Pain Relief During Child Labour Nursing Essay

Pain during childbirth is a very subjective matter and varies considerably between women. It is generally considered to be severe pain with only 2-4% of women reporting minimal pain in labour.

The pain of childbirth is arguably one of the most severe types of pain a woman will endure in her lifetime . Relief of the pain of childbirth has always been controversial. Misinterpretations of biblical scripture (“In sorrow thou shalt bring forth children”) resulted in centuries of denial of pain relief, as clergy insisted that suffering in labour was consistent with divine intent. Midwifes in 15th century were actually burned at the stake for offering pain relief during labour.

Nowadays things are very different..although analgesia during labour is not mandatory however women should be given the different options for pain relief available and let to make an informed decision. Most women seek pain relief when the active phase of first stage begins. There are generally no contraindications for pain relief.

It is strongly recommended for certain maternal conditions: cardiac disorders, suspected difficult intubation and in situations where intrapartum manipulation is likelyabreech, multiple pregnancy.

Pain pathways in labour 5,6

During 1st stage of labour: pain results from both cervical dilatation + uterine contractions (myometrial ischaemia). Sensation of pain travels from the uterus via visceral afferent (sympathetic) nervesaenter spinal cord through the posterior segments of thoracic spinal nerves T10-T12 (body and fundus of uterus)

During 2nd stage of labour: pain is the result primarily from distension of the pelvic floor, vagina and perineum by the presenting part of the foetus and travels via sensory fibres of the sacral nerves S2,3,4 (pudendal nerve)acervix and birth canal. Sensation of uterine contractions contributes to the pain as well.

Nerve supply

Female vulva area innvervated by branches of the pudendal nerve, derived from S2,3,4 leaves pelvis medial to sciatic nerve through the greater sciatic foramen. acrosses external surface of Ischia spineare-enters pelvis through the lesser sciatic notch and passing along the lateral wall of the ischiorectal fossa, divides into branches supplying most of the perineum.

Non-pharmacological methods: 4

Massage and touch: massage especially at the lower back modifying pain transmission along pain fibres and also relieving ‘stress’

Relaxation techniques
Rhythmical movements
Breathing exercises
Acupuncture
Mobilisation
Hypnosis
Aromatherapy

Warm baths/Hydrotherapy : soothing effect of warm water

Audioanalgesia: music can reduce stress and enhance pain-relieving measures

Heat and cold
Supportive midwife
TENS

a Transcutaneous electrical nerve stimulation: thought to work by promoting endogenous enkephalin release within the spinal cord where it acts to inhibit the pain transmission. It uses the gate theory of pain controlaby application of electrical current to the nerves that carry the painful stimuli; the transmission of pain is partially blocked. Skin surface electrodes are applied to the woman’s skin with low voltage electrical current which is modified by the woman. The electrodes are usually applied at the lower back covering T10-L1 nerve roots (uterus innvervation) early in the 1st stage of pregnancy for optimal effect.

1.Entonox: oxygen and nitrous oxide

Inhalation analgesia 50% Oxygen : 50% Nitrous Oxide

Indication: 1st stage of laboura Woman breathes the mixture during a contraction in the active phase of 1st stage and also 2nd stage of labour

Effectiveness: <50% obtain satisfactory pain relief; 20% obtain some pain relief; 30% find it ineffective

Duration of effect: time of inhalation only and takes 20-30seconds for peak effect

Must be used properly to be effective

Pharmacological methods
Advantages
Disadvantages

-Good analgesic and sedative properties

-Readily available

-Easily administered

-Does not adversely affect labour progress

-Can be given via PCA (patient-controlled analgesia): the woman controls the dose she is receiving (only used in some hospitals)

-Can cause neonatal sedation and respiratory depression (due to delay in gastric emptying)

*need to be treated with opioid antagonist injection e.g.naloxone, into the umbilical vein or im

-Side effects:

N&V

Respiratory depression

Over-sedation

2.Pethidine

100-150mg im injection

Opiate agonist analgesic

Indication: 1st stage of labour

Effectiveness: < 50%. Effect starts to take place in 15-20 mins with duration of 2-3hours

3.Epidural anaesthesia 7,8,9,10

Technique: injection of 0.25%/0.5% bupivicaine via a catheter into the epidural space (L3-4)

