Labor Pain Toolbox

This information also appears in audio form on episode 1 of the Transition to Parenthood Podcast.

illustration of toolbox

Over the past twenty years, I’ve taught childbirth education classes to thousands of expectant families, and the biggest question on their minds at that first class is always: How am I going to handle the pain? (Or for support partners: how am I going to support this person in coping with the pain of labor?)

So, we’re going to start there, with pain coping techniques. I think about this as stocking your toolbox – giving you lots of tools that you know how to use and when to use as this unique labor experience unfolds. Let’s “meet our tools” and learn the basics of how and when they are used, what the hoped-for benefits are and what the possible side effects are.

Non-Drug Coping Tools

There are lots of non-pharmacological coping tools which help you to work with your labor pain. They include cognitive tools like visualization, relaxation techniques, and focusing on your breathing; pleasant distractions like music, massage, aromatherapy and heating pads; and positions and movement that help labor to progress. In other episodes, I’ll offer details on these techniques and why they work. Although I will do my best at explaining them, the best way for expectant parents to really learn these skills is to take an in-person childbirth preparation class. The more skilled you are at comfort techniques, the more likely they will be effective during labor.

Some of the non-drug comfort techniques actually reduce the intensity of the pain (they help it to hurt less). All these techniques can reduce the unpleasantness of the pain – they help the laboring person feel as if she’s better able to cope – to feel like she’s working with her labor pain to make it manageable.

These non-drug coping tools are free to use, they can be started anytime and stopped anytime, most can be done anywhere, are in the control of the person in labor and their support team, and have few or no negative side effects.

Having a good working knowledge of several coping techniques is helpful for all people about to give birth and all support people. Since these options are no cost, no risk, it just makes sense to try them first. Even if someone has every intention of eventually using an epidural, starting with these and using them as long as they’re effective can help to reduce total pain med use and thus reduce possible side effects.

It is also helpful for everyone to have a good working knowledge of pain medications, which are also tools in the toolbox. In another episode, we’ll go into detail on all the options for labor pain medications, including IV opioids and nitrous oxide. For now, let’s talk briefly about epidurals, the most commonly used medication.

Epidural Analgesia

Epidural analgesia is given through an epidural catheter – a tube that is placed in your back, near the spinal nerves. The medication given is typically a combination of an opioid and an anesthetic. The anesthetic blocks pain stimuli from reaching your brain, so it actually reduces how much pain sensation you experience. But, it’s not good to take away all sensation, because then it can be challenging for someone to feel the urge to push and to push effectively. So, enough anesthetic is given to reduce the pain, and an opioid is also included. The opioid helps a person to care less about any pain they’re still experiencing. A research review found that if pain was rated on a scale from 0 to 10, an epidural lowers the pain about 3.5 points.

Once an epidural is started, it typically stays in place for the rest of the labor. About 90% of people report great pain relief. The trade-offs are that once someone has an epidural, they’re typically confined to bed and there’s a lot of equipment and monitoring, thus the labor may feel very medicalized. Common side effects are that blood pressure may drop, a fever can develop, the pushing stage may take longer or more medical interventions may be needed.

The Experience of Birth

There are lots of resources that stop with that – they list what the options are, how they work, and what the side effects are, then they leave it there.

But I think it’s also important to look at the lived experience of each option.  A birth can feel very different, depending on the choices that you make and which tools you use.

One research summary stated “they found no difference in satisfaction rates between those who had epidurals and those who did not.” But just a simple numerical rating comparison is not the whole story!

Think about this example… I might have three friends who all say “I had the best dinner last night. I would rate it 5 stars!” One tells me about a fabulous carnitas burrito and margarita. The other tells me about a great eggs benedict. And the third tells me about some amazing tom ka gai soup and yellow curry. They all made different choices about their meals, based on different goals, and they all lucked out by choosing good restaurants and no unexpected problems coming up. Three different five star meals.

But if I had switched any of their meals, would they have been equally satisfied?

I’m going to share two examples of safe and satisfying births, from opposite ends of the birth plan spectrum. Both of these parents had a “five star” experience, based on their preferences and goals.

Once, when I was shadowing a nurse at a hospital, I observed parts of one woman’s experience. This woman was having her third birth, and it was unfolding just as she had hoped. For all three of her babies, she had an elective induction at 39 weeks. As soon as contractions were established, she had an epidural catheter placed. This woman happened to be an anesthesiologist, and wanted to experience as little pain as possible, which makes sense for someone whose professional training is all about relieving pain. When I met her during labor, she was in a hospital gown, sitting in her hospital bed, reading a magazine, with her husband sitting and reading nearby, waiting for the labor to progress. She was lucky not to experience any of the possible problematic side effects from elective induction or from the epidural with any of the three births, which would not always be the case. But for her, they were all smooth and easy medical procedures, just as she had hoped.

