Navigating Labour Pain: A Physio Perspective - Part 2

In this episode, Dr Rangi is joined again 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 second episode of this two-part conversation, Rangi and Laura explore:

• What to look for when searching for information and resources for your birth goals
• Why it’s important for support people to be informed and prepared
• What to expect and how to cope when the plan changes
• A fresh look at intrinsic and extrinsic pain management methods, including TENS and pharmacological pain relief
• Practical tips to help you stay in the “zone” during labour

Transcript

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Welcome to Prepare, the Mercy Prenatal podcast dedicated to helping parents prepare for the journey of pregnancy, childbirth, and early parenthood. Mercy Prenatal would like to begin by acknowledging the Rawandri Wuiwarung people, traditional custodians of the land on which we gather today, and also the traditional custodians of the lands in which you're listening from today. We'd like to pay our respects to the elders past, present, and emerging, and we extend that respect to Aboriginal and Torres Strait Islander peoples listening today. Welcome back to Prepare. I'm Dr. Rangi, an obstetrician, gynecologist, and researcher here at Mercy Perinatal, and I'm joined again by the beautiful Dr. Laura Whitburn, a physiotherapist and academic focusing on improving the experience of labour pain and intrapartum communication. This is the second part of a two-part episode on this topic. In part one, we explored how your mind, hormones, environment, and support team can shape the way you experience labour, and we looked at intrinsic and extrinsic ways to manage it. In this second episode, we're moving to practical tools: how to find reliable information, the role of informed support people, a fresh look at pain relief options, and tips to help you stay in the zone. Now, Laura, there is so much information out there, probably too much, for people who are preparing to give birth. Can I ask, what advice would you give to people getting ready for labour and birth about how to find reliable information that aligns with their birthing goals? Yeah, yeah. Great question. I think that it's really valuable if they find some birth education where it does teach them about the birth physiology, the process that their body will go through during labour and birth, and this idea of the oxytocin and endorphin system that is so beautifully designed to actually support them during labour and help them get through this very intense and challenging experience. So if they can find some antenatal education that includes education about that, that's really great. It's then about for what type of birth do they want and feel comfortable with and getting the right support people and care providers that can help. It would be about thinking about what all their options are also for different models of care that they can enrol in and finding the model of care that works the best for them, where most people find the most satisfaction and have the most positive experience where there is a continuity of carer within there. So there's that ability to build a relationship with their caregiver and have that same caregiver be there during their labour and birth. I think another aspect of it is thinking about who else is going to be in the room during their labour and birth and how are those people preparing. Because as I sort of said before, what they say and do can really powerfully shift how that woman is labouring and birthing and thinking about her birth. So they equally want to do their own preparation so that they understand how influential they can be in a positive way, but also in a potentially unintentional negative way, so that they can be very careful with the subtle messaging or cues that they're giving and making sure they're not unintentionally, you know, seeding any ideas of the woman not being able to cope or feeling like she's getting tired and can't go on, or you know, sort of these negative seeding things that can happen and do happen a lot during labour. Because it is also scary being a support person, isn't it? Apparently. I've never I've only ever been the labouring person, but um yes, I could imagine it would be, absolutely. So I think they equally need to go through that journey of understanding birth physiology so that they understand that although it's you know sounds a bit impossible when you sort of sit back and think about it, how on earth are we going to get a baby out? Exactly. But if you understand the birth physiology, it's actually this amazing ability of the body to be able to birth. I suppose the the other thing I think would be important to touch on is sometimes, for whatever reason, even if you do have that positive mindset and view that labour is purposeful, there might be things outside of your control that mean that it might not go to plan or how you would want it to go, or perhaps you might not even have the choice of labouring because it might not be medically appropriate, unfortunately. For example, cases where there's something like placenta previa, where the placenta's in the way of where the baby needs to come out of the cervix, or the baby's distressed, or there's an underlying medical issue with the birthing person, lots of reasons beyond people's control. How couldn't we still frame that experience and the pain that might be associated with perhaps a cesarean section or even clinicians needing to help with an instrumental? How can we help people in terms of how they think about that experience and pain so that it's the best experience they can have? And to make the most of those intrinsic, intrinsic and extrinsic methods? Yeah, so I think that people would still want to be thinking about, yeah, what intrinsic and extrinsic strategies am I going to be needing? But yeah, what are the