Ask a bunch of expectant women what worries them about labor, and chances are many of them will say, 'the pain.' Much is made about pain in labor. Women prepare for it, nurses constantly assess it, anesthesiology departments exist to eliminate it, and so on. But while there are many experiences of labor pain, just about the only universal truth about it is that labor pain ends once the baby is out.

But a 2008 report from Childbirth Connection suggests that, for many women, pain is an ongoing problem after birth. The report also suggests that two common labor interventions - cesarean surgery and episiotomy - are highly associated with ongoing pain.

According to their national survey of mothers, reported in New Mothers Speak Out, 22% of mothers who gave birth by cesarean said that pain interfered 'quite a bit' or 'extremely' with their daily activities in the first two months. That's compared to only 10% of women who had vaginal births. Mothers who had vaginal births without episiotomies were the least likely to report that pain interfered at all with daily living. Episiotomy also increased the likelihood of painful intercourse in the first two months.

At six months, nearly 1 in 5 (18%) of mothers who had a cesarean still experienced pain at the incision site, versus only 2% of women who had vaginal births reporting continuing problems with perineal pain.

The Childbirth Connection survey did not ask about endometriosis, a common cause of chronic pelvic pain, but a growing number of case reports strongly suggest that cesarean surgery is associated with new-onset endometriosis.

This week I happened upon a study that reveals another aspect of labor and birth care that may affect postpartum pain. Researchers analyzed data from nearly 13,000 UK mothers of singleton, term, live-born babies. Participants were recruited into the study prenatally and answered questions about back pain in two postnatal surveys - one at 8 weeks and another at 8 months. The researchers set out to find out if mode of birth (spontaneous vaginal, instrumental vaginal, elective cesarean, or unscheduled cesarean) affected the likelihood of postpartum back pain. They concluded that it did not.

But here's an interesting gem that I almost missed [emphasis mine]:

A higher proportion of women who had an emergency caesarean section reported 8-week postnatal back pain compared with those who delivered spontaneously... Adjusting for the factors associated with emergency caesarean section and back pain decreased this association. By 8 months, the prevalence of back pain fell, but remained higher amongst emergency caesarean sections. Epidural analgesia and 'in preferred position in labour' were the two most influential confounders.

What does this mean? I had to go back to an earlier study that reported outcomes from the same dataset in order to figure out what 'in preferred position' was referring to. It turns out researchers asked women how much of their labor was spent in their preferred labor position. Options were, 'no/hardly,' 'sometimes,' or 'always.' The results of this earlier trial showed that being in the preferred position in labor reduced the risk of cesarean surgery. The fact that the researchers in the new study controlled for it tells us that being in one's preferred position in labor also was protective against postpartum back pain. It also tells us that having an epidural in labor increased the likelihood of postpartum back pain, although this finding has been inconsistent in other studies.

What other labor and birth practices could affect postpartum pain? What about skin-to-skin contact after birth? Only one tiny study involving only 20 mother/baby pairs has looked at whether skin-to-skin care affects nipple soreness and it did not find an association. Another small study (not published but included in the Cochrane systematic review) looked at breast engorgement pain and did find that skin-to-skin contact was protective. A much larger body of literature shows that skin-to-skin contact in the hour or so after birth increases the duration of breastfeeding, which lends additional support to the possibility that skin-to-skin care reduces breastfeeding-related pain (a common cause of early weaning).

Another Cochrane systematic review tells us that upright pushing positions are associated with a much lower rate of episiotomy. Although no study has evaluated pushing position and its direct effect on postpartum pain, anything that reduces episiotomy will in turn reduce postpartum perineal pain and painful intercourse.

In the same vein, practices that reduce operative delivery will in turn reduce postpartum pain associated with these modes of birth. These practices include letting labor begin on its own, providing continuous labor support, and reducing the use of interventions such as epidural analgesia and routine continuous electronic fetal monitoring.

It seems to me that we overemphasize the physiologic pain related to labor and completely ignore the pathological pain related to interventions and injuries in childbirth, many of which could be averted. My question to my readers is this: how do we reframe the conversation about childbirth-related pain to look more holistically at pain throughout the childbearing year and beyond?

Citations:
Moore ER, Anderson GC, & Bergman N (2007). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane database of systematic reviews (Online) (3) PMID: 17636727

Gupta JK, & Hofmeyr GJ (2004). Position for women during second stage of labour. Cochrane database of systematic reviews (Online) (1) PMID: 14973980

Moore ER, & Anderson GC (2007). Randomized controlled trial of very early mother-infant skin-to-skin contact and breastfeeding status. Journal of midwifery & women's health, 52 (2), 116-25 PMID: 17336817

Patel RR, Peters TJ, & Murphy DJ (2007). Is operative delivery associated with postnatal back pain at eight weeks and eight months? A cohort study. Acta obstetricia et gynecologica Scandinavica, 86 (11), 1322-7 PMID: 17851815

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