PAIN MANAGEMENTPrepared by Mr’s :raheegeh Awni

Method of Grantly Dick-Read

• This method is based on the idea that fear and anticipation of pain arouse natural protective tensions in the body, psychic as well as muscular.

• Fear stimulates the sympathetic nervous system and causes the circular muscle of the cervix to contract.

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• The longitudinal muscles of the uterus then have to act against increased cervical resistance, causing tension and pain.

• According to Dick-Read, prenatal courses and training reduce fear, overcome ignorance, and build a woman's self-confidence.

• instructions– Exercises that strengthen certain muscles and relax others.– Breathing techniques that will enable the woman to relax in the first

stage of labor and work effectively with muscles used during delivery.– Explanations of the value of improved physical health and emotional

stability.

Psychoprophylactic or Lamaze Method

• Psychoprophylactic childbirth. • The woman is taught to replace responses of

restlessness, fear, and the loss of control with more useful activity.

• The mother-to-be is taught exercises that strengthen the abdominal muscles and relax the perineum.

• Breathing techniques to help the process of labor are practiced.

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• The coach serves as a conditioned stimulus using the sound of his or her voice, use of particular words, and repetition of practice.

• Medications are not encouraged for pain relief. Relaxation is the core component. Increased tolerance to pain is accomplished by decreased mental anxiety and fear.

The Bradley Method of Delivery

• Commonly referred to as coached childbirth,• Involves the concepts of leading, guiding,

supporting, caring, and fostering specific skills and confidence.

• Coaches attend classes and learn to help the woman long before labor begins.

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• In one study, Kennell and associates (1991) randomly assigned 412 nulliparous women in labor to either continuous emotional support from an experienced companion or to monitoring by an inconspicuous observer who did not interact with the laboring woman.

• The cesarean delivery rate was significantly lower in thecontinuous support group compared with that of the hands-off

monitored group (8 versus 13 percent), as was the frequency of epidural analgesia for vaginal delivery (8 versus 23 percent).

Management of Discomfort

Pain is unpleasant ,complex, highly individualized phenomenon with both emotional and sensory component

The pain and discomfort of labor have tow origins visceral, somatic.

Visceral pain : in the first stage of labor, located in the lower

portion of the abdomen, the pain from cervical changes, distention of the lower uterine segment and uterine ischemia

2) Somatic pain :

pain is intense, sharp ,burning and will

localized ,result from stretching and distention of perineal tissue and the pelvic floor.

Pain during the 3ed stage of labor are similar to that experienced early in the first stage of labor.

PRINCIPLES OF PAIN RELIEF • In a scholarly review, Lowe (2002) emphasized that the

experience of labor pain is a highly individual reflection of variable stimuli that are uniquely received and interpreted by each woman individually.

• These stimuli are modified by emotional, motivational, cognitive, social, and cultural circumstances.

• The complexity and individuality of the experience suggest that a woman and her caregivers may have a limited ability to anticipate her pain experience prior to labor.

• Thus, choice among a variety of methods and individualization of pain relief is desirable.

Factor influencing pain response

1-physiological

2-phychosocial

3-enviromental

Physiologic factor-The women with history of dysmenorrhea may

experience increased pain during childbirth- upright position during labor decreased pain and

increase comfort when compared with the supine potion.

-endorphins: higher level may increase the ability of women in labor to tolerate acute pain and reduce their irritability and anxiety.

culture

• It is important to recognize that although women behavior in response to pain may vary according to her cultural background.

• it may not accurately reflect the intensity of the pain she is experiencing

Anxiety

Excessive anxiety and fear increase catecholamine secretion, result in more pelvic pain stimuli reaching the brain, this in turn magnifies pain perception.

(lowe,2002)

Previous experience

• Women with first experience may not have develops effective pain coping strategies, and the nature of previous childbirth may affect woman's responses to pain.

Childbirth preparation• The (gate-control theory of pain) help to explain

why the pain relief techniques taught in child birth preparation class work to relive the pain of labor.

