What About Pain?

Pain is your body's way of telling you to take action. Consider the pain you feel when you burn yourself. The pain tells you to take your hand away from the flame! Similarly, when you sustain an injury, pain might influence you to apply ice or to get an X-ray.

Childbirth pain gives you a message: the time of birth is near. It encourages you to take action: to choose a safe place to give birth, gather your support people, and bring your baby into the world.

Yet childbirth pain is very different from most other types of pain.

• It is NOT is a signal that something is wrong. Childbirth pain helps you determine what is happening within your body, what part of labor you are in, and what actions you might take. 
• It is not constant, but comes and goes as the contractions do, giving you a chance to rest and regroup.
• It is pain with a positive purpose. Childbirth pain leads to the birth of your baby, which is greatly different from the pain of injury, infection, or chronic illness.

Recognizing the powerful effect that language can play on our perception, some childbirth experts suggest renaming childbirth pain to provide a positive association related to the work being done by the body, rather than the negative association that accompanies the word pain. One noted midwife, Ina Mae Gaskins, uses the term "rushes," and in HypnoBirthing® classes, women are encouraged to talk about "surges" instead of contraction pain.

How do I cope with pain?

Learning to cope with pain is not a new concept for most women. Everyone has experienced pain, and most of us already have identified measures that help. Here are some ideas that may help with childbirth.

• Try techniques that you found helpful before in coping with pain, such as cold compresses and rest for a headache or deep breathing or distraction for an injury. We will also review a variety of other techniques that might be new to you.
• If you have already had a baby, think about which pain management techniques were most successful to help you in preparing for childbirth again. If you felt somewhat unsuccessful in coping with childbirth pain before, you might be scared or nervous when you think about doing it again. Take some time to acknowledge this and recognize that these are normal feelings.
• Identify how you express pain. For many of us, this may be culturally or socially based. In some cultures, women are expected to be stoic about childbirth pain and may exhibit few signs of pain as they experience contractions. In other cultures, loud expressions of pain are expected. Of course, women may fall anywhere along this spectrum. You might find that you cry, moan, talk, or swear when you experience pain. Or you may close your eyes and try to remain calm. All of these responses are normal, yet some produce a greater reaction from those around you. After all, who doesn't want to help someone who is crying or moaning? As you prepare for birth, help prepare your support people as well, by talking or role-playing with them about how you might express pain and how they might best respond to this.
• Establish realistic expectations regarding childbirth pain. Some childbirth preparation materials talk about relieving discomfort, which might lead you to believe that it will go away with proper techniques. However, most women report that childbirth is hard work and painful and holistic pain management and comfort measures can seldom eliminate pain. What they can do is give you tools to minimize the amount of pain you have, effectively cope with the pain you experience, and conserve your energy to be able to effectively do the work of childbirth.

Give yourself permission to have your own experience with, and response to, the pain associated with childbirth. The best preparation is to remain open and receptive to the experience, as it is impossible to predict exactly what your labor will be like.

What causes pain in childbirth?

There are three basic types of pain in childbirth. Understanding what is causing pain during the different parts of labor helps you identify the work that your body is doing. Different techniques may be necessary to cope with these different sensations.

• The first type of pain is associated with muscle contractions as the cervix is opening or dilating. During this part of childbirth, the rows of muscles in your uterus contract (shorten), pulling open the cervix. Most women describe this feeling as an extremely strong menstrual cramp-like feeling. It may be felt in the lower part of the uterus, the low back, or both.
• The second type of sensation is a feeling of intense pressure as the baby gets lower and pushes on the muscles in the pelvis and on the bladder and rectum.
• The third type of pain, which occurs as the baby is being born, is a feeling of burning or stretching as the vagina and skin stretch to let the baby through.

How do fear and tension relate to pain?

In the 1920s, Grantley Dick-Read described what has become known as the "Fear-Tension-Pain" cycle. He suggested that fear causes a woman to become tense, and that tension increases pain. The increased pain, in turn, increases fear, and the cycle repeats.

Dick-Read suggested interrupting this cycle in two ways:

• Reduce fear by educating women about what is happening during childbirth
• Reduce tension by promoting relaxation, thus reducing the pain.

Most modern childbirth preparation methods have evolved from this theory.

What techniques can I try to cope well with labor?

There are many things you can do to minimize the amount of pain from contractions and to cope with the pain you do feel.

• Remember that your uterus is a collection of muscles. Like all muscles, those in your uterus work best with the least amount of pain when they are well hydrated and receiving plenty of oxygen. You can promote blood and oxygen flow to the uterus by drinking plenty of liquids and staying off your back. (Lying on your back can reduce blood flow to the uterus by almost 30%!) 
• Another way to reduce the amount of pain you feel with contractions is keeping your abdominal muscles relaxed. Many childbirth preparation methods focus on learning relaxation techniques to accomplish this. Progressive relaxation techniques, self-hypnosis, patterned breathing, visualization, and massage are all ways to promote muscle relaxation and minimize the amount of pain you experience.

