Do you know the difference between gender and sex? Probably not, neither did I until recent years, but its becoming increasingly important (especially for parents) to know the difference.
(caveat: I am not an academic scholar of gender or social science, although I do research in public health, this post is mainly made up of my own understanding of sex and gender and experiences as a woman, mother and doula)
Sex = male and female
Gender = masculine and feminine
Sex refers to biological differences; chromosomes, hormones, internal and external sex organs.
Gender is socially/culturally constructed and describes the characteristics that a society or culture thinks are masculine or feminine.
People and organisations often use these words interchangeably, especially when talking about things like equality (how can you have equality in a socially constructed characteristic?) so are frequently using gender when they mean sex.
Part of this is to do with British prudishness and the fact we use the same word for male/female (sex) and reproduction (sex) so many forms ask instead for your ‘gender’ and then list male or female (sex) which for the majority of people is thought to be the same thing, but if gender is actually ‘the characteristics that a society or culture thinks are masculine or feminine.’ then maybe you’re gender isn’t quite so simple as male/female? If you don’t fit with the characteristics your society thinks are feminine and you are a woman, what is your gender?
I very rarely wear make up, I don’t often wear dresses or skirts. I don’t like the colour pink much. I like to light fires and camp and fish and chop wood.
Does this mean I am more masculine? Is my gender male? On the other hand I’m definitely biologically female. I’ve given birth twice! #confused
If only organisations/people understood that in most instances when we say gender, we mean sex.
Gender roles vary by historical time, country, religion and group etc. Originally gender roles came from sex differences or biology (women are pregnant, give birth, produce milk to feed babies etc.) so women stayed close to home and raised babies and young children while men hunted and protected (this again would vary by culture, time, place etc.) but from these roles came all our stereotypes of what it means to be a woman or a man (you can probably easily list what society sees as men’s things and womens things) and like the nursery rhyme above the idea that the sexes are different is reinforced from a very young age, even more so in recent years, with ‘gender (sex?) reveal parties and an obsession with boy/girl differences in clothing and toys.
Most people see gender roles as’ Stereotyping and limiting, trying to make little girls and boys fit into a prescribed box which limits their possibilities, and think it might be these gender roles that cause many of the problems in society, for example the high suicide rate in young men, may be in part caused by the idea that men ‘should’ be strong and silent, that its weak to ask for help or share feelings and so have to face their problems alone.
Gender roles have also limited women and girls (don’t get your dress dirty, don’t play rough, be nice, be pretty etc.) but its mainly biological sex not gender that globally leads to so much ineqality for women (e.g. femicide, selective abortion, unwanted pregnancy , rape, FGM, child brides, prostitution)
Only 100 years ago most women could not vote…
Around the world girls are still much less likely to go to school than boys and in many countries women and men do not have the same rights
(this should read sex equality not gender)
This is known as ‘patriarchy’ where men hold the power, and has been a common feature of most societies throughout history
In the last few decades many people have attempted to subvert and move away from gender roles and stereotyping.
And nowadays many people try to do what is termed ‘gender neutral parenting’ where boys and girls are treated the same, and not socialised into roles base on their sex. This can mean not always dressing them in blue/pink. Buying toys that aren’t branded for boys/girls etc.
Some people decide to ‘cross dress’ their children from a young age (deliberately, regularly dressing boys as girls)- this is different to children having access to a range of dress up clothes and toys and choosing their own as they wish, but more a parental choice. There is evidence that raising children without a sense of their own sex (and suggesting sex can be changed) is leading to more children with gender identity disorder.
Children’s sense of themselves is built by how adults and the world around them treats them, they follow our lead, so its important to consider carefully what we are telling them.
Parents may now worry that if their child is attracted to opposite sex toys/clothes that that is a sign they are transgender, rather than it being a child’s normal curiosity. Many children love to dress up and have different interests, this can be effected by their siblings, culture, parents, personality. It is common for children to go through a period of ‘trying on’ different personas, and living as characters in their imaginary world or from media they watch, this does not mean they are transgender.
This reinforcing a binary rather than freeing children from the constriction of gender roles
There have also always been people that didn’t fit with societies views of sex and gender. Sometimes people deliberately tried to be different to cause controversy (like artists) . And men and women have cross dressed for entertainment or access to lives they couldn’t live as themselves (especially women who were unable to publish books as themselves, go into medicine, be pirates…)
So what is gender ideology and why is it harmful?
In the last few years there has increasingly been a change in the way gender and sex are talked about, with the idea that gender is not a binary and that people can be on a spectrum. That has led to people calling themselves a variety of names from non-binary, to queer and trans-gender. They have started describing people that are not trans as ‘cis’. What this means is that people born male and female are happy to describe their gender as masculine or feminine (but as I described earlier, gender is socially constructed ideas of what masculinity or femininity look like, they change all the time, and stereotype people, limiting them to a set of behaviours as ‘normal). I would argue that all people are ‘gender fluid’ to a degree. Our behaviour and self view changes.
This idea is regressive because it reinforces a gender binary. Instead of freeing people from having to behave in prescribed ways, it says that if you behave in male ways you could be a man (born in the wrong body) and visa versa.
In clinical psychology and psychiatry, individuals who experienced distress because they did not identify with their biological sex used to be known as ‘transsexuals’ A diagnosis of ‘transsexualism’ appeared first in DSM-III in 1980. Recently the name of the diagnosis changed to ‘gender dysphoria’ .
The term ‘assigned‘ sex or ‘assigned’ gender is now frequently used, which refers to when a baby is born and it is declared a boy or girl based on the appearance of external genitals. Between 0.018 and 1.7% of the population (dependent on definition https://www.ncbi.nlm.nih.gov/pubmed/12476264) have a ‘intersex‘ condition which can mean they have genitals that appear male/female when they are the opposite sex.
Gender and Sex are separate from sexuality, which is usually described as heterosexual (being attracted to the opposite sex) homosexual (being attracted to the same sex so lesbian or gay) or bisexual (attracted to both sexes) with additions in recent years of pansexual and asexual
Also known as LGB minority sexualities are discriminated against globally and face violence and are only now beginning to get equal rights in some areas (like same sex marriage).
Trans people were added to LGB in the late 1980’s, although strictly speaking trans is concerned with biological sex or gender not sexuality. The initialism has widened to include intersex and queer in recent years (LGBTQI) and gender identities appear to be ever increasing
Some people that feel that their gender identity does not match their biological sex (I would argue most of us feel this at times) want their body to resemble the gender/sex they feel more affinity to. There are a number of aesthetic and medical changes they can make
and legally people in the UK can apply for a ‘Gender recognition certificate’ to legally change their sex on their birth certificate to that which matches their preferred gender. In contrast to some systems elsewhere in the world, the Gender Recognition process does not require applicants to be post-operative (so a man can legally be a woman with a functioning penis and testicles, and a woman a man with uterus and breasts-that’s why you’ve seen newspaper articles about men having babies). They need only demonstrate to a Gender Recognition Panel that they have suffered gender dysphoria, have lived as “your new gender” for two years, and intend to continue doing so until death.
“Transgender activists say that the process of legal gender recognition is unnecessarily invasive, humiliating and lengthy. The UK government has proposed to reform the Gender Recognition Act to de-medicalise and speed up the process. The aim is to introduce a process based on self-declaration with no medical gate-keeping.”
So all you would need to do is say you feel like a woman or man to legally change sex. This potentially cause issues in same-sex institutions like prisons
The number of people applying for a GRC has been low (in line with what you would expect for people with dysphoria) but lately things have changed, many more people are identifying as gender non-conforming, non-binary-queer or transgender and correspondingly numbers of people requesting medical treatment to match the gender (sex) they feel more comfortable with. There are several groups that are transitioning more frequently
- Middle aged men
There could be several reasons for this steep rise in referrals
I feel it is concerning that so many more children are being referred for gender reassignment. This usually involves first socially transitioning children (as young as 3) by giving them an opposite sex name and dressing them as the opposite sex, then giving a child puberty blockers (untested as to long term consequences of blocking puberty for many years) and then giving cross sex hormones so the child develops opposite sex characteristics (e.g. a deeper voice in girls, facial hair and a higher voice in boys). Girls are advised to first bind their breasts and then have them removed (double mastectomy). Boys can be given artificial breasts and both boys and girls can have artificial sex organs (obviously all of this comes with medical risk)
These are often referred to as ‘top surgery’ and ‘bottom surgery’.
However much women or men change themselves, and even with legal recognition from a GRC it is not currently possible for humans to change biological sex and many transgender people choose not to go through medical or aesthetic procedures and are happy to remain anatomically the opposite sex to that which they identify.
There is increasing pressure for transwomen and transmen to be regarded as the sex they identify with (with the mantra ‘transwomen are women’) and language changed accordingly (so if transwomen (men) who self-identify as women (based on their gender identity) they should be accepted as women, despite still having male genitalia (leading to the conclusion that ‘not all women have vaginas’ and for transmen (women) not only women get pregnant or breastfeed. This has led to many organisations changing the terminology they use so as not to offend (using ‘pregnant people’ not women and ‘chest feeding’ not breastfeeding’)
So… to recap…
Sex refers to biological differences; chromosomes, hormones, internal and external sex organs. (except now it doesn’t)
Gender is socially/culturally constructed and describes the characteristics that a society or culture thinks are masculine or feminine. (except now it doesn’t)
If this is confusing, imagine how much more confusing it is for children, who are now having lessons in school about gender identity and being told they can be born in the wrong body…
Many children have neuro developmental conditions (like autism and ADHD) which leads to difficulties with executive functioning. This means their understanding of concepts around identity can be delayed, and they are also more likely to be gender non comforming. (50% of referrals of children to the Tavistock clinic are on the autistc spectrum)
My son has ADHD. Even at six and a half he still lives in a wonderful world where anything is possible. Fantasy and reality overlap, combine. A couple of weeks ago he told me he was the daddy of our two young cats (and yes, in case you were wondering trans species is a thing, like trans race and trans gender)
I talk to him a lot about his ‘science’ brain. About working out whats real and whats not, because whilst its cute to go along with fantasies about toys coming alive and super powers, its probably more likely to harm him than help him (though I’m sure a vivid imagination will benefit him as he grows)
And what about teenagers? I have one of them too, and she already has trans gender friends, and those describing themselves as pansexual and queer (she’s 14). I just hope she’s heard me talking about sex and gender to realise that its perfectly okay to step outside of the constraints of gender roles but that doesn’t mean you were born in the wrong body…
Teenagers are all about risk taking, and finding somewhere to belong. There are all sorts of groups encouraging gender questioning teens to see themslves as transgender, sending girls free chest binders (which can lead to irreperable damage to growing breast tissue or even gangrene) and telling them where to go (or even order online) testosterone.
Parents are advised to go along with affirming their childs new opposite sex identity, even if they had never expressed a similar desire before, with the threat of suicide risk
Self harm and suicida ideation are common in teenagers and both, puberty blockers & cross-sex hormones both carry risk of depressive side-effects and there is very little accurate data (especially now many surveys ask for gender, if this is all about identity then we can’t reliably know how many girls or boys are feeling this way)
“If we fail to record the biological sex of young people we are unable to try to understand why suddenly such a disproportionate number of young women want to ‘identify’ out of womanhood. Is ‘identifying as a boy’ just the latest coping mechanism for girls brought up in a culture where images of women being sexually abused in porn are casually passed around in playgrounds, and the internet ensures no escape from the pressure on girls to be ‘perfect’? And is the world so dangerous for lesbians that being seen as a man is a safer alternative?”