• -pain sensation travel along sensory nerve pathways to brain, (massage, music etc) help in reducing or completely blocking the capacity of nerve pathways to transmit pain .

support

– A woman satisfaction with her child birth experience is primarily influenced by the attitudes an behaviors of her caregivers, including the caregivers ability to communicate and to be helpful supportive accepting and kind, continuous support significantly relives pain improves outcomes, decrease complication of labor.

enviroment

• The quality of the environment can influence woman's ability to cope with the pain.

• women prefer to be cared by familiar caregiver in a comfortable homelike setting.

• Environment should be safe, private, space for movement (light, noise,temprature) adjusted according to woman ‘s preference.

Non pharmacologic management of discomfort

Pain relief during labor

Nonpharmacologic methods

• include psychoprophylaxis (Lamaze method), emotional support,

• massage, • hydrotherapy,• transcutaneous electrical nerve stimulation (TENS),• acupuncture, • hypnosis. • These techniques tend to work best early in the first

stage of labor when the pain is least intense.

Research finding

• RCT: The study findings was that 30min of yoga practice of at least three times per week for 10 week is an effective complementary means for facilitating maternal comfort, decreasing pain during labor and 2hr post delivery and shortening the length of labor .

• This result provides evidence of the benefit of using yoga as an alternative midwifery intervention to improve the quality of maternal and childe health care.

music reduces sensation and distress of labor pain.

In a RCT, the effect of music on sensation and distress of pain was examined in that primiparous women during the active phase of labor (2003).

Results of the hypotheses is that music would reduce both the sensation and distress of pain was supported, the music group had significantly less sensation and also distress of pain than did the control group over the 3hr post test.

Result:

• soft music decreased both sensation and distress of active labor pain in the first 3hr, It also delays increase in distress of pain for an hour, the sedative quality of the music helped women to relax and distract themselves from increasingly sever pain.

Intradermal water block• intradermal water block involves the injection of small

amount of sterile water (.5-1 ml) by using a fine needle .25 gauge into four locations in the lower back to relieve back pain.

• 1 over posterior superior iliac spine and 2 other placed 3cm below and 1cm medial to each of the first site,

• ( ID ) water blocks are effective in decreasing labor pain and suffering.

• Stinging will occur for about 20-30 seconds after injection.

• Effectiveness of this method may be related to mechanisms of counter irritation

( reducing localized pain in one area by irritating the skin in an area nearby.

It can be repeated.

Touch and massage

• Massage: is the intentional and systematic manipulation of the soft tissue of the body to enhance health and healing.

• On trials include systematic review studied 90 women , the women's blood pressure and the number of expression of anxiety significantly decrease in the touch group.

• The second trial of massage = 28 randomized women to receive either usual care or massage of head, neck, hand, and feet by their partner for 20minutes\hr for 5hr during labor, this reduces the women's pain and anxiety and improves their mood.

Acupuncture and acupressure

• Is a component of traditional Chinese medicine, done by the insertion of fine needles into the skin at a combination of specific point along meridians (channels of energy called Qi,” chee”) in the body, followed by routine ,heating or electrical stimulation, and the placement of needles depends on degree and location of pain, stage of labor, level of fatigue, tension, anxiety.

• Total 598 women, between those women randomly allocated to acupuncture and control group, women report of pain were significantly lower in the acupuncture group in all 3trials, and maternal satisfaction was high.

Breathing techniques• To provide distraction, thereby reduce the perception of

pain and help woman maintain control during the contraction.

• It can promote relaxation of abdominal muscle and increase the size of abdominal cavity.

• In second stage, breathing is used to increase abdominal pressure and help in expelling the fetus.

• Instruction to simple breathing for those who are unprepared is useful.

Touch and massage

• Are beneficial in relieving labor pain.• Touch as holding woman’s hand s and stroking

her body.• Therapeutic touch enhance relaxation, reduce

anxiety, and reliefs pain.

Hypnosis:

• Is state of deep physical relaxation with an alert mind producing alpha wave, hypnosis for child birth is almost always self-hypnosis.

• the hyptherpist teaches the women to induce the hypnotic state in her self during labor, sometime her partner is thought to relief techniques are “glove anesthesia”, and imaginative transformation in which the pain is acceptable, and contraction are seen as surges of energy that cause only alight pressure sensation.

