Coping with labor pain

Coping with labor pain

116 Journal ofPain Vd. II No. 2Fcbrum and Symptom Manugrnwn~ 1996 Coping with Labor Pain Catherine A. Niven, RGN, RSc, PhD, and Rarcl G$~rs, PhD...

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116

Journal

ofPain

Vd. II No. 2Fcbrum

and Symptom Manugrnwn~

1996

Coping with Labor Pain Catherine A. Niven, RGN, RSc, PhD, and Rarcl G$~rs, PhD k+?b~?~l [email protected] (C.N.). CLugow Gdrdonian Unitunity, Ckr~otu, and [email protected]~U of Psychology (KG.), CJnikd Kingdom

Uniwrsity OJ Skiing,

Stirling, &&land,

This qbloralory study aimed to revamine the wztun-, origin. and ejjerliwness o/pain Coping s&at+ used during chiLibirth. The labor pain a/ 51 British women was owwd amund lhe time a/ birth by visual analogue w&s and tlu McCiU Pain Qu&wnnniw. The use o//w& coping stra+ and fheir origins ~(1s e.&Mi.shed thmugh thp anal+ OJ data obtained in an &end& semi-stntciurad interview. Subjtrls we found to UK a rouge of shategia dun’ng k&x many of wtih lhq had pnxdoudy uwd to co/w with pain. The nature o/&se shdegie was, in esrcxce,amilor lo that dfwibai in lhe empirical U&mlun on pain coping, though il apppmed that slratwips had o~kn bret, acquired inf~ (LI t&l OS through shcrluwd training. The total numbrr [email protected] used in labs was rwgtztit# cow&d u&h (cc& OJ la&r pain. J Pain Symptom Manage 1996;11:116-125.

A number of studies have reported on the nature and intensity of pain experienced during labor and its relationship to a range of obstetric and psrhdogical v~riables.‘~ Recent reztrch on chronic and acute Pam has emphasized dte importance of pain-coping strategies7-” but die origin, use. and effectiveness of the range of State&s used in labor has not been directly BQminedTheprimatyaimofthissuKJywasto describe the tc3e of coping strategies in labor, focusing on strategies wbiih have been estab lkhed by clinical and experimental research as vdlid and potentially effective in reducing pain. Addrar r+titrt m7ucrn to: C. IGiven. PhD, Department of Rychology. GlasgowCakdonian Univetsity, Cowcaddcns Road, Glasgow Gi OBA. Scotland. united Ringdom. Acu/xedforp June 7.1995. 0 us. CpKCr Rin lldief cammittee.19% RaMKdhy~.NewYork,NerYork

and on sttategies which are taught to women attending preparatory education classes for childbirth. Pmliminary information on dtc origin and effectiveness of the sttatcgies used was also collated. Research on experimentally-induced pain has established the relative effectiveness of psychological strategies in modulating the characteristics of this pant. Roth relaxation Imining” and distraction’” have been shown to increase pain thresholds and tolrrance. The use of pleasant imagery as a focus of distraction has been shown to be more effective than the manipulation of expectations of pain in lowering self-reports of pain, and than the use of breathing techniques in increasing pain tolerance.14 “Revening the affect” of pain, i.e.. thinking of the sensation associated with pain as positive rather than negative, has been shown to be more effective than disttaction in otws9!24/96/$15.00

