Pain is defined as ‘an unpleasant sensation caused by noxious stimulation of the sensory nerve endings’ or ‘as a state in which an individual experiences and reports the presence of severe discomfort or an uncomfortable sensation (Mosby, 2009). During labour, pain is due to the interaction of a multitude of physiological and psychological factors. Physiologically, there is a multifaceted feedback loop between hormones, endorphins and the pain receptors, which stimulate on-going oxytocin production (Sprawson, 2017). This mechanism initiates uterine contractions and cervical dilatation, and allows the fetus to enter the pelvis, causing distension and stretching of the pelvic floor and vagina. This results in the sensation of pain. How the labouring woman then perceives this unwanted feature of childbirth depends on how she processes it (Sprawson, 2017). Several factors will influence this: the woman's personality, her expectations, her cultural and social background, her previous experience(s), how tired she is and if she has pre-existing fears and anxiety about labour and birth (McCormack, 2009). The World Health Organization (WHO) also states that environment of care, effective communication, continuity of carer, and personalised and woman-centred care are also important aspects to consider when providing respectful maternity care and addressing pain management (WHO, 2018).
Pain relief in labour
Asking staff in the unit in which I work the meaning of ‘pain relief in labour’ usually results in a cocktail menu of drugs being recited. When I ask them to think beyond the pharmacological methods, few manage to describe alternative means without encouraging lateral thinking and providing some assistance. However, even older midwifery textbooks cite the relationship between the midwife and the woman as the primary influence on how pain is perceived (Bevis, 1990). Pain perception and tolerance were also influenced by preparing the woman for labour through information-giving based on individual needs, alleviating fear, developing a birth wishes plan and meeting the clinical and support staff (Bevis, 1990).
It all sounds very simple, easy and achievable, especially with all the information available online, through the media, via reality shows and through ‘preparing for birth’ and parenthood classes. Women should therefore be well informed, anxiety levels should be minimal, and labour should progress with minimal intervention and maximum satisfaction (Bailey, 2017). Sadly, this is not the case, as shown by the increasing number of articles written about women's fear of childbirth and about post-traumatic stress disorder (PTSD) following birth, and by daily encounters with pregnant women at the antenatal clinics (Gribbin, 2017). Numbers of women afraid of labour and birth vary, but a Swedish research study estimated that it was around 10% (Størksen et al, 2015). These fears and anxiety of labour appear to have arisen secondary to birth becoming medicalised. Most births are now hospital-based, meaning that women are removed from observing, assisting and understanding this natural, physiological process (Stoll and Hall, 2013). With documentaries and reality television, the media has managed to demonstrate that normal birth requires the control of specialist doctors, that drug therapy is routine, and that women adopt a position of helplessness. As a result, people now perceive birth as hazardous (Stoll and Hall, 2013). On reviewing various studies, Gribbin (2017) discovered that 1%-10% of all pregnant women were reported to have complex tocophobia, due to multifaceted reasons that need to be identified and explored antenatally so that a realistic plan of care can be developed for every individual (Gribbin, 2017). There were some positive findings from the Swedish study, however: the researchers discovered that women who had a good understanding of the female reproduction system and saw an actual birth coped better and reported less anxiety and fear during labour (Stoll and Hall, 2013).
Addressing the problem
How can professionals change perceptions and make labour and birth a positive, fulfilling and satisfying experience for the woman and her family once again?
Firstly, information should be shared to add to the woman's existing knowledge and should be tailored to her individual needs. It should be presented factually so she is prepared and equipped in advance to make informed decisions during her labour. To assist this, care should be evidence-based and up-to-date (Nursing and Midwifery Board of Ireland (NMBI), 2015). However, preparing the woman for childbirth cannot simply focus on the different types of pharmacological interventions available: the complexity and interplay of all the factors that contribute to the pain of labour can be also relieved by a multitude of other methods. These non-pharmacological methods also need to be shared with the woman as she prepares for labour. This information giving should also be robust and evidence-based.
