ArticlePDF Available


Background. Increasing intervention in birth continues to be a cause for concern and epidural analgesia is an ever more common intervention. A major influence on rising intervention rates is the complex relationship society has with technology. Influenced by various political and cultural narratives, there has been a tendency to view technological advance as both neutral and superior in the human quest for progress. Aim. In this paper, the authors trace the dialectical relationship between culture and technology in order to investigate the way epidural analgesia is portrayed in the biomedical literature. Method. A purposeful literature search was conducted, with databases including CINAHL, MEDLINE, Scopus, Google Scholar, Academic Search Premier and thesis repositories. Relevant literature was identified and analysed using the analytic framework of critical discourse analysis and drawing on critical medical anthropology and Foucault's discourse analysis. Findings. The biomedical literature on epidural analgesia concerned itself with particular outcomes, such as increases in CS and instrumental birth rates, and yet maintained its narrative of epidural as 'safe and effective'. Implications. By exposing the contextual nature of knowledge, another standpoint is offered from which evidence and practice can be reviewed. This critical literature review provides an alternate reading of epidural text and challenges some of the assumptions made about epidural analgesia, and the practices that stem from these beliefs.
Please cite this as Newnham E, McKellar L & Pincombe, J 2016, A critical literature review of epidural
analgesia. Evidence Based Midwifery, 14 (1): 22-28.
Background: Increasing intervention in birth continues to be a cause for concern and epidural
analgesia is an increasingly common intervention in childbirth. A major influence on rising
intervention rates is the complex relationship society has with technology. Influenced by various
political and cultural narratives, there has been a tendency to view technological advance as both
neutral and superior in the human quest for progress.
Aim: In this paper, we trace the dialectical relationship between culture and technology in order to
investigate the way epidural analgesia is portrayed in the biomedical literature.
Method: Relevant literature was identified and analysed using the analytic framework of Critical
Discourse Analysis (CDA), and drawing on Critical Medical Anthropology (CMA) and Foucault’s
discourse analysis.
Findings: The biomedical literature on epidural analgesia concerned itself with particular outcomes,
such as increases in caesarean section and instrumental birth rates, and yet maintained its narrative
of epidural as a ‘safe and effective’ analgesic option.
Implications: By exposing the contextual nature of knowledge, we offer another standpoint from
which evidence and practice can be reviewed. In this critical literature review we provide an
alternate reading of epidural text and challenge some of the assumptions made about epidural
analgesia, and the practices that stem from these beliefs.
Key words: Childbirth, epidural analgesia, evidence based practice, technology, Foucault, Critical
Medical Anthroplogy; discourse analysis.
The epidural is considered a ‘routine’ analgesic choice for healthy women in labour, and its use is
increasing, both in Australia, and other high-income nations (Walsh, 2009; Lain, et al., 2008). In
Australia in 2012, 32.5% of women in labour used regional analgesia for labour pain, of which the
majority was epidural or caudal (30.5%) (Hilder et al., 2014). While epidural analgesia has substantial
analgesic properties, it is also associated with increased risk of adverse outcomes. Significantly, the
use of epidural analgesia during birth transfers a labouring women out of the category of ‘normal’
labour and increases her risk of intervention (Walsh, 2009; WHO, 1996).
In this paper we undertake a critical review of the epidural literature as it related to the doctoral
research of one of the authors (EN). The research, an ethnography that examined influences on
women in their decision to use epidural analgesia, used Critical Medical Anthropology as the primary
theoretical framework and also drew on Foucauldian and Feminist theory. These theories encourage
examination and critique of the power relationships that serve to normalise particular behaviours,
through which medicine is identified as a dominant discourse (see Newnham, 2014). Foucault’s
description of dominant discourses (what Foucault termed ‘power/knowledge’) includes formations
of practice that, given particular social and historical ‘conditions of existence’ come to define what is
known and accepted, and therefore what is played out in the social world. Discourses shape social
understanding and practice by imposing boundaries on what can be articulated and by whom, by
deciding which knowledge is to be kept and which excluded, and by circulating certain statements
and censoring others (Foucault, 1991).
Notions of context and contingency, central to the Foucauldian argument, are also present in critical
theory, and are drawn on here in the examination of the ubiquity and the claim to authority of the
medical model of birth. This critical review of the medical research into epidural analgesia highlights
the contradictions and distinctions of current ideas, delineating the way that epidural is constituted
as a safe intervention in the biomedical discourse. Fundamental to the location of frameworks of
power in critical research is the reflexive positioning of the researcher (Singer and Baer, 1995;
Thomas, 1993). We were expressly looking for other ways to think about epidural use to add to the
‘epidural evidence’ of biomedicine. The declaration of the epistemological position held by the
researcher works in two ways; first, by being honest in the declaration, potential bias is laid open to
discussion and critique. Second, the researcher then seeks to examine the data in a way that is
framed by their position, but not held to it. There is an intellectual promise that by revealing their
position, in being epistemologically transparent, that the data is not plied to say one thing or
Literature relating to epidural analgesia, labour and childbirth, technology and relevant critical
theory were accessed from databases including CINAHL, Medline, Scopus, Google Scholar, Academic
Search Premier and thesis repositories. Reference lists of relevant books, theses and articles were
read and further literature identified. The critical literature review presented here forms the first
part of a broader critical discourse analysis of epidural analgesia, using of Fairclough’s (1995) critical
discourse analysis (CDA) methodology. In keeping with Foucauldian ideas of ‘power/knowledge’,
CDA accepts that ‘hegemony is constituted in the discursive practices of institutions’ (Fairclough
1995, p. 91). Outlining his theory of 3-dimensional CDA, Fairclough identifies the importance of
linking the macro-discourse of state and policy to the discursive practices identified at the micro-
level through the use of three levels of analysis: wider social understanding, the properties of the
texts themselves, and how the texts are produced and consumed (Fairclough 1995). Working with
these three levels of discourse, the first levelthe broader medical and social understandings of
epiduralis unpacked in this critical literature review. This provides the background for the two
remaining levels of 3-dimensional CDA. The discursive properties of the texts themselves were
explored in an analysis of the language of risk and safety within hospital and policy documents (see
Newnham et al., 2015). The third levelthe production and consumption of text and the effect of
discourse on individual experienceis where discourse intersects with the lives of women, including
the information they receive and the choices they are able to make. According to Fairclough (1995,
p. 88) the inclusion of all three aspects of discourse are necessary for comprehensive analysis.
Without the broader context (in this case, medical constitution of epidural knowledge), the micro-
experience cannot be made sense of, or is perhaps left unquestioned.
From this perspective we first examine the influence of the ‘evidence-based medicine’ discourse and
how it affects the way in which particular knowledge is produced. We then examine the significant
epidural literature in the medical field, specifically primary research and systematic reviews.