5.SD108853924(95)001581

VoL II No. 2 February 1996

Gaping with labor Pain

reducing the distress associated with prolonged experimental pain’s The use of complex breathing techniques, as taught in one form of preparatory training for childbirth, has been shown to be relattvely effective in reducing experimental painI In studies of experimentally-induced pain, the intensity of noxious stimulation was known and was held constant between experimental and control groups. Thus, these studies were crucial in establishing that coping strategies have the potential to reduce pain. Studies of clinical pain where the extent of noxious stimulation was less amenable to control, have shown that relaxation was associated with reduced levels of headache, migraine, and back pain;“.‘* that the use of pleasant imagery was effective in reducing self-reported discomfort in a dental situation;” that the reinterpretation of painful stimulation (a process akin to reversal of affect) was more effective in reducing ratings of chronic pain experience than distraction:‘~ and that the use of complex breathing techniques was associated with lower levels of pain in labor.*’ Such studies demonstated the validity of coping strategy use and, taken together with the labotatorybased studies, suggest that coping strategies can modulate clinical pain. These studies involved the use of strategies (e.g., relaxation, imagery, and reversal of affect) that are taught to the subjrats by researchers and healthcare personnel, including clinical psychologists, medical ptactitioners, and physiotherapists. The precise natures of these strategies have, therefore, been formalized and may differ from those of suategies that have been informally acquired or spontaneously generated. For example. people who have never been taught Jacobs son’s progressive relaxation techniquesT’ may still use relaxation suategies that do not involve the progressive tensing and relaxing of ~rious muscle groups but which are equally effective in reducing pain. Similarly. research studies involving the use of diitrdction typically utilized instruction in the use of mental disuacters such as mental arithmetic, rather than in more commonplace disuacten such as reading or engaging in some diitracting task Strategies for coping with the intense pain of childbirth are taught at antenatal or Prepared Childbirth Training (m) classes. PCT

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typically involves the teaching of relaxation and “lamaze” breathing techniques; the pro vision of information and reassurance about childbirth; and ttaining in the use of a variety of cognitive coping skills, usually involving some form of distraction. Antenatal classes run in Britain by the National Health Service focus more on the provision of information than on the use of cognitive coping skills. The breathing exercises utilized are less complex. Otherwise. they follow much the same format as PCP*” A number of studies have shown that PCT was associated with lower levels of labor pain. ***‘-‘* But, as with studies of clinical pain, such studies have not yielded information about the particular strategies used in labor since training in a strategy does not ensure its utilisation. Nor can they reveal the use of sttategies that were not learned at PCT classes but were otherwise acquired. for example, through coping with episodes of pain experienced previously. Misattribution of pain to a harmful source has been shown to increase pain percep tion.‘7:M As the pain of childbirth could be attributed by the panurient to either harmless sources, the normal processes of childbirth (normalization), or to harmiul sources, some abnormality in herself or in the baby, the former might be expected to be related to lower levels of pain than the fatter. Similarly, women in childbirth may vary in their percep tion of being “in control.” In an important early study, bowe? demonstrated that if a subject believes that she or he has control over noxious stimulation, the pain and anxiety levels associated with such stimulation were lower than when no perception of control existed. Thus, perceptions of control could affect levels of labor pain. The purpose of this Study presented here was, fitst, to examine the use and perceived effectiveness in labor of formally classified coping strategies, namely those discu=sed above-relaxation, din-action. use of imagery and reversal of affect-which have been validated through clinical studies and shown to have potential for pain modulation. The use of structured breathing techniques, as taught in British antenatal classes,was also examined. as prevtous research has only established dte effectiveness of the more complex breathing techniques taught in PCT, along with two fur-

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Nivm and Gijzhm

tier aspects of coping wilh pain emphasized in antenatal uaining, normalization and control. These do not constitute coping strategies per se but instead reflect positive cognitions that theoretically relate to pain perception. Second, we aimed to examine the use of idiosyncratic strategies not classified formally in previous studies of experimental or clinical pain. Women in labor do 1101necessarily use the strategies that they have been taught in antenatal ~lasses.~ and suufies of clinical pain have reported the use of spontaneously generated suategies, which may vary in nature from those acquired through formal uaining.s’ Third. analysis was directed to the origins of the su-ategies used during childbirth, as the question arises as IO whether the origin of suategies used during labor lay in antenatal uaining or was more dependent on informal sources of acquisition including previous pain experience.

Fifty-one British women were interviewed on duee occasions: durmg the active phase of the fine smge of labor, 24-48 hr after giving birth and 3 months later. Table I details the settings and the assessments carried out at these times. Informed consent was obtained separately for the hospital assessmentsand the home interview. These were 51 women giving birth in a maternity unh in Central Scotland. The characteristics of these women are shown in Table 2. Subjects were drawn from a sample of 101 women, broadly representative of women giving birth in the United Kingdom. who were participating in a study of labor pain, of which thisstudyfonnsa~BelweenQetimeof recruitment to the study and the home interview 3 months later. 3 subjects moved from the

area of the study. and a further 20 subjects became uncontaccable or lived too far away to make home interviewing feasible. A further 5 subjects could r.ot participate in rhe home interview becaura of lack of time or privacy, and, in one case, illness in the baby. This left a pool of 81 subjects. So of whom were utilized in the pilot study described below. The remaining 51 subjects comprised the study sample.

