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Course: Maternity Nursing�Topic: Pain Management During Labour

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Module Goals

The learner will be able to:

Explain the causes of pain in labour
List medications given during labour for analgesia
Describe alternative methods of pain management

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Pain In labour

Labour discomfort is an Intense painful experience

Physical Pain

Muscle cramps, uterine contractions, dilation of the cervix, stretching of the perineum, vaginal examinations

Emotional Pain

Fear, anxiety, tension, exhaustion, self -doubt

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Pain in labour is intense. The amount of pain varies from person to person. Some might have intense pain while some experience little pain. There are two types of pain

Physical pain: Physical pain is caused by the progressive contraction of the uterus, dilation of the cervix (0-10 cm) which leads to the desire to push or bearing down when the cervix is at 10 or completely dilated. Pain is felt over the abdomen at first which later is felt in the lower back when the cervix is fully dilated. Certain procedures like vaginal examinations, catheterization, IV cannulation, forceps delivery, vacuum extraction, or episiotomy, can also be very painful.

Emotional Pain: The labour pain can be more intense with negative emotions attached to it. Such feelings can be exhaustion, body tension, anxiety, fear, and self- doubt.

Learning about the pain and causes of pain will help to find all the methods to relieve the pain. Before labour starts, know who the patients support system is going to be during the labour, discuss the available options, and decide what is best.

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Causes of Pain in Labour

First stage:

Due to dilation of the cervix, hypoxia of uterine cell during contraction, stretching of the lower uterine segment

Second stage:

Hypoxia of contracting uterine cells with contractions, distention of the vaginal and perineum, and pressure on adjacent structures

Third stage:

Contractions and cervical dilatation as placenta is delivered

(Anesthesia needed for episiotomy or cervical tear repair)

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Childbirth pain does not indicate a physical problem or injury. Labour pain is the result of physical effort. The uterus is contracting, the cervix is dilating (opening), and labour is progressing. Childbirth pain may be tolerated more effectively if you are able to make the mental “jump” from pain as a warning signal to pain as an indicator of progress.

First Stage

Your cervix will dilate from 0-10 (some women already have dilation when they begin labour). If you are in clinic your healthcare provider will check you cervix to see how much it is dilated and how far down the baby has progressed. This stage of labour last about 12 hours for the first baby and 8 hours for the second. The more babies you have usually the shorter this stage will be.

First Stage of labour has 3 phases:

Early labour--cervix opens to 4 centimeters. Women will usually remain at home during this time as the pain is not too intense. They may continue to relax, rest, drink clear liquids, eat a light meal (they should not eat a full or heavy meal during this time) but should keep track of contractions. When they notice a change in the frequency of contractions and are having difficulty talking--- then this is the time to go to their health provider or to whomever will assist with the delivery.
Active labour--cervix opens from 4-7 centimeters. Most often contractions are now 3-4 minutes apart and lasting about a minute. Talking becomes more difficult and their “bag of waters” or amniotic sac may rupture which will cause a gush of fluid. Note the color and smell of the fluid as it should be clear without a noxious smell. If the bag of waters breaks, expect the contractions to increase in numbers and intensity. The use of the non-pharmacological pain relief methods are useful during this part of labour.
Transition to Second Stage of labour--The cervix will dilate from 7- 10 centimeters. This is typically the most difficult part of labour. Contractions are normally 2-3 minutes apart and last 60-90 seconds. The patient may feel tired and frustrated. They may become sweety, sick to their stomach, shaky, hot, or cold. A support person is most helpful during this time.

Second Stage of Labour

This stage begins when the cervix is COMPLETELY dilated. There is no rim at all. Contractions push the baby down the birth canal and the woman may feel intense pressure in the rectum (she often says she needs to have a bowel movement). The women should feel an urge to push down. Have her push during the contraction and rest between contractions.
The length of this stage varies depending on whether or not the women has had a baby before, the size and the position of the infant.

Third Stage of Labour

Once the baby is born the third stage begins. In this stage the “after birth” or placenta is delivered. Contractions will continue to help the women push the placenta out. It usually takes 5-15 minutes. The healthcare provider should NOT PULL on the placenta. It will break away on its own. This will be a time when hemorrhage can occur and the amount of bleeding should be noted.

