The reality of labor pain: why it’s worse than natural childbirth advocates will admit

Pregnancy Backache

What natural childbirth advocates like Milli Hill don’t know about the neurophysiology of pain could fill a book — or several.

Hill recently wrote The myth of the painful birth – and why it’s not nearly so bad as women believe. It is a typical paean to ignorance and disrespect — implying that childbirth pain is culturally conditioned and due to lack of support.

Milli Hill and her natural childbirth colleagues don’t know much about history. They don’t know much biology, either.

At the moment, we simply do not know what birth would be like for women if they were given more positive messages and went into labour feeling strong, confident and capable. We simply don’t know what it would be like if all women were given one-to-one support from a midwife they really trusted, or if we created birth rooms, even in hospitals, that were dimly lit, homely and uninterrupted.

Since the beginning of time women have described childbirth as agonizing because they always gave birth in hospitals with bright lighting and unsympathetic male physicians. Oh, wait! Up until very recently all women gave birth in dimly lit, homely surroundings complete with one-to-one support from a midwife.

Obviously Milli Hill and her natural childbirth colleagues don’t know much about history. They don’t know much biology, either.

When it comes to sport, we all seem to understand just how much negative thoughts can affect your performance both physically and mentally. We know how powerful a confident attitude can be. Perhaps it’s time to consider that with birth, things are no different.

Wrong! The neurophysiology of sports pain is very different from the neurophysiology of childbirth pain.

Let’s start with the most basic difference. Most sports pain is somatic pain whereas labor pain is visceral pain. The distinction is critical.

According to Wikipedia, somatic pain can be deep or superficial:

Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles, and is dull, aching, poorly-localized pain. Examples include sprains and broken bones. Superficial pain is initiated by activation of nociceptors in the skin or other superficial tissue, and is sharp, well-defined and clearly located. Examples of injuries that produce superficial somatic pain include minor wounds and minor (first degree) burns.

The pain of crowning, when the baby’s head stretches the vagina, is somatic pain, but the pain of uterine contractions is visceral pain:

Visceral structures are highly sensitive to stretch, ischemia and inflammation, but relatively insensitive to other stimuli that normally evoke pain in other structures, such as burning and cutting. Visceral pain is diffuse, difficult to locate and often referred to a distant, usually superficial, structure. It may be accompanied by nausea and vomiting and may be described as sickening, deep, squeezing, and dull.

The neurophysiology of the visceral pain of uterine contractions is very different than that of somatic pain. Most importantly, visceral pain activates the autonomic nervous system, the nerves which control the automatic functions of the body like heart rate and blood pressure. In other words, visceral pain — unlike somatic pain — has a variety of effects that go beyond the conscious sensation of pain. These include elevated heart rate, elevated blood pressure, nausea and vomiting, and profuse sweating. Visceral pain — whether it originates in the heart, the gall bladder, or the uterus — is often perceived as “sickening.”

In her piece, Hill claims:

…[E]ven in ‘the nightmare labour from hell’ – 36 hours of contractions coming thick and fast – she can still expect to be without pain for around 60 per cent of the time.

That statement might be true if we were talking about the limited nature of somatic pain. If you poked someone with a pin for 20 seconds out of each minute they would feel fine for the 40 seconds that you aren’t poking them. But it’s definitely not true for visceral pain like uterine contractions. Even when the pain recedes the elevated heart rate and blood pressure as well as the nausea, vomiting, sweating and overall sickening sensation often do not recede completely before the next contraction begins. So women in labor do not spend most of the time feeling well except for intervals of pain. They spend most of the time feeling awful.

That has important implications for the philosophy of natural childbirth. The pain of uterine contractions is very different from the pain of athletic endeavor. The idea that the pain of labor is socially conditioned is nonsense; we can identify the receptors and trace the pain pathways. Most importantly, the pain of uterine contractions triggers a cascade of neurological responses that are not under conscious control.

