Category Archives: labor pain

New Ways to Talk about Labor Pain V: Research on Effectiveness of 3 Mechanisms

table

In 2012, a new Cochrane review of pain management for women in labor was released. Although it had positive things to say about the non-pharmacological techniques, it also said that research into their efficacy was unclear due to limited evidence…

“WHAT WORKS: Evidence suggests that epidural, combined spinal epidural (CSE) and inhaled analgesia effectively manage pain in labour, but may give rise to adverse effects. … WHAT MAY WORK: There is some evidence to suggest that immersion in water, relaxation, acupuncture, massage and local anaesthetic nerve blocks or non-opioid drugs may improve management of labour pain, with few adverse effects.  Evidence was mainly limited to single trials. …INSUFFICIENT EVIDENCE: There is insufficient evidence to make judgements on whether or not hypnosis, biofeedback, sterile water injection, aromatherapy, TENS, or parenteral opioids are more effective than placebo… Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby, however, their efficacy is unclear, due to limited high quality evidence.”

A 2014 review by Chaillet, et al (Chaillet, et al. (2014) Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2): 122-37. http://www.ncbi.nlm.nih.gov/pubmed/24761801) is a significant addition to the research about non-drug approaches.

Chaillet, et al pooled techniques into three categories. If you’ve read my posts from the past few days, you’ll be familiar with these concepts. Also, see the chart at the top of this post for more information.

  • Gate Control mechanism = apply non-painful stimuli on the painful area. Methods included massage, bath, positions, walking, and birth ball. The theory is that this will block some of the intensity of the pain.
  • Diffuse Noxious Inhibitory Control (counter-irritant) = create pain or discomfort anywhere on the body. Methods included acupressure, acupuncture, TENS, sterile water injections. The theory is that this discomfort causes the body to release endorphins which reduce pain intensity. (Birth combs also fit in this category although they were not included in the research.)
  • Central Nervous System Control (cognitive/support techniques). Methods included  attention focus, education, relaxation, hypnosis, continuous labor support.

By pooling studies together, you get larger sample sizes which increases the statistical significance of the results. Note, all techniques were compared to “usual care” which might have ranged broadly depending on the preparation of the laboring family and the support they were given by caregivers. It is possible that some in the “usual care” groups were also using a variety of coping techniques. So, the true difference between people who use some coping techniques and those who use none may be even greater than these results indicate.

The results of this review were:

  • Gate Control mechanism. Those who used these techniques had lower pain intensity (as predicted), were less likely to use epidural, and needed less Pitocin.
  • Diffuse Noxious Inhibitory Control (counter-irritant). Those who used these techniques had lower pain intensity, were less likely to use epidural, and more satisfied with birth. (Two trials found women felt safer, more relaxed, and more in control.)
  • Central Nervous System Control (cognitive/support techniques) Those who used these techniques were less likely to use epidural, Pitocin, less likely to need instrumental delivery or cesarean, and had a higher satisfaction with birth. The CNSC did not reduce the intensity of the pain so much as they reduced the unpleasantness of the pain. (See more on intensity and unpleasantness here.) So, although labor still hurt a lot, women felt better able to cope – more like they were working with labor pain.

The most effective technique overall was continuous labor support, such as that offered by a doula. The effectiveness of support was already demonstrated in a Cochrane review by Hodnett et al, (Hodnett E, Gates S, et al.. Continuous support for women during in childbirth. Cochrane Database Syst Rev. 2013. CD003766)

The best results in pain coping were from combining the labor support and education which reduce the unpleasantness of pain with gate control or DNIC techniques that reduce the intensity of the pain.

Recommended: be sure to also check out Henci Goer’s discussion of this study on Science and Sensibility.

New Ways to Talk about Labor Pain, IV: Bonapace Method

The Bonapace Method for reducing pain during childbirth can be used instead of, or in conjunction with, a traditional childbirth education class.

This method does not just teach pain coping techniques, but also teaches about the role of labor pain, how pain messages are transmitted in the body, and three mechanisms that help moderate the perception of pain. Those mechanisms are:

Cognitive structuring / central nervous system control (CNSC). Understanding labor pain and progression – what’s happening and why – enhances a sense of self-control. Focusing on something positive (like a self-affirmation) helps with labor pain.