Data is important, its not just about high income countries, this type of ideology could effect global data collection which is vital to prevent violence to women and girls (VAWG)
VAWG data is essential to help quantify and qualify problems, inform policies and design programs based on evidence. The need for better collection of data related to violence against women has been recognised by the EU, the Council of Europe and, at international level, by the United Nations in their commitment to eradicate violence against women
Our kids grew up with Harry Potter, they love the idea that there is magic, transmutation, and that the inner you can ‘sort’ you into groups based on your true identity…
Belief in magical thinking (pseudoscience) and conspiracy theories are increasingly popular with adults too: anti-vaccines, gut instinct (logical falacies/cognitive biases) homeopathy, climate change denial, chem trails, flat earth…
There’s also many teenagers involved in cosplay and anime whch is all about dressing up and changing sex/species etc, is there any wonder kids are struggling with identity issues, especially if we are telling them in primary school that its possible to change to the opposite sex.
Many studies have found that a large percentage of children that question their gender (sex) identity will eventally desist and accept their sex (with many of these coming out as lesbian or gay) but if they have already been socially transitoned as young children, had puberty delayed and or cross sex hormones they may be infertile, have an inability to have a satisfying sex life and/or have had sexual organs removed.
I would argue its unethical to make descisions like these for children that will affect their long term futures, these descisons are better made as adults
Its become very difficult to talk about these issues openly as globally, gender ideology has been accepted as truth without discussion and the majority of people don’t understand the concepts well enough to see the future implications of descisions like self decleration of sex and tranitoning children. People that speak up are labelled as intollerant, bigots, right wing. It was only after I was thrown out of a parenting group (which was for evidence based parenting) for questioning if there was research evidence about transitioning children that I began to understand who serious this situation had become. (people who speak up about trans gender ideology are known as gender critical or terf’s: terf stands for trans exclusionary radical feminist and is used as a threat by trans activists)
A woman was recently suspended from the Labour party for saying women don’t have penises..
Please if it concerns you too, speak up, talk to you’re children and teenagers about sex and gender. Talk to your friends and colleagues.
What is a woman? Barbie doll’s? Is it make up and hair styles and shoes (sugar and spice and all things nice…)
Are men GI Joe’s tough, muscley, silent, no emotions? (puppy dogs tails…)
Not all trans people support this ideology, many are horrified by whats happening, and speak out
Lets go back to all working together to reduce the limiting constraints of gender roles, embracing the feminine within men and boys and the masculine within girls and women, fighting to stop violence against all people and equal rights whatever our sex or sexuality
Thanks to all those actively subverting against gender norms (like the artist Grayson Perry in the picture below and the recent Welsh Government campaign #thisisme which challenges gender sterotypes to tackle violence against women, domestic abuse and sexual violence) and speaking out about gender ideology. We need a completely different construction of gender to make room for trans people without harming human rights.
My girl. On your 14th birthday. Thank you. Being your Mother has taught me everything that is important to know.
Waiting for you taught me about longing, about wanting something so much you don’t know if you can live without it. It taught me surrender and acceptance and then you taught me joy.
Being pregnant with you my life changed, I made so many friends that I love today, I learnt about a woman’s power, about choice about consent.
Your birth was hard and I learnt stamina and pain and the amazement of recognition of another soul grown in your body.
It changed the course of my life, led me to a love of research and my work now in Public health, and of supporting other people’s journeys to parenthood through being a doula.
Learning how to be a mother, to be in relationship with another person, unconditional love that is bottomless and ever expanding. Being a home to someone, physically and emotionally, being a safe place of succour and life, giving more.
How to grit your teeth and keep breastfeeding, swearing through pain, because damn it I was going to do this, and the ease of feeding once we got through the early days, learning what you liked as a person (being rocked in the baby chair so hard it was like a roller coaster and being upright all the time). The contentment of knowing this was the only important thing I needed to do at this time, to nurture this person. Being in a physical relationship of the comfort of anothers body and learning how to let others rest in you.
Bravery to embody my choices with joy, to mother by living my life with you in it, learning yes I could take babies to festivals, parties, travelling.
Supporting other mothers and fathers walk the path, realising the absolute importance of friendship and comradeship through life.
And as you grew you taught me so much about letting go, giving space to another to evolve and become themselves
“Your children are not your children.
They are the sons and daughters of Life’s longing for itself.
They come through you but not from you,
And though they are with you yet they belong not to you.
You may give them your love but not your thoughts,
For they have their own thoughts.
You may house their bodies but not their souls,
For their souls dwell in the house of tomorrow,
which you cannot visit, not even in your dreams.
You may strive to be like them,
but seek not to make them like you.
For life goes not backward nor tarries with yesterday.
You are the bows from which your children
as living arrows are sent forth.
The archer sees the mark upon the path of the infinite,
and He bends you with His might
that His arrows may go swift and far.
Let your bending in the archer’s hand be for gladness;
For even as He loves the arrow that flies,
so He loves also the bow that is stable.”
Khahil Gibran on Children
I am so proud of the person you are becoming, the woman you are growing up to be. Sharing life with me, always resilient and courageous, no nonsense, a wonderful big sister, picking up the slack when I need help. Working together as a family through our life.
Excerpt from a poem I wrote about my girl a few years ago:
I can’t write a poem about my girl,
She’s too big for the page,
She’d argue with everything I wrote down
Stick out her pointy little chin
And karate chop me.
Or cover me in glittery lip gloss kisses.
Her tight brown silky ringlets bouncing,
Eyes like melted chocolate covered daggers,
Skin a creamy frappuccino.
It only seems like yesterday she was born, stargazing,
Stubborn from the start.
When you were two you led a troop of toddlers across the field of Africa Oye
To the ice cream van,
You held out your warm, grubby, empty little hand
And like a miracle,
He handed out each of you an ice cream:
You knew he would,
Your will could move mountains.
Shaking your booty to 4Music
Singing your heart out to R n B tunes,
Wanting to know where your brown mother is.
Sorry huni, there’s just me…
I have previously discussed some of the issues which complicate the discourse around ‘normal’ birth’ and ‘safe’ birth and the concept of risk.
The term ‘normal’ is problematic as it has social meaning (i.e what is usual) and also that what is not ‘normal’ is ‘abnormal’ .
I prefer to use the term ‘physiological’ which means the usual fuctioning of a living organism.
There is current discussion on the push for ‘normasl’ birth and to reduce the CS rate and/or unneccessary interventions.
This is a complex issue, there is still much to learn about how and why risk status changes during the birth process and when it is necessary to intervene to prevent risk.
For my Masters in Public health dissertation I was interested in the differences in post birth condition of mothers and babies after vaginal births with and without common interventions.
For this I used the current definition of ‘Normal birth’ (from http://www.birthchoiceuk.com/Professionals/BirthChoiceUKFrame.htm?http://www.birthchoiceuk.com/Professionals/statistics.htm )
women have a “normal birth” if they do not have any of the following procedures:
- induction of labour (with prostaglandins, oxytocics or ARM)
- epidural or spinal
- general anaesthetic
- forceps or ventouse
- caesarean section
I looked at ‘The Incidence of Women giving birth in Liverpool in 2005-07 having a ‘Physiological Birth’ as compared to ‘Normal Births’ and ‘Cephalic Vertex Births’: Are there differences in health outcomes for mothers and babies by type of birth?’. This was a quantitative hospital-based cross-sectional study using delivery records’ data available at Liverpool Women’s Hospital (LWH). All birth records with a gestation of 37-42 weeks from 01.01.2005 to 31.12.2007 were obtained for mothers who gave birth to live singleton infants and whose delivery records had been entered on the hospital database (13, 963 Vaginal births)
I presented my results at the ‘Normal Birth confernce in 2009.
The incidence of physiological birth in Liverpool in 2005-07 was 24.5%
19.1% of women having their first baby had a physiological birth.
Physiological birth was associated with-
- Greater odds of breastfeeding after delivery and on discharge
- Lower odds of having a post partum hemorrhage
- Lower odds of having a perineal tear
- Lower odds of babies being born in a compromised condition
The powerpoint I prsented at the conference with the full results is attached below. This data is currebntly unpublished although I have been working on a journal article for some time.
Can birth be painless?
A recent article by Milli Hill in the Telegraph suggested that birth not be as bad as people fear.
But this has created a backlash from people who feel that this view contributes to the trauma of women who go into labour convinced they can birth without needing pain relief, or at home, or without ‘losing it’.
As a doula I have accompanied many women through birth and given birth myself twice. So I have seen labours that were unbearable from the early stages to women having ecstatic birth, women singing through their second stage.
In my previous blog I talked about how childbirth is a profound event for women, where pain creates an altered state of consciousness which may help women cope with the pain of childbirth and prime women to experience the psychological shift to becoming a mother.
I agree with Milli that it’s well known that fear and anxiety can lead to greater pain during birth. The associations between expectation, cultural conditions, personal outlook (including locus of control) memory and preparation in relation to pain during childbirth are complex. It has also been suggested that attachment style can effect labour pain.  and can also effect whether the presence of a partner during labour reduces pain
People can be surprised by their own response to the sensations of birth, some people cope better than they imagined. One aspect which has not been discussed is the role of malposition- the position of the baby effects:
- Length of pregnancy (more likely to go overdue and therefore have an induction)
- Length of latent phase (https://magicalbirth.wordpress.com/2014/11/24/prolonged-latent-labour/)
- Length of First stage (with increased need for augmentation)
- Length of second stage (with increased likelihood of assisted birth or emergency caesarean)
Pain– women with a baby in a malposition (OP/back to back, asynclitic, deflexed etc.) are more likely to experience extreme pain from early in labour, this combined with a greater length of labour and exhaustion make it more likely they will need pharmacological pain relief (and malposition is also associated with breakthrough pain during an epidural and needing more top ups of pain medication[5, 6]) Increased pain during labour, is itself is a marker for CS risk
There are a number of ways women’s pain is assessed and documented in labour. One recent tool is the Roberts ‘Coping with labour’ algorithm which provides a mechanism for pain documentation, and care suggestions for the laboring woman. This has been assessed in a large tertiary care hospital as more useful and helpful than a numeric rating scale. 
There is some evidence that antenatal birth preparation can reduce anxiety about birth and decrease labour pain experienced.[11, 12, 13] and there are numerous papers describing environmental factors (circadian, lighting, music, furniture, place of birth[14,15]) non pharmalogical pain relief methods (water, massage, aromatherapy) support (continuity of care, doulas, midwives) and maternal factors (fitness, exercise, personality, preparedness, movement etc.)[16,17]
Severe pain in labour has been associated with both postpartum depression  and PTSD
The coping with labour algorithm looks like a useful tool to combine a better understanding of the factors that can effect coping in labour and ways to help women cope.
The new algorithm was designed in part to reduce dissatisfaction with the numerical pain rating scale, women found the questions intrusive and distracting. The coping with labour tool can be used by midwives from observation and queries about coping to women are only made on arrival, when noticing changes or a shift change. There is also an understanding that not coping in labour can signal the ‘transition’ between first and second stage and be a sign of rapid progress, when reassurance of the physiology of normal labour could reassure women and reduce anxiety in relation to overwhelming sensations.
One woman I spoke to found being asked about pain, contributed to her focus on the pain, and made her doubt her coping ability:
“The ONLY reason I had pethidine with my first was because the midwife (after a shift change the first never mentioned it) kept saying ‘did I want pethidine’ ‘are you sure you don’t want pethidine?’ ‘it’s only going to get worse, would you like the pethidine now?’ – I gave in to stop her asking”
Both distraction and catastrophizing have substantial effects on perceived pain, so questioning women about pain in labour could effect women’s perception of coping.
Looking at longer term outcomes, in a five-year follow-up study of a randomised controlled trial; “The Ready for Child” trial. To compare the long term perspective of the birth experience in nulliparous women attending a structured antenatal programme to that of women allocated to standard care. Birth characteristics of women reporting a less positive birth experience in the long term, irrespective of group allocation, were significantly more likely to experience an epidural, cardiotocography monitoring, and less likely to used water as pain relief and have a spontaneous vaginal birth.
Another study to investigate women׳s use of pharmacological and non-pharmacological labour pain management techniques in relation to birth outcomes, found that:
•Water use for pain decreases the likelihood of special care nursery admission.
