[This information also appears in audio form on episode 4 of the Transition to Parenthood Podcast.]
Pain vs. Suffering
Pain has two components: Intensity and Unpleasantness. Intensity is the objective experience – how it feels – where does it hurt, how much does it hurt, how would you describe the pain. Unpleasantness is the subjective experience – how you feel about the pain – how hard is it to cope with, and how much do you want to escape it.
Another way to describe this is pain versus suffering. You can be in a lot of physical discomfort and not be suffering – ask anyone who has run a marathon or climbed a mountain. It is hard and grueling but they are working to achieve a goal. So, that could be high intensity but low unpleasantness. On the other hand, you can have suffering with no pain or little pain. For an athlete with a minor sprain that is keeping them out of the final competition, the intensity of the pain is low, the unpleasantness is high. (Watch this video on Pain vs. Suffering.)
So, when considering labor, it’s worth thinking about both sides of labor pain. Often in hospitals, a patient will be asked to rate the intensity on a pain scale from happy face to frowny face. But that’s only half the story. I also want to ask the person in labor how she’s feeling about the pain. (See the Pain Coping Scale here.) Is it easy to cope with it? Or can she cope only if she works hard and has a lot of support? That’s what I call “working with labor pain” – where she may be in a lot of pain, but feels like it’s manageable. (She can still use the 3R’s.) Or… has the pain overwhelmed her and she’s suffering?
Even if someone’s pain medication preferences had led them to plan an unmedicated labor, if their labor unfolds in a way that, even with all the best labor support and active use of coping techniques, she is still suffering, it may be a time to re-evaluate the question of pain medication.
However, in our “labor pain tool box”, we can stock lots of no-cost low risk tools we can use to make labor pain more manageable before we turn to pain medications.
I’m going to cluster these tools into four categories: cognitive strategies, gate control, counter-irritants and body mechanics. If you’re wondering what those words even mean, don’t worry – I’ll give you a quick summary first, then several concrete examples.
- Cognitive Strategies – Choose what to think about during labor and how to think about labor differently. This is using things like visualization, affirmations, or a conscious reframing of the pain – like saying to yourself “yes, it hurts, but that’s a good sign – it means my baby will soon be here.”
- Gate Control techniques – Focus your attention on pleasant sensations, such as massage, music, or a bath to distract you from the pain.
- Counter-irritants. Create minor discomfort that you control to distract yourself from pain that you can’t control – like when you bite your lip to distract you from a painful procedure.
- Body Mechanics. During labor, the baby descends through the pelvis, rotating to find the best position for a smooth and easy birth. If the laboring person can change their position, use movement and massage, it can help labor to progress more quickly and less painfully.
Let’s start with that first category of cognitive strategies – what we think about.
These begin with educating yourself about the labor process before labor begins. If you understand what is happening and why, then during labor you can remind yourself that labor pain is normal, and that you have skills to cope with it. The unknown can be frightening, and any time we’re scared, things hurt worse than they otherwise would. Education gives us the information we need to interpret what is happening to us and reduce that fear of the unknown. [Learn how to choose a childbirth class.]
During labor, cognitive strategies again come into play. Whenever you start to focus on the pain, you can choose to instead think about something positive (like a self-affirmation or a prayer or even just counting out loud), or focus your attention on something else (a visual focal point might be something like a photo of a favorite vacation spot, or a beloved toy from your own childhood that you are looking forward to giving to your baby), or even just choose to bring your attention to your breathing instead of to the pain. Every time you catch yourself focusing on the contraction, just remind yourself – breathe in… breathe out.
Visualization is a cognitive strategy. There are two options I find most effective that we can try out here. First, a visualization tied into your breathing. Take a deep breath in, letting your belly expand then your chest… then let that breath flow back out. As you take the next deep breath in, imagine breathing in relaxation that flows through your body, and as you breathe out, release tension. As you breathe in, imagine breathing in strength and energy. As you breathe out, let go of fatigue. As you breathe in, breathe in confidence and faith that all will be well in the end. As you breathe out, let go of your fears. At any point in labor, you can imagine breathing in whatever would help you to cope and releasing whatever is not helpful to you.