Employing the chosen theory, a critical ‘reading’ of this literature is provided, identifying the role of
technological rationalism and the impact of these dominant discourses on epidural and birth
Questioning epidural analgesia
From an anaesthetic risk perspective, improvements in drug dosage and administration have made
epidurals relatively safe and they are particularly useful in situations where caesarean section is
necessary, enabling women to remain conscious and decreasing risks for both mothers and babies
by avoiding general anaesthetic. Yet intervention in labour, including the use of epidural, can
dramatically change the birth outcome for otherwise low-risk women (Tracy et al., 2007). Despite
this, biomedical research on epidural use in labour perpetuates a discourse of the ‘safety’ of the
epidural, even while examining its negative consequences. This perpetuation of epidural safety in
medical discourse, despite its effect on birth outcomes, calls for a closer investigation of epidural
knowledge and practice. The prominence of medically-focused research perpetuates one particular
kind of knowledge about epidural analgesia, resulting in the acceptance of this technology as a
‘common sense’ option in Western birth culture (see Wendland, 2007; Downe and McCourt, 2008).
As a result, other options for birth are marginalised by their absence in the literature, and the
resulting lack of alternatives. While judicious use of epidural analgesia may be beneficial in particular
situations, its use as a common analgesic option therefore requires closer examination.
Evidence based medicine: biomedicine as a dominant discourse
One of the main claims by biomedicine over other knowledge disciplines is its claim to unbiased
truth and rationality. Although useful in providing measurable evidence, the claim by science to lack
of bias is contested, as scientific knowledge is embedded within a historical context influenced by
economic and social structures. Evidence-based medicine (EBM), with the randomised-controlled
trial (RCT)the gold standard of scientific medicineat its pinnacle, is problematic because
although evidence-based principles have their place, and have been particularly useful in removing
questionable practices in midwifery and obstetrics, they also pose a potential dilemma (Johnson,
1997, Walsh, 2012). Privileging the RCT over other research methods can flaw trial design by
prompting researchers to fit research projects into an RCT design, also affecting the kinds of
questions being researched (Keirse, 2002; Kotaska, 2004; Steen and Kingdon, 2008). Murphy-Lawless
(1998, p. 14) expresses this dilemma as ‘what is measured is often meaningless, but without
measurement there is no science’. Insofar as they mediate which questions are being asked, the
RCTand other scientific methodsare biased in that they derive from a worldview that privileges
one kind of knowledge over other forms (see Roome et al., 2015).
Given this, much mainstream researchwith its assumptions about knowledge, empiricism and
medical authorityserves to embed particular worldviews, for example, of women’s bodies as
uncertain, of technology as safe, or of the doctor as rescuer. With these ideas promulgated in the
collective understanding comes a concomitant normalisation of the safety of intervention.
Conversely, normal physiology, labelled as unpredictable, becomes risky. As these ideas become
entrenched into practice, they circulate the power/knowledge of medical birth discourse (see
Newnham et al., 2015; Foucault, 1980), to which we now turn in the context of epidural research.
Epidural analgesia: exploring the evidence
The physiological problems associated with epidural use in labour which can lead to birth
intervention include: altered uterine activity (either increased or decreased); labour dystocia
thought to be due to relaxation of pelvic floor and malrotation of the foetal presenting part; slower
dilatation of the cervix; decreased oxytocin release by the pituitary gland and subsequent need for
oxytocin augmentation; and decreased maternal bearing down efforts due to motor block (Finster
and Santos, 1998; Gaiser, 2005; Jain et al., 2003).
However, research into epidural use has been conflicting, with early research showing high rates of
instrumental and caesarean birth rates associated with epidural use. One extensive review of
epidural research identified how the relationship between epidurals and caesarean section found in
previous decades has since been attributed to the denser motor block of those early epidurals
(Gaiser, 2005). Research looking at the effects of newer, low-dose epidurals has found a strong
causal relationship between epidural and instrumental deliveries, and motor weakness remains
considerable even with low-dose techniques (Jain et al., 2003). Additionally, studies are still
identifying a relationship between epidural analgesia and caesarean section (Kotaska et al., 2006,
Ros et al., 2007, Tracy et al., 2007). However, as no causal link has been isolated, it is possible that
epidural use and caesarean section are outcomes from an as yet unknown common cause. One of
the difficulties with epidural research is distinguishing the reverse causality between the need for
epidural and the presence of a pre-existing labour dystocia (Gaiser, 2005). The most recent Cochrane
systematic review, which compared epidural to non-epidural or no analgesia in labour, noted the
conflicting findings of previous research about whether or not epidural analgesia increased the risk
of caesarean section, and concluded that while epidural use does not increase the overall risk of
caesarean section, it does increase the risk of instrumental birth (Anim-Somuah et al., 2011).
Identification of any causal relationship is challenging because epidural analgesia is not a sole
intervention, but brings with it numerous other interventions, such as intravenous fluid
administration, electronic foetal monitoring (EFM) and labour augmentation, making it difficult to
extrapolate any particular influence. For instance, two studies looking at the difference in birth
outcomes when inserting epidural analgesia early or late in labour showed no difference in
instrumental delivery rates. What they did identify was a positive correlation between intravenous
oxytocin and the caesarean section rate (Chestnut et al., in Finster and Santos, 1998; see also Wang
et al., 2009). If epidural analgesia necessitates exogenous oxytocin use, and oxytocin use increases
the risk of caesarean section, then epidural analgesia is going to influence, if not directly cause this
outcome. Similarly, EFM has been shown to increase caesarean section rates (Alfirevic et al., 2013;
Devane et al., 2012). Also confounding attempts at correctly ascertaining the effects of epidural
analgesia have been ‘natural experiment’ studies whereby changes in policy or accessibility that
either increase or reduce epidural rates have not resulted in a corresponding relationship in
numbers of instrumental birth (Gaiser, 2005). Thus, Gaiser (2005, p. 13) stated that with the new
research demonstrating the effectiveness (or at least diminishing the connection between epidural
and caesarean section) of new epidural techniques, obstetricians declared that epidural analgesia
should be accessible to all women unless medically contraindicated.