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Pain Management

Non-Pharmacological:

Emotional support
Instructional support
Relief measures

Pharmacological Analgesic:

Local anesthesia
Regional anesthesia (e.g. Epidural)
General anesthesia

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Non-Pharmacological:

Emotional support: From husband, midwives, nurse, family
Instructional support: nurse/midwife- Pushing/ bearing down, deep breathing
Acupuncture and hypnosis
Massage, warm pack and thermal manual methods
Reflexology
Biofeedback for pain
Bathing in water bath
Patterned focused breathing techniques

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Non- Pharmacological:

Emotional supports, encouragement from husband, family members, and healthcare providers will help the pregnant woman to distract from the pain and discomfort. It will enhance the progress of labour.

Instruction provided by the midwives or nurses during the labour like how to push, when to push, pursed lips breathing, e.t.c. can act as pain relief methods.

Relaxation such as breathing techniques, visualization, yoga, or music would help with reducing pain, and improve women’s experiences of labour. Some women even prefer complementary therapies like acupuncture, massage, herbal medicines, hypnosis, aromatherapy.

Evidence:

Moderate-certainty evidence suggests that pain scores in the first stage of labour are probably reduced with massage compared with usual care.

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Non-Pharmacological

‘Back labour’

Infant is in occiput posterior position placing pressure on mother’s back/sacrum and causing intense lower back pain.

Suggest use of shower or bath (water is comforting and reduces sensation of pain)
Provide counter pressure against sacrum (alleviates pressure on back)
Assist the mother to knee chest or hand and knee position (gravity lifts infant off mother’s spine)
Pelvic rocking

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Non-Pharmacological

Breathing techniques:

Relaxing- Slow rhythmic breathing, music, or singing- in early phase (1-3 cm)
Patterned breathing- short rhythmic mouth breathing ( 4-10 cm)
Short Panting or blowing breaths (for intense contractions or to stop from pushing

Ambulating: In early labour

Encouragement and praise: Emotional support throughout labour. Letting the mother know that she is doing well

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What Would the Nurse Do?

A 16-year-old patient presents in labour following a normal pregnancy. She is very anxious, does not cooperate with the labour staff, and complains of unbearable pain during contractions. She bears down with every contraction even though the cervix is only 4 cm dilated. The patient is told to behave herself. She is informed that the worst part of labour is still to come and is scolded for becoming pregnant. As she is a primigravida, she is promised analgesia when her cervix reaches 6 cm dilatation.

Evaluate this scenario and recommend alternate nursing interventions.

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1. Why is the patient frightened?

Because she is unprepared for labour and does not know what to expect. Also, she is in a strange environment, and the staff are unfriendly and aggressive. Being anxious results in her experiencing her contractions as very painful while the pain in turn makes her even more anxious.

2. What should have been done during the antenatal period to avoid the present situation?

Receiving good information about the process of labour at antenatal visits, attending antenatal exercise classes, and visiting the labour ward during the last weeks of pregnancy would have resulted in a far more relaxed patient in labour.

3. What should have been done in the labour ward to reduce her anxiety?

She should have experienced a pleasant atmosphere in the labour ward with understanding and encouragement from the staff. They should have reassured her that everything was under control and that there was no reason for her to be frightened. The staff themselves should appear confident, relaxed, and caring. A family member or friend of the patient must remain with her.

4. What would have been the correct management of labour for this patient, beside reassurance?

She should have been encouraged to concentrate on her breathing during contractions. Besides, she should have been given adequate analgesia as soon as possible.

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Pharmacological Pain Relief

Sometimes women do not want to bear the pain, and they prefer different methods of pain relief if available in the hospital or clinic

Narcotic analgesics
Local anesthesia
Dissociative anesthetic
Regional anesthesia

Spinal block
Epidural anesthesia

General Anesthesia

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Narcotic Analgesics sometimes helps to “take the edge off”

Systemic analgesics reduce your awareness of pain and have a calming effect. The medications used are known as opioids. These drugs will not cause you to lose consciousness. Systemic analgesics usually are given as a shot or through an intravenous (IV) line (this is a small tube that is placed into a vein through which medications or fluids are given). Side effects are minor and may include itching, nausea, vomiting, feeling drowsy, or having trouble concentrating. However, The risk of narcotic analgesics is that they cross the placenta and can cause fetal respiratory depression

Local anesthesia into the vagina or the area surrounding it to ease pain, especially helpful when pushing.

