Painful birth?

Can birth be painless?

A recent article by Milli Hill in the Telegraph suggested that birth not be as bad as people fear.

http://www.telegraph.co.uk/women/health/myth-painful-birth-not-nearly-bad-women-believe/

But this has created a backlash from people who feel that this view contributes to the trauma of women who go into labour convinced they can birth without needing pain relief, or at home, or without ‘losing it’.

http://www.independent.co.uk/voices/childbirth-painful-labour-telegraph-article-positive-thinking-hypnobirth-birth-myth-a7635511.html

As a doula I have accompanied many women through birth and given birth myself twice. So I have seen labours that were unbearable from the early stages to women having ecstatic birth[1], women singing through their second stage.

In my previous blog I talked about how childbirth is a profound event for women, where pain creates an altered state of consciousness which may help women cope with the pain of childbirth and prime women to experience the psychological shift to becoming a mother.

https://magicalbirth.wordpress.com/2016/05/04/childbirth-pain-disassociation-and-altered-states-of-consciousness-birth-as-a-heros-journey/

I agree with Milli that it’s well known that fear and anxiety can lead to greater pain during birth. The associations between expectation, cultural conditions, personal outlook (including locus of control) memory and preparation in relation to pain during childbirth are complex. It has also been suggested that attachment style can effect labour pain. [2] and can also effect whether the presence of a partner during labour reduces pain[3]

People can be surprised by their own response to the sensations of birth, some people cope better than they imagined. One aspect which has not been discussed is the role of malposition- the position of the baby effects:

• Length of pregnancy (more likely to go overdue and therefore have an induction)
• Length of latent phase (https://magicalbirth.wordpress.com/2014/11/24/prolonged-latent-labour/)
• Length of First stage (with increased need for augmentation)
• Length of second stage (with increased likelihood of assisted birth or emergency caesarean)

Pain– women with a baby in a malposition (OP/back to back, asynclitic, deflexed etc.) are more likely to experience extreme pain from early in labour, this combined with a greater length of labour and exhaustion make it more likely they will need pharmacological pain relief (and malposition is also associated with breakthrough pain during an epidural[4] and needing more top ups of pain medication[5, 6]) Increased pain during labour[7], is itself is a marker for CS risk[8]

There are a number of ways women’s pain is assessed and documented in labour. One recent tool is the Roberts ‘Coping with labour’ algorithm[9] which provides a mechanism for pain documentation, and care suggestions for the laboring woman. This has been assessed in a large tertiary care hospital as more useful and helpful than a numeric rating scale. [10]

There is some evidence that antenatal birth preparation can reduce anxiety about birth and decrease labour pain experienced.[11, 12, 13] and there are numerous papers describing environmental factors (circadian, lighting, music, furniture, place of birth[14,15]) non pharmalogical pain relief methods (water, massage, aromatherapy) support (continuity of care, doulas, midwives) and maternal factors (fitness, exercise, personality, preparedness, movement etc.)[16,17]

Severe pain in labour has been associated with both postpartum depression [18] and PTSD[19]

The coping with labour algorithm looks like a useful tool to combine a better understanding of the factors that can effect coping in labour and ways to help women cope.

The new algorithm was designed in part to reduce dissatisfaction with the numerical pain rating scale, women found the questions intrusive and distracting. The coping with labour tool can be used by midwives from observation and queries about coping to women are only made on arrival, when noticing changes or a shift change[9]. There is also an understanding that not coping in labour can signal the ‘transition’ between first and second stage and be a sign of rapid progress, when reassurance of the physiology of normal labour could reassure women and reduce anxiety in relation to overwhelming sensations.

One woman I spoke to found being asked about pain, contributed to her focus on the pain, and made her doubt her coping ability:

“The ONLY reason I had pethidine with my first was because the midwife (after a shift change the first never mentioned it) kept saying ‘did I want pethidine’ ‘are you sure you don’t want pethidine?’ ‘it’s only going to get worse, would you like the pethidine now?’ – I gave in to stop her asking”

Both distraction and catastrophizing have substantial effects on perceived pain[20], so questioning women about pain in labour could effect women’s perception of coping.

Looking at longer term outcomes, in a  five-year follow-up study of a randomised controlled trial; “The Ready for Child” trial. To compare the long term perspective of the birth experience in nulliparous women attending a structured antenatal programme to that of women allocated to standard care.  Birth characteristics of women reporting a less positive birth experience in the long term, irrespective of group allocation, were significantly more likely to experience an epidural, cardiotocography monitoring, and less likely to used water as pain relief and have a spontaneous vaginal birth.[21]

Another study to investigate women׳s use of pharmacological and non-pharmacological labour pain management techniques in relation to birth outcomes, found that:

•Water use for pain decreases the likelihood of special care nursery admission.

•Epidural use for pain increases the likelihood of special care nursery admission.

•Epidural use for pain increases the likelihood for instrumental childbirth.

•Epidural and pethidine use decrease the likelihood of continuing breast feeding.

•Breathing techniques and massage increase likelihood of continuing breast feeding[22]

So can labour be painless?

Yes sometimes, and there are ways to help cope better in labour, but a large part is down to luck/ chance and not within our concious control, needing pain relief when pain is severe and unremitting is not a failing

“my inner sex
stabbed again and again with terrible pain like a knife.
I have lain down.

