Navigating Labour Pain: A Physio Perspective - Part 1

"What strategies are in your power all the time that you can use whenever you need them? And then what strategies have you got where you might need a little help or support to enact them?"

In this episode, Dr Rangi is joined by Dr Laura Whitburn, a physiotherapist-turned-researcher and Senior Lecturer at La Trobe University with a special interest in improving the experience of labour pain and intrapartum communication.

In the first episode of this two-part conversation, Rangi and Laura explore:

• The power of the mind, support people and environment in shaping labour pain
• How labour pain differs from other types of pain, and how meaning and perception influence the experience
• The impact of the social environment during labour
• Intrinsic and extrinsic approaches to pain management
• The role hormones play in labour and pain
• How support people can help during labour 

Join us next week for part two, where Rangi and Laura continue the conversation on coping with labour pain.

Transcript

SPEAKER_05 0:00

So, welcome back to another episode of PREPARE. And we're so excited today to be joined by Dr. Laura Whitburn, who is a physiotherapist who is now primarily an academic, and her main passion and area of focus in her research and teaching is improving the experience of labour pain and intrapartum communication. So I think this is such an important topic for everyone who is berthy. And we're so excited to have you, Laura. Thank you so much for joining us. Thank you for having me on. I'm really excited to be here. So I would love to hear a bit more about what drew you to this important topic and a little bit about your research.

SPEAKER_01 0:42

Yeah, sure, yeah. How did I get here? Yep, I started my life, or my life, I started my career as a physiotherapist, as you said. And I always had this fascination about labour pain. As a physiotherapist, often we would see people experiencing, you know, different types of pain due to various injuries or pathologies or things going on with their nervous system. And in that sense, even in everyday life, pain is often framed in a negative way. It's associated with something potentially going wrong with our body or something, a sign that our body's trying to give us a warning sign of some potential danger. But I was always fascinated about labour pain because it kind of goes against that rule, because during a normal labour, which is often described as the most intense experience a woman will have in her life, a most intense pain experience they'll have, and yet during a normal labour there's nothing going wrong with the body. It's actually this really healthy, really necessary and important physiological process which we need to go through, otherwise we wouldn't be having babies and continuing our species. So I was always really curious about that. What's different about labour pain? What's unique about it? What differentiates it from other types of pain? And if we can better understand it, maybe then we can better support women and birthing people to experience it as they're birthing. So I decided to step away from the clinical world and wanted to do a PhD on this topic. So my PhD was titled The Nature of Labour Pain, and it explored exactly that, trying to understand what that experience is like, what shapes it, why different people experience it differently, and ultimately what could be better done to help people have positive experiences of it.

SPEAKER_05 2:38

Yeah, that's amazing, Laura. I think it's all of those questions are so important for, as we were saying, every single person that is going through a birthing process. What did your research find?

SPEAKER_01 2:51

So my research actually involved a few studies, and they were all qualitative studies, which means that I mainly did in-depth interviews with women about their experiences. And in fact, a couple of those studies involved women here at Mercy Hospital. I wanted to really build up an understanding of labour pain from women's experiences to better describe what it's like. And there are a few main things that came out of my PhD work. The first was how labour pain can be very different from normal, typical pains. Okay. And the meaning that a person thinks about the pain at the time will really shape how they experience it. And what we found was that women tend to experience labour pain as either this positive, purposeful, productive pain that's associated with their body working hard towards birthing their baby. And when they frame the pain in that way, it seems to help them be able to cope and engage with the intensity and persist through labour. Okay, great. However, they can also experience pain in the opposite way. Feels like a threatening, scary experience that's very hard and just stressing. And when it's experienced in that way, then understandably it'd be very much harder to cope with and persist with. So that was one of the main findings, this idea that labour pain could be experienced either as this purposeful pain or this threatening pain. Okay. So the next thing was well, what what determines whether a person will experience it as a purposeful pain or as a threatening pain? Yeah. And so one of the next major findings from my PhD was that what can shape that is a lot about the people in the room and what they say and what they do. Can really shape and change the meaning behind that pain. Okay. They can say little things that can help that woman frame it as purposeful. This is your body working really hard, you're doing really well, everything is going exactly as it should. Little messaging like that can help them frame, yeah, frame it as this purposeful experience, this purposeful sensations that are working towards this desirable goal. Or there can be this subtle cueing that may be unintentional, probably is unintentional, but actually frames the pain as potentially threatening or scary, or that the person isn't going to be able to persist and cope with it. And that can then flip the meaning for that woman to thinking of this is okay, this is scary and threatening, and I don't know if I am going to be able to cope with this. And so, yeah, that the social the effect of the social environment can be really powerful during labour.

