 And then it gives me great pleasure to introduce our speaker for session five, Tracy Donaghan. Tracy Donaghan is a registered midwife from Ireland. She is the author and founder of the Gentle Birth App, a digital positive pregnancy birth companion with a special interest in emotional wellbeing in pregnancy and the impact of mindfulness on maternal and infant health. Tracy has been a guest speaker in Brazil, Ireland, the UK and the USA. Also a Dona International approved birth doula trainer. She facilitates the training of professional birth partners internationally. She has also published four books. The Irish Better Birth Book, Gentle Birth, Your Positive Birth Begins Here. The Irish Cesarean and VBAC Guide, Unmindful Pregnancy. Her vision is to create an international community of conscious, expectant parents who will lead the evolution of a new generation of a more conscious, compassionate, joyful society. Tracy lives in Texas with her two sons and her husband. Thank you so much. We are so honored to have you speaking with us today. Thank you, Tracy. Hi, everybody. Thank you so much for the lovely introduction, Jane. Yes, I am an Irish registered midwife and currently living in Texas. So, before I begin, I want to tell you a little story. A few years ago, during my training, a labouring person came into the units thinking they were in labour. On examination, they were found to be fully effaced and about one centimetre dilated but not having regular contractions. So, it was suggested that they go home. But mum had about a 30-minute drive home and her history was that she'd had two previous precipitous births. So, she really wanted to stay. She felt like things were going to kick off at any moment. So, we got her settled into a little six-bedded antenatal ward and she took out of her labour bag a little handheld gaming console what was then a PlayStation DS. And she seemed very comfortable and never asked for anything. So, I would kind of check in with her and we all figured that she'd be there for the night. A couple of hours later, we hear her shouting, the baby's coming. And the baby was born safely on the bed moments later. So, we were more shocked than the parents. Needless to say, the labour ward manager wasn't thrilled. And when I talked to the mum, she said that she'd done something similar with her last baby. She played a game and it took her mind off the pain. So, I kind of just filed that away in the back of my brain. And I'm sure some of you listening in tonight have had kind of odd experiences like this. So, I guess let me first address the title of this session. Labour pain, it's all in your head. So, of course, all pain is real. This is not about dismissing or trivializing women's very real experiences of pain in labour. I just think we can do something more for them. So, we're going to take a look at how we can change that experience with the latest in pain research. And starting off with the fact that pain is actually made by the brain. It's responding to the information received by the senses. And based on this information, previous experiences, and what mum has learned about birth, that'll influence how much pain that person feels in a healthy, normal labour. So, basically, the brain is making an educated guess about how much danger it believes you're in, and that will either increase pain or reduce it. So, throughout today's session, I'm going to share some insights with you from some of the leading neuroscientists and pain experts, such as V.S. Ramachandran, Larimer Moseley, and others. So, I've been fascinated by the maternal brain for forever. But I have to say what I learned on the brain in my midwifery training was very limited. I learned lots about hormones. I learned lots about normal physiology and the massive adaptations that the body goes through, but very little about the massive adaptations that the maternal brain goes through. And the majority of women experience some level of pain during labour. But, as you know, not everyone experiences it the same way. There's a huge variation from someone feeling just pressure to orgasmic sensations to the worst pain ever. And that's despite baby size. So, today, I'm going to guide you through some of the new pain signs and potential cognitive strategies for coping with labour pain that may be a way to improving physiological birth rates, specifically in hospital. Standard childbirth education just hasn't evolved with the science of pain education or psychology. And data suggests that when learners have basic pain literacy through an educational intervention, midwives and childbirth educators can help parents intentionally hack processing networks of the brain to reduce the need for analgesics in labour, especially if the birthing person wants to avoid medication. So let's quickly look at what we're going to cover tonight, today, wherever you are in the world. We're going to look at opposing approaches to pain. Quickly look at the different pain theories. Why is it that labour is so painful for so many? Pain and the brain factors influencing pain perception in labour, some of the new research and implications for childbirth education. I'm not going to spend any time on risks to medication in labour. I think we can all recognise that physiological birth matters, but it is close to impossible to have a physiological birth in a busy maternity unit. And that's where most women, especially in the developed