Understanding Labor Pain

This information also appears in audio form on episode 2 of the Transition to Parenthood Podcast.

For many people, the better they understand their pain, the better they can prepare for it, and cope with it. The first question many people ask is:

Does labor always hurt?

No, not always.

Once, at a birth, I worked with an interpreter who was surprised to discover that the laboring mother found labor painful. The interpreter said she’d had two births, and with each just had mild discomfort for a few hours, then the baby was born. Some people absolutely do have this mild experience of labor.

On the other hand, some parents have incredibly intense contractions, but they perceive them as pleasurable, not painful. Some even have what’s called an “orgasmic birth”. This makes more sense than you might think, because oxytocin, the hormone that causes labor contractions, is also present in large amounts when you orgasm.

Many midwives recommend that couples in labor use lots of loving touch, open mouth kissing, nipple stimulation and perhaps love-making, all of which stimulate oxytocin flow. The common line is: “what got the baby in can get the baby out.”

Most of the stories I have heard of orgasmic births are from women who: had given birth before, who were birthing at home or in a place they felt very safe, surrounded by people they knew well who were confident about their ability to give birth, and who were raised in a culture where birth was perceived as normal and not painful. An orgasmic birth is much less likely for a first time parent giving birth in the hospital who has been raised in a culture like America where birth is viewed as traumatic. (Watch a Ted Talk from midwife Ina May Gaskin on Reducing Fear of Birth.)

So, I don’t expect that many people listening to this podcast will end up having an orgasmic birth – but I do like to put that idea out there, because if you can interpret any of your labor sensations as just “intense” rather than interpreting them all as “pain”, I think that can lead to a less painful birth.

There is a childbirth preparation method known as Hypno-Birthing which has enabled many people to have a very positive labor experience with minimal pain. Hypno-Birthing uses deep breathing and visualization techniques to reach a state of deep relaxation without the fear that can increase pain sensation. (Here’s a sample script.) Search online for more information about this method.

Some parents are definitely able to achieve a pain-free birth through using other comfort techniques I will describe on this podcast, including movement, massage, warm baths, and more. It is definitely worthwhile to learn all the comfort techniques you can. It’s great to use oxytocin and endorphin building techniques, whether that’s love-making or just anything that makes the birthing person feel safe and loved. These will definitely reduce the pain you’re experiencing, and if you’re lucky, you may have a pain-free or even orgasmic birth, and wouldn’t that be fabulous?

However, I usually tell my students to expect that even with these techniques, labor may hurt. So they need to make a plan for how they will cope if it does hurt.

Why does labor hurt?

For nine months, your cervix has had one important job – to keep the baby in. Now, over a period of about 24 hours, that cervix will soften, thin, and open up to let the baby out. During labor, the large muscles of the uterus contract – tighten – for one full minute of hard, intense work, then relax, then a couple minutes later do it again, and again for hours. If you did this hard work with any of your other muscles, you’d expect them to start burning with the exertion, right?

There’s also the pressure of the baby’s head on the pelvic floor, bladder, and rectum and the stretching of the vaginal tissue. That’s a lot of physical sensations, guaranteed.

If you can try to accept those sensations and imagine yourself working with the pain, that may make it more manageable. If you interpret all those sensations as pain, you dread the pain, and fight the pain, that can make it much worse.

What makes labor pain different than other pain

It can be summarized in with the acronym P.A.I.N. The P is for purposeful – this labor pain has a purpose – it’s a sign that your body is working really hard to bring your baby into the world. It’s also a signal for you to go to someplace that is safe to give birth and to gather the people around you who will help you with your labor. Many people experience less pain once they feel safe.

The A acronym is for Anticipated. You know that labor pain is coming, and you’re preparing for it, by listening to this podcast, right? You are making a plan for what factors you want to have in place to help you to cope. And during labor, you can anticipate when the next contraction will come by noticing the typical pattern of contractions. Predicting when the next one will arrive helps you prepare for it.

The I is for Intermittent. Contractions are not continuous – they come and go. Take full advantage of the breaks between contractions to rest and relax as much as you can. One tool to help with that is the Cleansing Breath. As a contraction fades away, take a deep breath, and blow it out. This signals to you and to everyone in the room that the contraction is over, and reminds you to let it go and relax. Partners, if you see the laboring person still tight and tense at the end of a contraction, encourage her to use the cleansing breath.

The N in our acronym stands for Normal. Other times in life, pain is a signal that something’s wrong, and that we need to figure out what it is and fix it. But in labor, we know exactly why the pain is there. If we can relax and say, “OK, the pain sucks, but it’s normal and I just need to figure out how to cope with it” it will begin to feel more manageable.

Now, I remember as a first-time parent, when the labor contractions kicked in, thinking “OK, I know they said it was going to hurt, but this REALLY hurts… can that possibly be normal???”

I wish I’d had a doula or other experienced person by my side to reassure me that yes it’s hard and yes it’s normal and to help me focus on what I needed to do to work with it.

 What are labor contractions like?