• It emphasizes on enhancing relaxation and diminishing fear, anxiety and perception of pain.

• The woman receives posthypnotic suggestions as ‘’ you will be able to push out easily.’’

• A total of 172 women participated in the 3trial, one trial found a decrease in use of anesthesia, one trial elevated maternal satisfaction with child birth and reported increase satisfaction in the hypnosis group.

Transcutaneous nerve stimulation (TENS)

involves placement of two pairs of flat electrodes on either side of woman’s thoracic and sacral spine.

These electrodes provide continuous low intensity electrical impulses stimuli from pattery-operated device.

During labor, the woman increases stimulation from low to high intensity by turning control knobs on the device.

electrode is placed at level of T1, S2, S4.

Aromatherapy:

Is the sciences of using highly concentrated essentials oils or essences distilled from plants in order to utilize their therapeutic properties .

herbal teas and vapors.Lavender clary sage and bergamot promote

relaxating,camomile oil.

lavender

Clary sage

camomile

Bergamot clay

On large, uncontrolled prospective study reported on the use effectiveness of aromatherapy over an 8 year period during this time 8050 women received aromatherapy during labor (to reduce, fear, anxiety, pain ,nausea, vomiting, to enhance women's sense of well-being and to improve contraction.

Mother and midwifes reported on the effectiveness of the oil in accomplishing the purpose for which it was given.

Application of heat and cold Heat applied to the women's back, lower abdomen,

groin and perineum, to relief pain, and to relieve chills, decrease joint stiffness, reduce muscle spasm, heat is contraindicated if a women has a fever, or prone to hemorrhage, and not used in regions of impaired sensation (analgesia, or anesthesia)

Cold: is applied on the women's back, chest or face during labor cold has the additional effect of relieving muscle spasm and reducing inflammation and edema.

Study; Appling ice massage to 49 women hand the result revealed significant reduction in pain when measured on a visual analog scale.

Continuous labor support Is refer to non –medical care of the laboring women

throughout labor and birth by trained person, include (continuous presence, emotional support, physical comforting. information and guidance,nonmidical information and advice)

-15 RCTs,including 12,791 women, labor support was provided by Varity of people.

The meta analysis revealed that women were less likely to experience analgesia instrumental delivary,cesarean birth, and report satisfaction.

Bath in labor Immersion in warm deep enough to cover the

woman’s abdomen is used to enhance relaxation, reduce labor pain, and promote progress.

- finding of prospective cohort studies found that decrease in pain upon entering the water followed slow rise in pain score.

music

• Music, tapped or live, enhances relaxation during labor, thereby reducing stress, anxiety and the perception of pain.

• It can be used to promote relaxation in labor and to stimulate movement as labor progresses.

• Pharmacologic management of labor discomfort

Systemic analgesia

• The major pharmachologic method for relieving labor pain.

• Cross maternal blood-brain barrier to provide central analgesic effect.

• They also cross through placenta.

ANALGESIA AND SEDATION

• PARENTERAL AGENTS: • 1- opoid agonist analgesia• Meperidine and Promethazine. Meperidine, 50 to 100 mg,

with promethazine, 25 mg, may be administered intramuscularly.

• . Meperidine readily crosses the placenta, and the half-life is approximately 13 hours or longer in the newborn.

• These analgesia decreased gastric emptying • And increase nausea and vomiting.• Its depressant effect in the fetus follows closely

behind the peak maternal analgesic effect.

• Fentanyl. This short-acting (30-60 min) and very potent synthetic opioid may be given in doses of 50 to 100 microgram intravenously every hour.

• Its main disadvantage is a short duration of action, which requires frequent dosing or the use of a patient-controlled

• intravenous pump.• Used with induction of epidural nerve block

anesthesia.

2-opoid agonist-antagonist analgesia

• Butorphanol (Stadol) & Nalpuphine (nubain): are synthetic narcotics, given in 1- to 2-mg doses, compares favorably with 40 to 60 mg of Meperidine.

• provide adequate analgesia without causing respiratory depression in mother and neonate.