Pain As.wwnmt Labor pain was assessed using visual analogue scales (VAS)“’ and the McGill Pain Questionnaire (MPQJ.ss The scores reported reflect the VA8 as measured on the normal O-100 scale, and the Total Pain Ranking Index (PRI) of the MPQ. Assessments of pain obtained during the active phase of the first stage of labor are designated VASI , PRf I ; and those obtained 24-48 hr after the birth, when the pain of labor and delivery was recalled. are designated VAS2, PRf2. While the practice of asswing labor pain by recall has been queT&2 subpa-

KTL II No. ZFebrumy 1996

coping wilh L&n

tied,” there is good evidence for congruity, when using the MPQ, between in-pain reports and reports by recall.3”-ss

Pain

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ing style but the precise nature of the stmtegies that wds of interest

The 3- to CMonth In&ruiew coping Strategy As.wsment The direct observation of coping sttategia throughout labor was impracticable in this study. Such observation could, in any case, only yield data on behavioral strategies. The use of disuaction. imagery, revemal of affect. normalization. and control could only be assessed by subject report If this is obtained during labor, it might interfere with the use of these strategies, consequently rendering this methodology unethical. A pilot study carried out with SO subjects found that mothers asked about copingstrategy use at the same time as postnatal pain assessment were reluctant to participate in a lengthy interview. Many were tired and preoccupied with the baby. Accordingly, only pain assessments were made at that time and the coping strategy interview was deferred. Pilot interviews, carried out with the SO mothers who formed the pilot sample, found that a S-month postnatal interview was the optimal time to elicit detailed information about coping-strategy use. At this time, the subjects had some opportunity to adjust to motherhood; had established some sort of routine with the baby, allowing them to predict relatively undisturbed periods suitable for interviewing; and had babies who were sleep ing through the night, allowing their mothers to be clear thinking during the day. The unstructured pilot interviews revealed that subjects were confident about their ability to recall strategy use. The range of strategies that formed the focus of this study were widely reported to have been used. some during labor and some during previous experiences of pain unrelated to childbirth, supporting the did:ty of these stmtegies established in previON r-ch. Additional strategies which were difficult to categorize conventionally were also reported, many of which appeared to have been spontaneousty generated. As in the studies of the spontaneous use of strategies to cof. with dental pain carried out by Chaves and Brown.” the present study made use of a detailed self-report procedure rather than a SQndacdized questionnaire such as the Coping Suaugy @testionnaire;W as it was not the cop

The int&tiew was concerned with the stmtegia that subjects used to cope with pain, both in labor and during other pain episodes unrelated to childbirth. It was considered essent?d that the interview should be conducted in a friendly, relaxed, and nonjudgmental manner. While quantifiable data were required, the methodology had to facilitate free recall of strategy use and avoid any embartassment of the subjects. (Idiosyncratic strategies might otherwise be forgotten or seem too silly to mention.) Accordingly. a semistructured interview was conducted as a dialogue consisting of a series of questions regarding the strategies used to cope with labor pain and dealing with other pain experiences. Th~sc questions were followed by a number of probes designed to clarify, extend. or help in the categorixation of the original response. For example, the primary question concerning the general use of coping strategies: “What do you do when you are in pain?” was followed by probe questions directed LO 3vorse pain” and “everyday aches and pains.” Similarly, queries specifically related to the use of relaxation: “Do you relax? How?” were followed by the probe “Did it (the behavior) make you feel more relaxed, or did it just take your mind off the pain?’ In investigating the possible use of relaxation to cope with labor pain, the primary question: “Did you relax” was followed by a probe sequence of questions: “How? Did you use the relaxation techniques taught at antenatal classes? Did you use breathing exercises? Did they relax you?’ Subjects showed little difhculty. using this style of interview formal in recalling relevant details of how they coped with pain as natural cueing of memory occurred. and the questions and probes ensured that relevant material was not overlooked. Seven primary questions about labor were directed to the possible use of relaxation, distmction. imagery, reversal of affect and breathing techniques. Attribution of labor pain to normal and abnormal sources, and feelings of control were elicited. Suppfementary opeaended questions examined the timing of sttat-

