The simplest explanation of how we feel pain is that our bodies sense pain when nerves send messages to our spinal cord and our brain. Our brain then interprets those signals into the feeling of pain. Since each of our brains is different, pain is subjective, and people interpret pain differently. When you think about birth, pain is either the first thing that comes to mind or the last thing you want to think about. There is the occasional anecdote about a pain-free birth, but most expecting mothers experience some level of labor pain and discomfort. It seems counterintuitive that something necessary for our survival would be difficult and come at a high cost. In this article, we reframe how you may think about labor pain so you are not terrified going into the experience, have a better idea of what to expect, and understand why birth can involve pain.

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Labor and Birth Vocabulary

There are varying opinions on the language used to describe labor and birth. Some practitioners and expecting parents choose words like surges or waves rather than contractions. Rather than using the word pain, you may choose discomfort. Whatever vocabulary you choose to use, labor and birth can be challenging and physically demanding. Throughout this article, I use the word pain to focus on the evidence and research that uses this term.

Reframing Pain

Labor and birth typically involve the sensation of pain. There are some anecdotes about pain-free births, but there is some pain for most expecting mothers. Culturally in the west, we portray childbirth in movies and television as an excruciating event where the mother is screaming, usually at the father, about how much giving birth hurts. I want to reframe how you may think about labor and birth and pain so you are not terrified going into the experience, have a better idea of what to expect, and understand why birth can involve pain.

How We Feel Pain

The simplest explanation of how we feel pain is that our bodies sense pain when nerves send messages to our spinal cord and our brain. Our brain then interprets those signals into the feeling of pain. Since each of our brains is different, pain is subjective, and people interpret pain differently. We entirely create feelings of pain in our brains. This means that it is more than the sensation that goes into how we experience it. We also make our sense of pain by our surroundings, our emotional state, past experiences, and expectations.

Assessment of Pain in Research

Assessing pain in research is difficult since all pain is subjective and self-reported. The visual analog scale was first used in 1921 and is the most common tool used in studies today. Participants record scores by making a handwritten mark on a 10-cm line representing a continuum between “no pain” and “worst pain.” In more recent years, some researchers also use an electronic version of this scale. The problem is that no two people will experience pain in the same way at the same level, even with identical measures applied to induce pain. In studies with larger sample sizes, you may get a better idea of participants’ level of pain. Even an in-depth analysis of how women experience pain in labor will not give you an accurate representation of what you can expect.

Theories as to Why Childbirth is Difficult or Painful

There are several theories as to why labor and birth are painful. Some religions believe that childbirth pain was a punishment for Eve eating from the tree of knowledge of good and evil (Genesis 3:16). In historical texts going back as far as we have recorded history, there are references to women experiencing pain during birth. It seems counterintuitive that something necessary for our survival would be difficult and come at a high cost.

The Obstetric Dilemma

The idea of the obstetric dilemma was proposed in 1960. This is a hypothesis to explain why birth in humans is more difficult than in other primates. It says there was a biological trade-off of two things. The first is that when humans started walking upright, hips became narrower, the shape of the pelvis and birth canal changed. The other part of this hypothesis is that with increased brain size, babies’ heads got bigger. Combining a smaller pelvis in the mother and a bigger head in the baby made childbirth more difficult.

The obstetric dilemma hypothesis also suggests that humans had to shorten the length of gestation to allow birth at a time when heads could fit through the birth canal. Proponents of this idea suggest this is why babies are born dependent on the care of parents. This concept of humans being underdeveloped at birth has led to referring to the first three months of life as the fourth trimester.

Some people in the scientific community have challenged the idea of a shortened gestation to allow for passage through the birth canal. Some researchers propose that gestational length is a function of constrained maternal metabolism, and labor begins when fetal energy demands exceed the mother’s ability to meet those demands.

The Move from Nomadic to Agricultural Societies

There are also other answers proposed as to why birth became more difficult about 10,000 years ago. When humans began settling down and farming and changing their diets, they got shorter in height. A shorter height is associated with a narrower pelvis. Due to carbohydrate-rich diets, their babies got bigger in size and weight.

The Evolution of Childbirth

Evolution has made changes to allow for an easier birth. Hormones during labor and birth work to relieve pain. A woman has a different pelvis than a man does. At puberty, a woman’s pelvis widens. You also go through changes during pregnancy, like releasing the hormone relaxin to loosen your joints. Your baby will be born with their skull plates not fused, making their head more malleable when maneuvering through the birth canal. Research shows that females with a large head possess a birth canal that can better accommodate large-headed neonates. This is evidence that evolution has adapted to some of the challenges of childbirth.

