Labor Pain

How Painful is Childbirth?

There is an expectation among modern women that childbirth is the worst pain you could ever feel. Because of this, women approach childbirth with overwhelming fear of the pain and attempting to remove it all in search of a good birth experience. How painful is childbirth really? Can you have a good birth experience if you feel pain?

Ronald Melzack researches experiences of pain, and studied the pain of labor. Through his research he found that overall childbirth can be called severely painful, but the intensity of the pain is variable. About 25% of first time mothers and only 11% of experienced mothers rated labor as horrible or excruciating. In fact 9% of first time mothers and 24% of experienced mothers said they had low levels of pain. With 17% of women having low levels of pain, the “easy” labor can not possibly be as rare as we think it is.

For many women labor is the first experience with any real physical pain. Women who have experienced other physical pains tend to rate childbirth lower on the scale than things like kidney or gall stones, Lyme disease, chronic back problems, some broken bones, double ear infections, toothaches in need of root canal and recovering from cesarean surgery. Some women even claim the pain of labor is easier to handle than the pain of a broken heart. The point is, how painful childbirth feels is somewhat relative. Without another pain to compare it too, calling childbirth the most painful experience is prejudiced.

If only 18% of mothers rate labor as excruciating, how likely are you to be included in that group? Research by Lederman found that overall, you are likely to experience more intense pain if you:

One of the most startling facts about the pain of labor is its relation to the mother’s confidence in her ability to cope. In general, the more confident you are you will be able to cope, the less pain you will feel. Another important factor is the people you have with you at labor, because your ability to cope with the pain of labor will be influenced by the interactions you have with those attending you (midwife, doctor, nurse). This paints a far different picture of what you will need to get through labor than the old “high pain tolerance” theory. In fact, you can be a wimp about pain and still cope well with labor pain.

In A Wise Birth, authors Penny Armstrong and Sheryl Feldman explain that women who are treated well by birth attendants, have their needs considered and bodies respected and whose mothering responsibilities are honored will give birth more easily. In contrast, women who are challenged by their birth attendants, restrained, distrusted and treated indifferently will have more trouble with labor. They conclude, “drugs and technology in birth, as in life, have proved to be poor substitutes for true, human attention.”

Studies on doulas continue to prove their statement correct. A doula is a professional childbirth assistant. She does not offer medical help, instead her job is to simply be with the mother and serve any needs she may have. You may find a doula rubbing a back, suggesting positions, teaching a partner how to give a massage or just talking to the mother. What effect does this attention have? Women with doulas need less medical intervention to give birth, are less likely to need medication for pain, and are more satisfied with the childbirth experience. Again research shows a high pain tolerance is not what it takes to cope well with labor.

Not only can you cope well if you are a wimp about pain, but you can have a great labor and be satisfied with the experience even if you feel pain. In fact, in one study, the mothers who refused anesthesia felt more pain, but they had higher scores of satisfaction with labor both immediately after the birth and one year later. Another study found no difference in satisfaction immediately after birth, but within two days mothers who had chosen to use epidurals had less positive feelings about childbirth. All of this tells us that removing the pain is not related to having a good childbirth experience.

Where does all this leave you? There are several things you can do now to give yourself the best chances for a low pain labor and positive birth experience. First, educate yourself about the process so you are less likely to be anxious and fearful of what to expect. Second, learn different techniques for working with your body and managing the pain you feel in labor. Third, make sure your caregivers will be supportive of you during labor – if they won’t or can’t, hire someone else. Finally, hire a doula to be with you during labor. These four things will give you the best odds for a manageable labor, regardless of how painful it is or is not.

Childbirth Pain Research

Hodnett ED. Home-like versus conventional institutional settings for birth (Cochrane Review)
In this review, Hodnett found that a home-like setting for a birth center was associated with lower rates of intrapartum analgesia/anaesthesia (pain medication), augmented labour (using pitocin to "speed things up"), and operative delivery (cesarean surgery) , as well as greater satisfaction with care.

Leeman L, Fontaine P, King V, Klein MC, Ratcliffe S. The nature and management of labor pain: part II. Pharmacologic pain relief. m Fam Physician. 2003 Sep 15; 68(6): 1115-20.
In this article from an evidence-based symposium in 2001 on the nature and management of labor pain, researchers noted that every form of medication has its drawbacks. They state "Research is needed regarding which pain-relief options women would choose if they were offered a range of choices beyond epidural analgesia or parenteral opioids."
In Part One of this article the authors state, "Nonpharmacologic methods of pain relief such as labor support, intradermal water blocks, and warm water baths are effective techniques for management of labor pain. An increased availability of these methods can provide effective alternatives for women in labor."