On the other hand…

Once, I was at a baby shower, where the guests were asked to tell the stories of their births. When everyone else had spoken, the last person took her turn. She told us that she had planned a home birth with a midwife and planned for no pain medication. She went into labor at home – she had her partner and doula by her side, the birth tub was set up in the living room with the Christmas lights twinkling and her favorite music playing, the midwife came – all was going as planned. But she said “labor was so much harder than I expected. My partner was great… we tried lots of comfort techniques, and they helped, but I was still feeling really overwhelmed and wondering whether I could do it. The midwife suggested that I get down on my hands and knees. And as soon as I did, somehow my tiger came out! I rocked back and forth, and I roared! I felt so powerful! And I rocked and roared through the rest of my labor and it was great! And after the birth, when I lay in my own bed nursing my baby, I was still on this incredible high about how powerful I was!” At that point, the mother paused in her story, looked around a little meekly and said “I’ve never told anyone that story. But before that labor, I never knew I had a tiger. And it turns out that I’ve needed one. My younger son has lots of special needs and I’ve needed to advocate for him, and so I love that I have a tiger I can call on when I need it.”

Both of these mothers had, what was for them, a very positive, satisfying birth experience, based on their personal goals.

Now, if you think the first experience sounds perfect, we should acknowledge that there’s no guarantee it will go quite so smoothly for you – there can be risks and undesired side effects from pain medications and interventions, so you would want to educate yourself on those thoroughly in order to make an informed choice. And if you plan the perfect home birth, there’s also no guarantee that all will go smoothly, and I definitely can’t guarantee you’ll find your tiger.

Nevertheless, it is very helpful for expectant parents to spend time reflecting on the big picture of what they hope the birth will look like. I mean, if you really want a great carnitas burrito, you’d be sure to choose a Mexican restaurant, right? And you’d probably do a little research and ask for some advice and trust your intuition in making choices about which restaurant to go to and when, right?

In another episode of the podcast, we’re going to take a look at how you choose the best caregiver and the best birth place for you, how to choose childbirth education classes and labor support, and how those choices influence your birth. For now, we’ll just look at the role your pain coping choices play in the experience.

If you choose not to use pain medications, you’ll want to stock up your toolbox with lots of pain coping options. Listen to the other episodes of this podcast, but also take a local, in-person childbirth class, where you’ll see an instructor demonstrate techniques, you’ll get to practice them, ask questions, and get feedback.

Have realistic expectations about comfort techniques. If you expect them to “take away your pain” then you will be disappointed. But, if you want to feel like you have lots of tools to work with the pain, and make it more manageable, and that you have the strength to make it through, even if it hurts, then you’re more likely to have a positive birth experience. We call this “working with labor pain” because it is really hard work – both the person in labor and the support team should expect to work hard, all the way through the labor, whether that lasts a few hours or a few days. Support partners, you’ll spend time walking up and down the hallway, and slow dancing and climbing stairs, and sitting on the hard tile floor next to the bathtub and rubbing her back non-stop and maybe holding a bucket while she throws up. It’s hard work. But it can also feel empowering that you are doing this hard work together and that you can overcome these challenges.

If you choose to use pain meds, you’ll want to learn more about them, and you’ll also want to stock your toolbox with other coping tools…. 90% of people get great pain relief from an epidural, but for some they’re OK but not great… and for around 2 – 3% of people, epidurals do not provide relief, so everyone needs to have a fallback plan just in case.

Epidurals come with a lot of equipment and monitoring and that can make a birth feel very medicalized. It can be hard to think of it as the momentous life transition it is. I have heard tales from many births where the laboring person had chosen to go as far as they could without pain meds, so they were working hard, but they were surrounded by their support team and felt very connected. But then the epidural took effect and the physical pain went away, and everyone sat down, and turned on the TV to kill time waiting for the birth, or the support team fell asleep, and the birthing person felt alone or disconnected from the birth. It’s important for everyone to remember that labor support is still needed after an epidural is in place, and to still stay emotionally present in the experience.

Pain Medication Preference Scale

As you plan ahead for a birth, an important tool is the pain medication preference scale, which appears in our book Pregnancy, Childbirth and the Newborn or you can find it easily via a google search. It provides an easy shorthand for describing your preference on a scale from +10 which means you want anesthesia before labor begins and want to feel no pain at all, to – 10 where you don’t want pain medication no matter what. +10 and -10 are not realistically possible, but if someone marks them, it helps the caregiver understand just how strong their feelings are on, and helps them work together to build a realistic plan. Some other points on the scale, as examples, are +3 – I want to use some pain medications but I also plan to use self-help comfort measures for as much of labor as I can, and -5 – I have a strong desire to avoid pain medications. I will accept medications for a difficult or long labor.

Here’s how you’ll use the pain medication preference scale: During pregnancy, the pregnant parent looks at it and decides what rating best describes her preferences. Separately, her partner and other key support people look at it and decide what they wish her preference was. Then they compare answers. If they’re on the same page, then they move forward on making a birth plan. If they have radically different answers, then they sit down and talk it through and try to understand where the other person is coming from and come up with a plan they can work with together. In the end, the primary decision lays in the hands of the person who will be giving birth. If a support partner has a difficult time supporting that plan, they may benefit by having an additional person at the labor who can support it, whether that’s a friend, family member, or doula.

