New Ways to Talk about Labor Pain, 1: Intensity &Unpleasantness

scales

Melzack and Casey* described multiple components of pain:

  • Intensity (they called it sensory-discriminitive): how intense it is, the quality of pain and where it is located – more objective
  • Unpleasantness (motivational-affective): are you suffering and how badly do you want to escape from the pain – more subjective
  • Interpretation (cognitive-evaluation): how intense and unpleasant a pain seems to us is influenced by things like our cultural beliefs and whether we believe the pain to be a sign that “something must be really wrong”

In our book, Pregnancy, Childbirth, and the Newborn, we discuss the difference between pain and suffering. You can have pain without suffering – ask anyone who has run a marathon or climbed a mountain…. it’s hard, grueling effort, but they feel utterly exhilarated when they reach their goal. You can have suffering without physical pain, such as that experienced with grief over a loss or betrayal by someone you had trusted. Suffering can be eased with support or worsened through isolation.

So, some women in labor have very intense pain, but it’s low in “unpleasantness” – they’re not suffering if they feel like they are working with their labor pain and they have the support they need to meet the challenge.

We offer in our book the illustrations shown at the top of this page. The pain intensity scale is often used in hospitals for post-operative patients to determine whether they have sufficient pain medications or need more. We encourage women that if they are asked to rate pain intensity, they do so. But then they can offer a second rating – on unpleasantness – how hard they are struggling vs. how well are they coping. A rating of 0 would mean they were really suffering and felt desperate to escape. But a rating of 7 or 8 acknowledges “yeah, sure it’s unpleasant… but I’m doing OK.”

So a person in labor might rate their intensity very high, but also be high on the pain coping scale. They are working with their labor pain. Another person might not be as high on intensity, but might be very low on the coping scale – they’re suffering, and might choose pain medication to reduce their pain intensity.

Using these terms in our childbirth classes gives people in labor other ways to talk about their pain, and it can also offer reassurance to partners: their support may not be able to reduce the intensity of labor pain, but it can make it much more bearable… much less unpleasant.

* Melzack R, Casey KL. Sensory, motivational, and central control determinants of pain. In: Kenshalo DR, editor. The skin senses. Springfield, IL: Charles C. Thomas; 1968. pp. 423–443.

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Teaching Physical Skills

A common mistake I’ve seen in childbirth classes (and other types of classes) is that when an instructor teaches a physical skill, they spend several minutes talking about it, then run out of time for the students to actually DO the skill. I encourage you to flip it around. Talk as little as possible to give your students a sense of what you’ll be asking them to do and why, and then get them practicing as soon as possible. In my workshops, I teach that if you’ve got ten minutes, you spend one minute giving a very brief description of the activity. One minute demonstrating the activity. Then you have eight minutes for them to practice. As they’re practicing, you can walk / look around the room and give feedback, ask questions, and answer questions. But during 80% of the time you’ve got your students engaged and doing something with their bodies, rather than just sitting and listening to you. Here’s more details on each of the steps:

Step 1: Description

First, give a very brief overview of what you are going to do, describe when they would use this technique, and why – what the benefits of the technique would be. For example:

“I’m going to show you slow deep breathing. You can stay sitting and we’ll practice it together. Slow breathing is often the first comfort technique you’ll use in early labor. It helps you to relax, brings lots of oxygen to your baby and your muscles, and gives you something to focus on rather than just the pain.”

“I’m going to show you how to swaddle a baby – wrap it up tightly in a blanket. This is a great first step when you’re trying to calm a crying baby or when you’re trying to settle a drowsy baby to sleep.”

Keep this very brief. Provide just enough info so they know what to expect, and why it’s relevant to them, then quickly move on to them actually performing and practicing the skill.

Step 2: Demonstration

Next, demonstrate how the skill is done, with your body and/or AV’s, narrating each step as you do it. (It may also help to draw a diagram on the board, or point to a poster to illustrate a point.) Teach only the most basic version of the skill at this time. You’ll cover variations and adaptations during practice and feedback. Break the skill up into concrete, teachable steps, and illustrate each step clearly. Examples:

“Stand next to the chair, and place one foot up on it like this. You want your feet to be at a 90 degree angle from each other to open up your pelvis as much as possible to let that baby descend and.rotate. Then you’ll rock back and forth like this – see how much that changes the shape and position of my pelvis? OK, let’s all try.”

