Birth Without Fear, Birth Without Pain

Dr. Grantly Dick-Read’s Simple Instructions for a Joyful, Pain Free Childbirth

A review of Dr. Grantly Dick-Read’s 1942 book  Childbirth Without Fear

When I was pregnant I read so many books on managing labor! There are a lot of helpful approaches out there these days for women interested in having an empowered birth experience. Recently I went back and read this classic book that inspired many of the natural birth educators whose teachings on birth we still rely on today, like Ina May Gaskin, Sheila Kitzinger and Michael Odent. I was surprised, then, when I read Dr. Dick-Read’s instructions for a pain-free birth and learned some things I had never heard before! I wish I had read this book when I first got pregnant, so I thought I would review it to share some of his advice with others who are looking for help with their births.

At the turn of the Twentieth Century, in a time when obstetricians in the U. S. were implementing mandatory use of anesthesia and forceps, Dr. Dick-Read, like most of his obstetrician colleagues, was convinced that labor and birth were agonizing ordeals and anesthesia was a merciful medical necessity to relieve his laboring patients from their suffering. In 1903, however, inspired by a country woman who repeatedly refused his attempts to give her chloroform for pain during the birth of her child, Dr. Dick-Read began to investigate the possibilities and realities of natural childbirth, When he asked this woman afterward why she had refused his treatment, she said, “It didn’t hurt. It wasn’t meant to, was it, doctor?” This simple statement lingered in his mind for years and eventually caused a complete revolution in the way he conceived of the presence and role of pain in childbirth.

Pain, biologically speaking, plays a protective role, warning us of danger and injury. Why, Dr. Dick-Read wondered, would something so necessary to the survival of the species as childbirth be accompanied with pain? After graduating from Cambridge, fighting as a medic in World War 1, and training in Obstetrics in the London Hospital, a young Dr. Dick-Read wrote his first book manuscript in 1919, in which he explained his theory that pain in childbirth is a largely unnatural, culturally-materially produced phenomenon. Relying on cutting edge research into the mind-body interactions that produce pain, he described what he refers to as the fear-tension-pain syndrome: the mind perceives danger, the body tenses and prepares to combat the danger, and the result of this tension is pain as a response of the tense body to certain stimuli. Pain can be avoided if the body is not unnecessarily tense, which it often is in pregnancy and childbirth, as a result of common anxieties and fears as well as modern life, which promotes stressful, tense bodily habits and patterns.[1]

In the early Twentieth Century it was an obstetric dogma that childbirth was a harrowing, anguished, and dangerous ordeal that, in the name of safety and mercy, required significant medical intervention. Dr. Dick-Read was among the first obstetricians to propose and support a trend toward natural childbirth. He writes of thousands of women who, on their own and with his help, birthed their children without pain. Many of his very skeptical colleagues asked him, “Why do so many women experience pain, then, if pain is not a necessary part of labor and birth?” Dr. Dick-Read argued that in a society in which obstetric medicine, popular culture, and women’s storytelling between themselves conditions women to expect pain and suffering during labor and birth, fear of childbirth is the norm. So the near-universal experience of pain during childbirth is not because birth is biologically painful, but because we expect it to be so: our fearful expectations create the painful reality they expect.

Dr. Dick-Read’s theory began from his observations of natural births with no medical intervention in which women gave birth without pain, and on the contrary, often with feelings of elation, joy, and spiritual ecstasy. In 1932 he finally published his manuscript, revised and expanded with case studies from 13 years of clinical experience in obstetrics, as the book Natural Birth, aimed mostly at midwives and physicians. In 1942 he wrote Birth Without Fear to share his educational experiences and methods with a wider audience, and it became an international best-seller. His observation of thousands of births over his 40-year career in obstetrics caused him to believe that elation and joy are the natural emotional state of childbirth – either because of the hormonal process that accompany a relaxed, fearless birth, or because of a beautiful life force at work in bringing new humans into the world, or both. His clinical experiences led him to assert in Childbirth Without Fear that 90-97% of women ought to be able to have a relaxed, fearless, painless birth. [2]