The Mechanisms of Labor and Birth

Understanding the mechanisms at work can help explain why labor and birth can be painful. Labor and birth is a complex process that has evolved over a long time. What we have today is birth that is much safer than it was thousands of years and even decades ago. We have access to several interventions and treatments that can alleviate some or all of the pain associated with childbirth. As you are navigating your pain medication options and preparing for labor and birth, it may help you understand the mechanisms at work during birth and better understand labor and birth pain.

The First Stage of Labor

In the first stage of labor, your uterus contracts. Contractions are your uterine muscles tightening and shortening. These help your baby descend and help your cervix starts to dilate (open) and efface (thin).

Contractions fall in a pattern with a rise, peak, and a break in between them. You can think of them like hills on a graph. As labor progresses, contractions get longer, stronger, and closer together. This means that the pain or discomfort also gets more intense. This pain is focused in your lower abdomen and can also present in your lower back.

Hormones in the First Stage

Oxytocin is the hormone responsible for contractions. Your body also releases beta-endorphin, a stress hormone that acts as an opiate or pain killer. High levels of beta-endorphin reduce the levels of oxytocin, which can slow down your contractions. While this may seem counterproductive to birth, this allows you to experience the positive effects and relief from beta-endorphins and at a pace where your body can handle the stress. Beta-endorphin doesn’t just relieve pain, it also induces feelings of pleasure and euphoria. The high levels of beta-endorphins help you enter an altered state of consciousness. This acts similar to the drug morphine. You will sometimes hear birth educators or practitioners talking about a birthing mother being in labor land. This term describes a state where you zone out of your surroundings and focus on what is going on internally with your baby and your body.

The Second Stage of Labor

The second stage of labor is also known as the pushing stage. At this stage, your cervix is dilated to 10 centimeters and is fully effaced. You are still experiencing contractions, and you may experience pain and pressure due to your baby descending. Even though your cervix is dilated, your vaginal opening and perineum need to stretch to allow your baby’s head to emerge. This is sometimes referred to as the ring of fire to describe your skin’s sensation stretching around your vaginal opening and perineum. Unfortunately, tearing is quite common as a result of extreme stretching. Some techniques, like slow pushing, warm compresses, and applying pressure, can help. For more information on vaginal tears during birth and healing, see this article.

Hormones in the Second Stage

Your body releases additional hormones that assist during this stage. This is where your fight-or-flight (catecholamines) hormones come in. These include adrenaline, also called epinephrine, and noradrenaline, also known as norepinephrine. Your adrenal gland secretes these hormones in response to stress, and they get your body ready for a fight or flight response.

While these hormones can slow things down a bit in the first stage of labor, they act differently in the second stage, just before your baby is born. Right before the moment of birth, there is a sudden increase in catecholamines, especially noradrenaline. This works with oxytocin, which activates the fetal ejection reflex. Stereotypically when this happens, you will get a sudden rush of energy, you will be upright and alert, your mouth will be dry, and your breathing will be shallow. You could express fear, anger, or excitement, and the rush of these fight or flight hormones will cause several powerful contractions designed to birth your baby quickly and easily.

These hormones will also help your baby during labor by protecting them against the effects of hypoxia, which is a lack of oxygen; when your uterus contracts, oxygen flow is temporarily restricted. After birth, your levels of catecholamines drop sharply, which helps your body release more oxytocin.

Your Baby is Also Working During Labor

Primates, our closest relatives, have a straight birth canal that allows a baby to descend directly through it. In humans, babies have to rotate internally to fit through the pelvis. Typically, a human baby descends head down into the pelvis, tucks their chin into their chest, turns their head and shoulders from sideways to facing your back. As their head emerges, they rotate sideways to allow their shoulder to fit through the birth canal. Part of your labor is your baby working on going through these movements.

Interventions for Pain Relief

According to the American College of Obstetricians and Gynecologists, there is no other circumstance in which it is considered acceptable for an individual to experience untreated severe pain that is amenable to safe intervention while the individual is under a physician’s care.

Epidurals are the most common form of pain relief during birth. Nitrous oxide is also used, more often outside of the United States. Plus, you can also utilize transcutaneous electric nerve stimulation (TENS), intravenous pain medications, pudendal nerve blocks, local anesthetic injections, and in emergencies, general anesthesia. For more on these, see this article. Thankfully, we have interventions available for parents who want to utilize them.

Other Factors that Can Influence Your Perception of Pain

You can employ additional methods to positively impact your birth, influence your perception of pain, and shorten your time in labor. Even if these tools make a small contribution, using several of them can add up.

