by Andrea Robertson Why does pain in labour scare us so much? Everywhere a pregnant woman turns she is confronted by messages that she will need “something” to help her get through the trials of labour. Trying to “suffer” the pain of contractions without assistance is being unnecessarily “brave” now that there are so many ways to ease or even stop the pain altogether. After all, there is no need to be a martyr is there? There is no doubt that the majority of women giving birth today are offered drugs during labour.
A review of any hospital’s birth outcomes will reveal that over 90% of women were given pain medication at some point. With 70% of all births in Britain having a midwife in charge and a national epidural rate of around 30%, it is clear that a lot of women are being given a lot of drugs, mostly opiates such as pethidine or heroin (known euphemistically as diamorphine). Not all midwives fit this description though, and many feel chuffed when they enable women to “get away with only a bit of entonox”, even during a water birth or at a home birth.
Many midwives counter these figures by saying that they are offering “choice” and that maternal request is the driving force behind high levels of medication use. It would be interesting to study these claims and to discover whether it was the midwife, or the woman, who first mentioned pain medication during labour. Almost all women will call for help at some point, and this is often a useful sign of the transitional phase of labour, but a demand for an epidural or pethidine at this point is not the result of an informed choice: it is a cry for help that may be better handled using traditional midwifery skills. Before considering the influences that have shaped women’s lack of confidence in being able to give birth normally, the thinking of midwives deserves closer examination.
Midwives who are concerned about the welfare of the baby and want to encourage breastfeeding will usually begin by suggesting so-called “non-invasive” ideas for easing pain in the hope that these will be enough. Instead of offering the pethidine or ordering an epidural they may suggest a warm bath, massage with aromatherapy oils, reflexology, homeopathy, acupressure or using a TENS machine. However, these complementary therapies are also interventions, and midwives may be just substituting one form of invasive procedure for another.
Apart from the use of immersion in warm water during birth, other alternative therapies have not been rigorously tested for efficacy or even safety during labour. Whilst many of these strategies may enable women to avoid the use of prescription drugs during birth, there is another aspect of their use that is often overlooked: the potential psychological impact on a woman’s beliefs and feelings about herself and her capabilities that may be engendered as a result of accepting outside “help”.
When she is offered even a small amount of say, Entonox during labour, what message might a woman receive about the midwife’s perceptions of her strength and resilience – “You are not capable of doing this yourself – you need me and my drugs to help you through”? What effect might this have on a woman’s ability to take charge of her life, feel confident in nurturing her child and trust in her own maternal instincts? Perhaps the midwife feels she is “helping” or being kind and caring, or perhaps she just wants to feel useful or needed.
The birth process is possibly the most powerful experience in a woman’s life, a unique opportunity to discover and assert those hidden talents that empower and uplift. To rescue her from this may be to rob her … Where does the drive to do something about relieving the pain in labour come from? Even midwives, who should be knowledgeable about the nature, purpose and benefits (!) of labour pain worry that women can’t do it without help.
I believe that much of the distrust in women’s abilities to labour well comes from a complex mix of recent history of birth management, personal experiences and unresolved grief. For the last 100 years women have been encouraged to use drugs to blot out the experience of labour. For the last 50 years birth has become entrenched in hospital settings. The increasing use of technology, restricting women’s mobility and the desire to be proactive rather than reactive to signs of possible deviation from the “norm” have all created environments in which the natural ebb and flow of birth has been restricted and proscribed. As a result, women have (perhaps understandably) wanted to block out distressing memories of being humiliated and restrained during labour and have willingly accepted medication that sedates and obliterates the pain brought on by these practises.
Midwives, at least those who are women, have either witnessed these developments or have had personal experience of them. They too are carrying memories and perhaps grief from their impact and, unless they are sadists, often fervently hope that other women will not suffer as they have. When their midwifery education has begun with training as a nurse first, it can be hard to shake off the basic philosophy of easing suffering that underpins nursing practice. If this is then coupled with traumatic personal birth experiences it can become a powerful mix, resulting in strong rescuing behaviours being exhibited towards women giving birth.