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eg use (in early or laler surges of labor; in transition or during delivery) and details of any behaviors, cognitions, etc., which the Sub ject rated as helping her cope with the pain. A similar list of questions was asked about cop ing with previous pain experiences unrelated to childbirth, probing botb severe and mundane pain experiences. The origin of stratcgies v.as explored through questions on antcnatal class attendance and Ihe use in labor of strategies that h.td been taught at classes. spomaneously generated to cope wirh previous pain episodes, or otherwise acquired. InIerviews varied in length, USwdlly taking around 30 min Intewiew Ana& The tape-recorded interviews were analyzed by the principal author and, in 50% of the cases, by an independent raIer. The use and classification of suategies was agreed upon by the ~‘dte~s in over 96% of cases, wiIh diffcrences being resolved by discussion. Strategies, whether acquired through formal training or informally, were categorized as primarily involving relaxation, dislrdclion. imagery, reversal of alfect. breathing techniques, normalization, or conlrol. This catego rbation was based initially on descriptions of wawgy use drawn from published studies (see Table 3). Strategies that did noI fall within these caIegories were classilied as idiosyncratic. The subjects’ responses IO probe questions were used to clarify categorization. For example, “watching TV’ could be categorized as “disuaction” if dte subject’s response indicated that it “took my mind OS the pain” or “pan of a general relaxation response” if il was associated with a statement such as “I put my feet up and watch mind-numbing rubbish on the TV when I want to relax.” The subject’s categorization was taken as de,initive if it conuadicted a classification drawn from the literature. Suategy use versus non-use was assessed for each strategy classification: (a) during labor and (b) during previous episodes of pain.

htensilJ of LAtQr Pain The average intensity scores for labor pain amessed during the active phase of the fh

and Cijsbm

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stage of labor were VASI of 60 (SD. 20; range. 5-100) and PRII of 25.4 (SD, 9.2; range, 7-59). VAS 2 scores were 85 (SD, 25; 20-l 00) and PRl2 scows were 34 (SD, 11.4; 7-68). reflecting the assessment of the pain of labor and delivery. These scores did noI differ significantly from those of the total sample of 101 women and, as with comparable studies of labor pain inlensity. show high levels of pain experience but wilh great variability.‘-s N&m of Coping Strategies The sIraIegies used by the subjects IO cope wirh labor pain and with episodes of pain previously experienced are described in Table 3. One distinctive form of “idiosyncmtir stmtegy” was found IO be utilized by a number of subjects. It wdt characrerized as “focusing” and is listed separately. Table 3 shows that many of the strategies used by the subjecls could be classified under headings derived from clinical and experimental studies. Their specific nalures, however, often differed from those reported in Ihe literature and taught in antenatal training. Coping Stralegiex and Levels of hbur Pain The average levels of labor pain associated with Ihe use of each strategy are shown in Figure 1. These data are not reliably associated with analgesic use which is independently related to levels of labor pain. Individual analysis of strategy use versus non-use was planned on Ihe basis of limited data oblained from the pilot study, which allowed some analysi; of levels of labor pain as related IO suategy use. hSUming chat a CI’itkal effect reflecting changes in pain scores of ten poinls would be of clinical significance, calculations indicated 1ha1 an Nof around 50 sub jects would be sufficient to give 80% power for I testing. However, examination of the main dam seI showed that while ten-point differences in pain scores were -iaIcd with the use of relaxation, reversal of affect, and breathing techniques, standard devialions were too wide, and Ihe distribution of subject numbers was mo uneven to yield satishtctory power. Furthermore, few subjects used only a single strategy. The median number of strategies used by each subject in labor was four (range, l-6). The local number of stmtegies used was

NC” applirahlr

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Yomillg

chrmlghour labor; 20 fcb ““~1 ol co”r~ol’* at wme when rontncdo~r~ wddcaly inrrravd ill inwnin. or inwrwltion. when cxhauued. at delivery: 12 felt “or ““I of conwol”

during

prc\ioru

episodes

of pain

docw’t

work if

scene m diuncl from shon.liwd t,carment; I wed romandc KC,,C for

“diuracdon

5 loond

it bclpl”t

10 focus Uuhcu mind

on lhcir

pai”

