By Pat Thomas
All women use pain relief in labour. Their methods can range from self-help techniques such as being upright, being mobile, water, yoga, meditations, music, massage, homeopathic remedies and various breathing techniques to less invasive (though often not very effective) paraphernalia such as the TENS machine. From a medical point of view, however, pain relief falls into two categories of drugs: analgesic and anaesthetic. In order to save women from the so called excruciating pain of labour, these drugs are pushed on nearly every labouring woman who walks through the door of the maternity ward.
When we decided to focus this journal on pain relief we realised we had a mammoth task ahead of us. This is why we chose in the end to focus on the most contentious forms of pain relief, the epidural and pethidine.
Among women the debate is hotting up. The word on television and in women’s magazines is that modern women do not need to suffer labour pains. We hear that labour and the pain associated with it has outlived its evolutionary usefulness. We have now reached a stage in the popular media, as well as in the hospital, where the caesarean operation under an epidural is being touted as a superior form of pain relief.
For many of us this is a worrying trend. The fact is that childbirth is painful. Pain is part of the process - so much so that some believe if you take away the pain you take away the experience as well. Certainly the pain of childbirth is one of the reasons why doctors believe it to be a pathological condition. Doctors see part of their duty as relieving human suffering and for someone with a broken arm or a brain tumour this interpretation may be correct. But the pain of childbirth is not pathological, it is purposeful. In normal, physiological labours it is rarely unmanageable or totally overwhelming provided the woman is upright, mobile and has all the support and encouragement it needs.
Because the pain of childbirth is a universal experience, we can assume that it is pain, not painlessness, which is normal. Since nature rarely does anything without a purpose it's worth asking what the purpose of pain in labour might be. The answer seems to be that it's physiological as well as psychological. Physiologically, women need to know when they are in labour. They need to know how far along they are and whether the birth of their baby is imminent. The different types and levels of pain which a woman feels at different stages of labour provide this information.
Psychologically, working with or submitting to the power of labour offers an opportunity for self-discovery which is unique to women. Those who have experienced labour without the usual pain relieving drugs may go through a powerful psychological transition which women who have chosen to eliminate the pain may not experience. In light of this, taking away the pain of childbirth, may significantly "diminish [its] quality and significance." 
Certainly there is no evidence that women's levels of satisfaction with birth are linked to the absence of pain. In fact, the group of women who are most likely to express dissatisfaction with birth are those who have had epidurals and had no sensation of pain at all. 
Levels of pain in labour are not predestined and they can change according to the kind of social support a mother has, whether she feels safe in her place of birth, her own level of fear about the birth process, what position her body is in, the way the baby is lying and what interventions, if any, she has had. What is more, in a normal labour the level of pain builds gradually allowing the mother time to physically and psychologically. But how many labours today are normal? Caregivers would do well to remember that choosing pain relief is not the same as being unable to refuse it if, for instance, the mother has been induced of rendered immobile by continuous EFM.
While there are many methods of natural pain relief available, for a mother in hospital whose labour is being medically directed, these are likely to be pretty ineffective thus adding to the myth that so-called natural pain relief doesn’t work. But when all is said and done, pain is usually the one thing (next to tearing or episiotomy) that women fear most. In response to women's confusion and fear there have been a number of different drugs - analgesics, tranquillisers and anaesthesia - concocted to relieve the pain of childbirth. Some are more effective than others, and ironically, the more effective the drug is at relieving the mother's pain, the greater number of adverse effects it has on her baby.
It seems to be part of the perverse nature of medicine that health practitioners see it as their duty to discourage mothers from smoking or drinking during pregnancy, then, when they go into labour, inject them with some of the most powerful drugs known to man. How can it be that drugs, when taken socially or for pleasure are 'proven' to have damaging side effects for mothers and babies, yet those which are administered for alleged medical purposes have none? This is, of course, is a fine example of medical propaganda. A drug, is a drug, is a drug, no matter if it is prescribed in a hospital or bought on a street corner, and all drugs produce side effects.
When using drugs in labour it is important to be able to assess the extent to which the cervix has dilated. If the cervix is nearly fully dilated, between 7- 10cms, it may be better to avoid some forms of pain relief which can slow down the second stage of labour and cause the baby's condition to deteriorate. Used early on in labour many of the drugs used for pain relief have had time to be cleared out of the mother's and the baby’s system. When drugs are used during the later stages of labour there is a greater risk that they will remain in the baby's bloodstream after birth and take longer to clear. The baby's fragile system then has to cope with the extra burden of adjusting to life outside the womb as well as trying to detoxify itself.
