Effectively Managing Pain During Childbirth

1
Effectively Managing Pain During Childbirth

• Kristi Saxon RNC, CNM, MSN

2
Objectives

• The participant will understand the physiology of
  pain experienced during the intrapartum period.
• The participant will be able to identify both
  nonpharmacologic and pharmacologic approaches for
  the management of pain during the intrapartum
  period, including which methods are
  evidence-based.

3
Labor and Childbirth Pain

• Normal
• physiological
• phenomenon

4
(No Transcript)
5
Physiology of Labor Pain
6
Visceral Pain

• Occurs during 1st stage of labor
• Diffuse abdominal cramping and uterine
  contractions
• Caused by uterine distention and stretching of
  the cervix
• These stimuli are transmitted to the spinal cord
  at the level of the tenth thoracic to the first
  lumbar root
• Often felt in a different part of the body than
  from where it originated

7
(No Transcript)
8
Somatic Pain

• Occurs in 2nd stage of labor
• Sharper, stinging, more continuous type of pain
• Usually in the vagina, rectum, and perineum
• Due to stretching of the structures of the lower
  birth canal
• Caused by the descent of the fetus
• These stimuli are transmitted via the pudendal
  nerve to the second to fourth sacral nerves
• Accompanied by a very powerful urge to push, or
  bear down

9
(No Transcript)
10
Pain of Nulliparous Women

• Experience more sensory pain during early labor
• More often describe pain as severe, intense,
  or very painful than multiparous women
• Pain reports were less when antenatal classes to
  prepare for labor pain were taken

11
(No Transcript)
12
Pain of Multiparous Women

• Experience more intense pain during the late
  first stage and the second stage of labor
• Most pain a result of rapid fetal descent

13
Factors that influencepain perception

• Cultural values and learned behaviors
• Womens expectations about labor pain
• Birth environment
• Physiologic and psychosocial influences

14
Cultural values andlearned behaviors

• Caucasian women want nurture and support during
  labor most believe highly in pharmacologic
  management of labor pain
• Hispanic women moan and rub thighs and abdomen
  rhythmically
• Haitian women use massage, movement and
  position changes reluctant to accept pain
  medication
• Filipino women believe that noise and activity
  around them during labor increases labor pain
• African American women more vocally expressive
  of pain often surrounded by female family
  members or friends
• American Indian women stoic use meditation,
  self-control and traditional herbs to manage pain
• Puerto Rican women often very emotive and
  verbally express labor pain

15
Womens Expectations

• Anxiety and fear of pain correlate with a higher
  reported experience of pain
• According to Grantly Dick Read Anxiety about
  the pain of labour was a strong predictor of
  negative experiences during labour, lack of
  satisfaction with the birth, and poor emotional
  well-being postnatally.
• A womans confidence in her ability to cope with
  labor pain is the best predictor of pain during
  the first stage of labor
• Past experiences of labor pain can affect
  subsequent pregnancies either positively or
  negatively

16
Birth Environment

• Should foster a sense of comfort and privacy
• Surrounded by as many or as few individuals as
  desired
• Relationship with caregivers important
• Amount of support received from caregiver
• Quality of relationship with caregiver
• Involvement with decision-making

17
Physiologic and Psychologic Influences

• Fear
• Anxiety
• Confidence
• Mental preparedness
• Helplessness or loss of control
• Lack of support system
• Insufficient resources for coping with labor
• Fear of death of self or baby
• Hunger
• Fatigue

18

• Nonpharmacologic
• Approaches
• To
• Labor Pain
• Management

19
Continuous Labor Support

• Refers to non-medical care of the laboring woman
  throughout labor and birth by a trained person,
  usually a doula
• Labor support includes continuous presence,
  emotional support, physical comforting,
  information and guidance for the woman and her
  partner, facilitation of communication,
  nonmedical information and advice, anticipatory
  guidance, and explanations of procedures.

