‘Pain is my friend, pain is my friend, pain is…’, such a common mantra repeated over and over on the lips of so many of us as we work towards our health, wellbeing and fitness goals, or strive for peak performance, personal best achievements, or whenever we work with the functional physiological pain of our body striving. We know it takes working with physiological pain to pursue these goals. The huff, puff, sweat, strain and challenge of it are expected, supported and culturally celebrated.

But this positive ‘pain is my friend’ mantra is not so much repeated on the lips of birthing women. No, birthing women more often repeat over and over an acculturated ‘get me the epidural, get me the epidural’ mantra. The cultural norm with regard to birthing has moved a long way from celebrating, let alone supporting birthing women to embrace the physiological pain. Instead we demonise labour pain; pity birthing women and ‘save’ them from the challenge.

But of this cultural norm doesn’t sit quite right with you and you have a yearning for normal physiological birth, it’s valuable to understand the feedback loop that physiological pain creates for efficient birthing.

Pain as the pathway to your birth-friendly hormones

Oxytocin and endorphins work together for efficient physiological birth and pain is the catalytic agent. High levels of oxytocin drive the contractions; the contractions create functional physiological pain, which cases the release of endorphins.

Endorphins give some moderation of the pain, but more importantly they swamp the ‘thinking brain’ to release the labouring woman’s birthing instincts. It’s a tailored recipe, refined over the ages. Embracing and working with the normal functional pain of labour is a key to unlocking this hormonal formula.

But it’s not so simple, because the default settings in the birth culture are entirely stacked against those who want a physiological birth, especially with regard to pain dynamics.

Crisis of confidence: The challenging edge of achievement

In all peak performance and personal best achievements, including birthing, there are vulnerable ‘feeling like giving up’, ‘hitting pain barrier’ moments, which during birth I call ‘crises of confidence’.

During these crises of confidence the birthing woman’s resolve is severely compromised. The combination of the painful reality and the undermining cultural messages about pain in labour leave her wanting our – ‘give me the epidural’ she wails. What happens now is crucial to the outcome of the labour. Will her yearning for a normal physiological birth collapse or will she be supported to continue on?

To get a greater sense of how this all unfolds there are some other factors to understand.

Pain and culture: Circles of influence

Let’s use five concentric circles to help get a sense of the circles of influence that press in on the birthing woman about pain.

These circles of influence will help give an overall picture of the many things that have an impact on labour pain – it’s not all about strong contractions.

The outer circle represents the wider cultural circle; it’s shaped by the ‘spirit of the age’, and represents cultural biases, including all those interventionist ‘labour-bypass era’ inclinations.

Inside this circle is the wider circle of family and friends, with all the attitudes, stories and suggestions they offer about labour pain.

Inside this circle is the circle of birthplace culture, with its practices and procedures regarding pain.

Then there is the circle of known support, which includes whoever women choose to have with them and their take on pain in birthing.

Finally, right in the centre, sits the birthing woman with her lived experience of comfort, discomfort and pain zones.

Wider cultural circle

Pregnant women are bombarded by negative messages about pain in labour and these negative undermining messages also creep into their head and psyche, so willing women need to protect themselves from this way of thinking by positively reframing their attitude to labour pain.

But when push comes to shove and a moment of vulnerability hits, what happens? Well, if the embedded cultural messages take over then pain-relief thinking wins out. Will the birthing woman be at the mercy of this thinking, or will she have a buffer zone to protect her?

Wider circle of family and friends

When the birthing woman hits a pain barrier she will be far more likely to overcome it if she has a buffer zone provided by her own wider circle of family and friends. This wider circle of family and friends is made up of ‘her people’. Not those she will have with her at the birth, but all her other close family and friends who live within her in the form of stories, comments, suggestions and attitudes. Do they moderate the cultural message and provide a buffer? Or do they amp up the cultural message and reaffirm that she was stupid to ever think she could do it without an epidural?

If this wider circle of family and friends doesn’t provide a buffer zone it will instead act as an amplifier and multiplier of the acculturated ‘pain relief’ mindset. Now what’s going to happen?

This is where the philosophy and practices within the chosen birthplace come to the fore.

Circle of birthplace culture

Presently, apart from in small pockets, the circle of birthplace culture will be made up of midwives and obstetric teams who are strangers to the birthing woman. Relationships within this circle are forged due to institutional circumstance with whoever is on roster at the time. This circle also includes the philosophies, routines, practices, power relationships and workplace regulations, which influence not only who will be working with the birthing woman but also how they work. And generally, regarding pain, the default setting is medical pain relief.

