Analgesia in Analgesia in LabourLabour

Max Brinsmead MB BS PhDMax Brinsmead MB BS PhDMay 2015May 2015

This TalkThis Talk Pain in LabourPain in Labour

– Who gets it and how badWho gets it and how bad– Pain & satisfaction with the birth experiencePain & satisfaction with the birth experience– The role of endorphinsThe role of endorphins

Non – Pharmacological OptionsNon – Pharmacological Options– Position for labourPosition for labour– Breathing and relaxationBreathing and relaxation– Massage and TouchMassage and Touch– Distraction and MusicDistraction and Music– Acupuncture and HypnosisAcupuncture and Hypnosis– Transcutaneous Electrical Nerve Stimulation Transcutaneous Electrical Nerve Stimulation

(TENS)(TENS)– Other methods e.g. AromatherapyOther methods e.g. Aromatherapy– Labouring in Water Labouring in Water – The role of antenatal educationThe role of antenatal education– The role of a support personThe role of a support person

This Talk (2)This Talk (2) Pharmacological OptionsPharmacological Options

– Nitrous oxide by inhalationNitrous oxide by inhalation– NarcoticsNarcotics

Advantages and DisadvantagesAdvantages and Disadvantages Choice of drug, dose and routeChoice of drug, dose and route

– Sterile Water by Injected PapuleSterile Water by Injected Papule Anaesthetic Techniques Anaesthetic Techniques (not (not

considered)considered)– Epidural and CaudalEpidural and Caudal– SpinalSpinal– Paracervical BlockParacervical Block– Pudendal BlockPudendal Block– Perineal infiltrationPerineal infiltration

Pain in LabourPain in Labour 80 – 90% of women describe their pain in 80 – 90% of women describe their pain in

labour as “very severe” or “intolerable”labour as “very severe” or “intolerable” Pain does not correlate with...Pain does not correlate with...

– AgeAge– EducationEducation– Social classSocial class

Satisfaction with “the birth experience” Satisfaction with “the birth experience” does not correlate either with the pain of does not correlate either with the pain of labour or with satisfaction with analgesialabour or with satisfaction with analgesia– Only 60% of women are “moderately satisfied” Only 60% of women are “moderately satisfied”

with their analgesia and with their analgesia and – 20% still rate their pain as “severe”20% still rate their pain as “severe”

Pain in Labour (2)Pain in Labour (2) Patient’s rating of pain in labour and Patient’s rating of pain in labour and

satisfaction with analgesia VARIES satisfaction with analgesia VARIES according to when they are studied:according to when they are studied:– In labourIn labour– Immediately postpartumImmediately postpartum– Several weeks postpartumSeveral weeks postpartum

This is due to the This is due to the amnesic effectsamnesic effects of labour of labour and is presumably mediated by endorphinsand is presumably mediated by endorphins– ““Nature’s opiates” Nature’s opiates” – Which are elevated by pregnancy and...Which are elevated by pregnancy and...– Highest in labourHighest in labour

Pain in Labour (3)Pain in Labour (3) Patient’s reaction to the pain of labour will Patient’s reaction to the pain of labour will

vary according to her expectations vary according to her expectations – PersonalPersonal– CulturalCultural

The continuum ranges from...The continuum ranges from...– ““No woman needs to suffer”No woman needs to suffer”– Therefore it is our role to remove it completelyTherefore it is our role to remove it completely

To...To...– It is “natural” or “ordained”It is “natural” or “ordained”– And a “part of the experience”And a “part of the experience”

Most women are somewhere in betweenMost women are somewhere in between – so your role is to establish rapport and find out where so your role is to establish rapport and find out where

they arethey are

Pain in Labour (4)Pain in Labour (4) In providing analgesia carers of In providing analgesia carers of

labouring women need to...labouring women need to...

– Examine their own beliefs and valuesExamine their own beliefs and values– Respect a patient’s right to chooseRespect a patient’s right to choose

Because a sense of control is Because a sense of control is importantimportant– And what correlates with satisfaction with labour And what correlates with satisfaction with labour

is the is the attitudeattitude and and supportsupport provided by the carer provided by the carer

Position in LabourPosition in Labour Pain is greatest when the patient lies on Pain is greatest when the patient lies on

her backher back Patients should be encouraged to adopt Patients should be encouraged to adopt

a position of comforta position of comfort There is evidence that remaining There is evidence that remaining

upright and mobile improves labour upright and mobile improves labour efficiencyefficiency

Mobility may be encouraged by the use Mobility may be encouraged by the use of Birth Balls...of Birth Balls...– But RCTs have not been doneBut RCTs have not been done