world, are giving birth. The American College of Nurse Midwives, the Midwives Alliance of North America and the National Association of Certified Professional Midwives, issued the following consensus statement that identified practices and policies consistent with supporting a physiological approach to labour and birth. Hospitals in the United States do not prioritise promoting and protecting physiological birth. Water immersion is almost unheard of and forget about water birth. In a national survey of a representative sample of women who give birth in US hospitals between July 2011 and June 2012, only 13% gave birth without any major obstetrical interventions, such as epidurals or augmentation of labour. These interventions override normal physiology and while the judicious use of each is essential for providing safe and high quality care, their overuse directly affects maternal and fetal outcomes and increases costs. In some of the hospitals where I've worked as a birth doula, there's an 80-90% epidural rate for first-time mothers. Of the 4 million women who give birth each year in the US, it's estimated that 1.6 million are likely to use the epidural. Another study from Finland suggested that around 66% of women having their first vaginal birth will request epidural analgesia. In Brazil, where women can access epidurals and that's not common, 97% would consider having it again. And the decision to use epidurals is affected by many factors, including culture, background of women, their knowledge, education and financial status. So I think everyone here probably recognizes that hospital is not the optimal place for physiological birth, but hospital culture isn't changing anytime soon. So part of this session is to consider how we can help parents stack the odds in their favour of having a physiological birth in a hospital environment if that's what they choose. But it is not an equal playing field where unmedicated birth is a real option for most women, especially when it's so much easier in some hospitals to have an epidural than it is to have a bath. Numerous studies and systematic reviews suggest the use of non-pharmacologic approaches to pain management either as a primary method or as a complement to pharmacologic approaches. But the effectiveness of non-pharmacologic approaches on obstetric interventions and outcomes really isn't clear. And there really isn't any consensus for the use of non-pharmacologic approaches to pain relief in hospital settings. And unfortunately what we tend to see in the US is a system of profits over physiology. And I'll come back to this more later. So let's look at the quick bit, the function of pain. So if you talk to any pregnant person in the last few weeks of pregnancy, labour pain is front and centre in their minds. And some of them are probably fantasising about being one of those women who have gas pains and then realise it's actually labour and they're eight centimetres. I know people this has happened to, it's not common, but it can happen. So pain is critical for survival. It motivates you to do something. And when we look at the function of pain in labour, what the research suggests is that it provides feedback to drive changes. So think of in labour that might drive position changes, movement changes. It's a protective sign that there may be danger. And it drives help seeking behaviours because we want support. So there's two very different models when it comes to the approach to pain and pain management. There's the medical model, which is the tissue-based model. And that's focused on labour pain being pathological and it just needs to be eliminated. In 2017, ACOG released a statement that said, labour causes severe pain for many women. There is no other circumstance in which it is considered acceptable for an individual to experience untreated severe pain that is amenable to safe intervention while the individual is under a physician's care. I think it's safe to say that nobody should suffer in childbirth, but the medical view is very narrow. And in my opinion, it's the medical approach that has contributed significantly to the opioid epidemic. And then of course, there is the opposing model, which is what I think is the midwifery model of pain. And I'm sure most of you will agree that in labour, pain has a function. It is productive. It is purposeful. And it is a normal part of the labour experience. The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. And interestingly, they are revising this at the moment with the following definition being pain being an aversive sensory and emotional experience typically caused by or resembling that caused by actual or potential tissue injury. So note the emphasis on emotional experience in both definitions. And yet the medical model doesn't take this into account. Emotions play a really important part of pain modulation. So think about how emotional regulation is being taught in current childbirth education. So whether you subscribe to the medicalized model or the working with pain model, it's important to understand that pain is an output of the brain, not the tissues. It's an opinion, a perception. And we all perceive things differently, including pain. I don't know if you remember a few years ago, there was all this debate on social media about the dress. So the dress, depending on who was looking at it, was it gold and white or was it black and blue? So while I was preparing