Circle of known support

This circle of known support is made up of the people known to the birthing woman that she chooses to have with her at the birth and usually includes her partner and perhaps other family or friends. It may also include caregivers she is engaging for the birth; an independent midwife, doula, or private obstetrician. (I’m including private obstetricians here, although they do not actually fulfil a pain-support function.)

I separate this circle of known support into two distinct types: the naïve support circle and the facilitating holding circle.

The naïve support circle often becomes, in the moments of a crisis of confidence, when the birthing woman wants all the drugs she can get, the mouthpiece for the dominant negative cultural messages.

The facilitating holding circle, however, is specifically designed by a savvy willing woman to support her through pain and distress barriers, in order to back her birth intentions. If the cultural messages about pain in labour have been multiplied by the wider support of circle of family and friends and reinforced by the birthplace culture, these negative messages are all going to come rushing in, swamping even the willing woman’s original intentions and confirming her present distressed ‘I can’t do it!’ self-talk.

If the willing woman’s original intentions are to be honoured it will now fall to the circle of known support to hold the line. Is there any buffer zone? Any protective force field within this circle, protecting her from both her own self-doubts and the multiplied, magnified cultural messages.

Buffer or sabotage?

For the birthing woman, whether she’s a ‘willing woman’ at the onset of labour or not, when she hits a pain panic – a crisis of confidence – how many circles can she lean into, how many wi9ll hold for her and provide a positive, energetic buffer? Will any amplify a positive message and back her intentions for normal physiological birth? Or will all those negative attitudes come rushing in, multiplying as they crash through circle after circle to eventually crash through the willing woman’s now flimsy-seeming intentions?

Hopefully a willing woman is blessed with a wider circle of family and friends who can provide at least the initial much-needed buffer from the negative cultural messages. Then the savvy willing woman can, by her choices, increase that buffer zone and back herself by ensuring she has a birthplace culture and a facilitating holding circle that match her intentions – her choices are so important.

With birth stats for pain relief use in labour running at 75% and 85% for first births, it’s clear that most women do not have support for working with pain in labour. And while many willing women expect their personal; attitude to give a buffer zone, without a carefully chosen circle of support it’s obviously tough to stay with her own intentions. This isn’t to say that a woman’s own pain attitude isn’t important. The birthing woman’s attitude to pain provides the portal through which all the positive or negative messages from the circles of influence will flow.

Midwives’ attitudes to pain

Research into midwives’ attitudes to pain in labour identified a ‘pain-relief’ paradigm and a ‘working with pain’ paradigm. This research revealed fundamental differences in understanding pain in childbirth – differences that have major consequences for a woman’s birthing potential.

Whether it’s an independent midwife specifically chosen by the birthing woman, or a midwife who has been assigned though a ‘know your midwife’ program, or a ‘strange’ midwife who is on shift at the time, the midwife counts so much when it comes to pain in labour.

Pain-relief paradigm

This paradigm dominates most hospital birth settings and is informed by medical, obstetric and nursing theory. It is based on pain-relief management developed for pathological pain in nursing, medicine, emergency and surgery situations – you known, the ‘asses your pain between one and ten’ routine. The bottom line is that pain should be controlled so that you can remain ‘comfortable’.

The experts in pain-relief management are anaesthetists, medical caregivers, chemists, nurses and midwives influenced by this pain-relief paradigm. They know about the drugs and the epidurals – the ‘when’, ‘how’ and ‘how much’.

This paradigm is based on the belief that the importance of women being comfortable and pain free, outweighs any of the disadvantages, risks and unintended consequences of pharmacological pain relief. Besides these caregivers are used to picking up the pieces medically when it all goes pear-shaped.

This is the default setting regarding pain in labour. Any distress on hitting a crisis of confidence, instead of being normalised and supported, will become entry points for pain-relief options. These options are supposedly offered in the spirit of ‘informed choice’, but in reality, in the absence of any other meaningful support for boosting pain tolerance, they actually work as ‘nudge’ choices and are almost impossible to opt out of.

‘Working with pain’ paradigm

In contrast to the medically influenced pain-relief practices, a ‘working with pain’ philosophy comes out of a ‘keeping birth normal’ midwifery understanding. This midwifery philosophy is underpinned by two core beliefs. Firstly, that normal physiological birth takes normal physiological pain and that, with the right encouragement, women can work with that pain. Secondly, that functional pain plays an important role in the physiology of normal birth because, as mentioned previously, functional pain is a stimulator of endorphins, which are part of the hormonal cascade that promotes normal physiological birth and enhances bonding behaviours.

