Chapter 25 Working with pain in labour
This chapter explores the midwifery art of being with women in pain in labour. The advantages of promoting women’s confidence in their ability to cope with pain are discussed in relation to evidence that supports this approach. Historical, psychosocial, cultural and feminist perspectives on pain in labour are presented in order to inform and highlight exemplary midwifery practice.
This chapter is concerned with the midwifery art of being with women in pain in labour. As such, it explores the rationale for engaging with women and their families1 around the role of pain in normal birth. While acknowledging that midwives must be prepared to support all women in labour, including those who choose to use pain medication (van Hoover 2000), it is not the intent of this chapter to give midwives information about specific methods of ‘pain relief’ and their administration; there are comprehensive textbooks about pain in childbirth that cover this more fully than is the intention here.2
There are also handbooks that explore the practicalities of supporting labouring women using ‘active birth’ techniques (Robertson 1994; Simkin & Anchetta 2000). The authors of this chapter are assuming that midwives will be aware of the benefits of providing supportive strategies such as encouraging women to move around, find positions that feel right, use water, and make noise if they wish. It is essential that midwives have these skills if they are to work with women in pain and encourage normal birth. In a culture where epidural anaesthesia is increasingly being promoted, it is also important that midwives are able to articulate why there is value in working with pain in labour, as opposed to taking away pain (Leap & Anderson 2008). This is especially important because although there has been an increase in numbers of women wanting to use epidurals, there has also been an increase in those wanting to avoid all kinds of analgesia (Henry & Nand 2004; Horrowitz et al 2004).
It has been suggested that anticipation of labour pain causes intense anxiety for many women (Coombes & Schonveld 1992; Lowe 1989; Shearer 1993) and that this can have a negative effect on their experience of birth (Green et al 2003). This chapter offers an overview of the evidence that midwives can draw on in order to engage with women around pain in labour, with a view to addressing these anxieties and enabling situations in which women can feel more powerful and confident as a result of their experiences of pregnancy and birth. In order to achieve this, it is imperative that midwives explore and appreciate the various meanings that may be associated with labour pain for individual women and their families (Mander 2000). An understanding of how perspectives on the physiology of pain and the culture of ‘pain relief in labour’ have evolved over the past century in industrialised countries will provide a starting point.
A comprehensive history of the development of pain theories can be found in Melzack and Wall’s The Challenge of Pain (1988). The traditional theory of pain is known as ‘specificity theory’. Pain is seen as no more than a particularly complex signal, broadcast over nerves leading from the site of injury to the brain, as first suggested by Descartes in 1664 and modified by Muller in 1842 and von Frey in 1894. Various theories on pain were developed in the first half of the 20th century, but a major breakthrough occurred in 1965 when Melzack and Wall proposed the ‘gate control theory of pain’; this provided a conceptual framework for understanding how pain messages are filtered and facilitated or inhibited through a ‘gate’ in the spinal cord that modulates reception and responses (Melzack & Wall 1965). In recent years, Melzack (1999) has proposed the ‘neuromatrix’ theory of pain, which retains key elements of the gate theory, but includes additional inputs from the brain. Memory, emotion, cultural factors, stress regulation, immune systems and past experiences all play a role in how the brain processes and synthesises genetic and sensory nerve impulses. The neuromatrix theory of pain can be used to enable understandings about the complexity of responses to pain and may also provide a framework for exploring the beneficial effects of non-pharmacological methods of pain relief in labour (Trout 2004).
The notion of a systematic approach to ‘pain control’ in labour began in Edinburgh with the experimental work of James Young Simpson in the 1840s (Caton 1999). Simpson’s introduction of inhalation anaesthesia in childbirth spawned a series of campaigns led by middle-class women demanding access to this resource. Such demands played a significant role in the move from home to hospital birth in the 20th century. Debates and concerns about the advisability of analgesia and anaesthesia, in terms of safety and possible physical and psychological consequences, have changed little since Simpson’s day. The potential harmful side-effects of drugs and the social value of pain versus the preservation of meaning in childbirth when pain is removed continue to be hotly debated issues (Caton 1999) that affect how women approach labour pain.
