By Nicky Leap
Why study pain?
The pain of labour is a constant feature of the discussion in unstructured antenatal groups (Leap 1992) and women have highlighted the fact that the attitudes of midwives have a profound effect on their experience of giving birth (Kitzinger 1988; Oakley 1981; Philips et al 1984; Leap & Hunter 1993; McCrea et al 1998). This understanding motivated me to explore midwives’ ideas and understandings regarding pain in labour.
My personal interest was also fueled by fourteen years of practice specialising in home birth and working with women who consistently expressed views about their experience of pain in labour. Discussions with colleagues in the South East London Midwifery Group Practice (now the Albany Midwifery Group Practice, Kings Health Care, London) — who prioritise reflective practice (Leap 1996b) often centred around justifying our actions when being accused of ‘withholding pain relief’ from labouring women. I was keen to explore how midwives can respond when confronted by accusations such as: “Why on earth would you not offer all women pain relief in the 1990s?”.
The study: ‘A Midwifery Perspective on Pain in Labour’
For these reasons, I chose to explore ‘A Midwifery Perspective on Pain in Labour’ as the area of enquiry for my MSc in Midwifery (Leap 1996a). Initially, I carried out an extensive literature search on pain, drawing on multi-disciplinary discourses, including explorations of labour pain in novels, poetry, short stories, plays, biographies, oral history and books on childbirth aimed at pregnant women. I then analysed original qualitative data obtained from semi-structured interviews with 10 midwives, all of whom were known to me as having considerable home birth experience to draw on in expressing their perspectives on the subject. One midwife was from the Netherlands and another was from Ontario, otherwise all the midwives were practising in Britain in a variety of settings. I knew that I would be working with an articulate group, used to expressing their ideas and reflecting on their experiences and therefore, likely to yield data that would act as a ‘catalyst for conceptualisation’ (Kirkham 1987, Appleton 1995). I was eager to explore practical, emotional, cultural and philosophical issues relating to pain in labour and to develop midwifery theory of consequence for childbearing women.
The ‘pain relief paradigm’ and the ‘working with pain’ paradigm
In the course of the interviews, the midwives described two distinct approaches to pain in labour. I named these the dominant paradigm (or ‘mind set’) of ‘pain relief’ and the paradigm of ‘working with pain’. Although the ‘working with pain’ concept tends to be embodied in midwifery knowledge and philosophy, this labelling of concepts is not meant to imply polarised notions such as midwifery versus medical, or home birth versus hospital birth. Indeed, the study included descriptions of midwives ‘working with pain’ in hospital settings as well as descriptions of midwives taking a ‘pain relief’ approach out of the hospital into home birth settings.
The midwives described a labour ward culture where the offering of ‘pain relief’ was seen as an essential role of the midwife and an important choice for women, regardless of the type of labour. The personal discomfort experienced by practitioners around being with women in pain was described in terms of reactions to the noise and behaviour of women in labour. It was seen that it is more work for the midwife to be interacting with someone in pain than someone who has had their pain taken away. A paternalistic system where practitioners want to be ‘kind’ and make full use of ‘the benefits of modern technology’ was described — “In this day and age, no woman should have to suffer the barbaric pain of childbirth. You midwives are cruel”.
Concern was expressed about a system that prioritises what I call, ‘the menu approach’ (the list of what is on offer and the pros and cons of each method), in order to give women ‘informed choice’. This is a hierarchical menu, starting with the non-pharmacological methods that midwives tend to feel all right about, such as water and aromatherapy, and ending with the epidural at the bottom of the list. This ‘menu approach’ creates a culture where both women and their attendants end up seeing some form of ‘pain relief’, however seemingly innocuous, as a necessary part of the process of giving birth:
Developing an understanding of ‘normal’ and ‘abnormal pain’
All the midwives suggested, in one way or another, that the key to moving towards a different paradigm, one that ‘works with pain’, is developing an understanding of ‘normal pain’ as part of the process of labour. On the other hand, there was agreement that ‘abnormal pain’ is associated with abnormal labour — the body’s message that all is not well – and that ‘pain relief’ is usually appropriate in such cases.