Breathing & RelaxationBreathing & Relaxation

Limited studies show benefitLimited studies show benefit Harmless to mothers and babiesHarmless to mothers and babies Provided that prolonged breath-holding Provided that prolonged breath-holding

is avoidedis avoided So patients who wish to use this should So patients who wish to use this should

be supportedbe supported

Massage & Massage & Therapeutic TouchTherapeutic Touch

Has been studied by RCTHas been studied by RCT Shown to reduce the pain of labourShown to reduce the pain of labour Reduces anxiety and stressReduces anxiety and stress And resulted in better mood and less And resulted in better mood and less

postnatal depression in one studypostnatal depression in one study

Distraction & MusicDistraction & Music

Has been studied by one RCTHas been studied by one RCT Reduces both the pain and distress Reduces both the pain and distress

from painfrom pain Harmless to mothers and babiesHarmless to mothers and babies

Acupuncture and Acupuncture and AcupressureAcupressure

Has been studied in 4 RCTsHas been studied in 4 RCTs Reduces the need for pharmacological Reduces the need for pharmacological

pain relief and epidural anaesthesiapain relief and epidural anaesthesia Reduces the need for augmentation of Reduces the need for augmentation of

contractionscontractions But not the rate of spontaneous birthBut not the rate of spontaneous birth

HypnosisHypnosis

Has been studied in 5 RCTsHas been studied in 5 RCTs Reduces the need for pharmacological Reduces the need for pharmacological

pain reliefpain relief And the need for augmentation of And the need for augmentation of

contractionscontractions

Transcutaneous Transcutaneous Electrical Nerve Electrical Nerve

Stimulation (TENS)Stimulation (TENS) Has been studied in 10 RCTsHas been studied in 10 RCTs None showed any reduction in pain or use of None showed any reduction in pain or use of

further analgesiafurther analgesia Some actually showed an increase in pain Some actually showed an increase in pain

scoresscores So this method should not be offeredSo this method should not be offered But I allow TENS by patients who wish to do soBut I allow TENS by patients who wish to do so

AromatherapyAromatherapy

Has been studied in one RCTHas been studied in one RCT Found no effect on pain or the need for Found no effect on pain or the need for

other analgesiaother analgesia And no effect on the rate of And no effect on the rate of

spontaneous birthspontaneous birth But I allow aromatherapy by patients But I allow aromatherapy by patients

who wish to do sowho wish to do so

Labouring in WaterLabouring in Water Studies consistently show that women who Studies consistently show that women who

have access to water (bath or shower) resort have access to water (bath or shower) resort to epidural anaesthesia less frequentlyto epidural anaesthesia less frequently– Please note that this does not mean “water births”Please note that this does not mean “water births”

Does not affect any other outcome...Does not affect any other outcome...– Length of labourLength of labour– Rate of SVDRate of SVD– Infant outcomes (Apgars etc)Infant outcomes (Apgars etc)– Maternal trauma (to the perineum)Maternal trauma (to the perineum)– Infant or maternal infectionInfant or maternal infection

But keep temperature <37.5But keep temperature <37.500 C C– And keep it cleanAnd keep it clean

Antenatal EducationAntenatal Education Reported pain in labour is influenced by a Reported pain in labour is influenced by a

patient’s expectationspatient’s expectations– So preparation for childbirth is one important So preparation for childbirth is one important

component of antenatal carecomponent of antenatal care However antenatal education does not However antenatal education does not

influence...influence...– The use of analgesia in labourThe use of analgesia in labour– Length of labourLength of labour– Rate of SVD, assisted birth & need for CaesareanRate of SVD, assisted birth & need for Caesarean– Infant outcomes (Apgars etc)Infant outcomes (Apgars etc)– Any measure of maternal outcomeAny measure of maternal outcome– With the exception of satisfaction if the education is With the exception of satisfaction if the education is

provided by the same person who provides provided by the same person who provides intrapartum careintrapartum care

Role of a Support Role of a Support PersonPerson

Rates of spontaneous birth are possibly Rates of spontaneous birth are possibly increased...increased...– and length of labour is reduced byand length of labour is reduced by

One to one care from an empathetic personOne to one care from an empathetic person This can be provided by a female companion This can be provided by a female companion

or “doula”or “doula” Whether this role can be taken by a Whether this role can be taken by a

patient’s male partner has not be confirmedpatient’s male partner has not be confirmed But it is a shame if his only role at a birth is But it is a shame if his only role at a birth is

to protect his wife from uncaring midwives!to protect his wife from uncaring midwives!