A contraction builds in intensity – picture a mountain – when you just barely feel the contraction, it’s like starting to climb the mountain. As the muscle tightens more and more, it feels more and more challenging until you reach the peak. Then you feel the tightening begin to relax and fade away, as you go over the peak of the pain, and return to comfort.

Then there will be a break before the next contraction begins.

A series of contractions may feel like waves – where you ride the crest of one, come down off it, then feel another wave carry you up again. Early in labor, the contractions may be short, and may have a long distance between them. The further you go in labor, the longer the contractions are, the stronger they are, and the closer together the waves crest.

What does a labor contraction feel like?

Some people describe them as lower abdominal pain, similar to menstrual cramps, but most say “contractions were WAY worse than any menstrual cramps I’ve had!” Some experience them mostly as a restless, irritable low backache – it may come and go in waves, or may be continuous. Some say they feel the pain in their back first, then it wraps around to the front – sort of like putting a belt on, and the further you go in labor, the wider the belt until it may stretch from your fundus (the top of your uterus) down to your upper thighs.

People who have given birth may describe the pain as dull, sharp, throbbing, crampy, or burning.

I remember in my first two labors feeling like everything in me was pulling inward, and gathering all my attention at the core of my body. One of my doula clients described this as the shrink wrap effect – if you’ve ever used the plastic film that shrinks down as you heat it, it just keeps getting tighter and tighter around whatever it’s wrapped around. In late labor, you’ll also feel an intense downward pressure.

What makes labor pain worse?

A certain amount of discomfort may be inevitable. However, it helps to be aware of things that make it worse than it needs to be, and how we can minimize those factors.

Fear-Tension-Pain Triangle

In the 1940’s, a British obstetrician named Grantly Dick-Read observed that some women in labor experienced much more pain than others. He developed a theory of the fear-tension-pain triangle. The more fear someone has, the more tense their muscles become, and the more pain they experience.

I want labor support partners to think of ways to transform that triangle… if we increase a laboring person’s sense of safety and confidence, fear decreases. If we can help her to relax, tension decreases. If we can increase her physical comfort, pain decreases.

Transforming Fear into Confidence

Let’s start with fear. Prior to the labor, learning more about what to expect, learning and practicing pain coping techniques, lining up support people and making a birth plan can increase confidence. Choosing caregivers you trust, and a birthplace where you feel safe and supported will reduce fear. During labor, one of the key roles of the support team is to consider all the ways to increase the sense of safety for the person in labor. When she feels safe, her oxytocin and endorphins increase, her adrenaline decreases – this means less pain and faster labor progress. This topic of reducing fear and increasing sense of safety is so important, it will be its own podcast.

Transforming Tension into Relaxation

The next factor in transforming the fear-tension-pain triangle is to think about ways we can transform physical tension into relaxation. Some options are slow deep breathing, relaxation techniques, massage, and warm baths.

Slow deep breathing is a great place to start. Right now, just take a deep breath in through your nose, letting your belly expand, then your chest. Then let that breath out through your mouth. Ah… don’t you feel more relaxed after just one deep breath? As you read the rest of this article, just keep that up – take nice deep breaths in through your nose, and out through your mouth. (Learn more about breathing techniques in labor and the research on their effectiveness.)

One effective relaxation technique is to tune into your body, notice where you’re feeling tension – then take a deep breath, visualizing relaxation flowing in to that tension spot, and as you breathe out, imagine the tension escaping with your breath.

Another technique is to do a conscious process of relaxing all your muscles – you can run through them in your mind, or your partner can coach you. (We have a script for this in Pregnancy Childbirth and the Newborn. Or here’s one I found online.) First you relax your toes, then feet, then ankles, and so on till your whole body is relaxed.

Massage will reduce muscle tension. There are different kinds of touch that are helpful. Some people like still touch – just a hand resting on them, anchoring them and reminding them to relax. Some like light stroking – stroke in one direction, like down their arms, then lift your hand to the starting point and stroke again – do it in rhythm with her breathing. Some like effleurage – light strokes in a circular motion. Many pregnant people unconsciously massage their own bellies this way. Some like firm kneading massage. Or a combination – firm massage on their shoulders then soft strokes on their arms. And sometimes it depends on their mood of the moment.

A great way for a couple to prepare for labor is to spend a few minutes of each day trying out different massage techniques and learning what each person likes. This also allows you to learn where the other person typically holds their tension, so during labor, the support person can be on the lookout for those hot spots. (Search YouTube for videos for Massage in Labor, and check out the evidence on the effectiveness of massage.)

Warm baths are very relaxing for many people, though they don’t work well for others. (Learn more about how to use water for comfort in labor.) In my experience, there’s a few key factors. The temperature has to be just right – warm enough that it feels great, but not so hot that you have to keep getting up out of the water to cool off. Bigger tubs where the laboring person can get into any position are best. In a smaller tub, partners can suggest that lying on her side or being up on her hands and knees may feel better in labor than lying on her back. I usually put a hand towel over her exposed back, and pour warm water over her in rhythm with her contractions to keep her back warm. Don’t expect the bath will fix their pain immediately – it won’t – it takes a while for endorphins to kick in, so commit to staying in the bath for five contractions – it usually will be helping by that time – if it’s not, then get out and try something else. (Evidence on effectiveness of hydrotherapy.)

