Labor Pain Management Research Articles

How Caregivers Manage Pain and Distress in Second-Stage Labor

Innovative care interactions are needed when helping a woman who exhibits severe pain or distress during the second stage of labor. We describe how caregivers and laboring women interacted during second-stage labor, with particular attention to how caregivers managed pain and distress. We used observational methods to perform a microanalysis of behaviors from video-recorded data. Pain occurred during labor contractions, and distress (an emotional response to pain) manifested primarily between contractions. Four patterns of women's behavior were identified: 1) no pain or distress, 2) low-level pain and/or distress, 3) focused working, and 4) severe pain and/or distress. Successful care was identified as enabling the woman to maintain herself in any state other than severe pain and/or distress. Particular modes of speech used by the caregiver enabled the attainment of successful care when the woman was not in severe pain or distress. When severe pain or distress existed, innovative caregiving transitioned the woman to another state. Successful intervention strategies included 1) giving innovative directions and 2) "talking down." Ordinary modes of "birth talk" can be used when severe pain or distress is not manifested and when the primary care problem is to assist women with bearing down. Innovative care interactions are needed when faced with severe pain or distress. Managing labor pain is an ongoing focus of clinicians who provide care to women in labor. In addition to pain, women might also experience distress, an emotional response to the labor experience. Whether from choice or necessity, caregivers for laboring women need nonpharmacologic interventions and interpersonal skills that can help women endure labor and give birth. Labor is hard work, and even in precipitous labors most women require assistance. Care given to a laboring woman consists of employing comforting strategies that help her cope with the pain of uterine contractions. The purpose of these comfort strategies is to help the woman find needed resilience during labor. Most cultures have mechanisms for providing this kind of support. In this article, we identify patterns of behavior used by laboring women and describe successful and unsuccessful strategies used by caregivers to help these women deal with pain and distress during the second stage of labor.

Transcutaneous electrical nerve stimulation (TENS) for pain management in labour

Transcutaneous nerve stimulation (TENS) has been proposed as a means of reducing pain in labour. The TENS unit emits low-voltage electrical impulses which vary in frequency and intensity. During labour, TENS electrodes are generally placed on the lower back, although TENS may be used to stimulate acupuncture points or other parts of the body. The physiological mechanisms whereby TENS relieves pain are uncertain. The TENS unit is frequently operated by women, which may increase sense of control in labour. To assess the effects of TENS on pain in labour. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2008). Randomised controlled trials comparing women receiving TENS for pain relief in labour versus routine care, alternative pharmacological methods of pain relief, or placebo devices. We included all types of TENS machines. Two review authors assessed for inclusion all trials identified by the search strategy, carried out data extraction and assessed risk of bias. We have recorded reasons for excluding studies. The search identified 25 studies; we excluded six and included 19 studies including 1671 women. Fifteen examined TENS applied to the back, two to acupuncture points and two to the cranium. Overall, there was little difference in pain ratings between TENS and control groups, although women receiving TENS to acupuncture points were less likely to report severe pain (risk ratio 0.41, 95% confidence interval 0.32 to 0.55). The majority of women using TENS said they would be willing to use it again in a future labour. Where TENS was used as an adjunct to epidural analgesia there was no evidence that it reduced pain. There was no consistent evidence that TENS had any impact on interventions and outcomes in labour. There was little information on outcomes for mothers and babies. No adverse events were reported. There is only limited evidence that TENS reduces pain in labour and it does not seem to have any impact (either positive or negative) on other outcomes for mothers or babies. The use of TENS at home in early labour has not been evaluated. TENS is widely available in hospital settings and women should have the choice of using it in labour.

Labor pain management by posture control behaviors learning : Postures chosen by primigravidas during the first stage of delivery

Labor pain management by posture control behaviors learning : Postures chosen by primigravidas during the first stage of delivery

Bilateral femoral neuropathy after vaginal delivery: A case report.

Epidural analgesia is frequently used for the management of labor pain in parturients. The neurologic complications of epidural analgesia are rare, but they are catastrophic when they occur. We report here on a case of bilateral femoral neuropathy in a vaginal delivery patient with epidural analgesia. The patient complained of weakness of both thighs and numbness around both knees. Neurologic examination and electromyographic study revealed that they occurred due to the delivery itself. The patient had not fully recovered at eight weeks after delivery. The declining incidence of postpartum femoral neuropathy may reflect a reduced duration of labor in accordance with modern obstetric practice, and particularly the more frequent use of Caesarean delivery. The exact etiology of postpartum femoral neuropathy is unknown, and the possible factors are direct compression of nerves that are proximal within the pelvis by either the fetal head or birthing instruments, or this malady is the result of pressure induced ischemia at the level of the inguinal ligament when the pregnant woman is in the lithotomy position.

The use of the Visual Analogue Scale for the assessment of labour pain: a systematic review.

