Many women are going into labour vastly underestimating how painful it can be and overly optimistic that they will be able to manage without drugs, a study suggests. How has this happened?
By Clare Murphy
Health reporter, BBC News website
Has pain relief during labour been demonised?
Researchers at the University of Newcastle who looked at evidence from the UK and beyond found significant discrepancies between women's expectations of labour and their actual experience.
In England around a quarter of women who give birth end up having an epidural, the spinal analgesia which eliminates the pain of contractions, although many did not plan on having one.
Growing emphasis on birth as an entirely natural process - which may be better carried out in your front-room than in a labour ward - also means many women feel they have somehow failed if they end up rapidly making their way through every form of pain relief available.
Campaigners fought hard for many years to "demedicalise" childbirth and reduce the number of unpleasant, invasive, and potentially unnecessary procedures many women were subjected to in the course of delivering their child.
But there are fears the pendulum may now have swung too far the other way, with the many advantages of modern medicine forgotten in the desire to take the process back to basics.
After all, you wouldn't have your teeth pulled without an anaesthetic, so why would you embark on something as major as childbirth simply preparing to grit them?
Much evidence suggests, however, that women who are well supported by midwives and partners throughout their labour and made to feel at ease are the ones who manage their pain the most effectively and require the fewest drugs.
Tens machines: electrical pulses help block the body's pain signals
Entonox (gas and air): takes the edge off contractions
Pethidine: an opioid which may make mother and baby sleepy
Epidural: a spinal analgesia which numbs the lower half of the body
But even with all the helping hands she may wish for, a woman needs to be aware that this is sometimes simply not enough, the Newcastle team concluded.
"Of course it is important to have hopes for how you would like your labour to be.
"But those involved in providing ante-natal sessions, while listening to these, need to make sure that women are aware of how things may go and help them construct realistic expectations," says Joanne Lally, who led the research.
"You shouldn't have to feel a failure because you've ended up with a lot of pain relief.
"The problem with some of the courses out there is that they concentrate so much on doing it naturally that inevitably women feel as though they've done something wrong when those techniques simply aren't enough for them."
The National Childbirth Trust is one the major private providers of ante-natal classes in the UK, seeing perhaps as many as a quarter of all women preparing to give birth and also carrying out instruction on behalf of the NHS.
The NCT classifies "normal" birth as one which does not involve anaesthetic and would like to see a reduction in the use of epidurals, although it insists this does not mean it is against the use of pain-relief.
"We have campaigned for a long time for normal birth, and the bottom line is that we encourage women to have confidence in themselves and their bodies," says Gillian Fletcher, a former president of the NCT.
"But that doesn't mean we don't talk about pain relief in our ante-natal sessions.
"We help women weigh up the pros and cons of every method. Of course epidurals are brought up - but we do make clear that if you have one you are two to three times more likely to end with a forceps delivery."
"What's crucial is that women are ready to negotiate with their midwife, and don't find themselves lying flat on the bed, which we now know is a sure way to a more difficult experience."
But regardless of the content of ante-natal sessions - be they provided privately or by the NHS - women themselves should perhaps be less competitive with each other about how they give birth, argues Anna Davidson of the Birth Trauma Association.
"Ante-natal sessions do need to be more realistic - perhaps including women who have given birth and had very different experiences. But mothers themselves need to stop being so gladiatorial about what they managed to endure.
"We sometimes seem to forget that while childbirth is natural, women in the past regularly died as a result of it, and we should be a bit more positive about the advances medicine has brought us."
One obstetrician believes the tide is perhaps turning yet again.
"I have seen many women in the last decade with completely unrealistic expectations, who end up incredibly disappointed when they have not been able to give birth without significant pain relief," says Patrick O'Brien, a consultant and spokesman for the Royal College of Obstetricians and Gynaecologists.
"But I get the feeling that things have started to change, and more women realise there is only so much you can plan for.
"Find out about aromatherapy - but find out about epidurals too - and prepare to be flexible. I do think that message is getting through."