Gate ControlTheory. Non-painful stimulation blocks part of the pain message transmitted by the spinal cord. Note: Bonapace interprets this differently than I have see elsewhere, saying specifically that it is pleasant sensation applied where the pain is located. The description on their website says “To activate this mechanism during childbirth, the fingers must be run lightly over the painful area, particularly during contractions.”

Diffuse Noxious Inhibitory Control (DNIC). (I call this counter-irritation) Creating a second pain elsewhere on the body (i.e. not where you’re already hurting). The brain wants to reduce the pain’s effect on the body as a whole, so releases endorphins to do so. But the sensations near the second pain are still felt because the body is assessing them. (So, under this theory, holding a birth comb tightly causes a release of endorphins which helps with the labor pain, but the user is still aware of the pressure points from the comb on their palm.) In the Bonapace method, sensitive points on the body (trigger areas) are massaged by the partner, causing pain.

In a journal article (“Evaluation of the Bonapace Method: a specific educational intervention to reduce pain during childbirth”, J Pain Res 6: 653-661 at http://www.dovepress.com/articles.php?article_id=14256), Bonapace et al, compare the results of a “traditional childbirth training program” (TCTP) with the Bonapace method. Study participants chose which class to take from these options.

The TCTP was a 4 week class, with a total of 8 hours of class time, started around the 23rd week of pregnancy. It covered A&P of childbirth, exercises, stages of labor, variations, pain meds and newborn care. Relaxation, visualization, massage, and labor positions were not taught. Only breathing techniques were practiced.

The Bonapace class was 4 weeks, 8 hours, starting in the 30th week. The entire program was dedicated to pain management and partner participation. It covered 1) CNSC through breathing, relaxation, and cognitive understanding of labor pain and endorphins, 2) Gate control – non-painful stimuli such as walking and light back massage between contractions, and 3) DNIC where the partner did painful massage of acupuncture triggers points in the lower back, hands, and buttocks.

39 women participated in the full study. In labor, every 15 minutes, participants were asked to rate their pain on two scales: intensity and unpleasantness. (If pain medications were given, they stopped assessing pain after the medication. If that participant had pain scores for two phases of labor, they were kept in the study, if not, they were dropped.

Those who had learned the Bonapace method had an average of 45% less pain intensity and 47% less unpleasantness than those who had received the “traditional” childbirth education. No difference was found in the use of pain medication.

The reduction in intensity of pain was consistent for nulliparous and multiparous parents. On the “unpleasant” ratings, there was a larger reduction in scores for nulliparous than multiparous. This is likely due to anxiety… a nulliparous woman with no birth experience and no training / childbirth preparation is likely to be anxious about labor pain (and, of course, anxiety increases pain). With the TCTP, her anxiety may have been somewhat reduced and thus her pain unpleasantness would be reduced, but with the Bonapace method, her anxiety and thus unpleasantness were much more reduced.

This study indicates that being given information about the physiology of pain, and plenty of education in clear, simple techniques to manage it, has a significant impact on pain intensity and pain coping.

New Ways to Talk about Labor Pain III: Diffuse Noxious Inhibitory Control

Diffuse Noxious Inhibitory Control (DNIC) is one of the mechanisms we can use for managing pain. That name is a mouthful, so I call these counter-irritants. (Read my post on birth combs as a DNIC tool here.) The principle is that if a laboring mom adds a pain or discomfort on her body during a contraction (like biting her lip, pressing her fingernails into her palm, or putting ice on her back), that helps to distract her brain from the pain. TENS, sterile water injections, acupressure, and birth combs are all DNIC tools for labor.

One theory for why these are effective is that the pain from these sensations causes a release of endorphins, endogenous opiates that help to reduce our perception of pain.

Another has to do with how the brain processes stimuli coming in on various pathways. (This is similar to the Gate Control mechanism of pain, which says that when we provide stimuli on fast-moving nerve pathways – like through sound, smell, touch with our sensitive fingers and toes – then those block some of the pain coming in on slower pathways – like labor pain.)

Chaillet, et al says that DNIC primarily reduce the intensity of pain. I believe that they can also help to reduce the unpleasantness of the pain. (see my post here for the difference between the intensity of pain and the unpleasantness of pain.) If mom is in control of the counter-irritant, it may give her more of a sense of control over the labor pain. She may feel like she can’t escape the labor pain (it’s highly “unpleasant”) but that she could stop biting her lip anytime she wants… being in control of something is better than feeling totally out of control. It’s one way of “working with labor pain.”