Lynn Clark Callister, RN, PhD; Inaam Khalaf, RN, PhD; Sonia Semenic, RN, PhD(c); Robin Kartchner, RN, BSN; Katri Vehvilainen-Julkunen, CNM, PhD The Pain of Childbirth: Perceptions of Culturally Diverse Women
Pain Manag Nurs 4(4):145-154, 2003. In this analysis of cross-cultural studies of pain management in childbirth the researchers found that women from every background found ways to make their pain meaningful as a coping mechanism for labor. They also noted that women who feel confident and supported report less pain. Their research confirmed the findings that pain or lack of pain has little to do with satisfaction of the childbirth experience.
The researchers noted that it has been shown that the amount of pain felt by the mother and the amount of pain "seen" by the nurse is not always the same. In cases where beliefs and customs influence the way the laboring mother behaves orappearss it is important that the nurse not go by visual cues to the pain but ask the questions, "Is your discomfort being managed at an acceptable level now?"

The Nature and Management of Labor Pain: Part I. Nonpharmacologic Pain Relief From American Family Physician

Bennett, A., Hewson, D., Booker, E., & Holliday, S. (1985). Antenatal preparation and labor support in relation to birth outcomes. Birth, 12,9.
Women who received epidurals were less satisfied with thier childbirth experience.

Brewin, C. & Bradley, C. (1980) Perceived control and the experience of childbirth. British Journal of Clinical Psychology, 21, 263-269.
Pain-free childbirth is no garuntee that a woman will have a satisfying experience.

Brown, M.S. (1978). Culture and Childbearing. In A. Clark (Ed.). Culture and Childbearing. Philadelphia: F.A. Davis.
The context in which a woman gives birth is much influenced by her cultural milieu.

Callister, L.C. (1995). Cultural meanings of childbirth. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24(3), 327-331.

Davenport-Slack, B. & Boylan, C. (1974). Psychological correlates of childbirth pain. Psychosomatic Medicine, 36, 215.
The most important factor in contributing to a positive experience in labor was a woman's desire to be an active participant.
Younger women reported experiencing more pain in childbirth

Klusman, L. (1975). Reduction of pain in childbirth by the alleviation of anxiety during pregnancy. Journal of consulting and Clinical Psychology, 43, 162.
women with lower levels of anxiety have lower levels of pain

Chaney, J. (1980). Birthing in early America. Journal of Nurse Midwifer, 25, 5.
women whose husbands are present at labor and birth reported less pain

Nettlebladt, P., Fagerstrom C., & Uddenberg, N. (1976). The significance of reported childbirth pain. Journal of Psychosomatic Research, 20, 215.
Women with lower levels of education reported experiencing more pain in childbirth.

Lowe, N.K. (1993). Maternal confidence for labor: Development of the Childbirth Self-Efficacy Inventory. Research in Nursing and Health, 16(2), 141-149.
the more confident the woman is in her ability to cope with childbirth, the less perceived pain she will have and the better she will cope

Lowe NK. The pain and discomfort of labor and birth. J Obstet Gynecol Neonatal Nurs. 1996 Jan;25(1):82-92.
One unique aspect of childbirth is the association of this physiologic process with pain and discomfort. However, the experience of pain during labor is not a simple reflection of the physiologic processes of parturition. Instead, labor pain is the result of a complex and subjective interaction of multiple physiologic and psychological factors on a woman's individual interpretation of labor stimuli. An understanding of labor pain in a multidimensional framework provides the basis for a woman-centered approach to labor pain management that includes a broad range of pharmacologic and nonpharmacologic intervention strategies.

Lowe NK. Explaining the pain of active labor: the importance of maternal confidence. Res Nurs Health. 1989 Aug;12(4):237-45.
This study was designed to investigate the relationships between the perception of pain during active labor and nine predictor variables: age, parity, childbirth preparation, state anxiety, confidence in ability to handle labor, concern regarding the outcome of labor, fear of pain, cervical dilatation and frequency of uterine contractions. The sample included 134 low-risk women at term with a normal singleton pregnancy. Standard and stepwise regression was used to examine the ability of the selected variables to explain the variance in the sensory, affective, and evaluative components of pain as measured by the subscales of the Pain Rating Index of the McGill Pain Questionnaire. Although significant proportions of variance were explained for each component of pain, the study variables were most powerful in their ability to explain the variance in the affective component of active labor pain. The stepwise analysis suggested that of the nine variables, confidence in ability to handle labor was the most significant predictor of all components of pain during active labor.