•Epidural use for pain increases the likelihood of special care nursery admission.
•Epidural use for pain increases the likelihood for instrumental childbirth.
•Epidural and pethidine use decrease the likelihood of continuing breast feeding.
•Breathing techniques and massage increase likelihood of continuing breast feeding
So can labour be painless?
Yes sometimes, and there are ways to help cope better in labour, but a large part is down to luck/ chance and not within our concious control, needing pain relief when pain is severe and unremitting is not a failing
“my inner sex
stabbed again and again with terrible pain like a knife.
I have lain down.
I have lain down and sweated and shaken
and passed blood and feces and water and
slowly alone in the centre of a circle I have
passed the new person out”
(from ‘The language of the brag’ by Sharon Olds)
- A huge number of factors combine to effect how women experience pain and cope with labour
- Malposition is an important factor that can increase pain and negative outcomes
- Women who experience severe pain may have a malpositioned baby, if this does not resolve, pharmacological pain relief may be needed
- Birth preparation can provide women and their birth partners with tools that can help women cope with labour
- Focusing on pain in labour can increase pain, use of language related to ‘coping’ with labour might be more appropriate
- Offering pain relief in labour may
- Women that experience severe pain and require pharmacological pain relief, despite intensive birth preparation are not personally responsible for the level of pain they experience, it is likely that a combination of childhood experience, cultural environment and malposition combine to create intolerable pain
- There should be no shame in needing more pain relief than was planned
Mayberry, L., & Daniel, J. (2016). ‘Birthgasm’ A Literary Review of Orgasm as an Alternative Mode of Pain Relief in Childbirth. Journal of Holistic Nursing, 34(4), 331-342.
- Costa-Martins, J.M., et al., The role of maternal attachment in the experience of labor pain: a prospective study. Psychosomatic medicine, 2014. 76(3): p. 221-228.
- Krahé, C., et al., Attachment style moderates partner presence effects on pain: a laser-evoked potentials study. Social cognitive and affective neuroscience, 2015. 10(8): p. 1030-1037.
- Sng, B.L., et al., Incidence and characteristics of breakthrough pain in parturients using computer-integrated patient-controlled epidural analgesia. Journal of clinical anesthesia, 2015. 27(4): p. 277-284.
- Wong, C.A. The Influence of Analgesia on Labor—Is it Related to Primary Cesarean Rates? in Seminars in perinatology. 2012. Elsevier.
- Hess, P.E., et al., An association between severe labor pain and cesarean delivery. Anesthesia & Analgesia, 2000. 90(4): p. 881-886.
- Alexander, J.M., et al., Intensity of labor pain and cesarean delivery. Anesthesia & Analgesia, 2001. 92(6): p. 1524-1528.
- Ismail, S., S. Chugtai, and A. Hussain, Incidence of cesarean section and analysis of risk factors for failed conversion of labor epidural to surgical anesthesia: A prospective, observational study in a tertiary care center. Journal of anaesthesiology, clinical pharmacology, 2015. 31(4): p. 535.
- Roberts, L., et al., The coping with labor algorithm: An alternate pain assessment tool for the laboring woman. Journal of Midwifery & Women’s Health, 2010. 55(2): p. 107-116.
- Fairchild, E., et al., Implementation of Robert’s Coping with Labor Algorithm© in a Large Tertiary Care Facility. Midwifery, 2017.
- Firouzbakht, M., et al., The effect of perinatal education on Iranian mothers’ stress and labor pain. Global journal of health science, 2014. 6(1): p. 61.
- Toohill, J., et al., A Randomized Controlled Trial of a Psycho‐Education Intervention by Midwives in Reducing Childbirth Fear in Pregnant Women. Birth, 2014. 41(4): p. 384-394.
Brixval, C. S., Axelsen, S. F., Thygesen, L. C., Due, P., & Koushede, V. (2016). Antenatal education in small classes may increase childbirth self-efficacy: results from a Danish randomised trial. Sexual & Reproductive Healthcare, 10, 32-34.
Bernitz, S., Øian, P., Sandvik, L., & Blix, E. (2016). Evaluation of satisfaction with care in a midwifery unit and an obstetric unit: a randomized controlled trial of low-risk women. BMC Pregnancy and Childbirth, 16(1), 143.
van Haaren-ten Haken, T. M., Hendrix, M. J., Nieuwenhuijze, M. J., de Vries, R. G., & Nijhuis, J. G. (2017). Birth place preferences and women’s expectations and experiences regarding duration and pain of labor. Journal of Psychosomatic Obstetrics & Gynecology, 1-10.
Jones, L. V. (2015). Non-pharmacological approaches for pain relief during labour can improve maternal satisfaction with childbirth and reduce obstetric interventions. Evidence-based nursing, ebnurs-2014.
Levett, K. M., Smith, C. A., Bensoussan, A., & Dahlen, H. G. (2016). Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour. BMJ open, 6(7), e010691.
- Kwok, S., et al., Childbirth pain and postpartum depression. Trends in Anaesthesia and Critical Care, 2015. 5(4): p. 95-100.
- Soet, J.E., G.A. Brack, and C. DiIorio, Prevalence and predictors of women’s experience of psychological trauma during childbirth. Birth, 2003. 30(1): p. 36-46.
Campbell, C. M., Witmer, K., Simango, M., Carteret, A., Loggia, M. L., Campbell, J. N., … & Edwards, R. R. (2010). Catastrophizing delays the analgesic effect of distraction PAIN®, 149(2), 202-207.
Maimburg, R. D., Væth, M., & Dahlen, H. (2016). Women’s experience of childbirth–A five year follow-up of the randomised controlled trial “Ready for Child Trial”. Women and Birth, 29(5), 450-454.
Adams, J., Frawley, J., Steel, A., Broom, A., & Sibbritt, D. (2015). Use of pharmacological and non-pharmacological labour pain management techniques and their relationship to maternal and infant birth outcomes: Examination of a nationally representative sample of 1835 pregnant women. Midwifery, 31(4), 458-463.
*This post evolved out of my birth experiences, attending over 40 births as a doula, and conversations with women and their partners at the home-birth group in Liverpool that I ran over a number of years. Quotes come from conversations on the #MatExp Facebook group. This is a long post, there is a summary of points made and implications for practice at the end
Transition to Motherhood
The transition to motherhood is a profound psychological event, which has been described as a ’normative crisis’ in the female life cycle requiring the giving up of one identity and the assimilation of another. This can be accompanied by changes in behaviour, mood and self that can feel overwhelming. There is little professional or public literature which agrees on the psychological symptoms women experience.
In antenatal classes women are prepared for childbirth and motherhood, mainly through factual accounts of the physical processes occurring, how the baby develops and grows, the changes in the body, how the cervix dilates, uterus contracts to push the baby out. Breasts produce milk for the baby. But there is little preparation for the mental changes that occur in pregnancy, birth and postnatally, except for warnings about low mood. Psychological changes are seen in the lens of deficit and crisis.
Adolescence too, whilst historically and culturally celebrated, in the western world is also increasingly seen as a ‘risky’ time and surveillance encouraged for potentially pathological symptoms. 
These transitory times of life which include psychological ‘crises’ include puberty, marriage, birth, and death, have been marked by initiation rituals since prehistoric times. Native and premodern societies used rituals during these transitional periods in life, (which are viewed as normal and expected personal development and growth) to celebrate and assign social identity.
The social meaning given up to Motherhood in Western modern society is that woman should be happy, content, enjoy mothering and that mothering comes naturally.  This comes in a social setting where there is increasing pressure on women to be financially independent, leading to later age to start a family, and fewer women experienced in childrearing of younger siblings. There has also been a movement away from organised religion.Thus the removal of childbearing experiences from the religious realm has created a culture with “no sacraments for the blessing of childbirth, no ritual to support a woman in childbirth”; this, in turn, “robs this part of feminine life of all its psychological depth and importance”
Three phases have been said to occur during all initiatory processes: separation, liminality, and integration. (For motherhood, this could be marked by pregnancy, birth and postnatal phases)and childbirth can be seen as similar to initiation ritual through several psychological elements, such as the experience of pain or powerful bodily sensations, an altered state of consciousness(’laborland’) a symbolic experience of death and rebirth, self-‐ transcendence, or an ecstatic feeling of unity.
Mental state during childbirth
Although little literature exists to describe to expectant women how being in labour feels, there are cultural expectations of women’s experience and behavior during birth, which usually revolve around pain and drama. Midwives describe using women’s behavior to assess whether active labour has begun and how labour is progressing.[10-12] this behavior is described as ‘labour-land ‘or being ‘In the zone’ and is thought to be due to the hormones released during labour and the pain of contractions.
“Hormones also have an effect on the way pain is experienced in labour. The hormone called beta-endorphin is an opiate or pain-killer that occurs naturally in the body. It is similar in a number of ways to the synthetically produced drugs pethidine and morphine. The subtle balance of hormones changes again when the cervix reaches full dilation. This phase is called the ‘transition”
“Labor land is like a deep meditative state. It is like an out of body experience except that it occurs so internally, totally within your body and in the meditative part of your mind. Being in this state allows the mom to get into the rhythm of her contractions and to develop a routine of what works for her to stay on top of the intensity of her labor.
It is important that no one tries to talk to her or pull her into her conscious mind when she is in labor land. This can take her out of her zone and make it more difficult for her to deal with the sensations she is experiencing.
Some people don’t appreciate the power and importance of labor land and interpret this altered state of consciousness from the outside as a state of weakness where the woman is incapable of dealing with what is around her. This is not a state of weakness but a state of great strength. This is where a woman accesses the full power she has within. Being able to go so internal does leave her vulnerable to outside stimulation. As a support person you are the protector of her space. Your job is to take care of all the external factors so she can stay internal through the birth.”
These changes of behavior in active labour include:
- Sense of separation of mind and body
- Altered time perception
- Zoning or spacing out
- Feeling like things are unreal
- Being unaware of things happening
Women and midwives have also described:
- Not wanting to eat or drink (altered taste perception)
- Altered sense of smell
- Sensitivity to noise and light
- Not wanting to speak, be touched, and communicate
These types of behaviour are known in psychology as ‘dissociation’ and describe a ‘detachment from reality’. This detachment can be temporary (linked to a particular experience) or on-going/repeating.
Dissociation is thought to be a normal human function and is a spectrum that encompasses daydreaming, meditation, hypnotherapy. Dissociation is used by athletes to cope with performing at the limit of their capabilities for long periods. . Lack of an ability to dissociate may be linked to anxiety disorders.
Dissociation is also the means by which the mind protects itself from trauma (and is associated with post-traumatic stress disorder-PTSD). When an experience is traumatic the mind dissociates, however sometimes (especially if the experience is repetitive in nature) or happens during childhood, the dissociation can reoccur in situations that are not currently traumatic or even lead to multiple identities developing.
Altered states of consciousness and dissociation during childbirth
There have been few studies that have looked at how common experiences of dissociation are during childbirth. Two recent studies found a prevalence of approximately 10% (11.3% of the sample experienced significant dissociation.) 
One of these studies found that important predictors of dissociation in labor included both predisposing (e.g. childhood maltreatment trauma, pre-existing psychopathology) and precipitating (e.g. perception of care, negative appraisal of labor) factors. 
Other studies have found much higher rates using qualitative methods (it may be the reports depend on factors such as when women were asked, what instrument is used to measure experience and cultural factors). In Anderson’s study on women’s experience of the second stage of labour sense of separation of mind and body was one of the strongest findings in her study the author concluded that disassociation was not a frightening experience but it enabled the women to keep in control. 
It may be that a woman’s interpretation of her experience as unexpected and/or different/abnormal may affect whether the experience of disassociation during childbirth is adaptive (useful/helpful) or maladaptive (frightening/trauma inducing).
