A History of Pain Relief During Childbirth

Fig. 62.1

a Scottish obstetrician James Young Simpson was the first to use inhalation anesthesia (ether) for labor pain relief. Shortly thereafter he discovered the anesthetizing capacity of chloroform and applied it, too, for labor pain relief. (Courtesy ofhttp://commons.wikimedia.org/wiki/File:Princes_St_Gardens_James_Young_Simpson.jpg)b Dining room of the home of James Young Simpson, in Edinburgh, Scotland, where the initial experiments with anesthetic and euphoric properties of chloroform were noted by Simpson and his friends. (Courtesy of the author)

The First Women to Benefit from Anesthesia: The Royal and the Wealthy

In 1853, Queen Victoria’s use of chloroform to relieve her labor pain during the birth of her eighth child, Prince Leopold, ended any lingering moral opposition to the relief of pain during childbirth. She also received chloroform in 1857 for the birth of her ninth child, Princess Beatrice. It is reported by the Queen’s biographer, Elisabeth Longford, that she wrote in her diary after the delivery of Prince Leopold: “Dr. Snow gave the blessed chloroform and the effect was soothing, quieting and delightful beyond measure.”

Those fortunate enough to find a physician willing to provide chloroform or ether soon followed the Queen’s example. Women with political and economic power began to challenge the medical establishment, demanding pain relief during childbirth in particular, and better maternal and infant care for all women.

In England there was a literary connection [10]:

“Mrs. Charles Dickens was expecting her eighth child in 1849. Her husband first ‘made himself thoroughly acquainted in Edinburgh with the facts of chloroform’, and then (as described in a letter to a friend) he insisted on the attendance of a gentleman from Bart’s Hospital who administers it in the operations there and has given it four or five thousand times. It saved her all pain (she had no sensation, but of a great display of sky-rockets) and saved the child from all mutilation. It enabled the doctors to do in ten minutes what might otherwise have taken them one and a half hours; the shock to her nervous system was reduced to nothing, and she was to all intents and purposes well, next day. Administered by someone who has nothing else to do, who knows its symptoms thoroughly, who keeps his hand upon the pulse and his eyes upon the face, and uses nothing but a handkerchief, and that lightly, I am convinced that it is as safe in its administration as it is miraculous in its effects.”

Obviously, the anesthetist from Bart’s (St. Bartholomew’s) was John Snow.

“I feel proud to be the pioneer to less suffering. This is certainly the greatest blessing of this age and I am glad to have lived at the time of its coming…” Fanny Appleton Longfellow. 1847, Cambridge Massachusetts [11]

The first American woman to use analgesia during childbirth was Fanny Appleton Longfellow (1817–1861), wife of the famous poet and scholar, Henry Wadsworth Longfellow [12]. For aid in her third delivery, Fanny Longfellow sought out a prominent physician, Nathan Keep (1800–1875), who had experience in the use of ether, and became the Dean of Dentistry at Harvard [11]. In 1847, while under the influence of ether, Fanny Longfellow gave birth to a little girl (also named Fanny) in Cambridge, Massachusetts, and enthusiastically endorsed the use of this new pain relieving substance (see box). Boston, Massachusetts continued to pioneer American obstetric anesthesia; a colleague of Keep’s, Walter Channing (1786–1876), gained great popularity with his use of ether to relieve childbirth pains (Fig. 62.2). Channing was from an aristocratic New England family [13]. His brother, William Ellery Channing (1780–1842), founded the Unitarian Church, and his grandfather, William Ellery (1727–1820), was a Supreme Court Judge of Rhode Island and a signatory of the Declaration of Independence. Not all these fellows were upright citizens. Harvard College expelled Walter for his participation in a notorious food fight, known as the “Rotten Cabbage Rebellion of 1807”, a student-led protest concerning the poor quality of the food served in the dormitories. Harvard College has a long tradition of student-led revolts, and a tree, planted in the late 1700s, at the East end of Hollis Hall, is known as the “Rebellion Elm” (protests often centered around this tree).

Fig. 62.2

Walter Channing, American professor of midwifery and sometime Dean at Harvard was an early advocate of ether inhalation for labor pain relief. He assisted in the founding of the Boston Lying-In Hospital. (Courtesy of Brigham and Women’s Hospital, Boston)

After finishing his medical education at the University of Pennsylvania in 1812, Walter Channing returned to Harvard Medical School to become Professor of Obstetrics and Medical Jurisprudence, and then the first Dean of the Medical School, (1816–1847). In 1832, he assisted with the founding of the Boston Lying-In Hospital, a forerunner of today’s Brigham & Women’s Hospital. Channing detailed his extensive experience with ether during childbirth, in his 1848 book entitled “A Treatise on Etherization in Childbirth” [11]. Note that Channing and Keep, the first Deans of both Harvard Medical School and Harvard Dental School respectively (although the term was not used until years later) were anesthesiologists, largely remembered for their work in obstetric pain relief. They reflect the strong tradition of prominent physician practice of pharmacological means of pain relief.

Obstetric Anesthesia From the Start of the Twentieth Century to the Present

Two interconnected threads led to the advancement of obstetric anesthesia from the beginning of the twentieth century to the present. First was the movement to assure pain relief during labor, a movement that took several forms. Some approaches had pain prevention as the immediate goal; others acted as a distraction. Pain prevention included administration of opioids; administration of inhaled anesthetics, particularly ether, chloroform and nitrous oxide, but also ethylene, trichloroethylene, methoxyflurane, and cyclopropane; and finally (and dominant today), administration of epidural analgesia. The application of epidural analgesia required development of methods of anesthetic delivery that provided analgesia with minimal interference in the progress of birth. Second was the movement to give women greater control over their participation in the delivery experience. It increased participation of the father in the birth process.