for this session, I had a look at it again. And it was definitely for me, it was white and gold. A study by Shaftley reported that individuals who saw the dress as white and gold showed increased activity in certain parts of the brain associated with more sophisticated thinking. So I think I'll go with that analysis. So VS Ramachandran is a leading pain researcher. And according to Ramachandran, there is no direct hotline from pain receptors to pain centers in the brain. And as I mentioned in the very beginning, pain is dependent on output from the brain. It depends on context. It's trying to answer one really important question of how dangerous this is. So it's a best guess of what is happening in the body. And it's not always an accurate one. So we can't talk about pain without also talking about suffering. And I will agree 100,000% with the medical model here in this day and age. Given the resources we have available in the developed world, no mother should experience suffering and labor. And yet it happens more than we'd like to admit. Pain can exist without suffering. When a mother is working hard during labor, but she's coping well. Suffering happens when a mother feels overwhelmed and doesn't have the resources to cope. And unfortunately, staff can contribute to a mother's experience of suffering. So I'll briefly touch on the different pain periods. I promise you I won't bore you to death. It all comes together. The Cartesian model would be more in line with the medicalized model of pain. So it implies that pain signals are sent from the uterus to the spine and then up to the brain. But the mind or emotions, beliefs, meaning has no influence on that sensation. It's purely a physical phenomenon. Mind and body are separate. Pain is a sensation. But today, as you're seeing, we're talking about pain also being a perception. And a lot of staff still assume that there are these pain receptors in the tissues and these send pain signals. But this model doesn't take into account phantom limb pain. So a long known but little acknowledged fact about pain is that it tends to have little or no correlation to the extent of tissue damage. Hurt doesn't always mean harm. There's research papers suggesting that women who've had mastectomies have nipple pain or have an itch on their nipple. But yet the nipple doesn't exist. The breast has been completely removed or women are reporting period pain after a hysterectomy. So there's no nerves that are dedicated to sensing and transmitting pain. Then we look at the neuro matrix model. And this approach is looking at how the brain is produced by an output of neural networks distributed throughout the brain. Again, rather than directly by illness or injury. Then we move on to the bio psychosocial approach. And this maintains that there's very real interactions between biological, psychological and social factors that contribute to pain. No two women experience labor pain the same way. And as midwives, we already use a bio psychosocial approach. We know that if we treat the whole woman body, mind and spirit, we impact all of those factors contributing to her pain perception instead of only treating the mechanics of the pain itself. So for considering that pain is a perception as well as a sensation. There's a famous rubber hand experiment. So the rubber hand experiment is a vote when a subject watches a rubber hand being stroked or touched while their own hand is stroked or touched simultaneously. So it leads the brain to think it's actually your hand. Now in one study participants had their brain scanned while acupuncture was performed on that rubber hand. So they've tricked the brain into perceiving that the rubber hand is having acupuncture. But when this was done during a brain scan, networks in the brain lit up as if the acupuncture was happening to the real hand. So the big question is why is labor so painful for so many? So obstetrician, Barrett Carlson Tingaker's 2008 research suggested there's limited nerves in the uterus in pregnancy. In her thesis, she examined the source of pain during childbirth and how uterine sensitivity is completely reduced during pregnancy. Her results show that sensation mainly comes from the cervix where the number of nerve fibers is much greater than in the uterus at full term pregnancy. But what was interesting was that I know and I'm sure you do as well of people walking around at five centimeters and not in any great pain. So nerves are activated by three different kinds of stimulus. There's thermal, mechanical, such as stretching or pressure and chemical prostaglandins. So what nerves remain, they are detecting some kind of stimulus happening in the tissues. Again, that could be pressure or stretching. And then the brain gets to decide what to make of this and how to feel about it and if we need to do anything about it. But if most birthing people are experiencing pain and labor, the remains that question of why this biological function that's necessary for survival should be so painful. So pain is protective. As I mentioned earlier, the research suggests that is to get the mother's attention to get her to a safe place and to surround herself with support. It's also motivational to do something to protect the tissues if the brain perceives them to be under threat, but hurt doesn't always mean harm. What's fascinating is that pain always doesn't always provide a measure of the state of those