That one ^I hate it. Of course you're going to have pain - it's labor! It's expected!
Some problems with using a numerical pain scale in labor and delivery, is that women might be left wondering: if I give my pain a low number, does that mean the pain is going to get worse? (More than likely, yes. But once again, it's "labor". And it's normal.)
Or, a woman might think that if she gives a high number in early labor, it means she'll get pain medication or an epidural sooner. (Not necessarily.)
How about the lovely Joint Commission, who says we need to offer pain medication (different types) depending on the severity of the pain on the pain scale? (Once again, I must declare: pain in labor is NORMAL! It doesn't mean it automatically needs medication to "fix it"!)
So, I've brought this topic up at work. Because, as you can tell, I hate using the 0-10 pain scale in labor and delivery.
What about a coping scale? -- I posed this question at our practice group meeting. I know, no one really seemed too interested in the topic, but hey, I am interested in it. So, off to research coping scales.
Interestingly enough, I did find one research article that goes about the creation and utilization of a coping with labor algorithm. Very close to what I was looking for. In an article in the Journal for Midwifery and Women's Health, I found such a concept of a coping algorithm for labor and delivery.
"The Coping With Labor Algorithm: An Alternate Pain Assessment Tool for the Laboring Woman" by Leissa Roberts, Brenda Gulliver, Janet Fisher and Kristin Cloyes. This article contains two fantastic algorithms to determine how well (or not) a woman is coping during her labor progress. (The actual article is here. However, if you aren't a subscriber, you can't access the full article. Luckily, I can access it via my school library!)
But what I really wanted to find was a numeric scale, or something I can introduce to the unit to quantify how the woman is coping with labor. Enter Penny Simkin's chart:
Thank you Penny Simkin!What are the 3 Rs, you might ask? According to Penny, they are:
The ability to Relax during and/or between contractions,
The use of Rhythm characterizes their coping style, and
The use of Rituals, or Rhythmic activities with each contraction.
I so, so, SO like this coping score system MUCH better than the "can you rate your pain for me, on a scale of zero to ten, with zero being no pain, and ten being the worst pain in your life?"
Quantifying the very subjective nature of pain while in labor is so different for each woman. Using the coping scale with how each woman is coping with the contractions actually shows how well (or not) she is managing the "pain" of her labor. Then again, I hate the use of the word "pain" when it comes to labor. Yes, it is painful. However, to bring up the word "pain" can actually make it MORE painful for some women.
Once again, I go back to the "duh" mentality of the fact that it's labor, of course it is painful. Must we remind women of this pain by asking her, repeatedly, to rate her level of pain? Quite simply: NO.
29 comments:
Very interesting. I remember being asked this during my first birth (very medicalized, ended in a c-section after a classic cascade of interventions). When I was around 3-4cm a doctor asked me to rate my pain and I said it was around a 4 (I didn't want to run out of numbers since it was obviously going to get worse!). They watched me through a contraction and afterward said "Are you *SURE* it's just a 4? That didn't look like a 4." Way to make me feel like I wasn't coping well... I agreed to an epidural soon after.
In my VBAC a few years later at a different hospital, no one ever asked me to rate my pain. I wonder why that is. (just to wrap up the story, I did have a wonderful med-free intervention-free VBAC)
wow-that's awesome! kudos to you for going to the research and finding a studied scale to use!
to tell you the truth, I have never used the 1-10 pain scale on laboring moms. It just didn't ever seem appropriate.
Attended a lecture by Penny Simkin - she's an amazing person.
:)
Great post!
That scale makes so much more sense. I was asked to rate my pain and first the nurses we annoyed with me because I said I had no pain but they asked me in-between contraction and I had no pain than. I'm not a totally idiot but I had never had a baby before and them asking me questions was more bother-some than the contractions. Once it was clarified that they wanted to know how much pain I was in during a contraction I honestly didn't know how to rate it because like you said duh there was pain but I in no way felt I needed help dealing with it.
I think we can only accurately answer the pain scale question AFTER labor is over. Looking back, I would have said my pain was at an 8 at the highest. But during, I probably would have said a 20! The "coping" scale is much better.
Interestingly during my last birth I was *never* asked to rate my pain during labor. Not once.
Great post! I love the coping scale idea.
Why should a woman have to experience pain in labour? Nobody is going to do an appendectomy without pain management and say "oh this is an appendectomy, so pain is expected." The belief that a "natural" birth is better because it is natural is merely a logical fallacy. I'm not advocating c-sections for everyone or anything like that, but unless there are extraordinary medical risks making giving medication for the pain too dangerous, why should a 21st century woman have to suffer?