In childbirth classes, we can talk about counter-irritants by suggesting options to the pregnant parent (ice, squeezing something, TENS). We can use the concept to better explain sterile water injections (some parents are mis-educated in advance, and think that the injections themselves relieve pain… they’re shocked at how much the injections hurt! So, we want to explain in advance that they do hurt… like a bee sting… and that’s the idea, because they trigger an endorphin release.

In classes, we can also let the support person know that some people in labor develop a spontaneous ritual where they are causing pain to themselves (like pulling their hair)… help the partner understand that the person in labor is looking for counter-irritant – an uncomfortable sensation to distract her from the pain, and they can help her find one that gives that counter-stimulation but doesn’t harm her (like squeezing birth combs).

In the Bonapace method (I’ll post on that tomorrow), the DNIC mechanism that is taught is for the partner to do painful pressure on acupuncture trigger points. I personally prefer using only counter-irritant techniques that the person in labor applies and controls. I personally don’t like to teach partners to do anything painful to a woman, even if it might have benefit for labor pain. (A licensed massage therapist who has been clearly trained in safe high pressure massage I have no concerns about.) If I were to teach this in a class, I would set clear expectations that the laboring woman controls this firm massage – she asks for it to be done, and if she doesn’t like it, she tells her partner to stop, and her partner should stop.

New Ways to Talk About Pain II – Working with Labor Pain

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.

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.

Handouts on Sleep and Hormones

I just put up copies of two handouts you may find helpful in your work.

My handout on Hormones of Pregnancy, Labor and Postpartum was written for prenatal yoga instructors and has tips for how they may use this info in their work. But the content about hormones is relevant for anyone.

Another handout covers Infant Sleep from 0 – 6 months. A collection of tips on what to expect for typical sleep patterns and what parents can do to help baby sleep.

Reflexology combs for labor pain relief

combCounter-irritants for pain relief

As a childbirth educator and doula, I wish we all talked more about “counter-irritants” as effective methods for pain relief during labor and birth. By counter-irritant, I mean the person in labor does something which is uncomfortable but helps to distract her from the labor pain, such as biting on her lip, squeezing her fingernails into her palms, using a fist to thump on her thigh, or pulling on her own hair. These are all actions that are within her control – she can start or stop anytime she wants to – she chooses how intensely to do it so that it will bring her attention away from the contraction pain that is not within her control.

The issue is that some of these spontaneous techniques can cause pain or minor injury to her. I like to talk about these behaviors in class so partners know that if someone in labor is doing this, it’s because it’s helpful to her. We shouldn’t stop them form using a coping technique. But the partner may need to help her figure out how to adapt it in a way that provides the pain relief but doesn’t cause harm on its own.

Sometimes it’s a simple in-the-moment fix – for the mom who’s hitting her thigh we might place a pillow there to cushion the blow. For the mom digging her fingernails into her palm, we might be able to give her a washcloth to grip tightly, or better yet, a comb or brush to squeeze.

Birth combs – How to Use Them and Why They Help

In some traditional cultures around the world, laboring women hold onto wooden combs. When a contraction comes on, the mom squeezes the comb so it presses into her palm – she squeezes as long and as hard as she finds helpful. Then she relaxes her grip between contractions, but usually chooses to continue holding the combs.

What to use: I use reflexology combs from Mildred Carter’s Reflexology – shown in the photo at the top. Sadly, they’re no longer available… But here are some alternatives I’ve found that I believe would work well:

How to hold it: the photo at the top of this post illustrates it, and this drawing from Page 9 of this booklet on Acupuncture in Labor also shows how you would hold the comb.

birth comb for labor pain

There are a few theories as to why birth combs might be helpful.

  • One is “Diffuse Noxious Inhibitory Control“. If we create pain or discomfort anywhere on the body, it causes the release of endorphins which reduce the perceived intensity of the pain. (Note: TENS and sterile water injections would also fit in this category of pain relief.)
  • One is related to Gate Control theory: Our brain can only pay attention to so many stimuli at once, so the pressure on the nerve pathways of the hand travels to the brain faster than abdominal pain, and crowds out the abdominal pain signals.
  • One is reflexology or Chinese medicine-based. There are meridians – energy pathways – that cross the palm. Pressing on trigger points there helps to release stagnant chi, allowing healing energy to flow.
  • One is psychology – because the mom is in control of the pain from the comb, it makes her feel less out of control from the labor pain – more like she’s “working with labor pain.”

