27 Sep Working with pain in labour
By Barbara Hanrahan – SACPE course developer
Much is written on understanding pain and pain relief in labour. When new mothers are asked to describe the pain they felt in labour there are a variety of answers. Some women will depict a positive experience by saying labour was exhilarating, gave her a sense of strength and feel empowered. Others will depict a negative experience saying painful, exhausting and traumatic. Whilst some women may even say tedious, uncomfortable and manageable.
The preparations a woman makes for birth influences her birth experience. When women are taught coping techniques and choices of pain relief, they cope with pain during contractions.
“The pain is hard to explain. The contractions were intense. My body demanded my complete attention. The contractions were all my body would let me think about, just then.”
An important part of coping with pain in labour is for the woman to have the continuous support of a birth companion of her choice. Research has shown that continuous labour support reduces complications, decreases medical interventions and supports the transition the woman makes from pregnancy to being a mother. Powerful stuff!
For most women there is a plethora of preparation courses –childbirth education classes, the internet, hired doula, relaxation, books ……..
So what should a woman and her partner know about pain in labour?
Understanding and working with the physiological process of labour and birth
When women, partners, birth companions and midwives know and respect the physiological process of labour and birth – they are better at giving comfort, encouragement, suggesting helpful positions and using comfort measures that increase oxytocin and endorphins. Thus promoting a progressive physiological labour and birth.
Pain in labour isn’t a sign of harm or injury – It’s a sign that the labour is progressing. Pain with a purpose. Women need to know that the pain in labour is temporary and normal.
Contractions are the work of the uterus in moving the baby down onto the cervix where the pressure from the foetus’ head triggers more oxytocin to be released. Thus contractions start to last longer, feel stronger and are more rhythmical. Longer, stronger and closer together is a sign of active, accelerating labour. The baby pressing on the cervix and the surge of natural oxytocin helps shorten, thin and dilate the cervix. Women and their partners need to know that THERE IS NO PAIN BETWEEN CONTRACTIONS. Relaxation between contractions helps the woman to prepare for the next contraction.
Why labour is painful
The physical changes that contribute to pain in labour are
- Reduced oxygen to the uterine muscle and the build up of lactic acid during contraction causes pain. As soon as the contraction is finished, the oxygen supply floods into the uterine muscle and to the foetus.
- The stretching of the cervix as it effaces and dilates (thins out and opens) – remember that the cervix is the bottom end of the uterus so the stretching and thinning is brought about by the contractions.
- Pressure of the baby on nerves in the cervix and vagina, as well as on the urethra, bladder and rectum. It is essential for a labouring woman to empty her bladder regularly – not just so as to avoid a full bladder impeding the descent of the foetus – but also because a full bladder increases the pain during contractions as it is squeezed and pressurised.
- Tensing and stretching of the ligaments that support the uterus in the pelvis and the pelvic floor muscles.
10 KEY messages about coping with pain in labour are
- Continuous support through the whole labour.
- Positioning so that the potential of the pelvis is increased by 25%. eg leaning forward against the bed – lifts the sacrum and assists in providing more room for the baby as it moves into the pelvis.
- Upright positions that use the force of gravity to aid the descent of the foetus.
- Hydration – a woman needs to drink a minimum of a cup of fluid an hour to prevent dehydration, which may cause foetal distress.
- Using comfort measures for coping with the pain during contractions – this reduces the pain perception at the time. eg hot pad; massage, breathing through each contraction, a focal point eg A picture that you take with you to aid coping skills, or distraction eg a visualization – such as a flower slowly opening.
- Involving the partner in these comfort measures – where, how and when to massage the woman’s back, ensuring the woman is sipping fluid continuously, wiping her brow with a cool cloth, fanning her during a contraction and much more. This helps the partner to “sit in the woman’s pain” without feeling that he needs to rescue her.
- TOUCH, TOUCH – pleasurable sensations (including smell, taste, hearing….) “race the pain to the brain” and release endogenous endorphins which assist the woman during the contractions.
- Create a conducive environment around you ensuring your dignity and sense of privacy.
- Using affirming words and terms rather than medical terminology. Giving the woman positive feedback.
- Honesty about pain relief options that are viewed from the risk : benefit as it specifically applies to that individual woman and her labour. It’s useful to also ask “what happens if we wait?”
Pain in labour is usually part of the physiological process and progress of labour. Suffering is not. Pain is an unpleasant physical sensation. Suffering is a debilitating emotional state. Suffering in labour comes from a perceived threat – physical or psychological; helplessness; feeling out of control; fear of dying; and fear of the baby dying.
Part of childbirth preparation is to assist the mother in identifying factors that will increase her perception of pain in labour and what she can do to remove or modify such factors.
Expectations of labour and birth that don’t match up to what the woman is experiencing. Encourage her to verbalise and then assist her adaptation of expectations.
Feeling watched or judged or by being around unsupportive staff or relatives. …. Turn your head away from the cause of this anxiety, put a light shawl over your head and shoulders to reduce visual impact.
Lack of preparation – continuous affirming support through the labour.
Misinformation about labour and birth – uncovering the woman’s core belief about labour.
Decisions or feelings that are ignored and make the woman feel disrespected.
Frequent and long contractions which may cause you to lose your focus and panic. Drop your lower jaw – this helps you loosen your core and pelvic floor muscles. Pain perception decreases.
Long labour that could lead to exhaustion – encourage fluids and energy nibbles, assist with relaxation techniques between contractions, affirming words and body language, periodic resting in an upright chair or on her side on the bed.
Unhelpful hospital policies – eg partner or birth companion excluded from accompanying the labouring woman; interventions that limit mobility such as a continuous blood pressure cuff or continuous electronic foetal monitoring.
When woman are encouraged to release control during labour and birth – they feel more “in control” vs trying to control the labour experience. Losing control happens when the labouring woman feels overwhelmed and helpless. The best remedy for helping a woman who feels she has lost control is continuous, affirming support and encouragement. Powerful stuff! Birth plans must be flexible with options. Helping the woman focus on one contraction at a time.
“My partner verbally celebrated the passing of each contraction with… well done, that contraction has gone, down and dusted…. Which really helped me roll from one contraction through another one at a time.”
The painful and non painful stimuli a woman perceives in labour are affected by her past experience of pain. There may be pre existing medical conditions, personality factors such as resilience, temperament, cultural or familial attitudes and beliefs, previous trauma and sexual abuse … amongst a lot of other factors that differ from women to women and in different labour settings. The answer to overcoming these influences in labour is one on one continuous affirming support. Encouragement and physical comfort can overcome the effect of these stimuli on a woman during labour.
“For personal and cultural reasons my partner was not with me during labour. I asked a good, calming friend to accompany me and she really helped feel strong and able during the labour.”
“The midwife was kind and gentle and explained what she was doing at the time. So I was able to tell her about my fears.”