Despite this optimism, more recent studies are again confounding the existing evidence. The
Comparative Obstetric Mobile Epidural Trial (COMET) (Cooper et al., 2010) compared two types of
low-dose with traditional (high-dose) epidural. A no-epidural comparison control group was
matched for mode of delivery. The authors stated ‘[t]he mode of delivery and numbers recruited to
each group illustrate the previously reported findings of an increase in spontaneous vaginal delivery
with both mobile techniques and the expected higher number of spontaneous vaginal deliveries and
fewer operative deliveries, especially by caesarean section, in the comparison group’ (Cooper et al.,
2010, p. 32, emphasis added). So, while some researchers are declaring an impasse in relation to
epidural research and a green light for routine epidural use, these authors were expecting higher
rates of instrumental and caesarean delivery in their epidural groups. The figures demonstrate this
with the spontaneous vaginal birth (SVB) rate in the no-epidural group (approximately 75%) double
that of the SVB rate in the high-dose epidural group (approximately 35%) and still much higher than
in both of the low-dose groups (both approximately 43%). Conversely, all three epidural groups had
rates of caesarean section nearing 30%, while the no-epidural group had a 9% caesarean section
rate. Instrumental births were around 40% in the high-dose group, 30% in the low-dose groups and
15% in the no-epidural group. An Australian population-based descriptive study also showed a
threefold increase in caesarean section rates with epidural alone, as well as when used in
combination with oxytocin (Tracy et al., 2007). The US survey Listening to Mothers found that of 750
first time mothers with term pregnancies, 47% were induced, and
of those having an induction, 78% had an epidural, and of mothers who had both attempted
induction and an epidural, the unplanned caesarean rate was 31%. Those who experienced either
labor induction or an epidural, but not both, had caesarean rates of 19% to 20%. For those first-time
mothers who neither experienced attempted induction nor epidural, the unplanned caesarean
section rate was 5% (Declercq et al., 2013, p. 24).
While again, one cannot infer causality in this study, these practices contribute to the ‘cascade of
intervention’ that can lead to caesarean section.
A small number of studies call for caution with regard to epidural analgesia, and suggest solutions
such as restricting its use (Hemminki and Gissler, 1996), the need for further research (Nystedt et al.,
2004), and the provision of comprehensive informed consent about the risks (Kotaska et al., 2006). It
is concerning that there is only minimal reference in the literature to the fact that maternal oxytocin
production is inhibited by epidural use (Gaiser, 2005; Rahm et al., 2002). As well as contributing to
the need for exogenous oxytocin, reduced endogenous oxytocin may be the causative factor in
reduced breast-seeking behaviour in the newborn and reduced breastfeeding rates in women who
have had an epidural (Wiklund et al., 2009) and, theoretically, could also affect the woman’s
experience of maternal bonding. Although the reduced effects of endogenous oxytocin with epidural
analgesia, as well as the detrimental effects of exogenous oxytocin are now recognised, there is a
lack of robust research in this area (Buckley, 2015; Foureur, 2008; Uvnäs Moberg, 2003).
Although there were efforts to decrease problems associated with epidural use such as: ceasing the
epidural when the woman is 8cms dilated; decreasing the amount of local anaesthetic used in order
to decrease motor block, while still maintaining sensory block; allowing a longer second stage for
women using epidural analgesia; and waiting for descent of the presenting part before commencing
active pushing (Finster and Santos, 1998, Gaiser, 2005), the early findings of increased caesarean
section and instrumental birth rates did not lead to a concerted effort by the medical community to
avoid epidural analgesia altogether. The increasing popularity of epidural analgesia despite
unfavourable research results can be explained in part by the continuing discourse of ‘safe and
efficacious pain relief’ (Drysdale and Muir, 2002, p. 99). Clearly the high caesarean section and
instrumental birth rates were cause for concern. Yet, rather than discontinuing epidural use (as
happened so rapidly, for example, with the discontinuation of vaginal breech birth after the Term
breech trial (Downe and McCourt, 2008; Steen and Kingdon, 2008), research simply continued on
and on for some decades. Not simply because epidural is an effective analgesic agent, but, I propose,
because epidural use, instrumental birth and caesarean section fit within a medical discourse that
favours control, technology, and intervention (see Walsh, 2009).
Moreover, it appears that the consequences of epidural analgesia were also ignored because they
affected women’s experience, rather than measurable medical outcomes. Therefore, while
instrumental delivery appears as a consequence of epidural analgesia in the biomedical literature,
the consequences of instrumental birth for women, and their future health and wellbeing are not
discussed (for an example of this see Sharma et al., 2004). With the exception of one study (Cooper
et al., 2010), which looks at satisfaction rates, instrumental birth as an outcome is largely dismissed,
and there is a tacit assumption that increased obstetric intervention is an acceptable risk factor.
However, for women, instrumental birth may not be an acceptable risk factor. Both instrumental
birth and coached pushing, rates of which are increased with epidural analgesia, increase the
likelihood of third and fourth degree tears. The sequelae of this severe perineal trauma can include
pain, fear of birth, incontinence, sexual dysfunction, post-traumatic stress disorder and depression
(Creedy, 1999; Hayman, 2005; Rådestad et al., 2008). These outcomes, and their corollaries, indicate
that instrumental birth rates need to be a serious consideration in the epidural analgesia debate.
Essentially, after forty years of medical research into the risks of epidural analgesia there are still no
definitive findings about its effect on childbirth (Toledo et al., 2009, Gaiser, 2005, Jain et al., 2003),
although it is likely that it does increase instrumental birth rates (Anim-Somuah et al., 2011). The
only outcome that is clearly upheld throughout current research is that despite the still unproven
effects of epidural analgesia on labour, it provides the most effective analgesia (Cooper et al., 2010,
Wang et al., 2009, Jain et al., 2003). A discussion of the safety and effectiveness of epidural analgesia
prefaces the majority of the research articles and epidural analgesia is cited as the ‘gold standard for
analgesia in labour’ (see Amedee Peret, 2013; Norman, 2002: 28). This emphasis on the relief of pain
at any cost is indicative of what is important to biomedical culture, which both influences and
reflects wider cultural norms.
A critical reading of the evidence
The influence of the ideology of technology becomes most clear when medicine is on the
scene…things that can be quantified are made real; those that cannot be quantified come to seem
unreal. Infection rates are an observable measure for childbirth; joy is not (Rothman, 1989, p. 86).
Biomedicine continues to implement practices based on technology and intervention by upholding a
fairly circumscribed research agenda. In disseminating particular kinds of data in specific ways there
are things that are not identified, that are left silent. These include maternal subjectivity,
consequences for the mother-newborn dyad, and long term health outcomes (Wendland, 2007). In
effect, by their lack of representation in the data, biomedical research reproduces underlying
Western cultural values by minimising the importance of women’s experiences and implementing
simplistic, mechanistic answers to complex problems. An example of this is Ramin and colleagues’
(1995, p. 788) comment that ‘pain relief during labour is of paramount importance, and in most
circumstances the two-to four-fold increased risk of caesarean delivery associated with epidural
analgesia is a secondary consideration’. This illustrates the medical perspective of the ‘abnormality’
of labour pain and the priority to alleviate it, and normalises technological intervention such as
caesarean section, while ignoring its significant risks. It also focuses on the pain of the physiological
event, while ignoring the pain caused by the intervention. It is unlikely that caesarean section is a
secondary consideration for women. Pain in labour is complex and when women have been asked,
labour pain (and its relief) is not necessarily ‘of paramount importance’ (Karlsdottir et al., 2014, Leap
and Anderson, 2008), so from many women’s perspective the opposite is the case. In rejecting
women’s experiences as important data, research in this field can fail to include interventions that
seem insignificant to medicine, but may be highly significant to women (Baker et al., 2005).