The Visual Analogue Scale has been frequently used to assess parturients' pain intensity, but the psychometric properties of this scale have not been critically reviewed. In addition, limited research has been undertaken to investigate whether this is the most appropriate pain measurement tool in the obstetrical care setting.The overall objective of this review was to measure the psychometric properties (i.e. reliability, validity, sensitivity and specificity) of pain assessment tools that are used to assess women's childbirth pain.Types of participants Pregnant women at term (37-42 weeks gestation) who delivered in the hospital setting with cervical dilation from 0cm to 10cm were included.Types of intervention(s)/Phenomena of interest The Visual Analogue Scale and other pain measurement tools.Types of outcomes Reliability, validity, sensitivity and specificity of the pain measurement tools.Types of studies Randomised controlled trials (RCT) that examined the psychometric properties of the Visual Analogue Scale and other measurements for the assessment of labour pain were included. Due to a limited number of RCT on this subject, papers using secondary analysis, descriptive, correlational and comparative designs were also included.A three-step search strategy was utilised in this review. An initial limited search of MEDLINE and CINAHL was undertaken, followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then undertaken and was extended to other relevant databases. Thirdly, the reference lists of all identified reports and articles were searched for additional studies.Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MASTARI).MAStARI was not used to extract data in this review as predetermined in the protocol because both of the reviewers were in agreement that the data should be extracted by a tool which focuses on the psychometric properties assessment according to the objectives of this review. Therefore, a Data Extraction Form for Psychometric Assessment was developed to extract data from papers included in the review.Four studies were included in this review: 1 RCT, 2 quasi experimental studies and a cross-sectional descriptive study. As the included studies utilised different study designs and collected data at different times, data were unable to be combined in meta analysis and are presented in narrative synthesis.Four studies were included in the review. The evidence on the psychometric properties of the labour pain scales is sparse; therefore, the use of the Visual Analogue Scale for the assessment of labour pain is currently not supported by the evidence of this review. There was evidence that showed that the use of the Visual Analogue Scale in repeated measures of labour pain, such as increasing pain, can result in inconsistency and have a 'ceiling effect'. High correlations were found between several pain scales such as Visual Analogue Scale, Box Numerical Scale and Verbal Rating Scale providing insights into the interchangeability between the scales in the obstetrical setting. In addition, the findings also highlight that at present, there is no gold standard to measure pain during labour.Implications for research There is a need for more and better-designed studies to focus on the use of the pain measurement tools for labour pain in the obstetrical care setting. Further research to address the need for a new labour pain scale that will enhance labour pain management is required.Implications for practice Healthcare professionals should take note of the limitations when using the Visual Analogue Scale to assess childbirth pain, such as inconsistency of results and the 'ceiling effect'. To implement the most appropriate tool for an individual parturient, nurses need to be aware of those available and their limitations, since there is currently no gold standard measure.

Modern neuraxial labor analgesia: options for initiation, maintenance and drug selection

In the present review we outline the state-of-the-art of neuraxial analgesia. As neuraxial analgesia remains the gold standar of analgesia during labor, we review the most recent literature on this topic. The neuraxial analgesia techniques, types of administration, drugs, adjuvants, and adverse effects are investigated from the references. Most authors would agree that central neuraxial analgesia is the best form to manage labor pain. When neuraxial analgesia is administered to the parturient in labor, different management choices must be made by the anesthetist: how will we initiate analgesia, how will analgesia be maintained, which local anesthetic will we use for neuraxial analgesia and which adjuvant drugs will we combine? The present manuscript tries to review the literature to answer these questions.

The Pain of Labour.

Labour is an emotional experience and involves both physiological and psychological mechanisms.The pain of labour is severe but despite this its memory diminishes with time.Labour pain has two components: visceral pain which occurs during the early first stage and the second stage of childbirth, and somatic pain which occurs during the late first stage and the second stage.The pain of labour in the first stage is mediated by T10 to L1 spinal segments, whereas that in the second stage is carried by T12 to L1, and S2 to S4 spinal segments.Pain relief in labour is complex and often challenging without regional analgesia.Effective management of labour pain plays a relatively minor role in a woman's satisfaction with childbirth.

Strategy to Eliminate Pethidine Use in Hospitals

Strategy to Eliminate Pethidine Use in Hospitals

Battlefield Acupuncture

Battlefield Acupuncture

A comparative analysis of pain management by midwives

The study was set up to investigate the management of labour pain by midwives and traditional birth attendants. A qualitative research methodology was used to seek the views of 50 midwives and 60 traditional birth attendants on pain management during labour. Data were analyzed manually using themes that emerged from the study. The results revealed that pain was generally regarded as a normal physiological response to labour and was given little attention. Midwives identified pharmacological and nonpharmacological methods of relieving pain. Traditional birth attendants identified the use of herbs, baths, adopting the most comfortable position, as well as being with a companion as the ideal methods of pain management. Challenges experienced by midwives were lack of resources to effectively deliver quality care and poor referral system, socio-cultural issues and absence of a policy guideline to safeguard practice. Traditional birth attendants experienced challenges relating to poor recognition by the modern health care sector and poor referral system to modern maternity care facilities. Recommendations were made to educational institutions to stream line their curriculum to take into consideration sociocultural aspects of childbearing. A recommendation related to policy makers was to design institutional guidelines, which set out a national strategy for safe motherhood and maternity care.