tissues. Lorimer Moseley, absolutely incredible pain researcher, neuroscientist, described the time when he was doing some pain research in an emergency room and a patient came in with a hammer in his neck. So Lorimer proceeded to ask him what happened and the man joked that him and his friend were pretending to throw the hammers and his friend accidentally let go and it lodged in his neck. Now this sounds horrific and you'd imagine that this would be incredibly painful, but he's chatting away and doesn't seem very bothered by the pain. And at one point he bends over and holding the hammer because it's protruding from his neck and he puts his hand up over his head acting like this is a fin. And he starts moving around and saying, what am I? What am I? And he's asking everybody, what am I? So everyone's looking at this man walking around with this. So can you imagine this sound? So he thought this was a great joke and said, I'm a hammerhead shark. And then proceeded to bang his knee off a table and the pain from his knee overtook him and the pain from his knee was far more intense than anything he was feeling in his neck. So hurt doesn't always equal harm. So in Lorimer Moseley's explaining pain work, Moseley has a really creative approach to how the brain assesses signals from tissues. He calls them dims and sims. So a dim represents a signal that there is danger in me message and a sim is a safety in me message. So in labor, is the brain getting more dims or sims from nerves? And it's important to note as well that they're not only are signals coming up to the brain, but the brain also gets to decide by sending messages and signals down that it will amplify or inhibit those signals based on the level of danger the brain perceives. So dims are things that the brain might see as credible evidence of danger in me or birth is dangerous. So these can be things that mom is going to see, hear, things she believes, things that are happening in her body. Same way, sims are things that the brain might see as evidence of safety, things she believes, things she hears, things she sees. So Moseley and Butler propose that you will have pain when your brain concludes there's more credible evidence of danger in me than there is credible evidence of safety in me. What is it about standing on a Lego that sends the brain into a frenzy of danger in me messages. So if anyone figures that out how to increase safety messages, let me know. So when I'm teaching parents, I take them through an exercise that helps parents identify their own unique dims and sims for at home and at the hospital. So I asked them to consider what do I see, bloodstained mucus, machines, instruments, forceps, so they'll assume parents are getting lots of danger messages. What am I hearing? Words I don't understand, medical jargon, danger or safety? Maybe there's a conversation happening in the corner of the room, whispered conversations that don't include me, danger or safety. What do I smell, danger or safety? So these will all have an impact in how mom is perceiving that experience. So is it either birth is dangerous, birth is normal. So then we've got a baseline of what those danger messages are likely to be triggered in a busy hospital. And we can help parents anticipate disruptions and dims and create strategies to reduce as many of those danger messages as we can. And explore what they can do to increase those safety messages. Fear, stress, anxiety amplifies all of those danger signals. So we can start them with education and understanding more about brain pain and labor. Get them meditating, get them using hypno birthing, anything that we can do to get them to reduce the fear and turn down the volume of those signals. We need to crowd out the dims with Sims. The brain is boss and we can train it to respond differently. And as we're going through this information tonight, also keep in mind that what parents believe about labor pain also has an influence as well on their own expectations and pain perception around breastfeeding. Pain perception can even be changed on how we actually see an injury. So if you use a magnifying glass to make a small cut look bigger, the brain turns up the pain, make a smaller and the brain turns down the volume on that output. Not looking at an injection makes it hurt less. So I think it's probably a good thing that we can see epidurals if we get one. So everything that hurts involves this back and forth discussion between the brain and the peripheral nervous system. So this is an example that I would use with parents that I work with. So I'll have them consider 41 weeks, the first time mom starts to experience tightening and sensations she has never experienced before. The nerves begin to experience stretching and pressure. So the user sends a signal up to the spinal column and like a relay race, it passes the signal up to the brain to the thalamus. And the thalamus acts like a air traffic controller and it decides where the signal goes next. So on receipt of the signal, the thalamus asks the pain committee, how serious is this signal? Is this something we need to be worried about? And for the majority of expectant moms, the rest of the brain responds immediately with, yes, this is really bad. It's all about blood and tearing and pooping and being out of control. Horrible pain we saw it on TV. So we have this now experience of danger, Will Robinson, danger. So the brain sends an excitary message back down to the user saying, keep it up, keep it up, this is dangerous. We need to protect mom. We need to make sure mom is taking notice and seeks help. And just like the children's story about chicken little, your brain perceives the sky is falling in. Now let's see how that experience could be a little different. 