Comparative to biomedical research, there are fewer studies concerned with women’s experiences
of birth, although research of this nature is increasing. Not discounting the importance of medical
research, comparing the two does generate a clear picture of what is seen as important (see also
Van der Gucht and Lewis, 2015), and this appears to be the advancement of technology and
medicine, rather than the experience of women and protecting birth from unnecessary technological
intervention. Indeed, evidence that supports non-technological practices is not easily implemented,
while technologically-focused evidence is often taken up instantaneously (Romano and Lothian,
2008). What this shows is that although ‘evidence-based’ medicine can have a positive impact, it is
not paragon of unbiased universal answers, but is subject to, and replicates, powerful social
discourses, such as scientific and technological rationalism.
Rationalising technology
There is a common point of view that holds technology to be politically neutral, ahistorical, and
autonomous, with little human control or direction, except in the luck or genius of those who can
discover its secrets (Hill, 1988). Termed ‘technological determinism’, this viewpoint has been
criticised for failing to acknowledge the social, historical and economic influences on the
construction of scientific knowledge. Critics of the technological determinist position call for scrutiny
of the underlying assumptions of technology use. Some decades ago, Marcuse (1972, p. 22)
observed that
in the contemporary period, the technological controls appear to be the very embodiment of Reason
for the benefit of all social groups and intereststo such an extent that all contradiction seems
irrational and all counteraction impossible.
Technological determinism depends on the perpetuation of ideas that suggest all progress is the
‘embodiment of Reason’, a position of techno-rationalism. Progress is positioned as a moral good
within society. Arguments that critique progress are therefore defined, by their juxtaposition to the
‘rationality’ of advancement, as unreasonable and irrational (Blackwell and Seabrook, 1993). This
argument is reflected in the ‘pain relief as progress’ theme in the epidural literature. Crowhurst and
Plaat (2000, p. 164), for example, comment that labour analgesia is a part of the modern Western
lifestyle, along with ‘air travel, the mobile phone and the personal computer’, implyingas they
quote the biblethat any other choice is irrational and archaic. They state:
the greatest advances in analgesia and anesthesia for labor and childbirth in the 20th century have
been (1) the discovery and development of today’s safe and efficacious analgesic techniques; (2) the
social acceptance that it is unnecessary for parturients “to bring forth children in pain and sorrow”
(Crowhurst and Plaat, 2000, p, 164).
Of course the reverse side of this argument is that anyone who wants to argue the merits of pain
are, by default, relegated to a regressive paradigm of anti-progress and dark ages mentality. The
implicit assumption of the ‘pain relief as progress’ theme is that not wanting to relieve the pain of
childbirth must therefore be absurd. Choosing pain appears to be an irrational choice in this context.
However, as Leap and Anderson (2008) suggest, there are positive and purposeful aspects to labour
pain: it summons support, heightens joy, reinforces triumph, and triggers neurohormonal cascades.
Pain in labour is therefore not a simple or reducible medical problem. However, the relief of pain in
labour is an ongoing concern of biomedicine, particularly within anaesthetics, and has even been
described as a ‘human right’ (Cohen, 1999, p. 224). This feeds straight back into the technological
determinist argument; withholding pain relief is not only anti-reason, it is anti-human.
Problematicallyand noted by midwives from the time of their introductionmedical technologies
can interfere with the process of being present to the labour process, that commitment to women’s
embodied experience that midwifery philosophy upholds (Leap, 2000). Low-tech interventions such
as continuous support during labour can decrease women’s need for analgesia, as well as operative
birth rates (Hodnett et al., 2013). This more traditional midwifery practice of providing physical and
emotional labour support contributes to a shared embodied experience. Some women and midwives
expect and put their faith in the use of technology (Sinclair, 2011; Sinclair and Gardner, 2001), and in
some cases it is both useful and necessary. However, reliance on medical technologies establishes
the indirect surveillance of disembodied processes that neglects the historic embodied relationship
between the woman and midwife (Barger-Lux and Heaney, 1986; Sandelowski, 1998; Sandelowski,
2002). Knowledge and practice that support the normal process of birth and women’s embodied
experiences are typically not supported in medical birth settings. The positioning of obstetrics with
‘technology’ provides access to dominant techno-rational norms of science and safety, and allows
the perpetuation of technologically-oriented practices that are not clearly evidence-based over
simpler, low-tech midwifery practices that can actually reduce childbirth intervention rates.
Despite the lack of conclusive evidence, the salient assertions in the biomedical epidural literature
are that epidural analgesia is essentially safe, should be available for all women and is in fact a
‘human right’, and is modern and progressive while childbirth pain is archaic. Underlying this is the
unease about epidural outcomes and there are constant recommendations that research needs to
focus on improving these by varying the doses and/or drugs used. Essentially, women are offered
the promise of ‘safe, pain free’ labour, based on inconclusive research.
Challenging paradigms
The pain relief as progress’ discourse in the epidural literature forms part of what Leap and
Anderson (2008, p. 38) have termed the ‘pain relief paradigm’, whereby midwives who have
internalised the techno-rational assumptions outlined above perpetuate a belief that women cannot
endure the pain of birth. These authors recommend that midwives examine their own beliefs about
pain and if possible adopt a ‘working with pain’ approach, which accepts pain as a normal part of the
birth process (Leap and Anderson, 2008), and this support can actually reduce women’s desire for
analgesia (Romano and Lothian, 2008; Walsh et al., 2008). Pain is also viewed positively by some
women as a rite of passage that supports their transition to motherhood and brings a sense of pride
and accomplishment (Lundgren and Dahlberg, 1998; Karlsdottir et al., 2014; Van der Gucht and
Lewis, 2015). Satisfaction with the birth experience is not necessarily related to pain relief, and is
complex and multi-faceted (Lundgren and Dahlberg, 1998; Kannan et al., 2001; Hodnett, 2002),
illustrated by the fact that some women who have had an epidural express less satisfaction with the
birth process than those who have not had one (Waldenström et al., 2004). Importantly, women are
not necessarily well-informed about epidural risks and it has been suggested that the need for an
epidural in labour may not be related to actual levels of pain, but to a woman’s pre-existing ‘birth
ideology’ (Heinze and Sleigh, 2003, p. 330). It has also been proposed that increasing uptake of
epidural analgesia could be due more to unsupportive and fragmented maternity care than actual
pain relief requirements (Walsh, 2009). From this perspective, epidural analgesia is not so much a
‘human right’ and ‘rescuer of women in pain’ as a potentially unnecessary intervention: one that is
not well-explained, does not always alleviate women’s ‘suffering’ in labour, and might actually
decrease women’s joy in the birth process.