SPEAKER_05 5:42

That's really amazing information that you were able to get. And I think as clinicians in this space, we often see that on a day-to-day basis, that it can make such a big difference who is in the room and the quote unquote vibe of what's going on can really shape a person's experience and the partner's experience or the support person's experience. I suppose to sort of elaborate on that further, not just in the room, but did you find any information about what can be done before you get to that point to shape that experience?

SPEAKER_01 6:19

Well, actually, so more recently I did another study of women here at Mercy Hospital. We um surveyed and interviewed over 50 women and birthing people before they gave birth for the first time. So this was them preparing to give birth for the first time. And we asked them, what do you think really matters during your labour that's going to help you cope? And we analyzed all the data, all these amazing things that they told us about. And we came up with these three categories of things that they felt would really help them to do during pregnancy that would help them then cope well during labour. Yeah. The first was framing labour intensity as purposeful, this purposeful pain. Women, when they stop and think about it, I think they know that labour is a little bit different from other in experiences of pain, and they know that if they can get in their head that this is this intensity is actually this productive and purposeful sensation that's working me towards this desirable goal of my baby being born, that's really helpful.

SPEAKER_05 7:29

Yeah.

SPEAKER_01 7:30

So if people can do that work during pregnancy to just start to unpick what is pain and how is labour pain different, that can be really good for setting this really helpful mindset during labour of the pain being purposeful. Setting the stage. So taking the time to just think about and build some trust that your body knows what to do and it will be able to do it, and that it's inherently able to do it. Now, there's times when the body does need some assistance, and that's why we've got magnificent, you know, medical support around us. But it's this underlying trust that there is this ability and capability that the woman's body and mind can do it. The second major thing was creating a relationally safe environment. So they knew how important it was going to be to have the right safe, relationally safe, which means that the people around them make them feel safe, make them feel emotionally safe and physically safe, and that that was going to really shape how they felt during their labour. So they wanted to have a support person of choice present. Yep. They would ideally like to know their care providers, know their midwife, know their obstetrician.

SPEAKER_05 8:50

Continuity of care, continuity of care.

SPEAKER_01 8:53

Absolutely. And you know, we can all relate to that. We must prefer to have people around us that we know and have already met and they know our story and they know our preferences and desires, and that makes it much easier to then trust in those people. Of course, particularly when it's such a vulnerable space. Exactly. Yeah. They also wanted to make sure that the people around them were going to help them feel informed throughout the labour. Um, and like you mentioned before, that sort of calm environment, creating that nice calm zone, that space. So that was the second major thing. Okay. And then the third thing that women told us were really important to help them feel confident and help them during labor was they wanted to feel prepared and they wanted to know what the process was all about. What was the physiological process that their body was going to go through? Yeah. Because that would help them then understand, you know, what to expect, understand even the role of sensations. You know, pain actually plays a really important role in helping to get the body to release more oxytocin.

SPEAKER_05 9:58

Yes.

SPEAKER_01 9:59

So it's really useful actually when you think of ah, okay, with each contraction, the more intense it is, the more oxytocin my body's going to release, and that's going to actually help me birth really effectively and efficiently. So understanding the birth physiology. They wanted to understand the pain relief options that were available, absolutely. But also they wanted to have a toolkit, what we call the toolkit of strategies, that they could draw on during labor. And that didn't just mean what are the pain relief strategies. Yes. This is a toolkit of strategies that helps them feel safe in control and calm. What are you actually planning? And these participants in this study gave us a wonderful list of all the things that they were thinking about, they were preparing, they were planning to use during their first labour. And people are probably very familiar with us categorizing pain relief strategies as pharmacological and non-pharmacological, and Jim probably very familiar with thinking, yeah, and preparing for. So drugs versus non-drugs. Drugs not versus non-drugs. And I've always had a little bit of an issue with this way of categorizing strategies because once again, I'm I'm very interested in the power of language and communication. And the the subtle messaging behind that way of categorizing. Because what it's doing by categorizing things as either pharmacological or non-pharmacological, it's saying that pharmacological is the best. And anything else that's non-pharmacological, that's secondary. Other it's inferior. Whereas we know that there are some really powerful and important and effective non-pharmacological strategies that women find really important during labour and birth, things like using water or a bath or breathing techniques or a massage or a TENS machine, things like that. Or movement. Or movement, yes. The other thing that that categorization does is it centers on what can be done to the woman. True. Because pharmacological strategies, she can't use those at any time she wants. They require someone else and something else. So it's kind of taking away from also the autonomy and her control and her power. So we've decided to categorize things differently. Great. And we use the category. We've decided on the categories of intrinsic strategies and extrinsic strategies.