Local anesthesia is the use of drugs to prevent pain in a small area of the body. The anesthetic drug is injected into the area around the nerves that carry feeling to the vagina, vulva, and perineum. Local anesthetics provide relief from pain in these areas. The drug also is used when an episiotomy needs to be done or when tissues need to be repaired after childbirth. When used to relieve pain during childbirth, the drug is given just before delivery. Rarely, a woman may have an allergic reaction to a local anesthetic or may have nerve or heart problems if the dose given is too high. Local anesthesia rarely affects the baby.

Dissociative anesthetic has been found to produce dissociation of the mind from the body (a sense of floating), distorted perceptions and in rare cases, visual hallucinations (Alcohol and Drug Foundation-https://adf.org.au/drug-facts/nitrous-oxide/#:~:text=Nitrous%20oxide%20is%20classified%20as,in%20rare%20cases%2C%20visual%20hallucinations.)

Nitrous oxide (more commonly used in Europe and Australia and known as a “dissociative anaesthetic”) is a tasteless and odorless gas (also known as “laughing gas” ) used as a labour analgesic by some hospitals. It reduces anxiety and increases a feeling of well-being so that pain is easier to deal with. Nitrous oxide is mixed with oxygen and inhaled through a mask. A woman holds the mask herself and decides when she will inhale. It works best when a woman begins inhaling 30 seconds before the start of a contraction.

Nitrous oxide is safe for the mother and the baby. Some women feel dizzy or nauseated while inhaling nitrous oxide, but these sensations go away within a few minutes.

Regional anesthetics greatly reduces or eliminates pain throughout the birthing process. It can also be used if a cesarean section becomes necessary. It is administered by an anesthesiologist during labour to reduce discomfort. There are three types:
spinal
epidural
combined spinal/epidural

With all three, medicines are placed near the nerves in the lower back to “block” pain in a wide region of the body while the patient remains awake.

e. General Anesthesia is used for emergencies during the birthing process. It induces sleep and must be given by an anesthesiologist. although safe,

general anesthesia prevents the patient from seeing the baby immediately after birth.

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Use of Analgesics in Labour

In the first stage of labour:

Patient ask for pain relief
Painful uterine contractions during a normal labour
Painful contractions + oxytocin stimulation
Painful contractions with slow progress during the active phase

Second Stage:

Episiotomy
Instrumental Delivery

Third Stage:

Episiotomy with perineal tear

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When to give analgesia to a patient in labour?

In the first stage of labour when:

Patients ask for pain relief.
Patients experience painful uterine contractions during normal labour.
Patients have painful contractions and besides, require oxytocin stimulation of labour.
Patients have painful contractions with slow progress during the active phase of the first stage of labour, e.g. with an occipito-posterior position.

In the second stage of labour when:

An episiotomy is done.
Instrumental delivery is done.

In the third stage of labour when:

An episiotomy or perineal tear is repaired.

Why do you need to give a patient analgesia during labour?

Patient comfort is the priority of the healthcare provider: it is a primary responsibility of a healthcare worker to help the patient tolerate labour with as much comfort as possible. Though the pain in the labour is a normal process, patients should frequently be asked whether they need pain relief. If required, the most appropriate and effective form of analgesia available should be offered. Once a patient is relieved from the pain, the progress of labour may be more rapid. Analgesics do not relieve all pain; however they “take the edge off” to help the patient tolerate it a little more.

Should all patients receive analgesia?

No. Some patients have little pain in labour and, therefore, may not need an analgesic. Other patients feel that they can tolerate the pain of uterine contractions, e.g. by concentrating on their breathing and choose not to have analgesia. It is important to consider the patient’s wishes when deciding whether or not to give analgesia. However, most patients may need analgesia during labour.

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Methods of Providing Analgesics

General Methods:

Support
Calm environment
Encouragement

Specific Methods:

Opiates, e.g. pethidine
Inhalational analgesia, i.e. nitrous oxide with oxygen
Local anesthesia
Epidural anesthesia
General anesthesia

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General Methods to Reduce Pain

Knowledge and information of what to expect
A pleasant environment
Support system: Husband, family, friends
Allowing to walk around during labour

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What general measures help to reduce pain during labour?