How Continuous Support Can Influence Pain

Continuous support is when one person is by your side to support you for the duration of labor. Support can be in many forms, including psychological, physical, emotional, informational, advocacy, and encouragement. A support person can be a nurse, midwife, doula, childbirth educator, partner, relative, or friend. In all of human history, this was the norm. Since most births in the United States have been taking place in hospitals since the mid-1900s, continuous support is not necessarily the norm. In a hospital birth, you will likely see several nurses throughout your labor, and often your primary care provider is not present for your entire labor.

There is evidence that continuous support during labor can positively impact the use of pain medication and the duration of labor. In a Cochrane review of 27 studies, they found that the mean length of labor was an average of 41 minutes shorter with continuous support. The less time you are in labor, the less pain your experience. The review also found women with continuous support were less likely to have pain medication. Although four of the studies included reports of labor pain after birth and continuous support did not seem to affect the pain experienced.

How Your Labor Room Environment Can Influence pain

There is a strong argument that the environment you give birth should be similar to the environment you make love. In recent years there has been more attention to modifying hospital rooms to be more comfortable spaces. We are also seeing more hospitals incorporate sensory rooms that focus on elements that make the environment more relaxing and help patients with pain management.

This study examined Snoezelen rooms for birth. Snoezelen is a Dutch term that describes a controlled multi-sensory environment. These rooms featured an overhead projector emitting green light and different images, and there was an aquarium with live fish. The rooms had oil-burning candles with the option to add a drop of lavender essential oil. Rooms also had light music playing. The Snoezelen rooms were associated with a lower mean score of pain intensity than the control group. The mean pain score of participants in the Snoezelen rooms was 5.26, compared to 9.56 for those in the control group. You may not have access to a Snoezelen room, but you can alter the light, smell, and sounds of any environment. For more on this topic, see this article.

How Positions Can Influence Pain

There is evidence in support of laboring in an upright position. In a review of women during the first stage of labor, overall, it was concluded that there is clear and important evidence that walking and upright positions in the first stage of labor reduce labor duration, the risk of cesarean birth, and the need for an epidural.

This study compared women giving birth in an upright position to women who labored and gave birth lying down. Women who used upright positions more than 50% of the time had more effective uterine contractions and more perineal muscle relaxation, and their births were significantly shorter. Also, they had lower rates of requests for epidurals or other medication, less assisted deliveries, and fewer cesarean sections.

The position you are in has a lot to do with how you experience pain, how effective your contractions are, and how you cope with pain. You will need to try different positions throughout your labor to find what works for you at that time. No matter what interventions you use or where you give birth, you have some options regarding the positions you are in. Even limited to a hospital bed, you can sit upright and use support from your partner, a doula, or nursing staff. For more on labor, positions see this episode.

Ideas to Keep in Mind

There are several ideas for you to keep in mind as you are preparing for your birth, and hopefully, you will remember during labor. These are not evidence-based techniques for coping with pain. Here are a few parting thoughts from someone who has spent thousands of hours researching labor and birth and experienced unmedicated birth.

You are Birthing a Human

As much as pregnancy and birth are a natural phenomenon, let’s not understate the amazing fact that your body is creating human life. All humans cannot do this since you have to have a uterus to grow a baby. No laboratory or machine can replicate creating human life. The journey and energy it takes to hold your baby in your arms can be challenging. It is nothing short of a miracle that you are capable of pregnancy and birth. Please give yourself and your body some credit.

Birth as a Transformational Rite of Passage

Many people view labor and birth as a transformation and a rite of passage. In the book, Ancient Map for a Modern Birth, Pam England writes about the birth of a child and a new self. You are embarking on a journey of becoming a mother which will forever change who you are and how you exist in the world. Even if this is not your first baby, you are still going through a transformation as you grow your family.

Break Between Contractions

Even when contractions are at their strongest, it is not one continuous contraction. There are breaks. Try to enjoy the breaks in between contractions.

You are not Doing this Alone

From the first signs of labor, you are not going through this alone. You and your baby are experiencing this event together, and you both will need to work through it. Hopefully, you have additional support in a birth partner, doula, nurses, doctors, midwives, and other support staff. You may have moments where you feel alone, and labor feels hard because you are the only one feeling contractions. Your baby is with you. Every contraction you have, every millimeter they descend, all of the movements they make, and the positions you try. You and your baby are doing this together.

Light at the End of the Tunnel

The pain and discomfort you may experience during birth are finite. It will not last forever. There are some cliché sayings like, “keep your eye on the prize.” There is value in keeping in mind that you will be holding your new baby at the end of labor and birth. You will look into that beautiful face, and you will never be the same again. The reward of holding a baby that you created and brought into the world is worth every single contraction and all of the hard work in labor. There is also the prize of feeling empowered as a new mother. You can do this, and you will feel amazing at how capable and powerful your body is.

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