When women become pregnant a massive amount of change occurs. These changes are under the influences of hormones; stimulated, secreted, and received, in fine balance to moderate women’s systems and enable the pregnancy to continue and thrive.
Prolactin and progesterone aid early implantation by providing a lush uterine endometrium in which to reside (Blackburn, 2003; Douglas, 2011), nitric oxide and progesterone renders the uterus unaffected by contractile stimulus, oxytocin, prostaglandins and oestrogen then bring and maintain contractions (Abbas, Monaghan, & Campbell, 2010; Blackburn, 2003), and prolactin and oxytocin enable breastfeeding (Wall, 2009).
Physical changes occur as the growing pregnancy and fetus are sustained and nourished: the circulating plasma volume increases up to 40%, the respiratory system increases volume and flow, the urinary system increases filtration, pelvic ligaments and joints relax under the influence of relaxin and breasts enlarge and commence lactogenesis (Blackburn, 2003; Pairman, Pinkcombe, Thorogood, & Tracy, 2008; Stables & Rankin, 2011).
The maternal brain adjusts to the needs of the pregnancy and preparation for childbirth: stress and immune responses are muted to protect the pregnancy, and keep homeostasis intact whilst these changes are occurring (Blackburn, 2003; Douglas, 2011; Wall, 2009).
To commence labour and birth the baby another finely balanced hormonal/physical process commences. There is still some ambiguity surrounding what exactly what causes labour to commence (Blackburn, 2003; Stables & Rankin, 2011), but it seems likely that interaction between fetal and maternal systems triggers a cascade of hormonal responses that set about softening of the cervix, and removes the inhibiting factors therein allowing the uterus to respond to contractile inducing stimuli (Abbas et al., 2010; Blackburn, 2003; Douglas, 2011; Wall, 2009).
After birth these hormones remain actively involved in physiological processes that enable mothering, attachment, and nourishment of the infant to occur. Additionally oxytocin and progesterone continue to act on the myometrium, and involution, recovery, and regeneration of the uterine tissue is achieved. Withdrawal of some of these hormones causes a prompt decrease in circulating plasma volume, mostly via diuresis in the kidneys.
Adjustment within the maternal brain follows birth, enabling focus to be on the infant and bonding; in theory a relaxed and enjoyable time under the neurohormonal influence of oxytocin progesterone, and prolactin (Blackburn, 2003; Douglas, 2011; Fernandez et al., 2012; Love, 2014; Pairman et al., 2008; Stables & Rankin, 2011).
At every point across the childbirth continuum anxiety, fear, and stress can have an overarching and detrimental effect on finely balanced neurohormonal biopyschophysical processes (Adams, Eberhard-Gran, & Eskild, 2012; Alder et al., 2011; DiPietro, 2012; Dixon, Skinner, & Foureur, 2014; Douglas, 2011; O’Donnell, O’Connor, & Glover, 2009; Otley, 2011; Sylvester, 2007; Wall, 2009; Williams, 2013).
The focus of this essay will be on fear, anxiety, pain and stress within the childbirth continuum, and midwifery care that can decrease that fear, anxiety, pain and stress, and therefore potentiate a positive experience that empowers women, and results in positive sequelae for both mother and infant: within childbirth and beyond.
When stress is perceived hormones secreted via the hypothalamic-pituitary-adrenal axis mount a response to the real or perceived stressor (Blackburn, 2003; Engelmann, Landgraf, & Wotjak, 2004; Wall, 2009).
The hypothalamus releases corticotrophin releasing hormone (CRH), a panacrine hormone that stimulates the neighbouring anterior pituitary gland to secrete adrenocorticotrophin releasing hormone (ACTH); an endocrine hormone that travels to the adrenal cortex actioning the release of steroid hormones cortisol and glucocorticoid.
These hormones act to elicit a physical reaction to the stressor, enabling it to be met and dealt with, or avoided: fight or flight.
Peripherally blood vessels constrict; blood flow and oxygenation is redirected to the large muscle groups, heart and brain.
Respiration rate increases, enhancing oxygenation, pupils dilate, and the large muscle groups prepare for activation (Engelmann et al., 2004; Stables & Rankin, 2011).
The elicited response is comparable to the threat perceived: the greater the threat the greater the response.
This allostatic mechanism lasts until the threat has subsided; at this point, via hormonal feedback systems, the secretion of these hormones subside, and normal activity resumes (Engelmann et al., 2004; Shannon, 2007).