20
Continuous Labor Support

• Cochrane meta-analysis
• 15 RCTs
• 12,791 women
• Found a decrease in operative vaginal deliveries,
  cesarean deliveries, and request for analgesia or
  anesthesia
• Less likely to report dissatisfaction or a
  negative rating of their birth experience

21
Warm Water Baths

• Involves immersion in warm water deep enough to
  cover the womans abdomen
• Cochrane analysis
• 8 RCTs
• 2939 women
• Women who used water immersion during the first
  stage of labor reported statistically
  significantly less pain than those not laboring
  in water
• Also, statistically significant reduction in the
  use of analgesia/anesthesia
• No adverse outcomes on labor duration, operative
  delivery, or neonatal outcomes

22
Intradermal Water Injections

• Used to decrease low back pain in labor
• 4 intradermal injections of 0.05-0.1mL sterile
  water (using a 1-mL syringe with a 25-guage
  needle)
• Injection over each posterior superior iliac
  spine and 2 others placed 3cm below and 1cm
  medial to each of the first sites.
• 4 RCTS (451 women)
• Effectively reduced severe low back pain
• Pain relief lasted 45-120 minutes
• Women still used other medications
• Maternal satisfaction with this method varies
• More research needed

23
Maternal Movement and Positioning

• Limited research available
• However, several descriptive studies report pain
  reduction and enhanced satisfaction from freedom
  of movement during labor and birth
• Most women prefer upright positions over sitting
  or supine
• Authors of Cochrane review concluded that there
  is no indication of harm from upright positions
  during second stage and that women should be
  allowed to make informed choices about the birth
  positionsthey might wish to assume for delivery
  of their babies.

24
Touch and Massage

• Used during labor to enhance relaxation and
  reduce pain and suffering
• 3 RCTs (1 on touch and 2 on massage)
• Touch RCT
• 90 women
• Blood pressure and expressions of anxiety
  significantly decreased in the touch group
• Massage RCTs
• 28 women
• Reduced pain and anxiety
• Improved mood
• 60 women
• Significantly lower pain reactions in the latent,
  active and transitional phases of labor
• Drawbacks
• Partners must be taught appropriate massage
  techniques before labor or during labor by a
  skilled doula, midwife, or massage therapist
• However, these studies indicate that women
  appreciate being touched and massaged during
  labor, and these simple interventions may reduce
  pain and enhance feelings of well-being

25
Acupuncture
26
Acupuncture

• 3 RCTs
• 598 women
• Not proven to be statistically more effective
  than controls
• More large studies needed

27
Acupressure

• Pressure is applied simultaneously to both sides
  of the spine in the lower back
• Force is initially applied during contractions
  and then continuously
• 2 RCTs
• 202 women total
• Significantly decreased reports of labor pain in
  both studies
• Also, one of the studies reported a significantly
  shorter labor time

28
Aromatherapy

• The science of using highly concentrated
  essential oils or essences distilled from plants
  in order to utilize their therapeutic properties
• Lavender, rose, jasmine, juniper, geranium or
  frankincense used to relieve anxiety and fear
• No properly controlled trials available

29
Music and Audioanalgesia

• The use of auditory stimulation, such as music,
  white noise, or environmental sounds to decrease
  pain perception
• 1 RCT by Phumdoung Good
• 110 primiparous women
• 55 women assigned to soft music group for 3
  hours, 55 women in control group
• Pain measured before starting the study and every
  3 hours
• Women in the music group had significantly less
  sensation of pain
• More RCTs needed

30
Childbirth Education

• Individual or group classes designed to inform
  pregnant women and their partners about labor and
  birth, early parenthood, and infant feeding
• Insufficient evidence (no recent trials) on
  influence of childbirth education on pain

31
Breathing Techniques

• Often presented during childbirth education
  classes
• Intended to complement and promote relaxation or
  to provide distraction from labor pain
• Have not been studied as independent variables in
  RCTs

32
Transcutaneous Electrical Nerve Stimulation
(TENS)

• Transmission of low-voltage electrical impulses
  from a handheld battery-powered generator to the
  skin via surface electrodes
• Pair of electrodes placed paravertebrally at
  levels of T10-L1 and at S2 to S4
• Controlled by laboring woman
• Causes a buzzing or prickling sensation that may
  reduce awareness of contraction pain
• A meta-analysis 10 RCTs in 877 women, 436
  receiving TENS and 441 as controls, revealed no
  significant difference in pain and the use of
  additional analgesic interventions was not
  different between the two groups

33
Hypnosis

• A state of focused concentration in which
  suggestions may be made, focusing on diminishing
  awareness of pain, fear and anxiety
• Cochrane review of 3 RCTs
• 172 women total
• 1 trial found no difference between hypnosis and
  control groups
• 1 trial found a decrease in the use of anesthesia
• 1 trial found a decrease in the use of narcotics
• Overall, insufficient evidence of reduced use of
  pain relief medications among women receiving
  hypnosis
• Contraindicated in persons with any history of
  psychosis