‘Working with pain plays an important role in the physiology of normal birth because, as mentioned previously, functional pain is a stimulator of endorphins, which are part of the hormonal cascade that promotes normal physiological birth and enhances bonding behaviours.

‘Working with pain’ in labour, just like working with functional pain in other endeavours, requires practical skills and summons intense human support. Experts in these forms of support are personal trainers, coaches, supports psychologists, team mates, yoga teachers, massage therapists, and so on – and, when it comes to birthing, the experts are midwives who are influenced by this paradigm, doulas and maybe mothers, sisters or best friends who have already climbed this mountain.

When birthing women are well supported by midwives who embody this ‘working with pain’ philosophy, they will be encouraged through pain barriers, supported through any vulnerability or crisis moments and guided into a deeper rhythm of engagement with their body and birthing power.

Now there is a need, obviously, to be able to discern the difference between normal (physiological) and abnormal (pathological) pain states in labour. As a general rule though, birthing women can trust the pain in all its intensity and give expression to it – singing out their birth song and rocking out their birth dance.

The impact of the midwife

Willing women will need to know if the midwife is a facilitating midwife for normal physiological birth, or a midwife more attuned to techno-medical practices.

Does it matter? Sure does.

Let’s imagine a typical situation. A birthing woman hits a crisis of confidence; she’s distressed and feels she can’t go on. ‘I can’t do it,’ she wails. ‘Help me, help me, get me something’, imploring her support team to get her an epidural now! Regardless of her intentions before the birth, now she wants out.

If she is birthing in a setting dominated by pain-relief practices, any emotional distress will be interpreted by the midwife as ‘unnecessary suffering’. Then, being a caring midwife within this pain-relief paradigm, the midwife will feel that her best duty of care at this crisis moment is to ‘save’ the birthing woman from that suffering. The way she can do that is by offering the birthing woman the ‘pain-relief menu’. Then the birthing woman, in her distress, and in the absence of any other buffer, will gratefully accept the drug smorgasbord on offer.

On the other hand, if the women is birthing in a care setting based on the ‘working with pain’ model, the midwife will respond differently. Far from seeing ‘suffering’, the midwife will see ‘potency’. In fact, she has been waiting to see these moments of vulnerability because she knows that they are signs of progress, signs that the hormones and contractions are intensifying. The midwife celebrates this intensity jump-up, soothing, encouraging and boosting the birthing woman’s pain tolerance, building her into a deeper engagement with her labour.

It’s not rocket science; it’s very easy to see the different possible outcomes in these scenarios. Same woman, same pain vulnerabilities but different possibilities based on the midwifery support she receives. Willing women need to be savvy about these pain dynamics; they can’t leave it to chance. They must strengthen their facilitating holding circle to ensure they are surrounded by the expertise they need at these crisis of confidence moments.

Willing women of course need to look to their own attitudes to pain in labour, they also need to develop resources for boosting their pain tolerance thresholds, however I do hope my explanation will alert them to the cultural and structural issues that also play out when pain dynamics get going and help them to make savvy choices in support of their birthing intentions.

Rhea Dempsey is a qualified childbirth educator and counsellor, and the author of Birth With Confidence and Beyond the Birth Plan (both published by Boathouse Press). She has attended the births of over one thousand babies as a doula and now educates parents-to-be and healthcare professionals on how best to support physiological birth.

A version of this article, based on Rhea’s book Birth With Confidence, originally appeared in Nurture Magazine.

New mothers experience a range of feelings about the birthing experience of their sweet babies. Feelings range from joy, ecstasy and exhilaration; through to sheer exhaustion, overwhelm or disappointment. Or some women can be left feeling shell-shocked, despairing or traumatised.

A mother might call her birthing experience a ‘bad’ birth if it was longer, harder, more difficult or involved procedures which she hadn’t expected. However, most mothers experiencing a ‘bad’ birth will usually come to understand the ‘what’ and the ‘why’ of her experience and then find she can settle with it.

A mother may be traumatised by the birthing experience if she experienced something during the labour and birth that involved actual or threatened serious injury or death to her baby or herself. The same applies if she experienced intense fear, helplessness, loss of control, and horror. Birth trauma can also occur if she feels stripped of her dignity. In the case of birth trauma, new mothers find it difficult to settle with their experience.

The stats 

The statistics in Australia suggest around a third of birthing women are thought to have experienced birth trauma, with two to six percent of these women going on to experience PTSD secondary to the birth trauma. These high levels of birth trauma have a lot to do with what’s been called a ‘broken system’, which doesn’t meet the needs of birthing women.