Under extreme and un-abating stress the HPA axis can be skewed, and this maladaptation can result in a state of hyper vigilance, anxiety, and depression (Engelmann et al., 2004).
In pregnancy the HPA axis stress response is muted, although exactly how is not easily elucidated from the literature. Some suggest the levels of CRH and hence ACTH are increased 2–4 fold in pregnancy, due to both maternal and placental sources, thereby seeing the adrenal cortex release increased levels of cortisol, (Blackburn, 2003; Stables & Rankin, 2011).
Others suggest that the presence of oestrogens cause maternal desensitisation to CRH, therefore a decrease in ACTH levels, which in turn lead to less release of cortisol (Esel, 2010). Progesterone and oxytocin are also thought to have a moderating role within the HPA axis (Ford & Ayers, 2009; Lee, MacBeth, Pagani, & Young, 2009; Love, 2014).
Within the vast amounts of literature postulating the exact hormonal response within the HPA axis in pregnancy, what is agreed upon, is that the altered HPA axis and ensuing subdued stress response, is multi faceted, and results in a pregnancy protective environment under normal pregnancy conditions (Blackburn, 2003; Esel, 2010; Grattan, 2011; Pittman, 2011; Shannon, 2007; Stables & Rankin, 2011).
Pregnant women experiencing constant fear and anxiety can be in a constant state of hyper vigilance, and the HPA axis can be further skewed, with the associated hyper vigilance of distress overriding the normal adaptations of pregnancy (Adams et al., 2012; Alder et al., 2011; Engelmann et al., 2004; Otley, 2011; Sylvester, 2007).
This can result in consequences for the fetus.
Recent studies have shown that children of mothers who were depressed were more likely to suffer the condition themselves — whether solely due to genetic susceptibility, or related to the epigenetic influence of the intrauterine environment is yet to be confirmed, but at this stage a combination of the two seems likely (Apter-Levy, Feldman, Ebstein, & Feldman, 2013).
Concurrently it has been mooted that whilst there is a lack of research surrounding what is being called fetal, embryonic, or intrauterine programming, what research there has been is indicating that maternal stress does impact upon the intrauterine environment; thereby impacting upon the physical and neurohormonal outcomes for the fetus (DiPietro, 2012; Douglas, 2011; Dulawa, 2014; O’Donnell et al., 2009; Smith et al., 2011).
Additionally potential links to the development of stress, depressive and anxiety disorders in childhood have been suggested — linked to the intrauterine milieu when the maternal HPA axis is over activated, and to sub-optimal maternal interactions following birth (Alder et al., 2011; Apter-Levy et al., 2013; Brown & Grattan, 2007; Dulawa, 2014; Esel, 2010; Kurth & Davalos, 2012; Nilsson & Lungren, 2007; Otley, 2012; Turner, 2013; Wall, 2009).
More research into this area is warranted.
When women enter labour they do so under the influence of yet more finely balanced neurohormonal changes.
Prostaglandin release increases the sensitivity of myometrial oxytocin receptors, increased 300 fold at term, and the progesterone/oestrogen ratio becomes oestrogen dominant: further increasing responsiveness to Oxytocin, and seeing the uterine quiescent properties of the progesterone dominant environment lifted.
Gap junctions increase, Ca+ ions are freed for action potential, and uterine myometrium is contractile (Abbas et al., 2010; Blackburn, 2003; Pairman et al., 2008; Stables & Rankin, 2011).
Additionally an increased amount of circulating CRH, from both placental and fetal sources, act concurrently to trigger uterine contractions, under the influence of prostaglandins and oxytocin (Blackburn, 2003). Prostaglandins affect the cervix: softening and ripening, and along with oxytocin secreted in bursts from the maternal posterior pituitary gland (Apter-Levy et al., 2013; Lee et al., 2009; Love, 2014; Wall, 2009), acts within the myometrium by enhancing pacemaker and action potentials that result in intramuscular ionic shifts and myometrial contraction (Blackburn, 2003; Stables & Rankin, 2011).
In advancing labour Fergusons reflex sees uterine contractions strengthened and the presenting part of the fetus applying pressure to the cervix, providing feeding back to the maternal hypothalamus and influencing the further release of oxytocin (Stables & Rankin, 2011).
Whilst a degree of coritsol and catecholamines are important in supporting this process and preparing the fetus for extrauterine life, when levels get too high they can inhibit the release of oxytocin (Leap, Sandall, Buckland, & Huber, 2010; Otley, 2011; Sylvester, 2007; Turner, 2013; Wall, 2009), endorphins (naturally occurring pain relief) and CRH: uterine perfusion will decrease, the myometrial contraction will subside, labour will slow, and the fetus can get distressed (Adams et al., 2012; Blackburn, 2003; Flink, Mroczek, Sullivan, & Linton, 2009; Pairman et al., 2008).