Informing women
It is difficult to find the keywords to obtain articles pertaining to pain-relieving options used in labour, other than those looking at epidural and neuraxial anaesthesia. However, the Cochrane database revealed 23 systematic reviews that had investigated different methods used to support and assist women during labour, as well as an overview of systematic reviews (Jones et al, 2012). Pain management techniques examined by Cochrane reviews have included immersion in water (Cluett and Burns, 2012); massage, reflexology and other manual methods (Smith et al, 2018a); relaxation techniques (Smith et al, 2018b); acupuncture and acupressure (Smith et al, 2011a); aromatherapy (Smith et al, 2011b); transcutaneous electrical nerve stimulation (TENS) (Dowswell et al, 2009); maternal positions and mobility during first stage of labour (Lawrence et al, 2013); and hypnosis (Madden, 2016). Reviews also examined the effect of continuous support during childbirth (Bohren et al, 2017).
Anyone involved in antenatal and intrapartum care should consult these reviews so that they are aware of the variety of pharmacological and non-pharmacological methods employed by women to help them cope with childbirth (Table 1). All the reviews look at the effects of the intervention, the safety of the intervention and any other outcomes, which ensures the reader is provided with reliable information derived from reviews of primary healthcare research.
Table 1. Methods of pain management for childbirth
With this knowledge, professionals involved in antenatal care and antenatal education can engage in conversations and impart a wealth of evidence-based information that can only enhance the informed decision-making that women engage in during pregnancy and birth. It also ensures that the professional is familiar with methods and interventions that women may seek advice about but which are not commonly used in the local maternity care setting. It is also important to remember that when women make an informed choice, this decision must be respected even when, at times, these choices may deviate from ‘the norm’, as defined by the professional or the organisation in which care is delivered (Jackson, 2017). These concepts are further reinforced following the recent WHO publication that aims to ensure that all women have a positive childbirth experience (WHO, 2018). The guide advocates respectful maternity care based on personalised, woman-centred care and minimal medical interventions in normal labour. The recommendations include effective communication, continuity of carer(s), a chosen labour companion, effective pain relief and upright positions during labour and birth (WHO, 2018).
Care should offer choice, normalise birth, ensure a positive experience and ensure the woman and her family are the main decision-makers in partnership with the caregivers
As well as providing evidence based, up-to-date information to enable informed decision-making, health professionals should inform pregnant women about the reality of labour. This needs to begin with a conversation about the signs and stages of labour, what to expect during these events and the average length of time labour takes. From interactions with women during the antenatal period, reality programmes and documentaries of labour and birth have left many first-time mums-to-be with the belief that labour takes only a couple of hours. There is also an idea that it is not very painful and that pain relief will not be required. However, statistics from the maternity unit at Sligo University Hospital for 2017 report a 40% intramuscular opioid use, 37% epidural rate and a 63% Entonox rate during labour, with women often using a combination of these methods. This care is in a unit with a 71% vaginal birth rate and where one-to-one midwifery support is given to all labouring women.
One-to-one care
Recent research has found that continuous one-to-one care and support in labour reduces anxiety and stress, with women describing less pain (Sprawson, 2017). In one study, one-to-one support was shown to reduce the use of epidurals in labour, which increased the rate of vaginal births and resulted in greater satisfaction and positive birth experiences (Hodnett et al, 2013). The researchers believed that these findings arose from the women being empowered to believe in the normal physiology of labour, which enhanced their feelings of being in control (Hodnett et al, 2013). However, as older midwifery text books show, these findings are not a new concept; just caregiving that has been overlooked, ignored or considered out-of-date over the past couple of decades.
