The Nature and Management of Labor Pain: What is the Evidence?

Labor pain and how to deal with it have been investigated and debated for decades. It is a topic where maternity and anesthesiology professionals are often on opposite sides of the fence. Thus, the invitational meeting jointly sponsored by two venerable and prestigious organizations, the Maternity Center Association and the New York Academy of Medicine, and held in New York City on May 4 and 5, anticipated some understandable tension and disagreement as well as agreement among the meeting participants. Without a doubt, those maternity health practitioners, anesthesiologists, researchers, health workers, and educators who were fortunate enough to attend “The Nature and Management of Labor Pain: An Evidence-Based Symposium,” received a rare learning experience. Not only did they hear ten presentations of outstanding quality, but they also shared in a multidisciplinary endeavor that opened fresh dialog and presented up-to-the-minute evidence with the potential to influence future practice and research. The Symposium, planned by a multidisciplinary steering committee, endeavored to use the evidence-based framework to seek the truth about labor pain and its management by presenting papers from health professionals in obstetrics, anesthesiology, epidemiology, midwifery, nursing, childbirth education, and health policy. Specifically, the Symposium objectives were to identify actions that could be taken now, based on the best current available information, to do the following: • Make accurate information about labor pain and methods to relieve it available and easily accessible to the relevant clinical and other health professionals. • Make accurate, meaningful information on these subjects available and easily accessible to child-bearing women and the general public. • Improve women's access to a choice of reasonably safe and effective pharmacological and non-pharmacological methods for pain relief during labor. • Assure that women receive full information on all methods of labor pain relief that are available in their place of birth and have the freedom to choose which of these methods they will use. • Identify important gaps in the knowledge base, and develop and address research priorities. Of the ten papers, seven were systematic reviews, and all underwent a rigorous referee process before the meeting. The first paper, “The Nature of Labor Pain,” by Nancy Lowe, CNM, PhD, was followed by four papers on various aspects of epidural analgesia, including mode of action, efficacy, safety, and effects, which were presented by Donald Caton, MD, with co-authors Michael Froelich, MD, and Tammy Y. Euliano, MD; Ellice Lieberman, MD, DrPH, with co-author Carol O'Donoghue, MPH, MSN: Barbara Leighton, MD, with co-author Stephen Halpern, MD; and Linda Mayberry, PhD, RN, with co-authors Donna Clemmens, PhD, RN, and Anindya De, PhD. The second group of papers included presentations on parenteral opioids by Leanne Bricker, MB BCh, MRCOG, with co-author Tina Lavender, PhD, MSc, PGDip, RN, RM; nitrous oxide by Mark Rosen, MD; selected nonpharmacological methods (intradermal water blocks, touch and massage, immersion in water, maternal movement and positioning, continuous labor support) for labor pain relief by Penny Simkin, PT, with co-author MaryAnn O'Hara, MD, MPH; pain and women's satisfaction by Ellen Hodnett, RN, PhD; and patterns and choice issues in labor pain management by Theodore Marmor, PhD, with co-author David Krol, MD. Critique panels of invited experts from various health disciplines provided additional insights and explored the presentations, the first panel on the unintended effects of epidurals and the second on implications for core practice-oriented disciplines. The sessions for audience discussion were, not surprisingly, extremely vigorous and provided lots of strong opinions, lively interaction, and additional valuable information on new research in pain management. The ten symposium papers, with additional and updated information and data, are expected to be published together as a supplement of the American Journal of Obstetrics and Gynecology early in 2002. Thus, the latest knowledge and evidence on labor pain and its management will be made available as quickly as possible to a wide audience. As noted earlier, labor pain management is an area that engenders disagreement and diverse and strong feelings among health professionals, and it did so at this meeting, especially on the topic of epidural analgesia. Disagreement occurs in other countries also, as can be noted from the column by Sheila Kitzinger, in her Letter from Europe in this issue of Birth. She reports that the Royal College of Anaesthetists in Great Britain recently conducted a debate about pain in childbirth, and asked her to represent women who declined medication for pain relief (as did Cherie Blair, wife of the Prime Minister, for the recent birth of her