possible pathways that this birth could head towards? Because, as you said, they may be for reasons out of anyone's control and need for a certain pathway to keep everyone safe. I think that this is where having continuity of care can really help because you get to build that understanding and appreciation and understand all the possibilities for my unique situation throughout that pregnancy journey, so that when you're there in you know, in labour or already at the end and the plan changes, I guess there's already that trust in your caregiver that is necessary and have that, I guess, confidence also to question and understand exactly why this is, you know, this is the way it is. I think that one thing that women talk about really struggling with is not so much that the plans changed and they needed that emergency cesarean or they needed to end up being induced when they didn't want to or whatever, but it's feeling like they weren't heard, their concerns weren't heard around those times. And so feeling dismissed, feeling out of control. When we know there is, you know, there's aspects of all labour and birth that you're not going to be in control, but it's feeling like you have no control or say in your experience. Still feeling like you have a voice is really important. Yeah, so still feeling like you have a voice in your herd. And I think that's not so much about the you know, families who are preparing for their um first experience, that's probably a good message for the caregivers on the other side. Yeah. Um, but that that that's really important, particularly in those moments where things don't go to plan, or perhaps there is a course of action that is going to be unexpected or you know, unplanned. Yeah, yeah. That's a really good point. In terms of going back to some of the intrinsic methods you mentioned, we mentioned things like vocalizing and breathing, mindfulness. And those things can be uh implemented at any point, can't they? Yeah, really, at any stage of the labor, whether you're at home or in the healthcare setting. Some of the extrinsic things you mentioned, like the TENS machine. How does a TENS machine work just for the listeners at home? Yeah. Um, so a TENS machine, TENS stands for transcutaneal electrical nerve stimulation. So a TENS machine is a little electrical stimulation machine that works through some pads that you attach to your skin. So these sort of sticky pads that you pop on your skin, and it sends a very safe, a sort of electrical stimulation through your skin that sort of makes your skin tingle. And in doing so, it stimulates lots of different nerve endings and sends lots of different sensory messages up to the spinal cord and the brain, okay, and can have this really powerful effect of almost like scrambling messages that are being sent up to the brain that might otherwise be perceived as painful coming from the contractions. It's almost like scratching an itch. You know, a scratch scratching is actually another uncomfortable, sort of layering an uncomfortable sensation on top of the itch, and it sort of scrambles the whole messages that enter the brain and can make it feel much more tolerable. So TENS machines tend to be really effective, particularly if they're used from the very start of labour. Okay, because the earlier you can start using the TENS machine and start to sort of send these extrasensory messages up to the spinal cord and brain, it's actually gonna help sort of stimulate those endorphins a little bit sooner than they otherwise would be stimulated. And the other great thing about a TENS machine is I use a TENS machine for both of my labours and oh my gosh, they were the best. Great. Um, and it was this sense that okay, I can feel my contraction coming on, I'm gonna tend turn my tens on now, and as my contraction builds, I'm gonna follow it by increasing the intensity with my TENS machine. And then as my contraction peaks and starts to then reduce, I'm gonna then you know take off the intensity on my tens machine. It was almost like in this weird way, I was controlling the contraction. Because you were so aware of the build-up and the yeah, it was like, yeah, it was just this sort of weird phenomenon of feeling like I was sort of matching it and I was sort of working with it and going on this journey of the contraction with it. So, yeah, when we asked the participants in our study about all these strategies and they listed all the intrinsic and all the extrinsic methods. I'm actually just looking at the data here on my screen. Yeah. The most common extrinsic strategies were shower and bath, was number one, where almost 50% of the participants mentioned that they wanted to use that. Yep. Which is a good message for any hospitals or birthing centres that are thinking about installing some more baths. Yes, please do. Yes, people want them. Yes. TENS Machine was the second extrinsic strategy that was most commonly mentioned by about 35%. Okay. Touch and massage was next, particularly from sort of their support person. And where do people usually find that the most beneficial on their bodies? Or is it subjective and they kind of just have to see how they feel? I would say it's very subjective because I thought I would like a massage. And you didn't. You didn't want anyone touching you. So um, but it can be really good to practice some different spots during pregnancy and see what does feel good, uh, particularly for a support person who may not, you know, know how to massage. And massages can kind of feel a bit pinchy and uncomfortable if the person doesn't know what they're doing. That's right. And that's definitely not what you want to experience later. Definitely not what you want to experience. I mean, luckily my partner was also a physio, so techniques, but even so, I actually didn't want to be touched anyway, so it didn't matter. So the fourth most common extrinsic strategy was the social environment. So