• The major side effects are somnolence, dizziness, and dysphoria.

• Neonatal respiratory depression is reported to be less than with meperidine, but care must be taken that the two drugs are not given contiguously because butorphanol antagonizes the narcotic effects of meperidine.

3- Narcotic ( opoid) Antagonists

• Naloxone is a narcotic antagonist capable of reversing respiratory depression induced by opioid

• narcotics. It acts by displacing the narcotic from specific receptors in the central nervous system. Withdrawal symptoms may be precipitated in recipients who are physically dependent on narcotics. For this reason, naloxone is contraindicated in a

• newborn of a narcotic-addicted mother (American Academy of Pediatrics and American College of Obstetricians and

• Gynecologists, 2002). • Naloxone, along with proper ventilation, may

be given to reverse respiratory depression in a newborn ( narcosis).

4- NITROUS OXIDE Opoid antagonist

• self-administered mixture of 50-percent nitrous oxide (N2O) and oxygen provides satisfactory analgesia during labor for many women.

• (Rosen, 2002a). • Some preparations are premixed in a single cylinder

(Entonox), and in others, a blender mixes the two gases from separate tanks (Nitronox).

• The gases are connected to a breathing circuit through a valve that opens only when the patient inspires.

REGIONAL ANALGESIA

• (nerve block analgesia and anesthesia) Various nerve blocks have been developed over the years to provide pain relief during labor and delivery.

• They are correctly referred to as regional analgesics

1- Local infiltration anesthesia

• Used when episiotomy is to be performed or when lacerations need to b esutured.

• About 10-20 ml of 1% lidocaineor 2% chloroprociane is injected into the skin and then subcutaneously.

2- PUDENDAL BLOCK.

• This block is a relatively safe and simple method of providing analgesia for spontaneous delivery.

• The end of the introducer is placed against the vaginal mucosa just beneath the tip of the ischial spine.

• Pudendal block usually does not provide adequate analgesia when delivery requires extensive obstetrical manipulation.

3- PARACERVICAL BLOCK.• This block usually provides satisfactory pain relief

during the first stage of labor.• Because the pudendal nerves are not blocked,

however, additional analgesia is required for delivery.

• Usually lidocaine or chloroprocaine, 5 to 10 mL of a 1-percent solution, is injected into the cervix laterally at 3 and 9 o'clock.

• Bupivacaine is contraindicated because of an increased risk of cardiotoxicity.

• Block may have to be repeated during labor.

• Complications.• Fetal bradycardia is a worrisome complication

that occurs in approximately 15 percent of paracervical blocks.

3- SPINAL (SUBARACHNOID) BLOCK.

• Introduction of a local anesthetic into the subarachnoid space .

• Advantages include a short procedure time, rapid onset of the block, and high success rate. Because of the smaller subarachnoid space during pregnancy, likely the consequence of engorgement of the internal vertebral venous plexus.

Spinal anesthesia (blocks) An anesthetic solution containing a local anesthetic alone or in

combination with fentanyle is injected through 3d 4th 5th lumber space into subarchniod space

-Advantage's of administration is: absence of fetal hypoxia, maternal consciousness is

maintained,exellant muscular relaxation, blood loss is not excessive.

- Disadvantage:-Medication reaction, hypotension, ineffective breathing pattern,

the need for operative birth increase, after birth the incidence of bladder and uterine atony, spinal headache is higher.

Spinal anesthesia

Vaginal Delivery.

• Low spinal block is a popular form of analgesia for forceps or vacuum delivery.

• The level of analgesia should extend to the T10 dermatome, which corresponds to the level of the umbilicus.

• Blockade to this level provides excellent relief from the pain of uterine contractions.

• Lidocaine produces excellent analgesia and has the advantage of a rapid onset and relatively short duration.

Cesarean Delivery.

• A level of sensory blockade extending to the T4 dermatome is desired for cesarean delivery depending on maternal size, 10 to 12 mg of hyperbaric bupivacaine or 50 to 75 mg of hyperbaric lidocaine are given.

• The addition of 20 to 25g of fentanyl increases the rapidity of the onset of the block and reduces shivering.

