Effectiveness of Pain Management During Labour

The effectiveness of pain management is influential to a woman’s health and wellbeing during labour. As midwives, it is essential to understand the physiology, influencing factors and perception of pain. Pain perception involves sensory, behavioural and environmental stimuli, an example of this is the ‘gate control theory’. This theory suggests, communication signals within the brain act as a gate to increase or decrease the signal of nerve impulses from peripheral fibers to the central nervous system. An “open” gate permits the signal of nerve impulses, hence the brain perceives pain. A “closed” gate prevents signal of nerve impulses, reducing the perception of pain. There are numerous methods of pain management available, depending on the level of pain being experienced by the woman, these can be divided into pharmacological and nonpharmacological methods. Non-pharmacological referring to methods that do not involve medications and pharmacological referring to methods that involve medication. The purpose of this essay is to discuss pain management methods; non-pharmacological and pharmacological. Whilst there are many options, in this essay, I will focus on the non-pharmacological method of water immersion and the pharmacological method of analgesia through epidural. I will discuss the benefits, side effects and contraindications of the chosen method with consideration to maternal comfort, pain perception and outcome of labour.

When determining pain management methods, the outcome should be to the benefit of the mother and baby and aimed at achieving a normal birth. (NSW Department of Health, NSW Department of Health, 2018) state, birth with minimal intervention or no medical intervention is considered normal. To assist women achieve normal birth, education is fundamental, NSW Department of Health (2018) suggests, access to evidence based information and practical skills should be made available, this will aid in making an informed decision. Several factors influence pain during labour, such as; the size and presentation of the foetus, maternal position, primipara versus multipara, augmentation, emotional and sensory stimuli. Additionally pain management discussion should begin during the antenatal period. In the case study, Jane had not attended any antenatal classes in preparation for labour. Rankin (2016) states, missing the opportunity to explore pain management options can lead to anxiety during labour. There are different stages of pain during labour, the physiology of pain alters at each stage, producing varied levels of pain. Rankin (2016) states, during the first stage of labour, pain is a result of cervical dilatation and uterine contractions of the myometrial. During the second stage of labour, pain is due to the distension of the pelvic floor and pressure to the vagina and perineum by the presenting part of the foetus. Lastly, familiarity of pain signals allows the midwife to offer a rational range of pain management options, depending on the medical status of the women, progress of labour and resources at the facility.

Non-pharmacological methods are based on the principle; labour pains can be exceeded by the use of non-analgesic methods, implementing the ‘gate control’ theory of pain management. Non-pharmacological methods avoids the use of drugs for pain management, a common non-pharmacological method of pain management is the use of water immersion. Cluett, Burns, & Cuthbert (2018) states, water immersion involves a pregnant women being completely submerged in water during any stage of labour. Rankin (2016) states water immersion modifies the women’s perception of pain and decreases intervention. There are considerations prior to offering water immersion. Johnson & Taylor (2016) state, specific criteria must be met, these include; low-risk pregnancy and labour, suitable for intermittent auscultation, single foetus, cephalic presentation and is considered full term at 37 weeks. Contraindications according to Johnson & Taylor (2016) include; maternal pyrexia, maternal discomfort, opiate use in labour, haemorrhage, pre-eclampsia or prolonged rupture of membranes. In the case study, Jane is presenting at 40 weeks gestation, term fundus, with cephalic presentation. Experiencing mild to moderate contractions, cervix is 3cm dilated and fully effaced and membranes intact. Midwifery management of this scenario indicates Jane is eligible for water immersion as a form of pain management. Pairman, Pincombe, Thorogood, & Tracy (2015) states, the benefits of water immersion include; aiding the descent of foetal head, promoting upright maternal positions, increased mobility, and a shortened length of first stage of labour. Jenkins & Totora (2013) state water immersion leads to a reduction in adrenaline levels thereby encouraging the flow of oxytocins and endorphins, resulting in a natural balance of pain and relaxation supporting labour progression. Thus, evidence suggests water immersion may be associated with improved uterine perfusion, less painful contractions and a shorter labour with fewer intervention.

