How Practising Yoga Can Help Women Have a Straightforward and Less Painful Birth

Sarah Oxley May 2014

ELECTIVE

HOW THE PRACTISE OF YOGA CAN HELP WOMEN HAVE A MORE STRAIGHTFOWARD AND LESS PAINFUL CHILDBIRTH EXPERIENCE

How practising yoga can help women have a straightforward and less painful birth

Introduction

The discussion will be in two parts; the first will explore what causes labour pain and the second, will look at how practising yoga can reduce it. It will draw off both my experience of going through three labours and the years I have worked as an antenatal and yoga for pregnancy (YFP) teacher for the National Childbirth Trust (NCT).

The causes of labour pain

To get a better understanding of what causes labour pain, it is important to firstly, outline how labour works (i.e. the physiology of labour). The process of labour is involuntary; we cannot control it (although we can influence it as we will see later). All bodily involuntary processes are controlled by our primitive brain. The primitive brain begins labour through the sustained release of a combination of three hormones: oxytocin, endorphins and adrenalin.

Oxytocin is the key driver of labour as it is the hormone which stimulates the uterine muscles to contract. It is these contractions which drive all three stages of labour (the opening of the cervix in the first stage; the ‘ejection of the foetus’ in the second stage and the ‘ejection of the placenta’ in the third stage). Oxytocin is fondly called the ‘love’ or ‘bonding’ hormone, as it is allows us to fall in love, stay with a partner, make love, experience orgasms, create new life and enable the mother, father and baby to ‘bond’ after the birth. It is also called the ‘shy’ hormone as it will only be released when the body is in a relaxed and calm state (known as the parasympathetic state). Labour will only begin therefore, if the environmental conditions are suitable to allow oxytocin release. Such conditions are usually in areas where it is quiet, undisturbed, and dimly lit as it is in these areas where the mother will feel safe, secure and calm. Think about the last time you made love. Most people do not do so in environments where there are bright lights, lots of disturbance and noise!

Endorphins contribute to the body’s own pain relieving system in that they diminish a person’ s perception of pain and can have a sedatary affect. High endorphin levels can alsoproduce an altered state of consciousness that helps with the flow of the labour process, even when it is long and arduous. Endorphins and oxytocin are closely linked in that high levels of oxytocin produce high levels of endorphins.

Adrenalin is actually a natural antagonist of oxytocin but is required at a certain level to help the mother cope with the physical demands of birthing a baby (childbirth is often compared to running a marathon in terms of its energy expenditure). Second stage (when the baby is pushed down the birth canal and out into the world) is more physical than the first, so adrenalin levels naturally rise as first stage ends and second stage begins. Once second stage is complete the levels will drop enough to get the mother to the end of third stage.

The physiological process is the same for all mammals (including humans). Discomfort or ‘labour pain’ occurs if this process is interrupted by the stimulation of what is known as the fight/flight response or sympathetic nervous system (Odent 1994, Dick-Read 1940 – see appendix A). If a threat or danger is detected, fear will cause the primitive brain to take steps to slow down or stop labour, so that the mammal can fight or flee. This makes perfect biological sense, as a mammal will not be able to protect herself effectively if labour is still in full force. The fight/flight response is initiated through a significant rise of adrenalin levels. As mentioned, adrenalin is an antagonist of oxytocin, so once its levels rise oxytocin levels fall. As oxytocin levels fall, endorphin levels soon follow suit. Together, these factors can cause a rise in labour pain because:

To help the body fight or flee from the danger blood is diverted to the brain and the outer limbs and away from all other muscles including the involuntary muscles of the uterus. If a muscle does not get enough oxygen, it will tire out more quickly due to a build-up of lactic acid (a by-product of a working muscle).
As the hormone levels to drive labour drop (oxytocin) and hormone levels to stop labour rise (adrenaline) there ends up being a degree of conflict between the uterine muscles which action labour and the uterine muscles which shut down labour. Any further contractions will be a lot more painful and uncomfortable as a result of muscle tension generated by this conflict
The drop of endorphin levels will mean a significant reduction in their pain killing effects, meaning that pain perception will change also.

Within the normal physiology of labour, the fight/flight response is temporary, lasting only until the danger or threat has been dealt with (a few minutes). With the reduction of fear and stress, the body will switch off the fight/flight response and once more move into parasympathetic state where labour can resume once more.

