Before you book an epidural …

© 2009 The Royal College of Midwives. Evidence Based Midwifery 7(3): 89-93
89Walsh D. (2009)

Pain and epidural use in normal childbirth.

Denis Walsh PhD, MA, RM, RGN.Associate professor of midwifery, University of Nottingham, Nottingham City Hospital, Postgraduate Centre, Hucknall Road, Nottingham NG5 1PB England. Email: denis.walsh@nottingham.ac.uk

This paper is based on the Zepherina Veitch Memorial lecture given at the RCM’s
annual event held in Belfast on 18 June 2009.

Abstract
With epidural rates doubling in the UK over the past 20 years, the impact on normal labour and birth is profound. Changes have also occurred in wider birthing milieu, such as the rise of a risk discourse, the diminishing of a ‘rites of passage’ meaning to birth, the growth of obstetric anaesthetic services and the advent of informed choice in maternity care policy. This paper discusses these issues and argues that inadequate service provision and an impoverished approach to labour pain rather than women’s preferences are contributing to the rise in epidurals. An elective epidural service in relation to low-risk women is challenged and a call made for an urgent debate on how maternity services and ultimately society should respond to these profound changes.

Key words
Epidural, Zepherina Veitch memorial lecture, normal birth, risk, pain, evidence-based midwifery

Introduction
This paper discusses rising epidural rates in low-risk labour in the UK, proffering some reasons for this trend. The side-effects of epidurals are detailed and, from this, the suggestion is made that epidural use is incompatible with normal labour. It then argues that inadequate service provision is the main contributor to the rise. Contrasting pain paradigms are then outlined, based on Leap’s (2000) and later Leap and Anderson’s (2008) seminal research and writing. Their approach of ‘working is pain’ is critically examined to see if it offers a way forward for the current debate around labour pain.An epidural epidemic?Epidural rates have doubled in the UK from 17% in 1989 to 33% in 2007/08 (BirthChoiceUK, 2009). Though the reasons for this have never been investigated, it is likely that some of the following play a part in this change:

• Elective epidural provision is now almost universally available in consultant maternity hospitals in the UK. A survey in 2006 found only four out of 196 consultant maternity units did not provide this option (Jones et al, 2008). Obstetric anaesthetists now have their own association and their numbers have grown substantially over the past 20 years (Wee et al, 2002)

• Epidural provision has been available in some UK maternity units for nearly 30 years and hence, crosses two generations of childbearing women. Anecdotally, midwives say the mothers of the childbearing women now more commonly recommend epidurals to their daughters than they did a generation ago

• Celebrity birth stories and media portrayals of childbirth often include epidurals

• Over recent decades, there has been a loss of ‘rites of passage’ meaning to childbirth, so that pain and stress are viewed negatively (Leap and Anderson, 2008)

• A technorationalist society considers pain as either preventable or treatable (Lauritzen and Sachs, 2001)

• The pain relief paradigm is dominant in maternity services (Leap and Anderson, 2008)

• The movement to institutional birth (93% hospital verses 7% home and birth centres) reinforces medical solutions to clinical symptoms, such as pain (Walsh, 2007)

• Fragmented models of care and loss of continuity contributes to greater use of pharmacological agents in labour (Hodnett et al, 2007)

• Informed choice as an ethical imperative influences practitioners’ responses to maternal requests for pain relief in labour (Walsh, 2007)

• The risk discourse predisposes to childbirth intervention including the use of pain-relieving agents (Walsh, 2007).

Several of these factors work in tandem. ‘Technorationalist society’ (Lauritzen and Sachs, 2001) is shorthand for a society that equates all scientific advances with progress. In relation to pain, technology and drugs have either prevented pain from emerging or treated it effectively when it does. It is counter-cultural in such a society to see a purpose to pain, especially physical pain related to biological function, which is how traditional and indigenous societies have probably viewed childbirth over thousands of years (Kitzinger, 2000). Childbirth within indigenous societies studied by Jordan (1993) was viewed as a ‘rite of passage’, an anthropological phrase referring to growth milestones. Rites of passage are associated with movement from one level of maturity and responsibility to another (van Gennep, 1966) – in the context of childbirth from woman to mother. It commonly involves passing through an experience of challenge and uncertainty known as a luminal phase before re-integrating into the new role. Allied to an antipathy to childbirth pain, is a risk discourse that carries within it several paradoxes. In the West, it has never been safer to have a baby if judged by maternal and perinatal mortality rates (Department of Health, 2007), yet it appears that many women have never been more frightened of the process. The relatively new diagnostic category of ‘tokophobia’ (morbid fear of labour) is testament to that (Hofberg and Brockington, 2000). Another paradox is a high degree of risk aversion, yet a willingness to embrace medical interventions like drugs and surgery that carry risks themselves. Risk aversion appears to operate quite selectively. Mixed messages co-exist like a public health message to avoid any form of drug pre-conceptually and prenatally, but accept an array of drugs during intrapartum care. Discussion about epidurals is often linked to the broader discussion of medicalisation of childbirth, because epidural typifies the ‘cascade of intervention dynamic’ that contributes to.

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