In this interview with SADE OGUNTOLA, an obstetric anaesthetist and a lecturer with the University of Ibadan’s College of Medicine, Dr Kehinde Adebayo, claims every woman can have a nearly painless labour.
Can labour be pain-free?
Yes. The assumption is that to go through labour and to be a true mother, you must go through pain but that is not necessarily true. Pain relief in labour is achievable, and its whole aim is to ensure that labour is as pain-free as possible.
So, how do you know they are in pain?
There are different methods of scoring pain. So usually we tell women in labour to grade the severity of their pain from, say 1 to 10. The assessment is not static. It can be 2 over 10 when labour starts, and it can get to 10 over 10 in between labour and that very severe pain can be terrible.
Generally, labour pain is one of the worst possible pains a human being can go through. I think it’s only second to tooth pain/kidney stones worldwide. Sometimes it can be killing. Because of the severity of this pain, it affects the mother and the unborn child in how well they cope during or immediately after labour.
How does labour pain affect the unborn baby and the mother?
A pain in the mother that is not treated leads to hypo- and sometimes hyperventilation, which in turn worsens ventilation and leads to exhaustion. Exhaustion reduces the oxygen flow to the baby, and this could affect the immediate post-delivery status of the baby, causing insufficient oxygen transfer to the baby while the labour is still going on. Moreover, because of the normal physiological responses to trying to prevent pain, sometimes it affects even the respiration of the mother. But the most important thing is that unrelieved pain is a bad thing in labour.
What exactly can medicine do to relieve the pain?
I always say that anaesthetists are the people God sent to take away the curse placed in the Garden of Eden that Eve would have pain in labour. God has given us the knowledge to take away pain. We have both pharmacological and non-pharmacological methods. We can treat it using drugs either by directly passing the drugs into the veins or by applying the drug to the exact point where the pain is originating from. The pain of labour, like pain in most parts of our body, gets its sensation from the spinal cord. So, when we do regional anaesthesia, we numb that area temporarily so that labour can progress without affecting the process of the delivery. But pharmacologically, we can also give drugs through the vein that goes around the pregnant woman’s body to relieve their pain. Diversionary techniques like acupuncture and exercises are things that have been described as being used to relieve pain in labour.
Can you elaborate on these alternative methods for managing pain?
The gold standard for managing labour pain is regional anaesthesia; that is the best option because you’re targeting the source of the pain without affecting any other part of the body. So it could be by combined spinal epidural and epidural analgesia. That’s the gold standard. However, this is only carried out by obstetric anaesthetists; they are trained in doing it. Of course, the use of drugs can be done by many anaesthetists to lower the pain perception generally. Enough must be used to cater to pain relief without it crossing the placenta to the baby. If too much is given, the baby still in the womb ends up sharing in the pain drug. But of course, it’s an effective way too of taking care of labour.
When we were growing up, people, even our mothers, used different diversionary techniques, like “Go and be swimming,” “Go and be dancing,” and “Be blowing into a bottle.” These techniques, in a way, also help divert the attention of the woman in labour from feeling pain. However, they are much less effective than the regional technique and the pharmacological techniques.
Also, the Asian communities have tried to use acupuncture, the application of pins to different parts of the body to treat pain in labour. But that is not very common amongst us here. And it is not as effective as the regional technique of relieving pain in labour.
Of course, different pain relief methods can be combined in labour, but the truth is that pain relief is individualized. What will work for Mrs. A is not the same for Mrs. B. Even in the same woman, it’s not a one-size-fits-all. What had worked with a past pregnancy may be different. from what will be needed in another pregnancy. That is why the expert, the obstetric anaesthetist, in collaboration with the pregnant woman, must discuss and decide what will be the best pain relief method to adopt for each labour.
Are there any risks or side effects associated with pain medications during labour? People talk about, “I had an epidural, and now I have issues with my limbs,” and so on.
For everything you do in life, there are consequences or there are side effects. Not necessarily adverse effects. There is an emphasis on those words. A side effect is what you do not plan the agent to do for you that it does for you, whereas an adverse effect is a negative effect. I mentioned briefly the other time that if you are using a pharmacological method and you are giving into the vein, you have to be careful not to allow the drug to cross the placenta or use drugs that can have much negative effect on the baby. That is why regional anaesthesia is the gold standard, because it spares a lot of trouble, and the side effects are almost zero.
