Tag Archives: coping

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

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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, 1: Intensity &Unpleasantness

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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.