Science & Sensibility welcomes new contributor, Penny Simkin, PT, CCE, CD(DONA). Thank you for sharing your decades-long experience and expertise with us!

Introduction
After the health of mother and baby, labor pain is the greatest concern of women, their partners, and their caregivers. Nurses and doctors promise little or no pain when their medications are used, and feel frustrated and disappointed if a woman has pain. Most are also extremely uncomfortable with her expressions of pain during labor - moans, crying, tension, frustration - because they don't know how to help her, except to give her medication.

An enormous industry exists in North America to manufacture and safely deliver pain relieving medications for labor. Hospital maternity departments are designed with elimination of pain as a primary consideration, complete with numerous interventions and protocols to keep the pain management medications from causing serious harm. When staff believe that labor pain equals suffering, they convey that belief to the woman and her partner, and, instead of offering support and guidance for comfort, they offer pain medication. If that's the only option, women will grasp for it.

This brings me to the topic of my blog post today - Pain, Suffering, and Trauma in Labor.

Definitions of Pain and Suffering
If we check the definitions of 'pain' and 'suffering' in lay dictionaries, the two are often offered as synonyms of one another, which helps explain the fear of labor pain. It's a fear of suffering. But if we consult the scientific literature, there is a distinction among pain, suffering and trauma. As described in Lowe's fine paper on the nature of labor pain (1), pain has been defined as, 'an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.' (2) The emphasis is on the physical origins of pain.

Lowe also points out that 'suffering,' can be distinguished from pain, in that by definition, it describes negative emotional reactions, and includes any of these: perceived threat to body and/or psyche; helplessness and loss of control; distress; inability to cope with the distressing situation; fear of death of mother or baby. If we think about it, one can have pain without suffering and suffering without pain. We can all recall times when we have been in pain, but did not fear damage or death to ourselves or others, nor did we feel unable to cope with the pain. For many people, athletic effort, recovery from planned surgery, dental work, and labor are painful but these people do not suffer with them. This is because the person has enough modifiers (knowledge, attention to other matters or goals, companionship, reassurance, touch, self-help measures, feelings of safety and other positive factors) to keep her from interpreting the experience as painful. All pain is not suffering.

By the same token, I'm sure we can recall times when we have suffered without pain. Acute worry or anguish about oneself or a loved one, death of a loved one, cruel or insensitive treatment, deep shame, extreme fear, loneliness, depression, and other negative emotions do not necessarily include real or potential physical damage, but certainly cause suffering. Therefore, all suffering is not due to pain. In fact, it is these negative modifiers that turn labor pain into suffering.

Of course, the goal of childbirth education has always been to reduce the negative modifiers, and increase the positive ones. The goal of anesthesiology has been to remove awareness of pain, in the assumption that when there is little or no pain, there will be no suffering. I'll get back to that point later in Part 2 of this blog.

Suffering and Trauma
According to the American Psychiatric Association, the definition of trauma comes very close to the definition of suffering. 'Trauma' involves experiencing or witnessing an event in which there is actual or perceived death or serious injury, or threat to the physical integrity of self or others, and/or the person's response included fear, helplessness, or horror. (3) Neither suffering nor trauma necessarily includes actual physical damage, although it may do so.

One's perception of the event is what defines it as traumatic or not. As it pertains to childbirth, 'Birth trauma is in the eye of the beholder' (4), and whether others would agree is irrelevant to the diagnosis.

Birth trauma and Post-Traumatic Stress Disorder (PTSD) after childbirth
A traumatic birth includes suffering and may lead to PTSD, which (according to the APA) means that the sufferer has at least 3 of the following symptoms that continue for at least one month:

• nightmares
• flashbacks
• fears of recurrence
• staying away from the people or location involved
• avoiding circumstances in which, it can happen again
• amnesia
• emotional numbing
• panic attacks
• emotional distress

One national survey found that 18% of almost 1000 new mothers (up to 18 months after childbirth) reported traumatic births, as assessed by the PTSD Symptom Scale, a highly respected diagnostic tool. Half of these women (9% of the sample) had high enough scores to be diagnosed with PTSD after childbirth. (5)

Other smaller surveys (using women's reports as the criteria for diagnosis) have found that between 25% and 33% of women report that their births were traumatic. Of these, between 12% and 24% developed Post-Traumatic Stress Disorder (PTSD). In other words, between 3% and 9% of all women surveyed developed PTSD after Childbirth.(6-9)

As we can see, every woman who has a traumatic birth does not go on to develop the full syndrome of PTSD. If they have fewer symptoms than the three or more required for the diagnosis, they may be described as having PTS Effects (PTSE). Though disturbing, the women are more likely to recover spontaneously over time than those with PTSD. The question of why some women get PTSD and others do not is intriguing and multifactorial: the propensity to develop post birth PTSD has to do with how they felt they were treated in labor; whether they felt in control; whether they panicked or felt angry during labor; whether they dissociated; whether they suffered 'mental defeat;' (that is they gave up, feeling overwhelmed, hopeless and as if they couldn't go on) (9, 10). Another risk factor for developing birth related PTSD is having a history of unresolved physical, sexual and/or emotional trauma from earlier in their lives. Even though unresolved previous trauma is unlikely to be healed during pregnancy, most of the other variables associated with PTSD can be prevented 'through care in labor that enhances perceptions of control and support' (9).

In Part 2 of this blog post, I will suggest practical ways to apply what we know about the risk factors for childbirth-related PTSD, and how we can address these before, during, and after childbirth. I will discuss prevention and reduction strategies which can collectively reduce the likelihood of traumatic childbirth and subsequent PTSD.

This blog post series will be featured in the Fall 2011 issue of the Journal of Perinatal Education. For references, please contact Ms. Simkin directly at: penny@pennysimkin.com or reference the JPE issue: Summer 2011 Volume 20, Number 3.

Post By: Penny Simkin, PT, CCE, CD(DONA)

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