In the early 1930s, Grantly Dick-Read published Childbirth without fear: the principles and practice of natural childbirth (Dick-Read 1933). This book launched the concept of eliminating the cycle of ‘fear, tension and pain’ through counteractive education and training. Gentle, coached breathing and relaxation, with the emphasis on collaboration with a coach, were to play a vital role in keeping the woman on course in the teachings of the natural childbirth movement and later the ‘psychoprophylaxis’ movement in Europe and North America. In the latter decades of the 20th century, the mechanistic focus of psychoprophylaxis increasingly gave way to the psychosexual approach, a model that sees acceptance of labour as purposeful within the highly charged, significant act of giving birth, with its far-reaching sequelae for women’s lives (Kitzinger 1962, 1987). This approach became incorporated into that of the active birth movement (Balaskas 1983), which drew on activities and philosophies associated with the yoga tradition in teaching women to develop ‘all of their bodily resources for giving birth, to follow their own instincts and to take full control of the childbirth experience’ (Balaskas 1992, back cover).
In the 1980s, a new dimension to understanding pain in labour, incorporating neurohormonal physiology, was provided by Michel Odent (1984), who proposed that intrinsic opiates, such as the endorphins released by marathon runners, enable labouring women to enter a state of consciousness that enhances the progress of labour as well as providing a way of coping with pain. Odent drew on the work of Newton and colleagues (Newton et al 1966; Newton & Peeler 1968) in suggesting that privacy, intimacy and non-disturbance are required to enable the delicate balance of hormonal cascades to interact and promote effective physiological processes. Odent (1984, p 14) described the ‘virtually ecstatic state’ induced by endogenous opiates where women labour undisturbed as something that has always been sensed. This ‘sense’ of women having some ‘inbuilt’ coping mechanism has probably always been familiar to midwives in the absence of any physiological explanations, as described here by a retired midwife who practised in the 1930s in Britain:
I think myself that the system has a certain amount of sedative in itself that it releases at a time like that. I’m sure it has, because I’ve seen people that looked as if they were half sozzled—and they didn’t have anything! Just looked like somebody ‘gone’—and they hadn’t had any dope. (Leap & Hunter 1993, pp 168–169)
The familiarity of women disappearing into their own world in strong labour meant that midwives and childbirth educators embraced the theory of the body’s own pain-modifying substances as ‘Nature’s reward’ (Ginesi 1996, p 9). A full scientific description of the role of endogenous opioids in spontaneous labour is needed if ‘endorphin’ theory is to be given widespread credence. However, it is thought that incoming impulses of pain stimulate the release of encephalins, dynorphins and endorphins in the dorsal horn of the spinal cord and that these opioid-peptides have the ability to inhibit the sensations of pain carried by neurons to the brain.
Overall, in the past few decades, challenges to the concept of managing labour pain with anaesthesia and analgesia in industrialised societies have tended to concentrate on ‘non-pharmacological methods of pain relief’ (Simkin 1989) and have therefore often upheld the basic concept of controlling and minimising pain. Midwives who have written about the role of the midwife in relation to pain in labour have continued this trend by focusing on the skills needed to facilitate ‘pain relief’ (Moore 1994). With the development of antenatal education came a belief that midwives should be preparing women for labour by giving them ‘informed choice’ about all the ‘methods of pain relief’, the benefits and disadvantages of each.
In recent years, the offering of what Leap (2000b) has referred to as the ‘menu’ of various methods of ‘pain relief’ has been associated with the notion of a woman’s right to make ‘informed choices’ about all aspects of her care (Department of Health 1993, 2007; NHMRC 1996). This approach requires practitioners to adopt a systematic approach to explaining the advantages and disadvantages of each method ‘on the menu’ so that the woman may make appropriate choices, usually in advance of labour. Many practitioners and women therefore assume that some form of pain relief in labour is necessary. This assumption also underpins most research in the area. In contrast, midwives are increasingly articulating an approach that contributes to positive birthing experiences through building women’s confidence in their ability to find ways to deal with labour pain through drawing on their own resources (McCrea et al 2000). The rationale for this ‘working with pain’ approach rests in a belief that pain is purposeful in promoting normal birth and that the ‘triumph’ women experience after a drug-free labour can have far-reaching consequences for how they feel about their capabilities as women and as mothers (Anderson 2000; Leap 2000b; Leap & Anderson 2008). Listening to women’s ideas and experiences concerning pain in labour reinforces this theory.