Several weeks of practice will help these techniques become ingrained habits and easier to use during times of stress or pain. See the Mind Body Therapies topic for an explanation of several relaxation techniques. If you would like to try it, click on the Body Scan and Meditation [1] activities in the right-hand column to listen to a guided practice.

• The use of warm or cold compresses, to either your back or your low abdomen, might help alleviate pain. Hydrotherapy, either in a shower or tub, can also help to reduce pain and promote relaxation. You can sit on a stool in the shower if you are tired, and direct the flow of water at either your back or your abdomen, whichever feels best. If using a tub, the deeper the water, the better, as you can immerse your abdomen. If your tub is shallow, try putting a towel over your abdomen and have your partner slowly pour water over the towel during contractions. Prepare in advance: find a stool that fits in your shower or tub and doesn't slip, and also try the water pouring exercise ahead of time.
• Choosing positions of comfort is also helpful. During your labor, you might find that upright positions such as standing, walking, or sitting in a rocking chair or on a birthing ball (a physical therapy ball) might help you cope with contractions. Swaying or moving your hips could help, while also encouraging the baby to choose the best path through the bones of your pelvis. In general, you should follow your body's messages and choose positions that feel the best. There is one exception to this general guideline, and that is, as mentioned above, you should avoid lying on your back. Even if this feels better, it decreases the effectiveness of your contractions and may decrease oxygen to your baby.

If you find that your contractions are particularly painful in your back, this can be a signal that your baby is facing your front, or "sunny-side up," also called a posterior position. For some babies, this is the way they fit best through the bones of the pelvis, but most babies fit better if they are facing your back, called the anterior position.

If you experience back pain or if your midwife, doctor or labor nurse tells you that they think the baby is in a posterior position, use this pain as a message, and try some forward leaning positions that might encourage your baby to turn. You may try lying on your side, tipped far over almost onto your stomach. Or try spending time resting on your knees and forearms, or standing and bending forward at the waist. These positions also let your partner apply firm counter-pressure to your back or hips, which may greatly help alleviate the back pain. Ice packs or warm packs applied to your back may also help. You can combine therapies, by using these forward leaning positions in the shower or tub. Your midwife or doctor could also help alleviate back pain by the use of sterile water papules, which are small injections of water just beneath the skin in your low back.

The books listed below under Additional Readings describe these and many other techniques for coping well with childbirth. Another resource is easily available on the web: Penny Simkin is a physical therapist and childbirth expert who has written several books and journal articles. She has also published a downloadable pamphlet Comfort in Labor [2]. When you reach the website, it will ask you to register, which is free.

Are there other techniques to reduce labor pain?

Acupressure is another method of pain reduction some women have used very effectively during labor. A variety of pressure points may be used, and if you are interested in these techniques, you should do some advanced planning. While you or your partner may do them during labor, you might want to visit an acupressure practitioner with your partner before labor begins to make sure you understand the technique. An excellent resource for using acupressure in labor can be found in the web publication Natural Pain Relief Techniques for Childbirth Using Acupressure [3], by acupuncturist Debra Betts.

Other alternatives for reducing pain include the use of a transcutaneous electrical nerve stimulation unit or TENS unit. This is a device with small electrodes that you place on your skin, and then use to deliver electrical impulses during your contractions. You can rent one of these units ahead of time. Ask your provider for a referral to a physical therapist or chiropractor who can help you obtain one and show you how to use it.

Other complementary therapies such as Reiki [4], Healing Touch, or Reflexology [5] may also be used during labor. You may include a practitioner of one of these methods on your birth team, or, if you have planned in advance, you may learn techniques such as Reiki yourself.

Finally, consider the addition of a doula to your support team. A doula is a person who provides continuous support to a woman in labor. She may be certified through a doula training organization and has studied a variety of techniques for coping with labor. She remains with you throughout labor, and can help you and your partner use the right technique at the right time during labor. The use of a doula has been consistently shown to be associated with shorter labors, less use of pain medication, and fewer cesarean sections. The topic How Can I Arrange the Best Birth Support has additional information about how to find a doula.

What about pain during the last phases of childbirth?

As your labor progresses, and your baby moves further down in the pelvis, your feelings of pressure may increase. Eventually, this feeling of pressure will change, and you may begin to feel a need to push or bear down. For some women, this feeling is subtle, for others, it is overwhelming. Again this feeling is a signal or message, telling you that it may be time to begin pushing during your contractions, to help bring your baby down further. Some women feel this phase of labor is a relief from the pain of labor contractions, as they can start responding to the contractions by bearing down, helping with the downward movement of the baby.

Generally, you may follow your body's messages and push as you feel comfortable. You may do this in a variety of positions; view examples of effective birthing positions. Your midwife, doctor, or labor nurse may help give you guidance to push effectively.