There are several crucial components to breaking the cycle of fear-tension-pain in childbirth, but according to Dr. Dick-Read, the most important one is education. Since the fear-tension-pain syndrome is a product of a deep mind-body harmony, it needs to be addressed at the level of thoughts and emotions, and at the level of the physical body. Dispelling fear and anxiety, both generally and about motherhood and birth itself, are crucial to helping a mother enter the emotional-physical state she needs to be in in order to birth without pain. He believed that the obstetrician’s main task was to educate women to understand that birth could be painless and enjoyable. He also recommended that midwives and obstetricians help women know what to expect during pregnancy and labor so that they can handle the changes and movements of their body in an intelligent and helpful way. He also advocated that pregnant women train in progressive relaxation. This way when labor starts, they are able to reach a state of deep relaxation without much effort by relying on the habits built during pregnancy. In addition, he emphasized the importance of women training women to control how they interpret the strong sensations from the laboring uterus and cervix. During labor, a women will experience a changing series of stresses, effort, expansion and contraction, and stretching in the uterus and cervix. The expectation of pain can cause women to interpret these sensations as painful, which results in a tense body and launches a fear-tension-pain cycle that is difficult to break. Learning how to recognize these sensations as work, rather than pain, is crucial to a relaxed and painless birth.

Childbirth Without Fear is so much more than a manual for natural birth. It is an anthropological gem. Dr. Dick-Read’s book includes not only anecdotes from his many years of clinical experience, his opinions about the role of men in pregnancy and birth, his commentaries on the state of obstetrical medicine, and his responses to his critics, but also his musings on marriage, about the viability of deism or materialism for explaining the universe in a meaningful way, and even recounts some of his experiences in the First World War. Some of his anecdotes comments seem terribly old-fashioned, and others are still perfectly timely and relevant.

But since pregnant women and their care givers may not have the time or interest to wade through the additional material, I have distilled his clinical and educational recommendations to make them more accessible.

Dr. Dick-Read’s Instructions for a healthy, enjoyable birth

What to do during pregnancy:

  1. Spend your pregnancy as happy as possible. This ideally includes emotional and physical support from your partner so that you do not feel alone with your all the feelings and changes that pregnancy and motherhood bring.
  2. Pregnancy is an important time for attending to your fears and anxieties. According to Dr. Dick-Read, women often transfer other anxieties onto their attitudes about pregnancy and birth when they get pregnant. This produces a tense, unhappy pregnancy and can lead to health complications in both mother and baby. In addition, fears about pregnancy and birth are very common in our society. These fears and anxieties are normal, but need to be dealt with and dispelled in an emotionally supportive context that includes loved ones and health care providers. He actually recommends that obstetricians and midwives play this role – of caring for each pregnant woman’s mind so that she can be calm, confident, and happy during both pregnancy and birth.
  3. Practice progressive relaxation during pregnancy. This helps to eliminate muscle tension from the body, which is the cause of pain in childbirth. Without muscle tension, there will not be pain. Dr. Dick-Read’s mantra was ¨Tense woman, tense cervix; relaxed woman, relaxed cervix.”
  4. He recommends not worrying too much about your diet. He says that women from all kinds of cultures and places with widely varying food availability and nutrition give birth to healthy babies. Limit your alcohol intake and eat relatively healthfully and relax and enjoy your food.[1]

 

What to do when labor begins:

  1. When your uterus/abdomen is tightening rhythmically and repeatedly, perhaps starting every 20 minutes and getting more frequent with time, you are entering the first stage of labor, in which your uterus works to open your cervix to allow your baby to pass through. The best thing you can do during this phase is to disengage your mind and let your uterus contract without your conscious awareness or interference. The more you try to engage mentally with these first phase contractions, the more likely you are to experience tension and pain.

Dr. Dick-Read actually recommends lying in bed in a state of total relaxation. This is why relaxation practice during pregnancy is so important, so that you are easily able to enter that state.