Humansare different to other mammals in that we have the ability to intensify and prolong our fight/flight response. This is one of the main reasons as to why we tend to experience more painful and problematic labours than our mammal cousins (Dick-Read 2004, Odent 1994). This unfortunate ability is the result of the influence of part of the brain called the neo-cortex. Compared with other mammals the human neo-cortex is the biggest part of the brain. It is highlyspecialised and sophisticated. It is responsible for everything which sets us apart - our intellect, our behaviour, our ability to talk, reflect, analyse, rationalise and process sensory information. It is the part of the brain which we use the most and it has the ability to influence and disrupt other areas of the brain.

As we have seen with wild mammals, the primitive brain will respond and take action against ‘real’ threats of danger. Once the danger has passed, labour resumes as normal. With humans, the primitive brain will not only respond to a real threat but also to ‘imagined threats’ generated by the neo-cortex. The trouble with mentally made up threats, because the fear is not concrete (‘real’), it cannot be easily eradicated. This means that the body will be in danger of staying in the fight/flight response for prolonged periods of time. If this happens, the body may fall into what is known as the fear/tension/pain cycle (Dick-Read: 2004). The fear generated and maintained by an overstimulated neo-cortex, causes tension in the muscles of the body; more tension generates more pain; more pain generates more fear which generates yet more tension which generates more pain. It is this which causes women to suffer a lot more labour pain and unfortunately once in the cycle, it is very difficult for women to break free from it.

‘Midwives know the detrimental impact of fear and stress on labour and if this cannot be reduced or alleviated, the difficult complicated labour and birth the woman was dreading can become a reality. Women with fear of birth have longer labour and are more likely to require interventions including caesarean section.’ (Adams et al 2012 cited by Butcher 2014:21)

Exactly how much labour pain a woman may endure during labour will depend purely on the amount of perceived fear and anxiety she has generated,processed, and stored in her mind (neo-cortex). If the influence of fear is strong as she enters labour, the fear/tension/pain cycle will be right initiated from the start.

The current childbirth culture unfortunately contributes to the sad fact that most women are frightened of giving birth. Right from the word go women are subjected to medical check-ups, tests and routine scans to make sure everything is ok. She is given a whole list of things she can and can’t do, from exercise to eating habits. She is told about possible risks and things which may go wrong. Away from the maternity clinics the bombardment of negative sensory information continues in the form of books, the internet and television. Childbirth is often portrayed as a risky and unpredictable event and only manageable if the women rely solely on obstetric help and as much medicalised pain relief as possible (Kitzinger 2001, Robertson 1994). Furthermore, dramatised medical births are often seen with the woman lying passively on the bed doing what she is told. This further disempowers women’s confidence in giving birth, as it implies that pregnancy is an illness and when it is time, they are better off behaving like patients and letting the ‘professionals’ birth their baby for them. Ironically, women who do labour lying down, will experience even more pain due to the fact that such positions do not support the physical process of labour. Childbirth is more straightforward if the women stays upright, forward and open (NCT professionals call these UFO positions) as these positions anatomically support the uterus, accessory muscles, the baby and the pelvis (Balaskas 1989, Robertson 1994, Allahbadia 1992). Go against this and labour pain increases due to a number of factors (please see appendix B for details) ensuring the fear/tension/pain cycle remains ever present. So, it can be seen that negative portrayals of childbirth along with the reliance of modern obstetrics reinforce feelings of fear and anxiety towards childbirth (Campbell 2010).

During labour itself (even, if women start in the right frame of mind), fear can be easily triggered if the neo-cortex is stimulated. This can easily be done through the simple action of a midwife or health professional asking questions. To answer the woman must use her neo-cortex. This action not only disengages her from the cues of her primitive brain but also invades her private space. Fear increases as a result and if it remains the fear/tension/pain cycle will be triggered.

So, it becomes clear that in order for women to get through labour with the minimum amount of pain they need to develop the tools to avoid getting trapped in the fear/tension/pain cycle. To achieve this,women must learn how to keep their bodies in a parasympathetic state and avoid the negative influence of the sympathetic (fight/flight) state. As the influence of neo-cortex is the main instigator and driver of the latter, women need to learn to control the power and domineering effect of this part of the brain. This is where the practise of yoga can really help.

Yoga: the perfect childbirth partner

As a result of using yoga methods during my own three labours and my experience of running both NCT standard antenatal classes and YFP classes, I am a firm believer that yoga is a natural partner for childbirth. Comparing the women’s labour experiences after attending standard antenatal and YFP classes, women who attend the latter do report having more straightforward and less ‘painful’ labours.

