Access to Adequate Pain Relief is a Right– Prof. Senanayake
Childbirth is one of the major events in a woman’s life. According to official records, around 334,000 Sri Lankan mothers delivered children during 2019.
The overall emotional experience of labour is now considered one of the key determinants of the well-being of the mother during childbirth. Beyond medical interventions and monitoring, making the expectant mother feel safe and comfortable is understood as a requirement in this life-changing event.
Access to adequate pain relief and the presence of a companion of choice during labour is significant in this regard. We had the opportunity to discuss this issue with an internationally recognised expert and researcher in Obstetrics and Gynaecology, Prof. Hemantha Senanayake, Emeritus Professor of the University of Colombo, a former President of the Sri Lanka College of Obstetricians and Gynaecologists, as well as the Perinatal Society of Sri Lanka.
By Dr. Prasad Weerasinghe (MBBS, M.Sc.)
Labour pain is among the most severe pains ever evaluated. Experiencing such pain was accepted as a part of giving birth, or as a norm, previously. Today, pain relief during childbirth is a well-accepted phenomenon and practised all over the world. What are the significant benefits that we can achieve from adequate pain relief? Are there any harmful outcomes of inadequate pain relief during labour?
A: Yes, you are right. There's no doubt that labour pain is the worst pain a human can endure. It's likened to breaking many bones of the body at once, according to scientific publications. But when the mother sees her baby and forms that bond, she finds great relief in the reward she gets for going through that pain. Otherwise, we can't explain the state of overpopulation in the world.
Anybody who sees a woman go into labour knows that it is an ordeal. But the reward overrides the pain. However, in the short-term, during the day itself, inadequate pain relief will affect the mother's experience of labour. Furthermore, if a mother is shouting, getting agitated and becoming tense with the pain, then she will get exhausted.
It's like a marathon. People run marathons in two hours, but here this is something that is going on for 10 or 12 hours. So, it is best if the pain is managed well, or else the mother will get exhausted. When the mother gets tired, the uterus, which is a muscle, will also get tired, and this will prolong labour. It turns into an exhausting cycle that results in dehydration and electrolyte changes, and the mother becoming acidotic, and this will reflect in the baby.
When you say the baby is acidotic, it results in foetal distress and asphyxia. Therefore, managing labour pain has a lot of advantages, and it changes the mothers' experience of labour positively. Relieving labour pain makes childbirth a more human experience, rather than a dehumanising one.
Every mother has a right to have adequate pain relief during labour. Is this right being accepted at policy level in our country? If so, when did we achieve that landmark?
A: The Ministry of Health has informed service providers to ‘give pain relief during labour;’ but that statement alone cannot be treated as a landmark. Pain relief has been used at State hospitals before, but the issue is that the tendency to use it is minimal.
For example, in an ideal setting, pain relief should go right up to the availability of epidural anaesthesia. But epidurals are available only in a few State-run hospitals in the country, even with a significant number of anaesthetists and trainees in that field. Care providers do not see it as a right of a mother. I must emphasise this: every patient has an equal right to get the best possible care.
So if we have enough staff and are still unable to provide the best possible care – like an epidural where it’s needed – it is then substandard care. I will give you an example:it is accepted that induced labour is more painful than spontaneous labour. With induced labour, the delivery is prolonged and more painful. While Sri Lanka has one of the highest rates of induction of labour in the world, yet we are not providing adequate pain relief for these mothers. So, there are questions about the quality of our management of labour.
On top of that, we also have a high rate of caesarean sections. Many such cases are the result of the way foetal distress is diagnosed. It also has a connection with pain relief and the mother's mental and physical condition.
The worst aspect of this is that some care providers, particularly women, assume that the mother must feel the pain to appreciate motherhood. Now, this very old-fashioned biblical-style mindset that has passed down through generations and is still in operation. Sometimes hospital staffers also maintain this traditional mindset and tell mothers that it’s normal to experience such pain, and refuse to give epidurals. That is a problem we have in Sri Lanka.
As you mentioned,the Sri Lankan caesarean-section rate is reported to be high. It was 40.5 per cent in 2019. According to the WHO, when the caesarean-section rates go beyond 15 per cent, it doesn’t bring any additional benefit to the mother or the baby according to population-level data. Do you think giving adequate pain relief can reduce the number of elective caesarean-sections done due to mothers’ requests because of the fear of normal labour?
A: Yes, the fear of normal labour is one reason mothers opt for caesarean-section deliveries. However, reducing caesarean-section rates involves approaches from several levels. Just pain relief will not be enough. And we must improve care from various aspects.
For example, now one of the quality indicators is the number of women who are delivering in non-supine positions, which at least a semi-reclining position. Many mothers in Sri Lanka will deliver in the supine position or lying flat. This is considered the worst position to adopt in labour and delivery.
So reducing caesarean-section rates will involve measures such as improving the knowledge of our midwifery nurses, midwives, etc. They are doing deliveries, so they must be driven to different things, rather than sticking to an ancient recipe. Therefore, reducing caesarean-section rates will require a multifaceted, multipronged approach.
What is the role of keeping the mother well-informed and updated throughout the labour and reassuring the mother frequently regarding pain relief?