Ah, but Tina, pain does not always equal suffering!
I like the coping scale SO much better too! I am going to introduce it to my clients, maybe put it on birth plans. :)
I hate that pain scale all the time but I found in particularly frustrating while I was in labor. Luckily my nurse could see I was having a hard time with it and told me it wasn't important she just needed a number to put in the computer.
I love the coping scale though, it really makes sense.
interesting! the second scale seems much more intuitive for birth but literal types always want to assign everything numbers that they can quantify later.
i was never asked about the scale during my labor. i wonder why not? maybe because i had asked pain/drug relief not to be discussed? (the hospital i delivered at was all up in my birth plan in a fabulous way!)
Tina, I would certainly never begrudge any woman the option to have the pain relief she desires but they aren't without consequences. Some would argue that epidurals placed at the wrong time slow labor and start a cascade of interventions leading to a major abdominal surgery that could have been avoided. Why wouldn't you want to avoid major surgery? Women have to rely on health professionals to guide us as to when pain relief is best used instead of just shouting DRUGS DRUGS DRUGS!
This post is fabulous!!! I have often voiced my hatred for the numerical pain scale. I love this concept of a coping scale!
It's a logical fallacy to compare labor pain and appendectomy pain; they are not at all comparable. I've found that I can cope very well with labor pain, even though I have a low tolerance for pain in general. It's to my advantage to retain full feeling and range of motion while giving birth--I have almost certainly -prevented- a lot of pain for myself that way.
I don't often read all the comments, but I did see Tina's. There's someone who obviously has not learned about the possible consequences of pain relief!!
I like your response...pain doesn't have to mean suffering. It's not pain like a bad burn, or broken leg. It's pain with a purpose, intermittent, and (Usually), easy to cope with if prepared. There's no comparing it to an appendectomy, LOL. I can't tolerate ANY sort of dental pain, but labour? Easy peasy. I have been thining about making a chart showing how long contractions last at different stages, and how long it actually hurts during contractions, and add up the total amount of "pain" time. It's surprisingly little, compared to the overall amount of labour time! Why risk the side effects/consequences of epidurals, etc, just for what might amount to an hour or two of "pain"?
@ Tina and all:
I am so glad to see this issue brought up again on another blog site! Addressing pain, alone, without the laboring woman's ability to cope, isn't terribly fruitful in the setting of labor and birth. For an extensive description of determining pain versus suffering, read Penny Simkin's two-part series on this very topic, on Science & Sensibility:
http://www.scienceandsensibility.org/?p=2145 (part one)
http://www.scienceandsensibility.org/?p=2312 (part two)
Like, agree
I also often have the feeling that women tell me an artificially high number because they are afraid they won't otherwise get pain meds (our docs don't really care as long as baby looks good... they can get meds, but pts don't realize that). Yeah, lots of people talking, talking on phone, watching TV, in no apparent distress at all, with an 8/10...
Pain is pain is pain is pain. It is carried on the same nerves, caused by the same chemicals: there is no more reason to tolerate pain in labor than elsewhere.
Asking someone about pain no more causes them to hurt than asking someone if they are depressed causes suicide. Laboring women may well decide to buy out of the NCB hype and get medicated, but asking them if they are hurting isn't going to make them hurt.
I disagree, fuzzy... first, people tolerate pain in many settings outside of labor for a variety of different reasons. If I have a headache, I'll try drinking a lot of water and taking a nap before I'll take ibuprofen, even knowing it will take longer for my headache to go away, because I don't like to mask with meds what I should be doing to take care of myself. My mother declines novocaine for basic dental work because she hates feeling numbed up. People with chronic pain issues are constantly balancing the side effects of their pain meds with the amount of pain they are willing to tolerate to lead a functional life without feeling zombiefied by meds. Right? We are always considering trade-offs between the things we do to manage pain and the side effects of those things, not just in labor.
And I don't think asking people about their pain scale constantly "makes them hurt", but I don't think it helps them handle their pain either. If you were running a marathon, how would you feel about someone checking it with you at every mile marker asking "Are you tired now? How exhausted would you rate yourself, on a scale of 1 to 10? Oh, an 8, wow, wow, that's pretty high. You sure you're OK?"
