Tag Archives: labor pain

Pain Med Preferences

In classes, we talk about the Pain Medication Preference Scale from Pregnancy, Childbirth, and the Newborn. We have the expectant parents look at it together, and then encourage the pregnant parent to choose the number that best represents their preferences, and the support partner to choose what they WISH the pregnant parent would choose.

Then we have them discuss. Often they align, but not always. Sometimes there is a pregnant parent who is hoping for an un-medicated labor who has a partner who can’t bear the idea of seeing them in pain. Sometimes a pregnant parent wants medication, but the partner has concerns about side effects on them or the baby. I would much rather this issue come up during pregnancy when they can resolve it rather than arising without warning in labor.

I have designed a new worksheet that asks more questions about labor coping preferences that they can fill out separately, then discuss, to further illuminate these issues and enhance the discussion they can have about goals and preferences before labor begins. You can see the Pain Preferences Worksheet here – feel free to print and use in class.

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.

Grab Bags

Grab bags are a fun and interactive teaching technique that is easily adapted to a wide variety of topics. Basically, you gather up a collection of small items that symbolize each topic you want to cover – you may find these things around your house, in your kid’s toybox, at a Goodwill or a dollar store. Put them in a bag. At class, pass the bag around, and each student takes one (or each couple, depending on how many items there are). They then hold it up to show the other students, and they talk about how they think it relates to the topic, and you follow up with any additional information or discussion to add some more “meat” to the conversation.

What kinds of topics it works well for:

I use it for places where I have lots of little things I want to talk about that don’t need to come out in any special order… basically, whenever I find myself with a  lecture with 7 or more bullet points, I know that will seem like just an endless jumble of info to my students, so I start thinking about other techniques to use, and this is a great one.

I also find it works well for introducing the awkward topics. During the prenatal wellness section, when discussing all the things students “shouldn’t do”, it’s easy to turn into a nag. Here, when the candy cigarette appears, I “have to” talk about smoking but it  feels less judgmental. During postpartum, when the condom appears, it introduces the topic of sexuality after baby in a gentler way than me announcing “Sex” or writing it on the board.

However, don’t overuse it! I think it would feel gimmicky and tired if you used it multiple times in one series.

Here are examples of topics I have used it for:

Prenatal Wellness Lunchbox: I use one of my daughter’s old lunchboxes to contain this – I think it’s nice for our students to see signs that we are parents – it helps them connect. I fill  it with items that symbolize healthy choices for pregnancy, and not-so-healthy choices.

Sample items: calcium tablets, iron supplements, raisins, protein bar, tuna, caffeinated soda, a prenatal appointment reminder card, flyer for prenatal exercise class, cigarette, alcohol, Tylenol, condom, plastic baggies with “substances” in them. I label them so they know what it’s supposed to represent, and what it really is: “cocaine (baking powder)”, “marijuana (parsley)”, and so on.

Comfort items for labor: When I introduce it, I talk about how every pregnancy book has a list of items you should take to the hospital. But you often don’t need them all. For example, if it says “eye drops” and you don’t own any eye drops, you don’t need to go out and buy them! They’re not one of the comfort items you use in your life. But they are a good reminder to people who wear contacts to consider bringing contact supplies or a pair of glasses if needed. Then I say “So, this bag is just a collection of ideas about what kinds of things people find helpful for comfort in labor. Hold up your item, say how you think it would be useful in labor, and then say whether you think you would find it helpful.”

Sample items: heating pad, ice pack, massage tool, tennis ball, snack (clif bar, peanut butter crackers…), water bottle, CD (note that many students will use their smart-phone for music… the CD is a little dated, but I’m not putting my phone in the bag…), reflexology combs, toothbrush, mints, shorts, sweater, etc.

Postpartum adjustment: items that address physical, emotional, and lifestyle adjustment. Sample items: Maxi pad, peri bottle, tucks pads, stool softeners, condoms, breastmilk pads, kleenex (to symbolize baby blues), phone number for PPMD hotline, alarm clock (to represent sleep / frequent wake-ups), easy-to-eat food, phone to represent reaching out for support, red silk rose to talk about romance / relationship after baby.

A grab bag alternative… If you feel like you’re over-using the grab bag technique, but want some of the same effect, Teri Shilling from Passion for Birth has a postpartum bathrobe, where she fastens all these symbols all over a bathrobe that she wears when she presents this topic. It’s a very entertaining visual aid!

Try some experiments with grab bags. They’re always entertaining!

A note on number of items: My class size can vary from 6 couples to 14 couples. I may have 14 items in a bag. If I have 14 couples, they draw one item per couple. If I have 7 couples, they draw one item per person. But if I have ten couples, then I have two options for how to handle it. Pass the bag around once and have them take one item per couple, then pass it again, asking those who are willing to take a second so we can cover them all. Or, I can edit the bag before passing it around and only include the 10 most important items and put four others away.

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