Why does childbirth hurt?

Several days ago I wrote about the philosophy of natural childbirth advocacy and its indifference to women’s need for pain relief (Natural childbirth and the invisibility of women’s needs). To the extent that natural childbirth advocates acknowledge the existence of childbirth pain, they subscribe to the “if only” school of pain management.

The “if only” school insists that a woman would not experience childbirth as agonizing …

… if only she were more knowledgeable about childbirth.
… if she hadn’t been socialized to believe that labor is painful
… if only she had eaten right and exercised.
… if only she had better support.
… if only she hadn’t had an IV and/or electronic fetal monitoring.

In other words, the “if only” crowd believes that pain is not intrinsic to childbirth; it’s someone’s fault. But pain is intrinsic to childbirth, and to understand why, requires knowledge of the neurological basis of pain itself.

Contrary to the false dichotomy of “good” pain and “bad” pain imagined by natural childbirth, which has no basis in neurology, there are two sources of pain in childbirth, exactly the same as the two sources that exist everywhere else in the body. These two types of pain are visceral and parietal (or somatic) pain.

Here’s the technical explanation from a paper written by a certified nurse midwife:

… During the dilatation phase of labor (first stage), visceral pain predominates, with pain (nociceptive) stimuli arising from mechanical distention of the lower uterine segment and cervical dilatation… These nociceptive stimuli of the dilatation phase are predominantly transmitted to the posterior nerve root ganglia at T10 through L1. Similar to other types of visceral pain, labor pain may be progressively referred to the abdominal wall, lumbosacral region, iliac crests, gluteal areas, and thighs… As the pelvic or descent phase of labor advances (late first stage and second stage), somatic pain predominates from distention and traction on pelvic structures surrounding the vaginal vault and from distention of the pelvic floor and perineum. Sharp and generally well localized, these stimuli are transmitted via the pudendal nerve through the anterior rami of S2 through S4.

Translation:

The pain of contractions is visceral pain caused by the uterine effort to push the baby into the vagina. This visceral pain is the type of pain that comes from internal organs, exactly the same as the visceral pain of a gall bladder attack or a kidney stone. The visceral pain signals are transmitted to the spinal cord through the spinal nerves of the lower thoracic and upper lumbar vertebrae and thence to the brain.

The vaginal and perineal pain of the end of labor is parietal or somatic pain. Parietal pain is sharp and well localized. The parietal pain impulses of crowning and birth are transmitted to the spinal cord through the spinal nerves of the sacral vertebrae and thence to the brain.

An epidural blocks the visceral pain of labor by “numbing” the nerves that transmit the pain to the spinal cord. The parietal pain of labor can be eliminated by “numbing” the spinal nerves that transmit the pain or, in the case of local anesthesia, by “numbing” the nerves located where the pain begins.

The key point is that the two types of labor pain are exactly the same as the two types of pain that can occur in other parts of the body. The nerve impulses are the same, they travel to the spinal cord on similar pathways, and they are sent to the brain in exactly the same way. They can also be abolished in exactly the same way.

Therefore, to understand why the “if only” school of management is wrong, not only in their understanding of pain, but also in their claims about what can and cannot “cause” pain, it helps to apply their claims to other forms of pain.

Consider gall bladder pain, a classic form of visceral pain that occurs when the gall bladder attempts to squeeze out bile but cannot because the duct is blocked by gallstones. Would a patient in the midst of a gall bladder “attack” have less pain if only she were more knowledgeable about gall bladder attacks? If she hadn’t been socialized to believe that gall bladder attacks are painful? If only she had eaten right and exercised? If only she had better support? If only she hadn’t had an IV and/or electronic blood pressure monitoring? The answers of course are no, no, no, no and no.

And why are all the answers “no”? Because gall bladder pain arises from the contractions of the gall bladder attempting to push out a gallstone, is transmitted to the spinal nerves and thence to the brain. The pain impulses from a gall bladder attack aren’t modified by knowledge, socialization, diet and exercise, nursing support or the presence of basic medical safety measures. There’s no reason to expect that they would be modified by these factors. Similarly, there’s no reason to expect that labor pain would be modified by these factors, either.

How about parietal pain? Consider pain from a broken bone, and ask the same questions. The answers will be “no” once again and for exactly the same reason. Just like knowledge, socialization, diet and exercise, nursing support or the presence of basic medical safety measures would not be expected to modify the pain of a broken bone, they cannot be expected to modify the pain of crowning and birth, either.

So why does childbirth hurt? Because of the pain! The pain that is produced by nerve signals, transmitted to the spinal cord, and carried to the brain in exactly the same way as visceral and parietal pain from any other part of the body.

There is no scientific basis for the claims of the “if only” school of childbirth pain. It’s just another attempt to render women’s needs invisible.

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