This morning, I saw a sad news that a parturient in a hospital in Yulin City committed suicide by jumping off a building due to pain.
The news triggered a heated discussion from various angles. Some people commented on [how painful it is to give birth to a child, which should make her jump off], while others asked [why family members should persist in choosing to give birth smoothly].
In fact, what saddens Dr. Clove most is that in China, less than 1% of parturients can enjoy [painless childbirth] during childbirth, compared with 61% in the United States.
This is because in China’s current public policy evaluation system, the improvement of women’s comfort does not seem to be considered in this category.
Therefore, the implementation of painless childbirth has become a [uneconomical] thing.
How painful is it to have children?
Four years ago, when I was pregnant, I discussed with my mother how to give birth. She told me: “If you can do it, do it” because of “less suffering”. Most women in my mother’s time believed that cesarean section could at least relieve labor pain.
How painful is natural labor? There are more than 700 answers to this question in Zhihu, Most of the answers were from eyewitnesses, They described the pain of giving birth without blessing and with bare hands as the pain of breaking 12 ribs, the pain of curved explosion in the lower abdomen, and the pain of being swung in the lower abdomen with a sledgehammer for eight hours… Only two answers said that it was not very painful. According to foreign statistics, about 1% of lucky parturients will feel less painful to have children.
Medical research shows that labor pain is the third largest pain after burning pain and colic of liver and kidney stones.
The pain of childbirth is the exclusive right of women, with the exception of the Huichol people in Mexico. This race believes that the pain of childbirth should be shared by men and women. During childbirth, the lying-in woman will hold a rope tied to her husband’s testicles. Every time she suffers pain, she will pull the rope so that the man can also suffer pain.
In a labor pain experience I witnessed, Fathers-to-be attach labor pains to their bellies that can simulate uterine contraction stimuli with electric current. One of the two fathers-to-be trembled during a level 4 pain, Hurriedly stop, the other insisted to level 7, within a few seconds, his face twitched and broke out in a cold sweat, [unlike the pain of stabbing you, there is no what pain point, just like the pain following your heartbeat]. During childbirth, the parturient may have to face level 10 pain, and the pain usually lasts for hours or even days.
Labor pain originates from waves of uterine contraction, which is a kind of intermittent radioactive abdominal pain, often accompanied by lumbago.
For primipara, Pain is often very long. The incubation period alone has an average of eight hours. While entering the period of rapid progress, The pain will be more severe. Apart from the factors of the parturient itself, The labor pain is also related to the fetal position, When the fetus is in the occipital-posterior position-that is, the fetus faces the front of the mother’s body instead of the tailbone, the parturient will experience a persistent compression low back pain, which will not relieve during uterine contraction. During low back pain delivery caused by the fetal position, the parturient will have little chance to catch his breath. The study also found that the labor process in Chinese is longer than that in European and American women.
At the gate of the midwife’s clinic, I met a 38-week-old pregnant woman, C, who was waiting. She wanted to consult the midwife to consider whether she would choose to give birth smoothly this time. The 80-year-old expectant mother, who was counting the fetal movements with her head bowed, has a rounded belly. She has gained nearly 19 kilograms and still looks like she has a collarbone. This is her second child.
C’s mother, An old aunt who experienced the whole process of her daughter’s delivery as a accompanying family member in the delivery room, She excitedly described the situation when her daughter gave birth to her first child: In 2005, there was no labor analgesia, and the severe labor pains lasted for two days and two nights. Finally, the doctor manually expanded the birth canal. After giving birth, the severely torn birth canal once made it almost impossible for the sutured doctor to give the needle. [Can suffer, my daughter is especially strong]. For her daughter’s upcoming delivery, the old aunt sighed, “Cut it if you can].
The other half will never understand this kind of torture.
Knowing that I was going to write about painless childbirth, a friend of mine, J, who had experienced painless childbirth and smooth dissection, told me: “I must praise the person who invented painless childbirth.” Three years ago, J stayed awake for two days, and the doctor finally decided that her labor process could be painless.
[(painless) I slept for 20 minutes as soon as I hit it. I was too tired.]
After accumulating physical strength, four hours later, she began to give birth on a trial basis, [after changing three groups of doctors, they all thought my head and basin were asymmetrical after evaluation, and finally decided to cut it off.] She did not need to re-puncture and directly increased the amount of anesthesia. She gave birth to a big head son weighing more than 7 kg by cesarean section.