Obstetricians and midwives’ role during this time is to assess the mental state of the laboring woman, and discuss and help her to dispel any fears or anxieties she may have at the onset of labor. They should take significant time at the beginning of labor to help you relax into a patient, calm, and relaxed state.

  1. The ideal emotional states for labor and birth are calm, slow, and gentle. You will be very sensitive to suggestions during this time, so only allow companions who are reassuring, calm, slow, and gentle with you. Patience is the best friend and guardian of a safe and healthy birth. Birth is hard work, and it is important to be surrounded by people who allow you to move gently and gradually through each phase as it unfolds, without anxiety, pressure, or hurry.
  2. Use deep breathing to relax during contractions as they intensify, and maintain a fully relaxed state between contractions.
  3. At certain moments, like during the height of contractions, you may experience a feeling of impending agony. This is only an expectation created by the effort of the uterine muscles as they contract. If you pay careful attention you will see that this feeling dissolves before the pain ever occurs. It is important to know to expect this feeling and to be able to dispel it without leaping ahead into the fear/tension/pain cycle.
  4. The only biologically possible or probable moments of pain might be the last few (6-8) contractions of the first stage, when the cervix stretches fully open to 10 cm. If this is the case, continue to relax and breathe deeply and know that in just a few contractions this will pass. Strong pressure or massage on the sacrum can help relieve this pain.
  5. The mostly likely state to follow full dilation of the cervix is a deep relaxation, a nearly sleepy state. Try to enter this as fully as possible, leaving conscious awareness behind as much as you can.
  6. When you start to feel an urge to push, you are entering the second stage of labor. In this stage, it is important to help the uterus with conscious effort and careful breath control. When you feel a contraction, breathe in deeply and then hold your breath, using your muscles to consciously help the uterus by pushing. Most likely you will make sounds to help relieve the tension as you release air after pushing.[2] Between pushing contractions, take two or three full breaths to clear the carbon dioxide (from the conscious and uterine muscle effort) from your blood and then return to a very deep relaxation between contractions. This is the stage where the contractions are the most work, but the relaxation should also be the deepest between them.
  7. When you start to feel a burning sensation in your perineum, this is normal and means the head is crowning. At this point, in order to keep your perineum intact (to avoid tearing), it is very important to fully relax all the abdominal muscles and let the uterus do all the work. During crowning and the final expulsion of the baby, use short quick breaths (panting) to help relax all your other abdominal muscles so that the uterus is the only muscle pushing the baby out through the birth canal. This allows the perineum to slowly adjust to the baby’s head and stretch, rather than tear, to allow the baby to pass through.
  8. When you catch your baby, gently help it pass its head up and over the pubic bone (rather than pulling it straight out). This also relieves tension on the birth canal and prevents tearing.
  9. Ideally you and baby both will want to nurse right away. Bring your baby to your chest and allow it to nuzzle your nipple and/or suckle. This helps promote the birthing of the placenta in a timely fashion and prevents hemorrhage. It also begins your bonding with your newborn and gives you both time to enjoy the great accomplishment of birthing and being born!

 

What to look for when you choose a birth care provider:

The Virtues of Birth Care: Dr. Dick-Read’s 3 P’s and 3 C’s

  • Personal interest
  • Peacefulness
  • Patience;
  • Confidence
  • Concentrated observation
  • Cheerfulness

Your birth care provider should know you personally and have a relationship of confidence with you so that you can talk honestly about your fears and anxieties both during pregnancy and during labor. This personal interest should extend to include the time and compassion to understand your personal history and the desire and ability to keep you company as you labor. Your own mental and emotional states are vulnerable to suggestion during pregnancy and especially during birth, so your care provider should help you shape your expectations for pregnancy and birth in a spirit of confidence, cheerfulness, and peacefulness – leading you to expect that things are progressing normally, that you will enjoy birth, that there is nothing to fear, that you and your baby are competent and capable. The majority of births are healthy and normal, and your provider should have an attitude of calm confidence in the health of natural birth, rather than an attitude of searching for and expecting abnormalities. Concentrated attention allows care providers to focus their efforts on recognizing the boundaries of healthy pregnancy and birth without focusing excessively on problem cases or potential risks. Patience is one of the ultimate virtues of a birth care provider, because it “carries health to both baby and child.” Many unnecessary and potentially harmful interventions can be avoided if your care provider is prepared to let your birth unfold in its own natural time, without hurry.