“You’ll hold the baby in your arms like this. See how my elbow is supporting his head and my hand is supporting the weight of his bottom? I hold him at the same height as the breast, with his tummy tucked tight against mine. OK, let’s all try.”

If there are several techniques you want to teach, teach them one at a time, with practice sessions between. So, don’t teach 6 positions, then have them practice all 6. Teach them one at a time.

Step 3: Practice

Next, have your students try the technique you have taught. This is where you should spend most of your time!

With hands-on experience of a technique, students will learn it better (and you’ll discover if you weren’t clear enough when you taught it!), remember it better, and adapt it to their use. This deeper learning means they are more likely to use this skill outside your class.

Practicing physical techniques in front of strangers can feel awkward to some people. Some things you can do to help with that: Turn on music during practice sessions so they can’t overhear each others’ conversations. Dimming the lights can also help, but don’t dim them too much, or it can feel strangely intimate. Acknowledge that it may seem silly, but tell them why you see value in teaching the skill. (“No, putting a diaper on a doll is really nothing like diapering your real squirmy baby. But it’s better to have practice some of the basic skills on a doll than it is to never have practiced.”) Be matter-of-fact about it when you demonstrate – if you’re embarrassed or awkward when you’re demo-ing, they’ll be embarrassed to practice it. Start with “easy” things that are generally socially acceptable, then move to things that might be more awkward. For example, teach ways to relieve leg cramps (calf stretches) first, then teach pelvic tilts standing up, then pelvic tilts on hands and knees, then squatting. Or teach hand massage, then upper back massage, then the lower back techniques like counter-pressure and double hip squeeze, which touch on more personal parts of the body.

Step 4: Feedback

The practice and feedback steps are often interwoven. Proper guidance results in quicker, more effective skill acquisition. Learning without guidance is learning by trial and error. It is slower, and less effective than learning with feedback.

As they practice a technique, they discover questions about it that they wouldn’t have ever discovered if you had just demonstrated it and not given them time to practice. During feedback, ask often if they have questions. Their questions will allow you to provide more details about the technique: the when, why, and how to do it get fleshed out in more detail during this process. All the things you may have been tempted to cover in lecture format will still get covered. However, because they come in response to questions and a state of inquiry amongst your students, they will pay more attention to your answer, and remember it better than they would have remembered lecture information you spoon fed to them.

As they practice, they may discover things that aren’t working for them, and you can provide suggestions for adaptation. Then they can experiment some more.

While observing them, you may notice that they misunderstood the demonstration. If so, find another way to show them, but point out that you are doing so. “Ok, let’s try doing this a little differently to see if that will work better for you.” Don’t criticize or blame them. Always find something to praise, and then mold that into success. Encourage them to problem-solve together.

For example, if during counter-pressure practice it looks to me like the partner’s hand is too high, instead of just telling him he’s doing it wrong, I might ask her, “how does that feel?” then I might say to him “your hand is a little higher than I typically place mine… try moving it down a couple inches.” Then I ask mom again, “How does that feel?” Then I encourage them to practice and experiment more with hand placement and pressure to find the spot that’s perfect for her.

Learning from other people’s examples – both good and bad

One of the best ways to learn how to teach physical skills is to watch other people do it. Watch lots of other people! Each one will highlight slightly different information, each will have different analogies. By watching several, you collect a sampling of good ideas. (And sometimes you learn what not to do.

Today, with YouTube, it’s easy to observe a wide variety of teaching styles. If you look up something like “pelvic tilts for pregnancy” or “bathing a newborn”, you will find lots of videos. Some are professional and polished. Some are made with phones propped up on someone’s dining room table.(And sometimes those are the best teaching examples….)

Watch several videos, taking notes as you go along. What are the key points that they cover? Where did they give too much detail? Where were they not clear? How long did it take for them to get to the point of the exercise vs. did they spend a lot of time giving details you don’t really need to know? Did they make it look easy to do? (And I don’t just mean was it easy for them… I mean if I was a really uncoordinated feeling person and I watched them do it, would I think that I could do it?) How was their pacing? Could you practice along with them or were they too fast? Too slow?

Now you practice teaching it. Try out some of the things you saw in the videos. What works well for you? Are there things that you thought would work but you just can’t make it flow quite right?

When you’re teaching, try to pay attention to how much time you spend talking about something while your students sit still versus how much time they spend practicing. The more time they spend practicing and adapting something to their own abilities, the more likely they are to use it during labor or after birth.