Another helpful visualization is to imagine yourself in a safe place. Right now, try picturing somewhere that you feel safe and relaxed. Maybe it’s at the ocean, or by a stream in the woods, or at home in your big brown chair. (And if you’ve never been somewhere you felt completely safe, try to imagine what that might be like.) Think about what you would see in that place… is it light or dark? Is it warm or cool? What would you hear… the sound of waves, the creak of a rocking chair? What would you smell? Pine and cedar? Or chocolate chip cookies? What would you taste? Try to imagine this place with all your senses. The more you can bring it to life in your head, the more your body can relax, letting go of tension, releasing fears.
At any time when you want to relax, you can re-create this image in your head, and return to that feeling. [Note: on YouTube, you can find many recordings that guide you through a visualization of a safe place.] Partners, it helps if you know what safe place she pictures, so you can encourage her to think of it during labor, along with encouraging other cognitive strategies.
It’s important to note that cognitive strategies do nothing to affect the intensity of pain stimuli. We can’t expect them to. But they can do a great deal to reduce the unpleasantness of the pain and help you to feel more empowered.
Research has found that those who used cognitive strategies in labor were less likely to use epidural pain meds, less likely to need Pitocin to speed their labor, less likely to have cesareans, and had a higher satisfaction with birth.
Gate Control Techniques
The next category of comfort techniques is Gate Control Techniques – you could also call them “pleasant distractions”, where you focus your attention on something pleasant rather than on the pain. You already know this works. I’m sure you’ve had a time where you had a headache, and when you listen to music it helps. Or you felt sick but then you watched a movie and you didn’t feel nearly as sick while the movie was on. Or times you were so focused on work that you didn’t notice bodily discomforts – like the fact that it was way past lunch time and you hadn’t peed in hours!
Our brains can only pay attention to so many things at once. If all you do during labor is lay there and think how much it hurts, it’s going to hurt a lot. But, if your favorite music is playing, and your partner is stroking your arm in rhythm with your breathing, and you’re looking out the window at leaves blowing in the breeze, the labor pain is still there, but your brain has so many more pleasant things to occupy itself with that less pain stimuli gets through.
This relates to “the Gate Control Theory of Pain.” Imagine a gate where only so many things can pass through at once. Messages from your sensory pathways – what you see, hear, smell, and touch, travel fast, so they crowd through the gate, leaving behind the slower moving messages about abdominal pain. Having pleasant distractions means your brain actually experiences less of the pain. It is less intense and less unpleasant.
Think about what pleasant sensations you want to experience in labor:
- What pleasant sounds you might like to hear: favorite music? Your partner’s voice? The sound of the shower? The sound of ocean waves? For one of my clients, when I had asked her during pregnancy “when you were sick as a kid, what did your parents do that helped you feel better?” She told me that they read to her and that she still loved when her partner read to her. So at 3 in the morning, when she was in the bath tub, we read Frog and Toad Together and this delightful children’s story about waiting for the garden to grow was the perfect metaphor for a slow labor.
- What might you like to look at in labor? Pictures of loved ones? Art? A video? One of my clients looked at the tiles on the floor next to the bath tub… she would count the pattern during a contraction: white- white- white- white- pink. White- white- white- blue. She knew when she reached a certain point in the tile count, her contraction would be over.
- What smells would relax you? Note: at most hospitals, they ask that you not use aromatherapy that would send scents down a hall where they might trouble another person in labor. But you can have scents you can hold close – a lavender sachet, a cinnamon stick, scented lotion…
- What tastes do you enjoy? Make sure you know what the rules are about whether you can eat in labor. Then think about what tastes you like… you won’t want to eat chocolate all the way through labor, but an occasional taste of a favorite food can help you through a hard patch.
- What do you like to touch? A stuffed animal to stroke or squeeze? Your partner’s hand? A fidget? A stress ball? Do you like warm baths or hot showers? The feel of the water surrounding your body is a lot of gentle, relaxing stimulation of your senses.
