Pain, Women's Health, Infant and Children | May 24, 2016 | Author: The Super Pharmacist
Childbirth pain is an expected and normal part of giving birth. Although the intensity of labour pain varies considerably from woman to woman, and even from pregnancy to pregnancy, labour has been described as the most severe pain experienced by many women. Only a minority of women describes pain of low intensity.
Labour pain could be considered higher than other clinical syndromes such as back pain, arthritis, neuralgia and cancer, according to one study.1 However, the pain scores in this study had a wide range and were influenced by several variables. First time mums, mothers with a history of menstrual difficulties and mothers from a lower socioeconomic status showed higher pain levels. Although first time mums who received prepared childbirth training had lower pain scores, but still requested epidural anesthesia.
Another study reported that the average intensity of pain was high, with 60% of women reporting labour pain as being the most intense pain they had ever experienced.2
Studies have demonstrated that the mother's age, socioeconomic status, educational level, parity, history of dysmenorrhea or abortion, physique and physical strength, the newborn's body weight, sex, gestational age, type of delivery, and the duration of the first and second stages of labour influence the intensity of pain experienced by the mother.3-5.
Psychological factors such as anxiety and fear related to the labour process also influenced the perceived severity of labour pain.
Factors associated with greater anxiety and fear include:
The ability to cope with labour pain may be enhanced by the support of partner, midwife or pregnancy support group, and anxiety can be reduced with pre-childbirth education.6
A wide range of pain management methods are used by women during childbirth.
Many non-pharmacologic, complementary or alternative methods have been reported to reduce pain during labour and delivery. Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby, however, their efficacy is unclear, due to limited high quality evidence.
Dr. Ferdinand Lamaze, a French obstetrician, pioneered the Lamaze breathing technique in the late 1950s. Although the method was initially pioneered as just breathing techniques to reduce labour pains, the Lamaze technique has expanded to include educational and support components.
The idea behind the Lamaze method is that the parents—together—work with the mother's natural labour process to deliver the baby.
Through extensive practice, the mother reconditions herself so —instead of tensing when a contraction comes—she begins a rhythmic pant-breathing.
As she does this, the father times the contractions, steadies her and offers general moral support.
Lamaze is built on the basic principle that the woman has the ability to raise her pain tolerance
These techniques include: structured breathing patterns, focusing on an external point or image, and a relaxing touch technique call effleurage.10
First developed in 1947 by obstetrician, Dr. Robert Bradley, the Bradley Method did not become popular until after the release of his book entitled, Husband-Coached Childbirth, in 1965.The Bradley method emphasises what Bradley called, “the six needs of the labouring woman.” These needs include:
The Bradley Method relies heavily on training fathers/partners to be labour coaches. The primary techniques are supplemented with training in different labour positions and comfort measures. In order to master the ability to relax completely as a pain relief tool, couples are taught several different relaxation techniques and encouraged to practice relaxation daily.
This way the mother can rely on a conditioned relaxation response to her partner's voice and touch.
Immersing into a pool, tub or bath, where the mum's tummy is completely submerged, is used for relaxation and pain relief during any stage of labour. It is reported to alleviate pain and potentially optimise the progress of labour.19,20
The word hypnosis originates from the Greek ‘hypnos’ meaning ‘sleep’. In fact, it is not sleep but a state of focused concentration in which the patient can be relatively unaware, but not completely blind to her surroundings.
Hypnosis has been described as a state of narrow focused attention, reduced awareness of external stimuli, and an increased response to suggestions.12
Suggestions are verbal or non-verbal communications that result in apparent spontaneous changes in perception, mood or behaviour.
These therapeutic communications are directed to the person's subconscious and the responses are independent of any conscious effort or reasoning.
Women can learn self-hypnosis which can be used in labour to reduce pain from contractions.
A meta-analysis of 5 randomised controlled trials showed that hypnosis significantly reduced the use of pharmacological pain relief and of the need for labour augmentation 13
Relaxation techniques are mind-body interventions which are based on developing conscious awareness of muscular tension, the practice of releasing tension and maintaining relaxation often carried out in conjunction with focused breathing, meditation and visualisation.
These kinds of approaches are commonly used for labour and may all have a calming effect and provide a distraction from pain and tension.
