“It didn’t hurt, it wasn’t meant to, was it, doctor?”

A review of “Childbirth without Fear” for Deirdre Munro Global Village Midwives @GlobalVillageMw
by @DouglasNatusch

Introduction

A young doctor was attending a birth in Whitechapel in London in the first half of the 20th Century. What he later wrote could be from a scene from the television series “Call the Midwife”. The mother lived in a poor household in the East End of London. The doctor recalled having to provide his own towel and soap when he arrived as she had none to offer him. Despite the poverty of the surroundings he recollected “I soon became conscious of a quiet kindliness in the atmosphere. In due course the baby was born. There was no fuss or noise.” The mother declined chloroform when offered and it was when he asked her why she did so, she explained “it didn’t hurt, it wasn’t meant to”. These words had a profound effect on that young doctor. He went on to develop ideas and changed his practice. A desire to spread his ideas led to him writing a book, ‘Natural Childbirth’ and later ‘Childbirth Without Fear”. He didn’t just write books however, he start a social movement with a powerful thread, still running through Midwifery and Obstetrics today. His name was Dr Grantley Dick-Read.

Hello šŸ™‚ My name is Douglas Natusch. I am a Consultant in Anaesthetics and Pain Medicine in South Devon, UK. Delivering obstetric anaesthesia is a part of my role, one which I appreciate and value. I first came across Global Village Midwife after a post I had written on Twitter about the ‘Skin to Skin” campaign. When @DeirdreMunro asked if I would write a piece, I though it may be an opportunity to read ‘Childbirth Without Fear” and reflect on the book from the perspective of a current day anaesthetist.

Childbirth Without Fear

Obstetrics and childbirth as Grantley Dick-Read encountered in the first half of the century, was a very different world to the one he later aspired to achieve for the women he looked after. He deplored some contemporary views that women should know as little as possible about labour and leave things to interventions of (male) experts. He directly challenged his own profession and he also challenged practices in nursing and midwifery that he felt interfered with the relationship between mothers and their babies.

He describes deliveries at home and in hospital. What he describes is very far from current practice. In hospital he writes how women were often left alone and unprepared on wards during their first stage of labour as there was not enough staff to be with them. He wrote “I shudder when I pass the door of those wards where the women lie alone, enduring the first stage of labour”. Once ready to be delivered, women were moved to a birthing suite and inhalation anaesthetics like Chloroform or Ether were often offered in the second stage of labour. Dick-Read commented that with vaginal delivery under general anaesthesia, women missed seeing their baby born or hearing their first cry. He reflected sadly on a situation where he saw “Anaesthetics used in place of education, drugs an antidote for misunderstanding.” He was also concerned about over-intervention in the form of forceps and episiotomy as a consequence. During home deliveries he describes situations that varied but where sometimes unhelpful advice given by well meaning onlookers did not always creating a peaceful and relaxing environment for the mother.

Grantley Dick-Read believed and advocated empowering women to understand the process of labour, to understand their bodies and realised the importance of women learning to overcome fear of pain in labour. He wrote that when prepared and given the choice, “Women demand to stay conscious to see their babies born”. He postulated a Fear-Tension-Pain Syndrome that could be overcome with antenatal education and relaxation. The outcome of his method is best described by a experienced Midwife he quotes in his book, “the difference is the women. They seem to know their job before they start ; they know what first stage contractions are doing and realise it may be a long time before the “door is opened”. They understand why relaxation helps.”

He was an advocate of immediate mother and baby skin-to -skin’ contact at a time when that was not the norm. He said “there is no greater joy than that of a woman who sees her baby born and hold it in her hands whilst it is still linked to her body by the avenue through which its lifeblood surged from the selective source within her womb.” To my surprise, I realised he also encouraged breast feeding at a time when women were not encouraged to, or even actively discouraged ; “rooming in ” instead of babies being taken away to nurseries post delivery and fathers being present at the birth of their children. Much of what he advocated has become embedded into modern Midwifery and Obstetrics.

Dick-Read was also concerned about the effects of popular culture in literature and film that promoted a view that labour was inevitably painful and distressing.A deeply religious man he even questioned translations in the Bible implying childbirth was painful noting irregularities in translation of texts relating to childbirth. In short, he was promoting nothing less than a multi-dimensional or bio-psycho-social approach to pain in childbirth, decades before it was adopted in other areas of medicine. Sometimes what he writes seems remarkably current – not from around 60 years ago. At other times his language seems arcane. In context, he was born a Victorian and was a veteran of World War 1. Perhaps his lasting legacy is to have been an influence in the development of The National Childbirth, NCT which continues to provide education and support to women and their partners as well as helping change the attitudes and practices of professionals.

