Looking for Meaning in Labour Pain: Are Current Pain Measurement Tools Adequate?

With great advances in understanding the mechanisms of pain, new definitions [1] and classifications [2] have been developed to describe pain conditions. Despite this, pain assessment remains challenging. Our work has confirmed that pain associated with labour is different from other pain experiences [3, 4]. In an uncomplicated labour, increasing pain is a signal, not of pathology, but of progress toward the birthing of a baby. We have found that a woman’s interpretation of the meaning of the pain plays a critical role in her pain experience and how she copes [3, 4]. This commentary will focus on our concerns that current approaches to the assessment of labour pain are inadequate. In particular, we support woman-centred approaches to assessment and believe that capturing the meaning of the pain to the woman is critical in assessing pain. The late Ronald Melzack wrote an editorial proposing that labour pain provides a good model of acute pain [5]. Interestingly, he did not mention tissue damage at all but lists a number of variables shown to contribute to pain during labour. These include the size of the baby, the weight–height ratio of the mother, childbirth education, if it was the woman’s first time birthing, pain with menstruation, other pain unrelated to labour, socioeconomic status, birth position, and even time of day. Demonstrating his extraordinary understanding of the human pain experience, Melzack recognised that pain is always complex and influenced by multiple factors. He used this understanding to explain the great variability of women’s experiences of labour pain, but he also implied that pain associated with any acute injury is also susceptible to a range of influences. While agreeing with this premise, we feel it is important to make a distinction between labour pain and other pains (both acute and persistent). Pain associated with a normal, uncomplicated labour is different from other pains because of its unique context and meaning [6]. First, unlike other typical pains, it is associated with a nonpathological event. In labour, an increase in pain is to be expected and is usually a sign that the physiological process is progressing as desired. Second, unlike other typical pains, and despite its intensity, labour pain can be experienced as a “positive,” “productive,” or “purposeful” pain. Some women may even feel that “pain” is an inadequate description of their experience, based on typical contexts associated with pain: “I think of pain as being something unnatural happening in my body whereas the labour is something my body is meant to be doing” (p.1032) [3]. These features of labour pain may prompt the question: What is the usefulness of pain during labour? One possible explanation is to consider its behavioral effect on the labouring woman, which is likely to be beneficial to both her and her baby. During the first stage of labour, the pain diverts the mother’s attention toward herself and her unborn baby. It motivates her to stop what she is doing, find a safe place, and behave in a way that alerts others that she needs assistance. This social role of pain is probably not unique to labour, but the type of support required is quite different—that is, support that facilitates the woman toward a self-belief mindset, to engage with the intense sensations of her body working powerfully to birth a baby, while remaining safe. This unique context of the pain allows for varied responses to the underlying question: “What does this pain mean to me at this time?” One response reported by many women is that the pain helps them “track” their progress through labour; increases in intensity can indicate labour progression [4]. The medicalised view of labour pain appears to have missed the distinction between labour pain and other pain experiences, viewing pain as always a sign of suffering, and, in the context of labour, advocating for its eradication [7]. Further to this is the setting in which childbirth typically takes place. In 2018 in Victoria, Australia, 96% of births occurred in a hospital [8], a place typically associated with illness or unwellness. It may be that within this medicalised setting, physiological labour pain is more likely to be perceived by a woman as akin to a pathological pain, altering her perception of its meaning [6]. Intrapersonal and interpersonal factors can influence the birthing woman’s interpretation of the meaning of her pain. This includes cognitions, such as attitudes or beliefs, the actions and words of those around her from moment to moment, and the broader cultural and social attitude to labour in the setting in which she is birthing [6]. Our research found that when women remained focused, in a “mindful” state (accepting, nonreactive, and nonjudgmental), they reported feeling more capable of managing the pain [3]. This can be facilitated by cultural or religious beliefs that many women draw on during labour to augment their self-efficacy to cope with the pain [6]. A focused woman, able to maintain a belief that her pain can be explained as part of the progression toward birth (i.e., purposeful and productive pain), has a different experience from the woman who is concerned the pain is a sign of dysfunction, or who, despite pain, is unable to identify the progress she is making [4]. A lack of focus, either because of distractions in the environment (for example, interruptions to the labour by monitoring or physical assessments) or “distractive” thoughts (for example, worrying about the remaining duration of the labour or concern for the well-being of other children) can make a woman’s pain feel more intense or aversive [3]. It may be that a focused state with an accepting attitude allows for an integration of the pain as a necessary part of the birthing process, whereas lack of focus makes the pain feel less integrated into the birth process, and the required context for a positive meaning of pain is lost [3]. Further to this is the powerful effect of the social environment in facilitating or diminishing a woman’s sense of being able to cope [4]. The words or actions of a woman’s caregivers can influence a woman’s focus and the cognitions and emotions associated with her pain experience [4]. Known and trusted caregivers can tacitly reassure a woman that her pain is productive and purposeful and increase her confidence in her ability to cope [4]. Alternatively, a lack of familiarity, lack of empathy, or loss of sense of privacy are some of the social factors that can