Moving Beyond the 0–10 Scale for Labor Pain Measurement :

Background Childbirth is one of the most painful events that a woman is likely to experience, the multi-dimensional aspect and intensity of which far exceeds disease conditions. A woman's lack of knowledge about the risks and benefits of the various methods of pain relief can heighten anxiety. Women are increasingly expected, and are expecting, to participate in decisions about their healthcare. Involvement should allow women to make better-informed decisions; the National Institute for Clinical Excellence has stated that we need effective ways of supporting pregnant women in making informed decisions during labour. Our aim was to systematically review the empirical literature on women's expectations and experiences of pain and pain relief during labour, as well as their involvement in the decision-making process. Methods A systematic review was conducted using the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Bath Information and Database Service (BIDS), Excerpta Medica Database Guide (EMBASE), Midwives Information and Resource (MIDIRS), Sociological Abstracts and PsychINFO. Studies that examined experience and expectations of pain, and its relief in labour, were appraised and the findings were integrated into a systematic review. Results Appraisal revealed four key themes: the level and type of pain, pain relief, involvement in decision-making and control. Studies predominantly showed that women underestimated the pain they would experience. Women may hope for a labour free of pain relief, but many found that they needed or benefited from it. There is a distinction between women's desire for a drug-free labour and the expectation that they may need some sort of pain relief. Inaccurate or unrealistic expectations about pain may mean that women are not prepared appropriately for labour. Many women acknowledged that they wanted to participate in decision-making, but the degree of involvement varied. Women expected to take control in labour in a number of ways, but their degree of reported control was less than hoped for. Conclusion Women may have ideal hopes of what they would like to happen with respect to pain relief, control and engagement in decision-making, but experience is often very different from expectations. Antenatal educators need to ensure that pregnant women are appropriately prepared for what might actually happen to limit this expectation-experience gap and potentially support greater satisfaction with labour.

Data on expectations and experiences of pain in labor are presented from a prospective study of over 700 women who gave birth in six maternity units in southeast England. Most women preferred to keep drug use to a minimum, even though they expected labor to be "quite" or "very" painful. The ideal of avoiding drugs was unrelated to education or social class. Women who preferred to avoid drugs were more likely to do so, and were more satisfied with the birth overall than women who used drugs. In general, women tended to get what they expected. Breathing and relaxation exercises were widely used, and were most successful for those who had expected them to be so. Anxiety about the pain of labor was a strong predictor of negative experiences during labor, lack of satisfaction with the birth, and poor emotional well-being postnatally.

The incidence of general anaesthesia (GA) has been used as a marker for the quality of obstetric anaesthesia care. Recent guidelines suggest the rate of GA for Caesarean section in parturients with pre-existing epidural analgesia for labour should be <3%. The primary purpose of this study is to determine whether or not this is an achievable standard in a university teaching hospital. We also wished to determine the factors influencing the incidence of inadequate anaesthesia. We studied a consecutive cohort of 501 patients who had a Caesarean section after epidural labour analgesia. The incidence of GA, the total incidence of failure, and the factors previously associated with failure were recorded. Factors shown to be significant with univariate analysis were used in a binary logistic regression to determine the independent risk factors for failure. Twenty-one of 501 parturients required GA (4.1%, 95% confidence interval 2.6-6.3%), not significantly different from 3% (P=0.1). Fifteen of 21 (71%) of these occurred intraoperatively. The total rate of failure was 30/501 (5.9%, 95% confidence interval 4.0-8.4%). Maternal height and the number of clinician top-ups in labour were the significant independent risk factors for failure. Intraoperative conversion to GA may increase both maternal and fetal risks. Strategies to reduce the incidence may include early recognition of inadequate labour analgesia and reliable assessment of adequacy of surgical anaesthesia.