Meeting the needs of birthing women would look a lot like what the Positive Birth Movement states would be a recipe for a positive birth – women are where they want to be; choices are informed by reality not fear; women are listened to and treated with respect and dignity; mothers are empowered and enriched and memories are warm and proud. I’m sure if this was the case in births then birth trauma would be a thing of the past.

How do you know if you’ve experienced birth trauma?

Women who experience birth trauma often continue to re-experience the traumatic events through flashbacks, disjointed memories, anxiety, hyper-arousal and avoidance of possible trauma triggers past the first few weeks post birth.

They may also experience fear of subsequent childbirth, which may influence the number of children they have, or the trauma may resurface as increased levels of anxiety in subsequent pregnancies and births.

How can we try to avoid birth trauma?

Get access to midwifery continuity of care, or if that’s not possible, get a doula. The research says that tapping into midwifery continuity of care programs and working with the same midwife across the pregnancy, birth and postnatally is best for satisfaction with birth.

This is because the same midwife has been with you and can help to fill in any gaps and explain the what and the why of how the birth unfolded. The research also says that the supportive relationships formed in midwifery continuity models makes for more normal birth outcomes and also better emotional outcomes in difficult births where interventions are necessary. In fact, midwifery continuity of care has been described across the world as ‘gold standard’ in maternity care.

It’s a pity then that only eight percent of women in Australia get to access these continuity of care models. If midwifery continuity isn’t available, a growing number of women are choosing to work with doulas in order to get that continuity, and the doula research certainly backs their choice.

What can we do if we feel we have experienced birth trauma?

Acknowledgement of the distress and trauma is one of the most important things. Many women feel silenced about the distress they feel after the birth, because of the ‘the healthy baby is all that matters’ cultural mindset, so they need to find someone who acknowledges that it’s a more complex picture than that.

Yes of course everyone, including the mother, is happy to have a healthy baby but we know this isn’t all that matters. Having healthy mothers who feel positive about themselves and the birthing experience is very important for the mother’s and the baby’s continuing wellbeing.

Can birth trauma lead to PND and how can we prevent this?

Acknowledgement and support is the key here.

If the birth trauma isn’t acknowledgement and supported, and women don’t find places to get psychological support for working through the trauma, then women with unacknowledged birth trauma can continue to be triggered back into the trauma memories.

Birth trauma for some women can also trigger previous life-trauma memories compounding their distress. Because family and friends often want to ask them about the birth, some women isolate themselves in order to be protected from distressing trauma feelings being reawakened. If the symptoms of birth trauma – flashbacks, nightmares and extra anxiety with the baby – are not acknowledged as being the result of birth trauma, women can feel they are losing touch with reality.

Also, many women blame and judge themselves and experience high levels of shame and guilt. This range of negative and distressing feelings are all risk factors that can cascade and morph into postnatal depression. So acknowledgement of the trauma and support for working through it is paramount.

Can birth trauma affect the baby?

Yes, birth trauma can create bonding disruptions – if regression or depression are responses to the trauma it will mean the mother is less available for her baby. Also her baby can act as a trigger, re-activating the trauma. If the mother isn’t well supported to understand and move through these feelings she may try to protect herself from the traumatic memories by distancing herself from her baby or going into task-mode. So then the baby misses all the warm closeness and bonding so necessary for its thriving.

The new mother may have internalised the birth trauma story as a ‘failure’ on their part, so their sense of confidence for mothering can be severely affected, which might mean that they’re less able to feel the delight of the baby or feel responsive in the ways that are so important for the baby’s development.

How can we help others who have experienced birth trauma?

Acknowledgement is the key thing. Never say ‘you’ve got a healthy baby and that’s all that matters’. This is often said in the spirit of being supportive but in fact it silences and internalises the new mother’s distress, which only compounds the problems.

Encourage her to get psychological support if the trauma symptoms persist past the first month to six weeks post birth.

Heaps of practical support for what is needed in the immediate aftermath of any traumatic experience is important for anybody experiencing any trauma, so much more so for a new mum suffering from birth trauma and dealing with the demands of her sweet baby. So get the rosters going – food, shopping, laundry, whatever – as well as bringing a listening ear, laughter and plenty of loving energy so the healing can begin.

Rhea Dempsey is a qualified childbirth educator and counsellor, and the author of Birth With Confidence and Beyond the Birth Plan (both published by Boathouse Press). She has attended the births of over one thousand babies as a doula and now educates parents-to-be and healthcare professionals on how best to support physiological birth.

A version of this article was originally published in KidSpot.