Epidural analgesia has been promoted as safe, efficacious, even necessary, by the biomedical
literature, even while demarcating its potential negative side-effects. The problem with wholesale
acceptance of ‘evidence-based’ scientific research is the lack of transparency of its own philosophical
premises. Dominant ideologies such as technological rationalism are therefore renegotiated and
perpetuated as if they represent a universalised reality. Most women will have been exposed to
these social discourses of pain and epidural use and may not have been exposed to knowledge that
challenges this paradigm. However, in light of the ongoing uncertainty about research findings, there
needs to be a robust and informed debate about the appropriate use of epidural analgesia in low-
risk labour.
This critical analysis of the discourse surrounding epidural analgesia has explored some of the ways
in which medical, scientific and technological discourses have influenced Western birth practices in
relation to the production of information about epidural analgesia. It adds to the growing knowledge
base about social contexts of birth, and delineates the way in which dominant ideas about
pain/relief are perpetuated. Childbearing women have to negotiate increasing amounts of
information from various sources, are faced with obstetric practices that are not necessarily
evidence-based or denied midwifery practices which are. Midwives and others interested in the
wellbeing of birthing women need to have an understanding of how various discoursessuch as the
biomedical epidural discourseare sustained as well as an awareness of alternate perspectives in
order to fulfil the midwifery responsibility to provide advocacy, information sharing, and to work in
partnership with women.
Alfirevic, Z., Devane, D. & Gyte, G. (2013). Continuous cardiotocography (CTG) as a form of electronic
fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic
Reviews, Issue 5. Art. No.: CD006066. DOI: 10.1002/14651858.CD006066.pub2. Accessed
Amedee Peret, F. (2013). Pain management for women in labour: an overview of systematic reviews:
RHL Commentary [Online]. World Health Organization: Geneva.
retf_com/en/index.html. Accessed 27/9/15
Anim-Somuah, M., Smyth, R. & Howell, C. (2011). Epidural versus non-epidural or no analgesia in
labour. Cochrane Database of Systematic Reviews. Issue 12. Art. No.: CD000331. DOI:
10.1002/14651858.CD000331.pub3. Accessed 30/01/13
Baker, S., Choi, P., Henshaw, C. & Tree, J. (2005). 'I felt as though I'd been in Jail': women's
experiences of maternity care during labour, delivery and the immediate postpartum.
Feminism & Psychology 15, 315-342.
Barger-Lux, M. J. & Heaney, R. P. (1986). For better and worse: the technological imperative in
health care. Social Science & Medicine 22, 1313-1320.
Blackwell, T. & Seabrook, J. (1993). The revolt against change: towards a conserving radicalism,
Vintage: London.
Buckley, S. (2015). Hormonal physiology of childbearing: evidence and implications for women,
babies, and maternity care. Childbirth Connection: Washington.
Cohen, S. (1999). Labor epidural analgesia: back to the dark ages or a potential win-win situation?
International Journal of Obstetric Anesthesia 8, 223-225.
Cooper, G., Macarthur, C., Wilson, M., Moore, P. & Shennan, A. (2010). Satisfaction, control and pain
relief: short- and long-term assessments in a randomised controlled trial of low-dose and
traditional epidurals and a non-epidural comparison group. International Journal of Obstetric
Anesthesia 19, 31-37.
Creedy, D. (1999). Birthing and the development of trauma symptoms: incidence and contributing
factors. Unpublished PhD thesis, Griffith University: Queensland.
Crowhurst, J. & Plaat, F. (2000). Labor analgesia for the 21st century. Seminars in Anesthesia,
Perioperative Medicine and Pain 19, 164-170.
Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S. & Herrlich, A. (2013). Listening to Mothers III:
Pregnancy and Birth. Childbirth Connection: Washington.
Devane, D., Lalor, J., Daly, S., Mcguire, W. & Smith, V. (2012). Cardiotocography versus intermittent
auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing.
Cochrane Database of Systematic Reviews. Issue 2. Art. No.: CD005122. DOI:
10.1002/14651858.CD005122.pub4. Accessed 4/3/15
Downe, S. & McCourt, C. (2008). From being to becoming: reconstructing childbirth knowledges. In:
Downe, S. (ed.) Normal childbirth: evidence and debate. 2nd ed. Elsevier: Sydney.
Drysdale, S. & Muir, H. (2002). New techniques and drugs for epidural labor analgesia. Seminars in
Perinatology 26, 99-108.
Fairclough, N. (1995). Critical Discourse Analysis: The critical study of language. Longman: London.
Finster, M. & Santos, A. (1998). The effects of epidural analgesia on the course and outcome of
labour. Bailliere's Clinical Obstetrics and Gynaecology 12, 473-483.
Foucault, M. (1980). Two Lectures. In: Gordon, C. (ed.) Power/Knowledge: Selected Interviews and
Other Writings 1972-1977 by Michel Foucault. Harvester Wheatsheaf: London.
Foucault, M (1991). Politics and the study of discourse. In: Burchell, G., Gordon, C. & Miller, P.
(eds.) The Foucault Effect: Studies in Governmentality. Harvester Wheatsheaf: Chicago.
Foureur, M. (2008). Creating birth space to enable undisturbed birth. In: Fahy, K., Foureur, M. &
Hastie, C. (eds.) Birth territory and midwifery guardianship: theory for practice, education
and research. Elsevier: Sydney.
Gaiser, R. (2005). Labor epidurals and outcome. Best Practice & Research Clinical Anaesthesiology
19, 1-16.
Hayman, R. (2005). Instrumental vaginal delivery. Current Obstetrics & Gynaecology 15, 87-96.
Heinze, S & Sleigh, M. (2003). Epidural or no epidural anaesthesia: relationships between beliefs
about childbirth and pain control choices, Journal of Reproductive and Infant Psychology 21,
Hemminki, E. & Gissler, M. (1996). Epidural analgesia as a risk factor for operative delivery.
International Journal of Gynecology & Obstetrics 53, 125-132.
Hilder, L., Zhichao, Z., Parker, M., Jahan, S. & Chambers, G. (2014). Australia's mothers and babies
2012. Perinatal statistics series no. 30. Australian Institute of Health and Welfare: Canberra.
Hill, S. (1988). The Tragedy of Technology. Pluto Press: London.
Hodnett, E. (2002). Pain and women's satisfaction with the experience of childbirth: A systematic
review. American Journal of Obstetrics and Gynecology 186, S160-S172.
Hodnett, E., Gates, S., Hofmeyr, G. J. & Sakala, C. (2013). Continuous support for women during
childbirth. Cochrane Database of Systematic Reviews. Issue 7. Art. No.: CD003766. DOI:
10.1002/14651858.CD003766.pub5. Accessed 4/3/15
Jain, S., Arya, V., Gopalan, S. & Jain, V. (2003). Analgesic efficacy of intramuscular opioids versus
epidural analgesia in labor. International Journal of Gynaecology and Obstetrics 83, 19-27.