Whilst in a dissociative state “Some sensory cues are likely to provoke alarm in us all, such as sudden unexpected loud noise or rough aggressive touch” (from http://www.iriss.org.uk/resources/trauma-sensitive-practice-children-care)
“At the heart of trauma is terror”
Another consideration is what occurs during disassociation (if the woman experiences interventions, upsetting care, coercion or difficulties during the birth).
A combination of negative emotions prior to and during birth (particularly shame) with dissociation and an instrumental delivery appear highly correlated with developing PTSD after birth. Both dissociation and shame can adversely affect interpersonal relationships (which may make it difficult for midwives and other care-givers to create and maintain a positive relationship with a woman during childbirth, and suggests that continuityof care may mitigate this by building up trust and respect prior to labour.)
This may also be why changes of shift can be difficult for women who have built up a positive relationship with a midwife as they can interpret their leaving as abandonment or feel unable to build a relationship with a new caregiver.
Transfer from one environment to another (MLU to CLU or home to hospital) can also be trauma inducing. 
The hospital environment itself can be triggering, as an unfamiliar environment may present as a threat (which is why making birth environments as home-like as possible is not just window dressing but may actively prevent trauma).
Place of birth appears to effect both optimism and resilience, with home and natural hospital births being associated with a better childbirth experience. 
The recent UK NHS maternity review suggested low-risk women should be encouraged to birth at home or in a midwife led unit. 
I asked women on the #MatExp Facebook group (over 1000 women, partners and healthcare providers interested in improving maternity care) about their experiences of disassociation during labour.
“My first labour I freaked… I hated everything about it, and if I could have exited my body there and then I would have. I felt “spaced” and drunk and I didn’t know what time it was. I can’t really describe it well – sorry. Second time round I listened to hypnosis during labour and it really grounded me, as a result I felt much more in control and towards the end I even announced I was bored!”
“I remember getting so annoyed at the midwives talking with my second. I had my headphones in and I could still hear them even though they were being respectful (and it turned out there was some pretty scary stuff happening with my baby) but I could hear them whispering and I wanted to tell them to shut up because I was concentrating, but I couldn’t find my voice. And when they touched my arm to get my attention I was SO angry with them for breaking my little bubble. Feelings I’d never have usually.”
“It was definitely like a trip. First time, 2nd was too quick and I was too in my rational head until the last 5mins. But first time I had that amazing experience of connection: to all the mothers who were labouring with me in that moment around the world, to all the mothers who ever had been and all the mothers who ever would be. It was enormous and wonderful and comforting. The daffodils out of the window meant something deep and meaningful too, but can’t for the life of me remember what! Anyway, definitely like one of those trips where you’re convinced you’ve got the answer to life, the universe and everything!”
“Like being in a parallel universe. Human interactions are difficult and confusing. Strangers are scary. I was unable to speak, unable to even access the vocabulary! All sensations on high alert and almost unbearable: slightest noise, smell, taste, light. Everything is very black and white like when you’re a child.”
“My first labour I had birth trauma. I felt like a bystander with everything happening to me but no involvement from me, a nightmare that ended up with a fully dressed baby that could have been anyone’s handed to me. I watched myself being cut open via the lights in theatre &it was like watching it happen to someone else on a YouTube video. My vbac’s were very different, I did still have an “out of body” experience when in active labour, I was very aware of touch & vocal about whether I liked it or not. I also hypnobirthed & felt more aware of what was happening in my own body, I knew my 3rd baby was on his way well before my midwife did & didn’t need a VE to tell me otherwise.”
“Being in an altered state is the only place to be in labour in my view. Enabled me to transcend some less than idea birth environments and supporters. Did not protect from ptsd in first (difficult) birth – I think because the sensations are kind of imprinted deep in the psyche when you are in that state. Even now I long to dance in the stars as I once did – and thank the Goddess for those amazing experiences.”
“Yes definitely an altered state, that wasn’t scary for me as it’s how I’ve always got through severe pain or fear and it feels like something I can control (lack of control – now that does scare me!) The down side was that I seem very quiet and calm and I don’t think anyone around me realised how bad the pain and exhaustion had got. I also found it impossible to maintain that and have a conversation and make decisions. Unfortunately as we hadn’t planned at all for things going wrong and I didn’t know the midwives there wasn’t really anyone I could hand over to.”
“This is how gas and air made me feel! Everything was spinning, I was detached, couldn’t form a sentence, it was awful..”
“Second time was definitely a trip! I had no drugs at all. At times I completely went inside my body and experienced the contractions as balls of intense creation energy, sorry if that sounds so hippie but there is no other way to describe it! I felt like a goddess! In between I felt stoned or slept. Amazing! Afterward I felt healed from my first (highly medical) birth.”
“I felt horribly out of it during my second labour. I remember telling my husband I needed the loo and he got a little cross, telling me I had to speak up and tell be midwives but I couldn’t. I was literally frozen with fear. At one point I had a senior midwife holding open my cervix with her hands, two anaesthetists, three other midwives and two doctors in the room with me, all wearing masks, all talking over me. I’ve always felt so guilty about not being able to speak up and blamed myself for a long time for what happened. I didn’t know it was a common thing for women to feel that way”
“I remember them discussing me getting an epidural as my blood pressure was so high and I was just on the bed screaming through the contractions. Everything was so fuzzy. I knew they were talking about doing something I didn’t want but couldn’t do anything about it. An anaesthetist kept coming in and out. In the end I was fully dilated before they could do it so I never had it. Terrifying.”
“I loved my first two stages of labour, didn’t feel it hurt at all, laboured unexpectedly quickly (from midwife who didn’t know me point of view -she later asked if I had a high pain threshold – I don’t remember it being painful at all until she pulled out the placenta) at home so when paramedics arrived I smiled and was happy to have them in my birthing space as only my husband was there who was an unwilling birth partner. They said they didn’t realise how far I was along as I was so calm. I remember them trying to hold my hand and I thinking I didn’t want them in my personal space. Also they tried to give me gas and air which I hadn’t asked for and being irritated I had to push it away, it was interfering in my space. Then after she came out I turned to pick her up and they shouted ‘no’ at me – it knocked me out of my zone and into fear and compliance – I feel traumatised about that. And I saw them get my baby’s first gaze, I was devastated!! She was cleaned before she was given to me and I transferred into hospital for placenta delivery after being told no midwifes available to come out to me. In retrospect I wish I’d free birthed or had a doula as everything was so lovely before anyone interfered.”
“Regards ‘altered state’ yes. I had a long induction (started in the Monday morning, baby delivered at 10am on the Thursday by forceps) where I was left alone a lot and really expected to know what was happening without anyone telling me. I felt very very isolated and detached. Wandering the corridors of the ward at night unable to sleep or eat. Labour was around 20 hours and not allowed to eat and couldn’t rest. Was put on a drip for fluids only during labour. I think lack of sleep and nourishment really contributed to my trauma. I was so spaced out. I’ve no doubt some of the midwives tried to communicate with me but I didn’t take anything in. In theatre I had a traumatic delivery. Baby was out very fast and then taken to NICU – I then had a 4.5l PPH during a further 2.5 hours of surgery to try to stop the bleeding under spinal block. I lost consciousness at one point – I really thought I had died. I really thought I could just let go. I felt like I was watching myself on the table at times. Covered in blood. The whole time I felt like I was going to fall off the table (strange angle to preserve blood flow to my head) so felt in constant danger the whole time.”
“I had gas and air at a few points too and that was mind altering in a different way, quite nice when I thought things were going well and I could chat away on it though I was a little concerned I was embarrassing myself like a drunk person! Once it was clear things weren’t going well I was given it again but it did nothing for the pain and I just got rather paranoid and scared, so I think state of mind before hand is quite important, with my third I experienced going inside my body and I actually saw my son going through the birth canal from Inside it was so weird but amazing and I had no drugs”
It seems there is a complex relationship between previous experiences, personality type, the natural process to dissociate during childbirth and experiences during childbirth (which encompass both intervention and care) which affect the sense of agency and body ownership and may or may not lead to PTSD after birth.
Pain, memory and PTSD
The relationship between pain, dissociation, childbirth and PTSD is not simple and the literature is contradictory. Studies have predominantly showed that women underestimate the pain they would experience during birth. 
Epidural anaesthesia has been associated with a lower prevalence of postpartum depression but not PTSD. Women have described feeling ambivalent about epidural pain relief. Describing relief but a change from euphoric to a ‘normal ‘state which indicated to the author that the internal experience is in focus before the use of epidural analgesia, while the more external experience is predominant after initiation of epidural analgesia. Optimal desired pain control during the birth process may decrease the prevalence of postpartum depression.  How we interpret pain has everything to do with how we will respond to it and our expectations and emotions also play a part in how we experience pain. Memory of pain and affect is influenced by the meaning and affective value of the pain experience. In a study where expectations and memory of pain were studied in women, who gave birth by vaginal delivery or Caesarean section, or underwent gynaecological surgery, surgery led to an overestimation of all but one of the recalled variables of pain. Participants who gave birth by Caesarean section were the most accurate at recalling pain and affect. Memories of pain and affect were most variable in participants who gave birth by vaginal delivery. 
Fear of childbirth results in experience of more intense labour pain and report a negative experience of birth. 
When studying women’s memory of labour pain post childbirth it was found that memory of labour pain declined during the observation period but not in women with a negative overall experience of childbirth. Women who had epidural analgesia reported higher pain scores at all time points, suggesting that these women remember ‘peak pain’.
Protective factors relating to PTSD and childbirth
A critical review of qualitative literature relating to the factors affecting women’s experiences of pain in labour found two main themes (i) the importance of individualised, continuous support and (ii) an acceptance of pain during childbirth 
In a second critical review of qualitative research this time looking at women’s experiences of coping with pain during childbirth feeling safe through the concept of continuous support was a key element of care to enhance the coping ability and avoid feelings of loneliness and fear. A positive outlook and acceptance of pain helped women cope. These findings were consistent across socio-economic, cultural and contextual differences suggesting that experiences of coping with pain during childbirth are universal. 
The ability to move during labour, and change position can be helpful both to facilitate birth without injury  and also a greater sense of control . In one study where women randomised to kneeling or sitting positions in the second stage of labour.A sitting position during the second stage of labour was associated with a higher level of delivery pain (P < 0.01), a more frequent perception of the second stage as being long (P= 0.002), less comfort for giving birth (P= 0.03) and more frequent feelings of vulnerability (P= 0.05) and exposure (P= 0.02). 
A study in Taiwan found women that were randomised to an upright pushing position had a lower pain index (5.67 versus 7.15, p=0.01), lower feelings of fatigue post birth (53.91 versus 69.39, p<0.001), a shorter duration of the second stage of labour (91.0 versus 145.97, p=0.02) and more positive labour experience .
An upright birthing position has also been shown to enhance fathers’ experience of having been positively and actively engaged in the birth process  which is important as men can also develop PTSD from childbirth [38-39], Women who report experiencing less stress in their couple relationship are less likely to report PPD symptoms even when they have a personal history of depression and or PPD  and a woman’s perceived social support has been found to buffer against the potentially traumatic effect of an emergency C-section.
Both mothers and fathers mental health after birth can effect parent-baby interaction and attachment. 
Having a high ‘sense of coherence’ was protective against PTSD following childbirth . The three constructs that underpin the SOC are ‘comprehensibility’ (one must believe that one understands the life challenge), ‘manageability’ (one has sufficient resources at one’s disposal) and ‘meaningfulness’ (one must want to cope with the life challenge).  A review of the literature found that women with strong SOC were more likely to experience uncomplicated birth and birth at home, identify normal birth as their preferred birth option in pregnancy and identify a desire to avoid epidural anaesthesia in labor compared to women with low SOC. 
Increasing pregnant women’s sense of coherence could be a modifiable factor to increase the normal birth rate, reduce PTSD and reduce improve postpartum emotional state. .