Knowledge of what to expect during labour. This important information should be provided during antenatal visits to patients who will be experiencing labour for the first time.
A pleasant environment and support. Encouragement of those who are attending to the patient.
The help and support of a family member, partner, friend, or doula are of great value.
Allowing patients to walk around during labour.

The preparation of birth starts from the antenatal period. A woman having her first pregnancy must be explained how the whole pregnancy and delivery are going to look like (in a very simple language and terms). She should also be taught relaxation and deep breathing exercises in the antenatal period.

During the labour, especially in the active and latent phase of the first stage of labour, the patient has to be encouraged to walk around and not lie down on the bed. Walking distracts the mother from pain and there will be the progress of labour i.e. contractions will be more effective.

A nurse or midwife has to prepare a nice and calm environment, caring attitude to the patient and the family. Thorough and gentle clinical examinations, rubbing the patient's back, talking to her, teaching the stress-relieving methods can help to relieve the stress and pain to some extent.

Most patients find it helpful to have someone with them during labour especially their loved ones like husband, family member, best friend. Sometimes a layperson or doula can fulfill this role perfectly well.

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Specific Method: Sedation During labour

Opioids: (Pethidine)

Commonly used in the first stage of labour
Have sedative effect
Side effects: Nausea and Vomiting
Used together with Promethazine

Remember: Higher doses of Pethidine can cause respiratory and central nervous system depression, drop in blood pressure in Mother, and respiratory depression on fetus

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Which analgesic drug is commonly used in the first stage of labour?

During the First Stage of Labour, Pethidine is a powerful analgesic but commonly causes nausea and vomiting as a side effect. Pethidine also produces some sedation. To suppress nausea and vomiting, Promethazine (Phenergan) or hydroxyzine (Atarax) is used.

Pethidine and Phenergan have used together as it:

Increases the analgesic effect of pethidine.
The sedative effect makes the patient more relaxed.
Reduces nausea and vomiting of the patient caused by Pethidine.

Note: The dose of promethazine is 25 mg and hydroxyzine is 100 mg, irrespective of the amount of pethidine given.

Pethidine can cross the placental barrier. An overdose of pethidine may cause respiratory depression in both the mother and her infant. A drop in blood pressure may also occur.

There is no limit to how late in labour pethidine can be given. If the patient needs analgesia she should be given the appropriate dose. However, if she receives pethidine within 6 hours of delivery, the infant may have respiratory depression at birth.

Respiratory distress in infants due to pethidine overdose can be treated with Naloxone.

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Specific Method: Sedation During labour

Inhalation Analgesia: Entonox

Mixture of 50% Nitrous Oxide and 50% Oxygen supplied in cylinders
Breathed in by patient through a mask
Short-Acting
Safe for mother and fetus
Best for patient requiring analgesia for the first time in advance labour
Does not have any side effects and causes overdose

Disadvantages:

Very expensive
Not always effective
Requires apparatus for administration
Patient often hyperventilate: Pins and Needles in their face and hands

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What Would the Nurse Do?

Cervical dilatation in a multigravida patient in labour at term progresses from 3 cm to 8 cm in 4 hours. The patient complains that her contractions are very painful. The midwife informs her that she is progressing fast and that her cervix will soon be fully dilated. She adds that the patient must continue without analgesia for the last 2 hours as the delivery will soon be over.

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1. Do you agree with the patient’s management?

No. The patient needs analgesia and the most appropriate form of analgesia should be offered to her.

2. What would be the best form of analgesia to offer this patient?

Entonox as it works rapidly and is completely safe. She also only needs analgesia for a short time as her cervix will soon be fully dilated.

3. If Entonox is not available or if the patient is unable to use Entonox correctly, what another form of analgesia should be considered?

Pethidine and promethazine (Phenergan) or hydroxyzine (Aterax).

4. What would be the best route of administering the pethidine to this patient?

The pethidine should preferably be given intravenously by a doctor. Pain relief will then be obtained in 5 minutes and the effect of the drug should last 2 hours.

5. The infant is delivered 45 minutes after the pethidine is given. What complication of the drug may be present in the infant at delivery?

The infant may have respiratory depression and as a result, may not breathe adequately at birth.