I have lain down and sweated and shaken
and passed blood and feces and water and
slowly alone in the centre of a circle I have
passed the new person out”

(from ‘The language of the brag’ by Sharon Olds)

SUMMARY

• A huge number of factors combine to effect how women experience pain and cope with labour
• Malposition is an important factor that can increase pain and negative outcomes
• Women who experience severe pain may have a malpositioned baby, if this does not resolve, pharmacological pain relief may be needed
• Birth preparation can provide women and their birth partners with tools that can help women cope with labour
• Focusing on pain in labour can increase pain, use of language related to ‘coping’ with labour might be more appropriate
• Offering pain relief in labour may
• Women that experience severe pain and require pharmacological pain relief, despite intensive birth preparation are not personally responsible for the level of pain they experience, it is likely that a combination of childhood experience, cultural environment and malposition combine to create intolerable pain
• There should be no shame in needing more pain relief than was planned

Links

https://www.scienceandsensibility.org/p/bl/et/blogid=2&blogaid=95

http://www.nhs.uk/news/2015/02February/Pages/could-saying-ow-boost-pain-tolerance.aspx

References

1. Mayberry, L., & Daniel, J. (2016). ‘Birthgasm’ A Literary Review of Orgasm as an Alternative Mode of Pain Relief in Childbirth. Journal of Holistic Nursing, 34(4), 331-342.
2. Costa-Martins, J.M., et al., The role of maternal attachment in the experience of labor pain: a prospective study. Psychosomatic medicine, 2014. 76(3): p. 221-228.
3. Krahé, C., et al., Attachment style moderates partner presence effects on pain: a laser-evoked potentials study. Social cognitive and affective neuroscience, 2015. 10(8): p. 1030-1037.
4. Sng, B.L., et al., Incidence and characteristics of breakthrough pain in parturients using computer-integrated patient-controlled epidural analgesia. Journal of clinical anesthesia, 2015. 27(4): p. 277-284.
5. Wong, C.A. The Influence of Analgesia on Labor—Is it Related to Primary Cesarean Rates? in Seminars in perinatology. 2012. Elsevier.
6. Hess, P.E., et al., An association between severe labor pain and cesarean delivery. Anesthesia & Analgesia, 2000. 90(4): p. 881-886.
7. Alexander, J.M., et al., Intensity of labor pain and cesarean delivery. Anesthesia & Analgesia, 2001. 92(6): p. 1524-1528.
8. Ismail, S., S. Chugtai, and A. Hussain, Incidence of cesarean section and analysis of risk factors for failed conversion of labor epidural to surgical anesthesia: A prospective, observational study in a tertiary care center. Journal of anaesthesiology, clinical pharmacology, 2015. 31(4): p. 535.
9. Roberts, L., et al., The coping with labor algorithm: An alternate pain assessment tool for the laboring woman. Journal of Midwifery & Women’s Health, 2010. 55(2): p. 107-116.
10. Fairchild, E., et al., Implementation of Robert’s Coping with Labor Algorithm© in a Large Tertiary Care Facility. Midwifery, 2017.
11. Firouzbakht, M., et al., The effect of perinatal education on Iranian mothers’ stress and labor pain. Global journal of health science, 2014. 6(1): p. 61.
12. Toohill, J., et al., A Randomized Controlled Trial of a Psycho‐Education Intervention by Midwives in Reducing Childbirth Fear in Pregnant Women. Birth, 2014. 41(4): p. 384-394.
13. Brixval, C. S., Axelsen, S. F., Thygesen, L. C., Due, P., & Koushede, V. (2016). Antenatal education in small classes may increase childbirth self-efficacy: results from a Danish randomised trial. Sexual & Reproductive Healthcare, 10, 32-34.
14. Bernitz, S., Øian, P., Sandvik, L., & Blix, E. (2016). Evaluation of satisfaction with care in a midwifery unit and an obstetric unit: a randomized controlled trial of low-risk women. BMC Pregnancy and Childbirth, 16(1), 143.
15. van Haaren-ten Haken, T. M., Hendrix, M. J., Nieuwenhuijze, M. J., de Vries, R. G., & Nijhuis, J. G. (2017). Birth place preferences and women’s expectations and experiences regarding duration and pain of labor. Journal of Psychosomatic Obstetrics & Gynecology, 1-10.
16. Jones, L. V. (2015). Non-pharmacological approaches for pain relief during labour can improve maternal satisfaction with childbirth and reduce obstetric interventions. Evidence-based nursing, ebnurs-2014.
17. Levett, K. M., Smith, C. A., Bensoussan, A., & Dahlen, H. G. (2016). Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour. BMJ open, 6(7), e010691.
18. Kwok, S., et al., Childbirth pain and postpartum depression. Trends in Anaesthesia and Critical Care, 2015. 5(4): p. 95-100.
19. Soet, J.E., G.A. Brack, and C. DiIorio, Prevalence and predictors of women’s experience of psychological trauma during childbirth. Birth, 2003. 30(1): p. 36-46.
20. Campbell, C. M., Witmer, K., Simango, M., Carteret, A., Loggia, M. L., Campbell, J. N., … & Edwards, R. R. (2010). Catastrophizing delays the analgesic effect of distraction PAIN®, 149(2), 202-207.
21. Maimburg, R. D., Væth, M., & Dahlen, H. (2016). Women’s experience of childbirth–A five year follow-up of the randomised controlled trial “Ready for Child Trial”. Women and Birth, 29(5), 450-454.
22. Adams, J., Frawley, J., Steel, A., Broom, A., & Sibbritt, D. (2015). Use of pharmacological and non-pharmacological labour pain management techniques and their relationship to maternal and infant birth outcomes: Examination of a nationally representative sample of 1835 pregnant women. Midwifery, 31(4), 458-463.