Nonpharmacologic and Pharmacologic Methods of Pain Relief for the Laboring Woman
Objectives
As you complete this module, you will learn:
Causes of pain in labor and nonpharmacologic therapies for pain control
The role of a professional doula in providing support to women giving birth
Those measures that need to be taken to safely use hydrotherapy for women in labor or giving birth
The technique for administering subcutaneous/intracutaneous injections of sterile water to treat severe back pain in labor
Breathing techniques to assist the woman in progressing through labor and birth
Pharmacologic interventions, rationale, and factors to consider when administering medications to laboring women for pain relief
Interventions and rationale for nursing care for women who choose neuraxial anesthesia to manage labor pain
Maternal and fetal effects of nitrous oxide when used as labor analgesia
Which peripartum patients and procedures are best suited for nitrous oxide use
Administration techniques for nitrous oxide delivery that support patient safety
Key Terms
When you have completed this module, you should be able to recall the meaning of the following terms. You should also be able to use the terms when consulting with other health professionals. The terms are defined in this module or in the glossary at the end of this book.
acupressure
acupuncture
anxiolytic
arachnoid space
catecholamines
conduction anesthesia
doula
effleurage
epinephrine
extradural space
homeopathy
hyperventilation
lithotomy
nonpharmacologic
neuraxial anesthesia
nitrous oxide
subdural space
transcutaneous electrical nerve stimulation (TENS)
Part 1 Pain in Labor and Nonpharmacologic Modes of Relief
MICHELLE R. COLLINS
The Experience of Pain in Childbirth
There are many characteristics universal to labor and birth, one of the most significant being the discomfort, or pain, that women experience. Though the physiologic cause of labor pain is universal for women, the experience of one’s interpretation of that pain, as well as how it is dealt with, is certainly individualized. From the beginning of time, women have used various methods to cope with pain in labor and birth. Women in the Andes region of the world chewed coca leaves for pain (the same plant from which the modern cocaine is derived). According to ancient records, Greek women chewed willow bark during childbirth; willow bark being a predecessor to modern day aspirin.1
Pain, or rather one’s experience with pain, is influenced by a multitude of factors, to include culture, age, personal experience with pain, parity, and physical/psychological and emotional support. Providers who are knowledgeable, clinically competent, caring, and skilled at providing both pharmacologic and nonpharmacologic methods of pain relief are needed in labor and delivery units and birth centers. Every laboring woman deserves kindness, compassion, and support as she navigates the process of giving birth. This aspect of your caregiving is really the art of nursing. Unfortunately, in today’s fast-paced medical environment, nurses have limited time to spend providing supportive care.2
Studies indicate that the satisfaction a woman experiences during childbirth is related to either her ability to remain in control or to influence what happens to her.3 For women, those factors which have great influence over the satisfaction with their birth experiences include their own personal expectations, the amount of support they felt was given by caregivers, the quality of the relationship between them and their caregiver, and their inclusion/involvement in decision-making.4 Maternal perception of control is closely related to satisfaction, and the issue of control can be seen in terms of power. Both the birth setting and its participants powerfully influence the process of childbirth, shaping the role and amount of control held by a laboring woman, those who support her, and her caregivers. The birth experience belongs to the laboring woman and all efforts should be made to support, accommodate, and encourage both her and her support persons. Care providers should be committed to meeting the needs of the laboring women and their support persons and not committed to arbitrary and restrictive rules.
The goals of intrapartum care are to do the following:
Promote maternal coping behaviors
Provide a safe environment for mother and fetus
Support the mother and her family throughout the labor and birth experience
Follow through on the woman’s desires and choices throughout labor, whenever possible
Provide comfort measures and pain relief as needed
Offer reassurance and information, doing so with attention to the mother’s and family’s cultural needs
The caregiver should do the following:
Create an environment sensitive to the psychological, spiritual, and cultural needs of the woman and her family
Monitor maternal and fetal well-being
Listen actively
Be vigilant in recognizing that body language, as well as spoken word, has a powerful influence over maternal perceptions of the birth experience
Use language that is culturally appropriate, provides positive reinforcement, and empowers women and their families
Touch so as to be therapeutic
Use knowledge of both nonpharmacologic and pharmacologic therapies for pain relief
Integrate the woman’s support person(s) in all of these responsibilities so that he, she, or they become an essential and valued part of the profound experience of birth
Cultural Sensitivity
Diversity is the norm in our society, requiring healthcare providers to be aware of beliefs and cultural practices of the families for which they care. Quality of care in obstetrics can be measured by cultural competency or the ability of a provider to incorporate knowledge of beliefs and cultural norms as they relate to the birth experience.5 Women give birth within the context of their cultural background and traditional norms, incorporating factors such as dietary practices and birth rituals. Other cultural norms surrounding birth, such as food intake, labor and birth positioning, support behaviors, and early infant caretaking need to be addressed by the caregiver.
