The Case for Choice in Labor Pain Management

by Melissa Garvey, ACNM Writer and Editor

Early this year, ACNM released a new Position Statement on the use of nitrous oxide for managing labor pain. Unless you are a midwife or other clinician, it can be hard to understand why nitrous oxide and the ACNM Position Statement is such an exciting topic. I just finished combing through a thorough, informative post at Science and Sensibility that helped me realize why—as a 29-year-old woman hoping to someday experience pregnancy and birth on my own terms—my enthusiasm has piqued. Nitrous oxide has the potential to expand access to choice related to one of the most sensitive issues around birth—pain management.

As certified nurse-midwife Judith Rooks so aptly articulates in the Science and Sensibility post, “Every woman and labor is unique. There is no single best method of labor analgesia. Every method has advantages and disadvantages, and different women value different things.” Just as women need options in where and with whom to give birth, women need to be able to choose which methods of pain control best match with their beliefs, experiences, health status, and stage of labor.

I won’t even try to rival Judith Rooks’ overview of what nitrous oxide is, how it is used, and how it works. Instead, I leave you with four ways nitrous oxide has the potential to expand access to choice.

1. More Options for Pain Management in Homes and Birth centers. While midwives can help women manage the pain of labor through a variety of options like massage, emotional support, and water immersion, many women find it comforting to know that their midwife can order pain medication if they end up needing it. In homes and birth centers, that drug could be nitrous oxide rather than an epidural, which is only available in hospitals.
2. More Options for Pain Management in Hospitals. If a woman decides that she wants an epidural, she has to wait until labor is well established and for the anesthetist or nurse anesthetist to administer the epidural. That same woman can use nitrous oxide to take the edge off the pain while she waits to be able to have an epidural. Depending on her response to nitrous oxide, she may even decide she does not need the epidural.
3. Freedom to Move. If delivered through portable equipment, nitrous oxide can be used without sacrificing movement during labor. Women can still change positions, walk, go to the bathroom, or soak in a tub.
4. Freedom to Change Your Mind. If a woman decides that she does not like how nitrous oxide makes her feel or decides she no longer needs it, her body will be completely free of it in less than five minutes from the time she stops inhaling it.
   

According to Judith, only two hospitals in the US currently offer nitrous oxide for labor pain management. Most birth sites in the US do not offer the drug largely due to lack of equipment and manageable concerns over the risk of nitrous oxide to health care workers. The new ACNM Position Statement addresses some of the concerns related to nitrous oxide, and a new company is preparing to make the equipment. Let’s hope this is the start of a growing wave of support for more choice in how laboring women cope with pain.

Denis Walsh, mommy wars, and coming together On Common Ground

Originally published on Science and Sensibility by Amy Romano, CNM, for Lamaze International

Last week, I was thrilled and humbled to be asked to contribute to the On Common Ground collection at RH Reality Check. My assignment was to write a piece from the maternity care perspective that represents common ground for people on opposing sides of the abortion debate. I was asked to help readers who cannot agree even on the basic precepts of an issue discover concerns and beliefs held in common. I hope I succeeded. But I may have stepped from one divisive debate right into another. In my article, Improving Maternity Care: A Mother and Child Reunion, I discuss how what happens in birth can affect a woman’s transition to motherhood, and even her biological bond with her baby. Sound familiar? This is a bit like what midwife and researcher Denis Walsh is reported to have said in a recent article. The article, published in the Daily Mail’s Online Edition, ignited a storm of attacks against Dr. Walsh, who is a man, for allegedly saying that epidurals can complicate maternal-infant attachment and breastfeeding. A look at the hundreds of comments on the feminist site Jezebel will give you a sense of how unpopular his remarks are.

Whether Denis Walsh said what was reported or not (there’s a good chance he didn’t), this isn’t the first time any of us have heard the claim – and even the science behind the claim – that epidurals disrupt the biological processes of maternal-infant attachment and breastfeeding. These claims are made about cesareans, too. But clearly, even the most eloquent and informed among us (for example, Denis Walsh) are unable to talk about these effects in language that resonates with the majority of women.

Is there a better way we can talk about the impact of maternity care practices on mother-infant attachment? I think so.

In my article at On Common Ground, I discuss the beneficial effects on maternal-infant attachment of two practices: continuous support in labor and skin-to-skin contact between mothers and newborns after birth. I give an example from a randomized controlled trial comparing women who had continuous support from friends or family members trained as “lay doulas” with other women who labored without such support. I also discussed the findings of a Cochrane systematic review of studies of skin-to-skin contact. In both cases, beneficial effects included easier transitions to motherhood and improved maternal-infant attachment.

These are practices we can offer women whether or not they have epidurals, and regardless of how they give birth. More importantly, they improve mother-infant attachment whether or not women have epidurals and regardless of how they give birth.

In the doula study, postpartum effects were profound. Women who had continuous support were more likely to describe their babies as “very easy” and to believe that their babies cried less often than other babies. They were more likely to pick up their babies when they cried and to report that they were able to sense their babies’ needs “very well.” Regarding their own postpartum experience, they were more likely to say that the transition to motherhood had been “very easy” and to report that they had received support from others in the previous week. Women assigned to the doula group also scored more favorably on measures of self-worth including sense of self as a woman, sense of their bodies’ physical strength, and ability to be a good mother. Do you want to know what did not differ? The rates of epidural use (85% doula group vs. 88% no doula group) and cesarean surgery (19% doula group vs. 18% no doula group).

The systematic review of skin-to-skin contact included mostly studies of vaginal births in women without epidurals, but one study included in the review looked only at women who had scheduled repeat cesareans under spinal anesthesia. This study in fact yielded some of the most impressive differences in maternal-infant attachment behaviors of all of the studies included in the review. Some of the differences in maternal attachment behaviors persisted an entire month after giving birth.

I believe that mothers and babies experience physiological and emotional benefits when the woman has an unmedicated vaginal birth. But in our culture, women are not given a fair shake to achieve unmedicated vaginal births, and are fed messages that they shouldn’t care how they give birth as long as there’s a healthy baby. Even when care is top-notch, some women will still need epidurals or cesareans. Do we really want to tell these women that they might not be able to parent effectively?

The Healthy Birth Practices that Lamaze International has been championing for years allow us to have our cake and eat it too. Taken together as a package of care, they decrease the need for cesarean surgery and pharmacologic pain management. As we have seen in the two examples here (which represent two of the six Healthy Birth Practices), they may also mitigate or even overcome the effects of epidurals and cesareans on maternal-infant attachment. How’s that for a win-win?

We need to find common ground with women when it comes to talking about birth and bonding. Focusing on outcomes, which can result from choices, circumstances, or system effects, dooms us to alienate some women and ultimately fail to reach them with information that matters. Let’s instead advocate for better, safer care in labor – The Healthy Birth Practices – and fight to make sure no woman is denied access.