Monthly Archives: August 2015

Midwives, labour, birth and pain science




Midwives are amazing creatures.  Long before the advent of pain scientists, midwives have known a thing or two about pain:

  • Fear about childbirth will increase the pain experienced
  • A lack of knowledge will enhance fear
  • Fear and anxiety can interfere with our body’s ability to function at its best
  • People’s experience of the same painful stimulus varies incredibly across a population and is influenced by many factors

Similarly, long before the Moseley’s, Louw and  Butlers  of the pain world starting banging on about pain education, midwives knew that if a pregnant woman had a good understanding of the physiological processes that were going on in her body during pregnancy and labour, she was less likely to be distressed and anxious about these processes (aka-bringing a baby into the world!).    Like in chronic musculoskeletal pain1, education and reassurance prior to childbirth has been shown to deliver significantly better clinical outcomes, in terms of reductions in interventions and mental health outcomes2,3 .

In some pockets of the community internet (and Northcote), there is a sense that natural, drug free childbirth is a reflection of a mother’s mother-liness (is there such a word?) and that if she had to have a caesarian section, she just wasn’t trying hard enough/allowed those wretched doctors to violate her/  didn’t read the right books or do the right course.  They can also convey the idea that not achieving (or aiming for) natural birth will mean a lack of bonding between mother and child or blah blah blah bollocks.   There probably exists an argument on the other side of the fence that our caesarian rates are too high compared to the WHO recommended 10% and that we could be putting more attention on reducing the rates to a level that balances safety for mum and bub against the cost and complications that potentially accompany a surgical birth.

So, in honour of my beautiful sister-in-law who is about to give birth to my niece or nephew, I have penned a few thoughts about childbirth ….. and pain:

  • Be careful whose advice you take… including mine! Childbirth is one of the most emotional experiences you will ever go through.  It is rare for a woman to experience it and for it not to leave some kind of mark (not talking about stretch marks or episiotomy scars!)  The emotional toll following childbirth, even in the “best” ones, can feel a little like PTSD (or a lot like PTSD in some cases).  People will want to tell you their story, which is a natural reaction to such a big emotional event, and is an often an important debrief for them.  They might want you to do things the way they did…. Or not do things the way they did.  Then next woman might give you the complete opposite advice.  Keep that in mind whilst politely listening to their stories.  Remember that the horror stories will perpetuate much more so than the cruisy birth stories      (Bad news sells much better than good news – ask any journalist!). Hearing these horror stories can contribute to your fear levels, even if only subconsciously.


  • A little bit of knowledge goes a long way. Take your advice from someone you trust and who hopefully will be caring for you during the birth process.  As I mentioned above, having a good understanding of the process is helpful to normalise the sensations  that you will experience.  The idea is hopefully that during the labour you can experience a level of acceptance of the process, rather than fighting the sensations and this will allow the labour to progress.  As in other elements of healthcare, the rapport you have with your caregivers has an important effect on the clinical outcomes.


  • Have realistic expectations. They call it labour for a reason – it is unlikely to be a walk in the park.  On the other hand, if things go pear shaped, and interventions are needed, don’t get yourself in a twist worrying that things didn’t go to plan.  Be grateful that we live in a country that offers safe and clean hospitals and well trained medical staff that can help you if you need it.  A healthy and safe mum and bub have to be the first priority.


  • Breathing is powerful. As in any other event where pain might be present, deep breathing and other relaxation techniques can be an effective tool with no risks or side effects.  The evidence, although not particularly comprehensive on the subject, suggests that relaxation techniques can help reduce the incidence of instrumental delivery4. Deep breathing helps to engage the parasympathetic nervous system, which can help initiate the body’s own pain modulation.  Most protocols suggest practising the techniques in the weeks leading up to delivery.


  • Set up your support team well.  Let them know your thoughts and values around delivering your baby and trust that during the process they can advocate for you well, so you can focus on…. other things… probably breathing.  Arm your supporters with the same reassuring education material – they can help normalise things for you, when things feel anything but normal.  This will help keep the fear out of the process.


  • Try a TENS machine and heat packs, especially in early labour. It’s pain science in action!  You can often hire the TENS units so that you don’t have to buy them.  For the heat packs, it can be helpful to have a few on the go so that you can rotate them for re-heating.


  • Those in science and healthcare have a solid understanding of the “shit happens principle”. It can be helpful to get on board with this one.  It says that sometimes, despite doing all the right things, they don’t always go as intended.  So whilst the stats might say that doing your relaxation and breathing, staying active during labor and educating yourself will improve your chances of a vaginal delivery, they don’t speak for the individual….. and hence, shit happens.  Sometimes we just can’t be in control of everything and it is best to go with the flow.  Trust that your caregivers are making the decisions in yours and your baby’s best interests.


I could go on….. but instead, let me tell you about the birth of MY first child………….