41 weeks at first time mom starts to experience tight things and sensations that she hasn't experienced before. Same thing happens. The user is starting to stretch and relax and stretch and relax. The signal goes to the brain and the brain sends a message out to the pain committee to see, well, how serious is the signal? Of course, this is all happening in like milliseconds. Is this something we need to be really worried about? How dangerous is this really? And in this case, the rest of the brain responds quite differently. And it's like, cool. This means baby is coming. We are so excited. This is something really good. This means progress. The baby is coming. Brain relaxes and sends a message down saying, hey, tell those guys down below to chill out. So that it sends an inhibitory signal back to the uterus because these sensations are not something we need to be worried about. And this is adapted from the work of Larmor Mosley. And something of interest is that when we're practicing meditation, the thalamus reduces inactivity. So less of those signals are even passed through. So pain and labor is influenced by several factors. And I'm sure you're all well aware of these. Meaning, expectations, emotional state, focus, support, and the environment. And I want to take you back to 20 years to what Penny Simkin talked about with the meaning of labor pain. That is time to take a broader look at the meaning of pain and childbirth. By doing so, caregivers and educators may come to appreciate that labor pain deserves a more sophisticated approach than eradicating it for women or helping them tough it out. Neither of these approaches addresses the real issues of the complexity of labor pain and its potential positive or negative long term impact on each woman. So when we look at the meaning of pain for the two people in my example, the meaning of labor pain was very different. And when reviewing the literature, you'll find that when a mom sees pain as productive or functional, she can accept it more readily. There's a purpose behind those sensations. And literature aside, I'm sure you've all experienced this with birthing people you've worked with. With any other pain, as those sensations get stronger, it's usually associated with a problem. But in labor, it's associated with progress. And staying in the moment makes a really big difference as mind wandering, which we do around 50% of the time can triples up. The more accepting a mom is of the sensations, the more likely mom is to cope well. Laura Whitburn and Lester Jones published one of the first studies to describe how cognitive processes are related to the experience of pain in laboring women. Laura's research on mindful acceptance about being focused or in the zone or distracted and distraught. So part of our work is to help moms change the meaning of labor pain so that it's more normalized. And as it's so subjective, we know it can't be explained by tissue damage alone. So the meaning will impact mom's perception. So if mom sees it as threatening, which of course it is for many, many women, their experience is quite different. And just paraphrasing from Laura's work, when we look at moms not being in the present moment and being distracted either internally or externally, women started to catastrophize. Their women didn't remain in the present moment and they were concerned about how much time had passed or how much time was left to go. And hospital distractions definitely can pull women from that present moment or from tuning into their bodies. And women will talk about having to have the monitor on the whole time and how disruptive it was or as soon as they lose their focus, they found that they experienced more pain. And then we have mindful acceptance, being in the moment, being focused. So when you talk to women about their expectations of labor, I have found that a lot of women tend to catastrophize events as if they feel they don't deserve to have a great birth. And you'll hear things like I wouldn't be that lucky or joking saying I'll be screaming for the epidural. So catastrophizing occurs when we start to anticipate or visualize all the things that could go wrong and focusing on them instead of what usually goes right. And then we're leaving little room to consider any other reality. Every day the women in your care are mentally rehearsing the kind of birth they don't want. What I'm teaching I ask parents to visualize or ask them actually if they do visualize and most of them say no and they think it's kind of new age. And now I ask them if they worry. And of course they do. And they're actually experts in visualization just the wrong kind. They're mentally rehearsing the kind of birth they don't want. I don't want to tear. I don't want a caesarean. I don't want a forceps. And the brain cannot tell the difference between what's happening right now and something we're vividly imagining. So it affects their entire outlook and can create this kind of self-fulfilling prophecy. So interestingly in Viringa's 2011 research in the Netherlands, it was a study of 270 women and their research suggested