As previously discussed, pregnancy and motherhood can be seen as a ‘normative crisis’ and requires profound psychological role transition. Childbirth marks the separation of mother and child as a unit:
“The extreme nature of this experience is what makes the act of delivering a baby a psychological transition, an event of trial and ritual that marks a profound change in a mother’s life.”
There are similarities between mystical and traumatic experiences  and self-induced stress is used cross-culturally as a form of healing. 
“In rituals and with medicinal plants, people push past normal limits in order to experience power, energy, and transformation” 
Substances that that create dissociative states (like LSD, peyote, MDMA) have been used historically and culturally for ritual and healing and are also used recreationally in contemporary western contexts. Users describe the capacity of hallucinogenic drugs for healing and personal growth; even adverse experiences (“bad trips”) were regarded as valuable for these purposes  and some small studies have also looked at using hallucinogens to therapeutically treat long term PTSD and treatment resistant depression. [50-51]
Posttraumatic Growth (PTG) – deriving benefits following potentially traumatic events – has become a topic of increasing interest.
Some studies have looked at PTG after childbirth. Many women report positive changes as a result of their birth experience experience of peritraumatic dissociation and symptoms are most associated with the greatest levels of growth.  Posttraumatic growth in postpartum suggest a potential protective role of posttraumatic growth on the development of disordered eating symptoms. 
Social support has been seen to predict PTG. 
The transition to ‘motherland’ (constructing a new identity as a mother) can be hindered by traumatic birth experiences that reduce sense of coherence and the ability of the body to successfully birth or feed their baby. 
Mastering pain has been viewed as an integral part of a self-actualizing experience. Women have described a sense of achievement and feeling of pride in their ability to cope with intense pain, which increased their sense of self-efficacy. When empowered by their own attitudes and with the assistance of others, these women felt they met and mastered their birth experience, and some described giving birth as a transcendent experience. 
A study exploring first-time mothers’ experiences of birth found that women ‘processed the birth’ by ‘remembering’, ‘talking (storytelling)’ and ‘feeling’. This activity appeared to help most women resolve their feelings about the birth and understand what it actually means to be a new mother. 
I asked an antenatal teacher what they taught women and their partners about state of mind during birth:
“I talk about undisturbed birth producing sensations of an altered state of consciousness facilitated by the increase of the hormones Beta-endorphin and Oxytocin. I describe this as a natural, helpful aspect of undisturbed birth, producing feelings like being “in the zone,” “miles away” or “going off to another planet” combined with the body’s natural pain relief.
As a hypnotherapist I talk about these experiences as being a form of “birth hypnosis” / “birth trance” which can also include (positive) time distortion, altered physical sensations, and sometimes visual or auditory perceptions; all normal aspects of hypnosis. I introduce this state through a series of exercises and ask their partners to observe. We spend time on how partners can help facilitate and protect this helpful state for their partners. I teach them to practice entering this state with self hypnosis and recordings which I create for them in order to make it a welcome and familiar part of birth for the woman and her birth partner so that it is there to tap into during birth. This was certainly my own experience in my second (pain-free) birth where I used hypnotherapy and self hypnosis.
Unfortunately this state is inhibited when birth is disturbed, when a birthing woman is fearful and in the fight-flight-freeze state. I think first time birthing women often push this helpful aspect of birth away, feeling that they need to stay “on top” or “in control.” When high levels of Catecholamines: adrenalin and noradrenaline are produced, fear and pain (without the soothing effects of beta-endorphin) are part of birth. I suspect that this is where traumatic experiences arise. The combination of (negative) time distortion and possible visual and/ or auditory hallucinations with fear and pain is certainly frightening and I suspect for some women traumatising. This was the case for me in my first posterior birth.”
- The transition to motherhood is a profound psychological event, which has been described as a ’normative crisis’ in the female life cycle.
- Transitory times of life which include role changes (puberty, marriage, birth, and death) have been marked by initiation rituals since prehistoric times.
- Childbirth can be seen as similar to initiation ritual through several psychological elements, such as the experience of pain or powerful bodily sensations, an altered state of consciousness (’laborland’) and a symbolic experience of death and rebirth.
- Many cultures use substances to create dissociative states during rituals and for healing.
- Dissociative states of ‘altered consciousness’ are commonly experienced by women during childbirth.
- These states help women cope with the experience of childbirth and may prime women to experience the profound psychological shift to motherhood.
- If women are unprepared for this dissociative state they may feel frightened or ashamed, especially if women experience traumatic care or interventions, this can result in women developing PTSD.
- Fear of childbirth results in experience of more intense labour pain and report a negative experience of birth
- Women who have unmedicated vaginal births are more likely to forget the pain of labour. Having an epidural can make women feel disconnected from the labour process and more likely to remember their labour as painful.
- Two main factors effect women’s experience of pain in labour:
- Support and (ii) acceptance
- A positive outlook and acceptance of pain helps women cope, experiences of coping with pain during childbirth are universal
- Freedom to move and adopt upright positions in labour give women a greater sense of control and a lesser sense of vulnerability and facilitated a positive birth experience.
- Having a high ‘sense of coherence’ is protective against PTSD following childbirth
- Childbirth is “an event so primitive and profound as to be difficult to fully assimilate or put into words. . .”
- Even if birth is experience as traumatic, it is possible to women to experience posttraumatic Growth (deriving benefits following potentially traumatic events)
- Experience of peritraumatic dissociation and symptoms have been found to be most associated with the greatest levels of growth.
- Social support is a modifiable factor that effects coping with childbirth, PTSD, PPD and postpartum transition to motherhood
Implications for woman and midwives
- Antenatal education should prepares women for the possible psychological changes and experiences during pregnancy, birth and postpartum (including dissociation)
- Continuity of care is key to a feeling of safety and trust
- Preparation for childbirth should aim to reduce anxiety and enhance women’s sense of coherence and efficacy (including methods of non-pharmacological pain relief and mindfulness) [59-60]
- Maternal freedom of movement throughout labour is a simple measure to improve birth experiences for women and their partners
- Interventions to improve social support for women and enhance couple relationships in the antenatal period is key to improving postpartum mental health and improving parent/infant attachment
- Childbirth can be seen as a spiritually transforming experience, an increase in personal meaning, religiosity, and spirituality can increase well-being so access to the opportunity to incorporate personal spiritual practices or social experiences (such as mother blessings https://magicalbirth.wordpress.com/2012/05/03/hello-world/ ) could be helpful 
- Doula support can provide women and their families with continuity, one-to-one focus on their physical, emotional and spiritual needs during childbirth and postnatally to improve women’s self-efficacy and transition to motherhood and so could significantly affect women’s mental health in the peri-natal period and increase family sense of coherence
- Providing opportunities within a group for women to tell their birth stories following birth; may help women to process the birth and connect to other women.
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I decided to write this blog post after a discussion in #MatExp about the use of vaginal exams (VE’s) in labour.
There were concerns that women felt pressurised into consenting to vaginal exams in order to be admitted into birthing units in labour or to access pain relief/the use of a birthing pool etc.
It was discussed that vaginal exams can feel intrusive and be upsetting and that the evidence base for using them in labour is not strong.
Others felt that they are an essential part of labour management, needed to monitor progress and prevent harm from non-progressing labours.
People wondered if there are no other ways to assess progress?
Should vaginal exams be seen as part and parcel of normal labour care?
What are the risks/benefits to having VE’s and should women have more information antenatally about them?
My own experiences of vaginal exam in labour were not distressing to me, but as a doula I have witnessed distressing events occurring in relation to vaginal exams that include:
- A woman having 20 VE by 8 different people- her cervix swelled and she had a CS due to failure to progress at 9cm
- A woman who was asked to get out of a birth pool to check for 10cm dilation when pushing, she was told the midwife couldn’t check her in the pool, she was then not encouraged to get back in the pool
- Coercion of a woman with an abuse (sexual) history at a homebirth to consent to vaginal exams (when she had discussed not wanting them in appointments leading up to the birth) which was distressing for her
- Breaking waters during an exam without permission (I’m just breaking your waters as she did so)
- A midwife gave a vaginal exam, stated the woman’s contractions were less frequent and stated she would “Just have a little fiddle about”she then proceeded to give the most intrusive, painful and upsetting exam I have seem, which was traumatic to watch
- I have also seen good practice of very respectful care to women with abuse histories and a consultant midwife that was able to give exams when women were in pools/upright
Before we look at what vaginal exams are used for, I think it’s important to remember that for a woman having her first baby in the UK, a vaginal exam in labour might be the first time anyone has put their fingers in her vagina except during sex (which may or may not have been consensual or enjoyable)
A vaginal exam involves a health professional placing (usually two) fingers in a woman’s vagina in order to feel her cervix (the entrance to the womb) to assess her progress in labour (this can also be done as part as a membrane sweep in late pregnancy to encourage labour to start.) Vaginal exams in labour are seen as a ubiquitous part of assessing progress, and therefore diagnosing deviation from expected progress and reduce the risks associated with non-progressive labour. A vaginal exam is often one of the first routine procedures when a woman believes labour has started. A woman may have previously been offered one or more membrane sweeps in pregnancy (which is similar to a vaginal exam) to encourage labour to start.
An exam can assess if a women is in ‘active’ (also termed progressive) labour. Whether a woman is ready to go into labour is to feel her cervix, its position, thickness, texture and dilation. This can be given a bishops score (http://perinatology.com/calculators/Bishop%20Score%20Calculator.htm) which can be predictive of induction success although this seems to be more reliable in women having their first baby (nulliparous)  and is disputed as a predictor of labour outcome in women having a second of subsequent baby (multipara)Before labour a woman who has not previously had a baby will usually have a cervix which is:
- Long (thick)
Before active labour begins the cervix will more forward, soften, become thin and start to open. Sometimes this is accompanied by contractions and other signs (sometimes early or prodromal labour).
The first exam in labour is often to assess if labour has started. Early labour can potentially go on for days or stop and start again days later with no risk associated with this usually unless the bag of waters surrounding the baby breaks (which could introduce infection) although there is evidence that a long early labour can be due to a babies position and lead to a non-progressive labour and more intervention. The longer a woman spends in hospital during this early labour period the more intervention she is likely to have, also maternity units in the UK are not set up to cater for women in early labour so women are often sent home, sometimes repeatedly.
Active labour is considered to have started after 3-4cm dilation (opening) and will then usually continue with regular strong uterine contractions (which become stronger, last longer and get closer together until the baby is born). It had been thought for many years that labour is a linear process, but recent reviews of the evidence have suggested that dilation and labour length is less predictable, with the early first stage of labour (4-6cm dilation) taking longer (in the US, ACOG in part of a attempt to reduce the cesarean section rate have changed national guidelines to have active labour starting at 6cm instead of 4cm[4 5]).
How is labour progress assessed?
In order to assess labour progress, observations are made by the health professionals involved in a woman’s care. In the UK this is usually a midwife.
In NICE guidance (Intrapartum care for healthy women and babies [CG190] Published date: December 2014)
The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care.It has since acquired a high reputation internationally as a role model for the development of clinical guidelines.
A Partogram provides a graphic overview of the progress of labour and records information about maternal and foetal condition during labour. The World Health Organization has designated management of labour with the Partograph as one of the essential elements of obstetric care at the first referral level.
In 1991 in Asia, the WHO examined over 35,000 births in the largest trial of the Partograph ever done . The study found evidence that prolonged labour, postpartum sepsis, and stillbirth were significantly reduced when the Partograph was used. Augmentation rates and caesarean rates were also reduced. Another study looked at the effect of partogram on the frequency of prolonged labour, augmented labour, operative deliveries and whether appropriate interventions based on the partogram reduced maternal and perinatal complications introduction of partogram showed significant impact on duration of labour (p<0.001) as well as on mode of delivery (p<0.01) Results also showed significant reduction in number of augmented labour (p<0.001) and vaginal examinations (p<0.001). The authors concluded by using partogram, frequency of prolonged and augmented labour, postpartum haemorrhage, ruptured uterus, puerperal sepsis and perinatal morbidity and mortality was reduced.