Finally, as your baby is being born, you may feel intense burning as the baby comes out. While this is normal, and signals that your vagina and skin are stretching to make room for the baby, many women feel that they are tearing. Using warm wet compresses on your perineum (the skin between your vagina and anus) as you push may help guide you in knowing where to push and can alleviate some of the pain with crowning.

Your midwife or doctor can provide verbal guidance as you to push gently as the head is being born (called crowning) to help minimize any tears. The good news about this burning is that it is short lived, lasting only a few contractions at most.

Especially for first time mothers, doing perineal massage (massage of the skin around the back of the vagina) during pregnancy can help prevent tears, and give you some feeling of what this stretching sensation feels like. You can read about performing perineal massage [6] and see some pictures at the University of Michigan's School of Nursing website. Either you or your partner may perform the massage.

How is pain handled in the hospital?

In United States hospitals, pain management is usually a nursing performance goal, and nurses in hospitals are expected to assess and treat pain. Hospital funding from sources such as Medicare is dependent on hospitals meeting pain management requirements.

Given this, you may be asked to "rate" your pain on a scale and offered medication if your pain is above a certain level. These measures help the hospital staff to not only treat pain, but also to meet the requirements of their review committees.

Your labor nurses might suggest medication or epidurals as measures to help cope with labor pain. Because these options are popular among laboring women, your nurses might have little experience with some holistic measures for coping with labor. On the other hand, your nurses might have a wealth of experience with alternative methods for helping women with labor.

You can help your labor nurse and other hospital staff by:

• Telling them about your plans for coping with labor soon after your arrival, and asking for their help. If you have prepared a birth plan, show it to them.
• Letting your nurses know how you express pain, especially if you find that being very vocal is helpful to you.
• Letting your nurses know what has worked for you so far in your labor and what your plans are for pain management.
• Asking for other suggestions they might have.

You can also ask your nurses for their help in maximizing your freedom of movement and your ability to choose comfortable positions. Some hospital practices, such as continuous fetal monitoring or IVs can limit your activity. You can ask for intermittent monitoring or a saline lock instead of a continuous IV. If continuous monitoring becomes necessary, it does not mean you must stay in bed. You can ask to have rocking chairs and birthing balls moved close to the monitor, or to use telemetry monitoring if you wish to get into a tub or shower or walk.

What if I can't cope using these techniques?

Not every technique will work for every woman, and each labor is unique. Adopting a holistic approach to childbirth, by the very definition of the word "whole," may also mean considering the use of pain medication, or epidural or intrathecal (spinal) anesthesia.

Even if you don't think you will use them, ask your midwife or doctor what pain relief methods they commonly use, so that you can read about their benefits and risks before labor begins. Be sure to review the topics Why Should I Consider Holistic Childbirth and What Factors Influence the Natural Progression of Childbirth, as they contain information about the potential risks and benefits of pain medications and epidural anesthesia. If you begin to think about using medication during labor, keep the following guidelines in mind.

• Try not to make a decision at the peak of a contraction, but use the time between contractions to discuss what you've tried so far and what you might like to consider. Sometimes, more support can make a difference.
• Ask your nurse, midwife, or doctor not to offer pain medication while you are having a contraction. 
• Consider how far along you are in labor: perhaps ask to have your cervix checked. If you know that you may only have a little time to go, this might influence your decision. 
• Recognize that the use of medication is simply a technique at the end of a continuum, and not evidence of personal failure or failure of the use of other techniques. Remember that by using a variety of pain reduction techniques prior to medication, you reduce the amount of medication you take and thus the risks involved.

Additional Readings

Childbirth Preparation Books:

Active Birth: The New Approach to Giving Birth Naturally, Revised ed. 1992. Janet Balaskas. Harvard Common Press.

Birthing from Within. 1998. Pam England, CNM. Partera Press.

Ina May's Guide to Childbirth. 2003. Ina May Gaskin. Bantam.

Natural Childbirth the Bradley Way, Revised ed. 1996. Susan McCutcheon-Rosegg. Plume.

Pregnancy, Childbirth and the Newborn: The Complete Guide. 2001. Penny Simkin. Meadowbrook.

The Thinking Woman's Guide to a Better Birth. 1999. Henci Goer. Perigee Trade.

Especially for your partner:

The Birth Partner, 2nd Ed. 2001. Penny Simkin. Harvard Common Press.

References

Albers LL. (2007). The evidence for physiologic management of the active phase of the first stage of labor. Journal of Midwifery & Women's Health. 52(3), 207-215.

Caton, D., Corry, M.P.,  Frigoletto, F.D., Hopkins, D.P., Lieberman, E., Mayberry, L., Rooks, J.P.,  Rosenfield, A., Sakala, C., Simkin, P., Young, D. (2002). The nature and management of labor pain. American Journal of Obstetrics & Gynecology, 186(5), S1-S15.