Despite this one-to-one care in the maternity unit in the north-west of Ireland, there is still a requirement for a variety of methods to help the woman manage her labour. In 2017, according to the unit's maternity information record, less than 1% of women laboured without pharmacological methods. The records showed that 63% of labouring women used Entonox and a combination of other non-pharmacological methods including TENS, water, massage and hypnobirthing to manage and cope with labour. These other methods include adopting positions that have been shown to aid the birth process. In the past few months, a method known as ‘Labour Hopscotch’ has also been included to encourage a physiological birth (Thompson and O'Brien, 2015). Labour Hopscotch is a visual tool that helps the woman and her partner focus on remaining active during labour. It recommends breaking labour into 20-minute steps, which include being mobile for 20 minutes, remaining upright, bathing or showering, walking the stairs crablike, using alternative methods and massage (Ni Chríodáin, 2017). It is a useful resource that offers choice and reinforces the woman's ability to manage her labour with the support of her birthing partner and midwife. It also focuses on going ‘back to basics’ and rethinking strategies that have traditionally been used by birth attendants in the past and are now being recommended again (WHO, 2018).
This hands-on, ‘with woman’ aspect of midwifery had been lost, but is being embraced again in the Republic of Ireland, as midwives realise there is more to managing labour than using drugs (Thompson and O'Brien, 2015; Bailey, 2017). The re-emergence of informing women about optimal fetal positioning to reduce the rising amount of occipital posterior position in labour is also testiment to the lessons that midwives can learn from bygone years (Sutton, 2001). The terminology used in the practice standards for midwives in Ireland (NMBI, 2015) further reinforces the need for midwives to view labour and birth as a normal, physiological event, with the woman deciding what care is right for her and the midwife informing decision-making and helping women to have a positive birth experience (NMBI, 2015).
The National Maternity Strategy (Department of Health, 2016) has further aided this changing practice with its publication of how maternity services are to be provided. It clearly states that care should offer choice, normalise birth, ensure a positive experience and ensure the woman and her family are the main decision-makers in partnership with the caregivers (Department of Health, 2016). Because of this national document and advice from WHO (2018), midwives and maternity caregivers must go ‘back to basics’ to rethink how care is provided and used to best effect. This care must be high quality, safe and responsive to women's needs. The caregiver can no longer be in a position of authority but instead should use an informative model with the woman clearly in the driving seat. The woman can then make her decision based on information given by the caregivers who have, in turn, respected the evidence and presented it in an unbiased manner that the woman readily understands (Agarwal and Murinson, 2012).
These are changing and exciting times for midwives to once again become watchful, hands-on practitioners. Midwives must work with women, yet remain vigilant for signs of deviations from the norm. Midwives need to remain true to the philosophy that guides midwifery care, which encourages and enables this physiological process, yet remain cognisant of the rising complexities and co-morbidities that are part of daily practice (Gribbin, 2017).
Conclusion
As women reclaim responsibility for decision-making in labour and birth, midwives need to equip themselves with the knowledge needed to assist the women to make informed choices. Midwives can provide this information during antenatal interactions, making every encounter matter and ensuring that the women is aware of the physiological processes that occur during pregnancy and birth and knows what to expect. This should equip the woman with a variety of choices to help her manage the pain of labour and ought to make giving birth a fulfilling and life-changing event. Good antenatal preparation should also reduce the number of women who report being traumatised and are then anxious and frightened of subsequent pregnancies and labour.
There will be many who will challenge the ‘back to basics’ concept and claim that it is unachievable due to work pressures and staff shortages. However, it should be considered that unless there is an obstetric emergency, informing and preparing the woman and her family for this new baby is one of the most important remits of midwifery. Unfortunately, from a workforce planning aspect and when detemining skill mix and staff numbers using tools such as Birthrate Plus, information provision is not a priority and therefore not routinely built into the working day (Ball and Washbrook, 2011). This is clearly something on which managers and midwives need to reflect. Health professionals should also prioritise the importance of listening, discussing and informing to high quality midwifery care, as well as exploring how best to implement the latest recommendations on intrapartum care into their units.
Key points
The pain experienced in labour and childbirth cannot just be managed by pharmacological methods due to the interaction of both physiological and psychological factors
Professionals caring for pregnant and labouring women need to be familiar with both pharmacological and non-pharmacological methods
Professionals caring for pregnant and labouring women need to impart evidence-based, unbiased information, so that the woman is able to make informed choices about her labour and birth
One-to-one support in labour, with the woman at the centre of the decision-making process, needs to be the norm for all labouring women
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