Conquering Tocophobia with Haptotherapy

Tocophobia or severe fear of childbirth is rising in frequency.  More than 6% of women, and some men, experience tocophobia during pregnancy.  This leads to an increase in obstetric interventions including preterm birth, emergency cesarean section, or cesarean section at maternal request.  Severe postpartum fear of childbirth and trauma anxiety has also been reported.

Studies, primarily in Europe, over the past decade demonstrate an increase in evidence that Haptotherapy might be effective in reducing fear of childbirth in pregnancy women.  What is Haptotherapy and is there a way childbirth educators can incorporate aspects into their classes?

Haptonomy is a typical Dutch form of therapeutic assistance therapy discovered by Dutch physiotherapist Frans Veldman, and first used in oncology.  Haptotherapy is the field of application of Haptonomy.  Haptonomy is being in connection with someone in a non-judgmental way.  Practitioners work to establish an environment of acceptance and calm, peace and tranquility so that the client can let go and begin trusting their own inner wisdom.  It involves listening, accepting, sharing.  In some instances, touch relaxation or simply holding hands leads to the calming of the client and activating their inner resources. The goal is for the client to develop inner security, self-awareness and self-confidence.

The most recent Dutch study is examining a standard haptotherapeutical treatment for pregnant women (and their partners)  with severe fear of childbirth, implies teaching a combination of skills in eight one hour sessions. The internet group follows an eight-week internet course containing information about pregnancy and childbirth comparable to childbirth classes. The control group has care as usual according to the standards of the Royal Dutch Organisation of Midwives and the Dutch Organization of Obstetrics and Gynaecology.

Click here to read the full study.

Included are singleton pregnant women with severe fear of childbirth, age >= 18 year, randomised into three arms: (1) treatment with haptotherapy, (2) internet psycho-education or (3) care as usual. The main study outcome is fear of childbirth. Measurements are taken at baseline in gestation week 20-24, directly after the intervention is completed in gestation week 36, six weeks postpartum and six months postpartum. Secondary study outcomes are distress, general anxiety, depression, somatization, social support, mother-child bonding, pregnancy and delivery complications, traumatic anxiety symptoms, duration of delivery, birth weight, and care satisfaction.

Sessions include a getting to know each other opportunity, awareness and presence in pregnancy, identification of cause of fear of childbirth,  desensitization of body anatomy as well as hospital procedures through education, practicing correct pushing techniques, working with contractions and dealing with labor pain, labor rehearsals, and finally introduction to birth of the placenta and first days postpartum.

Haptotherapy has dynamic similarities to childbirth education classes.  One might even call them “old school” childbirth education where educators had the time to take the time to listen to the clients and their partners and confront fears one by one.

They say you cannot go home again, but it looks like we are….with a different name.

The Fetal Biome: The Beginnings of Prenatal Parenting

In 2001, I was reading a book titled Prenatal Parenting.  The author was Dr. Fred Wirth, a staff neonatologist at Reading Hospital and Medical Center in Reading, Pennsylvania. 

Wirth brought to light communication with the unborn child and called the womb the “intrauterine temple of learning”.  He believed in the empowerment of women and that they should take charge of their health care, not only as a means to a more satisfying birth experience, but as an optimal pregnancy and birth outcome catalyst.

“Faith and prayer are pivotal to my belief that you can increase the safety of your pregnancy by taking more responsibility for its outcome.  Thinking you are incapable of handling such responsibility will only work against you.  You must have faith in your ability to do this.”

And why not? Women are creating a wonderful environment both physically and emotionally for this baby.  The “faith” and “prayer” do not have to be religious.  But faith and prayer in a higher power or meditation and relaxation can help alleviate fear – and fear begets tension and tension begets stress hormones, which can have multiple negative effects on the growing baby and the pregnancy.

 

Fear is a huge topic today – with media input such as television views of childbirth and certain books and embellished stories from friends!  Fear of childbirth or tocophobia may include nightmares, panic attacks and psychosomatic symptoms.  The fear may be rooted in the misunderstanding of the pain in childbirth or apprehension in being at the hospital during the birth.  In our society hospitals are the place of illness and death – not the ideal location for pregnancy which is mostly a situation of health and wellness.  Again with the media, we have created a culture of avoiding pain: this medication for a headache, this medication for arthritis, this medication for menstrual cramps – we don’t have time for the pain.  And why should we – just take medication.

Therefore protecting the fetal biome is more than eating the right foods or consuming enough liquid to avoid dehydration.  It is a psychosocial journey of learning about the roots of fear, education on methods of comfort measures for the tension, as well as understanding the mechanism of pain and how to use the pain to the advantage of both the mother and baby.

When the above skill set is in process of being mastered, a powerful emotional bond begins to take place between the mother and child.  As childbirth educators and doulas, we can help mothers establish this reverence for the fetal biome and facilitate prenatal bonding.  What we teach our expectant clients has an impact on their relationship with their baby and may greatly influence the pregnancy.  Focus education not only on the expectant mother or the growing baby but the two as a dynamic dyad where love flows back and forth.