I5 fou”d L)IC ptcw”ce of a particular pewa) pi” rrlini”g. e.g., Mn. D ralki”g r” her founh chdd when in pain; IO u.wd wmc form of lime-limiti” ‘, c 8, at the dcnul office they would d””,& II w b owr ,n an hour” or durin6 ‘!!V dvvnenorrhra “it will be be”cr lomorrow:” 5 found il’hclpful 10 fcxur rhcir mi”d on lheir pat”; Mn. E prad daring rpiwdodn 01 sewrc ‘“1 ‘n. Mn H rr)~cd with were repeated cpi& o&% lo odng chcq1 wrgcry by “putting herwlf I” +rp”

and pniwmr “Pam iq a normal experience of “the wont” or

pain of

I inwrprewd d)Tmenorrhea “means my b&v i* working pn~pcrly. as every noman’( shwld; I’m glad 10 have h”

6 wed hdtdav pain of’dcnd vamr pwpo”

dia-aaion: 33 reponed pail. were”

51 rrponcd that sewor. unwul. pail) caud co~tccr~~: 21 reponed pa? of lifr:” 20 re orted any new pa,,, worr)i,,~. Ica d ,“k ,o lean of ‘what’s really wrong

19 frh “i” control” point in labor. e.g.. dwing rxaminatio” “neither in ronwol.

umi

N- 1; Strucwrcd rcchni “es N - IS. “Put feet u ICI mmd go blat;” N - ?4 , -kaw a drink” N - pd. “Have P c~garetw:” N - 6. “Warch mind-numbin rubbish on N:” N. 6. “Go ,.a be&” N. 2. Net & mwagc.

Number

Not apphcshlr

2 wed hohda went 10 diwdcc from pat” in acctve labor; I I wed imagery of ba b y as dwactoa. c g.? lakmg baby home. uwd rhroughou labor; 4 rxperienrced vcty unpleasant imngn of :hc pain iwlf cxpcricnrcd when pai” wa( mo%t inwnse. e.g.. “Black hole.” “whirlbIg purple rlo”di

IO uud tak-bawd diw-acto~ at home in ea in active labor; 11 wed menA diwacton e.g. round” ceiling rilcq: I6 complained in hmpiul. *%’here ‘.( nolhmg to witch but the clock”

cla during a&r L&K SO found brcalhing

Smqiea

17 uwd ur~tured wrhniqun taught in anwnalal 19 a”e~nw wuc~ured cechniqun unruceA~Uy, wrhniq”o were relaxing

labor

I uwd Lan~azr wchniqun uud 10 cav hreaw feeding wh cracked nipple

tcchniqoc%

used during

Tcrh~~iqur. of dcrp a”d rhatlow hrcalhina: :pan~-blmv’ hrcrthing. CIC.. C O ” luonal on rhr na,urc 01 Ihe pal” rxpcricncc. as laugh1 in Lamazr+mml ITT CIPIVI

Ca”lr”l

Brcarhi”g tcrhniqa~

Sauctured relaxado” e.g.. Jacobwn’?’

Number

Tobk 3 The Nature of copine

Nium and C+hen

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is Tdmtrrrr

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in

Kg. I Levels of labor Pain and coping strategies.

significantly and negatively correlated with LXeh of pain as assessed on the Total PRl measure of the M P Q recording the pain of labor and delivery (PRI2. r= -0.38, P< 0.01). The decrease in average levels of labor pain associated with increasing strategy use is shown in Figure 2. Comparison with levels of pain associated with other pain syndromes shows that levels of labor pain remain high even when large numben of pain coping sumegies are used.