Complications associated with regional analgesia

• 1- HYPOTENSION. This common complication may develop soon

after injection of the local anesthetic agent and is the consequence of vasodilatation from sympathetic blockade compounded by obstructed venous return from uterine compression of the vena cava and adjacent large veins.

• 2- HIGH SPINAL BLOCKADE. Most often, complete spinal blockade is the

consequence of administration of an excessive dose of local anesthetic agent.

• hypotension and apnea promptly develop and must be immediately treated to prevent cardiac arrest.

• 3- SPINAL (POSTDURAL PUNCTURE) HEADACHE. Leakage of cerebrospinal fluid from the site of puncture of the meninges is thought to be the major factor in the genesis of spinal headache.

• This complication can be reduced by using a small-gauge spinal needle and avoiding multiple punctures.

• 4- CONVULSIONS. In rare instances, postdural puncture cephalgia

is associated with blindness and convulsions. • Shearer and colleagues (1995) described eight

such cases associated with 19,000 regional analgesic procedures.

• It is presumed that these too are caused by cerebrospinal fluid hypotension.

• 5- BLADDER DYSFUNCTION. With spinal analgesia, bladder sensation is likely

to be obtunded and bladder emptying impaired for the first few hours after delivery.

As a consequence, bladder distention is a frequent postpartum complication, especially ifappreciable volumes of intravenous fluid are given.

• 6- OXYTOCICS AND HYPERTENSION. Paradoxically, hypertension from ergonovine or methylergonovine injected following

delivery is more common in women who have received a spinal or epidural block.

Contraindications to Spinal Analgesia

• Obstetrical complications that are associated with maternal hypovolemia and hypotension such as severe hemorrhage.

• disorders of coagulation and defective hemostasis.• the skin or underlying tissue at the site of needleentry is infected.• Neurological disorders • aortic stenosis or pulmonary hypertension

Spinal nerve block interventions

-prophylactic administration of IV fluid before epidural and spinal anesthesia for blood volume expansion to prevent maternal hypotension.

-encourage empty bladder before induction of the block, and at least every 2hr after.

-the midwife should palpate for the bladder distention -the midwife or the women partner must assists the women

to assume and maintain the correct position. -the women is protected from injury (raising side rails ,placing

a call bell, oxygen and suction ready)’

Cont- -the midwife must Make sure there is no prolonged pressure

on an anesthetized part. -change position every hour to insure adequate distribution of

the anesthetic solution and to maintain circulation to the uterus and placenta.

-assess the level of motor function ,sensation to prevent injury.

-midwife continue to monitor maternal vital sign blood pressure, contractions, cervix and station.

-determine the fetal response after administration

4- EPIDURAL ANALGESIA

• Relief from the pain of labor and childbirth, including cesarean delivery, can be

• accomplished by injection of a local anesthetic agent into the epidural or peridural space.

• Continuous Lumbar Epidural Block. Complete analgesia for the pain of labor and vaginal delivery necessitates a block from

the T10 to the S5 dermatomes

Complications. • TOTAL SPINAL BLOCKADE. Dural puncture with inadvertent

subarachnoid injection may cause total spinal block. Personnel and facilities must be immediately available to manage this complication, as described in complications of spinal analgesia.

• HYPOTENSION. By blocking sympathetic tracts, epidurally injected analgesic agents may cause hypotension and decreased cardiac output.

• CENTRAL NERVOUS STIMULATION. Convulsions are an uncommon but serious complication

• MATERNAL PYREXIA

Effect on Labor.

• Most studies, including the combined five randomized trials from Parkland Hospital report that epidural analgesia prolongs labor and increases the need for oxytocin stimulation.

Contraindications.

• As with spinal analgesia, contraindications to epidural analgesia include

• actual or anticipated serious maternal hemorrhage,

• infection at or near the sites for puncture,• neurological disease

Epidural Opiate Analgesia.• Injection of opiates into the epidural space to relieve

pain from labor has become popular. • Both cerebral and spinal opioid receptors are

stimulated by these narcotics (Ackerman and colleagues, 1992).

