This blog is intended to provide a discussion forum on topics surrounding pregnancy, labor, birth, breastfeeding and family health. The purpose is to review research studies, articles and highlight the buzz in health news. But please remember, I am not your health care provider and do not intend to give medical advice.:)

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Thursday, April 22, 2010

There are Different Kinds of Pain in Labor?

          Here are some personal thoughts and opinions. Yesterday I was the casualty of dental work. I say that satirically, of course. Dentists do wonderful things for people, but who enjoys going to one? I mean really. My dentist gave me local anesthetics so he could work on my teeth and gums with minor discomfort experienced by me, (that’s the idea anyway). Believe me I am grateful for pain and anesthetizing medications when it comes to procedures and things that correct disease, abnormality and dysfunction. After I left the office and for several hours, I avoided eating upon their advice. I began to notice something. Because the entire left side of my mouth (including my lips; oh yes, drinking was a hoot) was numb, I continuously bit my inner cheek, lips and tongue. Being numb, biting down on my precious tissues didn’t feel like pain, just pressure. As the day went on, the anesthetic started to wear off and the soreness started to really emerge from the poking and prodding and the need to keep my jaw as wide open as a boa. I also started to feel a lot of soreness the left side of my lips, inner cheek and tongue. I looked at my mouth and lips in the mirror and saw swelling and redness, abrasions and even blood on my cheek, lips and tongue. This soreness was actually self-inflicted! I was biting my own flesh and didn’t even realize it until damage was already done. Today, I still very much feel the effect of my anesthetized nibble. Oh I won’t be dramatic and say that it hurt so much I couldn’t cope, but for the last two days I haven’t eaten much more than yogurt. Food and drink sting those spots of broken tissue integrity.
So what’s the point? Well, it got me thinking about labor and birth (what doesn’t?). When a laboring woman is given an epidural (which are usually a combination of anesthetic and analgesic—pain reliever) or even an IV narcotic, her sensations, perceptions and actual comprehension of pain is altered, deadened. Pain, although unpleasant and often avoided is our brains’ way of protecting us. It is our brain communicating with our body. Pain can tell us, “hey, stop doing that” (biting me) or “change positions and relax” or “take your hand off the grill” or whatever in an effort to protect our bodies. Now, many will stop me here and say, “but labor and birth are always painful and it doesn’t mean that tissue is necessarily being damaged.” Well, yes and no. Yes pain is part of labor and birth. But not all pain in labor and birth actually belongs there.
Here's a very common scenario. Let’s say a woman has an epidural during labor. Her sensation and perception of pain (or even sensation of touch) is greatly decreased. It comes time to push. She can’t quite feel what she is doing, so the staff hollers “push!” over and over. So the woman dutifully bears down with all her might for extended periods of time. This woman may not know it yet, but she is actually starting to severely swell and her perineum tear. She barrels through the pushing because that is what she is told to do by people who (just like herself at this moment) can’t feel whether she is in pain. The communication with her body’s sensations has been cut off and she is oblivious to the fact that her tissue has suffered great injury. She will begin to feel it as the medications wear off. Pain protects us. If she had not had an epidural on board, she could have been more in tune with her body and her body just might have been telling her “SLOW DOWN!” “NOT SO FORCEFULLY!” For this woman, pain would have served as a warning and a protection. Pain can also be a communication between mom and baby. A malpositioned baby can cause mom notable discomfort. Discomfort in mom leads her to change position and changing position can enable baby to get into a better fit in the pelvis.
So am I suggesting that any pain in labor and birth means that there is tissue being damaged? On the contrary. Even though some women have reported having little to no pain during labor and birth, this is uncommon. The difference between pain that belongs in labor and birth and pain that serves as a warning is the type of pain it is, ‘acute warning’ or ‘productive.’ Pain that belongs in labor and birth is productive and is more similar to that experienced in an athletic event, such as an intense, powerful workout or a marathon. I know, some women despise that analogy because they think it doesn’t do justice to the “real pain” of “real labor.” Those women who say birth and labor are ten times more painful than any workout or marathon could possibly be, probably have not ever challenged their bodies during a workout or run a marathon. I stand by my analogy. I am no athlete. I am not a marathon runner nor do I do any intense weight lifting (oh, is it obvious?), but I enjoy climbing 14ers and those miles get painful. Are workouts and marathons and hiking 14ers supposed to be comfortable, pain-free activities? I think not. When athletes feel pain during a workout do they say, “ow ow, give me some pain meds, because lifting this weight is just too much!" or “give me a narcotic because I can’t run another step of this race without it!”? The idea sounds ridiculous to me. No they don’t, because pain during a workout usually means that muscles are being worked and tissues are being stretched. Note, I say usually, because even in athletics, acute pain can indicate that the athlete is pushing himself too hard (as in the laboring woman who also pushed too hard, no pun intended). Working out and running can be very beneficial for us, yet no one balks at a trained athlete and contemptuously accuses him/her of trying to be “macho” or a “cocky” by not using pain medications during his/her workouts. Yet so many people cop this attitude with a laboring woman who chooses not to have pain medications on board, accusing her of “trying to prove a point” or being “stubborn.” (If you have watched The Business of Being Born, you may have heard one OBGyn muse something like, “I see it as female machoism.”)
So there are different kinds of pain? Yes. There is pain that hurts like a broken leg and pain that is the result of tissues working hard. Try this. Think of hot and cold receptors. Is cold painful? The question even sounds strange to us. Well, it can be if it is too cold, but cold in and of itself is not painful. Is hot painful? It can be if it is too hot. But heat and cold are not sensations we consider in the context of pain, they are simply different sensations. Labor pain is similar in concept. A laboring woman experiences many different sensations: pressure, stretching, heat, cold, shivering, sweating, concentration, fatigue, breathlessness, energy, hunger, thirst to name a few. Are all of these painful? Some are, but not all. To drive the point home with another thought: Is hunger painful? Well, yes and no. Technically, hunger pangs can physically hurt, but we as adults understand why they hurt and the very fact that we understand the why means we are not overpowered by the sensation. We have perspective. When we understand physiologically what is occurring during labor and birth, we are not afraid of the sensations, because there is a purpose behind them.
Normal, purposeful pain is just that, it has a purpose, similar to an intense workout. Pain in labor is intermittent (it is not one long, constant experience of acute pain). It is finite, it will end. Labor pain does not feel like a broken leg or like stretching your lip over a watermelon, despite the comedic routine. Except for people like the Cosby's, those activities are abnormal; they are injuries. Labor and birth are normal and healthy. Labor and birth in and of themselves are disease-free. Did you hear that? Disease-free. When disease does occur it does so concurrently with pregnancy, causing the pregnancy, labor and delivery to become problematic. However, even in the presence of disease, the pregnancy, labor and birth are not actually diseased.
So in addition to pain having many levels and facets, it also has an indispensable purpose; whether it is to warn us that we are injuring ourselves or to remind us those things that are precious are worth working hard for. Going back to my dental anesthesia, (I ramble) I stated how grateful I am for pain relieve during and after procedures, for injury and other similar conditions. I believe if someone has experienced physical injury (surgical wound, broken leg), pain management is very appropriate. It’s appropriate because these kinds of things are abnormal or illnesses. Labor and birth, however, are normal, healthy states.
The follow up question to this is, what about when labor pain moves from the productive type to the injurious type? It pain management appropriate then? Well, let me provide suspense and tell that at another time. I could also go on about the partial effectiveness of pain medications and the topic of natural pain relievers (endorphins), but I will spare you and save that for a later date.

So, what is the lesson here? Never eat a steak after dental anesthesia.

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