The midwives’ understanding of ‘normal pain’ was expressed in direct relation to a concept of women’s bodies producing their own ‘pain coping mechanism’ as the pain forces a ‘folding in on themselves’. Commonly identified as ‘endorphin theory’ this notion was described in terms of women having their own pain relieving substances — endogenous opiates — within their bodies. Pain was seen as a trigger of hormonal cascades that promote normal labour. [It should be noted that the complex interplay of hormones and endogenous opioids in labouring women still needs to be identified and described.]
The midwifery skill of ‘being with women in pain’
The concept of ‘working with pain’ and enabling the woman to release her body’s own pain relieving chemicals demands a different midwifery approach, one that minimises stimulation to the senses so that women can ‘fold in on themselves’ thus enabling the hormonal cascade to develop. Midwives with this approach believe that women can cope with the pain of ‘normal’ labour and that the experience and expression of pain gives women and midwives ‘clues’ to how labour is progressing. The skill of being with women in pain in labour often rests in believing in women when they do not believe in themselves.
The purpose of pain
The midwives’ rationale for rejecting the ‘pain relief’ paradigm was described as two fold: believing in a purpose to pain and gaining confidence by responding to feedback from women. Their theories about the purpose of pain can be summarised thus:
- Pain as a trigger of neuro-hormonal cascades
- Pain stops women and allows them to find a place of safety to give birth
- Pain marks the occasion
- Pain summons support
- Pain develops altruistic behaviour in babies
- Pain heightens joy
- Pain as transition to motherhood
- The triumph of going through pain
- The expression of pain gives clues to progress
In spite of their convictions, unpredictability was seen as a relevant factor, especially the complex interplay of physiology and psychology, and all the midwives were at pains to warn against an approach that engages in stereotyping around who will and will not cope with pain in labour.
Some midwifery philosophies regarding being with women in pain in labour
The midwives in this study expressed strong practical and philosophical beliefs regarding their understanding of pain in labour. Some quotations are reproduced here to give an impression of the rich expressions, the depth and passion with which these midwives reflect on their work:
The pain is really your friend in labour. In these big transitions in life the pain is coming to help you. And that is such a different concept of pain, that pain is your friend instead of your enemy. It’s the same in big emotional problems, the pain actually helps you, like when you’re grieving… if you really dive into the pain, then finally the pain in someone becomes sweet. If you don’t go through this pain, it becomes sour. If you don’t want to take the pain of your soul, you loose feeling and then you get cut off from life. So I think pain is such an important part of life.
It seems like there’s something very real in quite a human context about being able to manage something that increasingly society manages for us. I think the problem in that is the competitive element that gets raised for women who ‘haven’t managed’ according to some kind of societal notion of a good birth: ‘managing your own pain is a prescription for a happy birth’. That’s been an ongoing problem for me, how I can frame or set up the possibility of pain being a degree and an entity that can be managed so that it doesn’t represent a failure experience.
I think the purpose of pain is to get the cascade going. At the moment the birth starts you have this self-reinforcing system of prostaglandins, oxytocin, endorphins and the like… Once the snow starts to roll, the process is self-reinforcing and it has to go on and on and on and the uterus has to get more powerful, powerful, powerful, stronger, stronger, stronger. And then the baby’s born and the process stops immediately like an avalanche — when the avalanche has fallen down, then it’s silence. And if you take away the pain — some people have the naivete to think you can take away pain — if you change one thing, you change the whole thing. One of the big aims of pain is to get the avalanche rolling. And very often you see that if you take away the pain, the avalanche stops in the middle of its rolling and the birth just doesn’t get underway.
I have difficulty with the notion of triumph. You have to be careful of not denigrating any woman’s experience because she could end up with this failure thing. It doesn’t take much for a woman to feel she’s failed. But yes, people can still feel good after a Caesarean section.
I say to women, “If you do into labour spontaneously at term and your baby’s in the right position, and you’re in a place where you feel safe, you’re not going to be sent more pain than you can deal with. I believe it. I really believe it. And this might sound cocky, but I also think that by saying it and repeating it, we make it possible for women to do it. What’s missing in antenatal care for women in our culture is that completely accurate confidence-building reinforcement of their own ability to actually have a baby.
My approach is to emphasise that the majority of labours will be normal but the way a normal labour feels will vary enormously between different women regardless of their attitude or preparation, that a 32 hour primiparous OP [occipito-posterior] labour will probably hurt more than an 8 hour multiparous labour. I developed this expression: “Biology first, Psychology second” when I talked with women about labour pain. I felt concerned about the limitations of ideology led birth and would often say, “You know, birth is not a very intellectual event.”