No amount of support in labor is going to prevent women from having a profound physical response to uterine contractions that goes far beyond the sensation of pain itself. In contrast, an epidural, which blocks the neural pathway by which uterine pain reaches the brain does more than merely eliminate the pain. It also eliminates the autonomic nervous system response. When the pain goes away, the nausea, sweating and sickening feeling usually go with it.

The bottom line is that natural childbirth advocates promote a philosophy based on wholesale ignorance of neurophysiology. Childbirth pain doesn’t come from lack of support or lack of confidence. It comes from pain receptors, neural pathways, and the activation of the autonomic nervous system. Telling women about the excruciating pain doesn’t set them up to fail as Hill would have us believe. It’s simply telling them the truth.

  • Zizi

    Heh. This reminds me of that episode of “King of the Hill” where Luanne is about to give birth to her daughter, and her sister-in-law has persuaded her to go to “The Birthing Circle LLC” rather than a hospital. It’s all very well and good at first, but as soon as the contractions set in she starts begging Hank and Peggy to get her the hell out of there and take her someplace where she will get drugs.

    “Visceral pain — whether it originates in the heart, the gall bladder, or the uterus — is often perceived as ‘sickening’.” As one would expect, considering that the cervix is innervated by the vagus nerve, after all. Top that off with the fact that we’re the only mammals that walk upright, fundamentally altering our pelvic structure, and it’s not hard to see why so many women opt for an epidural.

  • keepitreal

    The only time I’ve ever heard bragging about going pain-med free is when the man perceives his woman as a birth mare or the woman is a scripture-toting martyr OR has mental health issues.

    • Zizi

      This is actually a cultural norm in Japan and Sweden…unfortunately.

  • Aine

    Thank you Dr Amy for this explanation. One thing I clearly remember about my contractions was a distinct feeling of imminent doom just before each one. It didn’t feel directly related to the pain but was separate and distinct. I had an epidural each time so didn’t ever feel in unmanageable pain but the feeling of doom was still perceptible, although barely, after epidural. How fascinating to read a physiological explanation for what I thought was my own weird quirk, as I had never seen this feeling anywhere in descriptions of labour.

    One question though – NCB advocates are correct in saying other types of pain are because something is wrong. Other natural processes don’t hurt when occurring normally in a healthy person. I can understand why pushing a large head through a small orifice hurts but why should the dilation of the cervix and the first stage hurt? Is there any other physiological process that is comparable? I can’t think of any. Thanks.

  • Alexandra

    Just wanted to drop a quick line to say that this website convinced me to get an epidural for kid #2. I believed all the stuff about positive thinking and breathing and relaxation techniques for kid #1 and then the reality hit me like a truck. It wasn’t just one contraction, it was the cumulative effect of days of contractions, pushing, and then the stitches afterward that made me realize no Bradley method was going to compete with that kind of trauma and pain.

    My epidural was awesome and made giving birth like a trip to a spa. I know they don’t always work that well but it sure was better than all my relaxation techniques and I will always appreciate Dr. Amy’s blog for giving me permission to have one.

    • Wasnomofear

      You and me both! The understanding that it was all LIES – all the stuff about epidurals affecting babies that the natch community puts out – ugh. I was brainwashed into believing that I was making better, safer choices by delivering my first in a freestanding birth center. The knowledge gleaned from this site shook me to my core. Only by sheer luck of the draw were we mostly okay after her birth. The maternal request 39th week induction with epidural for my second baby was gloriously happy, clean, and safe, and my recovery was far easier and half as long as with the first. Thanks, Pitocin!

  • MaineJen

    OT, but…has anyone made the “Sad Paul Ryan” picture a meme yet? If not, someone more tech savvy than me needs to get on that.

  • Allie

    Well, that explains a lot. I was actually doing quite well with the somatic pain during labour when the vomiting began, and I never understood why until now. Blaming “social conditioning” for pain in labour is just as ignorant and misogynistic as blaming original sin.