Johnson, K. (1997). Randomized controlled trials as authoritative knowledge: keeping an ally from
becoming a threat to North American midwifery practice. In: Davis-Floyd, R. & Sargent, C.
(eds.) Childbirth and Authoritative Knowledge: Cross-cultural perspectives. University of
California Press: Berkeley.
Kannan, S., Jamison, R. N. & Datta, S. (2001). Maternal satisfaction and pain control in women
electing natural childbirth. Regional Anesthesia and Pain Medicine 26, 468-472.
Karlsdottir, S. I., Halldorsdottir, S. & Lundgren, I. (2014). The third paradigm in labour pain
preparation and management: the childbearing woman’s paradigm. Scandinavian Journal of
Caring Sciences 28, 315-327.
Keirse, M. (2002). Evidence-based childbirth only for breech babies? Birth 29, 55-59.
Kotaska, A. (2004). Inappropriate use of randomised trials to evaluate complex phenomena: case
study of vaginal breech delivery. British Medical Journal 329, 1039-1042.
Kotaska, A., Klein, M. & Liston, R. (2006). Epidural analgesia associated with low-dose oxytocin
augmentation increases cesarean births: a critical look at the external validity of randomized
trials. American Journal of Obstetrics and Gynecology 194, 809-14.
Lain, S, Ford, J, Hadfield, R, Blyth, F, Giles, W & Roberts, C. (2008). Trends in the use of epidural
analgesia in Australia. International Journal of Gynecology and Obstetrics 102, 253-258.
Leap, N. (2000). The less we do, the more we give. In: Kirkham, M. (ed.) The midwife-mother
relationship. Palgrave Macmillan: New York.
Leap, N. & Anderson, T. (2008). The role of pain in normal birth and the empowerment of women.
In: Downe, S. (ed.) Normal childbirth: evidence and debate. Elsevier: Sydney.
Lundgren, I. & Dahlberg, I. (1998). Women’s experience of pain during childbirth. Midwifery 14, 105-
Marcuse, H. (1972). One dimensional man. Abacus: London.
Murphy-Lawless, J. (1998). Reading birth and death: a history of obstetric thinking. Cork University
Press: Cork.
Newnham, E. (2014). Birth control: power/knowledge in the politics of birth. Health Sociology
Review 23, 254-268.
Newnham, E., McKellar, L. & Pincombe, J. (2015). Documenting risk: a comparison of policy and
information pamphlets for using epidural or water in labour. Women & Birth 28, 221-227.
Norman, B. (2002). Natural childbirth is inappropriate in a modern world. International Journal of
Obstetric Anesthesia 11, 28-30.
Nystedt, A., Edvardsson, D. & Willman, A. (2004). Epidural analgesia for pain relief in labour and
childbirth - a review with a systematic approach. Women & Children 13, 455-466.
Rådestad, I., Olsson, A., Nissen, E. & Rubertsson, C. (2008). Tears in the vagina, perineum, sphincter
ani, and rectum and first sexual intercourse after childbirth: a nationwide follow-up. Birth
35, 98-106.
Rahm, V., Hallgren, A., Hogberg, H., Hurtig, I. & Odlind, V. (2002). Plasma oxytocin levels in women
during labor with or without epidural analgesia: a prospective study. Acta Obstetricia et
Gynecologica Scandinavica 81, 1033-1039.
Ramin, S., Gambling, D., Lucas, M., Sharma, S., Sidawi, J. & Leveno, K. (1995). Randomized trial of
epidural versus intravenous analgesia during labor. Obstetrics and Gynecology 86, 783-789.
Romano, A. & Lothian, J. (2008). Promoting, protecting, and supporting normal birth: a look at the
evidence. Journal of Obstetric, Gynecologic & Neonatal Nursing 35, 94-105.
Roome, S., Hartz, D., Tracy, S. & Welsh, A. W. (2015). Why such differing stances? A review of
position statements on home birth from professional colleges. BJOG: An International
Journal of Obstetrics & Gynaecology 123, 376-382.
Ros, A., Felberbaum, R., Jahnke, I., Diedrich, K., Schmucker, P. & Huppe, M. (2007). Epidural
anaesthesia for labour: does it influence the mode of delivery? Archives of Gynecology and
Obstetrics 275, 269-274.
Rothman, B. K. (1989). Recreating Motherhood: Ideology and technology in a patriarchal society.
W.W. Norton & Company: New York.
Sandelowski, M. (1998). Looking to care or caring to look? Technology and the rise of spectacular
nursing. Holistic Nursing Practice 12, 1-11.
Sandelowski, M. (2002). Reembodying qualitative inquiry. Qualitative Health Research 12, 104-115.
Sharma, S., McIntire, D., Wiley, J. & Leveno, K. (2004). Labor analgesia and cesarean delivery: an
individual patient meta-analysis of nulliparous women. Anesthesiology 100, 142-148.
Sinclair, M. (2011). Use of technology in childbirth: the role of the midwife past, present and future.
The Practising Midwife 14, 34-37.
Sinclair, M. & Gardner, J. (2001). Midwives’ perceptions of the use of technology in assisting
childbirth in Northern Ireland. Journal of Advanced Nursing 36, 229-236.
Singer, M. & Baer, H. (1995). Critical Medical Anthropology. Bayswood Publishing Company:
Amityville, New York.
Steen, M. & Kingdon, C. (2008). Vaginal or caesarean delivery? How research has turned breech birth
around. Evidence Based Midwifery 6, 95-99.
Thomas, J. (1993). Doing Critical Ethnography. Sage: London.
Toledo, P., Mccarthy, R., Ebarvia, M. & Wong, C. (2009). A retrospective case-controlled study of the
association between request to discontinue second stage labor epidural analgesia and risk of
instrumental delivery. International Journal of Obstetric Anesthesia 17, 304-308.
Tracy, S., Sullivan, E., Wang, Y., Black, D. & Tracy, M. (2007). Birth outcomes associated with
interventions in labour amongst low risk women: a population-based study. Women & Birth
20, 41-48.
Uvnäs Moberg, K. (2003). The oxytocin factor. Da Capo Press: Cambridge, MA.
Van Der Gucht, N. & Lewis, K. (2015). Women׳s experiences of coping with pain during childbirth: a
critical review of qualitative research. Midwifery 31, 349-358.
Waldenström, U., Hildingsson, I., Rubertsson, C. & Rådestad, I. (2004). A negative birth experience:
prevalence and risk factors in a national sample. Birth 31, 17-27.
Walsh, D. (2009). Pain and epidural use in normal childbirth. Evidence Based Midwifery 7, 89-93.
Walsh, D. (2012). Evidence and skills for normal birth. Routledge: London.