 

FOOTNOTES

[1] What a difference from today’s micromanaging of pregnant women’s diets! As someone who followed a pretty clearly defined nutritional scheme during pregnancy, I am not really sure what I make of this, but in the spirit of a relaxed pregnancy I thought it was important to include it.

[2] This seems to be a biological need that helps the body release pressure from the chest in a gradual way.

 

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Health and the built environment – shared problems and shared spaces

Inspired by some of your comments on last week’s post about architecture and anti-depressants, this week I want to pass along another interesting nugget I stumbled across in my research about the role architecture plays in health.

Designing Healthy Communities is a project aimed at rethinking the role that the “built environment” has on key public health problems: not only depression but also heart disease, asthma and cancer. Dr. Richard Jackson, a leading physician who helped establish the California Birth Defects Monitoring Program and led 15 years of work at the Center for Disease Control on environmental causes of disease, argues that the way we design our environments has important consequences for our health.

Suburban sprawl, for example, prevents us from being able to easily walk or bike to the places we need to go; our dependence on cars to get around makes us more sedentary, which increases our risks for heart disease and other illnesses, and adds pollutants and toxins into the air we breathe, contributing to our development of chronic diseases like asthma and cancer. Because of this, cities like Denver are designing new live/work areas (like this one in Belmar) that make it easy for inhabitants to get around on foot or bike.

On the other hand, not having enough open areas in dense urban spaces prevents children from being able to play safely, away from moving vehicles – also encouraging sedentary lifestyles during key developmental stages – and minimizes access to fresh produce by not providing spaces for people to grow their own fruits, vegetables, and herbs. Preserving spaces for community gardens, as they have been doing in New York City, is one way to improve people’s access to these products.

Philosophically, this project is interesting for several reasons. First of all, it suggests once again that health is not something that we can isolate to a single cause. Certainly cancerous cells are a cause of cancer – but so might be where and how you live. But more  importantly, this project is a powerful reminder that health and disease quite simply cannot be tackled at an individual level. Finding solutions and cures to chronic diseases like heart disease, cancer, and asthma will not happen if we continue to focus on individual bodies as the “site” of illness or health. The causes of disease and their remedies will only become clear if we zoom out our focus on the problem to include not only the person but our environment as a whole, including the environment that we design and build to sustain and support our living.

This makes health a collective issue. Collective issues are tricky. They require cooperation, collaboration, dare I even say – consensus.

Many of us are accustomed to thinking of health as something we can pursue, choose, and foster individually. Academics in particular (including philosophers like Foucault and Deleuze and Guattari) have struggled long and hard to critique the normative and exclusionary definitions of health that tend to problematize individual differences. Western approaches to health, although they do promote a general norm that applies indifferently to all, encourage us to think of health as something that we can achieve through individual effort – if we just have the right exercise regimen, eat the right foods, take the right pills, or take ourselves to the right doctor for the right tests and treatments.

It is important to retain space for individual differences, preferences, and choice in defining and pursuing health. But much is at stake in this parsing out of where and to whom health belongs. We cannot solve the kinds of chronic and widespread problems we are facing if we do not also think about health as something that we choose and pursue together. We share our living environments and we (often unequally) share the effects that these have on our bodies. We can only promote health if we are willing to rethink some of the ways we have chosen to organize our lives together.

Why don’t we start by thinking about what kinds of living arrangements make for both healthy individuals and healthy communities?

(Note: there is a four-hour film series on Designing Healthy Communities that will be showing on PBS this spring; it’s also posted on the website. Check it out!)