October 7, 2012

Ina May’s Guide to Childbirth – book review

Ann Cowlin Pregnancy Pathway 1 Comment

Ina May’s Guide to Child­birth by Ina May Gaskin.

NY; Ban­tam, 2003.

The phys­i­ol­o­gy of birth is com­pli­cat­ed and still not well under­stood. Our sub­jec­tive expe­ri­ences of birth are rich­ly tex­tured. Per­son­al accounts spill over with com­bi­na­tions of intense sen­sa­tions, strong emo­tions, vague impres­sions and fine details. What is aston­ish­ing about Ina May’s Guide to Child­birth is how exquis­ite­ly she traf­fics in the lan­guage of an inter­nal land­scape to describe and explain this com­plex process. She tru­ly cap­tures the unique­ness and uni­ver­sal­i­ty of birth. I am adding this book to the list of rec­om­men­da­tions I give my clients, as well as sug­gest­ing it to oth­er teach­ers.

Devot­ing near­ly the first third of the book to pos­i­tive first-hand birth sto­ries pro­vides a sub­stan­tial ground­ing. Many times I found myself think­ing: Yes! That woman is describ­ing this or that essen­tial bit of wis­dom I want to impart to my clients. Let me point out one exam­ple.

On pages 24 and 25, one of nar­ra­tors describes 3 slices of her expe­ri­ence. First, she got advice not to read or learn too much and not to make a plan because the more details she had in mind, the less like­ly she would get what she want­ed. Too much read­ing would inter­fere with her abil­i­ty to go with her body, she was told.

Sec­ond, she describes her expe­ri­ence of being in a tub and how she need­ed a lot of reas­sur­ance because she was both scared and aware of the great pow­er in her body. The phys­i­o­log­i­cal phe­nom­e­na occur­ring in her brain and motor sys­tems indeed would be described as these sub­jec­tive states of being. She def­i­nite­ly per­ceived what was hap­pen­ing.

Third, she describes turn­ing from look­ing at things dur­ing a con­trac­tion to lis­ten­ing because look­ing made her think, while lis­ten­ing allowed her to feel and be instinc­tive, which felt bet­ter than think­ing and was not so over­whelm­ing. Thus, she was going with her body. We see her process in this nar­ra­tive.

The sto­ries all got me think­ing about whether I am telling my clients too much or too lit­tle! One of my teach­ing goals is to insure that clients dis­tin­guish between strat­e­gy and tac­tics. Exam­ple:  In the case of the sto­ry above, the strat­e­gy was to go with her body. The tac­tics she used were to not get too much infor­ma­tion so she did not have too many expec­ta­tions and to use sound rather than vision as her way of con­nect­ing inner and out­er real­i­ty.

As a teacher, I see my job as insur­ing that my clients who might hear this sto­ry do not think that they must use sound rather than vision in order to go with their bod­ies, but rather that this was a piece of the process for this woman to reach her objec­tive. It might work, but it might not. To get this across to clients, I tell sto­ries about births in which I have been present when oppo­site tac­tics accom­plished the same strat­e­gy or where the same tac­tic led to dif­fer­ent out­comes.

The mul­ti­tude of sto­ries she presents in part I allow part II – the text­book part – to come to life. Whether she is dis­cussing stages of labor, pain or release, she calls up sto­ries and because the read­er is already recep­tive to the notion of exam­ples, the illus­tra­tions help the read­er grasp what­ev­er point she is mak­ing about the process.

How­ev­er, the com­plex phys­i­o­log­ic sequence of birth, includ­ing its vari­a­tion from woman to woman, is less well served – in part because there is still so much to be learned about how birth hap­pens, and in part because the birth com­mu­ni­ty in gen­er­al (whether hav­ing had pro­fes­sion­al or aca­d­e­m­ic train­ing) is not as well versed in nor­mal phys­i­ol­o­gy as it could be.