But findings can be contradictory, another recent study looking at the role of partogram in the management of labouring mothers with high risk pregnancies at a tertiary care centre found that partogram use had no significant impact on duration of labour, rate of operative interventions and perinatal outcome. A Cochrane review on the effect of partogram use on outcomes for women in spontaneous labour at term found no evidence of any difference between partogram and no partogram in caesarean section (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.24 to 1.70); instrumental vaginal delivery (RR 1.00, 95% CI 0.85 to 1.17) or Apgar score less than seven at five minutes (RR 0.77, 95% CI 0.29 to 2.06). The authors stated ‘On the basis of the findings of this review, we cannot recommend routine use of the partogram as part of standard labour management and care’
There have been several versions of the partograph. The WHO version from 2000 starts active labour at 4cm dilation. There have also been recent studies looking at a ‘physiological partograph’ with a slower rate of expected progress in earlier active labour.
Partographs have an ‘action line’ (most also have an ‘alert’ line) which signify identification of slow progress and the point at which intervention is advised to prevent harm to the mother and baby. Many studies were done to assess the predictive value of these lines, one study found that the mean duration of active phase of labour increased as the partographic curve fell to the right of alert and action line. Increased rates of instrumental deliveries, LSCS, babies with lower APGAR score at 5 min, and NICU admissions were observed in group III (to the right of the action line) compared with groups I and II.(within normal curve or to the right of the alert line)another study found crossing the alert line in mothers who had normal vaginal delivery, with normal fetal heart rate, and with no oxytocin administration or amniotomy was predictive with high sensitivity for the need for neonatal resuscitation after birth.
How long should labour take and what are the risks of labour taking too long?
“The sun should not rise twice on a labouring woman.”(an old saying in tropical obstetrics)
Friedman’s curve has been used to assess the expected length of labour (usually 1cm per hour in active labour. With full dilation at 10cm and the pushing stage lasting approximately an hour) although other studies have suggested (especially the first time a woman gives birth) that labour takes longer, and in some places (for example the All Wales normal birth pathway) this is reflected in guidelines where women are expected to dilate 0.5cm per hour in active labour and take up to 3 hours in the second stage(pushing).
In many areas of the world, women give birth at home, without attendance by a trained health professional and only access care if they feel there is a problem with the labour. There are also cultural reasons that may discourage women from seeking help in labour as often failure to birth easily is thought to be due to actions of women during pregnancy.
In these countries, there is high maternal and neonatal mortality and morbidity relating to obstructed labour, (one of the five most common causes of maternal mortality) with many women (usually first time mothers) developing an obstetric fistula. Where the tissues that normally separate the vagina from the bladder and/or rectum are destroyed by the prolonged impaction of the presenting fetal part (usually the fetal head) against the soft maternal tissues that are trapped between the fetal head and the woman’s bony pelvis. The World Health Organization (WHO) estimates that more than 2 million women live with the condition and up to 100,000 new cases occur each year.
The formation of an obstetric fistula is a problem that originates during prolonged labor when that labor is obstructed. The critical problem in the first phase of delay is recognizing that labor is prolonged. By WHO standards, labor is prolonged if it lasts more than 24 hours.
Length of labour does not always predict fistula formation, it is strong, frequent contractions where the baby is impacted against the pelvis and does not descend. In women having second or subsequent births this more frequently results in uterine rupture.
Relatively short labours less than 12 hours in length may result in a fistula if the conditions for “a perfect storm” are present. In practical terms, this means that all cases of obstructed labor should be regarded as emergencies and treated promptly to avoid the development of serious complications.[15 16]
There are arguments about the slowest ‘normal’ rate of progress that does not result in increased risk  Quite a large number (approx. 37% in one study)of low risk women do develop dystocia, but we don’t know how to predict who will reliably. Some studies have also found that slow progress during a VBAC increases the risk of uterine rupture
Although labor dystocia (slow or difficult labor or birth) is the most frequently documented indication for primary cesarean birth, there is no universally accepted definition.” Failure to define dystocia in evidence-based, well-described, clinically meaningful terms that are widely acceptable to and reproducible among clinicians and researchers is concerning at both national and global levels.”
The frequency and reasons for vaginal examinations in labour
Even though NICE guidance states that women should be offered vaginal exams 4 hourly, a recent study found that almost 70% of women had more VEs than expected when the criteria of 4 hourly VEs was applied. The most common reason given by midwives for performing a VE was to assess labour progress and to assess the commencement of labour. 
Other reasons to do a VE include:
Ultrasound assessment of the fetal head position in labor is feasible in a busy labor ward. Digital examination is less accurate than ultrasound, in particular in cases of obstructed labor when medical intervention is more likely to be needed. Ultrasound assessment may prove useful in the prediction and diagnosis of difficult and prolonged labor
Second stage of labour
Vaginal exams are often given to diagnose the start of the second stage. Sometimes women feel an urge to push before their cervix is fully dilated (usually due to fetal malposition) and it is thought that pushing on an undilated cervix can cause swelling. There can also be a ‘lip’ of cervix remaining which can be due to asyncliticism (tilted head)
To help women push better?
In one study (Titled: “You’ll Feel Me Touching You, Sweetie”: Vaginal Examinations During the Second Stage of Labor) to determine how caregivers performed sterile vaginal examinations researchers examined videotapes of women during the second stage of labor. Results showed that the examinations were performed in a ritualistic manner by all caregivers, and the way the ritual was enacted repeatedly demonstrated the power of the caregivers over the women. The most common reason for performing the procedure, to help the woman push better, seems to be specific to the second stage of labor and is not described in the literature.
Other possible reasons include:
- Detecting baby position (especially if breech position or cord prolapse is suspected)
- Concern over babies’ heartrate and possible rapid labour progress
- Abnormal bleeding
- Making decisions about pain relief/transfer/intervention
- Deciding when to get in a birth pool
Evidence for and against vaginal exams in labour
Even though routine vaginal exams are now seen as part and parcel of intrapartum care the lack of evidence for their use is highlighted by some, with a Cochrane review concluding: “Women prefer vaginal exams to rectal exams. No other evidence was found to support or reject the use of vaginal exams. More research needed to find other ways to assess progress of labour [25 26]
What can the experience of vaginal exams in labour be like?
There have been few studies looking at women’s experiences of vaginal exams in labour, but those that have been done found that women find VEs in labour to be unpleasant, invasive, embarrassing and sometimes painful and that women felt powerless to control when and how the VE was conducted[21 27] The VE has been described as a type of health care ritual with the labouring women playing a generally passive role with no active part and the healthcare provider demonstrating that they are in control of both the woman and the process of labour itself Women have reported that they have to tolerate the pain and discomfort of the VE as it is an integral part of labour.
Studies exploring the qualitative experiences of midwives and women in relation to vaginal examination in labour have also described midwives using abbreviations or euphemisms as a means to distance themselves from the realities of the procedure. ‘Some midwives were observed washing women’s genitals in a highly ritualized manner prior to vaginal examination, apparently as a strategy for establishing power differentials. ’The authors conclude ‘It is also important to carry out vaginal examination in a way that is not demeaning and does not reinforce notions that women’s bodies are dirty.’
Previous trauma and abuse
Many women have experienced rape, abuse or other sexual offenses in their lifetime.
Based on aggregated data from the ‘Crime Survey for England and Wales’ in 2009/10, 2010/11 and 2011/12 around one in twenty females (aged 16 to 59) reported being a victim of a most serious sexual offence (rape) since the age of 16. Extending this to include other sexual offences such as sexual threats, unwanted touching or indecent exposure, this increased to one in five females reporting being a victim since the age of 16.
Many women do not disclose their experiences but the experiences during pregnancy and labour can trigger unwanted memories and fear. Worry about physical exams can stop women from accessing healthcare (for example cervical smears) and if women feel coerced or disembodied during childbirth they can be retraumatised. It is not always intimate procedures themselves that can be triggering for women, but how they are conducted, ‘re-enactment’ of abuse occurs as a result of crossing a woman’s body boundaries (and this can be a subjective internal sense) it is suggested that:
“As staff may not know of a woman’s history, they must be alert to unspoken messages and employ ‘universal precautions’ to mitigate hidden trauma. Demonstrating respect and enabling women to retain control is crucial. Getting to know women is important in the building of trusting relationships that will facilitate the delivery of sensitive care and enable women to feel safe so that the re-enactment of abuse in maternity care is minimised.”
Prior trauma is the most predictive factor of Post-traumatic stress disorder (PTSD) after birth. 
Consent to vaginal exams is necessary but women may not always understand the procedure or may feel coerced into having examinations done, as this is part of routine care, which can be traumatic, both for the woman, her birth partner/s or students, as described in this reflective piece-
It wasn’t supposed to be like this (c) S. Wallis
You thought, you would open up beautifully-like a flower does
air spreading your petals, slowly.
You thought, you would open up gently like an anemone,
red fronds unfurling with smooth salty ripples.
Not submit to this, four hourly ritual,
Spreading your legs wide, for relentless gloved fingers to press, into, you.
Assessing your readiness; your worthiness-
Like that boy at your fourteenth birthday party, after spinning the bottle.
You could taste your Mothers stolen vodka in your throat when he fingered you-
Biting your lip, trying not to cry out so the others would hear.
You thought the Universe would be moving through you,
Youe Man kneeling in worship at your feet-
With you birthing the world anew
Not strapped down,
With them crowding round and shouting that you are useless, that you aren’t trying
-that your baby is going to die if you don’t push harder.
And the student midwife is cutting you, and the senior midwife is cutting you again
And the surgeons are hovering, and your Man’s eyes are looking on with horror,
And your baby is limp and grey and quiet…
Even after she starts to cry, her eyes are screwed tightly shut,
And she is over with the medics, not on your belly like you thought
And they are stitching you up, and you are crying, and he is crying,
And you didn’t think it would be like this.
Are there other ways to assess progress in labour?
Several alternative ways to assess labour progress have been suggested, including:
Contraction shapes (fall to rise ratio is higher when labour is nonprogressive)
Changes in behaviour have been described by experienced midwives that signify active labour and progress in labour. These include:
- Breathing patterns
- Skin changes and body temperature
- Pain perception
There is good association between non-invasive ultrasound-based determination of fetal head station and clinically assessed cervical dilatation. When women were asked to compare the experience of vaginal exams and translabial ultrasound the majority (70.5%) considered VE worse than translabial ultrasound (TLUS) as compared to only 4% who felt the opposite.and has been found to be considerably less painful and may be useful to help predict which women will have vaginal births with prolonged second stage and which need assistance.
Purple line[42 43] the formation of a purple line during labour, seen to rise from the anal margin and extend between the buttocks as labour progresses has been reported. This is being looked at as an alternative measure of labour progress but may not have a high predictive value.http://www.sarawickham.com/questions-and-answers/evidence-for-the-purple-line/
What changes could we make to services to improve things?
It seems unlikely that a change of practice to stop or reduce the use of vaginal exams in labour would happen in the UK soon, so what can be done to improve things now?
In a study that looked to improve the vaginal examinations performed by midwives, suggestions included:
- Judging the necessity of vaginal examinations
- Using effective communication skills
- Informed consent
- Exploring the patient’s preferences and choices
- Providing sensitive woman-centred care
- Minimising variability during vaginal examinations
- Paying attention to the frequency of vaginal examination
- Using alternative ways to measure the progress of labour
- Managing unresolved traumatic experiences
Screening for prior experience of abuse, rape or PTSD symptoms prior to birth is also seen as key to prevent retraumatisation during birth. This screening needs to be appropriate
A thesis by Amina White ‘BEST PRACTICES FOR LIMITING RISK OF POSTTRAUMATIC STRESS RELAPSE DURING CHILDBIRTH’ outlines a three-part strategy for trauma-informed obstetrical care that calls for PTSD screening, avoiding posttraumatic stress triggers, and enhancing stress-coping resilience in order to promote the physical and mental well-being of trauma survivors during the birthing process.