Women entering labour experiencing fear, stress and distress can have, via the HPA axis, levels of cortisol and adrenaline that override levels of oxytocin and endorphins: for these women the allostatic physiological stress response to labour will become a pathological distress response.
Research has found that between 6 and 20% of women today have an over whelming fear of childbirth; in particular the pain of childbirth (Adams et al., 2012; Nilsson & Lungren, 2007; Otley, 2011).
Labour is painful: the pain of labour is due to the cervix stretching and dilating, and ischaemia of the myometrium caused by unrelenting contractions. Sensations of pain travel via afferent nerves to the spinal cord where it is dispatched to the brain for perception, and is hence ‘felt’ (Blackburn, 2003; Kulesza-Bronczyk, Dobrzycka, Glinska, & Terlikowski, 2013; Stables & Rankin, 2011; Talbot, 2012).
Pain perception is related to many factors: emotional, cultural, social, psychological (Kulesza-Bronczyk et al., 2013; Lundgren & Dahlberg, 1998; McIntyre, Francis, & Chapman, 2011; Rachmawati, 2012; Talbot, 2012).
There can be a perception of childbirth as dangerous, unpleasant, and wrought with overwhelming pain that will be suffered (McIntyre et al., 2011; Otley, 2011; Talbot, 2012).
This perception is based in society’s views that childbirth is a dangerous affair that women need medicine to save them from: and this perception is in turn is derived from discourse in the media, and shared experiences of labour as acutely frightening situations that are life threatening and terrifying (Martin & Robb, 2013; McIntyre et al., 2011; Otley, 2011, 2012; Talbot, 2012).
The way we view childbirth as a society, and the way we portray birth to each other is important. The pervading view in media that birth is dramatic has an impact on women’s views. Women feel distressed and confused re their role, they feel like they have a standard to live up to: they feel inhibited and in need of performing as per expectation (M. Odent, 2009; Otley, 2012).
The stories we tell each other as women matter as well: we pay more attention to friends and family and to internet blogs than we do to health professionals.
When we hear positive experiences where pain in labour was seen as maturing and strengthening, empowering and releasing, we are inclined to view impending birth as positive, when we hear negative distressed filled experiences we will expect likewise.
In this regard a pervading view of childbirth as negative and unduly painful can be self perpetuating (Bussche, 2007; Leap et al., 2010; Rachmawati, 2012; Sylvester, 2007; Talbot, 2012).
Research has found that women who fear childbirth as something that they will find too painful, will not cope with, and likely to overwhelm them, are more likely to experience this to be the case.
For these women their negative expectations are translated into negative experiences in reality (Alder et al., 2011; Bussche, 2007; Dixon et al., 2014; Flink et al., 2009; Leap et al., 2010; Nilsson & Lungren, 2007; Talbot, 2012). For these women post partum self esteem, and confidence in being a mother to their new baby is undermined (Leap et al., 2010; Nilsson & Lungren, 2007; Otley, 2012; Peterson, 2008).
When pain is feared, seen as an overwhelming threat, and fought, stress responses will ensue: catecholamine levels will rise, endorphin levels will decrease, and the response will override the process of labour (Kulesza-Bronczyk et al., 2013; Wall, 2009): the myometrium will become under perfused, oxytocin will be inhibited and labour will slow (Adams et al., 2012; Blackburn, 2003; Otley, 2011, 2012; Stables & Rankin, 2011; Sylvester, 2007; Wall, 2009).
Related to an under perfused uterine environment the fetus can become distressed (Blackburn, 2003; Talbot, 2012). At this point interventions will be employed to decrease the pain, resolve distress, and enhance the uterine contractions (Fernandez et al., 2012; Francis & Francis, 1956; Turner, 2013): thereby allowing labour to continue.
If the fetus becomes further distressed, or the labour stalls, birth can be brought forth also (Adams et al., 2012; Blackburn, 2003; Pairman et al., 2008).
These interventions will involve the use of pharmaceutical pain relief, or anaesthesia in the form of an epidural, the implementation of synthetic oxytocin to continue the uterine contractions, and ultimately could involve instrumental or surgical intervention for birth (Bussche, 2007; Pairman et al., 2008; Stables & Rankin, 2011; Turner, 2013).