Labour pain is complex and it is thought that the experience of pain itself may be mediated by physical, psychological, spiritual and cultural factors, such as tradition, anxiety, emotional associations, the position of the baby in utero, and levels of preparation and support (Mander 1998). Importantly, effective forms of pain relief are not necessarily associated with greater satisfaction when women evaluate their experience of birth (Heinz & Sleigh 2003; Hodnett 2002; Morgan et al 1982; Ross 1998). Studies have repeatedly shown that the quality of support and the caregiver relationship are so important to women that they override the influences of age, socioeconomic status, ethnicity, childbirth preparation and the physical birth environment; the influence of pain, pain relief and intrapartum medical interventions on subsequent satisfaction are not as obvious, direct or powerful as is the influence of the attitudes of the caregivers (Hodnett 2002).
Women have identified that support for coping with labour pain and access to different ways of reducing or relieving pain is important to them (Chamberlain et al 1993; Lundgren & Dahlberg 1998, 2002). The quality of these supportive interactions is more important to women than the level of pain per se (Callister et al 2003) and the attitudes of midwives have a profound impact on how women feel about their labours (Kitzinger 2000). It has been suggested that a form of reconstruction occurs after birth, when memories of labour pain are based on recall of the remembered emotional and behavioural consequences of the pain (Terry & Gijsberg 2000) and the meanings ascribed to the pain (Mander 2000).
In a number of studies, women have expressed satisfaction with the midwifery care they received when the midwife was ‘present’ in offering support and information (Hodnett 2002). They also valued feeling respected, and commented on the sense of trust that evolved, even when they had often not met the midwives prior to labour (Berg et al 1996). Culturally diverse groups of women have described childbirth as a difficult but empowering experience leading to a sense of achievement and a feeling of pride in their ability to cope with intense pain (Callister et al 2003; Dickenson et al 2003; Halldorsdottir & Karlsdottir 1996; Lundgren & Dahlberg 1998; Niven & Murphy-Black 2000). In contrast, women who have had obstetric intervention, particularly those who had unknown attendants, describe increased anxiety and pain, and place less emphasis on their active participation in birth (Callister et al 2003).
The rise in epidural and elective caesarean section rates has been apportioned to women making choices that help them deal with uncertainty and the fear of pain in labour (Silverton 2001). However, practice regarding epidurals, narcotics and elective caesarean section varies greatly regionally, between different maternity units and according to practitioner employment status, with particularly high rates in the private obstetrics sector (Roberts et al 2000). Variations appear often to be related to institutional or professional opinion factors rather than population factors or individual women’s choices (Hodnett 2002).
Women who express a desire to have a normal birth often cite concerns about the side-effects associated with the use of narcotics and epidurals in labour as a major source of motivation (Henry & Nand 2004; Soutter 2004). Such concerns sit within wider debates about the potential public and psychological health impact of rates of intervention that are above those indicated by current evidence (Johanson et al 2002; Maternity Care Working Party 2007; Tracy & Tracy 2003).
Although epidural analgesia is very effective in reducing pain, it is associated with increased risks of prolonged labour, fetal malposition, augmentation and instrumental vaginal birth (Anim-Somuah et al 2005; Howell et al 2001; Lieberman & O’Donaghue 2002; Mayberry et al 2002). Controlled observational studies also indicate a possible association with higher caesarean section rates, and although these findings must be viewed with caution due to methodological challenges, there is sufficient evidence to warrant concern. There has also been a suggestion that the rate of crossover in trials is masking the relationship between epidurals and caesarean section (Lieberman 2004). The only uncontaminated randomised controlled trial to demonstrate an association between epidural and caesarean section was published over 16 years ago (Thorpe et al 1993). This small trial showed that women having first babies who were randomised to have an epidural were 11.4 times more likely to have a caesarean due to dystocia than women who were randomised to have narcotic analgesia. The trial was discontinued on the grounds that it was unethical to continue to randomise women to have an epidural. Concerns have been raised that supportive midwifery care may be jeopardised by the monitoring activities associated with epidural analgesia in hospitals where there are high epidural rates; these concerns are particularly acute in terms of women’s ability to care for women who choose non-pharmacological pain relief (Mayberry et al 2002).