baby). Ms. Kitzinger was asked to speak against the motion, “That natural childbirth is inappropriate in a modern world,” and to present “the Cherie Blair point of view.” Nevertheless, at the same time during the New York Symposium, agreement could be found on many issues, both in interpreting the evidence and in recommending some constructive clinical steps forward. Although all sides did not agree on the best, safest, and most efficacious methods of pain relief, and some anesthesiologists remained unconvinced by the presentation on nonpharmacological techniques, by the end of the two-day meeting, participants agreed in a general way that women should be allowed to make informed choices for their pain relief based on the evidence and after being advised of risks and benefits. Some discussants pointed out that a major shortcoming of this otherwise highly successful and comprehensive Symposium was the absence of a focus on, and paper devoted to, the effects of pain and pain management on the fetus and newborn. Although the evidence in the literature is sparse, attention was drawn to two Swedish papers that were recently published in Birth (1, 2). Participants showed particular interest in the paper by Dr. Marc Rosen on “Nitrous Oxide for Relief of Labor Pain: A Systematic Review.” Although commonly used combined with 50 percent oxygen under the trade name Entonox in England and other countries, nitrous oxide is seldom used in the United States, yet the evidence shows that it is an effective and safe inhalation analgesia in labor, with a low incidence of side effects. Its “advantages are that the mother can remain awake and in control of the analgesia; that neither uterine activity nor ‘bearing down' during the second stage is affected” (3, p 328). The Symposium sponsors, the Maternity Center Association and the New York Academy of Medicine, and Symposium Project Director Judith Rooks deserve the highest praise for their vision in organizing such a timely, important, and potentially far-reaching project. Maternity health professionals and anesthesiology professionals were brought together in an environment to listen and learn, and to examine and explore the available evidence about pain relief in labor. It was also extremely fitting that a highlight of the meeting was the presentation of the Carola Warburg Rothschild Award to Sir Iain Chalmers, Professor Emeritus Murray Enkin, and Professor Marc Keirse in celebration of their humanitarian and scientific endeavors in advancing research and care in pregnancy and childbirth. Indeed, no one mentions evidence-based care in this field without thinking of these three scholars and their pioneering work on the systematic reviews of randomized controlled trials of care (3, 4). That this Symposium in New York was “evidence-based” was all the more important because, as I noted in my introduction of Chalmers, Enkin, and Keirse at the Symposium award ceremony, “knowledge about, and indeed application of, the systematic reviews, the Cochrane Library, and evidence-based care, although recognized and accepted in Canada and on the other side of the Atlantic, has been slow to enter mainstream obstetrics in the United States.” Reactions after the Symposium were rapid. Several participants told me that they were going back to their communities with new enthusiasm and ideas for research and practice. Some participants from Lamaze International who attended remained for two more days to hold a strategic planning session. Coming away from the Symposium, they were struck by the reality that whereas most women will be readily given an epidural on request and have that choice reinforced, those who prefer and ask for physiological pain-relief measures, on the other hand, often receive different and less positive feedback from caregivers and institutions. These women's voices are too often not heard, their choice not supported, and the nonpharmacological measures not available. Lamaze International plans to give its organization a renewed focus and emphasis on women's choices for nonpharmacological pain-relief methods, reflected in their new motto, “Voices and Choices in Birth.” Other participants also felt a sense of discouragement after the meeting. One family physician noted that too many practitioners accept the epidural “as a substitute for care.” He went on to say that “Birth has become an anesthetic event. Epidurals are used as second best when proper support is unavailable. We accept second best!” The papers from this Symposium, researched and written under such a rigorous scientific and evidence-based framework, will surely provide a solid basis on which maternity health professionals and institutions can explore and launch new ways to support women in labor and birth. The Maternity Center Association and New York Academy of Medicine have opened the door to the next initiatives for women's labor pain management and care.

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