Disacssion Although the accuracy of recall of strategy use cannot be conclusively demonstrated, the results of this study show that women report that a wide range of strategies are used when experiencing labor pain. While many of these coping strategies could be &&lied under the general headings of relaxation, distraction, etc., as described in empirical studies of experimental or clinical pain, the specific nature of informally acquired pain coping

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strategies differed from that of strategies utilized in empirical studies. For example. in tbe absence of formal training in the use of structured relaxation techniques, relaxation was achieved by “putting your feet up” or having a hot bath. When training in distraction is given, it is usually of a mental nature, but informal use of distraction was found to be usually of a physical nature: “keeping busy” Thus, the nature of a coping strategy seemed determined by the manner of its acquisition, whether through formal training as in antenatal classes, where the nature of strategies resembles that examined in empirical research studies, or through informal acquisition or spontaneous generation involving trial-anderror learning. The nature of a coping strategy was also determined by the situation in which it was used. For example, physical task-based disttaction could not be used in labor once the sub ject was hospitalized, so mental distracters were used instead. However, the range of mental distracters was further constrained when the subject was confined to a bed in a bare clinical room. The nature of the noxious stimulation may affect the kind of coping strategy used, labor pain apparently requiring or attracting strategies that were rarely used outside chilrlhirth. For example, the ttse of pleasant imagery was fairly common in labor. perhaps because a pleasant image of the baby sva.sreadily available, but was otherwise utilized infrequently. Xarmal attributions of labor pain were unsurprisingly more common than when pain was associated with disease, trauma. or surgery. Many subjecb reported that the intensity of pain also affected their strategy use. An increase in pain intensity, such as that which accompanies progress from early to late labor, could render an effective strategy useless and force a change in strategy or resort to pharrnacological analgesics. The use of idiosyncratic strategies was widely reported. Experimental research has largely ignored such strategies, so their effectiveness remains to be established empirically. The nature of idiosyncratic strategies reported by subjects varied considerably; only one group of strategies could be categorized togetherfocusing. Focusing acknowledges noxious settsations fully as pain without any sense of

Fig. 2 Levels of labor pain associated with the use of differing numben of su-a~egiesin labor, compared with levels of clinical pain

detachment and thus differs from apparently similar cognitive strategies such as “imaginative transformation of pain” or “somadsation.“Lw It may bear some similarity to the use of a coping suategy described by athletes as “going through the pain barrier.” The use of coping strategies was associated with lower levels of labor pain, although sub ject numbers were too small to allow extensive analysii of the nature of this relationship. This preliminary finding requires further study, as it is crucial to establish the effecti~rneu of coping strategies in modulating the pain of childbirth, one of the few acute pain situations where psychological analgesia is widely used. The use of coping strategies may modulate the noxious stimulation aosociated with labor or, alternatively, may be merely a correlate of low leds of pain, not causal. Experimental pain studies have shown that the use of strategies examined in this study can modulate the experience of noxious stimulation,‘**‘“*‘” but pain levds in such studies are low. When pain is intense, as in labor, coping strategies may be ineffective and therefore abandoned. Some subjects’ comments, for example, on the use of distraction, suggest that this may occur. This hypothesis would be supported by the results of studies on coping with chronic pain, which suggest tbrt coping strategies are rarely used.” Such studies, however. assess the use of strategies through coping sttategy questionnaires and may not focus the subject’s attention on active, behavioral strategies in the

same way as the interview described in this study. (Some comparison of both approaches will be possible following a study of coping with phantom limb pain currently underway; a pain that, while chronic. is the equivalent of labor pain in intensity) The increased effectiveness of multiple. as opposed to single, strategy use has been estab lished in a number of experimental and clinical pain studiesSw’ and is in agreemeut with the finding of this study, that the larger the number of strategies used, the lower the levels of pain. Such an effect may operate through the simultaneous activation of different pain modulatory systems.‘* Multiple suategy use in labor also reflects changes in strategy and, as such. may tr a measure of the flexibility of a subject’s response to labor pain which changes dramatically in its nature and intensity over the course of childbirth. Thus. a flexible as well as an aggregated response to labor pain, may be particularly beneficial. It is important to note, however, that even multiple strategy use does not ensure painless childbirth (see Figure 2). The association between substantial levels of pain and multiple ttrategy use. together with subjects’ reports 01 their efforts to cope with severe labor pain hrougb the use of strategies. would seem to suggest that suategies mc used in response to intense labor pain. Conclusively establishing the direction of this relationship is difficult, given that the precise level of noxious stimulation involved is unknown and that it is generally impo&ble to

