Pain and anaesthesia in childbirth

1. Pain and anaesthesia in childbirth How have attitudes and practice changed with medical innovations in the past 400 years? Emma Derby 91020267 MHL SSU March 2013

2. Introduction The process of labour and child birth is commonly thought to be one of the most painful experiences that a woman will endure. Over the last 400 years the development of anaesthesia has changed,our attitudes towards this pain,and how it is managed. This resource will look at medical advances in anaesthesia, and how these brought about a change in attitude towards women in childbirth. Figure 1: A foetus in the 9th month of pregnancy prior to the start of labour.1

3. Figure 2: Book cover for Francis Mauriceau’s book on obstetrics written in 1685.2 1600 AD Attitude to Pain: In the 1600’s people believed that women should endure the pain of childbirth because it was a punishment given by God. “Most people believe that there is no other reason for the cause of this Evil, but because God hath so ordained it, and that woman, according to his word, must bring forth with pain because of her Sin, according to what is written in the third chapter of Genesis”2 Management of Pain: As pain was believed to be a punishment from God, it was considered a sin to escape this. There were also no effective methods of pain relief available at the time. “Since a woman, for this cause, cannot expect to shun these pains, she must endeavour to endure them with patience” 2

4. 1846 AD The first operation was performed in America using Ether as an anaesthetic.3 1847 AD Chloroform was discovered, and found to be more effective than Ether.3 Figure 3: administration of chloroform5 Anaesthetic was used for the first time in labour on Fanny Appleton Longfellow in America. Afterwards she wrote, “I feel proud to be the pioneer to less suffering for poor, weak womankind. This is certainly the greatest blessing of this age.”4

5. 1850 AD Attitude to Pain: By second half of the 19th century attitudes towards women had started to change. The pain of childbirth was no longer viewed as something women must endure. “I am satisfied that no one sanae mentis now believes that it is more sinful to escape the pains of child-birth by means of chloroform, than to escape from toothache by extraction of the offending member”6 Management of Pain: There was an initial reluctance to give women anaesthesia in labour for fear of their safety as well as a belief it was unnecessary. Figure 4: Portrait of Queen Victoria9 “In most instances of natural labour chloroform contributes to the patient’s comfort, but not at all to her safety.”7 However after it was administered to Queen Victoria in 1853, it gradually became more popular and more publicised. Women in the general public began to demand anaesthesia in normal labour.8

6. 1900 AD The next major development in anaesthesia came at the start of the 20th Century with the discovery of ‘twilight sleep’. The drugs used made patients pain free and forget the experience of labour.By the 1930’s almost all women received these drugs in labour.8 As with chloroform, doctors were concerned about safety. The drugs were later shown to harm the baby by crossing the placenta and eventually they stopped being used.8 1940 AD In 1945 the first epidural needle was developed, which led to the use of epidural anaesthesia in labour.3 Around the same time the ‘natural childbirth’ movement began to gain prestige, which advocated education instead of drugs to relieve pain. “The best and safest anaesthetic in an educated and controlled mind”10

7. 2000 AD Attitude to Pain Today it is considered that women have a fundamental right to chose how they give birth, including their choice of pain relief. “If you want pain relief, and you are giving birth in an environment where such relief is available, you have the right to make the choice to receive it.”11 Management of pain Today there are lots of different methods used to relieve pain in labour. Some of these are natural methods such as education or complementary therapy. Others are more medical such as Gas and Air, morphine based injections or an epidural.12 In the UK women create a birthing plan so that they can think about what they want in advance.12

8. Conclusion 1600 Pain is punishment from God. Women must endure it. Over the past 400 years there have been huge changes in our attitudes and management of pain in labour. In the 17th century attitudes reflected the religious views held by society. After the discovery of anaesthesia in the 19th century pain relief started to be used in labour, and religious opposition gradually reduced. By the early 20th century almost all women were given pain relief in labour despite concerns over the safety of it. Today pain relief is down to the choice of the woman, and this choice should be respected by doctors and midwives. 1850 It is no longer sinful to avoid pain. Women can be given chloroform. 1900 Pain relief is given to almost every woman in labour 2000 Pain relief in labour is the choice of the woman.

9. References • Smellie W. A sett of anatomical tables, with explanations, and an abridgment, of the practice of midwifery: with a view to illustrate a treatise on that subject, and collection of cases. 1754. Image taken from: Plymouth Medical History Society Collection, Discover Library, Derriford Hospital. • Mauriceau F, Chamberlen H. The diseases of women with child and in child-bed : as also the best means of helping them in natural and unnatural labors. With fit remedies for the several indispositions of new-born babes. Illustrated with divers fair figures, newly and correctly engravings. 1683. • History of Anaesthesia Society. Anaesthesia Timeline. Available at: http://www.histansoc.org.uk/timeline.html [accessed 22/03/13] • Edward Wagenknecht. Mrs Longfellow: Selected Letters and Journals of Fanny Appleton Longfellow. 1956. Longmans, Green and Co: Toronto. • Image taken from: http://commons.wikimedia.org/wiki/File:Clover_with_his_chloroform_apparatus_1862.jpg [accessed 22/03/13] • p657. Provincial medical and surgical journal 10. 1848. • McClintock AH, Smellie W. Smellie's treatise on the theory and practice of midwifery : vol. III. 1878. • Image taken from: http://commons.wikimedia.org/wiki/File:Queen_Victoria,_1847.jpg [accessed 22/03/13] • Chesnut DH. Obstetric Anesthesia: Principles and Practice. 2004. Elsevier Mosby: USA • Dick-Read G. Chilbirth without fear. 1949. Heineman Medical Books:London. • 11. Human Rights in Childbirth. What are the human rights in childbirth? 2012. Available at: http://www.humanrightsinchildbirth.com/human-rights [accessed 22/03/13] • 12.NHS. Pain Relief in labour. 2013. Available at: http://www.nhs.uk/conditions/pregnancy-and-baby/pages/pain-relief-labour.aspx [22/03/13]