Watching women in pain has taught me humility. It has taught me to expect the unexpected and trust the process, to trust that women’s bodies were made to give birth. In learning to trust, I had to identify my own fear. Labours are so raw and that can be scary if you’ve been brought up in quite an inhibited way which I suppose I was. So helping women cope with these huge big emotions can be scary and I think it took me my first 100 births as an independent midwife to really get to trust the process.
Within the framework and context of the modern parlance of ‘choice’ and ’empowerment’, we shouldn’t forget that there is a place for professional interaction — for goodness sake, women need midwives and if we didn’t have a clearly defined role in all of that then we wouldn’t be needed. And I think some of that is to maintain a space of authority and knowingness. And I think the circle’s going to turn back to midwives seeing themselves as being very important to the relationship, only from a different perspective. But all of this ‘one to one’ and ‘know your midwife’ — midwives don’t even know themselves and the whole nature of the relationship is framed on intimacy and knowing.
What we’re really doing isn’t so very different from what people like Grantly Dick Read were doing back in the 1930s. I mean, they were saying to women, “You can do it. It’s OK. And I’ve got a mechanism to help you do it, and an explanation about how you can make it easier for yourself”. It was very prescriptive and it worked for people like my mother-in-law. And that whole ‘fear-tension-pain’ thing makes a huge amount of sense, and whether women feel safe and secure and how that affects their experience of pain. A lot of it’s psychology, well all of it with normal labour, I’m sure it is. And the attitudes of midwives antenatally will have a profound effect. If you can build up confidence in women that they can definitely get on and do this, then I think they will.
What gives me confidence is hearing how they feel afterwards, because if afterwards they said, “Listen you b—-, I wanted an epidural and you refused it to me” and they meant it, then I hope I’d change my approach … Women who’ve been ‘withheld’ from have told me afterwards that my overview was correct. They were grateful and said things like, “I didn’t really mean it [asking for an epidural]. It was an expression of my pain. What I wanted was something magic that no-one’s ever thought of before, that you were quickly going to invent right then to make it all better! But I really didn’t want an epidural. I’m glad that the relationship we had meant that you could interpret what I was saying”. There’s this whole element that’s embedded in our relationship of trust which allows us to interpret, which is not about being in authority… it’s very difficult [to explain]… I suppose I see it as our responsibility to believe in women, to believe they can do it, and to protect them when they don’t believe in themselves. It’s a protection against all that conditioning…
The findings of this study raise important practical and philosophical issues for debate by all those who have an interest in childbirth and the development of midwifery praxis. Since undertaking this study, I continue to make pain in labour a focal area of my research interest and increasingly find that the above described midwifery perspective is not the prerogative of midwives working predominantly in home birth settings. The ACE workshops will provide the opportunity for many midwives, working in diverse settings, to explore whether they share an understanding of the concepts presented in this paper.
I remain convinced that this midwifery knowledge is an important key to the concept of ‘keeping birth normal’ and that this notion is directly linked to enabling situations where childbearing women are able to take power and become confident mothers.
- Appleton JV 1995 Analysing qualitative interview data: addressing issues of validity and reliability Journal of Advanced Nursing. 22:993-997
- Kirkham M 1987 Basic Supportive Care in Labour: interactions with and around women. PhD Thesis. Manchester University.
- Kitzinger S (1988) The Midwife Challenge. Pandora. London.
- Leap N 1992 Helping You to Make Your Own Decisions: antenatal and postnatal groups in SE London. VHS Video. Available from ACE Graphics.
- Leap N 1996a A Midwifery Perspective on Pain in Labour. Unpublished dissertation submitted as course requirement of the MSc in Midwifery, South Bank University, London.
- Leap N 1996b Caseload practice: a recipe for burn out?
- British Journal of Midwifery 4 (6) 329-340
- Leap N & Hunter B 1993 The Midwife’s Tale: an oral history from handywoman to professional midwife. Scarlet Press. London.
- McCrea BH, Wright M, Murphy-Black T 1998 Differences in midwives’ approaches to pain relief in labour Midwifery. 14, 174-180
© Nicky Leap 2000
This paper was presented at the Enriching Midwifery Conference, Australia, March 2000 for Birth International.