the people wanted to actually construct a social environment that made them feel calm and safe and supported, yeah. And then the fifth was pharmacological pain relief. Okay. Yep. So that also just tells us that it's not pharmacological pain relief, which is the first thing that people think about as what strategies they want to use. Yeah. It's definitely part of the list. Yeah. But it's not, we we assume that it's the main things. It's all of the pharmacological and non-pharmacological methods. They're going to be all the strategies. But actually, there are all of these other things that people know and want to use and plan for that are just as sort of important to them. And can be used together as well. They can be used together, that's right. And we're then tapping into our internal capability to birth. Yeah. And so these strategies, so intrinsic strategies are the ones that can that that person can just use whenever she needs to to kind of help her stay in that positive zone. But then at times she may need some extrinsic strategies on top of that, just to help maybe re-center, re-enter, refocus, and get back into that zone. Yeah. So we're always trying to keep people into that zone. Just also, lastly, we did talk about the pharmacological methods, and I think it's still useful to go through those and go through some of the advantages and disadvantages, and we can both talk about those. What's a quick rundown of some of the drugs that we have available or pharmacological methods that people might have in their healthcare settings? Well, if I go back to, I think it probably depends on the healthcare setting. So yeah, you could probably talk about from mercy what they offer. In terms of, again, just going back to women and what they're thinking about. The ones that came up in our data were things like nitrous oxide and oxygen. So the gas often. Um, and that's a very commonly available and common one that people will use. So that's often something that people would use. Put pop a little a breathing tube in their mouth that's connected to the wall that releases this nitrous oxide with every breath that you take, and you often use it in conjunction with the contractions. It it hangs around in your body and then it goes away quite quickly, and it it can be useful to help with the pain relief. That's right, yeah. Interestingly, if you sort of think about well, what it what is the effect, what's making it effective? What it's also doing is helping her to really use her breath. When someone's using that gas in there, they're drawing the nitrous oxide oxygen through the mouthpiece. It's also just helping also to really draw out and control and focus on breathing. That's true. So, you know, it may be, it may be the effect of the nitrous oxide, but it may also just be a really good way to calm the body, to calm the nervous system through focus on breath and slowing the breath as well. That's a really good point. Some other ones that women mentioned were saline injections. Yes. I don't know if they're offered everywhere or if they're more specific to certain services. I think they can be offered in many places. But how do we know saline injections work? The idea is that they are a small injection of saline, which is a salty water, basically. Yep. So a very sort of clean, neutral substance that is injected into just under the skin. And it sort of has a similar effect to a TENS machine in that it's going to stimulate certain sensory nerves in the area to help sort of send some other messages up to the spinal cord and brain that can help to sort of scramble the other sensations that can be experienced as painful. Okay. Yeah. Great. And then I think obviously the most common one that people think about are epidurals. And there are lots of different types of epidurals, and you would be much better placed than me, probably, to talk about those. Yeah, so I suppose the other thing that we often offer is injections of pain relief or stronger medications like morphine, some places offer pethidine, and and those are stronger medications, as we mentioned, opioids. They can last for a few hours. Sometimes they can provide very good relief from the pain. There are some potential side effects with any medications we give. They can make you feel a bit drowsy, sometimes a bit nauseous, and it's hard to say for whom that will be. But it's something that if people did feel like they needed more support, but they didn't want to try an epidural, for example, yet, that is a good interim step. But we don't often like to give that medication too close to when we think a baby might be coming because it can make babies a bit drowsy if they're closer to delivery. So we would be working with your healthcare provider to make sure that it was appropriately timed and safe to do so. But as you said, it's really about that continuity of care and communication the entire way, making sure that everybody's aware of what's available, but also focusing on what the birthing person wants and needs. The epidural is, of course, as you said, something that people commonly think about. And that's basically a medication that can go into a certain level of your spine, and there's a little tube that stays in there that's inserted by an anaesthetist, which is a doctor that performs these procedures but also helps to put you to sleep for operations. And that little tube can administer a medication which is often similar to the morphine, but sometimes it is morphine, or a similar class. And that medication at that level of the spine can take away pain from that level down, and it often also takes away the sensation of being able to move. And ideally, we like you to be able to move as much as possible in labor and even with a perfectly working epidural, but sometimes it does impact your ability to move. It also takes away your ability to feel your bladder feeling, so we would need to put a catheter in