When women accept pain as part of labour, as something positive and bearable, as a sensation synonymous with childbirth and bringing forth life, as something they can cope with and work with, that mindset, with naturally occurring endorphins, can see the pain of labour journeyed in a way that enhances physiological processes (Christiaens, Verhaeghe, & Bracke, 2010; Dixon et al., 2014; Lundgren & Dahlberg, 1998; Nilsson & Lungren, 2007; Otley, 2012; Peterson, 2008; Talbot, 2012).
Progress should ensue and the fetus should remain unaffected by excessive and negative allostatic reactions to pain.
Interestingly, it is not merely deleting the sensation of pain that enables an experience to be felt as positive.
For women who are fearful of labour, and those not fearful of labour, it is sense of self control and self efficacy that relates to a positive experience (Bergstrom, Richards, Morse, & Roberts, 2010; Dixon et al., 2014; Ford & Ayers, 2009; Kulesza-Bronczyk et al., 2013; Lally, Thomson, McPhail, & Exley, 2014; Lundgren & Dahlberg, 1998; Martin & Robb, 2013; Nilsson & Lungren, 2007; Peterson, 2008).
Women that were able to make decisions and remain in control of the experience ultimately reported their birth experiences as positive: whether it was perceived as painful or not.
In a day and age where technology and medicine can manage birth to the degree that pain is masked and contractions are produced synthetically, does it matter whether women enter labour in fear and get saved by medicine, or enter labour positively and empower themselves?
Many would suggest that extreme importance lies in humans being born as near to physiologically naturally as possible (Apter-Levy et al., 2013; Fernandez et al., 2012; Kurth & Davalos, 2012; Lee et al., 2009; M. Odent, 2009, 2012; M. R. Odent, 2013; Otley, 2012).
When labour commences and continues physiologically, the fine hormonal balance is optimal and external interventions are rarely required.
When external interventions are not required, sequelae for mother and baby in the postpartum period are not under the influence of pharmacological remedies, but under the influence of physiological and evolutionally appropriate forces (Blackburn, 2003; M. Odent, 2012; Pairman et al., 2008; Stables & Rankin, 2011).
Oxytocin has a major influence on every part of childbirth, especially labour (and some would now say, on life itself) (Apter-Levy et al., 2013; Brown & Grattan, 2007; Fernandez et al., 2012; Grattan, 2011; Lee et al., 2009; Love, 2014; Wall, 2009). For labour to progress oxytocin needs to release: for oxytocin to flow naturally certain environmental circumstances need to exist.
Oxytocin performs best in a quiet, calm and known environment, and is facilitated by calm support. It is inhibited by loud, light, unknown and threatening milieu (Love, 2014; M. Odent, 2012; Otley, 2012; Turner, 2013; Wall, 2009).
Midwives supporting women in the childbirth continuum, protecting physiological birth in partnership with women (Pairman et al., 2008), can use this research based evidence in the practice they bring to their partnership with women (Informed Consent and Decision Making, 2000; Pairman et al., 2008).
Women should be supported in their own environment, as long as they feel safe and secure in that environment, by kind and calm people that trust the physiological process and the innate power of women to achieve childbirth unencumbered (Bergstrom et al., 2010; Dixon et al., 2014; Ford & Ayers, 2009; Hodnett, Gates, Hofmeyr, & Sakala, 2013; Maputle & Donovan, 2013; M. Odent, 2009, 2012; Peterson, 2008).
They should move as they want and react to their labour as they choose: be it with noise, internal peace and quiet, or directive assistance of others around them.
The use of warmth, massage, and water can offer relief from pain without interfering with the physiological processes (M. Odent, 2012; Pairman et al., 2008; Sylvester, 2007), and can be provided on women’s term — enabling women to remain in control of their body and their experience.
When they do, natural hormonal influences should pervade and labour, birth and an inspired postpartum period should ensue.
And when this happens, babies and children stand the best chance of being well cared for, nourished, and in benefit of a maternal interaction that sets them up to develop a neurohormonal system of their own that is healthy and sustains through generations to come.
Whilst it is known that not all women will travel through labour naturally, what we can extrapolate from the research, is that in making peace with the fear and pain of labour, and by accepting their own ability to journey through labour, for many women the interventions born from the fear and anxiety will be lessened and become unnecessary.
Midwives must work with women before, during and after childbirth, to dispel socially held views of labour as dangerous, threatening and insurmountable, and support women in society, pregnancy and labour to use their own coping mechanisms and inner strengths to travel through labour unassisted by interventions where ever possible.
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