Women’s Struggle for Pain Relief During Childbirth in the Early 1900s

In the US and Britain, shortly after the discovery of anesthesia, the quest for pain relief during childbirth became aligned with women’s advocacy for the advancement of their own political and economic power. This included demands for better health care for themselves and their children, improved maternal and child health, and a less painful birth experience. Because of the absence of medical birth control, women had many children and spent much of their adulthood pregnant.

Well into the early 1900s, childbirth remained dangerous for women throughout the world, even in medically advanced countries. Physicians contributed to the high mortality rate of women and infants by not washing their hands after examining and treating patients, particularly after conducting autopsies on patients dying from infection. They thereby facilitated the spread of the infectious disease also known as “puerperal”, or “childbed” fever. Ignaz Semmelweis (1818–1865), a Hungarian physician, noted in 1847 that far fewer women died from puerperal fever in midwife-led wards (where no autopsies where performed), than in physician-led wards. His observation preceded the germ theory of infectious disease, and was thus without explanation. Semmelweis’ simple admonition to wash the hands offended contemporary physicians (doctors were considered clean, not “dirty”), who ridiculed him. However, even before the advancement of the germ theory, physicians eventually recognized that they might spread infections from one patient to another, and increasingly washed their hands. The number of women dying from infection markedly decreased. Years later, when Pasteur’s and Lister’s studies explained these results, Semmelweis was given full credit for his insightful observations. As an aside, the Semmelweis Reflex is a rejection of a new idea that confronts what may be thought of “conventional wisdom” in this case that doctors were considered clean and thus not possibly a source of disease.

Women’s rights leaders in the US and Britain fought for a more humane birth experience for all women, not just the wealthy few. During the mid to late 1800s, and well into the early 1900s, only wealthy and well-connected women could benefit from the new “miracle” of a pain-free birth. Several organizations (see below) sought to remedy this social injustice.

“One of the most cruel class divisions yet remaining in this country is that rich mothers need not suffer in childbirth as though we were still in the Stone Age, while poorer ones far too often do.” A letter from a British writer, which appeared in the publication, “The Lady,” in 1942 [14].

The slowness of the medical establishment to make anesthesia widely available during childbirth frustrated early feminists who championed improved healthcare for all women and children. Some physicians believed that the risks to the mother and infant outweighed the benefits of pain relief, fearing, with good cause, that anesthesia could produce unintended side effects on both mother and newborn. Moreover, some physicians believed that pain was a natural part of the birth process. For example, a noted Russian surgeon who performed the first thyroid surgery under ether anesthesia, Nicolai Pirigoff, (1810–1881) claimed: “Haven’t midwives and parturients and indeed all others always viewed the agonies of delivery as an indicator of safety and a well-nigh holy accompaniment of childbirth?” [4] Charles Meigs (1792–1869), one of the most prominent American physicians of the nineteenth century, an outspoken opponent of pain relief in childbirth, and noted for making inflammatory social and cultural comments, pointed out that the “pain of labor had never been great enough to prevent women from having more children” [4]. Several political organizations consequently arose to overcome physician resistance toward the use of anesthesia during childbirth.

In the early 1900s, American journalists, Marguerite Tracy and Constance Leupp, wrote that the success of the campaign undertaken by women urging physicians to rid women of labor pain would,“relieve one-half of humanity from its antique burden of suffering which the other half of humanity has never understood.”[4]

The National Twilight Sleep Association

In 1914, several wealthy and politically influential US women formed an organization that sought to bring to all women in the US, a new pain relief technique, reportedly used with success in Europe in the first decade of the twentieth century. The Twilight Sleep method of pain relief combined morphine and scopolamine. Morphine dulled the pain and scopolamine produced memory loss, but had the unintended side effect of lowering women’s inhibitions. Laboring women given “twilight sleep” might exhibit bizarre and uncontrolled behavior. The small amount of morphine used was often ineffective against the pain, and women might thrash and scream wildly. (“As an intern, I well recall ordering an intramuscular injection of 10 mg morphine and 0.6 mg scopolamine for a laboring woman who later bit me as I tried to restrain her from climbing over the side rails and who later described the entire experience as absolutely without any discomfort’for her but not me!”Personal communication, Lawrence J. Saidman). Unaware of the pain they endured due to the amnesia produced by scopolamine, women often reported a pain free birth experience.

The women who formed the National Twilight Sleep Association successfully campaigned for the use of this technique during childbirth [4]. They held rallies and inspired women to demand that the medical establishment provide twilight sleep’or some form of pain relief’for all laboring women. Their well-organized, well-funded efforts had one critical flaw: twilight sleep didnot consistently provide adequate pain relief although the scopolamine usually (not always) erased the memory of labor pain. Physicians often put cotton and oil in patient’s ears, and blindfolded them to reduce perception of stimuli, but of course the bigger stimulus was that of labor. Often women were restrained to prevent harm to themselves or others. Of note, the husbands were sequestered in waiting rooms, unaware of all this activity. When one of its most prominent and outspoken advocates (Mrs. Francis X Carmody) died during childbirth in 1915, after receiving this method of pain relief, the National Twilight Sleep Association came to an end. Although twilight sleep probably did not contribute to her death, (which may have been caused by hemorrhage), this tragic event fueled a rising public concern about its safety. Nonetheless, some US hospitals continued to use twilight sleep until the 1960s.

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