that catastrophizing was the strongest predictor of a request for pain relief. And Ferb's 2005 research suggested that labor pain catastrophizing and not actual labor pain intensity predicted reduced interactions with new moms and babies. Another 2012 study from Brazil suggested that birthing people who catastrophize have three times higher risk for acute perineal pain and higher risk for developing persistent perineal pain. Flink, who compared catastrophizing with non-catastrophizing parents, found that catastrophizing parents experienced more severe pain up to one month after childbirth. So consider the implications on catastrophizing not just on labor, but on breastfeeding too. And there was some fascinating research from the UK as well focused on attachment patterns and pain perception and labor. And this was from 2015. And this research suggested that less secure attachment was an independent predictor of analgesic use. And it makes me think about what's happening in the US at the moment with women and babies being separated. So today I want to bring your attention to the following research. And you might remember at the beginning I mentioned how we've got limited research on how non-pharmacologic approaches can impact obstetric interventions. Chalier's 2014 meta-analysis included 34,000 women and 57 randomized studies of assessing the effects of non-pharmacologic approaches organized by mechanism of action rather than technique on obstetric interventions. The approach of focusing on central nervous system, so using the brain, had the most significant impact on epidural use, interventions and outcomes. Non-pharmacologic approaches based on the central nervous system mechanisms which mainly modulate unpleasantness of a sensation are associated with a reduction in epidural rate and a significant reduction in caesarean and instrumental births. Use of synthetic oxytocin, duration of labor and other outcomes. So moreover non-pharmacologic approaches that includes central nervous system, so the brain training and continuous support has been found to be the most effective strategy for reducing obstetric interventions when compared with normal care. So we've got to look at how we can help parents to access their endogenous pain mechanism. So you'll be very familiar with the gate control theory, DNIC, which is like acupressure, acupuncture, firm massage, and then CNS, central nervous system, brain modulation of pain sensation, activated by mental processes and emotions. The summary of this research was that CNSC was associated with one or more techniques, so including DNIC and gate control, so get that TENS machine on, was the most effective method for helping women work with pain. And I know that this goes against the suggestion, so what we're talking about using visualization, hypnosis, mindfulness, breathing. This does go against the suggestion that we often tell women that they need to turn off their thinking brain. But consider how helpful these cognitive processes can be to reduce those dims and ultimately pain perception in a busy hospital. It's the skillful use of the thinking brain in a busy hospital that can help get mom into labor land. I want to encourage you to take a look at a really impressive 2018 Canadian obstetric guideline. It's number 355, the physiological basis of pain and labor and delivery and evidence-based approach to its management. Because there's no point in us teaching parents all of this if we don't have care providers educated on pain science too. Hope that makes sense. So what can we do with this information about the pain science and pain education? What your brain is doing in labor is just as important as what your body and baby are doing. Currently, there's very few research studies that have been done to assess the efficacy of childbirth education programs. Cochrane Systematic Review revealed that these courses demonstrated no consistent effect, but an inclination towards knowledge, confidence and competence was deducted in small studies. And it's not easy to assess the benefits of childbirth education because there's so many different approaches and content. But there's definitely growing interest in this area. An unpublished prospective study by obstetrician Mareto Reardon in Ireland using the CNS approach found a significant decrease in induction of labor, epidural use, increased satisfaction with the birth experience and significantly higher initiation of breastfeeding. And I would encourage you also to take a look at Chanae Dufour's 2018 Canadian research as well. It was a small study but included pain education and also found an increase in physiological birth. So what can we do to help parents? First of all, we can start educating them on the biology of pain, help them understand how the brain processes these signals. Let's help them understand what distractions they'll be faced with in a busy hospital environment and how they can manage them at home, in car, on the way to the hospital and at the hospital, making sure we've got partner support being essential. I would say encourage them to have a doula present at the birth as well. Help them understand how to prepare for distractions and how to manage them to stay focused. Having written birth preferences, especially to say not to continue to offer pain medication. And because when staff keep asking about pain medication, women start to doubt if they're coping. And the US midwives