Supporting Someone in Labor Based on their Pain Med Preference

During labor, knowing someone’s pain medication preference is an essential guide for the support team.

Imagine I am supporting someone who told me that she is a +7 – I want pain medications as early in labor as my caregiver will allow, and definitely before labor becomes painful. Then I know that she is really concerned about the pain. Here’s the thing… most people experience some pain in early labor before it is time to go to the birth place and before an epidural may be available to them. I will need to provide extra-intensive labor support in early labor when she’s having any pain at all, and I also need to keep her informed as soon as pain medications become an option. I will have encouraged her to consult with her care provider at prenatal appointments to learn exactly what the guidelines will be so we can plan for it.

Now, occasionally, labor unfolds in unexpected ways – her labor may be so fast that she doesn’t get the epidural. Or, her labor may progress well without too much pain, and she may decide that she’s doing fine without the medication. So, the pain medication preference is just that – a preference that helps inform our support and her decision-making. But we’re not guaranteeing a pain medication plan, because we need to remain flexible in the moment and respond to her unique labor.

If I’m supporting someone who has told me she is a -7, which is defined as I strongly desire a nonmedicated childbirth because of its benefits to my baby and my labor, and the gratification of meeting the personal challenge. I’ll be disappointed if I use drugs, then that gives me a whole different job description! During pregnancy, I will encourage her to seek out education to prepare herself for labor, to practice comfort techniques in advance, and to be sure she has a strong support team in place. (Possibly including a partner, a supportive caregiver, perhaps a doula or an experienced friend as an additional support person.) We also set up a “code word” – a weird word that she wouldn’t otherwise say, like pumpernickel. If she says that in labor, she’s saying “I have changed my mind. I want pain medications.” Having the code word will give her the freedom to express herself during labor and know we will understand her. (For example, I had one client who had given birth before and she said “I will complain a lot in labor. I will say ‘I can’t! Give me drugs.’ That really is me saying “I need more help from you!” You’ll know that I actually want drugs if I say the code word ‘I’m done.’”)

During labor, I know I will be using many tools from my toolbox to support this person with a -7 preference. I also know that almost all women have moments in labor that I call hurdles… moments that are just too hard. Times when they say “I can’t do it!” And it’s not like they say that calmly… it’s more likely to be sobbed out as she looks at me with desperation in her eyes. “I can’t do it. I can’t. It’s too hard.”

If someone had told me ahead of time that they wanted pain meds, that’s likely when I’d check to see if they were available. But… for this person with the -7 preference, I look at her and say “I know, it’s really really hard. I get that. But let’s try something new, OK? Let’s see how that goes.” And then I reach into my toolbox and try something new.

I think about what I can do to change the environment – dim the lights? Turn music on or off? Go for a walk? Or stop walking and retreat to a quiet, private place? Try the bath? Or get out of the bath? Would a snack help?  I wonder about whether there is something that is causing fear or anxiety that I could reduce. I look for any coping rhythm and try to strengthen whatever it is that is helpful for her.

I suggest something new to try, and we try it for five contractions. Sometimes on the first one, she says “it’s not helping”. On the second, she says “I don’t think it’s helping.” On the third, it seems to be helping, and then if we’re lucky, then it helps for a few more hour. Until she hits the next “I can’t” hurdle and we have to try something new.

I believe that it takes time for a comfort technique to work because it takes time for the endorphins to kick in. As labor progresses, it gets more intense, and where the endorphins might have been enough to manage the pain till now, suddenly the pain is too intense. We have hit a hurdle. But if we can try something new to manage the pain, and it’s working, then after a few contractions, we settle into the rhythm, the endorphins kick in, and we have a new coping ritual to carry us for a few more hours.

On the other hand, if I try a new technique and it’s not helping after 5 contractions, it probably won’t help. So then we drop it and try something new.

Sometimes, someone who had rated that -7 will decide that labor is just too hard and she wants pain meds. I will say to her “Before labor, you told me that you were hoping to avoid pain medications. But I get that it’s really hard for you right now. I have a few more ideas in my toolbox that we can try – would you like to do that?” If they say no, then we work on both getting medications, and coming to terms with the fact that it’s OK if we need to adapt our plans to respond to the challenges of labor.

Labor Support

No matter what someone’s pain medication preferences are, one of the most essential tools in the labor pain toolbox is support. Continuous, compassionate, respectful labor support. That support can be provided by the laboring person’s partner or spouse, friends, family members, or by a doula – a professional labor support person. All of the episodes of this podcast have information about labor support, but I will have one episode where that is the primary focus, because it is so key to comfort in birth, to labor progress, and to satisfaction with the experience.

If you found this article helpful, I encourage you to check out more episodes of the podcast, find additional info on this site or in my book Pregnancy, Childbirth, and the Newborn: The Complete Guide. I also encourage you to seek out an in-person childbirth preparation class to learn more.

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