implicitly suggest to the woman that the pain experience is threatening [4]. The concept of safety is of particular relevance to modern understandings of pain. During the intense and challenging experience of labour pain, feeling safe may change the threat value of the woman’s pain and empower her to better cope with it [6]. The sense of safety that a woman perceives within the social environment in which she is birthing is likely an important factor in the meaning of the pain she is experiencing. Research demonstrates that continuous support by known and trusted caregivers improves women’s satisfaction with labour, decreases their use of analgesics, and improves health outcomes for the mother and her baby [9]. Woman-centred care is considered an important concept of maternity care. However, there is a range of perspectives on what constitutes this approach [10]. For woman-centred assessment of labour pain, this would include a mode of assessment that allows women choice and control over the process. In our research investigating women’s perspectives on pain assessment, the most preferred mode was a rating of pain or description of pain that they could give verbally [11]. Women felt they could participate in a verbal pain assessment during labour, but they were also alert to how their emotions or attention could affect the meaningfulness of the pain rating for those who were to interpret or act on it. Women also felt that retrospective assessment, which might be appropriate in research, was acceptable, with most believing that they could report their pain experiences accurately in the first post-birth weeks [11]. Ideally, assessing pain should empower the woman and promote engagement with her birthing focus. Women in our research were concerned that assessing pain during labour might either distract the woman from her focus or unhelpfully draw her attention to her pain [11]. When pain assessment is conducted primarily to determine the woman’s need for analgesia, interrupting the mindful focus of a woman could affect her ability to cope with her pain and set a context in which communication about pain focuses on pain relief. The simple act of asking a woman if she needs analgesia may be disempowering if the woman interprets the question as a negative evaluation by her caregiver of how well she is coping [12]. The fact that pain assessment often occurs in the context of decision-making means it is imperative that pain assessment reflects the woman’s individual interpretation of pain. Pain assessment must have the capacity to incorporate the woman’s culture and language and capture the influence of her life experiences. Cultural and religious beliefs, language, and life experiences collectively contribute to the meaning a woman attributes to her pain [13–15]. Accessing the meaning of pain would seem to be important in a woman-centred approach to pain assessment. Ideally, the assessor should be a trusted caregiver or advocate. A known and trusted assessor is likely to be attuned to the woman in a way that allows assessment to be carried out with minimal interruption to her birthing process [11]. Also, the pain assessment is then more likely to trigger action that is appropriate and amenable to the woman rather than to the agenda of the health care providers or indeed the maternity facility. It may be, however, that people in the role of pain assessor, even trusted ones, have their own motivations, including what they perceive to be in the best interests of the woman. This may influence their interpretation of the woman’s pain reports and behavior and may bias any decisions and subsequent action. It is therefore important that those who are responsible for assessing and responding to a woman’s pain are aware of and aim to put aside their own needs and preferences. A literature review conducted by Power et al. [14] evaluated pain assessment tools used in the context of childbirth between 1950 and 2013. They found that unidimensional tools of pain intensity are frequently used to measure labour pain. Measures include the Visual Analogue Scale (VAS), the Numerical Rating Scale (NRS), and the Faces Pain Scale. These scales are typically anchored by the statements “no pain” and “worst pain imaginable” (or similar), and responders rate their pain by placing a mark on a line (in the case of a VAS) or selecting from increments along the scale (for example, a scale of 11 points, from zero to ten). These simple and convenient scales are familiar to most clinicians, pain researchers, and patients. Nevertheless, the challenge for a person to decide on a single point to reflect a complex experience, especially during an unpleasant sensory and emotional episode, is not always recognised. Rather than being true indications of pain intensity, ratings on these scales are “better conceptualized as an attempt to construct meaning, influenced by and with reference to a range of internal and external factors and private meanings” (p.457) [16]. Ratings may be influenced by factors such as the rater’s emotional state [16], the need to please the assessor, and what the rater wants from the assessor (for example, more analgesia) [17]. Furthermore, because these simple scales measure only one dimension, there is limited opportunity for a woman to qualify her interpretation of that pain (i.e., its meaning to her at that moment) and thereby communicate her needs to her caregivers at that time. The Short-Form McGill Pain Questionnaire (SF-MPQ; an abbreviated version of the McGill Pain Questionnaire) is a commonly used, multidimensional pain assessment tool and has been adapted for use in labour by Capogna et al. [18]. The SF-MPQ consists of a composite of scales measuring pain intensity, as well as a pain rating index of 15 predetermined words. Eleven of these words focus on the sensory quality of the pain (for example, “throbbing”), and the remaining four focus on the affective aspect (all of which describe negative affective states; for example, “fearful”). Additionally, scales such as VAS or seven-point rating scales have been used to measure other dimensions, such as pain unpleasantness and the overall pain experience, by using the anchors “very negative” and “very positive” [19]. Behavioral observation has been formalised as a strategy to assess women in labour in the “Coping with Labour Pain Algorithm” [20]. Given the intensity of labour and the internal focus women adopt, an observation measure has obvious advantages. Women in our study suggested, perhaps facetiously, alternative methods of pain assessment, such as how