And for things like “I had an epidural, and now I have issues with my limbs, or I think I have pain in my back or knee,” a lot of that is just myths. They are not real. The example I give people is, if I operate on you today and you develop malaria tomorrow, the impression of the patient is that the surgery has caused malaria. Meanwhile, medically speaking, surgery cannot cause malaria. So, a lot of people after undergoing a particular procedure assumes that the procedure is the cause of another thing. But when it comes to regional anaesthesia, it is safe, and it has almost no negative side effects on the patient and the baby. So, yes, we can have pain relief in labour without any adverse effects. And a lot of people have been having it.
How effective, therefore, are relaxation techniques in reducing labour pain?
The relaxation technique is more like a diversionary technique. Sit in a bathtub; sit in warm water. Some people say go to the swimming pool. Some people say to watch TV. But I’ll give an example of a patient I’ve had to monitor her labour before I came into anaesthesia. She had some religious verses to read, and she was told to sit in a particular position. So, when the labour started at 2 to 4 cm., it was working. When we got to 6 cm., she had dropped the verses in her hand. By the time we got to 8 cm., she had changed her sitting position, standing and rolling on the floor and going around the room. So, these techniques work for some people, but they are not foolproof. They are not as effective in addressing it. So, yes, relaxation techniques, especially when they are combined with other things, would work. But, again, when we are practising medicine, we must contextualise it. What is practicable here? However, as a sole method of pain relief in labour, the relaxation technique is not effective.
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How do breathing exercises taught during antenatal care and mindfulness help a woman cope with labour pains?
Breathing exercise is a way to relieve a lot of tension. One of the ways to take care of anger is to take a deep breath. So it is assumed that if you can control your breath, you may be able to control pain. And that was extrapolated into labour. Yes, so they tell women in labour to “breathe with their mouth” and “not to push.” But if you are going through pain, you will know that if anybody is telling you not to shout, or not to scream, or to just breathe, you know that the person is not being fair. Labour pain for a lot of women can be that terrible. Breathing exercises, yes, when the pain is mild. But when the real pain sets in, no woman breathes to relieve labour pain. You see them; they are panting.
And again, if you have ever gone to a labour ward because they are told to open their mouth wide to breathe, they get a dry mouth, they are thirsty, and they are famished. Somebody is telling them to keep breathing with their mouth without any other intervention. So yes, diversionary is fine, but its effectiveness is limited.
What role, therefore, does a birth plan play in achieving a pain-free childbirth?
A birth plan is what you draw up with your obstetrician and your obstetric anaesthetist. There should be a point during the antenatal visit to discuss the birth plan. What am I doing? Am I going to be induced for this labour? If I fall into labour, am I going to have any form of pain relief in labour? So the plan is drawn, and it is very crucial. It is you who envisions what is to come, you plan for all eventualities, and you go into it prepared. But in this part of the world, we don’t plan for anything.
Women in Northern Nigeria, when in labour, hardly seem to make any noise. Do they need pain relief as well?
We also have the Hebrew women in the Bible who also do not express pain in any way. But that is a matter of psychological training. You see, it’s like one being in denial. For example, it used to be the teaching that men don’t cry and it is unmanly to speak out. But we saw what it led men to, including depression and suicide. Again, this group of women has been told it is taboo to cry, shout, or make noise for pain in labour. That is their belief. But I’m telling you that it’s just playing on the psyche, and it works for a group of people, but it is deleterious to another group of people.
Can having a caesarean delivery be an option for a pain-free delivery, as some women say?
A caesarean delivery can be pain-free and serve as an alternative, but is it cost-effective? There are clear-cut indications for surgery, and pain is not one of them. In many cases, exhaustion due to untreated pain may be a reason some women ask to have a caesarean delivery. However, it is not a strict indication of wanting to have a caesarean delivery.
What is your advise on pain-free labour?
The best way to improve the birthing experience in Nigeria, and especially to be pain-free, is education and awareness. We need people to know that services for pain-free labour exist; it is not taboo to be treated for pain in labour, and it does not affect the outcome of the delivery negatively. Also, it doesn’t go against any cultural or religious belief. Every woman can have an almost painless labour experience.