  • Gæst

    I love this – I had no idea there were two different kinds of pain. Obviously certain midwives had no idea, either. But I knew my labor pains were real and not imagined!

  • Islanddoc

    This is a fantastic article dr Amy, what a great explanation of pain! I HATE these midwife idiots with their nonsense about labour pain being basically our own fault. I had the most horrendously painful week of latent labour with very little sleep, then 36 hrs of labour with the last 12 hrs with an epidural, they wanted to let it wear off for pushing and the pain was so horrendous I wanted to die. Ended up with forceps delivery in theatre, retained placenta etc….A few years later I was involved in a head on collision as a passenger in a car, I had multiple rib fractures and a lacerated liver from the seatbelt, was airlifted to hospital, few days on high dependency unit, friends in intensive care, 2 weeks in hospital etc… I saw a consultant psychiatrist after for a few sessions to talk through the trauma etc and ended up bawling my eyes out about my labour and delivery! Near fatal Car accident actually less traumatic than the unrelieved pain of labour and the guilt from ‘giving in’ to the epidural – I had a dural tear and needed a blood patch but it was still worth it for the few hours of pain relief!

    • myrewyn

      Ugh I feel so bad about labor stories like this. I had two pretty straightforward labors and they were still hands down the worst pain I’ve ever been in (even with epidurals for the last parts). I can’t even imagine these hellish labors some of you have endured.

      • Who?

        Me too. Two six hour labours, really horrible for about 2 hours. No time for epidurals, which were less of a thing way back then anyway.

        My kids are 25 and 22, and if I see/hear those programs about childbirth and labour on tv I have to leave the room when I hear the sound the women make in unmedicated labour, as it flashes me right back to just how excruciating it was.

  • lawyer jane

    O/T: Great news about a new rotavirus vaccine developed for use in developing countries, where it can be stored without refrigeration! https://www.nytimes.com/2017/03/22/health/rotavirus-vaccine.html

    I love that photograph of the young mom getting great, modern medical care for her chubby baby.

    • AnnaPDE

      Yay for rotavirus shots. There was a rota strain going around in the south of Germany just when I was there over January, and my 1yo managed to pick it up on the last day. 3 days of puking and a week of runny poo for each of us, with staggered start in 36 hour intervals, but hey, we made it through with some extra laundry and no one was even close to dehydration.
      Contrast that with my “vaccines ok, but not the scary rota one, it gives the baby runny poo” friend from that area who caught the same bug. Her 1yo daughter ended up on IV fluids in hospital, along a bunch of other kids whose parents had similar ideas.
      I guess those icky nappies after the shot were worth it after all.

  • BeatriceC

    OT Leo update: his weight was down 3 grams this morning (and for a 130g bird, that’s a lot), so he got a full meal formula feed. Then he started falling off the sides of his bowl (the only thing he has that resembles a perch), so off to the vet we went. Dr. J. did an x-ray series. The good news is that there’s nothing alarming. The bad news is that there’s nothing alarming. He’s got a bit of a bloated abdomen, but other than that, things look good, which isn’t helpful in figuring out why he’s so very sick. He added sucralfate in addition to the antibiotic (baytril), in hopes that coating his digestive track and reducing gas will make his tummy feel better and he’ll eat more. HIs white blood cell count is down a little, but not nearly enough, so another week of antibiotics is in order. We also increased the temperature in his box, and I’m considering purchasing a brooder to keep him at a constant temperature instead of the regular ups and downs of an open bin with a heat lamp over it.

    • Poor baby birdie. I hope he gets better!

      • BeatriceC

        Thank you. And one dose of sucralfate has made a noticeable difference. He’s actually picking through his food bowls and nibbling with a little bit more energy than he’s had since before he got sick. He even threw food rejects out of the bowl, which is a really good thing, as that means he actually has some energy. It’s still nowhere close to enough eating to stop the formula feeds, but it’s a definite improvement.

    • MI Dawn

      So sorry to hear Leo hasn’t turned the corner back towards health yet. Keeping my fingers crossed!