Let me focus on two issues: One is pain/pleasure and the oth­er is hormones/behavior. Regard­ing pain/pleasure, Ina May makes a lot of impor­tant points, among them that how we expe­ri­ence an intense­ly sen­sa­tion­al expe­ri­ence depends to a great degree on our prepa­ra­tion and that dif­fer­ent women have dif­fer­ent pain/pleasure expe­ri­ences dur­ing birth. What she doesn’t tell us, though (and I sus­pect because it’s not com­mon knowl­edge), is that some of the fac­tors that con­trol how we expe­ri­ence sen­sa­tions are beyond our con­trol. We expe­ri­ence pain/pleasure through a series of sen­sa­tions, men­tal foci and behav­iors such as breath­ing and mus­cle release. These nerve impuls­es are for­ward­ed through­out the brain, some sen­sa­tions tak­ing on emo­tion­al con­tent – some ter­ri­fy­ing and oth­ers ecsta­t­ic – depend­ing on the neur­al pat­tern. This is the basis of both the fear/tension/pain syn­drome and the orgas­mic pat­tern. But the pre­cise pat­tern is depen­dent on genet­ics, as well as envi­ron­ment and behav­ioral train­ing.

Some indi­vid­u­als become aware of sen­sa­tions at a very low neu­ro­log­i­cal thresh­old; oth­ers do not. Some indi­vid­u­als quick­ly find sen­sa­tion of which they are aware to be uncom­fort­able or emo­tion­al­ly intol­er­a­ble; oth­ers do not. Some peo­ple need com­fort mea­sures for their dis­com­fort soon; some lat­er, or not at all. Tol­er­ance of what final­ly becomes pain or plea­sure (or just a sense of stretch­ing or motion through space) is also vari­able from per­son to per­son. Thus, the point at which we start has both bio­log­i­cal and psy­choso­cial deter­mi­nants with­in this already vari­able process. In describ­ing the vari­a­tion in how women expe­ri­ence pain and plea­sure in labor, Ina May is great at giv­ing us exam­ples and iden­ti­fy­ing psy­choso­cial or cul­tur­al vari­a­tions iden­ti­fied in research, but not so enlight­en­ing on the biol­o­gy of why and how. This may or may not mat­ter to the read­er.

The issue of hor­mones that gov­ern the vicious cycle we call labor is much less well under­stood. We have a pret­ty good con­cept of how prostaglandins, oxy­tocin and endor­phins are stim­u­lat­ed and affect the process, and Ina May describes these in acces­si­ble ways. But while adren­a­line is thought to inhib­it ear­ly release of oxy­tocin, there has been lit­tle dis­cus­sion of its impor­tance in the push­ing or ejec­tion phase (she does cite Michel Odent’s notion that adren­a­line might play a part in the ejec­tion reflex when a labor is slow­ing down). But, there is lit­tle recog­ni­tion out­side of the phys­i­ol­o­gy field that what hap­pens in tran­si­tion is our ener­gy sys­tem shift­ing to a sym­pa­thet­ic [adren­al] source to give us more pow­er to push. That’s why con­trac­tions change, why some women have a rest peri­od between, and why – back in the day – we used to say to a woman hav­ing dif­fi­cul­ty culling up her resources to push that she could get mad! Going through the effort and dis­com­fort is key to induc­ing the rush of beta-endor­phins. We know this, in a sci­en­tif­ic way, from research that tells us run­ners who lis­ten to music (relax­ing and dis­so­cia­tive) expe­ri­ence low­er rates of beta-endor­phins at the end of the run than run­ners who do not lis­ten to music, but work through the effort and dis­com­fort they expe­ri­ence (stress induc­ing).

One of the things that makes Ina May’s book so valu­able, in my mind, is the dis­cus­sion near the end about mid­wifery, sta­tis­ti­cal sup­port for nat­ur­al birth and enu­mer­a­tion of the risks asso­ci­at­ed with sur­gi­cal birth that are often glossed over when a fam­i­ly expe­ri­ences dys­to­cia. There are many ele­ments with­in the birthing com­mu­ni­ty striv­ing to cre­ate an acces­si­ble spec­trum of choic­es for birth. Let’s face it, birthing at home for low risk women, seam­less trans­port alter­na­tives, birthing cen­ters attached to med­ical facil­i­ties, and read­i­ly avail­able med­ical options when emer­gen­cies arise, would be a won­der­ful future. Birth atten­dants with uni­ver­sal accep­tance, vari­able but rig­or­ous train­ing, and delin­eat­ed scopes of prac­tice would be ide­al. Whether we get there remains to be seen, but I am glad Ina May exists, has her track record and is being lis­tened to in this effort.