Looking back on his whole labor process, J did not have any special regrets about the final autopsy, [in any case, I felt that painless gave me the chance to rest and recuperate, and later I also cooperated with the doctor to try to give birth smoothly, and I was able to clearly consider whether to change autopsy…]
Finding effective ways to relieve labor pain is an exploration that women in almost every culture in the world have never stopped.
Previous methods include soup made of poppy shells and marijuana, hypnosis or acupuncture to relieve pain, and even bloodletting to decompress nerves.
However, medical intervention in childbirth pain has not been the mainstream for hundreds of years. In the Pulitzer Prize book “The Other Half of the Sky”, it is pointed out that [after the anesthetic was developed, it was not allowed to be used by women giving birth for decades because it was taken for granted that women suffered].
In the last century, obstetrician James Young Simpson once asserted: “The medical profession has always opposed the use of labor analgesia, but it has little effect. Our parturients have been exerting pressure on us. Labor analgesia is only a matter of time.”
In 1847, Simpson used ether for the first time to give birth painlessly to a woman with a deformed pelvis. In 1853, Queen Victoria chose to inhale chloroform to relieve the pain when she gave birth to her eighth son. That year, in the distant Eastern Empire, Empress Dowager Cixi had just been concubined and she would not give birth until three years later.
Shortly after the emergence of labor analgesia, women in the United States and Britain launched social movements demanding labor analgesia. The central issue of these struggles is to make all women enjoy this humanized delivery method.
[This country still retains very cruel hierarchical differences, just as we still live in the Stone Age. Rich expectant mothers can not suffer from childbirth, while poor mothers still do as usual.]
In the early 20th century, an American female journalist wrote: Women appeal to doctors that if they can successfully free them from labor pain, they can save [half of human beings from this ancient torture, while the other half (men) will never understand this torture.]
By the 1950s, with childbirth becoming a product of institutionalization and standardization in European and American countries, [natural childbirth] without drug intervention was once again popular in the calls of parturients to regain their control over childbirth. The famous Ramez breathing method appeared at that time.
In the 1980s and 1990s, epidural analgesia (a kind of regional anesthesia) became popular for labor analgesia. According to the data at that time, between 1981 and 1997, the proportion of epidural analgesia for labor in major hospitals in the United States was 2/3.
Because she was lying in the hospital bed.
At first, China did not fall far behind. In 1964, through the analysis of 67 cases of [acquaintance-helped] labor analgesia, Dr. Zhang Guangbo made a report entitled “Continuous Epidural Anesthesia for Painless Labor” at the First National Anesthesia Academic Conference. Shortly after the report was published, the Cultural Revolution began.
Because it is suspected that labor analgesia in the early stage of labor may prolong labor, Increase the probability of cesarean section, In the last century, Most of the mainstream opinions in obstetrics and gynecology are that epidural analgesia is considered only when the uterine opening is more than 5cm. Until 2006, based on a large number of clinical research data, the American College of Obstetricians and Gynecologists and the American College of Anesthesiologists respectively issued clinical practice guidelines: [After the labor process starts, the parturient’s requirement for analgesia is the indication of labor analgesia (not the size of the uterine orifice)].
This is a great progress in obstetric anesthesia research after entering the new century.
However, in a 2004 Xinhua article, it was mentioned that [although the relevant technologies were mature 20 years ago, only about 10,000 of China’s 20 million mothers have enjoyed painless childbirth so far, accounting for less than 1%.]
According to a survey by Peking University Hospital, [only about 10 hospitals provide painless childbirth services all day long, while other hospitals either give up or only provide services to individual related households].
By chance, Dr. Hu Lingqun of the Department of Anesthesiology of Northwestern University’s Finnberg School of Medicine in Chicago was surprised to know the 1%. At that time, in the United States, the official labor analgesia rate was 61%.
After two years of preparation, In 2008, In the same year that China hosted the Olympics, The “Painless Delivery China Tour” team led by Hu Lingqun came to China. They hope to improve the utilization rate of painless childbirth in China through the education of medical staff and parturients, so that the utilization rate of painless childbirth among normal parturients in China can reach 10% within 10 years, resulting in a reduction in the rate of complications and mortality during childbirth and a reduction in the rate of cesarean section.