SPEAKER_05 12:58

I love it.

SPEAKER_01 12:59

So the intrinsic strategies are the strategies that women can use autonomously. They're available to them at any time. They can start to use them without needing any assistance from others or equipment. Awesome. And so it's things like breathing, movement, mantras, vocalizations, visualizations. Yes. So they're all things that women have the power and autonomy and control to use whenever they need. And then the extrinsic strategies are strategies that will need a little bit of assistance from others or some equipment. And would also include all of our pharmacological interventions. But it also includes things like a shower or bath or massage where you need someone else, or a fitball, sitting or rolling on a fitball, or a TENS machine, or yeah, your other sort of pharmacological epidurals and things like that. Yeah. Because what this categorization now does is now it's centering on okay, what strategies are in your power all the time that you can use whenever you need them, and then what strategies have you got where you might need a little bit of help or support to enact them?

SPEAKER_05 14:10

Yeah.

SPEAKER_01 14:10

And if women can be sort of going into labour and thinking about this toolkit of intrinsic and extrinsic strategies, it means that they've got strategies ready to go all the time. It also shifts the focus away from pain relief. Now we know that when women are in the depths of labour and it is hard, and I can say this from two births myself, it is hard and intense and overwhelming and challenging. But I wouldn't say what I necessarily needed was just for someone to take the pain away. Because I knew that the pain, as I I sort of spoke about, I knew the pain was purposeful. It was my body working really hard. Yeah. So what I actually needed was I just needed my support crew to just help me stay focused. Okay. Help me stay calm, help me stay in this positive mindset. Now there might be some moments where women, no, they just need pain relief. And that's totally okay. Yeah. But by framing the strategies as intrinsic and extrinsic, it takes the focus away just from pain relief. It might be that what they just need is their support people to come over and say, you are doing really well. Well done. Do you want to come over and help in the shower? Let's try this.

SPEAKER_05 15:33

Yeah, reminding them of some of those intrinsic strategies or easier extrinsic strategies. Yes.