When I used to doula at hospitals that used pain scales, I saw them used as pretexts for nurses to suggest early epidurals. They would ask a woman to pick a number in early labor and the woman wasn't really sure what to pick because she has no frame of reference yet. So she'd pick, say, a 4. Now labor is getting stronger and that was a 4, so now she's a 7 and the nurse would say "Seven! Do you need an epidural now?" I'm watching this woman - I've observed her labor patterns - I know she is not that far along and her 7-relative-to-4 could just as easily be someone else's 4-relative-to-1. But the nurse now has "7" to chart and has to/wants to suggest an epidural at what really is probably kind of an early stage. Even with a woman planning to get one eventually, not so good for labor progress.
More recently I have only doula'd at places with no pain scale... I don't notice anyone missing it. The women who want epidurals know when they've gotten to the point where they want one. The women who don't know they can ask if they change their mind. So simple! The end.
I love it and THANK YOU. I had not come across this 'coping scale' before. My last doula client wrote "please do not ask me to rate my pain" on her birth plan. This took me back to that :)
Great post! We adopted the coping scale on our unit a few years ago. I love it! I just makes more sense. Of course, she is in pain. Who cares how it is rated. Is she coping with it!?!? I also agree that labor pain is not ALWAYS equivalent to suffering. I did not feel that I suffered during either of my births. However, some women do feel like they are suffering and I am more than happy to help them cope by giving them meds or calling the CRNA if that's how she wants to cope. Tanashia
I know this is a bit different since it is after a c-section. One of nurses asked me to rate my pain on the 1-10 scale. Then she asked me what is the highest number I am able to cope with before I require pain meds. I thought this was great! Of course, this is after 2 previous sections, so maybe she figured by then I knew the score.
When I had my first child, the nurse never asked me to rate my pain, but a year later when I got a copy of my records, I discovered that she just made a number up and entered into the computer. Just another example of how I was kept out of the loop at my own birth!
I also wanted to say the pain from an appendectomy is pain from something being wrong. Your body is telling you there is a problem. That is not the case for labor pain. Labor pain is your body doing something right! So pain should not always be treated equally.
I was so aggravated with the nurse during labor when she kept asking me my pain scale. I wanted nothing more than to be left alone and go into my own little world.
My pain was a 10... but then I thought, burn victims must experience more pain, so I have no right to claim a 10. My point? Don't make me think about my pain!
If I have to deliver at a hospital and they ask this, I plan on saying '2' the entire time. LOL!
I love the coping scale! One woman maybe feeling what the next woman would consider an 8, while she only considers it a 3-4, It doesn't matter the pain level you feel but your ability to cope with said pain level.
I'm extremely pain tolerant, I would 'rate' the worst part of my pain with my DS a 6, 7 at most and only for a moment when I crowned his head/hand.
It may have been the worst pain I've personally felt, I have never been seriously injured or had surgery etc, however it still wasn't bad enough to give an 8. In fact I'm more nervous about nursing then I am about labor and delivery, had a little trouble with DS, it took two weeks to adjust his latch so I wasn't in tears every time he latched on. I'm hoping this LO catches on a little quicker.
I also remember seeing this chart on the wall at my first birth (actually, it was in my room after my cesarean) and there were only like three faces on it. LOL They never really asked me, and even when I was in a lot of pain, they didn't do squat about it. :/ So much for the chart.
I like Penny's version much better, too. :)
I wrote in my birth plan that I was NOT to be asked any pain level. I mentioned that I was perfectly capable of asking for pain meds if I felt it necessary, which I never did.
I wanted to share this experience I witnessed regarding the Pain Level question. My grandmother suffered a major stroke, and wasn't expected to survive the night. She did survive and perked up quite a bit after being hydrated. She looked good, although she had a respirator and could not talk. She smiled when I walked into the room and we held hands. There was no physical indication that she was in pain - no furrowed brow, no gripping hand hold, no fidgeting, nothing. However, the nurse that came to tend to her asked her over and over and over, three separate times, Are you in Pain? By the third time, I saw my grandma give in to the question and shake her head yes. It seemed that her answer was more to please the nurse and had nothing to do with the pain. She was subsequently given a pain med that made her unconscious/sleep for many hours, hours I would have prefered to spend with her awake. She passed away seven days after her stroke.
So I completely disagree that by being asked if you are in pain, doesn't bring on pain. When in birthing time, I was completely in my own zone and using Hypnobabies, I would be open to other's suggestions.
It seems that just by being asked, my mind starts darting around my body questioning, is there pain here? or there? and something that wasn't in my conscious mind, is brought there by the question being asked.
Therefore, I requested, and never was asked, what my pain level is.
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