Support for the Laboring Woman
Women tend to cope better, relax more readily, describe their babies more positively, have a more positive recall of the experience, and adjust more easily to parenthood when they receive kind and sensitive care during their labor. Women who are provided support in labor have shorter labors; use less medication; have less incidence of forceps-assisted, vacuum-assisted, or cesarean births; and have fewer babies with low Apgar scores.6 An understanding of physiology shows us that undue fetal stress may occur if the laboring woman is anxious or frightened, as a result of increased catecholamine levels and subsequent vasoconstriction. This may contribute to a compromised fetal state in some cases.
Knowledge is empowering. Keeping women informed during labor about what to expect, interpreting the sensations they are experiencing, and explaining their progress in labor are important elements of care.
The following elements are essential to cover when providing supportive care:
Helping the woman to feel that she can handle the sensations, intensity, and effort required of labor by giving constant feedback, explaining everything, being positive, and validating her efforts.
Reviewing with her how to breathe and how to position herself, placing her hands on the fundus to feel the oncoming contraction, and showing her the baby’s progress during pushing, in a mirror, if desired.
Recognizing that some women may have an unrealistic, idealized view of labor and what is involved, and that they may need assistance navigating the reality of their labor versus the idealistic version they had envisioned. Conversely, respecting, and acknowledging, that women can very often accomplish what they set their minds to when it comes to labor and birth, despite what caregivers feel about their capability.
Discussing potential barriers to labor progress such as fear, anxiety, or a history of sexual abuse or domestic violence.
Being concrete and specific with descriptions of things such as findings on pelvic exams, and ongoing assessments and plans, always with an understanding that information might need to be repeated.
In addition, a significant other, whether family member or friend, should be encouraged to stay to support the mother. The support person needs nursing care and attention as well. Nursing personnel should show the partner how to offer support, and then praise the partner’s efforts. Provision of snacks and fluids for the support person is an important component of supporting them as well. Additionally, being aware of any special needs of the support person assists nursing personnel in supporting them adequately.
Ambulation and Positioning
Healthy laboring women should be encouraged to change positions based on their comfort needs, as well as considering the position of the baby. Women who ambulate while in labor have shorter labors, less use of anesthesia, and report greater satisfaction with the birth process.7 Additionally, the various pelvic diameters are different in various positions; moving about in labor may not
only facilitate pain relief, but enhance optimal fetal positioning and descent throughout labor.8 Positions that women find helpful in labor include positions listed in Table 6.1 and Figure 6.1.
only facilitate pain relief, but enhance optimal fetal positioning and descent throughout labor.8 Positions that women find helpful in labor include positions listed in Table 6.1 and Figure 6.1.
TABLE 6.1 MATERNAL POSITIONS FOR LABOR | ||||||||||||||||||||||
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Positions that may provide comfort and help rotate a fetus from an occiput posterior position include the following9:
Knee press
Side or forward lunge
Pelvic rock on hands and knees
Exaggerated lateral position
Nurses should be advocates for promoting optimal positioning in labor and for birth. While important to consider such variables as fetal monitoring when positioning the woman, ease of monitoring should not be the main factor considered when position is chosen; very often women who do not require continuous electronic fetal monitoring have it applied and left on continuously, for the sake of nurse convenience. Women who are candidates for intermittent auscultation should be monitored that way. When she is in bed, promote right or left side-lying or sitting upright, to utilize gravity and facilitate descent.
Supine positions result in the heavy uterus resting on the major veins leading back to the heart, diminishing cardiac input. This may result in supine hypotension and fetal bradycardia. The risk is greatest when a lithotomy position is assumed.
Laboring women should be encouraged to avoid lying on their backs and to change position frequently.
It is unlikely that a supine position would be required to be maintained during labor for any reason. During a cesarean birth, however, the supine position cannot be avoided. To prevent supine hypotension, the woman’s right hip is elevated with a pillow or wedge so that the uterus can be shifted to the left. Raising the right hip relieves pressure on the vena cava and may improve circulation to the maternal heart, lungs, uterus, and placenta, resulting in fewer low Apgar scores, though most recent research on maternal positioning is somewhat conflicting.10
Fluids and Food
The policy of NPO (nothing by mouth) during labor is, unfortunately, a well-established routine in many hospitals. This practice dates back to 1946 when it was suggested that aspiration of acidic gastric contents was a significant cause of maternal morbidity and mortality.11 Although the risk of aspiration during childbirth has subsequently been proven to be extremely low, particularly because general anesthesia for childbirth is rarely used currently, and it is acknowledged that there is inherent risk in women being in a fasting state during labor and birth,12
mandatory fasting for laboring women is a practice that continues in many hospitals today. Consider the following:
mandatory fasting for laboring women is a practice that continues in many hospitals today. Consider the following:
 FIGURE 6.1 Maternal positions for labor and birth. Top row: Upright positions. Second row: Sitting positions. Third row: Kneeling positions. Fourth row: Second-stage positions. (Adapted with permission from Simkin, P. (1995). Reducing pain and enhancing progress in labor: A guide to nonpharmacologic methods for maternity caregivers. Birth, 22(3), 161–170.) |
Aspiration during general anesthesia in operative deliveries is directly related to difficult intubation, regardless of the patient’s oral intake.