hard the woman was gripping or how loud she screamed [11]. However, any behavioral measure will always be an indirect estimation of the woman’s pain experience and open to the interpretation of the observer. The literature demonstrates that there is currently no systematic inclusion of pain meaning in assessments of a woman’s experience of pain in labour. The focus continues to be on pain intensity, which promotes a primary response to reduce pain. The assumption drawn from this is that pain is threatening and must be eradicated. The relationship between labour pain and satisfaction with childbirth is complex [21]. In the context of childbirth, pain intensity is not a reliable indicator of a woman’s overall pain experience [21], and women can view labour pain as productive and purposeful pain, not associated with suffering [6]. The distinction between a pain that is perceived as purposeful and a pain that is perceived as threatening is critical for attempting to evaluate the effectiveness of nonpharmacological interventions. Many of these interventions do not attempt to diminish pain intensity but instead seek to change the context of the pain or the woman’s relationship to it (for example, breathing techniques or support from a known caregiver). Pain assessment tools that do not have the capacity to capture a positive interpretation of the pain experience will fail to recognise the effect of these strategies in helping a woman to manage her pain. The association between pain and suffering is also critical to explore. Turk and Wilson explain that “viewing suffering as an inevitable consequence of pain may unwittingly initiate and reinforce suffering” (p.354) [22]. When the people supporting the woman equate pain to suffering that must be relieved, choices that are not focused on pain relief become less available to the woman. The lack of choice, particularly the choice of preferred strategies, can be disempowering, reducing the likelihood the woman will persist with the effort of labour. Lack of differentiation between pain and suffering may be especially challenging for a woman trying to maintain a focused state of mind to “work with” her pain. The assumptions made from pain intensity assessment—that is, that pain must be reduced—may inadvertently divert a woman toward a more threatening meaning of her pain [12]. It would seem important that those supporting laboring women be alert to behavior that might enhance the threatening meaning of pain, including phrasing and questioning around pain assessment. When pain intensity assessment is prioritised to the exclusion of other dimensions common to the pain experience of the birthing woman, the complexity of influences contributing to the woman’s pain is missed. We have previously reported women’s criticisms of a pain intensity scale anchored by “worst imaginable” and discussed how women can quickly reach a maximum score when the intensity of their pain has yet to peak [11]. This cannot be interpreted meaningfully in the birth setting, especially if a woman feels she can express an increase only by going beyond the limits of the scale (e.g., 11 or more on a 0–10 NRS). This phenomenon demonstrates that women may be forced to “recalibrate” their pain scales when asked to rate their pain as labour progresses. Pain assessment should enhance the care women receive during labour. A woman who is experiencing intense pain but interprets it as productive and purposeful will have very different care needs from a woman who is experiencing an equally intense pain but feels afraid, alone, or helpless [4]. If pain intensity is a dimension that does not affect birth outcomes and cannot be meaningfully measured, then other dimensions of the pain experience demand more attention. Accessing the cognitive and emotional dimensions of the pain experience is likely to be more valuable, particularly with regard to the woman’s sense of safety. Existing multidimensional measures have preset lists of adjectives or questions that may not reflect the woman’s experience or, as our research suggests, the moment-to-moment change in the pain experience [4]. Additionally, woman-centred care would involve attending to the woman’s fears and concerns about the whole experience, including the physical environment, her interaction with others, and the safety of her and her baby. This requires support and strategies beyond pharmacological interventions. If those supporting the birth are not skilled in cognitive or behavior change strategies, the potential value of multidimensional pain assessment is reduced. Our research suggests that an important target of pain assessment in labour is the meaning of pain [4]. This incorporates the woman’s integrated evaluations of her sensory, cognitive, and emotional experience at a particular moment. We anticipate that there is value in tracking the meaning of pain throughout labour and that women, at any one time, can interpret the pain as productive and purposeful or threatening [4]. We believe there are likely fluctuations in these appraisals of pain that are associated with fluctuations in a woman’s state of mind between mindful acceptance and distracted and distraught states [3]. Furthermore, a woman who is supported by others to sustain a productive and purposeful interpretation of labour pain is likely to present with mindful acceptance and is more likely to persist with the work of labour. We continue to pursue an ideal strategy for labour pain assessment. Certainly, in dynamic and intense contexts such as labour, any pain assessment tool should aim to be convenient and brief and provide useful information to guide care. We believe, however, that a tool that fails to capture critical dimensions of the experience to fully inform decisions about woman-centred care, at any particular moment, is inadequate. Normalising pain in labour—that is, accepting that the work of labour (in the absence of dystocia) is intense and painful—may be essential in allowing us to move beyond the current focus on the intensity of the pain and toward a focus on the woman’s interpretation of the meaning of her pain. Determining which factors lead to a woman interpreting her pain as threatening is likely to provide new strategies for better supporting women during labour. These include strategies for pain assessment. Capturing the meaning of pain to the woman can determine how best to care for her. So, what might this look like in a pain assessment tool? There is clearly still much research to be done in this space. 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