  1. Mosely, L., Nicholas, M., & Hodges, P. (2004).  A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clincal Journal of Pain.  20( 5),324-332
  2. Johnson R, Slade P. (2002). Does fear of childbirth during pregnancy predict emergency caesarean section?  British Journal of Obstetrics and Gynaecology, 109(11):1213– 1221.
  3. Toohil, J., Fenwick, J., Gamble, J., Creedy, D., Buist, A., Turkstra, E., & Ryding, E. (2014). A randomized controlled trial of a psycho-education intervention by midwives in reducing childbirth fear in pregnant women. Birth, 41(12), 384- 395.
  4. Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., Jordan, S., Lavender, T., & Neilson, J. (2012). Cochrane Database Systematic Review, Mar 14;3:CD009234. doi: 10.1002/14651858.CD009234.pub2. Review.

Career Crisis?

Hands up who has stuck their nose into pain science, or just science in general, adopted some new ways of approaching patient care and got better outcomes?  Hands up, who has then poked their nose back into their profession’s water cooler discussions, be it at a conference, internet discussion forums or the actual water cooler itself, and found themselves despairing, pulling their hair out and declaring I CAN’T DO THIS ANYMORE – I NEED A CAREER CHANGE!!! ??

Over this last week I have had discussions with three colleagues who have approached me about wanting to make a career change out of their respective manual therapy industry.  They have approached me seeking some guidance into what might be possible, affordable, fulfilling career options to take sidesteps from their current careers. The recurrent undertones of discontent seem to follow these broad themes:

  • People in my profession aren’t keeping up with what is going on, in fact there seems to be pushback against any movement forward – It’ s like they WANT to keep us in the dark ages/on the fringe
  • The way that the practice that I work in is structured is designed to keep people sick/broken/in pain/fearful/coming back and I can’t seem to fight against these commercially driven factors to change things
  • My colleagues talk about change or keeping up to date but the other day I overheard him/her telling a patient that “once we get the MRI (for their non specific low back pain) then we can make a plan”.
  • I practice using a current understanding of pain, yet these “gurus” spouting reductionist nonsense often represent our profession to the public and the medical profession. They end up representing me and its not fair!
  • I am stuck in a rut and can’t seem to get my longer term patients to move to a more active management approach – it drives me crazy

I feel like I have been having these conversations almost weekly for a year – and I am no closer to coming up with answers for people regarding a tidy solution.  So, despite admitting to not having the answers, these are some of the suggestions that I have made to various people along the way.

  • Remember that the grass is always greener on the other side. Many people in the other careers that you might aspire to switch over to, have very similar issues and frustrations, sometimes they are exactly the same, sometimes slightly different.


  • Is switching to a different profession (within allied health/manual therapy) going to allow you to practice in such a different way as to dramatically improve your personal job satisfaction? Is the loss of income, costs of retraining and setting up going to be worth it?  If it is, then go for it…. But make sure you have thought it through really carefully. Remember that education is a massive industry these days, and it is buyer beware in terms of whether you will get a job at the end of a masters degree or other course.  Universities are more than happy to take your money and enroll you in a program with little or no reference to whether the industry can support all the extra grads.


  • Instead of focusing on what other people in your industry are doing or saying – just do your job really, really well. Focus on each patient as an individual and try to apply the best approach that you think will help that person, with reference to what the science tells you, but also with reference to your experience. Remember that the changes you can help a person to make in their life can be phenomenal.  The reality of improvements on functional testing or a pain catastrophising scale that we might judge our clinical success by, play out for the patient as things like getting back to work, playing with kids, getting back to the sport or gardening that they love.  That is a massive impact!  It is easy to get wrapped up in prestige, hierarchies and reputations of a profession, (especially in the presence of gurus) and forget that within each of those industries, there are great practitioners and crap practitioners.  Is the label that important? Does it change how you can deliver your service?  Can you slightly change your model of delivery and still stay well within your scope of practice?


  • Take stock of where you are at personally – have you had a holiday recently? Are you regularly engaging in conferences, seminars  or professional meeting to keep you motivated and in the zone? Are you working too many hours? Dealing with patients, especially ones in pain is draining in full time mode. Can you switch to part time or diversify your practice to break things up?  At a low ebb you will find yourself wanting to bail out much more readily. photo-Vietnam-beach-holidays-pics-hh_dp4270659


  • Can you refer those long term, dependent patients who are still stuck in passive mode, and haven’t made the progression to an active approach in line with your own changes, to someone else? It’s really hard to change the nature of that relationship once it has been established.  The effect they have on your mood, and that fact that you are probably not helping them much might mean that the kindest thing you can do for them is suggest that they “start fresh”  with a colleague who can show them a new way forward.  (Make sure you know that whoever you are referring to has a good grasp of a biopsychosocial approach!)


  • Pursue the stuff that you love outside of work. Remember that work is only part of your life and no career is going to give you complete and utter life satisfaction.


  • Stay off the idiot forums!! If that is your exposure to the nonsense that upsets you, just don’t go there, at least for a while.  Stick to discussions with like minded people  and hang out with people who you think can balance things well.


Over a series of weeks I will be interviewing some smart pain people, to hear about how they approach a fictional patient with hip osteoarthritis, who is convinced she needs a hip replacement.  The interviews go for 20 minutes – perfect for the commute or a procrastination session.

Interview #1 Dr Samuel Whittle

Interview #2 Dr Drew Slimmon