    • StephanieJR

      Come on, little Leo, we’re rooting for you!

  • SporkParade

    So, is there a biological explanation for why my first labor made me want to puke by the time I was 2 cm dilated, but I wasn’t nauseous at all during my second labor, even though #2 was tragically unmedicated?

    • MaineJen

      IDK, but I had kind of the same experience; during my first labor I don’t remember feeling nauseous (I didn’t particularly want to eat either), but I had also gone longer without eating beforehand, so maybe that had something to do with it?

      My second labor was quick, 6 hours from start to finish, and I had eaten a normal breakfast and lunch before heading to the hospital around dinnertime…during that one, I remember feeling like I was going to puke before I got the epidural put in (and had a baby half an hour later!).

  • critter8875

    Like shoving a grand piano through a transom.
    –Alice Roosevelt Longworth

    • Rivkah Rainey

      well, thats over doing it. Maybe an upright. lol.

      • MaineJen

        Carol Burnett said it best: “Take your bottom lip…and pull it over your head.”

  • SarahG

    I did have one-to-one support from a midwife during my labour. One I had gotten to know and trust throughout the pregnancy. Why on earth would that have made it less painful? Didn’t prevent the 3rd degree tear plus episiotomy and 50 stitches either. They really seem to think midwives are magical beings.

  • MaineJen

    Bookmarking for future reference. This is a wonderfully concise explanation!

  • Ada Barnes

    I can only wish my two childbirths on women who write this sort of garbage. 8lbs2oz/9lb4.5oz, OP, vaginal both times. Even if the pain wasn’t “real,” the resulting damage, requiring pelvic floor PT, is undeniable.

    • Empress of the Iguana People

      Did you trust your with-woman woman enough and drink enough coconut-kale-placenta smoothies? /snark

      • Ada Barnes

        Ha, I considered it, but deferred to the expertise of my highly-credentialed and well-educated midwife. I asked her about a lot of the alternative supplementing out there and asked her what legitimate evidence exists because I was not using my food dehydrator for placenta unless I was certain it was worth the trouble. The answer was, no.

        Unfortunately, I was surrounded with women with young children who were very into natural childbirth/orgasmic birth sorts of things. My second was supposed to be the “healing birth” that erased the trauma of the first. . . except it was worse. A second (but very close) second trauma to the birth itself was largely the fault of false expectations, and that was really hard to undo.

        • Kelly

          I think that is the worst part about all of this is that these natural birth people are leading women into birth blindly. If you expect it to hurt and to be miserable throughout labor, then I think people can handle the outcomes better. I tell my children that shots will hurt if they ask. They get anxious over the pain but they seem to react better than if it takes them by surprise. It hurts the same amount but they have mentally prepared themselves for it. I don’t see how that could be any different than preparing a woman for labor. Also, my second labor went very fast and I was only able to get the epidural for pushing. I had expected to get the epidural like I had for my first one and I was not prepared for the amount of pain I was in at all. The third time around, I prepared myself for any outcome including a c-section since I wanted to have prepared myself mentally for anything life threw my way.

          • myrewyn

            I would always rather be realistically prepared for things than have the truth glossed over.

          • kilda

            There really is never a good alternative to facing reality.

          • Inmara

            And the same with emergency C-sections. Considering the rate of C-sections which is around 21-23% where I live, in a birth class consisting of 20 women four of them might end up with CS. All that was said by midwifes leading the class was “Yeah, CS is nothing to be scared about, but we’re sure you won’t need that.” No practical information whatsoever, no idea how the preparation for CS will happen, what will come next and how to take care of herself after (often there is not enough time and hospital staff to explain it either).

          • Kelly

            My friend had to have one when her epidural stopped working and it freaked her husband and family out because they didn’t know what was happening. Glossing over “bad” outcomes isn’t going to make it less likely to happen.

          • Sue

            “Yeah, CS is nothing to be scared about, no big deal if you need one.”

            Fixed.

