Many years ago, I created a class I called Working with Labor Pain. I had realized that if women were expecting non-drug comfort techniques to take away their pain like an epidural can, then they would be disappointed. If they imagined that if they used a few deep breathing techniques and some visualization, then labor would be “easy”, they were in for a shock. But, if they understood that the techniques we taught could help them feel like they were working with their pain, then the pain would feel more manageable. Coping with labor would be hard work, but it didn’t have to be suffering. (See my last post for more on this distinction.)
Nicky Leap, a professor of midwifery at the University of Technology, Sydney, Australia, has done some great writing on this subject.
For her dissertation (Leap N 1996a A Midwifery Perspective on Pain in Labour – described here) she did a literature search on labor pain, including novels, poetry, short stories, plays, biographies, oral history and books on childbirth aimed at pregnant women, and she interviewed 10 midwives. “The midwives described two distinct approaches to pain in labour. I named these the dominant paradigm (or ‘mind set’) of ‘pain relief’ and the paradigm of ‘working with pain.'” The pain relief approach has the goal of reducing pain through medication. It assumes that not offering pain relief in labor is cruel in the days of modern analgesia. Working with pain is based on an understanding that normal pain is part of the process of labor.
Nonpharmacologic should be first method: labor support combined with Gate Control or counter-irritant. If not enough, and woman is suffering, then combine pain meds with nonpharmocologic, especially support.
The midwives felt that in normal labor, pain triggers endorphins that help the women to cope. Pain is an ally which tells women to summon support and find a safe place to give birth. Pain is a signal of labor progress. If a woman is supported through the pain by people who are confident in her ability to cope with it (to work with it), then she has heightened joy at the end of the process from the triumph of walking through that pain. In a normal labor, with safety and support, women aren’t sent more pain than they can handle. (Abnormal pain is associated with abnormal labor that might require intervention and might require pain relief.)
The midwives were concerned that when we offer the full menu of pain relief choices, with the benefits and risks of each method, that we create “a culture where both women and their attendants end up seeing some form of ‘pain relief’ … as a necessary part of the process of giving birth.”
In “Journey to Confidence: women’s experiences of pain in labour and relational continuity of care” (Leap, et al, JMWH 2010), Leap documents interviews with ten women who had midwifery care. They linked their confidence about pain coping to the way their midwives talked about labor pain openly, candidly, and calmly, explaining that it’s not like other pain, and that it’s manageable pain. During labor, when they were feeling overwhelmed, it was helpful reassured by the midwife that although labor was painful, the contractions were bringing the baby down, and being reassured that they could manage the pain. After labor, “women consistently linked their pride about coping with pain to feeling strong and confident and to a positive start to new motherhood.”
In Working with Pain in Labor (Leap, et al. New Digest, 2010) she says that if the pain relief paradigm is applied, then even when women say they hope for a drug-free labor, they may still begin labor with the expectation that they’ll need some form of pain relief. If they have unrealistic expectations about pain, they are not prepared for labor, and if “a woman experiencing normal labour is offered pharmacological pain relief, she will find it irresistible.”
On the other hand, if the caregivers have a philosophy where pain as seen as a normal physiological process, and mothers are given privacy and protection from disturbances, they can go into an altered state where oxytocin and endorphins help them cope.
In childbirth classes, we should think more about how we talk about working with labor pain for a normal labor that’s intense but not unbearably unpleasant versus how we talk about pain relief as a useful tool for any abnormal labor or any point where the pain has become suffering.
In the last edition of Pregnancy, Childbirth, and the Newborn, we added a chart comparing what labor is like without pain medications versus with pain meds. For the 2016 edition, I’m working on a clearer description that the role of pain meds is pain relief and the role of non-pharmacological options is to help us feel like we are working with labor pain and it is manageable and we can triumph over it.