Experts in anesthesiology agree that substandard management of anesthesia is a primary cause of pulmonary aspiration.
Maintaining NPO status actually results in increased gastric acidity.
Regional blocks have little effect on gastric emptying time and greatly reduce the risk of aspiration pneumonia.
A regional block is appropriate for most emergency cesarean births, so general anesthesia is very rarely utilized.
Routine intravenous (IV) fluid administration can induce fluid overload, hyperglycemia in the fetus, hypoglycemia in the newborn, and can alter plasma sodium levels.13
Hydration and the energy needs of the laboring woman are akin to the needs of a competitive athlete. Deprivation of food and fluids can directly affect labor progress and outcome.14
In 1999, the American Society of Anesthesiologists revised their recommendations regarding oral intake in labor. Clear liquids recommended for intake in labor include water, fruit juices without pulp, carbonated beverages, clear teas and coffee, flavored gelatin, fruit ices, popsicles, and broth. They recommend restrictions on a case-by-case basis only for those women who may be at increased risk for aspiration.15 Again, the restriction of food intake during labor can have a negative effect on laboring women.14
Bladder Status
Provide the woman with the opportunity to empty her bladder every 2 hours. A full bladder can halt progress in labor, especially descent of the presenting part. If a woman goes into birth with a full bladder, it can impede her uterus from being able to contract, and thus involute successfully, after placental delivery, increasing her risk of hemorrhage.
Pain Management
As noted previously in this module, pain is a subjective experience, and is defined completely by the individual having the experience. Pain management is approached in various ways and usually varies according to the stage of labor; the rate of progress; the condition of the mother and fetus; the skill, experience, and attitude of members of the obstetric team; and the requests and attitudes of the mother and her family.
The methods of pain management include the following:
Breathing and relaxation techniques
Comfort measures
Nonpharmacologic pain relief measures (e.g., hydrotherapy)
Analgesia
Anesthesia
Comfort Measures Nurses Can Use to Assist the Laboring Woman
Do not leave a woman in active labor alone; merely the presence of another individual in the labor room can be calming to the laboring woman.
Promptly change soiled and damp linen.
For mothers who are NPO status, provide frequent mouth care, give ice chips, lubricate lips, and/or encourage frequent mouth rinses.
Suggest ambulation, position change, or the use of a shower or tub, if available.
Apply massage to abdomen, back, and legs as desired. Effleurage to the abdomen is particularly relaxing for some women.
Ensure good ventilation in the room.
Control the labor room environment according to the mother’s wishes (e.g., lights, music, quiet, privacy).
Promote the participation of a coach or significant family member.
Offer support from a professional doula.
“Doula refers to a supportive companion professionally trained to provide labor support.”16 A doula’s focus is to provide emotional and physical support; the doula is not trained as a clinical caregiver, and should not be asked to participate in, or perform independently, any clinical tasks. Doulas may provide support during labor, birth, and the postpartum period. Women who have a doula have been shown to have improved birth outcomes and more positive feelings about their birth experience.17 Doulas may be particularly useful in busy birthing units where individualized care by a nurse or midwife is not possible.
What Causes Pain in Labor?
Pain can be physiologic as well as psychological and is affected by a variety of factors, including level of anxiety, environment, support, and previous experience with painful stimuli.
The physiologic causes are thought to include the following:
Hypoxia of the uterine muscle due to a diminished blood supply to the uterus during a contraction. While this is a normal, physiologic process, the hypoxia can cause muscle pain.
Stretching of, and pressure on, the cervix, vagina, and perineal floor muscles.
Distension of the lower uterine segment.
Traction on reproductive structures, such as the fallopian tubes, ovaries, and uterine ligaments.
Pressure on skeletal muscles.
Pressure on the bladder, urethra, and rectum.
Distension of the pelvic floor with laceration of the subcutaneous fascial tissue.