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Specific Method: Sedation During Labour

Local Anesthesia: Lignocaine/Xylocaine/Lidocaine

Injection given into the tissues
Available in different concentrations: Only 1% is used in labour
Causes burning sensation for 1-2 minutes
Action last for 45 minutes
Usually given prior to episiotomy, or repairing any tears
Given prior to performing pudendal block
Dangerous overdose effect: Convulsion

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Local Anesthesia:

Agents that are injected via syringe into the tissue which causes loss of sensation in the area. It can often cause a sharp burning sensation while injecting that will last for 1-2 minutes (Patient must be warned before injecting). Lignocaine or Xylocaine is the local anesthetic agent used most commonly in labour and delivery process. Although available in different concentrations, only 1% is the best choice in order to reduce the possibility of giving the overdose.

When to use a local anesthetic?

When performing an episiotomy, or when repairing an episiotomy or perineal tear.
When performing a pudendal block. The local anesthetic acts on the pudendal nerves and is usually given before an instrumental delivery.

What are the risks of local anesthesia?

Too much local anesthetic is dangerous and may cause convulsions.
The maximum safe dose of a 1% solution of lignocaine (Xylocaine) for a patient of average size is 4.5 mg/kg.
A local anesthetic can cause convulsions if it is injected into a vein in error.

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Specific Method: Sedation During Labour

Epidural Anesthesia

Given into the space of spinal nerves & blocks the pain
Needs special training and equipment
Available in level two or three hospitals

Indications:

Poor progress in active phase
Ineffective uterine contraction
Breech presentation
During C- Section

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Epidural Anesthesia

An epidural is an injection placed near the nerves in the lower back to “block” pain in a wide region of the body while the patient remains awake.

What are the indications for epidural anesthesia?

When there is poor progress during the active phase of the first stage of labour, e.g. due to an occipito-posterior position.
When ineffective uterine contractions are present, prior to starting oxytocin.
When it is important to prevent bearing down before a patient’s cervix is fully dilated, e.g. with a preterm infant or a breech presentation.
Cesarean sections may also be done under epidural anesthesia.
This is the ideal form of local anesthesia as it offers the patient complete pain relief. Unfortunately, special training and equipment are necessary for giving epidural anesthesia, and therefore, it is only available in most level 2 and 3 hospitals.

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Specific Method: Sedation During labour

Nursing Care of Epidural Anesthesia

Blood Pressure every 5 minutes for 30 minutes
Respiratory rate
Pain and sedation score
Insertion of urinary catheter
Epidural hematoma
Headaches

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Specific Method: Sedation During labour

General Anesthesia

Don’t feel pain, completely unconscious

Dangers of GA

Risk of vomiting and aspiration
Stomach emptying is delayed
Sphincter tone of lower esophagus is reduced
Intraabdominal pressure is increase

Precautions:

NPO
Antiemetic for vomiting
Gastric acid must be neutralized by antacid before giving GA

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General Anesthesia:

A process of infusing the combination of drugs causing the patient to become completely unconscious in order for the patient not to feel any pain.

Dangers of General Anesthesia:

The patient is at high risk of vomiting and aspirating her stomach contents because

Stomach emptying is delayed.
The tone of the sphincter in the lower esophagus is reduced.
The intra-abdominal pressure is increased.
During a general anesthetic, the risk of the patient vomiting is particularly high during intubation and extubation.

Precautions of General Anesthesia:

A patient who may require a general anesthetic should be kept “nothing per mouth” (NPO).
Antiemetic like Metoclopramide 10 mg (1 ampoule) should be given intravenously 15 minutes before the induction of general anesthesia.
The gastric acid must be neutralized by an antacid before the induction of general anesthesia.

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What Would the Nurse Do?

A multigravida patient, who has had two previous Caesarean Sections, is booked for an elective Caesarean Section under general anesthesia at 39 weeks gestation. The patient is admitted to the hospital at 07:00, having had nothing to eat since 24:00 the previous night. She is prepared for surgery at 08:00. As the patient has been kept NPO, no drug to prevent vomiting during intubation and extubation is given. Only an intravenous infusion is started and a Foley catheter passed before she is moved to the surgery area.

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Do you agree that a drug to prevent vomiting is not needed as the patient has had nothing to eat or drink for 8 hours?

No. All pregnant patients are at risk of vomiting during general anesthesia even if they have taken nothing by mouth during the past few hours.