The use of narcotics, such as pethidine, in labour is associated with harmful effects on the mother’s birth experience, longer labours, compromise of the baby and difficulties initiating breastfeeding (Heelbeck 1999; Hunt 2002). Furthermore, while such drugs induce sedation and may therefore give caregivers the impression of having relieved pain, women overwhelmingly report on how ineffective narcotics are in providing pain relief (Bricker & Lavender 2002; Olofsson et al 1996).
Studies comparing different types of pain have identified the severity of labour pain for the majority of women (Melzack & Wall 1965). However, the National Birthday Trust Fund’s Pain Relief in Labour Study (Chamberlain et al 1993) found major differences between the perceptions of over 1000 women and those of their birth attendants with regard to the experience of pain and the effectiveness of pain-relief methods. Professionals’ concepts of pain relief tended to be restricted to pharmacological methods—less so with midwives than with doctors—and they were more likely to agree with each other about the efficacy of different methods than with the women. This difference is understandable if one considers that although, today, books for women about childbirth tend to be illustrated throughout with personalised accounts of births, this is not generally the case with textbooks for professionals. Arney and Neill (1982) have suggested that professionals need to listen to the subjectivity of individual women’s experience in order to move away from the one-dimensional approach based on anatomy and physiology. Like Bendelow and Williams (1995) and Martin (1987), they stress the importance of learning from narratives in order to make more appropriate responses to those in pain.
The Association of Radical Midwives has always paid tribute to the value of learning from women’s accounts of their births and, since its inception in 1978, its newsletter has consistently published birth stories written by women. An example is the moving account by Agnes Kotreba (1994), who gave birth after a fast labour, before the midwives arrived. Her account acknowledges aspects of loneliness, potential death, images of water, and the physical and mental challenges of pain that are common themes elsewhere.
Dear God, how many more hours? I especially don’t let myself panic or drown in this tidal wave which breaks my entrails and comes from a distance like the sound of a plane, intensifying until it gets intolerable, and then nothing—nothing, no pain whatsoever. I’m like cleansed, surprised, pulverized—Will I have the strength to endure the next attack? … I twist myself in pain … I think I emit a sound … so far I am unable to show my suffering, it’s my business, my biggest intimacy, my most complete and total nudity. (Kotreba 1994, pp 16–17)
When listening to such accounts, Kelpin (1992) suggests that it is not useful to compare labour pain to any other pain. She also questions the validity of fragmenting our understanding by analysing the pain of labour within different theories such as physical, psychological, sociological and cultural perspectives. She suggests that such approaches militate against the understanding of the nature of ‘painfulness’ as lived by women and mothers and that the inwardness of the birth experience is an opportunity to be attentive to:
… the deep significance of the momentous quality of the pain … As we are surrounded by the deep sense of inwardness, we are forced to recognize our independence, our loneliness, our selfhood. To be conscious of our own existence. This actual self-consciousness exposes to us our wholeness, our strengths and our endurance. (Kelpin 1992, p 101)
The pain of labour is constructed by Kelpin as an expression of ‘the narrow gateway leading to release in the expanse of life’ (p 101). The release she describes with the birth of the baby is given the significance of change from ‘self-as-world’ to ‘baby-as-world’ where a new pain comes with the awe of focusing on a new being. She quotes Phyllis Chesler (1979, p 281): ‘Being born with motherhood is the sharpest pain I’ve known’ and uses words like ‘relief’, ‘disbelief’, ‘joy’ and ‘exhilaration’ to describe the excitement and poignancy of the new baby’s presence (p 102). This exhilaration usually masks the ability to recall the exact nature of pain.