Pharmacological pain relief relies on the use of medication; a form of analgesia is the use of an Epidural. Macdonald & Johnson (2017) state, an epidural analgesia is a central nerve block technique, achieved by the use of local anaesthetic, administered via a catheter into the epidural space between the spinal cord and the spinal canal. The use of epidural is a widespread form of pain management. Prior to offering this form of pain relief, it is essential to understand the contraindications. According to Johnson & Taylor (2016)  these include; coagulopathy, local sepsis, allergy to the medication and maternal refusal. According to the case study there is no contraindications for Jane, allowing epidural as an option. However, it is important to communicate the potential side effects prior to offering an epidural. According to Macdonald & Johnson (2017) these include; pruritis, urinary retention, nausea, vomiting and respiratory depression. Epidurals have been shown to provide superior analgesia, although this is not always associated with maternal satisfaction, for maternal comfort and reduction of anxiety it is important to ensure adequate administration of the epidural anaesthesia. Johnson & Taylor (2016) state there are some potential disadvantages when utilising an epidural such as; breakthrough pain, Anim-Somuah, Smyth, Cyna, & Cuthbert (2018) state breakthrough pain is when contractions are still felt over one area of the abdomen, potentially as a result of non-uniform anaesthetic. Equally important, is the influence maternal position has on the mechanisms of labour, physiology of pain and the progression of labour. Fleet, Jones, & Belan (2014) found women who utilise an epidural were more likely to be induced, experienced an increased second stage of labour and had a higher likelihood of an assisted vaginal birth. This can be correlated to the numbing affect an epidural has on muscles. Johnson & Taylor (2016) suggests the use of analgesia epidural can affect the pelvic autonomic and parasympathetic nerves, inhibiting oxytocin release, reducing the strength and frequency of contractions. Due to this, the rotation and presenting part of the foetal head may be hindered, the urge to push may be reduced, impacting the natural decent of the foetus into the birth canal. Thus maternal positioning may support progress of labour, finding an optimal maternal position to support natural decent into the birth canal. By altering the bed into an upright position, this will aid passive descent. According to Cheng & Caughey (2017) research, passive descent of the foetal head can maximize the efficiency of maternal pushing. In general, an epidural is an effective method of pain management, however, attentiveness to the physiology of pain, mechanisms of labour and foetal position are important to enhance the outcome of labour. It is suggested that when an epidural is in situ, passive descent should be used to increase the likelihood of a spontaneous vaginal birth, decrease instrumental intervention and reduce maternal pushing.

Implementing non-pharmacological and pharmacological methods, result in pain minimisation and increased maternal comfort. Water immersion has been found as an effective non-pharmacological method of pain relief, by improving uterine perfusion, minimising contraction intensity and reducing medical interventions. In contrast, the use of an epidural as a pharmacological method has been found to eliminate maternal pain, the likelihood of assisted vaginal birth increases, resulting in further medicalised interventions. As a midwife, it is essential to ensure women are confident in their choice of pain management. Regardless of the method chosen, the benefits, side effects and contraindications must be communicated as this can influence the outcome of labour.

References

• Anim-Somuah, M., Smyth, R., Cyna, A., & Cuthbert, A. (2018). Epidural versus non-epidural or no analgesia for pain management in labour. The Cochrane Database of Systematic Reviews, 5(5), CD000331. Retrieved from: https://www-cochranelibrary-com.ezproxy.uws.edu.au/cdsr/doi/10.1002/14651858.CD000331.pub4/full
• Cheng, & Caughey. (2017). Defining and Managing Normal and Abnormal Second Stage of Labor. Obstetrics and Gynaecology Clinics of North America, 44(4), 547-566. https://doi.org/10.1016/j.ogc.2017.08.009
• Cluett, E., Burns, E., & Cuthbert, A. (2018). Immersion in water during labour and birth. The Cochrane Database of Systematic Reviews, 5(5), CD000111.Retrieved from: https://www-cochranelibrary-com.ezproxy.uws.edu.au/cdsr/doi/10.1002/14651858.CD000111.pub4/full
• Fleet, Jones, & Belan. (2014). Subcutaneous administration of fentanyl in childbirth: An observational study on the clinical effectiveness of fentanyl for mother and neonate. Midwifery, 30(1), 36-42. https://doi.org/10.1016/j.midw.2013.01.014
• Jenkins, G.W., & Tortora, G.J. (2013). Anatomy and physiology: From science to life (3^rd ed.) Hoboken, NJ: John Wiley & Sons.
• Johnson, R. & Taylor, W. (2016). Skills for midwifery (4th ed.) United States: Elsevier.
• Macdonald, S. & Johnson, G. (2017). Mayes’ Midwifery. (15th ed.) London, UK: Elsevier.
• NSW Department of Health. (2018). Maternity: Towards Normal Birth in NSW (Publication No. PD2010_045) Retrieved from https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2010_045.pdf
• Pairman, S., Pincombe, J., Thorogood, C., & Tracy, S. (2015). Midwifery: preparation for practice (3rd ed.). Chatswood, N.S.W: Elsevier, Australia