Indication: First or second stage of labour; C-section

Effectiveness: Most effective way of relieving childbirth pains: Provides flexibility in pain management complete pain relief in ~95% of women. Bolus injection every 3-4 hours or continuous infusion

“Epidural anaesthesia provides excellent analgesia for labour and delivery and remains the most widely used local anaesthetic in obstetric anaesthesia”

Advantages
Disadvantages

-most effective method of pain relief in labouracomplete relief of contraction pain in 95% of labouring women

-it can be topped up for an instrumental delivery if required

-can be converted to provide anaesthesia for an operative delivery or for the removal of retained placenta

-epidural opiates e.g. diamorphine,morphine provide good post-op pain relief for hours

-allows women to be clear-headed and in control of labour

-invasive procedures

-can have side effects:

Transient hypotension; Dizziness; Shivering

a†‘ 2ndstage labour duration (a’operative vaginal delivery)

Small a†‘ in maternal temperature, urinary retention

Block may be unilateral or patchy

Motor nerves as well as sensory nerves can become blockedaloss of mobility

<1% chance of dural tap by the needle/catheter asevere headache which may require epidural blood patch as treatment Loss of sensation of full bladderaurinary retention , breakthrough pain and need for catheterisation

Post partum neuropathy

Meningitis; Epidural abscess/haematoma, Short-term backache

Epidural procedure:

Consent

Blood sample for coagulation studies (potentially at risk patients)

IV cannula for fluids (counteract hypotension)

Lady lying on her side or sitting with the back curved to open up the interverterbal spaces

Aseptic technique, anaesthetist infiltrates local anaesthetic into the skin over L2/3 or L3/4 (if combined spinal epidural used)

The epidural space is 4-5cm deep on average and a Tuohy needle is used (marked at 1cm interval to allow depth to be gauged)

The loss of resistance technique to saline or air is used to identify the epidural space

Epidural catheter threaded through the needle and the needle withdrawn subsequently

Local anaesthetic (bupivacaine) initially given in a test dose to make sure the epidural catheter ha not entered the subarachnoid space therefore resulting in consequent drop in BP

Bolus dose of the anaesthetic given and the epirual is run either on bolus top-up doses

1-2 hourly as required or more effectively as continuous infusion

*some may be offered patient-controlled epidural

BP readings taken at 5 minute intervals for 20 minutes after each top-up and at 30 minute intervals once established

Level of block height must be monitored by testing the dermatome level to which the block has spread using cold or touch sensation. Motor power is testedapatient to lift leg and bend knee

Record of: BP, block height and motor block

5. Spinal anaesthesia

Technique: injection 0.5% bupivicaone into the subarachnoid space

Indication: any operative delivery; manual removal of the placenta

Effectiveness: immediate effect and a single injection lasting 3-4 h

Side-effects: respiratory depression

6. General anaesthesia

Should generally be avoided

Best reserved for emergency C-section or instrumental vaginal delivery (due to speed of administration) and for entrapment of the aftercoming head at vaginal breech delivery (as it relaxes the cervix)

4.Local analgesia 11

Used for women who have not had an epidural anaesthetic and who require a forceps or vacuum extraction delivery

Repair of an episiotomy or a perineal tear

Some cases of breech delivery

Two techniques:

i.Pudendal Nerve block:

Technique: Inflitration of R and L pudendal nerves (S2-4) with 0.5% lidocaine

Indication: 2nd stage for operative delivery

Effectiveness: within 5 minutes with duration 45-90min

ii.Perineal nerve infiltration

Technique: Infiltration of perineum with 0.5% lidocaine at posterior fourchette

Indication: 2nd stage prior prior to episiotomy and 3rd stage for suturing of perineal lacerations

Effectiveness: within 5 minutes with duration 45-90min

Advantages
Disadvantages

-Rapidly administered

-Low incidence of hypotension

-Appropriate for women with hypovolemia and women at high risk of haemorrhage

-Higher incidence

Aspiration

Neonatal depression

Postpartum haemorrhage

-Complications:

Aspiration of gastric contentsapneumonia or pneumonitis (Mendelson syndrome)

Maternal hypoxic cerebral injury (failed intubation or obstructed endotracheal tube)

Injury to upper airway