But who can remember the pain [of childbirth], once it’s over? All that remains of it is a shadow, not in the mind even, in the flesh. Pain marks you but too deep to see. Out of sight, out of mind. (Atwood 1987, p 135)
Attempts to describe pain reinforce the elusive nature of pain but also the crossing of borders between the emotional and the physical way it is experienced. Pain has a common language, as this passage illustrates:
Pain … is stark and unyielding to decoration, pain fills the world to the hilt, bursting its edges in an unseemly way; pain doesn’t admit anything else—it usurps all the space available. (Kassabova 1999, p 52)
The pain described above is the pain expressed by a young woman who has had to leave her homeland and flee far across the world to a place of safety. Such is the universal nature of pain that it could equally well be describing the pain of a heart attack or the pain of labour. However, it should be noted that many women say that labour pain is quite different from any pain that is associated with injury or trauma, but that this is hard to explain in concrete terms.
In her important study of pain, Elaine Scarry (1985) states that the person in pain may experience pain as ‘the most vibrant example of what it is to have certainty’: pain is ‘effortlessly grasped’, while for the onlooker, the other person’s pain is so elusive that it could be seen as ‘the primary model of what it is to have doubt’; here, ‘what is effortless is not grasping it’ (Scarry 1985, p 4).
This concept is significant for midwives who sit alongside women in pain; they can respond to cues given by the woman in order to offer support and suggestions, but primarily the midwife’s role is to help the woman identify her own spontaneous coping strategies (Escott et al 2004) and to be alert to aspects of care and the environment that disrupt these (Spiby et al 2004).
Studies have suggested that midwives consistently underestimate the intensity of pain experienced by women in labour (Chamberlain et al 1993; Niven 1994). This may be a coping mechanism on the part of midwives as the onlookers of pain. Scarry’s reading of the role of the physician in hearing the fragmentary language of pain, ‘coaxing it into clarity’ in order to interpret it, could be applied to the role of the midwife, who equally needs not to bypass the person in pain as an ‘unreliable narrator’ since doubting people in pain amplifies their suffering (Scarry 1985, pp 6–7). However, recognising the severity of pain that a woman is suffering during labour does not necessarily equate to the need to offer pain relief. In fact, women identify that when they are in pain, any offer of pain relief is irresistible and undermines their confidence in their ability to cope without using pharmacological pain relief:
I didn’t really want an epidural. That wasn’t what I was saying. What I wanted was something magic that no one’s ever thought of before, that you were going to quickly invent right then to make it all better. But I really didn’t want an epidural. It was an expression of my pain. (Leap 1997, p 49)
Midwives have talked about the significance of the particular nature of pain in labour: its rhythms, the fact that it has a positive, finite goal and that it stops as soon as the baby is born and then cannot be recalled.
Afterwards, I’m still emotionally and physically wrecked and they’ve moved on completely. It’s like, through a fog they can remember the time they were pleading for an epidural but they’ve moved on. So that’s been significant for me just in terms of women’s ability to recover or move on or have a different agenda in a very short space of time. And that’s given me enormous confidence to … just be there … and not see pain as long-term damage. (Leap 1997, p 48)
New Zealand and Australia are multicultural societies and, as such, the midwife is likely to be involved in the care of women from a range of backgrounds, including those of Māori, Polynesian, Aboriginal Asian, Middle Eastern, African and European descent. She needs to be mindful that different cultural practices may be employed to help women cope with pain during labour. For some women, prayers may be read by family members or songs sung to provide support and to welcome a new member of the family. For some Māori women, these would be in the form of karakia or waiata.
Cultural perceptions and expressions of pain vary widely. Women from some European cultures, such as Greece and Italy, for example, tend to vocalise pain in an uninhibited fashion, while those from other cultures, such as Polynesian women, often appear to value stoicism. Samoan and Tongan women, therefore, may appear very calm during labour, with little outward show of their pain.
Midwives must be aware, however, of the potential pitfalls associated with ethnic stereotyping, and it is important never to assume that a woman will respond to labour pain in a culturally determined way. A book describing Māori women’s experiences of pregnancy and birth, Ukaipo (Rimene et al 1998