this particular circumstance, while with hypnosis, we simply change the word, eliminating the negative connotation altogether.

I think some people, when they hear "painless," assume that means not feeling anything--that the "hypno-anesthesia" would be like an epidural and make them numb. It doesn't work this way. Hypno-anesthesia is very strong endorphins. It's like when you cut yourself or you twist your ankle and at first it hurts a lot, but then it doesn't hurt as much, that's endorphins. They soothe and dull pain, but they don't take away sensation. With a pain-free unmedicated birth with hypnosis, you would still feel your baby being born, it just wouldn't feel like pain to you.

Sometimes the talk of feeling "only pressure and tightening" in Hypnobabies leads women to expect that birthing waves will feel just like Braxton-Hicks waves. This is not true either. Braxtion-Hicks are just tightening sensations, for me, birthing waves (and also the pre-birth waves that can occur irregularly for weeks before the actual birth) have an extra level of intensity--what I now call a "downward pressure" which signaled to me that my uterus was now working to begin moving my baby down instead of just flexing itself for the exercise.

One of the changes in the new 6th edition of Hypnobabies is the re-recording and re-naming of a track that used to be called "Painless Childbirth" to "Easy, Comfortable Childbirth." Hypnobabies appears to be moving away from using the word "painless," which, considering all of the misconceptions about it, I think is a good move. I feel like "comfortable" is a more accurate description of how Hypnobabies helped me. Whatever sensations I felt (some of which I may have called "painful" under other circumstances), I knew they were normal and was able to not be afraid of them, which allowed me to feel calm and confident and not out-of-control or panicky (except during the cervical lip and the pushing, but I have theories about that). I wouldn't say I was "in pain," because for me, being "in pain" never involves that degree of serenity and self-composure.

I know there are some women for whom surviving the pain of childbirth provides a sense of accomplishment. It makes them feel like they are "hardcore." I, on the other hand, am not "hardcore," nor do I want to be. I can get a sense of accomplishment from seeing that I did something most people experience as very painful, and it was mostly comfortable to me, and I did it with my mind!