I find pain fascinating*, especially after experiencing plenty of it in childbirth. It seems so basic a thing that it’s easy to assume modern medicine would have pain all figured out, but it really really doesn’t and not just because of a lack of basic biological knowledge (although that is a part of it). Everyone’s experience of pain is different so how can you impartially, scientifically, measure it? If you’ve been through childbirth could you accurately describe the pain? Could you compare the pain you experienced with that of another women? Probably not, psychology and circumstance are every bit as important as what is physically going on and what may be tolerable to one person may be unbearable agony to another and not through any particular weakness or wimpyness on their part.
So what is the best way to manage pain in labour? Given how long women have been doing the birth thing you’d think there would centuries worth of research, but there just isn’t. In fact no one even thought to try until a little over a hundred years ago, prior to that childbirth was just one of those curses that women must bear for Eve’s sin – if mothers are in pain, if some of them even die? Well too bad girls, should have stayed away from that apple!
Thankfully though we live in a slightly more enlightened age and some studies have been attempting to asses the effectiveness of various different types of pain relief. The Cochrane Library is an organisation that reviews publications on specific topics and by comparing the quality and results of all these papers, tries to give a review of what we know – and how reliably we know it. They recently published an overview of studies into pain management in labour. After looking at reviews of a total of 312 different trials they grouped pain relief methods into three sets:
Epidural, Entonox (gas and air)
What May Work:
Immersion in Water, Relaxation, Acupuncture, Massage, Local anaesthetic nerve blocks, Sedatives (non-opioid)
Hypnosis, Biofeedback, Sterile Water Injection, Aromatherapy, TENS, Opioid drugs (eg, pethadine)
So slap everyone on entonox and epidural and forget about the rest right? Of course, sadly, it’s not that simple. While there is a lot of evidence that the “what works” techniques are effective, they also tend to have a lot of side effects. Gas and air makes many people feel sick, epidurals increase the likelihood of needing an instrumental delivery etc. etc. There is less evidence in favour of the “may work” group, often only one or two small studies, but they tend to have few if any side effects. Some of the techniques in the “insufficient evidence” group are especially interesting. TENS is often recommended by midwives, but there is very little solid evidence for it’s effectiveness, opioid drugs get a bad press as there is a concern that (amoungst other things) they will reduce the likelihood of breast feeding, yet only two, of the 57 opioids studies reviewed, looked at breast feeding as an outcome.
So where does this leave us? Is the review all a bit pointless because it can’t tell us to pop everyone on an epidural and to avoid aromatherapy like a sweet smelling plague? I think it would be a shame if we gave in that easily. What this review highlights is that far more work is needed to determine how effective each option is, how likely and how severe side effects are and importantly how much someones individual personality and circumstances are likely to influence this effectiveness. I’ve said it before and I’ll say it again – pregnant women aren’t silly, hysterical creatures, if given the facts clearly, and early enough in the pregnancy that it’s not all a bit too immanent, then most will be able to make intelligent, rational decisions about what is best for them. Without this we will continue to have to put our faith in midwives, antenatal teachers and friends and family to advise us on this issue, and although these people may be well meaning, their own experiences will heavily influence their opinions of what works and what doesn’t.
Having had plenty of time to try out a few things I know that my own experience of various pain relief methods doesn’t exactly tally with this report. But I’m also aware that my state of mind influenced this. Things that worked brilliantly when I thought it was all going well, seemed utterly useless once I knew I was headed for theatre, in fact I think there is another whole blog post about the SouthwarkBelle guide to pain relief, but I may just have ranted enough for today…
*not in a creepy serial killer sort of a way, just to be clear.