Fetal Pain: Life in Troubled Waters

Abstract

Maternal well-being is the key to fetal well-being. A fetus is highly vulnerable and sensitive to pain and stress, and exposure has the potential for negative developmental consequences. Childbirth educators can help raise parental awareness about the importance of the maternal environment for best outcomes in fetal development.

READER'S QUESTION

Expectant parents in my childbirth class have asked whether their fetus can feel pain. I know that there has been controversy over whether newborns feel pain. What should I tell expectant parents about fetal pain? Does it even matter?

– A childbirth educator in Virginia

COLUMNIST'S REPLY

Yes, Virginia, there is pain, and it does matter. Although it may be true that fetal pain is difficult to measure—especially if you define pain as the subjective perception of the individual experiencing it—fetal pain and newborn pain are real. In 2004, The Journal of Perinatal Education published a definitive review of the research on pain processing and the neuronal consequences of pain in the very young (Page, 2004). The review's author, Dr. Gayle Page of Johns Hopkins University, states that identifying pain is “even more challenging when its victims are very young or preverbal” (p. 10). When someone cannot tell you in words about his or her pain, does that mean he or she has no pain?

Furthermore, I think fetal or newborn pain matters, and it appears that your expectant parents may think so also. You are correct that, in the past, many caregivers believed human fetuses and newborns did not feel pain. Their belief was in spite of the physical response of newborns to pain from such procedures as circumcision—a response consistent with body language that we all associate with pain. As a nurse, I was reassured many, many times by highly educated physicians (and nurses), well into the 1990s, that the behavior of my infant patients during circumcision that bothered me so much was not a reaction to pain, only “reflexes,” and that if infants had pain, it did not matter because they would not remember it.

The response of a fetus or a newborn to pain does not appear to be identical to that of an adult. The neural pathways of fetuses lack fully developed pain-inhibitory systems (Joseph, Brill, & Zeltzer, 1999), which means they are not capable of interpreting pain the way adults do. For them, localized pain is not felt as localized, but as global. Nociceptive pathways (the nervous system route that transmits pain to the brain) appear to be developed by 22–24 weeks in fetuses (Joseph et al., 1999). The belief that fetal behavior (e.g., changes in activity level) and biochemical measures of stress strongly suggest that fetuses and newborns “feel no pain” is not true (Anand & The International Evidence-Based Group for Neonatal Pain, 2001; Anand et al., 2006). It is, in fact, a tragic medical myth, one that professional groups such as the American Academy of Pediatrics (2000) and the National Association of Neonatal Nurses (Atimier, Brown, & Tedeschi, 2006) have worked in recent years to debunk.

The neural pathways of fetuses lack fully developed pain-inhibitory systems, which means they are not capable of interpreting pain the way adults do. For them, localized pain is not felt as localized, but as global.

In her review, Dr. Page demonstrates that infants not only feel pain, but they also experience negative, long-term physiologic effects from pain. Infants may also have long-term memories of pain, suggesting that the same is true for a fetus. Parents giving permission for medical procedures have often not been advised of this as a risk or as a disadvantage of the procedures. As childbirth educators, I think our duty to advise parents of the risks of pain and distress for newborns extends to the intrauterine environment of the fetus.

We know a hostile intrauterine environment increases the risk of such negative outcomes of pregnancy as preterm labor, premature rupture of membranes, and retarded fetal growth. Less obvious is that uterine environment can affect all aspects of growth and development of the sensitive fetus, even the development of temperament. What is temperament? Temperament may be a reflection of neurological development. It refers to some of the character traits that each of us exhibits. For example, do you need a lot of sleep or just a little? Are you reactive or calm? Are you spontaneous or very regular and predictable? Because we can identify traits like these from birth, they may have both genetic and prenatal environmental components. Women who experience high stress or emotional distress during pregnancy have different chemicals released into their bloodstreams than pregnant women who are safe and content. This means that the infants of troubled mothers may be floating in troubled waters.

Women who experience high stress or emotional distress during pregnancy have different chemicals released into their bloodstreams than pregnant women who are safe and content. This means that the infants of troubled mothers may be floating in troubled waters.

As caregivers, some of us may think we have no control over fetal pain and stress and no way to intervene. However, that is also not true. What are some of the causes of maternal biochemically induced intrauterine troubled waters? They are anything that causes distress for the expectant mother. Domestic abuse and drugs are extreme, but real, examples of causes of intrauterine violence on the fetus through the mother. A lack of physical affection and the absence of emotional support and acceptance from a caring and intimate partner or family member may also result in maternal distress, leading to global fetal distress.

Oratory stimulation leads to various responses in the fetus, including changing levels of activity and vital signs; thus, we know the fetus is a sensitive being. Tools to measure infant pain, such as the Neonatal/Infant Pain Scale, will help caregivers assess pain and study pain in the very young (Lawrence et al., 1993). Clearly, a need exists for ongoing studies on the critical topic of fetal pain and stress and their consequences for fetal development. Future research will provide us with a growing basis for best prenatal practices, as well as the best advice for parents.

Clearly, a need exists for ongoing studies on the critical topic of fetal pain and stress and their consequences for fetal development.

In the meantime, the best evidence now supports the conclusion that newborns and fetuses experience pain and that pain is not supportive of the best outcomes in their development. One way to reduce pain and distress in a fetus is to reduce the pain and distress experienced by expectant mothers. A healthy mother makes a healthy baby; a happy mother makes a happy baby; and a happy mother is more likely to have a happy and healthy baby.

The saying that “if Mama ain't happy, ain't nobody happy!” may be more true than we ever realized. Most parents are aware that the physical health of the mother is important for the fetus. However, who warns expectant women and their families of the possible dangers of maternal emotional distress or abuse to the development of the fetus? Those of us who work with new mothers are aware of the need to nurture each woman physically and emotionally, so she can nurture her newborn. Who informs the family of the need to emotionally nurture the expectant mother, in order to protect and nurture her developing fetus? If not you, the childbirth educator, then who?

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