Walsh, D., El-Nemer, A. & Downe, S. (2008). Rethinking risk and safety in maternity care. In: Downe,
S. (ed.) Normal childbirth: evidence and debate. 2nd ed. Elsevier: Sydney.
Wang, F., Shen, X., Guo, X., Peng, Y. & Gu, X. (2009). Epidural analgesia in the latent phase of labor
and the risk of cesarean delivery. Anesthesiology 111, 871-880.
Wendland, C. (2007). The vanishing mother: cesarean section and "evidence-based obstetrics".
Medical Anthropology Quarterly 21, 218-233.
WHO (1996). Care in Normal Birth. World Health Organisation: Geneva.
Wiklund, I., Norman, M., Uvnäs-Moberg, K., Ransjo-Arvidson, A. B. & Andolf, E. (2009). Epidural
analgesia: breast-feeding success and related factors. Midwifery 25, e31-38.
... midwifery) [30]. There is a large body of qualitative research that applies Foucauldian concepts and theories to analyse medical power [30][31][32]. ...
... Over 35 years ago, midwifery in the United States was referred to as "(almost) a profession" because it lacked ultimate control over its work; midwifery standards of practice were largely determined by obstetrics [49]. Since then the dominance of the obstetric paradigm over that of midwifery in many countries, including Australia, has been well-documented [32,39,40,[50][51][52][53], including specifically in the area of perineal care [41]. Midwives in our study reported submissive behaviour, like eye-rolling and complaining, but rarely assertively challenged the obstetric authority invisible in the bundle yet central to its' power. ...
Background A care bundle to reduce severe perineal trauma (the bundle) was introduced in 28 Australian maternity hospitals in 2018. The bundle includes five components of which only one – warm perineal compresses – has highest level evidence. There is scant published research about the impact of implementation of perineal bundles. Question How does a perineal care bundle impact midwifery practice in Australian maternity hospitals? Methods Purposively sampled midwives who worked in hospitals where the bundle had been implemented. Interested midwives were recruited to participate in one-to-one, semi-structured interviews. The researchers conducted critical, reflexive thematic analysis informed by Foucauldian concepts of power. Findings We interviewed 12 midwives from five hospitals in one state of Australia. Participants varied by age, clinical role, experience, and education. Three themes were generated: 1) bundle design and implementation 2) changing midwifery practice: obedience, subversion, and compliance; and 3) obstetric dominance and midwifery submission. Discussion The bundle exemplifies tensions between obstetric and midwifery constructs of safety in normal birth. Participants’ responses appear consistent with oppressed group behaviour previously reported in nurses and midwives. Women expect midwives to facilitate maternal autonomy yet decision-making in maternity care is commonly geared towards obtaining consent. In our study midwives encouraged women to consent or decline depending on their personal preferences. Conclusion The introduction of the perineal bundle acts as an exemplar of obstetric dominance in Australian maternity care. We recommend midwives advocate autonomy – women’s and their own – by using clinical judgement, evidence, and woman-centred care.
... Epidural anaesthesia is considered relatively safe, particularly when compared to general anaesthesia for surgical procedures. This has translated across to the obstetric setting as the epidural being a 'safe' analgesic for labour [1]. Whereas relatively safe from an anaesthetic perspective, epidural analgesia (EA) for childbirth is associated with risk factors, including hypotension, pyrexia, Entity Missing, PDF not created urinary retention, longer first and second stages of labour and increased rates of instrumental birth [2]. ...
Objective: To compare labour and birth outcomes between nulliparous women who used versus did not use intrapartum epidural analgesia. Design: Prospective cohort study. Setting: Two maternity hospitals in Ireland. Population: A total of 1221 nulliparous women who gave birth vaginally or by emergency caesarean section. Methods: Multinomial logistic regression was used to analyse categorical outcomes, with results presented as ratios of relative risks (RRR). For dichotomous outcomes we used logistic regression, with results presented as odds ratios (OR). Main outcome measures: Mode of birth, IV syntocinon use, pyrexia (≥38°C), antibiotic treatment, first stage labour ≥10h, second stage labour ≥2h, blood loss (≥500mls, ≥1000mls), perineal trauma. Neonatal outcomes included APGAR score ≥7 at 1min and 5min, admission to neonatal intensive care unit, and infant feeding method. Results: Women using EA were more likely to require a vacuum-assisted birth (RRR 3.35, p<0.01) or forceps-assisted birth (RRR 11.69, p<0.01). Exposure to EA was associated with significantly greater risk of ≥10h first (OR 6.72, p=0.01) and ≥2h second (OR 2.25, p<0.01) stage labour, increased likelihood of receiving IV syntocinon (OR 9.38, p<0.01), antibiotics (OR 2.97, p<0.01) and a greater probability of pyrexia (OR 10.26, p<0.01). Women who used EA were half as likely to be breastfeeding at three months postpartum (OR 0.53, p<0.01). No differences were observed between groups in neonatal outcomes. Conclusions: Our data shows significant associations between EA use and several intrapartum outcomes.
... All data were analysed through the lens of a three-pronged theoretical framework-CMA, Foucault, and Feminism-using continuous analysis and 'thick description' (Geertz 1973). We also adapted and used the Health care arena model (Baer et al. 1986;Newnham et al. 2016). We provide a more in-depth understanding of CMA and ethnography in the following pages. ...
This chapter focuses predominantly on the impact of the midwife-woman relationship. In this chapter, the intricacies of the women’s experiences of pregnancy and anticipation of birth are discussed and developed into a conceptual figure that illustrates their ambiguous approach to pain, the unknowable nature of birth, and the trust that women therefore placed in their own bodies. We further the argument that a focus on embodiment can provide a point of departure for contemporary attitudes to birth, discarding old dichotomies and embracing complexity. Drawing on contemporary childbirth literature, we reassert the centrality of the midwife’s role and approach to pain.
... All data were analysed through the lens of a three-pronged theoretical framework-CMA, Foucault, and Feminism-using continuous analysis and 'thick description' (Geertz 1973). We also adapted and used the Health care arena model (Baer et al. 1986;Newnham et al. 2016). We provide a more in-depth understanding of CMA and ethnography in the following pages. ...
This book examines the future of birthing practices, particularly by focusing on epidural analgesia in childbirth. It describes historical and cultural trajectories that have shaped the way in which birth is understood in Western, developed nations. In setting out the nature of epidural history, knowledge and practice, the book delves into related birth practices within the hospital setting. By critically examining these practices, which are embedded in a scientific discourse that rationalises and relies upon technology use, the authors argue that epidural analgesia has been positioned as a safe technology in contemporary maternity culture, despite it carrying particular risks. In examining alternative research the book proposes that increasing epidural rates are not only due to greater pain relief requirements or access but are influenced by technocratic values and a fragmented maternity system. The authors outline the way in which this epidural discourse influences how information is presented to women and how this affects their choices around the use of pain relief in labour.
