Pain is not Prerequisite for Birth

In my department, there is a widely-held opinion that obstetric theatre calls are “easier” than general emergency-theatre calls. We do not have an epidural service for labouring mothers at our hospital. If we did, I suspect the on-call anaesthetist would be a lot busier. Right now, the only pregnant women “lucky” enough to get spinal anaesthesia, are those being taken for a c-section.

Why don’t we have an epidural service? The touted reasons include staff shortages (anaesthetic staff and midwives), lack of adequate epidural monitoring infrastructure, insufficient funds for epidural anaesthesia consumables… and then there is also significant push-back from many in our hospital, whenever the question of an epidural service is raised.

“…and I think: have we forgotten what it means to be a clinician?”

Image: Stephanie Cheng

These days, I think often of persistent false beliefs about analgesia in childbirth. We blame resource scarcity, but I am convinced that we would make a plan were it any other specialty. Medicine continues to accept pain as a natural part of childbirth.

But, heck, where does the “natural” benchmark come from, anyway? Perhaps another time we can talk about that etymology in medicine.

“There is no other circumstance in which it is considered acceptable for an individual to experience untreated severe pain that is amenable to safe intervention while the individual is under a physician’s care.”

ASA, ACOG (1)

Literature suggests that religious views do still inform analgesic practices of many birthing professionals when patients are in labour (2). Religious texts have taught that labour pain is a consequence of original sin, a punishment inherited from the original matriarch (Judaism, Christianity). The pain of childbirth, and especially death during childbirth, confers a woman martyrdom (Islam). And pain of childbirth is glorified as a necessary suffering (Buddhism)(3).

Some practitioners believe that pain is a necessity to help them assess for warning signs during labour (4), and I think: have we forgotten what it means to be a clinician? (This reminds me of the old ancient belief that a peritonitic patient should not receive preoperative analgesia, lest the surgeon feel compelled to change their diagnosis.)

Anyways. Epidurals are a THING, guys.

The development of the McGill’s Pain Score Questionnaire in the eighties lead to literature suggesting that the pain of childbirth is as painful as the amputation of a digit (5). Except, of course, that an amputation is a much quicker process than childbirth, especially in nulliparous women!

A 2002 systematic review by Hodnett suggests that pain does not form a significant part of a woman’s satisfaction with her childbirth experience (6). (I dare someone to make this statement in a room full of women who have delivered without analgesia.) Yet few studies in this review address the question of pain, and while it may be fair to identify factors contributing to satisfaction, these studies are not sufficient for excluding pain as a major contributor.

Also, since when is satisfaction the primary aim of medicine? I did not become a doctor simply to “satisfy”. I became a doctor to relieve suffering. In those moments, when a body writhes in pain. When a young nulliparous woman is too scared to push, for fear of the tearing pain of an infant’s head on her perineum.  Some nights on labour ward call, I hear women trying to swallow their pain, and I wish I could do something to ease it.

There is good evidence that higher degrees of pain lead to higher rates of caesarean sections (7), but whether epidural anaesthesia in labour leads to higher rates of c-sections is more contentious – books could probably be written about inconsistencies in studies and methods, and clinicians would still disagree on the nitty-gritty. Kinda similar to arguments about formula feeding

I have many dreams for my career in anaesthesia, but right now, one of my major dreams is helping to set up an epidural service for our hospital. Maybe, one day, even changing some views about analgesia in childbirth. If certain analgesic modes increase the risk of converting to c-sections – and if avoiding c-sections is the end-point – the answer certainly does not lie in throwing the metaphorical baby out with the bathwater!

  1. Practice Bulletin No. 177: Obstetric Analgesia and Anesthesia, Obstetrics & Gynecology: April 2017 – Volume 129 – Issue 4 – p e73-e89
    doi: 10.1097/AOG.0000000000002018
  2. Aziato L, Ohemeng HA, Omenyo CN. Experiences and perceptions of Ghanaian midwives on labour pain and religious beliefs and practices influencing their care of women in labour. Reprod Health. 2016 Nov 14;13(1):136. doi: 10.1186/s12978-016-0252-7. PMID: 27842544; PMCID: PMC5109714.
  3. https://www.wildmind.org/blogs/on-practice/the-strange-myopia-of-birth-is-suffering
  4. McCauley M, Actis Danna V, Mrema D, van den Broek N. “We know it’s labour pain, so we don’t do anything”: healthcare provider’s knowledge and attitudes regarding the provision of pain relief during labour and after childbirth. BMC Pregnancy Childbirth. 2018 Nov 14;18(1):444. doi: 10.1186/s12884-018-2076-7. PMID: 30428840; PMCID: PMC6236945.
  5. Niven C, Gijsbers K. A study of labour pain using the McGill Pain Questionnaire. Soc Sci Med. 1984;19(12):1347-51. doi: 10.1016/0277-9536(84)90023-6. PMID: 6531713.
  6. Hodnett ED. Pain and women’s satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol. 2002 May;186(5 Suppl Nature):S160-72. doi: 10.1067/mob.2002.121141. PMID: 12011880.
  7. Woo JH, Kim JH, Lee GY, Baik HJ, Kim YJ, Chung RK, Yun du G, Lim CH. The degree of labor pain at the time of epidural analgesia in nulliparous women influences the obstetric outcome. Korean J Anesthesiol. 2015 Jun;68(3):249-53. doi: 10.4097/kjae.2015.68.3.249. Epub 2015 May 28. PMID: 26045927; PMCID: PMC4452668.

1 Comment

  1. Nancy Ackelson says:

    YES. (and yet another thing I can’t believe we have still not figured out!) My best wishes for realizing your dream Mariechen.
    ~ Nancy ❤

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