A: The process of reassuring the mother should begin long before labour begins; it must start in the antenatal period. Our mothers should be shown the labour rooms. There should be a visit there, so that the mothers have time to mentally prepare rather than coming there for the first time and experiencing something new and frightening.
As a result, many mothers think they are poorly treated during labour. There might also be some truth in that. For example,do we have a method to welcome and introduce the setting for a mother being admitted to the ward, which is a completely strange place for her?
Those are not big things. It's all about reducing the mother’s anxiety. You are asking specifically about pain relief. We need to tell the mothers that these methods are available to them– if you’re having pain and you can’t deal with it, tell us! A lot of the time, the mother shouts, because they are scared. They are afraid of the next thing because they think it could be worse, and then whether they receive enough attention; those factors are also there.
Are Sri Lankan mothers adequately informed about the availability and accessibility of labour pain relief options during ante-natal education?
A: I don't think it's done adequately; and I believe staff from the wards also must meet the mothers. That's why I see a visit to the ward where they are going to have the baby could be very useful in that ante-natal education process.
What is the importance of keeping a companion during labour regarding pain relief, and what are the other positive outcomes of a labour companion?
A: There is reliable scientific evidence supporting a labour companion. If you take a traditional approach to delivering a baby, other women typically from their social and family circle always supported women; but now that is no longer done, in the name of safety.
However, there's no basis for that. Scientific evidence shows that the presence of a labour companion makes the labour shorter, lowers the requirement of pain relief, makes the mother’s experience of labour better, increases the chances of normal delivery, lessens caesarean-sections, and lessens neonatal asphyxia.
There are massive benefits of this. This can be a realistic solution to the higher caesarean-section rates in the country. Keeping a companion also empowers the mother in a major way. There is somebody with the mother who is supporting her. And we’ve found in our experience, having pioneered this in Sri Lanka, is that women are treated better when they have a labour companion. They have less anxiety. And it's not about just reducing anxiety in the mind; it's about humanising the labour. I think we have a very long way to go in humanising this labour experience.
The labour companion is recognised as necessary at policy level and local clinical guidelines. You conducted a scientific study related to the implication of that policy at hospital level, which was published in an international journal (BMC) in 2011. So what did you find through that research?
A: As part of that study, we asked the responding obstetricians about their knowledge on the benefits of having a labour companion. We found that their knowledge was insufficient regarding the advantages of having a labour companion. However, those who knew the advantages showed a higher tendency to permit a companion.
This lack of knowledge will be further amplified among nurses and midwives. But I think that at policy level, the Ministry of Health should come out and say this is important and implement it. There’s also a circular encouraging such presence.
We find that sometimes these companions will be able to give clear fluids during labour, and avoiding dehydration is very important for good progress of labour. We find that sometimes they share their water with other women who don't have a companion. Those advantages are there. It's a very positive experience. All the feedback we get is positive.
One of the other things many people assume is that women do not really need a companion during labour, as there's nothing critical they need to do. However, they need to go and stand there and wait, so that the mother will be treated with dignity by the staff. We’ve heard of a lot of psychological and verbal abuse of labouring mothers. The studies are ongoing, but we do observe a lot of abuse.
What are the non-pharma -cological methods available for labour pain relief?
Number one is knowledge about the progress of labour and what to expect during delivery, as well as the knowledge about the availability of pain relief. Those are two essential factors. A mother without any knowledge, regarding what to expect and where she is delivering the baby, tends to develop a lot of anxiety. Non-pharmacological methods mainly deal with reducing that anxiety.
What are the main categories of medicine used for labour pain relief? Are there any limitations to using them?
A: Yes. Sometimes we prescribe Paracetamol in very early stages of labour. Many hospitals also now have a mixture of nitrous oxide and air (Entonox). Then we have opioid drugs, such as pethidine. The limitation is because of the tendency that the baby could be born asphyxiated if the birth takes place within three to four hours of its administration. But I believe people overplay this risk.
Of course, epidural anaesthesia is there; with this, the limitation is that there is a chance the mother might require a vacuum delivery or forceps delivery. But there is no increase in the caesarean-section rate. There is no change in progress. But with good management, mothers can have a normal delivery, because you allow a more extended period for the second stage when somebody is on epidural anaesthesia.
What is the current situation of the service availability of pain relief during labour at Government sector hospitals? Is it adequate?
A: It’s not adequate at all. Women are not asking for it, but we have sometimes seen the companions requesting it to be given. The mindset of staff needs to be changed to encourage giving pain relief. Also, the availability of epidural services is deficient in many places.
Can these kinds of quality improvements help bring the maternal mortality ratio further down?
A: That’s a difficult question to give an exact answer to. But there is no doubt that our labour-management should be improved. One of the things that increase the caesarean-section rate is the bad management of labour.
For example, when foetal distress is diagnosed based on the interpretation of the CTG reports, which is a graphical representation of foetal heartbeat and uterine muscle contractions. You need to look at it in so many ways. But often, these CTGs are interpreted by staff who have had no formal training in their interpretation. So maybe, we are over diagnosing foetal distress.
We have the average service providers interpreting a CTG and saying that this mother needs a caesarean-section. That is one of the things driving this. And then also say, for example, rather than getting every woman to lie down and wait during labour, keeping them ambulant (i.e. walking in early labour) or at least semi-recumbent or seated – those will change the situation. Improvement of labour care is required. We must strengthen our basics.