In the notes written by the players that year, Jennifer Jenkins, a maternity nurse from Ohio, was amazed by the calm and control of Chinese mothers in the face of labor pain, and also enjoyed the trust and respect given to her by the mothers here. She wrote: “Our American mothers’ expectations are getting higher and higher, and we are getting more and more impolite. Didn’t you ask me if I could have an epidural? It’s about what when the anesthesiologist came to give me epidural! Why did you wait so long? ]
[After the reform and opening up in the 1980s, labor analgesia and intensive care started again almost at the same time. By 2011, the former (intensive care) had spread to almost every hospital, while the latter (labor analgesia where anesthesiologists did not leave the delivery room 24 hours a day) had almost no.]
Why is painless childbirth such a state in China 30 years later? Hu Lingqun once threw the question to his two American friends, Harold Markowitz, an obstetrician at Boston’s Massachusetts General Hospital, and Pamela Fleur, director of obstetric anesthesia at the University of California, San Francisco School of Medicine.
[A man and a woman, an obstetrician, an anesthesiologist, two people in different places who do not know each other], but gave a strikingly similar answer: it depends on who is lying in the ward. [The delivery room is a lying-in woman, a group of women].
Dispute over Safety and Effect
In the 2008 painless labor team in China, Peng Mengmeng of the University of North Carolina, an interpreter with the team, recorded: “A doctor and I met a lying-in woman who politely refused labor analgesia while on duty. When asked why, the lying-in woman said that she had never heard of or knew anything about what, and I was about the same.”
[Here, many parturients, even medical staff, do not know the benefits of painless childbirth to mothers and infants, as if they are talking about negative things.] Peng Mengmeng wrote in his notes.
Although there is already a lot of evidence-based medical evidence to support the safety of painless childbirth, in order to avoid the so-called [adverse effects], a large number of Chinese choose cesarean section under severe labor pain.
In 2011, the People’s Daily mentioned that China’s cesarean section rate was 46.2%, ranking first in the world, and [fear of pain] was an important reason why many parturients required cesarean section.
Can painless childbirth really be completely painless? This involves a lot of numbers, As well as discretion. Among the analgesic effects expected to be achieved, professionals believe that the most ideal one is to feel uterine contraction but not pain, but in addition, due to dosage and individual differences, parturients will have various reactions: feel three points of pain, feel less than before, can walk labor analgesia, or, feel nothing.
A study in the United States around 2000 showed that about 12% of parturients could still feel pain with a pain index greater than 3, of which 6.8% started to be effective and became ineffective (as uterine contractions increased). In China, a statistical report from Liuzhou Maternal and Child Health Hospital showed that 89% of parturients could get completely satisfactory painless delivery in the whole process.
The biggest concern of Chinese parturients for painless childbirth lies in its safety. Will it have what effects on the fetus?
Huang Shaoqiang, director of the Department of Anesthesiology of Fudan University’s Affiliated Obstetrics and Gynecology Hospital (Shanghai Hongfang Obstetrics and Gynecology Hospital, hereinafter referred to as “Hongfang Hospital”), said: “The current concentration used for epidural anesthesia is only 1/5-1/10 of the concentration during surgical anesthesia, and the dose reaching the fetus is very small and its effect can be ignored.”
In a brochure prepared by the Director of Obstetrics at the Brigham Women’s Hospital at Harvard Medical School, Injecting drugs into the epidural space, Instead of directly entering the blood circulation, the drugs entering the fetus are extremely small. [Some of the drugs given orally, intramuscularly, intravenously and other ways used in the process of giving birth enter the fetus through the placenta. The biggest difference between epidural administration is the trace amount of fetal contact analgesic drugs, which is well known].
In that delivery room, most anesthesiologists are men-the labor intensity is too great.
Huang Shaoqiang told me some details of anesthesia, In the early stages of labor, only small doses and low concentrations are needed, At the end of the labor process, The contractions are getting stronger and stronger, The frequency is also becoming more and more frequent, What we usually do at this time is to increase the dose, However, sometimes the dose increase is not necessarily enough, What is needed at this time is actually to slightly increase the concentration]. However, due to human reasons, This is difficult to achieve, [we can only personalize as much as possible, but most of them may not be able to do it.] In this delivery room, about 60%-70% of the parturients can enjoy painless services, [except for contraindications, rapid labor progress, and some special personal reasons, basically, we will give them as long as required].