Want to read Dr. Wirth’s book Prenatal Parenting?  There are copies available on Amazon: click here.  And as former US Surgeon General C. Everett Koop said, “Read this book!  You will learn how to improve your birthing experience, as well as the health and happiness of your unborn child.”

The Evidence Says: Nitrous Oxide for Labor & Birth

Each year, Childbirth Today Blog brings a series called “The Evidence Says”.  This series covers major topics discussed in maternity care.  The 2014 Series begins with the topic: Nitrous Oxide.

Nitrous Oxide, or N₂O, has been a common pain reliever for labor and childbirth in Europe, Canada and Australia for several centuries.  First produced by an English chemist in 1772, it was the first anesthetic to be commonly used but was replaced by either and chloroform due to the potency.  Nitrous oxide depresses normal brain function, although exactly how has not been discovered.  It is thought to increase the release of endorphin, dopamine and other natural pain relievers in the brain.  Nitrous also has an anti-anxiety effect, which may help women with tocophobia.

When nitrous oxide is inhaled, it quickly mixes with the air in the lungs.  It then passes into the bloodstream and into general circulation.  The gas then changes to a solution and reaches the brain in approximately 20 seconds.  The amount of gas that reaches the brain depends on the concentration inhaled and how long it is inhaled.  Like other substances, nitrous oxide crosses the

placental barrier and enters the baby’s blood stream.  However, unlike other medications, nitrous oxide does not have to be broken down by the liver and is thus metabolized and excreted rapidly.  Because of this rapid metabolization, the medication does not become concentrated in either the maternal or fetal body. Nitrous oxide is considered safe for mothers, baby’s and care providers when the nitrous is delivered as a 50% blend with oxygen.

The odorless nitrous oxide is delivered via a machine (with mask) that mixes the gas with oxygen in certain percentages.  The gas is only delivered when the machine detects that someone is inhaling into the mask.  The mask reduces wastage and tries to prevent others in the room from experiencing the effects of the gas.  There are various types of machines on the market, however availability is limited in the U.S.   The University of California San Francisco birth center has had their own machines for years, even after some the nitrous oxide machine manufacturers in the U.S. ceased production of the machines, after the surge in popularity of the epidural and other medications used for labor/birth.  It is reported that other U.S. facilities use nitrous oxide including University of Washington Hospital in Seattle, St. Joseph Regional Medical Center in Idaho, Okanogan Douglas Hospital in Washington, and Vanderbilt in Tennessee.  This patient information page appears on the Dartmouth-Hitchcock Children’s Hospital at Dartmouth in New Hampshire – Click Here. The American College of Nurse-Midwives have a detailed position paper on the use of nitrous oxide.

The advantages of self-administering nitrous oxide include increase perception of control, can be used anytime during labor, does not appear to have adverse effects on the baby’s condition at the moment of birth, can be quickly administered and the effects are nearly immediate, effects reverse when inhalation stops, does not require the presence of an anesthesiologist.  While there are few reported complications using nitrous oxide as an anesthetic during labor and birth, nitrous does appear to have more side effects such as nausea, vomiting, dizziness and drowsiness.  Nitrous oxide administration does limit position changes and movement due to the mask being connected to the administration machine and may cause additional complications if used in conjunction with other pain relievers.

More research about the use of Nitrous Oxide for use during labor and birth.  However, at first glance, it does appear to be preferable to narcotics and epidural anesthesia.

References and Resources:

American College of Nurse-Midwives  (2011) Position Statement: Nitrous Oxide for Labor Analgesia. Last access 1/21/14. 

http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000080/Nitrous_Oxide_12_09.pdf

Agency for Healthcare Research and Quality. (2012). Executive Summary: Nitrous Oxide for Management of Labor Pain.  Last access 1/21/14.
http://www.effectivehealthcare.ahrq.gov/ehc/products/260/1230/CER67_NitrousOxide_ExecutiveSummary_20120817.pdf

Baysinger, C.  and the American Society of Anesthesiologists Research Statement (no date)
http://www.asahq.org/For-Members/Clinical-Information/Nitrous-Oxide.aspx#adverse

College of Midwives of Ontario (2012) Position Statement: The Use of Nitrous Oxide at Home Births.  Last access 1/21/14.
http://www.cmo.on.ca/documents/GCMO_C020812_TheUseofNitrousOxideatHomeBirths_Council_FEB82012.pdf

Jones, L. et al. (2012) Pain management for women in labor: an overview of systematic reviews.  Cochrane Database of Systematic Reviews. Mar 14;3.

Klomp, T. et al. (2012) Inhaled analgesia for pain management in labor.  Cochrane Database Systematic Review, September 12;9.

Rooks, J.P. (2011)  Safety and risks of nitrous oxide labor analgesia: a review.  Journal of Midwifery and Womens Health.  Nov/Dec. 56(6):557-65.

Ina May Gaskin addresses Tocophobia

I love Ted Talks and I especially love this one.  Ina May made this during the summer of 2013. Ina May Gaskin, MA, CPM, PhD (Hon), is founder and director of the Farm Midwifery Center in Tennessee. The 41-year-old midwifery service is noted for its women-centered care.