Lowe, N.K. (1991). Maternal confidence in coping with labor: A self-efficacy concept. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 20(6), 457-463.
The clinical study of labor pain suggests that a woman's confidence in her ability to cope with labor contributes significantly to her perception of pain during labor. Self-efficacy theory is examined as a framework for evaluating women's confidence in their ability to cope with labor. The major propositions of self-efficacy theory are described and related to the experience of women approaching labor. The implications for nursing practice are presented, and directions for the study of maternal confidence are proposed.

Green, J.M. Coupland, V.A. & Kitzinger, j.V. (1990). Expectations, experiences, and psychological outcomes of childbirth: A prospective study of 825 women. Birth, 17(1), 15-24.
A woman who expects childbirth to hurt is more likely to experience a painful childbirth.

McKay S, Barrows T. Holding back: maternal readiness to give birth. MCN Am J Matern Child Nurs. 1991 Sep-Oct;16(5):250-4.

Hodnett ED. Pain and women's satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol. 2002 May; 186(5 Suppl Nature): S160-72
The results of this study state "Four factors-personal expectations, the amount of support from caregivers, the quality of the caregiver-patient relationship, and involvement in decision making-appear to be so important that they override the influences of age, socioeconomic status, ethnicity, childbirth preparation, the physical birth environment, pain, immobility, medical interventions, and continuity of care, when women evaluate their childbirth experiences."
This leads the researcher to conclude, "The influences of pain, pain relief, and intrapartum medical interventions on subsequent satisfaction are neither as obvious, as direct, nor as powerful as the influences of the attitudes and behaviors of the caregivers."
Having a loving, supportive environment is invaluable to the laboring woman.

Josephine M. Green, BA(Hons), PhD, AFBPsS, CPsychol, and Helen A. Baston. Feeling in Control During Labor: Concepts, Correlates, and Consequences. Birth Volume 30 Issue 4 Page 235 - December 2003.
Abstract: Background: Many studies have revealed that a sense of control is a major contributing factor to a woman's birth experience and her subsequent well-being. Since not all studies conceptualize "control" in the same way or distinguish between "external" and "internal" control, the purpose of this study is to advance understanding of how these senses of control relate to each other.
Methods: Questionnaires were sent to women 1 month before birth to assess their preferences and expectations and at 6 weeks after birth to discover their experiences and assess psychological outcomes. Data are presented from 1146 women. Three control outcomes were considered: feeling in control of what staff do to you, feeling in control of your own behavior, and feeling in control during contractions.
Results: Women were less likely to report being in control of staff (39.5%) than in control of their own behavior (61.0%). Approximately one-fifth of the sample felt in control in all three ways, and another one-fifth did not feel in control in any of them. Parity was strongly associated with feeling in control, with multiparas feeling more in control than primiparas in all cases. In logistic regression analyses, feeling in control of staff was found to relate primarily to being able to get comfortable, feeling treated with respect and as an individual, and perceiving staff as considerate. Feeling in control of one's behavior and during contractions were primarily related to aspects of pain and pain relief, but also to antenatal expectations of control. Worry about labor pain was also an important antenatal predictor for primiparas. All three control outcomes contributed independently to satisfaction, with control of staff being the most significant; relationships with emotional well-being were also demonstrated.
Conclusions: All three types of control were important to women and contributed to psychological outcomes. Internal and external control were predicted by different groups of variables. Caregivers have the potential to make a significant difference to a woman's experience of childbirth. The ways in which women are helped to deal with pain will affect internal control; the extent to which they feel that they are actually cared about, rather than care being something that is done to them, will affect external control. Both contribute to satisfaction and emotional well-being.

Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative therapies for pain management in labour (Cochrane Review)
In this review, the authors found that the alternative therapies studied (acupuncture and hypnosis) may have benefits for pain management in labor. However, they caution that alternative therapies have not been thoroughly studied yet.

Resources

Melzack K, Taenzer P, Feldman P, Kinch R, (1981). Labor is Still Painful After Prepared Childbirth Training. Canadian medical Association Journal, 125:357-363.
Lederman R, Lederman E, Work B, McCann D. (1979) Relationship of Psychological Factors in Pregnancy to Progress in Labor. Nursing Research, 28(2):94-97.
Lowe, N.K. (1993). Maternal confidence for labor: Development of the Childbirth Self-Efficacy Inventory. Research in Nursing and Health, 16(2) 141-149.
Standley K, Nicholson J (1980). Observing the childbirth environment: A research model. Birth and the Family Journal, 7, 15.
Armstrong P, Feldman S. A Wise Birth. London:Pinter & Martin, 2007.
Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, (2003). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2003 Issue 3.
Morgan B, Bulpitt CJ, Clifton P, Lewis PJ, (1982). Analgesia and satisfaction in childbirth (The Queen Charlotte 1000-mother survey). Lancet, 1, 808.