In Huang Shaoqiang’s office, I saw the epidural equipment described by many parturients as making people [from hell to heaven].
A small box like a lady’s handbag, Responsible for pumping anesthetic evenly into the body of the parturient, A thin wire is connected to a controller that can be pressed. Just in the palm of your hand, When the analgesic effect is insufficient, the parturient can pump in anesthetic drugs additionally. To enhance the anesthetic effect, there are also needle tubes and transparent hoses for puncture. During the operation, the parturient’s body is curled into a shrimp shape. The puncture needle passes through the spinal foramen in the waist of the parturient and introduces a small catheter into the epidural cavity, which is a potential cavity filled with nerve roots outside the spinal cord cavity.
During the day, the delivery room of Red House Hospital was not very busy-the night before, Five babies were born there. All morning, There are only a few parturients in the waiting bed, Quiet. This quietness is due to the adoption of painless childbirth. [Once upon a time, the delivery room can be heard from a distance. Kill me, doctor, give me a dissection], Mao Liping, head nurse of the delivery room, told me. The medical staff here carry a [pain degree numerical estimation table] in their pockets. If the parturient reaches more than 3 points of the above [moderate pain, mild sleep impact], labor analgesia can be carried out.
[Often, we ask the parturient, the pain level is 1-10, what level do you think you are? They replied, I think it’s 200, Give me no pain at once]. She said, [Once upon a time, when the mother was in pain, We go to comfort, communicate, In fact, it is relatively pale and weak. It is painless. The parturient will not shout, does not need to consume too much physical strength to resist pain, the productivity has been accumulated, and the degree of participation and cooperation is much better]. The midwife, who has worked in the Red House for more than 20 years, attaches great importance to the [participation] of the parturient in the delivery process. She believes that painless treatment has improved the participation of the parturient in the delivery process.
Will painless childbirth lengthen the labor process and lead to the need to switch to dissection? Xu Changen, director of the delivery room of the Red House Hospital, replied that he did not find this point. Instead, he felt that painless surgery might make the parturient’s uterus open faster. [Sometimes, As soon as my stomach hurts, It is easy for people to use their strength unconsciously. It’s too early to use your strength, Cervical blood flow is easily blocked, cervical swelling, opening the uterine opening is even more difficult. After painless, relaxed, the uterine opening will open faster.] At present, the cesarean section rate in Red House Hospital is about 35%, [there are various reasons for the reduction of cesarean section rate, but if there is no painless delivery, it is still hard to imagine the cesarean section rate to reach less than 40%], Xu Changen said.
In a survey involving different countries, multiple hospitals and 37,000 parturients, it was found that the epidural analgesia rate in some hospitals increased 5-10 times in a short period of time, but the cesarean section rate did not increase with it.
Another study based on the data of more than 20,000 cases in Shijiazhuang and more than 15,000 cases in Wenzhou found that after analgesia, the usage rate of forceps did not change, but the cesarean section rate decreased. Painless childbirth did not increase birth injuries, but reduced the birth injuries of mothers due to the sharp decline in the rate of lateral incision of mothers.
In addition to relieving pain, A 24-hour anesthesiologist will be assigned to each delivery room. Or to ensure safety. Hu Lingqun believes that Anesthesiologists in obstetrics are like guardians in ICU. Obstetricians are responsible for matters related to pregnancy and childbirth, while anesthesiologists are responsible for managing the pain of parturients and monitoring the vital signs of parturients. In fact, he hopes that through the promotion of painless childbirth and the development of obstetric anesthesia, team medicine, which has become the mainstream of perinatal medicine in the world, will be carried out to comprehensively improve the safety of mothers and infants.
There are many unexpected risks involved in childbirth, Common, Such as fetal distress or massive hemorrhage of the parturient, The International Journal of Obstetrics and Gynecology pointed out in a commentary that, First aid for childbirth is [the arch stone on the arch of safe motherhood]. In the anesthesiology circle in the United States, epidural analgesic tube is considered as an example of [predictive medicine]-the possibility of death for parturients undergoing cesarean section under general anesthesia is high, and if this [life-saving tube] is placed in advance, the safety of parturients will be more guaranteed.