• Opiates alone usually will not provide adequate analgesia, and they most often are given with a local anesthetic agent such as bupivacaine.

• The major advantages of using such a combination are the rapid onset of pain relief, a decrease in shivering, and less dense motor blockade

scenario• A 38-year-old G3P2002 at 40 weeks gestational age presents to labor• and delivery complaining of gross rupture of membranes and regular uterine• contractions every 4 to 5 min. The patient has a history of rapid deliveries• and was very concerned when she broke her water that she would not• make it to the hospital. On arrival to L and D, the patient is in a lot of pain• and requesting relief immediately. You check her cervix and note that it is• C/3/−2 vertex.• What is the most appropriate method of pain control for this patient?• a. Intramuscular Demerol• b. Pudendal block• c. Local block• d. Epidural block• e. General anesthesia• The most appropriate modality for pain control in this patient is administration• of an epidural block. An epidural block provides relief from the• pain of uterine contractions and delivery.

• Three hours after administering pain relief to your patient, you• recheck her cervical exam for progress. Her cervix is unchanged at C/3/−2.• You look at the external monitor and note that contractions are occurring

every 2 to 3 min. • What is the best next step in the management of this patient?• a. Place a fetal scalp electrode• b. Rebolus the patient’s epidural• c. Place an intrauterine pressure catheter (IUPC)• d. Prepare for a cesarean section secondary to a diagnosis of secondary

arrest of labor• e. Administer Pitocin for augmentation of labor

• After placement of an IUPC, You continue to allow the patient to labor, and after two more hours you reexamine the patient and find that her cervix is unchanged. What is the best next step in the management of this patient?

• a. Perform a cesarean section• b. Continue to wait and observe the patient• c. Augment labor with Pitocin• d. Attempt delivery via vacuum extraction• e. Perform an operative delivery with forceps

Answer :• Arrest of labor cannot be diagnosed during the first stage of

labor• until the cervix has reached 4 cm dilation and until adequate

uterine contractions (both in frequency and intensity) have been documented. The

actual pressure within the uterus cannot be measured via an external tocodynamometer; an intrauterine pressure catheter needs to be placed.

• It is generally accepted that 200 Montevideo units (number of contractions in10 min ﾗ average contraction intensity in mmHg) are required for normal

labor progress.

A fetal scalp electrode would need to be placed in caseswhere the fetal heart rate tracing is difficult to monitor

externally. Acesarean section would need to be performed once arrest of

labor is diagnosed.• Augmentation with Pitocin would be indicated if inadequate

uterinecontractions are diagnosed via the IUPC. The epidural would

need tobe rebolused if the patient requires additional pain relief.

• A 29-year-old G2P1 in active labor at 41 weeks, with cervix C/5/0vertex, has just received an epidural for pain control. She is on Pitocin• because her uterine contractions had spaced out to every 10 min. The

midwife calls you because the fetal heart rate has been in the 70s for the last 3 min.

• All of the following are appropriate next steps except• a. Prep for emergent cesarean section• b. Check BP• c. Discontinue Pitocin• d. Administer oxygen• e. Turn the patient on her left side• f. Check the patient’s cervix

answer

• Prolonged fetal heart rate decelerations are isolated decelerations• lasting 2 min or longer, but less than 10 min from onset to return to

baseline.• Epidural analgesia is a very common cause of fetal heart rate

decelerations• because it can be associated with maternal hypotension and• decreased placental perfusion. Therefore, maternal blood pressure should• always be noted in cases of fetal heart rate decelerations. If maternal

blood• pressure is abnormally low, ephedrine can be given to correct the

hypotension.

• Because an umbilical cord prolapse can be associated with decelerations, the patient should undergo a cervical exam.

• In addition, the Pitocin infusion should be stopped because hyperstimulation of the uterus can be a cause of fetal hypoxia.

• The patient should be turned to the left lateral position to decrease uterine pressure on the great vessels and enhance uteroplacental flow.

• Supplemental oxygen should be given to the patient in• attempt to increase oxygen to the fetus. Only if the heart rate

deceleration persists is a cesarean section performed.

thank you