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Catherine Niven and Tricia Murphy-Black have provided an enlightening review of the mystery of labor pain and how women experience it and recall it ( 1). The study of labor pain is frustratingly complex. The choice of assessment techniques, timing of the initial assessments (whether and when during labor or afterward), each woman's previous experiences with pain and trauma, and the concurrent physical and psychological state of the woman all contribute to variability in responses. Similar problems exist with the later assessment of recall of labor pain.

Despite these difficulties in measuring pain and determining how accurately it is recalled, one thing is certain: labor pain is greatly feared by most expectant mothers and fathers. Furthermore, many caregivers believe that labor pain is not only unpleasant, unnecessary, and undesirable but also destructive emotionally, physically, or both. In addition to ensuring safe passage of mother and baby, the other major clinical responsibility of caregivers is to reduce the pain of childbirth. In fact, enormous financial resources are devoted to this pursuit, and a huge subspecialty of anesthesiology exists to eradicate labor pain.

It is ironic that Niven and Murphy-Black's review found that many women's later recall of labor pain indicated that they had largely positive feelings about their ability to cope with the severe pain. This may indicate that the severity of labor pain in itself is less important to some women than the meaning of that pain. For many women, labor pain is accompanied by feelings of emotional well-being, of being in control, and being nurtured and respected by their loved ones and caregivers. Their later recall focuses more on their sense of accomplishment in having dealt with the pain successfully (as they define success) and deemphasizes the severity of the pain.

If, on the other hand, labor pain is associated with suffering, shame, loss of control, loneliness, or helplessness, its meaning and impact are damaging to the woman's well-being and self-image. Her recalled pain may intensify over time. Her memories of the birth will be negatively influenced by the feelings that accompanied her pain.

What factors shape a woman's actual experience of pain during labor? Variations in the intensity of the contractions, her fatigue level, the position of the baby, and other physical factors undoubtedly play a key role, as do previous life experiences, such as unresolved physical, emotional, or sexual trauma, family dysfunction, loss of one or both parents, chronic illness, or others. These early factors diminish or destroy a child's sense of safety and stability. Such extreme stresses force the child to become emotionally self-sufficient and to take on adult responsibilities before she is ready. She “grows up” too fast and forms a view of the world as a dangerous, untrustworthy place of pain and unpredictability, which easily gets transferred to stressful situations like childbirth. Posttraumatic stress disorder after childbirth is likely to occur or recur when earlier traumas were never resolved. For her the pain of childbirth is likely to be especially severe and to take a great psychological toll. Tens of thousands of women every year bring such histories to childbirth and are likely to experience birth as trauma ( 2-4).

Women who grew up in safe, consistent, loving circumstances learn that their world is a predictable trustworthy place in which they are safely nurtured. Their emotional development is appropriate to their age, and the challenges they must face do not overwhelm them. For them the pain of childbirth does not represent another impossible challenge. They bring self-confidence and adult coping skills to the situation and are more likely to discover labor pain to be manageable, although severe, and to feel satisfaction in meeting the challenge.

The meaning of childbirth pain, then, is influenced by one's early life experiences. The pain may be experienced as trauma or as a truly difficult challenge in an intensely fulfillling, once-in-a-lifetime event. If caregivers could identify women prenatally who have unresolved trauma issues and provide appropriate individualized care and support to them during childbirth, they could decrease the numbers of women who are overwhelmed and devastated by the pain of labor. Furthermore, the ability to identify those new mothers for whom childbirth pain was traumatic and to help them process and resolve the traumatic aspects of the pain would improve their mental health and the well-being of their entire family ( 5).

It is time to take a broader look at the meaning of pain in childbirth. By doing so, caregivers and educators may come to appreciate that labor pain deserves a more sophisticated approach than eradicating it for women or helping them “tough it out.” Neither of these approaches addresses the real issues of the complexity of labor pain and its potential positive or negative long-term impact on each woman.

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