have a great approach with the promoting comfort in labor. So it is about assessing for comfort and coping instead of pain. So imagine having a comfort and coping scale instead of that pain scale. We also need to recognize that for moms who have experienced previous trauma, their pain threshold and pain tolerance is likely to be lessened because they are more stressed and indeed sleep deprivation can increase pain perception as well. We want to encourage parents to use their brain, so mindfulness training, hypnobirding, practicing visualization and that slow focus breathing, something they do throughout their pregnancy and not just on the day itself. And as I mentioned earlier, you'll see all of these approaches are equally applicable to breastfeeding. Lisa Amir's 2015 research on nipple pain being associated with breastfeeding and incorporating current neurophysiology. Again, looking at how we can increase the output from the brain to reduce those signals. Because it's estimated that 80 to 90% of new mothers will experience nipple pain during breastfeeding and around 20% will stop because of that pain. So when we figured out mechanics of breastfeeding, there's something else going on. There's lots that we can do to use the brain to actually modulate that pain experience. So in summary, physiological birth, we know this has benefits for mothers and babies. Research suggests that a brain-based approach that includes pain education and different cognitive coping strategies may increase rates of physiological birth and longer breastfeeding. And current childbirth education approaches don't include a huge amount on pain education. Significantly less time is devoted to these strategies compared to education on pharmacological options. And we tend to see that mainly in hospital-based classes. So understanding the neurophysiological mechanism of pain modulation and cognitive coping strategies can give parents more strategies to reduce pain and labor and reduce the use of pharmacological options and those associated risks. As we foster an understanding of labor sensations being productive, progressive and functional rather than something to be afraid of, it sets the stage for a more positive birth experience and postpartum. But as well as updating childbirth education, it's equally important that care providers have an understanding of these strategies as well so that we can all provide appropriate support. Those 2018 Canadian guidelines are really worth a read if you haven't checked them out already. And of course, more research is needed. Thank you everybody. I hope that was helpful. Thank you for your attention. Well, I think we're all blown away by your erudition and your care and love for physiologic birth. That was incredible presentation. So we've got like about two or three minutes for questions. So if you'd like to ask questions and Tracy, you'll be able to see them in the chat box. Really fantastic work. I hope it was helpful. I hope it was new information for some people. I know a lot of it was new for me years ago. Well, I think you're exactly right. I mean, when they moved birth primarily into hospitals, specifically as someone that's worked in this United States for a long time, just the denial of the care, the one on one care with a midwife is crucial. And I think you really hit the nail on the head. Yeah, unfortunately, especially nowadays, it's profits before physiology. I mean, for anyone in the US, you've probably seen the little bit of pushback to get nitrous into a lot of the hospitals. You know, has that anything to do with what nitrous builds insurance compared to having an epidural? I wonder. Thanks everybody. I'm glad it was helpful. It's great. And Celine says money. Yes, cash. Cash is king. And yeah, we had a lot of problems. I work in a birth center, Tracy. And then with the COVID thing, it was like how they said you couldn't hold your baby. And then they're saying, well, the arialization of nitrous in the air, we can't use nitrous. And I was like, that was very problematic. And then could you say again about the guideline 355 plays from VG Ross? So that is, yeah, it's 355. I think did I put it up here on? Yeah. It's the SOGC 2018 clinical practice guideline. It's an absolutely amazing document. And I have to thank Sine do for in Canada for pointing me in the direction of this publication, because I think we we could again, I think every country could could adapt these these guidelines and we can definitely, you know, improve childbirth education and use more of these kinds of strategies and talk to parents about how they're visualizing visualizing their their birth experience and having parents. And to change their thoughts and not assume that thoughts are facts. Yeah. And if anyone wants to email me, I'm, it's tdanigan at gentlebirth.com. I'm happy to share the slides and any any research that I mentioned throughout the day or throughout the session. Thanks everybody. We're all going on Amazon or whatever search engine we use for buying books so that we can purchase all every single book that you have. So thank you so much. It was a super presentation, very clear, fantastic slides. Actually, I love the slides. And we all say yay and happy international days of midwife Tracy and you really had a great turn out of 94 people at the height of the presentation. So incredible. So thank you for your commitment to women and families. I'm going to go ahead.