There are other factors that influence a woman’s thinking. Pregnancy magazines and chemist shops are full of advertisements and gadgets for pain relief in labour. TENS is a very good example of this – here is a device that is primarily used on labouring women in Britain (it is rare in other western countries) on the basis that it is “harmless” and will increase endorphins, the body’s natural pain easing opiates. Where is the research that supports this statement? Where are the studies that show using TENS during labour increases endorphins? Perhaps this is an example of advertising hype, aimed primarily at pregnant women but also at midwives who are wary of drugs but still want to be able to offer “something” to women in labour. It is an approach that is obviously working wonders for the balance sheets and company profits of the manufacturers, but what impact does it have on the beliefs systems of women? The evidence to date suggests that if TENS works at all, it is as a placebo. How many women do you know who have said “I couldn’t have done it without the TENS”, giving all the credit to the gadget when in reality they were probably managing the labour pain well using their own inner resources ? Every time a woman gets through “just with the TENS”, she is reinforcing the view that she is weak, with a low pain threshold that needs the help of technology to make it through a natural process. This is a sad state of affairs! Women get their ideas about birth from many sources. Prenatal education has a major role in providing information and many women list “finding out about the pain” as a major reason for attending classes during their pregnancy. Almost all programs have taken these fears on board and have provided a session neatly called “Pain Relief in Labour”. Think of the inherent message in this title alone! This session will revolve around discussion of a wonderful “menu” of options that woman can use to relieve the pain they fear so much. Given the level of apprehension in the minds of the women in the group, and the nervousness of many men in being able to cope with her in labour, it doesn’t matter in which order these options are presented: any sensible, fearful, woman will go for the one that has the greatest potential for taking all the pain away and opt for the epidural. Are we unwillingly contributing to the rise and rise of epidural use through this subtle selling technique? This whole approach to talking about pain in labour during pregnancy needs a radical overhaul. Begin with an explanation about the nature and purpose of the pain itself, the role of endorphins and then explore the instinctive measures that women have used for centuries to make labour more comfortable: being upright, moving about, keeping eyes closed, being in a dark place, companion of choice etc. An emphasis on the impact of drugs on the baby, their effect on breastfeeding and potential side effects for the woman must also be part of the story. The books that women buy in their bid to fully prepare themselves for birth and parenting (as if this is possible from a book!) may also be feeding into a woman’s lack of confidence. Take a look at any book about pregnancy and birth on the shelf in your local bookstore. Tucked away in an appropriate chapter will be found messages about “learning how to breathe” in labour and the importance of learning how to be relaxed if birth is to be easy and the pain bearable. The very idea that women need to learn “how to breathe” in order to give birth well is an insult that affects confidence. There is no evidence that “the breathing” works to relieve pain – it is just another form of intervention. Are the authors of these books reflecting the muddled thinking of those midwives whose need for control over women during birth also extends to those mantras heard in labour wards (“just give us another little push”, “push, push, push … now puff, pant, pant…”!) in second stage? A common complaint from midwives is that ‘there is no time’ to spend with women in labour supporting them through the process. Being “with women” during birth often requires very little of the midwife. Giving the woman more space and privacy and doing less rather than more gives a woman a chance to realises that she can do it “by herself”. Giving drugs and using complementary therapies, instead of easing the midwife’s load, actually increases it, as she will need to constantly check for adverse effects and monitor the impact they are having on the normal birth process. If we are to change women’s belief systems about pain in labour we need a consistent message from all sources: the books written for expectant parents, the messages given during preparation for birth classes, the behaviours of midwives around women in labour and most importantly. We also need insight into why we are so scared of pain in labour that we will go to almost any lengths to remove it as much as we can. What are you going to do about this issue in your own practice? This article first appeared in The Practising Midwife, Vol 5 No 1, January 2002.