What was the reaction to his ideas at the time?

Although some of his ideas were accepted and adopted at the time, which he recognised and was pleased to see, many of his ideas aroused professional controversy which he openly discusses in his book. What seems to have distressed him particularly was being accused of denying women pain relief in labour. Anaesthesia for labour pain had until then been seen as a modern and humane medical advance. It had received royal assent when Queen Victoria delivered one of her children with the assistance of Chloroform. Little had changed however in the practice of anaesthesia in labour it seems, up to Dick-Read’s time. It was delivered largely by non-specialist doctors, often the doctor delivering the baby. It is possible on reflection to understand why any challenge to this practice could have been regarded as regressive, unscientific and possibly inhuman by some at the time. Dick-Read was clear his method would not suite all situations. He advocated analgesia or anaesthesia if labour was complex or associated with malpresentation. In his book he outlines many of the techniques of pain relief used today with the exception of TENS machines and epidurals which were yet to be available.

It had also been suggested what he was doing in practice was merely a variant of hypnosis. He spends time clarifying why this was not the case and outlines the methods of relaxation he promoted. Dick-Read was clearly an enthusiast for natural childbirth. My only qualm was perhaps the statistic where he states that in 90% of suitable women severe pain can be eliminated by “substituting understanding for fear”. He provides no evidence in the book to support this statistic.

Changes in pain relief techniques in labour since Dick-Read

What has changed profoundly from my perspective since ‘Childbirth Without Fear’ was published has been the development of an Anaesthetic profession which he may be surprised to realise teaches its trainees about his ideas on the psychological prophylaxis of pain and whose trainees are now nearly 50% women. Dick-Read wrote that “The most important factor in the use of anaesthesia and analgesia in childbirth is the skill, experience and judgement of the attendant”. The Anaesthetic profession has made great efforts to improve Obstetric Anaesthesia both in terms of training anaesthetists and delivering a safe service in the UK over the last 4 decades which has shown success in reducing maternal mortality from anaesthetic causes in UK national audits. General anaesthetics are no longer delivered by doctors without a professional training in anaesthetics. Standards for Anaesthetic training and professional practice for the UK are now set by the Royal College of Anaesthetists @RCoANews. General anaesthesia is not offered as an option for routine pain relief in labour. Anaesthetists are now embedded members of the delivery unit team and are involved in variety of ways from providing epidurals for pain relief through to Intensive Care, where units are largely run by specialised anaesthetists. There is now an Obstetric Anaesthetists Association, @OAAinfo which is a charity aiming to disseminate good practice in Obstetric Anaesthesia including producing resources for patients on pain relief in labour which can be found at http://www.labourpains.com/UI/Content/Content.aspx?ID=5

Despite advances in anaesthesia, both in terms of techniques and drugs, good tools of communication remain as important as good equipment in my experience. For me, technical expertise is not enough unless it is not delivered in a context of understanding, clear explanation and above all kindness. Anaesthetists are relating to women at a key time of their lives often to deliver complex interventions at short notice. The best time to have discussions about pain relief in labour is before labour and anaesthetists do join discussions in ante-natal classes, Anaesthetics are still not a substitute for education and drugs are still not a substitute for misunderstanding.

Perhaps the most important thing is for all the professions involved in childbirth is to, like Dick-Read, reflect on what they are doing now that is seen as ‘good clinical practice’ that may have unintended consequences and need to change. Feedback from women and their families needs to be embedded as an integral part of service development along with audit. Listening to his patient is what started the change for Grantley Dick-Read.

When I was first asked for my comment on the ‘Skin-to-skin’ campaign on Twitter, I wrote that ‘something profound happens to women when they meet their baby’ and that ‘I have no words for their transformation’. I still don’t. I had considered writing an essay on current ideas about the neurophysiology of fear and pain, but suffice to say the brain can and does powerfully module its own input and the emotion of fear does have a role. What would happen if we were ever able to capture an image of the moment in a woman’s brain when she meets her baby? Something very profound in terms of neuronal function and neurotransmitters release, I suspect, but personally I do not think medical imaging is necessary. If you have the privilege of being present when someone is born, just take notice. It may be the greatest privilege of your life.

Dr Douglas Natusch
Consultant Anaesthetics and Pain Medicine
Torbay and South Devon Foundation Trust
Torquay, Devon.

A review of ‘Childbirth without Fear’, Dr Grantley Dick-Read 4th Edition 1959 expressing my own views, not those of my employer for @GlobalVillageMw

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