Massage may help to relieve pain by assisting with relaxation, inhibiting sensory transmission in the pain pathways or by improving blood flow and oxygenation of tissues.23
Reflexologists propose that there are reflex points on the feet corresponding to organs and structures of the body and that pain may be reduced by gentle manipulation or pressing certain parts of the foot.25
Acupuncture points used to reduce labour pain are located on the hands, feet and ears. Several theories have been presented as to exactly how acupuncture works. One theory proposes that stimulation of touch fibres blocks pain impulses at the ‘pain gates' in the spinal cord. The impulses in the pain fibres are thus less likely to reach the brain stem, thalamus and cerebral cortex.24
Transcutaneous electrical nerve stimulation (TENS) uses a device which emits low voltage electrical impulses. The electrical pulses are thought to stimulate nerve pathways in the spinal cord which block the transmission of pain. This is the basis of the gate control theory.26 It is also suggested that painful stimuli result in release of endorphins and encephalins, which mediate the experience of pain.27
Inhaled analgesia during labour involves the inhalation of anaesthetic agents while the mother remains awake. Nitrous oxide (in 50% oxygen) is widely used for analgesia in modern obstetric practice. The woman can self-administer under supervision, after initial instruction.28
Possible adverse effects are maternal drowsiness, hallucinations, vomiting, hyperventilation and tetany (involuntary muscle contractions), and maternal or fetal hypoxia (low blood oxygen) usually encountered when nitrous oxide use is excessively prolonged or extensive.
Most obstetric units in developed countries offer intramuscular opioids (pain-relieving medications). The use of pethidine, meptazinol or diamorphine during labour is common midwifery and obstetric practice in some countries.29 In other parts of the world, parenteral (intravenous or intramuscular) opioids commonly used in labour include morphine, nalbuphine, fentanyl and more recently remifentanil.30
There are concerns about maternal effects which include an impaired capacity to engage in decision making about care, sedation, hypoventilation, hypotension, prolonged labour, urine retention, nausea and/or vomiting, and the slowing of gastric emptying, which increases the risk of inhalation of gastric contents should a general anaesthetic be required in an emergency. Neonatal respiratory depression and hypothermia remain major concerns.
Pudendal and paracervical blocks are the most commonly performed local anaesthetic nerve blocks. A pudendal block (also called a saddle block) can be given through the vaginal wall and into the pudendal nerve in the pelvis, numbing the area between the vagina and anus. A pudendal block works quickly, is easily administered, and does not affect the baby. Pudendal blocks do not relieve the pain of contractions. A paracervical block is another form of local anesthesia where a local anesthetic is injected into the cervix. It reduces the pain caused by contractions and stretching of the cervix.
A spinal block involves injection of a local anesthetic, with or without an opioid, right around the spinal nerves. Spinal anesthesia numbs the body below and sometimes above the site of the injection. The mother may not be able to move her legs until the anaesthetic wears off.
Epidural anaesthesia involves the insertion of a hollow needle and a small, flexible catheter into the space between the spinal column and outer membrane of the spinal cord (epidural space) in the middle or lower back.
The area where the needle will be inserted is numbed with a local anesthetic. Then the needle is inserted and removed after the catheter has passed through it and remains in place.
A local anaesthetic, with or without an opioid, is injected into the catheter to numb the body above and below the point of injection as needed.
The catheter is secured on the back so it can be used again if more medicine is needed.
An epidural block numbs the nerves that carry the pain impulses from the birth canal to the brain and will usually offer complete pain relief.
A combined spinal-epidural involves a single injection of local anaesthetic or opiate, or both, into the cerebral spinal fluid as well as insertion of the epidural catheter.
The following summarises the results of a 2013 Cochrane systematic overview of current labour pain management. The overview includes 15 Cochrane reviews (255 included trials) and three non-Cochrane reviews (55 included trials). The results showed
These effectively manage pain in labour, but may give rise to adverse effects. Epidural, and inhaled analgesia effectively relieve pain when compared with placebo or a different type of intervention (epidural versus opioids). Combined spinal-epidurals relieve pain more quickly than traditional epidurals.
Women receiving inhaled analgesia are more likely to experience vomiting, nausea and dizziness. When compared with placebo or opioids, women receiving epidural analgesia had more instrumental vaginal births and caesarean sections for fetal distress, although there was no difference in the rates of caesarean section overall.
Women receiving epidural analgesia were more likely to experience hypotension (low blood pressure), motor blockade (muscle paralysis), fever or urinary retention.
Less urinary retention was observed in women receiving combined spinal-epidurals than in women receiving traditional epidurals.
According to the analysis, there is some evidence to suggest things may improve management of labour pain, with few adverse effects. These incluce:
Relaxation was associated with fewer assisted vaginal births and acupuncture was associated with fewer assisted vaginal births and caesarean sections.
Due to insufficient evidence, no judgments can be made as to whether hypnosis, TENS, or parenteral opioids are more effective than placebo or other interventions for pain management in labour.
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