Yoga works simply because of its holistic approach to health. Yoga is not just a physical exercise, but a path of personal development which works ‘on all aspects of the person: the physical, vital, mental, emotional, psychic and spiritual,’ (Saraswati 2013:1). Yoga philosophy calls these aspects of a person the five ‘sheaths of existence’ or koshas. Yoga means union; its practice works towards harmonising the relationship between our non-physical aspects: the pranayama (energetic), manomaya (mind), vijnanomaya(wisdom) and anandamaykosha (bliss) and our physical aspect (our flesh and blood or annamayakosha).

By learning about the koshas, women are taught not only how to stop ‘living in their heads’ (under the influence of the neo-cortex) but also how their ‘head’ influences how their body feels and vice versa. They learn that the mind is not separate from the body – they are intimately related and it is this knowledge that will empower women to renew their trust in their own ability to give birth. At the end of the day getting through labour is both a physical and mental feat and a woman’s perception and experience of pain is greatly affected by her state of mind (Campbell, Whitehead 2008, Pert 1999 cited in Dinsmore-Tuli 2006:111).

The pathway to harmonising the body with the mind (the physical with the non-physical) is achieved through working with the breath. The breath is the foundation of all yoga practice: without it, there is no yoga and no life (for that matter). It is how we take in energy or life-force (otherwise known as prana). The life-force we receive flows between the physical and non-physical koshas via the pranayama kosha. In other words the pranayama kosha is the bridge which connects our physical and non-physical layers. The way the prana flows between all five koshas affects how harmonious the link is between the physical and non-physical layers. In other words the way we breathe, affects the mind-body system (St. John 2009); how we feel physically affects how we feel mentally and vice versa.

‘The breath is the link (bridge) between our physical experiences and the energy which determines the nature of that physical experience.’

DinsmoreTuli (2008:4)

When we are fearful or anxious or our minds are jumpy the breath becomes erratic and shallow. When the mind is at peace, the breath is deeper, calmer and slower. The practice of yoga works to improve our relationship with the breath. In YFP classes, women are not only taught how to breathe properly (diaphragmatic rather than shallowly from the chest) but how to breathe mindfully. The different components of a typical class (pranayama, asana, deep relaxation, sankpala) invite women to work with the breath in a variety of ways. It is this regular, varied exploration that teaches women all the ‘tools’ they need to have a better, less painful birth. Each will be explored next.

“By learning to acknowledge the naturally occurring rhythms of breath, learning to breathe fully and then learning to use the breath to release and to slow physical rhythms, you can acquire a heightened awareness of the needs of the body.”

Dinsmore-Tuli 2008:9

Pranayama (breathing exercises)

Pranayama (yoga breathing exercises) teach women how to control and influence their breath. As mentioned, the process of slowing down and deepening the breath helps to calm and soothe the mind. As a result ‘stress is dispelled and a sense of peace takes its place,’ (Saradananda: 2007).

During pregnancy, especially for the first time women will go through many emotions. The practise of pranayama offers a way of channelling and releasing the effects of these emotions. As Balaskas (1994:64) notes,‘usually after such a release, you will feel relieved. It is as if the earth acts like a sponge, absorbing tension as soon as it leaves your body, leaving you calm and comforted’. Regular practice goes a long way to help women start labour in a positive frame of mind, less influenced by fear or anxiety. I have seen the healing power of the breath a few times within the space of a yoga class. One recent event occurred in December 2013. One client, after our closing pranayama which included a focus on the baby, burst into tears and ran out of the hall. Once she returned, we talked. I learned that it was in that ‘space’ that she accepted that she was actually going to have a baby. “The tears came from nowhere; I really shocked how overwhelming it was and how frightened I am about the birth.” I put this down to the fact that our modern lives are so busy that many women just do not have the opportunity to take in the changes that are happening day by day. She is now only a month away from labour and has been attending classes since she was 13 weeks pregnant. The change in her persona is amazing to behold. She started classes as a very timid, unsure, frightened young lady and has turned into a confident, assured mother to be.

During labour itself, the practise of pranayama helps women to cope with the flow of contractions. Pranayama practise in YFP classes (appendix C) focuses on extending the exhalation. In physiological terms there is a natural link between the heart rate and the exhalation, the heart rate beats more slowly during the exhalation than the inhalation (Coulter 2001 cited in DinsmoreTuli 2006:X). The slower the heart beat the more likely the body will remain calm and relaxed, helping the body remain in the parasympathetic state and consequently reducing labour pain.

Breathing techniques introduced in regular antenatal classes should not be confused with the practice of pranayama. Such techniques, unless they feel natural and instinctive for the women using them are of benefit during labour as they will feel forced. This forcing of the breath may upset the blood chemistry (triggering the fight/flight response) making labour harder and more stressful (Robertson 2002, St John 2009).