My experience with combs for pain

I am an amputee. Which means I have phantom pain. You may have heard it mentioned in studies where people rate the intensity of different kinds of pain. Broken bones, tooth abscesses, and kidney stones are pretty high on the list. But labor pain and phantom pain top the list as some of the most intense pain people experience. So, I’ll share how pain combs work on both these types of pain for me.

Although my right leg has been gone for over 35 years, any time I think about it (like as I type this sentence), I have a tingly sensation all up and down “where my leg should be.” About once every 6 weeks, I have pain that is severe enough that I can’t sleep through it or work through it. Over the years, I explored LOTS of ways to cope with phantom pain, including medications, massage, acupuncture, reiki and other energy medicine, etc. (I luckily have finally found something that fixes it for me. One tylenol and one ibuprofen. If I only take one of the meds, it’s completely ineffective, no matter the dose. But together they’re really effective!)

Prior to that, one of the most effective pain coping tools I had found was combs. As the phantom pain intensifies, squeezing the comb helps distract me from it. It helps me feel much more in control. It significantly reduces the effects of phantom pain, so I had used them for many years.

When I had my third baby, I brought my combs to the labor. My labor was quite fast. About 3 hours start to finish, with the 3cm – baby out portion lasting about 30 minutes. So, it was VERY intense. I was in a lot of pain with contractions, and my teenage daughter remembered the combs and suggested them. I used them through the rest of labor, and they were what made contractions bearable for me. Managing a contraction without them was very difficult, so having them was my top priority. At one point I’d gone to the bathroom and set down my crutches and my combs. When a contraction came as I was hopping toward the sink, I yelled for the combs – my partner tried to give me my crutches – which obviously would normally be a priority for me. But at that point I only wanted the combs, because I knew they were what would make the contraction manageable. In the photo below, you can see I was still holding a comb to manage the cramping contractions of third stage labor after my son was born.

Birth 009

So, the question is: are combs effective for people who have not used them for other pain management? (In other words, did they work for me just because they were a familiar pain coping ritual from my life, or would they work for anyone?)

I used them with two clients in labor. They both found them helpful for a portion of their labor. And here are… quotes from others who have used combs during labor

  • When I would use the combs, I couldn’t feel anything compared to when I walked around without them. Tracy
  • When the contractions peaked, I would squeeze my combs, and there was a big difference between “comb” contractions and “non-comb” contractions. I wouldn’t do a birth without them. Rachel
  • I used two combs. They were men’s combs with the all the same size teeth, with blunt ends NOT pointed ends. I loved them. Didn’t want to let go the whole labour.  Marlee
  • Do not under estimate the power of a comb.  The small blue plastic comb… was better then an epidural!  There are pressure points in your palm that help with pain relief in labor.  As a contraction built, I would squeeze my comb as tight as feasible, the teeth digging into my palm, hitting those points and providing immense relief.  I couldn’t have done it without that comb! source
  • I held a small black hair comb in each hand, squeezing them into my palm… I’m not sure how my labor and delivery would have been without holding them, but it actually went pretty fast. And I liked the sensation when I tried it, which is why I kept on with it. Viola
  • During contractions I was sort of searching with my hands for something to grab onto, I think to feel more grounded. My doula slipped a comb into my hand and I squeezed it instantly. It was awesome! ,,, I was still very much in pain, but it definitely made a noticeable difference and provided me with a bit of instant relief. I remembered her slipping it into my hand, but I didn’t remember what ever happened to it after that. I asked Dh one day if I used it for very long, or if I just dropped it after that contraction. He said that after Ds was born he pried it out of my still tightly squeezed hand. – Jennica

Combs are a cheap tool to obtain, and small and easy to toss into a birth bag, so I recommend them for all doulas as an option to bring along and try.

To learn lots more about coping with labor pain, check out The Labor Pain Toolbox, Comfort Techniques, and other articles on this site (or listen to those episodes on my podcast) and to learn about all the other topics related to the perinatal period, check out the book I co-author: Pregnancy, Childbirth, and the Newborn: The Complete Guide