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Introduction
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Women experience a wide range of pain in labour and exhibit an equally wide range of responses to it. Many are concerned about the effects of chemical forms of pain relief on themselves and their baby. An individual's reaction to labour pain may be influenced by the circumstances of her labour, as well as the environment and support provided to her during this period. Options for pain relief should be explored and discussed in the antenatal period. A number of these options are discussed in this guideline.
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Non-pharmacological methods
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These are said to support the natural physiological responses to labour pain, the gate mechanism of pain control and the release of endogenous opioids. (Melzack & Wall 1964).
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Relaxation / breathing techniques / massage
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- These forms of pain relief can allay anxiety, encourage relaxation, provide a focus of distraction from pain and tension and encourage a positive attitude.
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- Be aware that some women do not like to be touched in labour.
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Positioning and movement
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Mobility and the adoption of a position of comfort will be advantageous to the woman.
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- An upright or kneeling position is said to improve the dimensions of the pelvis and encourage forward rotation of the fetus.
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- This may lead to a decrease in the use of regional anaesthesia and analgesics.
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Temperature modulation: Hot or cold packs, hot or cold water
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Hot packs to the abdomen and back or the perineum in the second stage of labour have the potential to relieve the burning sensation of pain. For some women the use of extreme cold may be similarly useful.
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- Hot baths or showers produce a number of beneficial effects including relaxation and increased well-being.
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- A reduction in pain perception occurs as a result of the stimulation of tactile and thermal receptors by warm water. The response to this is to reduce pain stimulus at the dorsal column "closing the gate" to pain.
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Transcutaneous Electrical Nerve Stimulation (TENS)
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Is thought to work by interrupting pain transmission along the sensory pathway and by stimulating endogenous opioids.
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- Commonly two electrodes are adhered vertically over the woman's back parallel to her spine between the areas of T10 down to S4.
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- The electric current used may be of low frequency and intermittent, or high frequency and continuous.
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- Low frequency TENS stimulates the release of endogenous opioids while the high frequency current closes the pain gate. The sensation experienced may be felt as a tingling or as a sharper electric shock sensation. The current can be modified during use. Practice with the equipment is advised before use.
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Acupuncture
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A form of Eastern medicine said to relate to the flow of energy called Qi within the body where needles are inserted along specific pathways or "meridians".
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- Its action may be related to stimulating the release of endogenous opioids as well as the transmission of pain stimuli.
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- Acupressure and Reflexology utilize similar, but distinct techniques.
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Herbalism and aromatherapy
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These make use of natural plant extracts or essential oils.
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- These remedies may improve physiological balance, strength and stamina within the mind and body.
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- Knowledge of specific useage is important as the use of some of these remedies is contra-indicated in pregnancy and labour, while others may have an adverse effect on the baby if it comes in direct contact with them.
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Hypnosis
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Self-hypnosis and post-hypnotic suggestion can provide an effective form of pain control for suitable subjects.
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Information on hypno-birthing can be resourced from the Family Birth Centre.
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Intradermal injection
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Provide relief of pain and backache by injecting sterile water (0.1-0.5 mls) intradermally, to the lower sacral region. Refer to procedure (Intranet only): Intradermal injections of sterile water for the relief of backpain in labour
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Pharmacological Methods
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Inhalational analgesia
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Nitrous Oxide is used. This is a colourless, odourless gas. Used in higher concentrations it can provide effective pain relief, with the advantage that its effects are short lived, and there are minimal complications in the neonate. It is obtained by the woman's own respiratory effort via a piped supply.
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- Analgesia is obtained within 20- 30 seconds of commencement and maximum effect is felt after about 45 seconds.
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- The use of this form of pain relief is rarely contraindicated.
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- Self-administration is the recommended method for use as the patient drops the mask / mouthpiece if she absorbs too much of the gas.
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Opioids
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Pethidine is commonly used. Has been used as an analgesic for women in labour since the 1940's. While it provides satisfactory analgesia for some women, others may experience drowsiness or a perception of loss of control without adequate pain relief.
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- Side effects include a reduction in gastric motility with a subsequent increase in gastric acidity.
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- In the neonate opoids may cause respiratory depression at birth as well as neuro-behavioural side effects which can be exhibited in changes to feeding patterns and normal reflexes. Debate exists over the duration of the effect of Pethidine in relation to administration.
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Epidural analgesia
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Epidural analgesia can provide an effective form of pain relief in labour. It may be beneficial for women having a long or painful labour, be required on the grounds of fetal benefit, or administered for maternal or obstetric indications. It may also be provided at maternal request.
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- There are some medical contraindications to its administration.
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- Complications include hypotension, headache, dural tap and a "patchy" block. Other issues relate to the reduction of motor function and sensation in the woman's legs and impaired bladder function.
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- The use of low dose (ropivicaine/ fentanyl) patient controlled epidural analgesia (PCEA) reduces a number of the side effects experienced by the mother, retains the urge to push for the majority of women and reduces the likelihood of an assisted vaginal delivery.
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Intravenous PCA
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The use of an intravenous PCA may be of use for women where the placement of an epidural is contraindicated. The total drug requirement to achieve adequate pain relief is usually less using this method than with intramuscular narcotics or a continuous intravenous infusion. Fentanyl (10mcg/ml) is the drug of choice. Satisfactory pain scores can be achieved by 10- 20 mcg boluses with a lockout interval of 3- 5 minutes. A background infusion is not usually used. Other opioids may be delivered using this method. Side effects are similar to those of other narcotics. Eg. Pethidine.
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Conclusion
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The challenges of providing pain relief for women in labour and birth are complex, and delivering regional anaesthesia to control the pain is not the only answer. Women should be aware of all the options available to her when it comes to managing pain during labour.
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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