NOTE: Factors that undoubtedly influence the degree and character of pain include the following:
Nature of contractions (intensity, frequency and duration)
Degree of cervical dilatation
Degree of perineal distension
Maternal age, parity, and general health
Maternal position
Fetal size and position (e.g., posterior positions are usually accompanied by intense back pain felt during contractions)
Other factors that may influence a mother’s response to pain include the following:
Anxiety and fear
History of abuse or previous traumatic birth or hospital experience18
Cultural influences and upbringing
Value system and education level
Lack of knowledge or preparation
Absence of supportive significant person
Can Pain in Labor Have Harmful Effects on the Mother or Fetus?
Pain may have the following effects:
Hyperventilation, or rapid breathing associated with pain, leads to oxygen and carbon dioxide imbalance in maternal blood and lungs. This results in decreased blood flow to the uterus and brain. Breathing changes may also lead to fetal acidosis.
Enhancement in physiologic decrease in blood flow to uterus and placenta. With maternal stress, catecholamines, namely adrenaline, are released causing uterine blood vessel constriction, ultimately decreasing blood flow to the placenta and fetus.
Increase in maternal/fetal serum glucose levels. Adrenaline also causes high serum maternal glucose levels, leading to an increase of glucose in fetal blood and, therefore, in brain tissue. Such high glucose levels decrease the fetal brain cells’ ability to handle hypoxia and render those cells susceptible to damage.
Increase in maternal cardiac output and subsequently, blood pressure. Severe pain can also change cardiac rhythms and decrease blood flow to the coronary arteries.
Perpetuation of the fear, tension, pain cycle. Fear, tension, anxiety, and pain are intertwined; the greater the woman’s fear, the more muscular tension she displays, which leads to greater anxiety and physical pain, which ultimately leads to more fear.19
What Nonpharmacologic Pain Relief Measures Can Be Used with the Laboring Woman?
Many techniques and therapies can be used to provide nonpharmacologic pain relief during labor and birth. These can be used alone, or in combination with pharmacologic options, in an effort to delay, or completely forego, the use of pharmacotherapy.
The commonly used modalities include the following:
Acupressure
Acupuncture
Hydrotherapy
Massage, therapeutic touch, effleurage
Intradermal injections of sterile water
Heat and cold therapy
Aromatherapy
Music
Meditation
Hypnosis
Transcutaneous electrical nerve stimulation (TENS)
Herbal therapy
Homeopathy
Nurses may use the following techniques, found to be useful for women in labor:
Help mothers to identify the most comfortable position(s), as well as to encourage frequent position changes.
Provide hot and cold therapy with hot packs/heating pads or ice packs.
Utilize acupressure points.
Encourage the use of a tub or shower.
Provide or train a support person to use massage/effleurage techniques.
Apply counter pressure to coccyx with tennis balls or other massage devices; particularly helpful for women who have a baby in occiput posterior position.
Use the double hip squeeze to increase the outlet diameter and decrease pain. Hands are placed over the gluteus muscles with mothers assuming a position with hip joints flexed. Using the palms, pressure is given toward the center of the pelvis.20
Use intradermal injections of sterile water for severe back pain.21
Encourage support by a professional doula.
What Measures Should Be Taken to Safely Use Hydrotherapy for Women in Labor and/or for Birth? (Display 6.1)
Display 6.1 Safe Use of Hydrotherapy for Laboring Women
Nursing Responsibilities in Performing Subcutaneous/Intracutaneous Injections of Sterile Water
Sterile water injections have long been used to relieve acute pain such as that associated with renal colic, as well as other types of musculoskeletal pain. Possible theories that explain the reason for its efficacy include the blocking of pain pathways via stimulation of large nerve fibers (gate theory). There may also be an accompanying release of endogenous endorphins.22,23 This technique is particularly appropriate for women in labor who are experiencing acute back pain. A period of pain relief provided by this procedure gives an opportunity for rest and comfort and time for position changes to facilitate rotation of a posterior vertex to anterior (Display 6.2).24
Use of Acupressure and Acupuncture in Labor and Birth
Both acupuncture and acupressure have ancient origins in Chinese medicine. Acupuncture involves the strategic placement of specialized needles to stimulate particular points to produce analgesia. For labor pain, placement of needles depends on the degree and location of pain. Acupuncture has been used with some efficacy. How effective the acupuncture is depends on the degree of pain the woman is experiencing, as well as the stage of labor she is in, how fatigued she may be, as well as other mitigating forces like the woman’s degree of anxiety and muscular tension.25 Acupressure, or the application of touch at the same points used for acupuncture, stimulates the same points, but does not use needles. Research has indicated that women may experience good relief with the use of acupressure.26
Display 6.2 Subcutaneous/Intracutaneous Sterile Water Injections
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