Nitrous Oxide by Nitrous Oxide by Inhalation (Entonox)Inhalation (Entonox)

Is a weak analgesic agentIs a weak analgesic agent That “takes the edge off” the pain of labourThat “takes the edge off” the pain of labour Rapidly effective and rapidly excretedRapidly effective and rapidly excreted Can be used anywhere (including in water)Can be used anywhere (including in water) Has no effect on the progress of labourHas no effect on the progress of labour Causes dizziness/light headedness in 5 – 36%Causes dizziness/light headedness in 5 – 36% Success in its use is all about timingSuccess in its use is all about timing And this requires a little practiceAnd this requires a little practice NICE recommends that Entonox be available NICE recommends that Entonox be available

to all labouring women to all labouring women

Narcotic AnalgesicsNarcotic Analgesics Intensively used and studied for >50 yearsIntensively used and studied for >50 years But there are only a few placebo-controlled RCTsBut there are only a few placebo-controlled RCTs Is a relatively poor analgesic agent when Is a relatively poor analgesic agent when

compared to epidural anaesthesiacompared to epidural anaesthesia Causes nausea and drowsiness in womenCauses nausea and drowsiness in women

– This can interfere with her ability to cooperate in the This can interfere with her ability to cooperate in the 22ndnd stage of labour stage of labour

Should always be administered with an anti Should always be administered with an anti emetic drugemetic drug– Which actually enhances its analgesic effectsWhich actually enhances its analgesic effects

The main problem is its potential to cause The main problem is its potential to cause respiratory depression in the neonaterespiratory depression in the neonate– And a reluctance to feed which can last several daysAnd a reluctance to feed which can last several days

Neonatal Depression Neonatal Depression from Narcoticsfrom Narcotics

Depends on maternal metabolism of the drugDepends on maternal metabolism of the drug And this varies from woman to womanAnd this varies from woman to woman But the effect is “dose related” and...But the effect is “dose related” and... Because the breakdown metabolites of Pethidine Because the breakdown metabolites of Pethidine

are also a respiratory depressant in the neonateare also a respiratory depressant in the neonate The greatest potential for harm comes from The greatest potential for harm comes from

repeated dosesrepeated doses Whilst the effect can be totally reversed by Whilst the effect can be totally reversed by

Naloxone...Naloxone... This drug is often misused in neonatal resuscitation This drug is often misused in neonatal resuscitation

& has not been shown to be effective by RCT& has not been shown to be effective by RCT

Neonatal Depression Neonatal Depression from Narcotics (2)from Narcotics (2)

Because early studies suggested that the Because early studies suggested that the transplacental passage of narcotics is greatest in transplacental passage of narcotics is greatest in the first 2 hours after maternal administrationthe first 2 hours after maternal administration

Most midwifery and obstetric texts counsel Most midwifery and obstetric texts counsel against their use if delivery is expected within 2 against their use if delivery is expected within 2 hourshours

However, because of the wide individual variation However, because of the wide individual variation in metabolism...in metabolism...

It is my view that no woman should be denied her It is my view that no woman should be denied her FIRSTFIRST dose of a narcotic at any stage in labour dose of a narcotic at any stage in labour– But beware of the mother who goes to sleep when she But beware of the mother who goes to sleep when she

should be pushing!should be pushing!

Narcotic AnalgesiaNarcotic Analgesia Choice of Agent, Dose & Route of Choice of Agent, Dose & Route of

AdministrationAdministration There are a large number of studies availableThere are a large number of studies available Some suggest small advantages for Some suggest small advantages for

Diamorphine & Meptazinol over PethidineDiamorphine & Meptazinol over Pethidine But the best outcomes are achieved by the But the best outcomes are achieved by the

PCA administration ofPCA administration of an intravenously an intravenously administered short-acting narcotic e.g. Remifentaniladministered short-acting narcotic e.g. Remifentanil

Where such resources are not possible...Where such resources are not possible... There is quite a lot to be said for the use of Pethidine There is quite a lot to be said for the use of Pethidine

50 mg IV and 50 mg IM50 mg IV and 50 mg IM Provided the IM injection is not into subcutaneous fatProvided the IM injection is not into subcutaneous fat

– Upper arm is recommended over lower limbUpper arm is recommended over lower limb– Why do the ED docs always use SC morphine?Why do the ED docs always use SC morphine?

Sterile Water by Sterile Water by InjectionInjection

The intradermal injection of 0.1 ml of The intradermal injection of 0.1 ml of sterile water into 1 – 4 sites of sterile water into 1 – 4 sites of lumbosacral skin has been shown by RCT lumbosacral skin has been shown by RCT to reduce back ache in labour by up to to reduce back ache in labour by up to 60% for up to 2 hrs60% for up to 2 hrs

Causes a “bee sting” like painCauses a “bee sting” like pain– Presumably works by “inhibitory gate control”Presumably works by “inhibitory gate control”

Useful for the patient with an OP Useful for the patient with an OP When an epidural is not possibleWhen an epidural is not possible Not endorsed by NICENot endorsed by NICE

Sterile Water by Sterile Water by Injected PapulesInjected Papules

Any Questions or Any Questions or Comments?Comments?

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