If a laboring person is just not able to relax, nitrous oxide may help to reduce emotional anxiety enough that they are then able to relax their bodies.

At times, if someone is holding a huge amount of physical tension, it can slow her labor, and it appears in those uncommon cases that an epidural may allow her to relax enough to allow the labor to progress. However, since an epidural comes with more medical procedures and possible risks, it would be better to try non-drug ways to relax before taking this step for a stalled labor.

If you want to learn more about reducing physical tension in labor, we discuss slow breathing, massage, hydrotherapy, and relaxation techniques in detail in chapter 12 of Pregnancy, Childbirth, and the Newborn.

Transforming Pain by Increasing Physical Comfort

The third factor in the fear-tension-pain triangle is pain. We may not be able to take away labor pain, but we can think of all the other ways we could increase physical comfort.

Even when not in labor, if you’re too cold or too hot or hungry or thirsty then it is hard to be comfortable, right? Or if you’ve had to sit in one position for too long, or you really have to pee. So support partners, that should give you some clues about easy ways to increase her comfort.

After every contraction, offer a sip of water – she doesn’t have to take it – no need to over-hydrate. If it’s been an hour or more since she’s gone to the bathroom, suggest it. When we’re not in labor, we notice that we need to pee, but I’ve seen many people in labor who have that uncomfortable sensation in their lower belly and decide it must just be part of labor!

Suggest moving around and changing positions. Rituals – doing the same thing over and over – is reassuring in labor, so a person in labor may want to be in the same position for a long time, but if she seems open to changing, suggest a new position.

Make the environment comfortable – dim the lights if that helps the laboring person relax. Music if she likes it, quiet if she prefers that. Figure out how to get the room to a temperature where the person in labor is comfortable. Support partners – make sure to pack a pair of shorts and a sweater so you can adapt if the room temperature that works for her isn’t working for you.

Regarding hunger: In general, when we do hard physical work for many hours, we would want to eat, right? Although if the workout is really intense, like running a marathon, we may instead avoid eating. Labor is hard physical work, so many midwives recommend that in a normal labor, we make food available, but it is the woman’s choice whether or not to eat.

However, some hospitals have blanket policies that discourage food in labor for all patients and some care providers recommend against food in labor of patients with certain health conditions.

These policies are related to anesthesia concerns. If there is a high likelihood of a patient needing an emergency cesarean under general anesthesia, then having food in their belly increases the risk of vomiting and aspiration and aspiration related pneumonia which could lead to death. However, the chance of this is really low. Maybe in the realm of a 1 in a million chance. (If you’d like to read a summary of all the research related to this topic, check out the blog Evidence Based Birth.)

Ask your care provider at your next visit: for your unique health situation, what their recommendations and your birthplace’s policies are regarding eating and drinking in labor and what the reasoning is behind those recommendations. Then you’ll know your options.

Will you be limited to ice chips only? Will they recommend limiting to “clear fluids” which includes sports drinks, coffee, tea, broth, Jello and popsicles. Or can you choose what to eat? If you can choose, the best foods for labor are a mix of carbs for quick energy, and protein for some staying power. It’s probably better to avoid fatty foods that are hard to digest or spicy and acidic foods that hurt to throw up, as many people (though not all) vomit sometime during labor.

I once worked with a woman who had diabetes and whose caregiver had OK’ed eating in labor. This person had told us before labor that she wanted to avoid pain medications, but several times in labor, she hit a “hurdle” and said “this is too hard, I can’t do it, I need pain meds.” Each time her partner said, “We can absolutely do that, but first, let’s take your blood sugar and see if you need a snack.” Each time, her blood sugar was low, and she would eat a snack: a yogurt tube, toast with peanut butter, a handful of nuts, a hardboiled egg and some crackers… And after each snack, and then she was able to cope with the pain again. Then in a few hours, she would tell us again that it was too hard… then another snack would carry her through a few more hours. In the end, she achieved her goal of a labor without pain medications, and those snacks played a huge part in that achievement.

Takeaways

So, to summarize: in order to increase physical comfort, and thus decrease unnecessary pain, it is helpful for the laboring person to be a comfortable temperature, wear comfortable clothes, change positions from time to time, eat if possible, drink water as desired, and go to the bathroom as needed.

So, support partners. Remember the fear-tension-pain triangle. Try to think of all the ways you can transform that to a confidence-relaxation-physical comfort triangle.

Follow the lead of the person in labor. If you do anything (whether it’s touch her, talk to her, put music on, whatever) and it increases her tension – you see her stiffen, then stop doing that, and re-assess. Try something new on the next contraction. Whatever helps her to soften and relax will decrease her fear, decrease her tension, and thus decrease her pain.

I hope you’ve enjoyed this article. However, this material is not intended as a substitute for childbirth preparation classes! At an in-person class, your instructor will demonstrate techniques, show visual aids and videos of people in labor, and tell stories of births she has witnessed. All these techniques will help you better understand, remember and apply this information to your labor.

Resources for More Information