- How do you like to be touched? What kinds of massage do you like? Make sure your partner knows. Do you want your hands or feet to be massaged to pull your attention away from where it hurts, or would you like pleasant touch where you are hurting? So – effleurage of your belly, or massage of your lower back? Or, if your back hurt, maybe a heating pad or an ice pack? (Make sure the support team knows whether ice or heat is preferable for the laboring person.)
Any of that pleasant sensation will help to distract from the labor pain. Research shows that people who used gate control techniques had lower pain intensity, were less likely to use epidural pain meds, and less likely to need Pitocin to help their labor progress.
Partners – a caution here… I’m NOT saying to just keep throwing more stimulation at her till she’s overloaded! Too much is way too much in labor. It’s like running through Times Square on New Year’s Eve.
Instead, I try to imagine weaving a quilt to gently wrap her in – a beautiful environment of compatible stimuli. So, if the music is playing, and the lights are dim, and she’s rocking, and I’m touching her in rhythm with the music and with her rocking and her breathing, that will work wonders.
The third category of comfort techniques is what researchers call Diffuse Noxious Inhibitory Control. Phew… I call them counter-irritants. Counter-Irritants also work with the gate control mechanism. Except instead of the partner providing pleasant stimuli, the person in labor does something which causes mild discomfort to distract themselves from the pain. Like they clench their fists or grip the rails of the hospital bed or the sides of the bathtub and squeeze till their knuckles turn white.
Many books and classes on coping with childbirth pain never even mention this idea. But I find that counter-irritants are a very effective way of working with labor pain. My initial experience with this idea came from outside the birth world…
I happen to be an amputee – I lost my leg when I was a teenager. Amputees experience something called phantom pain – where they feel pain from a limb that’s no longer there. It can be a little tickle in my missing pinkie toe, or it could feel like someone is stabbing my missing heel over and over with a large knife. When it’s mild, I ignore it. When it’s hard to ignore, pleasant stimuli can help – like watching a movie. But when it’s really bad, the main thing that helps is a counter-irritant – I bite my lip, I dig my fingernail into my thumb, or I hold onto a comb or hairbrush so its tines dig into my palm. Having pain that I can control distracts me from the pain I can’t control.
After my second birth, when I began working as a doula and childbirth educator, I learned that there are traditional cultures that use “birth combs” that they hold and squeeze. So, for my third labor, I brought my “pain combs” along. (I have a set of specially designed “reflexology combs” but you could just use any comb with thick tines that aren’t too sharp for your palms.)
When a contraction came, I would squeeze the combs in my hands – the stronger the contraction got, the harder I squeezed. Every time I found myself thinking about how painful the contraction was, I’d instead bring my attention to the discomfort of the tines pressing on my palms. It made the contractions so much more tolerable! Because I could control how hard I squeezed the combs, it seemed as if I had some control over my labor.
Many people in labor create their own counter-irritant – they bite their thumb, they dig their fingernails into their palms, they pound a fist into their thigh, or they pull their own hair. These are all things that are helping them in some way. So partners, don’t just tell her to stop! Her choice to do this is a case of “better the pain I can control than the pain I can’t control.” However, some of these things can cause injury. So, if she’s pounding her fist into her thigh, perhaps you can put a pillow there to cushion the blow. Or if she’s digging her fingernails into her palm, it may work to give her a washcloth or a comb to squeeze.
The effectiveness of counter-irritants comes from both gate control style distraction, and because these painful stimuli trigger the body to release endorphins, a natural hormone that reduces the intensity of pain sensations.
Beyond the “spontaneous counter-irritants” someone might instinctively use, there are also a few comfort measures you might employ that use this mechanism.
- Acupuncture and acupressure involve using needles or pressure on certain trigger points. According to traditional Chinese medicine, pain is related to blocked meridians where your natural qi energy is not able to flow, and these methods unblock those. Some western theorists consider these techniques a counter-irritant measure. You can look online for tips on using acupressure for labor pain.
- There is a childbirth method known as the Bonapace method, which includes painful massage on “trigger areas” – sensitive spots on the back. Learn about it at bonapace.com.
