Women, Children s and Sexual Health Division Maternity Services Guideline: 1. Introduction It has been demonstrated that midwives sometimes underestimate the intensity of the pain experienced by women in labour and overestimate the efficacy of pharmacological pain relief Labour pain can only be partially relieved by the use of analgesic drugs such as Pethidine and Entonox It is clearly important that midwives acknowledge this with labouring women, and focus on the woman s ability to give birth normally (RCM 2008). The most powerful determinant of a woman s birth outcome is the ideology of her practitioner (MIDIRS 2002). Pain in labour is subjective, and all women will experience it differently. External factors can impact and influence a woman s perception and experience of pain. These can include: Birth environment Antenatal education Birth supporter Remaining mobile in labour Eating and drinking Water (pool birth) Massage Complementary therapies Breathing techniques Being actively involved in decision making Confidence in her carers 2. Aims and objectives To explore the physical, emotional and psychological aspects of pain control in labour and offer women a holistic approach in supporting a woman through her birth. 3. Coping Strategies for Labour 3.1 Breathing, Relaxation, HypnoBirth Breathing and relaxation techniques can help a woman to cope with the pain of labour. Breath holding leads to muscle tension and increased pain. Breathing techniques allow the muscles to relax, increasing oxytocin, relaxin, endorphins, decreasing adrenalin and allowing for appropriate maternal and fetal oxygenation. Midwives should be familiar with appropriate breathing techniques for labour and be able to support the woman and her birth partner in using these. Hypnosis is an effective method of relieving pain in birth without altering the normal course of labour. The use of hypnosis in labour leads to shorter first and second stages, less pain, analgesic requirements and reduced incidence post natal depression (Jenkins & Pritchard 1993). Page 1 of 5
3.2 Massage Massage techniques in labour can decrease the experience of pain and reduces muscular tension (Barnett 2002).Massage is cost-effective intervention and the partners' participation in massage can positively influence the quality of women's birth experiences. If a woman becomes over anxious during labour she can produce adrenalin which can affect the effectiveness of the contractions. As massage strokes spread and dissipate tension this can result in the pain becoming less localised and easier to cope with. Massage can: Reduce stress Support effective digestion and breathing through the stimulation of the vagal nerve. Lowers blood pressure; reduces anxiety levels. Reduces pain and increases range of motion for those individuals with lower back problems. Massage as pain relief can stimulate the body s natural endorphin production. 3.3 Active Birth and Mobility in Labour. Remaining mobile in labour and encouraging an active birth can impact on the woman s experience of pain. There are significant advantages to assuming an upright position in labour and birth (MIDIRS 2005). 3.4 Water immersion in labour and Waterbirth Immersion in water during labour and birth has long been used as an alternative form of relaxation and analgesia and both the RCOG, RCM support labouring in water for healthy women with Low risk pregnancy and spontaneous labour. NICE 2007 conclude that there is insufficient evidence on the use of water in the second stage of labour, to either support or discourage giving birth in water. Benefits of using immersion in water during labour and birth: Maternal relaxation A more gentle birth Transition from intra to extra uterine life is protected Shorter labour Less use of epidural/spinal block Less perineal trauma Less painful contractions Less need for pharmacological analgesia Less need for augmentation Care of the women Should be no different to that of any other low risk woman in labour. There is no restriction on when the woman may enter the pool this should be according to her requirements. (RCM 2010) Observations should be conducted in line with the CHUFT maternity Guideline No 3.2 Underwater sonicaids are available for use in the birthing pool Vaginal examinations can be performed in, or out of the water. Temperature of the water should not exceed 37.5 0 C Woman s temperature measured hourly to ensure that she is comfortable and not becoming Pyrexial. Ensure that the ambient room temperature is also comfortable for the woman. Page 2 of 5
The birth should be a hands off approach to minimise stimulation of the baby. A physiological third stage should be offered and can be performed in, or out of the water at the woman s choice. Blood loss in a birthing pool is difficult to assess and is described as >500mls or <500mls, if it is estimated as >500mls the woman should get out of the pool and be assessed for possible causes of PPH 3.5 TENS Transcutaneous Electrical Nerve Stimulation uses mild electrical impulses that pass through the skin via electrode pads. This enables the body to produce endorphins, enabling the labouring woman to adjust the levels to meet the needs of the pain. Pain is highly individual and women may feel that it's worth trying TENS. In addition, while it may not bring guaranteed pain relief on its own, TENS may be effective when used in combination with other pain treatments. 