In emergency situations, Immediate cesarean section that delivers the fetus as soon as possible, High-risk patients (such as the second child scar uterine vaginal trial) do not have epidural analgesia to escort, it is hard to imagine that it is necessary to avoid cesarean section as much as possible. Insurance companies in the United States even impose a mandatory stipulation that parturients must be in the delivery room with anesthesiologists stationed 24 hours a day before labor analgesia is required, and only scar uterine vaginal trial (after cesarean section) is allowed.
Obstetric anesthesia, which originates from labor analgesia and devotes itself to the safety of mothers and infants, begins with care for women and finally raises the safety of mothers and infants to a completely new level.
[If obstetric anesthesia is only targeted at labor analgesia and only focuses on reducing the cesarean section rate without medical indications, it is far from enough.]
In China, this is of particular practical significance. There was a cesarean section rate of 46.2% in the past year. After the two-child policy, that group of women once again became an important part of pregnant and lying-in women. It is of particular practical significance to develop obstetric anesthesia, carry out team medical treatment and popularize modern delivery rooms to fully open up for two children today.
Is it not cost-effective to reduce women’s pain?
For most Chinese parturients, [painless] is often a rare thing that can be met but cannot be found.
In an article in People’s Daily in 2004, the reason why painless childbirth technology is difficult to carry out was discussed, and anesthesiologists are lacking. The hospital needs to increase its investment, but the reduced cesarean section rate reduces the hospital’s income. The government department has adopted a strategy of not approving or opposing, [letting technology speak for itself].
At present, [painless childbirth] is usually regarded as a [luxury] rather than a basic medical need in China. Only a few regions, such as the Pearl River Delta, have included this technology in the scope of medical insurance. In some regions, painless childbirth has not even been included in the charging list.
Usually, painless childbirth in maternity specialist hospitals is better than that in general hospitals. It is said that this is because the anesthesia department of the general hospital needs to undertake the surgical anesthesia tasks of various departments, and it is difficult to separate manpower and energy to the delivery room to do (seemingly less urgent) labor analgesia work. However, critically ill parturients in general hospitals need the escort of obstetric anesthesia even more.
In “The Other Half of the Sky”, the author wrote helplessly: “Investment in pregnant women cannot be as cost-effective as other types of health work.”
From the perspective of the whole society, the greatest benefit of this technology is to reduce the pain suffered by women during childbirth, rather than to reduce the mortality rate-especially compared with vaccines and infectious disease prevention and control.
Because China has made remarkable achievements in reducing the maternal mortality rate, by 2012, China’s maternal mortality rate will reach a low value of 24.5 per 100,000.
In China’s current public policy evaluation system, The reduction of mortality rate is an important indicator-the existing data show that anesthesiologists can reduce the maternal mortality rate when entering the delivery room, but under the current maternal mortality rate base, this reduction is not so obvious-the improvement of women’s comfort level does not seem to be in this consideration category.
As far as hospitals are concerned, it needs to increase the investment in delivery rooms and anesthesiologists, and it hardly brings what output. As a result, labor analgesia has become an uneconomical input for a single hospital.
Why should painless childbirth be promoted?
[The biggest worry of a woman about giving birth is pain, As a manager, if you look at it from the patient’s point of view, you won’t feel uneconomical.] Duan Tao, former president of Shanghai No.1 Maternal and Infant Health Hospital, replied. Just as Simpson asserted in the last century that labor analgesia is only a matter of time, Duan Tao is also confident that the technology will be included in the charging list and the medical insurance list.
The American College of Obstetrics and Gynecology wrote in a 2004 consensus document: “Delivery causes most parturients severe pain. It is inhumane to let parturients experience such severe pain under the eyes of our doctors without giving analgesic treatment that has been proved to be safe and effective.”
Also in 2004, at the end of the Xinhua News Agency article on painless childbirth, Li Yinhe, an expert from the Chinese Academy of Social Sciences, was quoted as saying: “Whether a parturient gives birth is painful or not reflects the civilization of a society. Alleviating the pain for a parturient is a respect for the individual life and also reflects a fertility civilization.”