at the time, but it can be a very effective way to take away or significantly reduce the pain of contractions. One thing that is challenging is it can be harder to feel the pressure and that feedback, as you mentioned, Laura, from the contractions. So it might mean that your team needs to provide more support when it comes time to pushing. And as you also mentioned, if we do give it too early in labour, it can really interfere with that positive feedback. If we see that that positive feedback cycle with the hormones, with the oxytocin is not well established, and giving an epidural too early can sometimes not be beneficial to the progress of that labour. So we might need to then help with other means of progressing the labour. But again, it's open to everyone at any time. So I think one of the other things that is important to talk about in terms of language around pain and and all the methods we have is just reducing any negativity really and the the stigma that can be associated with anything to do with pain and labour, isn't it? Yeah, that's right. There's something called nocebo language, which is people might be familiar with placebo, the placebo effect. The placebo effect is where expectations and context can actually change someone's experience to make them feel perhaps less pain or more happy or more positive. The nocebo effect is the opposite of that, and that's where context and expectations can make someone feel more pain or more negative or you know have a have a worse experience. And the nocebo effect can really happen when it comes to talking about labor pain to a person in labor, and we don't want that to happen, we don't want that pain experience. We know that the contractions are intense and will be challenging, and we don't want to unintentionally make it worse or frame them negatively. So one thing that can help is just being very careful, even in using the word pain in labor because it's a little bit of an assumption that we're making when we ask someone, how's your pain? Yes. And it's sort of jumping to conclusion and doing that meaning making for them in what are these sensations, what do they mean? Oh, they're painful and pain is bad. And so we want to be a little bit careful, potentially, in even using the word pain and asking someone about how's your pain? Are you coping okay with the pain? Because you're kind of assuming that they're not. It's assuming that they're not. It's assuming that there is pain and that it's going to make the person focus on those. Painful sensations and it can unintentionally also come across as are you coping? Am I coping? Yeah. Am I going to be able to is there going to be a point I'm not coping? Should I not be coping? Should I not be coping? Do you need pain relief? Do you need let me know when you need pain relief? Is a really common comment that would probably be asked, a common question that would be asked of people in labour. Yeah. That's also got a lot of loaded sort of meaning to it in that is there going to be a point where I won't be able to and I will need pain relief? Is it a given? Is it a given? Yeah. So I think that it can be a good idea to avoid the use of the word pain where possible. Unless it's come from that person, absolutely, if they say, I'm not coping with my pain, or the pain is pretty okay at the moment. They're using the word themselves, that's okay. They're giving that meaning to the sensations. But it might be that instead of asking the person, how's your pain? Do you want anything for the pain? Because that would be no SIBO language. Instead, you could say something like, Are you comfortable? Do you need anything else to help you feel comfortable? That's much more positive. It's much more positive. And now they're thinking about comfortable. Am I comfortable? Well, I'm not, you know, I might not be comfortable, but I'm okay. I'm doing okay. But that also opens the door for that person to think about many aspects of being comfortable, not just that one sensation. Yes. So is their position comfortable? Is the lighting comfortable? Yep. All of those things. Yes, that's right. Or what would instead of how's my pain and do I need anything for the pain? It's about, yeah, am I comfortable? What are all the elements that would make me feel comfortable? I would just really like it if, you know, if there was a little bit less noise around me, or can someone turn the lights off? Or I I'd really help if someone could turn my music on, or I just need to get up and move, or something like that. And then I'll feel more comfortable. Yeah. Yeah. And that prod is important because sometimes, as you said, people will be in the zone. Hopefully, preferably, they'll be in the zone. Yes. Having someone prompt you to think about how you could optimize that is excellent, but using positive, neutral language. Yes, yeah, that's right. Fantastic. Thank you so much, Laura. We've covered so much ground in terms of how to think about pain in labor or or even that word. What does it mean? Um how to best arm yourself with the tools and the information going into it, which is I think the main thing that people I think we we are so trying to improve antinatal education and and people's preparedness for for this experience, which is one of the biggest experiences of their lives. But also, I think we've kind of covered some of the common myths and misunderstandings about pain in labour and and also what what options are available to people and how much they have in their control. Yeah. Which is great. So thank you so much. We're so grateful for you having joined us. And thank you again, Laura. Thanks for having me. And just a shout out to all of those participants, those birthing women and people who participated in my research. It was, you know, this has all come from you and your experiences. So thank you to all of them. Awesome. Thank you. Bye. 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.