Women also have the right to know about any side effects which pain relieving drugs may have for them or their baby. Unfortunately some doctors and midwives are terribly misinformed about the efficacy or side effects of most of the drugs which they use routinely and this ignorance gets passed onto mothers. The most common misconception is that pain relieving drugs, especially the epidural, do not cross the placenta. ALL drugs cross the placenta, though some appear to do less damage than others. What a mother puts into her body she puts into her baby's body as well.
Often, when considering the use of pain relieving drugs, we tend to focus on the immediate future both in terms of benefit and side effects. However, studies of the long term effects on babies whose mothers used drugs during labour make disturbing reading. These show a link between drug use in labour and drug addiction in later life.  This is due to what is known as 'imprinting' - a specific memory engraved during a short sensitive period - in this case, the crucial hours of labour - leading to specific behaviours in adult life. While addiction itself is not the result of imprinting, the tendency to use and abuse drugs is thought to be.
Labour involves a certain amount of stress for both mother and baby. If during this important time drugs which relieve that stress enter the baby's bloodstream, the baby has received an imprinted message that this is the appropriate response to stress. The greater availability and socially acceptable nature of drugs today means that more and more young adults may respond to this unconscious imprint later in life.
This was good quality research, yet when proponents of normal birth bring it up in debate, they are accused of scare mongering and "worrying" mothers unnecessarily. Apparently it is better if the mothers have the worry (of a sickly, addicted youngster) when they are long discharged from the maternity ward and no longer the responsibility of the medical staff. If this piece of research is really of no consequence, then why are our doctors and Department of Health (and even the media) so afraid to follow it up? Could it be linked to a nagging fear that follow-up might just tell us something we don’t want to know?
When exploring the issue of pain women should be encouraged to look at the pain of labour as part of the totality of pain they experience during pregnancy labour and beyond. How they cope and are supported through morning sickness and leg cramps is relevant to how they will perceive their ability to cope with the greater pain of labour. Women also need to look at labour pains in relation to their perceptions of themselves, their life experience and their bodies. By isolating labour pains, we cut women off from their ability to understand and cope with the major life transition.
In the last issue of the AIMS Journal Beverley Beech wrote a spirited criticism of the way that the magazine Bella treated the subject of caesarean section. Some readers applauded it, some did not. Some doubted that the media perception of birth was relevant. Yet there is evidence to show that women rarely receive all the information about birth which they require from their care providers.  Instead they receive much of their information about birth options from the media. 
But what I found most interesting in this survey was the great difference between the younger women in the survey and the older ones. Women under 25 were twice as likely to believe that caesareans on demand were a good thing (66% compared to 30 per cent). This is highly significant and relevant to the choice of pain relief. A younger woman may be less at ease with her body. She may more susceptible to the idea that when something goes "wrong" (and labour pains are seen as very "wrong") it is her fault. Younger women may be all too ready to accept the idea of their bodies as the enemy. Extreme pain relief saves this kind of women from failure and vanquishes the enemy of pain.
This is really the heart of the matter and something which everyone concerned with maternity care should take on board. When women despise their bodies they don’t think and they don’t care. They don’t care whether they starve themselves to death. They don’t care about the possible toxic side effects of the toiletries and cosmetics they use. They don’t care if male fashion designers set trends with clothes that degrade and insult them. They don’t care whether somebody cuts them open for no good reason.
Such a woman may even choose extreme forms of pain relief in the name of female power and choice. In a maternity service which encourages disempowerment among a culture of women who are already at rock bottom, the "choice" of an epidural or a caesarean may seem like a way of re-establishing some kind of power base. But how powerful might these women feel if they knew they were being referred to as the "section in room one" instead of "that jolly smart woman who exercised her right to choose" or if they heard the midwife approve of the choice of an epidural by saying "thank God for that, now we can get some peace."
In talking about pain relief, we need also to take a wider view of the generation we are now talking to. This is the ER generation. Emergencies are sexy and with any luck the registrar will look like George Clooney. Young women today like to think they have progressed so far beyond those "other women" of twenty years (or more) ago. I suppose if you count as progression moving from the brown-haired, blue-eyed Dr Kildaire who made the science of medicine so sexy to the dark hair and dark eyes of Clooney (and co) who make drugs (and blood and guts and shattering personal/professional relationships) so sexy, this is true.
But drugs, wherever they are taken, are not sexy. They are destructive, suppressive and damaging unless used with extreme caution and consciousness. And how many hospitals can genuinely say that they use, or encourage women to use, these powerful drugs in such a responsible manner?
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