34
Pharmacologic Approachesto Labor Pain Management
35
Systemic Narcotics

• Drugs given intravenously or intramuscularly
• Demerol, Morphine, Fentanyl, Stadol, Nubain most
  commonly used
• Usually given in intermittent doses at the
  patients request
• Primary mechanism of action is heavy sedation
• Review by Dr. Leanne Bricker and Tina Lavender
• Included 48 RCTs examining safety and
  effectiveness of opioids for labor pain relief
• Most trials compared opioid with opioid, but some
  compared opioid with epidural and opioid with
  paracervical block
• Not significantly effective for maternal pain
  relief
• If opioids must be used, Demerol is agent of
  choice because of its familiarity to caregivers
  throughout the world and relatively inexpensive
• Most women go on to have epidural anesthesia
• More research needed

36
Nitrous Oxide

• Inhalation anesthetic
• Flexible method can be used intermittently
• Takes effect in about 50 seconds
• Review by Dr. Mark A. Rosen
• 11 RCTs reviewed
• Difficult to compare and summarize
• Majority of women rated pain relief as high and
  would use method again
• In summary not as effective as epidural
  equally effective as paracervical block more
  effective than opioids
• More research needed

37
Paracervical Block

• Local bilateral injection near the cervix
• Given during 1st stage of labor
• Lasts about 2 hours
• Rarely used in U.S.
• Research review by Dr. Mark A. Rosen
• 4 RCTs reviewed
• effective and relatively simple technique,
  although the skill and experience of the operator
  are among the most important variables related to
  both efficacy and safety
• Further research needed

38
Epidural Anesthesia

• Central nerve block technique achieved by
  injection of a local anesthetic close to the
  nerves that transmit pain

39
Epidural Anesthesia

• Most widely used method of pain management in
  labor
• Cochrane review of 21 studies
• Epidural analgesia is effective in reducing pain
  during labor

40
Conclusion

• Effective
• Nonpharmacologic
• Methods
• Continuous Labor Support
• Warm Water Baths
• Intradermal Water Injections
• Maternal Movement and Positioning
• Massage
• Acupressure
• Music Therapy

• Effective
• Pharmacologic
• Methods
• Nitrous Oxide
• Paracervical Block
• Epidural

41
(No Transcript)
42
References

• Anim-Somuah, M., Smyth, R., Howell, C. (2005).
  Epidural versus non-epidural or no analgesia in
  labour Review. The Cochrane Database of
  Systematic Reviews, 4, 2005.
• Caton, D., Corry, M. P., Frigoletto, F. D.,
  Hopkins, D. P., Lieberman, E., Mayberry, L., et
  al. (2002). The nature and management of labor
  pain Executive summary. American Journal of
  Obstetrics and Gynecology, 186(5), S1-S15.
• Cluett, E. R., Nikodem, V. C., McCandlish, R. E.,
  Burns, E. (2002). Immersion in water in
  pregnancy, labour and birth Review. The
  Cochrane Database of Systematic Reviews, 2, 2002.
• Hodnett, E. D., Downe, S., Edwards, N., Walsh,
  D. (2005). Home-like versus conventional
  institutional settings for birth Review. The
  Cochrane Database of Systematic Reviews, 1, 2005.
• Lee, H. Ernst, E. (2004). Acupuncture for
  labor pain management A systematic review.
  American Journal of Obstetrics and Gynecology,
  191, 1573-1579.
• Leeman, L., Fontaine, P., King, V., Klein, M.,
  Ratcliffe, S. (2003). The nature and management
  of labor pain Part 1. nonpharmacologic pain
  relief, 68(6), 1109-1112.
• Marmor, T. R. Krol, D. M. (2002). Labor pain
  management in the United States Understanding
  patterns and the issue of choice. American
  Journal of Obstetrics Gynecology, 186,
  S173-180.
• Simpkin, P. Bolding, A. (2004). Update on
  nonpharmacologic approaches to relieve labor pain
  and prevent suffering. Journal of Midwifery
  Womens Health, 49(6), 489-504.
• Simpson, K. R. Creehan, P. A. (2007).
  Perinatal Nursing (3rd ed.). New York
  Lippincott Williams Wilkins
• The CNM Data Group, 1996. (1998). Midwifery
  management of pain in labor. Journal of
  Midwifery and Womens Health, 43(2), 77-82.
• Tournaire, M. Theau-Yonneau, A. (2007).
  Complementary and alternative approaches to pain
  relief during labor. Evidence-based
  Complementary and Alternative Medicine, 4(4),
  409-417.
• Trout, K. K. (2004). The neuromatrix theory of
  pain Implications for selected nonpharmacologic
  methods of pain relief for labor. Journal of
  Midwifery and Womens Health, 49(6), 482-488.