      • myrewyn

        I just have to say I’ve seen my share of placentas and I just can’t look at that and think… food. I read a story here where the mom was starting to hemorrhage at home so her husband whipped up a berry/placenta smoothie for her and I thought if anyone ever did that to me and I found out what was in it I would vomit until I had no internal organs left. I’m not typically squeamish but one just does not eat one’s own medical waste. I actually left a birth month club because there was a pregnant doula who would not stop talking about dehydrating umbilical cords and eating placentas (and I was not the only one).

        • Heidi

          WTF was a placenta smoothie even supposed to do for a hemorrhage?

          • myrewyn

            Magical thinking?

          • Heidi

            So I googled this hoping to find the story of placenta smoothies saving the day. Wow, I didn’t know placenta smoothies were so popular. I figured everyone was about encapsulation. Anyway one lady is all, “I drank it and I felt wonderful afterwards. I hadn’t eaten in over 12 hours.” I had McD’s after I gave birth because my sister was kind enough to get hubby and me something after-hours. I felt pretty great, too, after not having eaten for hours myself.

          • myrewyn

            I had hospital food after giving birth and it was the best meal I’ve ever had. There are some pretty funny photos of me just stuffing my face with it. GIVE ME ALL THE FOOD.

          • Heidi

            All the food. . .except placenta.

          • myrewyn

            Let’s just go ahead and declare placenta not a food.

          • Who?

            Confirm, surely?

            No one thinking clearly ever thought it was.

          • Inmara

            Basically this, yeah. “Placenta is organ that transfuses blood therefore eating it will stop hemorraghe because something-something sciency sounding I have no idea what exactly but trust me, I’m your CPM”.

        • myrewyn

          Oh, and then I would have cleansed my blender with fire and thrown it off a cliff anyway.

        • FEDUP MD

          Many of the animals who eat their own placentas also eat 1) their own feces and 2) their own young. I’d love to see what the natural crowd would think of trying that.

          • myrewyn

            Heh, sounds like rodents. The only animal I’ve seen eat its own placenta was a cat and she was pretty determined, even though I tried to take it from her. The dogs will try to get horse placentas (and any other medical waste a vet might toss their way… they learned to be vigilant during castrations just in case a vet was feeling generous). Needless to say the horses never ate their placentas so there goes the “all mammals do it” theory.

    • kilda

      your room probably just wasn’t dim enough.

  • TsuDhoNimh

    Also … the time between contractions is spent KNOWING there’s going to be another one. You get to anticipate it, fear it, feel it coming.

    I had electroconductive nerve testing … trying to stay relaxed knowing there was more pain coming was no fun. And that was just a short series of shocks on each arm.

    • SarahG

      Exactly!! The time in between is almost worse because you’re just waiting for the bloody next one.

      • Sarah

        And vomiting.

        • Who?

          and pooping.

          Just saying.

      • Kelly

        I could never relax. My mom told me to close my eyes and think of something relaxing. I wanted to punch her in the face.

    • LovleAnjel

      I had EC done for carpal tunnel, and when we got the the second arm, knowing it was going to happen all over again made me pass out.

      I had a partial epidural and same thing – between contractions I was in desperate anxiety over the next one coming.

    • Mel

      For a day before my son was delivered, I need frequent blood draws to monitor my platelets and liver enzymes since I had HELLP syndrome.

      I am usually a very easy blood draw – the veins in my hands and elbow can be visualized without a tourniquet and the veins don’t roll. Due to the messed up fluid dynamics when I had HELLP, it was really hard for anyone to get access for IVs and blood draws. I needed multiple attempts per blood test and got the best-est IV placing RN to work on my right arm for a half-an-hour to place a heplock (OT: They never had to use it, but I’d do it again in a heart-beat. I didn’t want anyone messing with access if I needed an emergency blood transfusion during the CS.). I had bruising all over my upper and lower arm, my right hand was swollen and bruised from two blown veins, and my elbow was bruised – but the shitty part about the elbow was a dip-shit tech who rubbed (instead of tapping) the skin to find a vein and skinned my inner elbow. That shit hurt like hell until I asked a tech for some vasoline to coat the sore skin so it stopped sticking to itself when I bent my elbow.