‘Obstetricians have a clear duty to inquire sensitively about past trauma and to screen trauma-exposed women for PTSD’
If a woman discloses her history, a plan can be made to reduce or avoid ‘micro triggers’
Not all women will want or feel it is necessary to disclose their history, so it is important during labour to look for signs of anxiety, discomfort or distress.
Narrative accounts suggest that survivors whose clinicians ignore distressing micro-triggers are more likely to perceive those clinicians as disrespectful and as providing substandard care
In the event that the clinician and medical staff are aware of a patient’s trauma history, it becomes especially critical to avoid phrases that accentuate powerlessness such as, “Just let it happen, you can’t fight it”
I have personally seen successful birth planning of women with abuse histories with Consultant midwives in the UK that resulted in positive birth experiences, including a homebirth and a planned caesarean section.
A doula may be able to support women in labour and can concentrate of communication, comfort and emotional support.
Vaginal exams are done in labour for many reasons. The first exam is usually to assess if a woman is in active labour. Once active labour has started exams are usual every four hours in order to plot labour progress on a pictorial record (partogram). Although vaginal exams should be ‘offered’ they have very much become part of routine care and women often feel unable to opt out.
Evidence of benefit from vaginal exams is scant, and little research has been done on women’s views in relation to their experience of vaginal exams or consent.
In low and middle income countries many women and babies are damaged by obstructed labour, which leads to negative outcomes including obstetric fistula, uterine rupture and stillbirth.
There is still disagreement about how long is too long to wait for labour to progress when labour is slow in both the first and second stage without intervening.
Possible disadvantages from refusing vaginal exams are: not knowing if active labour has started (so potentially having pain relief like an epidural or diamorphine when labour has not started) not knowing if labour has stalled or for how long (with possible risks to mother and babies health)
70% of women had more VEs than expected when the criteria of 4 hourly VEs was applied
Women find VEs in labour to be unpleasant, invasive, embarrassing and sometimes painful and sometimes feel powerless to control when and how the VE was conducted
1 in 5 women have experienced rape or sexual threats, unwanted touching or indecent exposure since age 16.
Experiences during pregnancy and labour can trigger unwanted memories and fear
If women feel coerced or disembodied during childbirth they can be retraumatised
Language used is important, as being asked to tolerate pain and discomfort, or ‘just a little’ longer can be similar to phrases used during sexual abuse and coercion. Respecting women’s wishes and boundaries is key
Be alert to signs that someone is consenting under internal duress as this can be extremely distressing
NICE guidelines state VE’s should be ‘offered’ they should not be required to access pain relief, birth pools or access to a maternity unit if other signs of active labour are present
Several alternative methods can be used to assess labour progress in particular trans-labial ultrasound is a promising method to sequentially assess labour progress
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- Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstetrics and gynecology 2010;116(6):1281
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- Neal JL, Lowe NK, Patrick TE, et al. What is the Slowest‐Yet‐Normal Cervical Dilation Rate Among Nulliparous Women With Spontaneous Labor Onset? Journal of Obstetric, Gynecologic, & Neonatal Nursing 2010;39(4):361-69
- Kjærgaard H, Olsen J, Ottesen B, et al. Incidence and outcomes of dystocia in the active phase of labor in term nulliparous women with spontaneous labor onset. Acta obstetricia et gynecologica Scandinavica 2009;88(4):402-07
- Vachon-Marceau C, Demers S, Goyet M, et al. Labor Dystocia and the Risk of Uterine Rupture in Women with Prior Cesarean. American journal of perinatology 2016
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- Shepherd A, Cheyne H. The frequency and reasons for vaginal examinations in labour. Women and birth 2013;26(1):49-54
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- Malvasi A, Barbera A, Di Vagno G, et al. Asynclitism: a literature review of an often forgotten clinical condition. The Journal of Maternal-Fetal & Neonatal Medicine 2015;28(16):1890-94
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I made a Storify book summarising the twitter chat I recently hosted
#MATEXP IS A POWERFUL SOCIAL CAMPAIGN INVOLVING PEOPLE FROM ALL WALKS OF LIFE FROM ALL ACROSS THE UK AND BEYOND
It aims to:
- Encourage and empower users of maternity services to join conversations about their experiences of maternity care, and what really makes a difference to that experience.
- Get health care professionals (in and beyond the NHS) and local communities to listen and work in partnership with women and families to improve maternity experiences.
- To enable anyone to take action to improve maternity experience, however big or small, whoever you are: user, partner, community group or NHS staff
Maternal mobility in labour
How often do you end up shouting at the telly when ‘One born every minute’ is on, and a labour is slow to progress or baby is not coping well and a woman is lying down? Try getting her up!
There’s a large body of research evidence that movement in labour improves outcomes so why do so few women feel able to change position in labour, especially in the second stage?
In 2015 in the UK, fewer women gave birth in a bed than in 2007 and more women chose a water birth or birthing pool (but still <10%)
But approx. 50% of women in 2015 having an unassisted vaginal birth gave birth lying down or lying down with legs in stirrups. The most common position for women to be in when they gave birth was lying down with legs in stirrups (35%), which is a 3% increase from 2013. It should be noted that 15% of women had an assisted vaginal delivery, which would normally require stirrups.
What affects choice of birthing position?
Barriers to maternal movement in labour have been suggested to include: (1) lack of space, (2) inadequate support, (3) use of unwarranted debilitating technology, and (4) movement restricting pain relief.
The link below shows how it is possible to achieve mobility with an induced multiple birth:
The advice given by midwives was the most important factor in this study influencing the choice of birthing positions.
In one study where women were randomised to use a birthing stool or usual care, despite being randomised (rather than freely choosing), women who gave birth on the seat were statistically significantly more likely to report that they participated in decision-making and that they took the opportunity to choose their preferred birth position. They also reported statistically significantly more often than non-adherers that they felt powerful, protected and self-confident.
Midwives should be conscious of the potential impact that birth positions have on women’s birth experiences and on maternal outcomes.. An upright birth position may lead to greater childbirth satisfaction. http://www.sciencedirect.com/science/article/pii/S1871519213000723
What about Dad’s and birth partners?
If a woman gives birth upright, the father is more likely to see the birth as positive, says a study from Sweden… http://fb.me/7BlBeD9fR
What about malposition?
Many women start labour low risk but experience a cascade of intervention, although there are a number of factors that cause this, I believe the (often) unrecognised missing cause in the majority of emergency caesareans, assisted deliveries and interventions causing long term morbidity to low risk women and their babies worldwide is malposition.
Malposition’s are positions where a baby is head down but is presenting in a way that increases the diameter that needs to pass through the pelvis and birth canal. This can be ‘back to back’ (or occiput posterior known as OP) where a baby has its spine against the mothers spine. Babies in this position are usually ‘deflexed’ (chin not tucked to the chest) and this can cause more pain and delays going into labour or in the first and second stage. Although most babies rotate into an easier position to be born, the longer this takes, the more likely it is that women will have interventions like induction, augmentation, systemic pain relief. Women whose babies stay OP (known as persistent OP) are much more likely to need assisted delivery, episiotomy and caesarean section. They also have a higher chance of perineal tearing, post-partum haemorrhage (blood loss) and postpartum infection. Babies are also more likely to show distress in labour, meconium in the amniotic fluid, lower Apgar scores and need time in NICU.
As well as OP other factors that can result in malposition are asyncliticism (a tilt to a baby’s head in late labour) and compound arms (up above the head)
Recent research indicates there is no ‘ideal’ birth position. But OA babies (with their backs to a mother’s front) are more often flexed (head tucked) which presents a symmetrical and smaller circumference onto the cervix. This leads to less prolonged labour and riper cervix.
Whether a malposition is a problem will depend on many factors-
- Pelvis shape/size
- Uterine ligaments
- Baby size
- Baby position (this can also encompass flexion (chin tucking) and arms above the head
- Mothers health in pregnancy (diet and exercise)
- Mothers mobility in labour
- Mothers pain relief in labour
Can we do anything about malposition in labour?
I addressed this in my latest post here:
There is a body of evidence that maternal mobility in labour improves outcomes and may aid rotation. More research is needed that can adequately measure maternal mobility in labour and interventions that match the multifaceted practices that midwives and doulas use to support women with prolonged labour or suspected malposition.
Women may want to mobilise in labour but feel restricted by social/cultural expectations (for example the use of the bed in the maternity room)or restricted by the technology being used (CFM, drip).
Comments on facebook about the topic have so far included:
“I think we should change the language. Maternal mobility is not important to women. It is essential to the process of birth. Birth is not able to process as well. We don’t say ‘mobility is important to men when having sex’ or ‘mobility is important to people emptying their bowels’. Saying it is important to women means it can be overridden by welfare of the baby. Suggest Margaret Garrett ‘dynamic positions’ book to anyone who thinks it is nice but optional.”
“Restricting mobility is a dangerous, and unproven, intervention. Spontaneous positioning is the NICE standard of care for ‘normal’ births & should be for all births. It is a human right. Great topic! Emerging evidence for upright breech birth | The midwife, the mother and the breech
SUGGESTED QUESTIONS FOR TWITTER DISCUSSION
- Should midwives tell women the position they believe their baby to be in antenatally?
- Can antenatal maternal posturing effect fetal position and outcomes?
- Can maternal posturing in labour effect fetal position and outcomes
- How can midwives and birth partners best support women with malpositioned labours for comfort and to improve outcomes?
- Do midwives and doctors facilitate or hinder movement in labour?
- How can we support high risk women to be mobile in labour? What about telmemetry and pool use/VBAC
- Should pool use be promoted to increase mobility?
- How does birth room environment design effect mobility?
- Does malposition make it harder for women to move in labour due to pain? How can we support them?
I will post a second blog post to summarise the twitter discussion after Friday.
Reply to Catie Mehl of Columbus Birth & Parenting and Angela Horn from Tuscon doulas recently published blog posts about malposition.
Prevalence of OP prior to labour
Up to approx. 30% of babies are OP before labour begins.
Some studies have found that fetal position before labour does not affect birth outcome but others have found the opposite, in one study occipital position was found to be a factor in predicting successful induction with cervical length being longer in OP positions prior to induction.
Around 80% of babies that are OP before labour begins, will rotate in labour
But the longer a baby stays OP in labour, the more likely they are to stay that way.
The deflexion associated with OP may be more important than the fetal position.
Malposition effects labour progress
Persistent OP is associated with prolonged first and second stages of labor and augmentation [5-7]
Malpositioned labours significantly more often cross the partogram action line
Malposition effects maternal and fetal outcomes
The incidence of persistent occiput posterior position was associated with significantly higher incidences of induction of labor, oxytocin augmentation of labor, epidural use, and prolonged labor
Maternal movement in labour improves birth outcomes
Can maternal position changes in labour effect rotation from OP to OA?
Most intervention studies using maternal position to try to rotate babies from OP to OA have been unsuccessful[9 11] although studies have tended to be for short durations (-10 minutes), and include participants that have an epidural (approx. 90%)
One study has been successful in effecting rotation from OP to OA using maternal movement. The authors conducted an observational cohort study of women in Padua, Italy having their first baby. They grouped women into Group-A when they spent more than 50% of their labour in recumbent position (supine or lateral) and in Group-B when they preferred an alternative position (upright, squatting, sitting on the ball, or “on all fours” position) the OP rate at the start of labour was comparable in two groups with 40.6% in Group-A and 36.5% in Group-B.
A strong significant difference was found in terms of delivery outcome.
CS was necessary in 27 patients: 46.4% in Group-A compared to the 12.3% in Group-B.
