Nature of Labor Pain

Although most women report that labor is painful, most physicians have surprisingly little understanding of the nature of labor pain. Pain is a subjective experience involving a complex interaction of physiologic, psychosocial, cultural, and environmental influences. A recent review by Lowe,1 which was based primarily on descriptive studies, focused on methods for measuring pain experience and physiologic and environmental factors that influence labor pain

During the first stage of labor, women usually perceive the visceral pain of diffuse abdominal cramping and uterine contractions. In the second stage of labor, there is a sharper and more continuous somatic pain in the perineum. Pressure or nerve entrapment caused by the fetus's head can cause severe back or leg pain. Nulliparous women generally experience more sensory pain during early labor,2,3 while multiparous women may experience more intense pain during the late first stage and the second stage of labor, as a result of rapid fetal descent.2,4

Cultural values and learned behaviors influence perception and response to acute pain. Women's expectations about labor pain often are confirmed by their experience of childbirth.5,6 Anxiety and fear of pain correlate with a higher reported experience of pain.5-8 A woman's confidence in her ability to cope with labor is the best predictor of pain during the first stage of labor, accounting for nearly one third of the reported variance in pain.

Women rate labor pain as more intense than their caregivers do.9 Cultural gaps between the patient and caregiver can exacerbate this difference. The birth environment affects a woman's experience of pain and her ability to cope with pain during labor. Adequately powered, prospective studies that examine the relationship between pain, birth environments, and various styles of care are needed.

Many clinicians assume that a major determinant of maternal satisfaction with childbirth is effective pain relief during labor. There are both affective and cognitive components to maternal satisfaction.10 A woman's sense of satisfaction with her childbearing experience changes over time; when measuring maternal satisfaction, the amount of time that has elapsed since the birth may be a key methodologic factor.

A systematic review of the literature by Hodnett11 on the relationship between the use of labor analgesia and maternal satisfaction concluded that pain relief does not play a major role in overall maternal satisfaction with the childbirth experience. Three randomized controlled trials (RCTs) included in the review did not demonstrate improved satisfaction with increased pain relief. Factors associated with increased maternal satisfaction were the quality of the relationship with the caregiver and the amount of participation in decision making during labor and delivery. The review also found that women preferred a home-like birth environment, and caregivers with whom they are acquainted personally.

Submit by Lauren.

  

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