Pain relief in labour: a qualitative study to determine how to support women to make decisions about pain relief in labour.

BACKGROUND: Engagement in decision making is a key priority of modern healthcare. Women are encouraged to make decisions about pain relief in labour in the ante-natal period based upon their expectations of what labour pain will be like. Many women find this planning difficult. The aim of this qualitative study was to explore how women can be better supported in preparing for, and making, decisions during pregnancy and labour regarding pain management. METHODS: Semi-structured interviews were conducted with 13 primiparous and 10 multiparous women at 36 weeks of pregnancy and again within six weeks postnatally. Data collection and analysis occurred concurrently to identify key themes. RESULTS: Three main themes emerged from the data. Firstly, during pregnancy women expressed a degree of uncertainty about the level of pain they would experience in labour and the effect of different methods of pain relief. Secondly, women reflected on how decisions had been made regarding pain management in labour and the degree to which they had felt comfortable making these decisions. Finally, women discussed their perceived levels of control, both desired and experienced, over both their bodies and the decisions they were making. CONCLUSION: This study suggests that the current approach of antenatal preparation in the NHS, of asking women to make decisions antenatally for pain relief in labour, needs reviewing. It would be more beneficial to concentrate efforts on better informing women and on engaging them in discussions around their values, expectations and preferences and how these affect each specific choice rather than expecting them to make to make firm decisions in advance of such an unpredictable event as labour.

More in hope than expectation: a systematic review of women's expectations and experience of pain relief in labour.

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.

Trends in the cause of late fetal death, 1982-2000.

BACKGROUND: Progress in reducing late fetal deaths has slowed in recent years, despite changes in intrapartum and antepartum care. OBJECTIVES: To describe recent trends in cause-specific fetal death rates. DESIGN: Retrospective cohort study. SETTING: North of England. POPULATION/SAMPLE: 3,386 late fetal deaths (> or = 28 weeks of gestation and at least 500 g), occuring between 1982 and 2000. METHODS: Data on deaths were obtained from the Northern Perinatal Mortality Survey. Data on live births were obtained from national birth registration statistics. Rate ratios (RR) and 95% confidence intervals (CI) for fetal deaths in 1991-2000 compared with 1982-1990 were calculated. MAIN OUTCOME MEASURES: Cause-specific late fetal death rates per 10,000 total births. RESULTS: Mortality in singletons declined from 51.5 per 10,000 births in 1982-1990 to 42.0 in 1991-2000 (RR 0.82, 95% CI 0.76-0.87). There was a greater decline in multiples, from 197.9 to 128.0 per 10,000 (RR 0.65, 95% CI 0.51-0.83). In singletons, the largest reductions occurred in intrapartum-related deaths, and deaths due to congenital anomalies, antepartum haemorrhage and pre-eclampsia. There was little change in the rate of unexplained antepartum death occurring at term (RR 0.97, 95% CI 0.84-1.11) or preterm (RR 0.94, 95% CI 0.82-1.07), these accounting for about half of all late fetal deaths. Unexplained antepartum deaths declined in multiple births and in singletons of birthweight < 1500 g. CONCLUSIONS: While late fetal mortality due to many specific causes has declined, unexplained antepartum death rates have remained largely unchanged. Improved identification of deaths due to growth restriction and infection, which may otherwise be classified as unexplained, is important. Further investigation of the underlying aetiologies of genuinely unexplained deaths is needed.

Multiple neonatal deaths due to a homoplasmic mitochondrial DNA mutation.

Mutations of mitochondrial DNA (mtDNA) are an important cause of genetic disease. We describe a family with an unusual homoplasmic mutation that resulted in six neonatal deaths and one surviving child with Leigh syndrome. The mother is clinically normal, but a severe biochemical and molecular genetic defect was present in both a fatally affected child and the mother. This family highlights the role of homoplasmic mt-tRNA mutations in genetic disease.