3.6 Entonox (Nitrous Oxide & Oxygen via Entonox Equipment) Nitrous Oxide provides analgesia within 20-30 seconds of inhalation with a maximum effect after 45 seconds. Midwives should explain this to the woman suggesting that she commences breathing entonox at the beginning of the contraction, maintianing a regular pattern of inhalation and exhalation. Adivse the woman to conitue for several contractions until she adopts the most apporpriate use for her. Advantages: Ease of use for the woman. Minimal accumulation with intermittent use Self-administration provides control. There is no evidence of harm to the baby (NICE 2007) Disadvantages: Drowsinesss, Disorientation Nausea may occur. Does not provide complete analgesia. 3.7 Opioids Inform women that pethidine, diamorphine and other opioids will provide limited pain relief during labour and may have significant side effects for herself such as drowsiness, nausea and vomiting and her baby such as short term respiratory depression and drowsiness (NICE 2007). Pethidine is the most commonly used opiate in labour but there are considerable doubts about its effectiveness and concerns about its potential maternal, fetal and neonatal side-effects (NICE 2007). Advantages Can make woman feel relaxed Disadvantages Limited pain relief Women feel less in control dissapointment Nausea Vomitting Delayed perstalsis Page 3 of 5
Possible Respiratory depression Neonatal drowsiness 3.8 Epidural analgesia Epidural analgesia is a commonly used method of pain relief in labour in the UK. For many women it is very effective, though some women do not experience total relief (MIDIRS 2005). There are a number of possible unwanted consequences and side-effects Advantages Effective method of pain re;leif Neonate less acidotic Less sedative effect on the neonate than opiods Disadvantages Doubles the risk of instrumental birth from 7% to 14% Prolonged second stage, requiring augmentation with oxytocin Lowered maternal blood pressure Urinary retention Itchiness Dural Puncture 1:13,000 nerve damage Epidural does not cause Higher incidence of caesarean section Long term backache Headache (OAA 2011) A labour involving epidural analgesia is high risk, and midwive s should ensure adequate monitoring takes place. CTG monitoring, BP monitoring, urine output and level of pain block all need to be documented appropriately. 4. Responsibilities It is the responsibility of the midwife to create an environment that facilitates normal birth and places emphasis on the woman s ability to birth without intervention. The value of women s own coping resources should be recognised and maximised, rather than placing an over-emphasis on pharmacology 5. Record Keeping All methods of pain management should be recorded in the woman s handhelds healthcare records and any medication should be recorded on the Medication Record Chart (Drug Chart). 6. Monitoring Compliance The Maternity Services will conduct; Review and audit of healthcare records and documentation at Multidisciplinary Statutory Training and discuss via group feedback session. Page 4 of 5
7. References and further Information J Adv Nurs. 2002 Apr;38(1):68-73.Effects of massage on pain and anxiety during labour: a randomized controlled trial in Taiwan. Bricker L, Lavender T (2002) Parenteral opioids for labor pain relief: A systematic review. American Journal of Obstetrics and Gynecology 186(5): S94-S109 Dowswell T, Bedwell C, Lavender T, Neilson JP. Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD007214. DOI: 10.1002/14651858.CD007214.pub2. MIDIRS (2005) The use of epidural analgesia for women in labour Informed choice for professionals leaflet MIDIRS (2005) Positions in labour and delivery. Informed choice for professionals leaflet NICE (2007) Intrapartum Care; care of healthy women and their babies. during childbirth. London: RCOG. National Institute for Health and clinical Excellence (NICE) (2007) Intrapartum Care; care of healthy women and their babies during childbirth. London: RCOG. Obstetric Anaesthetist Association (2012) Pain relief in Labour, OAA Available Online www.oaaformothers.info Royal College of Midwives (2008) Midwifery Practice Guidelines, Evidence Based Guidelines for Midwifery Led Care in Labour 4th Edition www.rcm.org.uk/college/policypractice/guidelines/practice-guidelines Shallow H (2003) My rolling programme. The birth ball: ten years experience of using the physiotherapy ball for labouring women. MIDIRS Midwifery Digest 13: 28-30 Torrance E, Thomas J, Grindley J (2003) Outcomes of pethidine or diamorphine administration. British Journal of Midwifery Tsui M, Warwick D, Kee N, et al. (2004) A double blinded randomised placebo-controlled study of intermuscular pethidine for pain relief in the first stage of labour British Journal of Obstetrics and Gynaecology 111: 648-655 Dymphna Sexton-Bradshaw Associate Director of Women & Children's/ Head of Midwifery Women & Children s Division Aban Kadva Consultant Obstetrician Lead Delivery Suite ------------------------------------------- ------------------------------------------- Anne Regan Liam McLoughlin Lead Pharmacist Lead Consultant Anaesthetist Version Author (s) Date Circulation Comments One Teri Gavin-Jones Consultant Obstetricians This guideline incorporates Parent Education Coordinator Supervisors of Midwives 2012 previous guidelines No s 7.5,7.8 & 7.18 Page 5 of 5