Why should a pregnant patient who has not eaten overnight still be at risk of vomiting during a general anesthetic?

Her stomach has a delayed emptying time, the lower esophageal tone is reduced and she has a raised intra-abdominal pressure.

What preventative measures should have been carried out during the pre-operative preparation of the patient for surgery?

Metoclopramide 10 mg (1 ampule) should have been given intravenously 15 minutes before the induction of anesthesia. It is an antiemetic, it increases the stomach emptying time, and raises the sphincter tone of the lower esophagus. These effects will reduce the danger of vomiting. An antacid should also be given before the general anesthetic.

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Red Flags: Epidural

Following an epidural there may be a temporary drop in the mother’s blood pressure and an accompanying decrease in the fetal heart rate

Assure that the mother receives an Intravenous bolus of 1000 mL of fluid prior to the epidural
Monitor the fetal heart rate closely especially in relation to contractions
Discontinue Pitocin, turn the patient to left lateral side, increase IV fluids and provide supplemental face mask oxygen until the fetal heart rate returns to baseline

May cause urinary retention; assess bladder frequently

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Cultural Considerations

Four Important cultural considerations:

Communication
Family dynamics
Provider Gender
Religious and Cultural Beliefs
Desires for labour

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Cultural competency starts with effective communication, listening, and respect.

Example: A Muslim female will likely not want to be examined by a male due to beliefs and modesty. She may also not like to the presence of male care providers in the room.

Four Important cultural considerations (https://utswmed.org/medblog/cultural-competency-pregnancy/)

Communication

Patients might be hesitant to ask question out of fear of judgment
Provide opportunities for open communication
Open communication so that patients feel comfortable to be honest and to not feel judged

Family dynamics

Men are household leaders in various cultures, and some patients defer to their partner for medical decisions.
Some patients feel strongly that procedures such as a hysterectomy reduce a woman’s body image or womanhood. Caution should be used with asking questions about intimate subjects.
Conversations about sexual topics can be awkward without a culturally competent provider. Pregnancy providers should be open-minded and get to know their patients’ situations and preferences without making assumptions.
For example, patients may be in a variety of circumstances and unique situations, such as women with more than one partner, same-sex couples, and patients who are surrogates for other couples.

Provider gender

Some patients request a male or female doctor due to cultural or personal preferences. If it is not an option, the healthcare provider should have a conversation with the patient to find solutions to make the situation more comfortable.
For example, a patient in labour with a premature baby who feels uncomfortable having men except her partner in the room during delivery and recovery. However, her baby needs immediate specialized care after birth, and all the pediatricians on staff are men. In order to respect the patient’s wishes and properly care for her baby, partitioning the room with screens provides for the male pediatrician to be present without invading the patient’s privacy.

Religious and cultural beliefs

Certain medical procedures associated with pregnancy, such as circumcision and blood transfusions in emergency situations, are not acceptable by all religions. Some cultures also have guidelines or traditions around co-sleeping, baptism, and baby-naming.
Some patients might seek traditional remedies before or along with treatments prescribed by their provider.
Food is largely related to religious and cultural beliefs. Try to match offerings in the hospital with specific diets and personal likes and dislikes. Have the team asks about vegan, gluten-free, kosher, and other needs and preferences in order to optimize nutrition and increase comfort during their stay.

Desires in labour

Women from some cultures avoid moving too much, some stay lying down, some prefer to sit or squat
Some cultures the does not attend the birth, but the mother or mother-in-law does
After childbirth, some women follow strict rules, such as staying bed for several days

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References:

BetterCare Learning programs (n. d).Maternal care: managing Pain During Labour (Chapter 10). Retrieved on 9^th of October 2020 from https://bettercare.co.za/learn/maternal-care/text/10.html#10-managing-pain-during-labour

National Health Service (2020). Epidural: Side effects. Retrieved on 13^th of October 2020 from https://www.nhs.uk/conditions/epidural/

National Health Service (2020). Your pregnancy and baby guide: Pain relief in labour. Retrieved on 13^th of October 2020 from https://www.nhs.uk/conditions/pregnancy-and-baby/pain-relief-labour/

WHO (2017). Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors. Retrieved on October 11 2020 from https://apps.who.int/iris/bitstream/handle/10665/255760/9789241565493-eng.pdf?sequence=1

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