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measure levels of intense. acute, clinical pain. such as labor pain. both before and after the use of strategies. Antenatal uaining is specifically destgned to teach relaxation and structured breathing techniques for use in labor and to encourage nortnalimtion and a sense of control.‘s”’ H-r, approximately one-half the subjects who attempted to put this teaching into practice with regard to the use of relaxation techniques in labor reported that they were unsuccessful, and a substantial proportion of “trains’ women did not report any use of breathing techniques. Similarly, many subjects who had attended antenatal classesdid not feel “in control” tbroughout childbirth. These reports might be taken along with similar findings40 to suggest that antenata! training is ineffective in teaching women how to cope with labor pain or in generating a genetalized senSe of coping “self-efficacy.” It must be acknowledged, however, that it is diflicult if not impossible to accurately prepare every human for the immensely varied and unpredictable experience of childbirth. Strategies acquired during antenatal classesmay be totally inappropriate when attempted during labor because the two situations are so d&sin&r, as well as being separated by a considerable period of time. This situation can be contrasted with that pertaining to the use in labor of informally acquired strategies. described by subjects as originating in their previous experience of coping with pain. The experience of pain outside labor had given them the opportunity to develop a tartge of coping strategies and to practice them in realistic conditions. This conttasts with the attempt to stimulate the acquisition of suaiegies by training. The sttategies taught at antenatal classes have not been ptacticed under realistic condtions. And, perhaps most crucially, the woman being taught coping strategies at antenatal classes has no evidence that they will work Other pain studies, both experimental and clinical, have found that subjects instructed in the use of specific cognitive coping strategies have used their own strategies (i.e., those that were already in their repertoire) to cope with pain. rather than the sttategies they had been taughteAs ThU5, the findings of this study are not pecuhar to childbirth and antenatal thining. hiore effective training in coping with

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pain might result from the incorporation of previously used strategies in the training regimen (see Niven4”). Additional informal “training” may occur during labor if midwives suggest the use of coping strategies, such as breathing techniques. As such training is concurrent with the pain experience, it may be more effective. In conclusion, the results of this study indicate that a considerable range of coping strategies was used by women during childbirth. Many of these seemed, in essence, similar LO those considered in the empirical literature and resembled strategies that women had used previously. The total number of strategies used in labor was negatively correlated with levels of labor pain, suggesting that the use of coping slratcgies in labor can modulate the pain. This relationship requires further investigation, ac does the origin of the strategies. The relative effectiveness of spontaneous versus taught strategies needs to be established.

1. Melrack R. The myth of painless childbirth (The John J. Bonica Lecture). Pain 1984;19321. 2. Melrack R. Taenzer R. Feldman P, Rinch RA Labor is still painful after prepared childbirth training. Can Med AssocJ 1981;125357. 3. Melzack R. Knich R. Dobkin P, Lebrnn M. Tacnrer P. Severityof :&or Pain: influence of physical as well a psychologic variables. Can Med Assoc J 1984;130:579. 4. Nivcn C. Gijsbers K. Obstetric and nonobstetric factors related to labor pain. J Reprod In: Psycho11984;261. 5. Reading AE. Cox DS. Psychosocialpredictors of labor pain. Pain 1985;22399. 6. Lowe NK Explaining the pain of active labor: the importance of maternal confidence. Res Nun Health 1989;12:237-245. 7. Wuitchik M. Bakal D. Lipshiu J. Relationships between pain, cognitive activity and cpidutal analgesia during labor. Pain 1990:41:125-192. 8. Pick B, Pearce S, Legg C. Cognitive responses and the control of post+peratiw pain. Br J Clin Psycho1199&29:44hr-l15. 9. Lrventhal EA. Leventhal H. Shachum S, Pasterling D. Active co+tg reduces reports of pain from childbirth. J Cixuult Qln Psycho11989;57:.%5-571. 10. Jensen MP, Turner JA, Romano JM, Karoly P. Coping with chronic pain: a critical review of the literature. Pain 1991;47:249-283. 1 I. Gamsa. A. The role of psychological factors in

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chronic pain. 1. A half century of study. Pain 1994: 575-15.

Wali PD. Meback 4 cds. Textbook of pain. 2nd rd. Edinburgh. LX Churchill livingstone. 1989.

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