Editor’s Choice

Pain in labour

The $64 000 question—why is human labour so painful? In 1993, Churchill Livingstone published a book called ‘Pain and its relief in Childbirth’ which I co-edited with Geoffrey Chamberlain and Ann Wright. It documented a country-wide survey by the National Birthday Trust of over 6000 women giving birth in UK in the last week of June 1990. The figures which stick in my mind are that despite the widespread availability of epidural anaesthesia (used by one in five women), only 6.5% of women said they had no, or only mild, pain, whereas 37.5% reported severe pain and fully 56% of women ticked the box describing the pain as ‘unbearable’. Perhaps labour pain is a signal for women to seek a safe place for delivery. It may be particularly severe in the human because the large fetal head (we have become brainier) has to pass through the relatively small pelvis, adapted to bipedalism. Pain normally serves to prevent us repeating an act which is damaging, but in the case of childbirth, the pain is so far removed from conception, and so many women have no choice on whether they become pregnant or not, that there can have been little or no selection pressure within our evolution to mitigate the suffering associated with parturition.

The National Birthday Trust was set up in the UK in the 1930s to campaign for safe and effective pain relief to be made available to women in labour. Although regional anaesthesia is very effective, its use requires a skilled anaesthetist to be available at all times and it has significant adverse effects. Accordingly, there continues to this day a search for alternative methods. A popular approach involves training in relaxation, pioneered in the UK by Grantley Dick-Read in his 1944 book Childbirth without Fear: The Principles and Practice of Natural Childbirth and in France by Fernand Lamaze in his 1956 book Painless Childbirth. Such techniques are often subsumed under the generic title ‘psychoprophylaxis’. But does it really help? All obstetricians will surely be familiar with the woman who seems calm and well prepared during pregnancy, but then ‘goes to pieces’ in labour, whereas some women who are very anxious antenatally cope remarkably well when it comes to the actual event. Is the reaction to labour mainly a matter of individual pain thresholds, or can training during the course of pregnancy make any difference? This is the question addressed in the Swedish prospective randomised controlled trial reported by Bergström and colleagues on page 1167. A total of 1087 first-time mothers and their partners took part in the study between January 2006 and May 2007. They were randomised into two groups to attend antenatal classes. The ‘natural’ group were taught psychoprophylaxis (relaxation, breathing and psychological coping techniques). The standard care group were provided with information about childbirth and parenting, modelled on the standard Swedish antenatal education programme. The epidural rate was 52% and the spontaneous vaginal birth rate 66% in both groups. The caesarean section rate was 20% in the ‘natural’ group and 21.5% in the standard group. The instrumental delivery rate was 14% in the ‘natural’ group and 12% in the standard group. There were no statistically significant differences between the groups in satisfaction with the childbirth experience or postnatal parental stress (measured at 3 months).

Why the lack of benefit? The antenatal classes comprised only four 2-hour sessions. Perhaps they were not long enough for women to learn the techniques thoroughly. Each group contained six couples, perhaps one-to-one training would have been more effective. However, psychoprophylactic training between sessions was encouraged, and a booklet to facilitate practice at home was given out. The jury is still out, but the onus is now on those who advocate the technique to substantiate it scientifically.

Some of us are old enough to remember when it was not unusual, if one suspected that pain and distress were largely psychological in origin, for patients to be told that they were being given injections of a pain relieving drug, when in fact the syringe contained only sterile water or saline. This would no longer be considered ethical, but it often worked well enough for many to wonder whether there was actually a physical benefit as well as a psychological one. On page 1158, Hutton and her colleagues have carried out a systematic review and meta-analysis of randomised controlled trials of the use of sterile water injections for back pain in labour. The technique was introduced into obstetrics in the 1970s, and involves injecting small amounts of sterile water either subcutaneously or intracutaneously at four points lateral to the lumbar spine. One hypothesised mode of action involves the gate theory of pain; producing cutaneous pain inhibits the activation of visceral pain fibres. Alternatively, it may cause the release of cerebral endorphins. Eight studies passed the authors’ quality check. They found a significant reduction in the pain score at all time points following the injections, up to 3 hours, and interestingly, they also found an approximate halving in the rates of caesarean section from 9.9% in the comparison group to 4.6% in the sterile water injection group, which was statistically significant. This may have occurred because the pain relief encouraged women to continue in labour when otherwise they would have requested a caesarean section. However, all studies combined involved fewer than a 1000 women, and larger randomised trials are needed before this technique can be recommended for widespread use.