... We drew on the more subtle poststructuralist concerns of perpetuated discourses and their implication in surveillance and discipline of the body. Leaning into post-structuralism was relevant because obstetric medicine is largely maintained through a biomedical hegemonic discourse that privileges technology and "complex practices" (see Newnham, McKellar, & Pincombe, 2016;Waitzkin, 1983). These supporting theoretical perspectives are commensurate with CMA methodology, which recognizes the subtle ways in which hegemonic discourses assert power through language, symbolism, and meaning, rather than overt mechanisms of control (Singer & Baer, 1995). ...
Full-text available
In this article, we discuss the use of critical medical anthropology (CMA) as a theoretical framework for research in the maternity care setting. With reference to the doctoral research of the first author, we argue for the relevance of using CMA for research into the maternity care setting, particularly as it relates to midwifery. We then give an overview of an existing analytic model within CMA that we adapted for looking specifically at childbirth practices and which was then used in both analyzing the data and structuring the thesis. There is often no clear guide to the analysis or writing up of data in ethnographic research; we therefore offer this Critical analytic model of childbirth practices for other researchers conducting ethnographic research into childbirth or maternity care.
Full-text available
Labour pain management is a major challenge in maternity care. Epidural analgesia provides safe and effective pain relief during labour. The objective was to assess the knowledge, attitudes and associated factors towards epidural analgesia during labour among pregnant women in Colombo region, Sri Lanka. This was a descriptive study conducted at two selected hospitals in Colombo Sri Lanka. The sample size was 260 and those below 18yrs were excluded. Participants were provided with a pre-tested questionnaire. Ethical approval was obtained from Faculty of Medical Sciences, University of Sri Jayewardenepura. Both knowledge and attitude were given separate scores and were categorized as ‘good’ or ‘poor’ based on their mean. Within the study population, 41.9% had heard of labour analgesia. Among them, only 6.7% had good knowledge and 15.6% had a positive attitude towards labour epidural analgesia. The patients with good knowledge about labour epidural analgesia had good attitude towards the procedure (p<0.05) and there was a positive association between those who had heard of analgesia and their sources of information. However, as the total level of knowledge and attitudes towards labour epidural analgesia was poor, it is recommended that the health care workers issue pamphlets carrying necessary information following discussions with the pregnant women. After admission they should be given clear information about risks and benefits of the procedure and a post-partum feedback would help in quality improvement. © 2019, College of Anaesthesiologists of Sri Lanka. All rights reserved.
This chapter presents a historical introduction to birth analgesia and the influence of scientific and medical discourse on understandings of women’s bodies, influencing the ways in which women themselves can frame their own corporeal knowledge. Here, the process of birth, and how it is understood within Western cultural discourses, is investigated more thoroughly. We highlight the influence of biomedicine as a dominant birth discourse and explore current medical knowledge about epidural analgesia, exposing some of the assumptions behind evidence-based medicine and technology use.
Objective: to investigate the personal, social, cultural and institutional influences on women making decisions about using epidural analgesia in labour. In this article we discuss the findings that describe practices around the gaining of consent for an epidural in labour, which we juxtapose with similar processes relating to use of water for labour and/or birth. Design: ethnography. Setting: tertiary hospital in Australian city. Participants: sequential interviews were conducted with 16 women; hospital staff (primarily midwives and doctors) participated during six months of participatory observation fieldwork. Findings: women were not given full disclosure of either practice and midwives tailored the information they gave according to the institutional policies rather than evidence. Key conclusions: informed consent is an oft-cited human right in health care, yet in maternity care the micro-politics of how informed consent is gained is difficult to ascertain, leading to a situation whereby the concept of informed consent is more robust than the reality of practice; an illusion of informed consent exists, yet information is often biased towards medicalised birth practices. Implications for practice: as primary maternity care-givers, midwives have a role in providing unbiased information to women; however it appears that hospital culture and policy affect the way that this information is presented. It is arguable whether women in such instances are giving true informed consent, and for this reason, the ethics of these hidden practices are questioned.
Technical Report
Full-text available
This report synthesizes evidence about innate hormonally-mediated physiologic processes in women and fetuses/newborns during childbearing, and possible impacts of common maternity care practices and interventions on these processes, focusing on four hormone systems that are consequential for childbearing. Core hormonal physiology principles reveal profound interconnections between mothers and babies, among hormone systems, and from pregnancy through to the postpartum and newborn periods. Overall, consistent and coherent evidence from physiologic understandings and human and animal studies finds that the innate hormonal physiology of childbearing has significant benefits for mothers and babies. Such hormonally-mediated benefits may extend into the future through optimization of breastfeeding and maternal-infant attachment. A growing body of research finds that common maternity care interventions may disturb hormonal processes, reduce their benefits, and create new challenges. Developmental and epigenetic effects are biologically plausible but poorly studied. The perspective of hormonal physiology adds new considerations for benefit-harm assessments in maternity care, and suggests new research priorities, including consistently measuring crucial hormonally-mediated outcomes that are frequently overlooked. Current understanding suggests that safely avoiding unneeded maternity care interventions would be wise, as supported by the Precautionary Principle. Promoting, supporting, and protecting physiologic childbearing, as far as safely possible in each situation, is a low-technology health and wellness approach to the care of childbearing women and their fetuses/newborns that is applicable in almost all maternity care settings.
Background: Historically, women have been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has become the exception rather than the routine. Objectives: Primary: to assess the effects of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies; (2) the provider's relationship to the hospital and to the woman; and (3) timing of onset. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013). Selection criteria: All published and unpublished randomised controlled trials comparing continuous support during labour with usual care. Data collection and analysis: We used standard methods of The Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors independently evaluated methodological quality and extracted the data. We sought additional information from the trial authors. We used random-effects analyses for comparisons in which high heterogeneity was present, and we reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data. Main results: Twenty-two trials involving 15,288 women met inclusion criteria and provided usable outcome data. Results are of random-effects analyses, unless otherwise noted. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% confidence interval (CI) 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.96) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition, their labours were shorter (MD -0.58 hours, 95% CI -0.85 to -0.31), they were less likely to have a caesarean (RR 0.78, 95% CI 0.67 to 0.91) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.85 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low five-minute Apgar score (fixed-effect, RR 0.69, 95% CI 0.50 to 0.95). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or breastfeeding. Subgroup analyses suggested that continuous support was most effective when the provider was neither part of the hospital staff nor the woman's social network, and in settings in which epidural analgesia was not routinely available. No conclusions could be drawn about the timing of onset of continuous support. Authors' conclusions: Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.
The use of medical instruments to facilitate the birth of a child is a process that dates back many centuries. Although the basic design and application of these instruments has remained unchanged over time, many of the indications for their use have altered dramatically. This review examines the current position of the obstetric forceps and ventouse in the accoucheurs' 'armoury', and provides a brief reminder of the technique required for delivery with each instrument.