      For the rest of my hospital stay, the sight of a person carrying a phlebotomist’s kit caused me to break out in a cold sweat and my BP would sky-rocket.

  • TsuDhoNimh

    Well, in the Biblical days, pain was so severe that it was considered to be a punishment from God.

    • Steph858

      The ‘punishment from God’ idea was historically used to condemn pain relief for labour. Strangely, the people who issued such condemnations never complained about men making farming work easier through the use of machinery …

  • Amy M

    If birth is so painless, then what purpose do any of the natural childbirth classes serve? Is Milli Hill trying to put them out of business?

    • Sue

      Winning comment!

      How to get all those Brownie Points and conquer the world if it’s not really suffering?

  • Ater

    Not to mention the exhaustion. I don’t know a single person who can be awake for 36 hours, 60!% of it in excruciating pain, and still be ok.

    • Mad Hatter

      I was up 36 hours and only a couple of it was excruciating pain. All things considered I think I coped well with the pain. But the exhaustion was just as bad and its not like I got a good nights sleep afterwards. (more like 18 months later) Then I was woke up every time I dozed off the first night and had a room full of visitors all the next day.

      • Kelly

        I kept falling asleep in between contractions. When I woke up, I didn’t know where I was and I freaked out. There were only a minute between the contractions so it wasn’t like I had a ton of time to get to sleep, I was just that tired. After experiencing that a few times, I made myself stay awake because it was too scary to keep feeling like that when I woke up. I then stayed up till that night and had a ton of visitors. By the time I got home, I almost dropped my daughter while sitting on the couch. I learned from the first time and got as much sleep as I could. Sleep deprivation is no joke. My last pregnancy, I got to sleep 8 hours the second night and it was glorious. I was actually able to function and I remember the first few weeks of my third baby’s life. These people are crazy. Only in childbirth are you expected to do any of this.

        • Gæst

          I was also falling asleep between contractions when they were getting pretty close together (I was being induced overnight) and it was bewildering alright. I couldn’t stop myself from going back to sleep and couldn’t do anything like breathing exercises or focusing on an object or any kind of bracing myself for the next one, and then bam! Woke up again. Waking someone up over and over again as they’re going to sleep is a form of torture unto itself! As soon as the pain woke me up enough to be able to speak I asked for the epidural.

        • Mad Hatter

          I fell asleep between pushing and apparently talked in my sleep too. I don’t know how I had time to do that, but I was pretty out of it except for watching the clock.

  • J.B.

    I guess Milli’s not a particularly active person either. If she’d ever done interval training, she might understand better that you can’t go all out very long, and then use the rest to slow the gasping and settle the urge to puke. There’s a reason really intense interval workouts are short!

    Thanks for the biological description, that’s fascinating to know.

    • fiftyfifty1

      “you can’t go all out very long, and then use the rest to slow the gasping and settle the urge to puke”

      Exactly. This is because extremely intense anaerobic activity can provoke both somatic pain AND visceral pain from ischemia (lack of oxygen) to the organs. Thus the puking.

    • Roadstergal

      Also, in athletics, you can mentally push through soreness and exhaustion for a specific endeavor, but pushing through pain (sprain, broken bone, etc) is a bad idea!

  • Empress of the Iguana People

    *snort* even if they did feel better the 40 seconds you aren’t stabbing them, they’d feel justified in beating the crap out of you to make you stop.

    • KeeperOfTheBooks

      My BFF tells me that in a couple of her labors, she had some officious person, usually a nurse, telling her that she was “pushing wrong, and no wonder it hurts,” without giving her constructive suggestions.
      Given that my friend both could reach a tray of sharp instruments and didn’t use them, I consider this further proof that she is a far nicer person than I.