- TENS – or transcutaneous electrical nerve stimulation involves using a special device, and four pads on the laboring person’s back that create a buzzing, tingling, prickly sensation. This is a counter-irritant, where the brain is distracted by the annoying sensation and doesn’t notice labor pain as much. Just search online to learn about TENS for labor.
- Sterile water blocks are when a tiny bit of water is injected into a woman’s back. It stings like a bee sting and causes an endorphin release. You can ask your care provider whether these are used at your birth place.
Research has found that people who used “diffuse noxious inhibitory control” techniques had lower pain intensity, were less likely to use epidurals, and more satisfied with their births. Two trials found that women who used them felt safer, more relaxed, and more in control.
The fourth category of comfort techniques is what I’m calling body mechanics. Body mechanics is about using our bodies in efficient ways that help us conserve energy and prevent injury. In labor, we can use an understanding of physiology to help labor to progress as quickly as possible, with as little pain as possible.
During labor, the uterine muscles are working to thin and open the cervix and move the baby downwards. At the same time, the baby is rotating to find the best path down. A baby’s head is not perfectly round, and neither is a pelvis. At the pelvic inlet, it’s wider side to side, and at the outlet, it’s wider front to back. So, most babies start labor facing sideways, and then during labor, rotate to face front or back. If your baby turns to face your back, which 75% do, then your labor and delivery will be faster and easier than if they face your belly.
The best way to help your baby find the optimal position is for you to change your own position frequently, giving them plenty of pathways to explore. [See illustrations of effective positions for labor.]
The best positions for labor are upright, forward leaning, and moving in ways that open the pelvis. If you are upright – so standing up or sitting up, rather than lying down, then gravity helps your baby to descend. If you are leaning forward rather than backward, that helps the baby to rotate to the best possible position, which helps labor to progress well. And if you are moving, especially in ways that change the shape of the pelvis or open the pelvis, rather than standing still, that gives baby more opportunity to find the best path. An acronym for remembering these criteria is U.F.O. – upright, forward leaning, opening. (Thanks to Mindy Cockeram for this acronym)
Some great options for U.F.O. positions and movement are:
- standing and leaning your weight onto a chair or table, while you sway your hips
- slow dancing with your partner,
- climbing stairs
- sitting on a birth ball and rolling back and forth, or rocking in a rocking chair
- getting on your hands and knees and rocking back and forth or swaying your hips side to side
- pretty much anything that gets you upright, leaning forward, and rocking in rhythm
Research shows that upright positions and movement in labor may speed up labor and do increase satisfaction with the birth process. [Lamaze offers good info on the pros and cons of various labor positions.]
Another way we work with body mechanics is by using firm massage techniques on the pelvis. These are especially helpful in a slow labor or if the laboring parent is experiencing a lot of back pain.
For these, the laboring parent should be on her hands and knees, or leaning against a wall, or sitting backwards in a chair with her arms resting on the back of the chair. In any of these positions, her back is exposed, and she’s braced so that if you press on her back, it won’t knock her over.
For the double hip squeeze technique: The partner places the palms of their hands on the roundest, “meatiest” parts of her buttocks. Press those hands inward, towards each other, and toward her belly button. This technique relieves back pain and shifts the shape of the pelvis. (video)
For the counter-pressure technique, the partner places their palm on her sacrum – that flat bony area at the base of the spine above the tail bone. Press down firmly. During labor, if she’s having a lot of back pain, I will use this on most contractions, but I also want her up and moving around a lot in ways that allow the shape of her pelvis to shift between contractions so her baby has a chance to shift to a better position. (video)
Try both of these massage techniques out at home now – it should feel good, it may feel great. Adjust till it works for you.
So, we’ve covered four different categories of comfort techniques, with lots of examples of each one. They are:
- Cognitive Strategies – what can you think about in labor, or how can you think about labor differently, to help the labor pain seem manageable?
- Gate Control techniques – what pleasant sensations can distract from the labor pain?
- Counter-irritants – is there some other annoying sensation you could create to focus attention on?
- Body Mechanics – are you using a variety of positions to help the baby to rotate and descend?
Here’s a free printable handout to remind you about these comfort techniques handout. You can print it and tuck it in your bag for the birth.