Home birth again

Over the last year or so, we have published a series of papers on home birth which have aroused considerable controversy, and have been widely reported in the media. This month, we publish another. On page 1177, Ank de Jonge and colleagues report on their study of perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births in the Netherlands from January 2000 to December 2006. The proportion of babies who died or were admitted to a neonatal intensive care was the same in both home (n = 321 307) and hospital (n = 163 261) groups, seven per 1000. Allocation to home or hospital was not randomised, so even after excluding obvious risk factors, women who choose birth at home may differ systematically from women who choose hospital birth. Nonetheless, the figures are reassuring about the relative safety of home birth in a setting such as the Netherlands, where appropriate facilities are in place to support it. Some have questioned the relatively high overall perinatal mortality rate, which puts the Netherlands below the European average, and which is perhaps surprisingly high for a well educated and relatively affluent population. But even if hospital rates were halved, the home birth perinatal mortality rate is surely still low enough for women to make their own informed choices about their place of confinement. For a more detailed discussion, please see our invited commentary by van Weel et al on page 1149.

Obstetric fistula

And now from women who request a home birth to women who would have been only too grateful to have had the option of a caesarean section, to prevent that dreaded complication of prolonged obstructed labour, the vesico-vaginal (‘obstetric’) fistula. On page 1258, Nielsen and colleagues report on the follow-up of 38 women following fistula repair in rural western Ethiopia. The results are encouraging; 21 (57%) were completely dry. However, 13 (35%) still suffered from stress or urge incontinence, and three (8%) had a persistent fistula. Fortunately, those who were mostly dry (92%) achieved social reintegration comparable with that before their fistula. Tragically, reintegration was complete enough for some women to become pregnant again, and of these, one woman died, three had stillbirths, and one got her fistula back. On page 1265, Andrew Browning describes the outcome of 49 women who became pregnant following their fistula repair, this time in northern Ethiopia, and who delivered in the government hospital adjacent to the fistula unit. Five of these had a planned elective caesarean, and 41 had an emergency caesarean, one of which was associated with a stillbirth. Three had vaginal deliveries, two of these were preterm with death of the neonate. But generally, the outcome was good. During the same period, 24 women presented with a repeat fistula associated with childbirth following a successful repair, but not cared for during pregnancy at the unit adjacent to the fistula hospital. They had all had stillbirths, six had caesarean section following 1.5 to 3 days labour, and one had a caesarean hysterectomy after 2 days of labour. It is not known how many women had died or had not re-presented. Browning comments that ‘unsupervised delivery following obstetric fistula repair is hazardous at best’. His results show the importance of making caesarean section available in developing countries; papers in this journal have suggested that this is best carried out by training surgical technicians who become technically proficient, but are not exposed to the temptation to emigrate to developed countries to improve their income.

Female genital mutilation and childbirth

Another paper from the developing world? No, the paper by Wuest and colleagues on page 1204 is from Switzerland. As they say, ‘due to migration many women with FGM now reside in Western countries’, so it behoves all of us to know how to deal with women who have had this barbaric procedure. Luckily, the outcome in the majority of the 122 patients reported was good, although there was an increased risk of both caesarean section and third-degree tears. 76% of the women were satisfied with their care, but four were dissatisfied because their requests for re-infibulation were denied—it is illegal in most Western countries. In the United Kingdom, over 60 000 women have had FGM, and the London Metropolitan police have set up a special unit to investigate and prosecute those who carry it out. They offer a £20 000 reward for anyone who can give information leading to the conviction of perpetrators. For more information on FGM, see http://www.forwarduk.org.uk/key-issues/fgm.

Ovarian cancer – can we do better?

Surgery has sometimes been accused of being more of an art than a science—its dependence on the skill of individual practitioners has meant that practice has taken a long time to become standardised. However, attempts to introduce consistency have been assisted by the development of multidisciplinary team meetings, at which all members of the team can contribute to decision-making. The interpersonal dynamics of these are often complicated, but can be defused to some extent by using decision tree analysis which formalises the process of deciding on treatment. Warwick and colleagues demonstrate on page 1225 that at least ten individuals can come to a consensus when writing a paper on ‘alternative management strategies’. While the details of their conclusions will be mainly of interest to oncologists, their systematic approach to decision-making using algorithms to model the effect of different treatment strategies should be of interest to anyone involved in group decision-making.

How to do laparoscopic sacrocolpopexy

Recently in this journal, we have had articles, commentaries, and letters regarding the relative merits of case series and randomised trials in surgical practice. For logistical reasons, case series predominate, and we have another series on page 1251. This is a report of 22 laparoscopic sacrocolpopexies by North and colleagues. When reading about surgical techniques in the past, one would often struggle to understand exactly what had been performed, and people often made long journeys to visit surgical units ‘to see for themselves’. Fortunately, nowadays technology has come to the rescue. If you want to see how North and colleagues used mesh inserted via the laparoscope to reduce the recovery time associated with open sacrocolpopexy, then access their paper on the Wiley Interscience website, and watch their excellent video. Follow this link http://dx.doi.org/10.1111/j.1471-0528.2009.02116.x and click ‘Supporting Information’ to find the video.