FEAR - contributing to labor interventions and PTSD

It is called tocophobia .  

It affects 1 in 10 women.

And it seems to be ignored by maternity care literature.

Yet, an amazing study done between 2006 and 2007 in Sweden's Karolinska Institutet, shows that psychoprophylaxis does help in some cases.

What is tocophobia?  From the Greek word tokos meaning childbirth and phobos, meaning fear, tocophobia is the fear (irrational) of childbirth.  Women and men can experience tocophobia and can experience a fear of dying, fear of pain, fear of lack of pain relief and fear of deformity of the newborn.  Occasionally tocophobia is culturally associated, such as when negative feelings toward childbirth are passed from mother to daughter or after seeing a film depicting childbirth early in life with no support or educational explanation.

In the medical literature, tocophobia or severe fear of childbirth (SFOC) is seen addressed more in

psychological journals or those from Europe than in the North American continent.  Maternal confidence and self efficacy are common threads in discussions of tocophobia or SFOC.  From the Nethersole School of Nursing in Hong Kong, the author writes that the efficacy-enhancing educational intervention should be further developed and integrated into childbirth education interventions for promoting women's copying ability during childbirth. Not only did the educational intervention promote a woman's self-efficacy but also reduced their perceived pain and anxiety in the first two stages of labour.

Further research in the literature demonstrates that prenatal anxiety was significantly related to self-efficacy for childbirth in late pregnancy, labor pain, number of hours at home in labor and admitting cervical dilation, and interventions used during the labor.


Kathy McGrath demonstrates that fear has its place in birth and new mothers can benefit from it:

Giving birth is meant to shake us right down to our roots so that we come out of it changed and ready to take on the daunting tasks of mothering a new baby. When birth goes well, from an emotional as well as a physical perspective, we come out of it empowered, awed, and humbled. When it does not go well, we can enter motherhood feeling disappointed, disillusioned, and disempowered. The stakes are high.

As childbirth educators and doulas, we need to approach this fear with caution and respect.  Not only does fear of childbirth result in extended length of labor, arrested labors, increased using of induction or augmentation, cesarean delivery, instrumental delivery but SFOC can affect mothers during the postpartum period as well with an increased risk of post-traumatic stress disorder (PTSD).  Fear and lack of control are elements contributing to PTSD.

SFOC is not addressed in the typical office visit.  Childbirth education classes are often discouraged.  Why are women's fears being ignored?  Why do we send new mothers, traumatized by a difficult birth that validated their prenatal feelings of fear, home alone with little or no support?

Give expectant mothers an atmosphere where they can feel safe in sharing their fear(s), where they feel they are heard and not judged.  Acknowledge the fear and share with them psychoprophylaxis!

What is psychoprophylaxis?  Based on a method of preparing women for childbirth with education, psychological and physical conditioning and breathing, psychoprophylaxis soon became synonymous with Lamaze, after Dr. Fernand Lamaze brought the Russian style of childbirth preparation to the West in the mid 1950s.  Quite simply, psychoprophylaxsis (psycho means mind and prophylaxsis means prevention) gives expectant mothers the educational and practical techniques to understand the careful hormonal orchestration of birth and be empowered to use simple techniques to produce effects that are not only healthy for both mother and baby but truly define self-efficacy for birth and the postpartum period.

As Barbara Hotelling so brilliantly put it: 
We once lost touch with a caring model of birth, and we are fortunate to have that knowledge and the availability of that model again. Childbirth education must evolve from the technological curriculum to a physiologic study of how well women's bodies are created, not for being delivered, but for giving birth.

With physiologic birth as our guide, we can reduce or eliminate tocophobia.


References:

Bergstrom M. et al.  Fear of childbirth in expectant fathers, subsequent childbirth experience and impact of antenatal education: subanalysis of results from a RCT.  Acta Obstetricia et Gynecologia Scandinavica 2013 Apr 16.

Harris, R., Ayers S. What makes labour and birth traumatic? A survey of intrapartum 'Hotspots'. Psychology and Health 2012; 27(10): 1166-77.

Hotelling, B. Considerations when using videos in Lamaze Classes.  Journal of Perinatal Education 2012 Summer; 21(3): 189-92.

Hotelling, B.  From Psychoprophylactic to Orgasmic Birth.  Journal of Perinatal Education 2009 Fall; 18(4): 45-48.

Ip, W et al. An educational intervention to improve women's ability to cope with childbirth.  Journal of Clinical Nursing 2009 Aug; 18(15): 2125-35.

McGrath, K. The Courage to Birth.  Journal of Perinatal Education 2012 Spring; 21(2): 72-79.

Rouhe H. et al. Obstetric outcome after intervention for severe fear of childbirth in nulliparous women, a randomized trial.  British Journal of Obstetrics and Gynecology.  2013 Jan; 120(1): 75-84. 

Saisto T., Halmesmäki E. Fear of childbirth: A neglected dilemma. Acta Obstetricia et Gynecologica Scandinavica, 2003 82(3), 201–208