Significant differences in terms of OP persistence at delivery were also found in those delivering vaginally: in Group-A patients, OP persisted till birth in 39.6% of the cases while in Group-B only in 28% of the cases
Other evidence for benefits of maternal movement in the first stage
Upright positions increase contraction strength. Women labouring in upright, non-recumbent positions have fewer POP deliveries, shorter labours and lower rates of assisted deliveries and CS
Sims’ posture on the same side as the fetal spine has been recommended to enhance rotation from posterior to anterior
Prince of Songkla University Cat (leaning over back of bed at 60 degree angle on knees)and upright positions together with music reduced the duration of active phase of labour and labour pain in primiparous women compared to oxytocin
Cochrane review: Maternal positions and mobility during first stage labour-“Walking and upright positions in the first stage of labour reduces the duration of labour, the risk of caesarean birth, the need for epidural, and does not seem to be associated with increased intervention or negative effects on mothers’ and babies’ wellbeing.”
Other evidence for benefits of maternal movement in the Second stage
Any upright or lateral birth positions compared with supine or lithotomy positions have been associated with reduced duration of second stage of labour, reduction in operative delivery, reduction in episiotomies, reduced reporting of severe pain in the second stage, fewer abnormal fetal heart patterns
“Use of the supine position is associated with negative maternal, fetal, and neonatal hemodynamic outcomes. Despite the persistence of the use of recumbent positions for birth, the evidence supports the merit of upright positions. “
Kneeling squat position significantly increases the bony transverse and anteroposterior dimension in the mid pelvic plane and the pelvic outlet
In a study using MR obstetric pelvimetry an upright birthing position significantly expands female pelvic bony dimensions, suggesting facilitation of labor and delivery
Women with epidurals that change position (every half hour from hands and knees, sitting etc in the passive part of second stage (giving time for the head to come down) and push in a lateral position with the upper hip abducted had greatly reduced assisted delivery rates (19.8% vs 42.1%) higher rates of intact perineum ( (40.3% vs 12.2%), lower episiotomy rate (s (21.0% in vs 51.4%) and time actively pushing, without incurring any other adverse maternal or fetal outcomes. Peanut balls have also been found to improve outcomes for women with an epidural. 
Women prefer freedom to move in labour
Freedom to change positions in labour has been identified as integral to a feeling of control and the management of pain in labour, due to the physical and psychological benefits
Women have described being in more control over their pushing in the second stage when they were in an upright position compared to a supine position
Is operative birth necessary?
In a review of >225 thousand birth records in the United states (2002-08) half of Caesarean Deliveries for dystocia in induced labor were performed before 6 cm of cervical dilation. Among intrapartum CDs, approximately half were performed for ‘failure to progress’ or ‘cephalopelvic disproportion’.
It has been reported that most cases of reported cephalopelvic disproportion (CPD) result from malposition of the fetal head within the pelvis (asynclitism) or from ineffective uterine contractions. True disproportion is an unlikely diagnosis because two thirds or more of women undergoing cesarean delivery for this reason subsequently deliver even larger newborns vaginally
Could we reduce intervention for dystocia and malposition with more time?
A review of the evidence relating to dystocia found that current understandings rest on outdated definitions of active first stage of labour, its progress and on treatments without a strong evidence base. These include the cervical dilatation threshold for active first stage, uncertainty over whether a reduced rate of dilatation and reduced strength of uterine contractions always represent pathology and the effectiveness of amniotomy/oxytocin for treating dystocia
It has been suggested that one of the ways to safely prevent primary caesarean deliveries is to increase the active phase of labour start to 6cm and the safe duration of the second stage to at least 2 hours for women having a second or subsequent baby and 3 hours for women having their first baby. or longer with an epidural although the safety of this is contested by some. 
Obstructed labour mostly caused by malposition (and often labelled as CPD) is common in lower income countries and has a high rate or maternal and fetal mortality and morbidity. More needs to be done to prevent and resolve malposition in situations where safe obstetric intervention may not be feasible to save mothers and babies lives and futures
Women in Low and middle income countries (LMIC) are described as having three delay to obstetric care. (1) deciding to seek appropriate medical help for an obstetric emergency; (2) reaching an appropriate obstetric facility; and (3) receiving adequate care when a facility is reached
Maternal and fetal morbidity and mortality is often due to this delayed treatment.
Prolonged obstructed labor can result in fistulas. Because obstetric fistulas are caused by tissue compression, the time interval from obstruction to delivery is critical. Women may not deliver in health care facilities if they do not meet their needs. (this includes the need to move around in labour and use upright positions to birth in, which may be discouraged in the hospital setting) There may be transport and cost implications or Beliefs that problems in labor arise from disturbances in the social environment (and may be caused by actions of the mother) rather than as simple problems of obstetrical mechanics 
Even after arrival at a health facility mean waiting time for women admitted with complications was as much as 24 h before treatment.
Barriers and facilitators maternal movement in labour
Barriers to maternal movement in labour include: (1) lack of space, (2) inadequate support, (3) use of unwarranted debilitating technology, and (4) movement restricting pain relief
Difficulty in conducting research relating to maternal movement in labour, which is often dynamic and needs to be directed by the woman, means that amassing strong evidence of the efficacy of maternal movement to resolve malposition is complicated. Cultural influences and provider influences also effect choice of maternal position. [36 37]
Fathers with a partner having an upright birth position were more likely to have had a positive birth experience, to have felt comfortable and powerful compared to spontaneous vaginal births where women adopting a horizontal birth position
Malposition’s are the root cause for much of the morbidity and mortality and unexpected intervention in labours worldwide. There is a body of evidence that maternal mobility in labour improves outcomes and may aid rotation. More research is needed that can adequately measure maternal mobility in labour and interventions that match the multifaceted practices that midwives and doulas use to support women with prolonged labour or suspected malposition.
Women may want to mobilise in labour but feel restricted by social/cultural expectations (for example the use of the bed in the maternity room) or restricted by the technology being used (CFM, drip).
Doulas and midwives can help to facilitate women’s choices by:
- Antenatal education that provide women and their partners practical experience of maternal positions that can facilitate labour and birth
- Discussing the barriers and enablers of maternal movement
- Practical support in labour if technology is needed (suggesting mobile telemetry as a possibility if available, holding monitors in place while women use birth balls or change position with CFM)
- Suggesting movement changes in labour that might aid women’s comfort or rotation
- Suggesting the use of a peanut ball if women have an epidural or need to rest in a recumbent position
- Suggesting position changes in the second stage (particularly if there is a delay or little change in descent)
- Rebozo can be a useful tool when women have difficulty moving (due to exhaustion, pain, pain relief or technology that restricts movement)42]
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Catie Mehl of Columbus Birth & Parenting and Angela Horn from Tuscon doulas recently published blog posts about malposition.
Does baby’s position matter in labor? (Part 1 and 2)
These two women presented on this topic at the 2015 ProDoula Instilling Strength Conference. Their presentation, “OP Babies: A Real Pain in the Ass,” examined common misunderstandings of OP babies and back labor and examined current body of research on these topics.
I would argue that the post might have benefitted from some literature searching support as there are many more studies looking at malposition and posterior presentation that have been published in the past twenty years (a quick search on google scholar shows these number into the thousands) than the twenty they read.
In Part 1 (Catie Mehl of Columbus Birth & Parenting) states:
You can’t prevent a posterior baby and start and stop labor is not because baby is OP
There have been few studies that directly looked at the association of fetal position and length or prevalence of prodromal labour. We do know that women that present to their chosen place of birth before active labour are more likely to go on to have more interventionsand prolonged latent phase (as well as PROM) has found to be a predictor of failed induction.
I have previously discussed this in my blog post here:
An OP position might not stop someone going into labour but it is associated with prolonged pregnancy and we also know that lack of fetal head engagement predicts prolonged pregnancy. [4 5]And that fetal head above the inter-spinal diameter and poor fetal head-to-cervix contact are associated with dystocia in labour. Descent of fetal head is correlated to dilatation of the cervix, and cervix dilatation < 4 cm at admission was associated with an increased risk of dystocia. Women admitted with little cervical dilatation may have unbearably painful contractions. High risk of dystocia in women admitted in early labour has also been found in many studies 
As the blog author states, OP babies tend to be deflexed and another study by Ashour et al. found that in women undergoing induction of labour, prediction of outcome can be provided by determining sonographically the preinduction cervical length, occipital position and degree of flexion of the head which were superior to Bishop score in predicting successful induction.
So this means that OP (and other malpositions) effect flexion and fetal head engagement which can lead to prolonged pregnancy and long latent phase/prodromal labour which is all in turn associated with longer labour more intervention in labour, failed induction, instrumental and CS delivery.
The authors then go on to state: “There is a belief that a person can prevent an OP baby by maintaining specific postures and avoiding others during pregnancy.”
I would agree that the evidence supporting the beliefs that OP is always a problem in labour and is also the only malposition that can effect starting labour and progress of labour is false.
My own position is that whether a malposition is a problem for an individual diad will depend on many factors-
- Pelvis shape/size
- Uterine ligaments
- Baby size
- Baby position (this can also encompass flexion (chin tucking) asyncliticism and arms above the head
- Mothers health both pre pregnancy and in pregnancy (diet and exercise)
- Mothers mobility in labour
- Mothers pain relief in labour
There is no one ideal position. Flexion (which can be effected by fetal position), asyncliticism (Asynclitism is one of the most frequent malpositions of the fetal head, occurring during both first and second stage of labor. Any fetal head position may be associated. OT position is frequently associated with asyncliticism. If the fetal head does not rotate at mid pelvis (spines) to OA or OP this may lead to deep transverse arrest) compound arms, fetal size and position (of both head and trunk) can all effect labor.
There is also little current evidence that it is possible to prevent malposition prior to labour (and as the authors state, the majority of malpositioned babies, rotate and can be born vaginally). Although we do know that the longer a baby stays in a malposition in labour, the more likely it is for them to stay that way. but…
“no evidence of effect” is not “evidence of no effect”
The evidence for maternal posturing in pregnancy to prevent malposition is currently weak. Is this because the right studies haven’t been done yet? Many of the studies finding no effect in pregnancy randomised women to interventions like Hands and knees rocking with pelvic rocking from 37 weeks (for 10 minutes twice daily ) had no effect on POP or outcomes and a Cochrane review concluded that use of hands and knees position for 10 minutes twice daily to correct occipito-posterior position of the fetus in late pregnancy cannot be recommended as an intervention
Those of us that work with women with malposition in pregnancy might see these interventions that have been studied as too little to change outcomes.
There is evidence of the benefit of general fitness in pregnancy on improving outcomes, and also birth ball use (it has been postulated that vigorous circles on the birth ball may aid flexion of the fetal head). A physical exercise program during pregnancy is associated with a shorter first stage of labor
I agree that the evidence is not strong that back pain in labour is due to fetal malposition (at least not always) but excessive pain, especially in early labour is associated with dystocia (which is associated with malposition) and more frequent breakthrough pain during epidural analgesia is common in dysfunctional labors  a recent study found that mothers who experience high levels of pain during pregnancy (lower back and pelvic pain which the authors postulate may be due to occurrence of malpositioning of the fetus during pregnancy.) are at increased risk of complications during labourand the authors go on to say that further investigation into the role of pain during pregnancy, fetal position and birth outcomes is necessary.
There is a large body of evidence that malposition effects women’s pregnancies, and can lead to pain in pregnancy, prolonged pregnancy, longer pre-labour and birth outcomes. There is currently little research that has found evidence of an effect of interventions on preventing malposition. OP is not the only malposition that can effect pregnancy and labour outcomes this is partly due to paucity of rigorous studies that use the range of methods currently being utilised by midwives and doulas..[18-21]. There is evidence for exercise in pregnancy to improve birth outcomes and reduce length of labour, pain and need for augmentation, assisted delivery and CS
I will address Part 2 of the blog (Does baby’s position matter in labour and can we do anything about it?) in a subsequent post
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