SPEAKER_01 15:39

Yeah, that's right. So the sensory feedback, which can often feel quite uncomfortable and intense, is actually a really important part of this physiology of labour and birth. But there's another really important part to the story that is really helpful for people preparing for labor to understand. Because built into this process is a really great sort of a protective or supportive mechanism that's going to help them as those contractions get more and more intense. Because oxytocin, as it travels down to the uterus and does its thing in the uterus, it's also traveling into the brain. And it's actually going to change the way our brain is functioning during labor. And we often describe this as sort of a you go into a zone, sort of the labor zone. This is a really important protective mechanism because what it's actually doing into in the brain is it's switching off the sympathetic nervous system, which is the part of our nervous system where we're usually in a protective fight, flight, or freeze sort of mode of action. It helps to switch that off. It helps to switch another part of the brain off that's our via center of the brain. So it's helping us feel calm, it's helping us feel connected and relaxed, and it's switching off the thinking brain. And when we're in labor, we don't want to be thinking. Because if we're thinking too much, we're thinking, how long has it been? Am I gonna, you know, am I having to do this? Am I gonna have to go? Yeah, am I gonna be able to do this? What's am I is my toddler okay at home? Like, is my partner doing all right over there? Are they hungry? Like, we don't want any of those thoughts when we're laboring. And so oxytocin does this really magical, fantastic thing of switching off the thinking brain. Then there's another system that will also kick in at some point. As the contractions get to a level of intensity that can be quite uncomfortable, there's another mechanism that switches on, and that's that our brain starts to release endorphins. And our endorphins are like our inbuilt painkillers. Um, they're like our inbuilt opioid system of our brain. And so we've got these inbuilt opioids that are gonna be released at some point and are gonna also help us with the intensity of the sensations. Happy hormones, happy hormones, calming hormones, switch off that thinking brain. So if women are sort of thinking about this mechanism as they're preparing for labour, hopefully it helps them think, okay, yeah, it's gonna get to this level of intensity, but because the oxytocin and beta endorphins in my brain are actually gonna change the way my brain is working, I'm gonna be okay, I'm gonna be able to cope. But there's one thing that can disrupt this process, and that's too much adrenaline. So if her brain releases too much adrenaline during her labour, it actually works against the oxytocin system, and it can decrease the amount of oxytocin, it can interrupt her ability to get into this zone. It's really good. I'm not thinking, I'm not, I'm just labouring zone. And so, what sort of things stimulate adrenaline? Adrenaline is that sort of that rush of energy that we get when we're on high alert or we've been stimulated or we're talking or we're thinking. So things like bright lights or loud sounds or unfamiliar surroundings or people asking quest lots of questions, or her just feeling unsafe and and a bit disturbed, okay, are going to increase adrenaline and actually interrupt this zone. Okay. So this is part, this is something that that people preparing for for labour can also be thinking about what can I do to make sure that I feel like I'm in a calm, sort of supported and undisturbed space as possible. A space that might have, you know, dim lights, I've got familiar sounds, maybe music could help. Yeah. Knowing my caregivers, knowing the people around me is going to help, but if there's going to be caregivers that I don't know that are going to come in, making sure that they don't just come and sort of s immediately ask questions and stimulate her thinking brain. We want to kind of keep her thinking brain offline as much as possible.

SPEAKER_05 20:06

Yeah. So really trying to keep that calming presence and everyone involved should be trying to follow soon.

SPEAKER_01 20:13

Yes, and that's where the support people play a really important role in sort of protecting that space around and advocating. And they can be the people who the questions sort of come through, come through the support person before going straight to stimulating the woman's brain. And of course, there are some things that absolutely she should be asked and spoken to. But if there's any opportunity where the support people can just help keep that zone quiet, keep that zone feeling calm, keep that zone feeling, you know, as as little stimulation as possible, then that's going to really help this oxytocin and beta endorphin system in doing its job to actually giving her immediate internal pain relief and helping her just not think it's going to go offline a little bit.

SPEAKER_05 21:01

Yeah. Yeah. Yeah, it's amazing. I think the main takeaway that I've taken from what you have found in your research is that the mind plays such an important role in preparing for labour but also how we manage it. It does.

SPEAKER_01 21:19

Yep. And the mind and also the people around us can really influence our perceptions of things. It's pretty powerful. We're very social beings. Yeah. And we're very much influenced by context and what's going on around us and what people are saying and doing around us. And it's a bit, you know, it can be a bit hard to believe how could you know what someone says change my pain? It does. Every pain in particular is a really interesting and multidimensional sort of experience where context and expectations and the meaning can really change it, change how it feels. And one of my Ph. Sort of a little sub-study I did. I asked my participants how they would have described the pain, but I also asked them to rate it on a scale of zero to ten. And I compared what they said about the pain and their rating. And I could have two women who told me their pain was an eight out of ten. But one said that it was this really powerful, purposeful, positive, you know, sensations of my body working hard. And the other said it was really scary and overwhelming and distressing. So that tells us that an eight out of ten pain for one person versus an eight out of ten pain for another person can be a totally different type of pain and need a totally different type of support or response to it. So we really need to, yeah, think about pain because it's quite a complex sort of experience. And ultimately it was the underlying meaning that, you know, the person over here who was experiencing it as this positive, powerful, purposeful sensations, that's totally different to this eight out of ten pain over here, where it was this scary and threatening and overwhelming sort of sensations.

SPEAKER_05 23:08

Yeah, that's a really good point. It's just so subjective pain, particularly this type of pain that we're talking about.

SPEAKER_00 23:15

Every pregnancy is unique. The information provided in today's podcast is for educational and general purposes only. It is not intended to be substitute for professional medical advice. It is important that you always seek the guidance of qualified health professionals with any questions you may have regarding your health, pregnancy, or any medical conditions.