Single dose spinal anesthesia for the management of labor pain in the developing world: defining the benefits

Single dose spinal anesthesia for the management of labor pain in the developing world: defining the benefits

TENS machines and their use in managing labour pain

Transcutaneous electrical nerve stimulation (TENS) machines have been used in medical practice since the 1970s, initially to combat chronic lower back pain. With a rise in interest of non-pharmacological methods of pain management during labour, the TENS machine has become increasingly used to manage labour pain. TENS machines are small and portable. They work by transmitting a controlled level of electrical stimulation into the skin via electrodes, which enables the blocking of painful impulses at the dorsal horn of the spinal column. It also stimulates the body to produce natural endorphins and enkephalins. With these attributes a TENS machine is a method of pain relief whereby there are no adverse side-effects to mother and/or child. It is non-invasive, can be used in the home and controlled by the woman. There is however little scientific evidence to support TENS machines as a stand alone form of pain control throughout labour. So far it is seen as better suited to being used in the very early stages of labour and then combined with either pharmacological methods or entonox.

Birth outcomes associated with interventions in labour amongst low risk women: A population-based study

Despite concern over high rates of operative birth in many countries, particularly amongst low risk healthy women, the obstetric antecedents of operative birth are poorly described. We aimed to determine the association between interventions introduced during labour with interventions in the birth process amongst women of low medical risk. We undertook a population-based descriptive study of all low risk women amongst the 753,895 women who gave birth in Australia during 2000-2002. Adjusted odds ratios (AOR) were calculated using multinomial logistic regression to describe the association between mode of birth and each of four labour intervention subgroups separately for primiparous and multiparous women. We observed increased rates of operative birth in association with each of the interventions offered during the labour process. For first time mothers the association was particularly strong. This study underlines the need for better clinical evidence of the effects of epidurals and pharmacological agents introduced in labour. At a population level it demonstrates the magnitude of the fall in rates of unassisted vaginal birth in association with a cascade of interventions in labour and interventions at birth particularly amongst women with no identified risk markers and having their first baby. This information may be useful for women wanting to explore other methods of influencing the course of labour and the management of pain in labour, especially in their endeavour to achieve a normal vaginal birth.

The effects of opioids, local anaesthetics and adjuvants on isolated pregnant rat uterine muscles

Local anaesthetics, opioids and adjuvants are often used for managing labor pain. Some others of these agents are reported to cause alterations on uterine contractility during labor. However, there are controversies and the effects of some others are unknown. In the present study, we aimed to elucidate the effects of opioids such as alfentanyl, meperidine, remifentanyl; local anesthetics such as mepivacaine, ropivacaine, bupivacaine; and adjuvants such as clonidine and midazolam on isolated pregnant rat uterine muscle. Strips of longitudinal uterine smooth muscle obtained from rats pregnant for 18-21 days were suspended in 20 ml organ baths. Isometric tension was continuously measured with an isometric force transducer connected to a computer-based data acquisition system. The effects of cumulative concentrations of alfentanyl, meperidine, remifentanyl, mepivacaine, ropivacaine, bupivacaine, clonidine and midazolam (10(-8) - 10(-4) M, for all) on contractions induced by oxytocin (1 mU/ml) were studied. Alfentanyl (10(-5) M), meperidine (10(-5) M), remifentanyl (10(-4) M), bupivacaine (10(-4) M), ropivacaine (10(-4) M) and midazolam (3 x 10(-5) M) caused significant decreases in contractile responses of uterine strips to oxytocin. Contrastingly, mepivacaine increased (33.1% +/- 7.2%) oxytocin-induced contractions of uterine strips while clonidine exerted no significant effect. The sensitivity of myometrial preparations to tested local anesthetics or opioids did not differ significantly. The findings of the present study demonstrated that some local anesthetics, opioids and adjuvants caused significant and agent-specific alterations on contractility of the pregnant rat myometrium. Therefore, they seemed to have a potential to influence uterine contractility during clinical management of pain during labor. However, further research is needed to extrapolate these finding to clinical practice.

Complementary and alternative therapies for pain management in labour.

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute towards the popularity of complementary methods of pain management. This review examined currently available evidence supporting the use of alternative and complementary therapies for pain management in labour. To examine the effects of complementary and alternative therapies for pain management in labour on maternal and perinatal morbidity. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006) and CINAHL (1980 to February 2006). The inclusion criteria included published and unpublished randomised controlled trials comparing complementary and alternative therapies (but not biofeedback) with placebo, no treatment or pharmacological forms of pain management in labour. All women whether primiparous or multiparous, and in spontaneous or induced labour, in the first and second stage of labour were included. Meta-analysis was performed using relative risks for dichotomous outcomes and mean differences for continuous outcomes. The outcome measures were maternal satisfaction, use of pharmacological pain relief and maternal and neonatal adverse outcomes. Fourteen trials were included in the review with data reporting on 1537 women using different modalities of pain management; 1448 women were included in the meta-analysis. Three trials involved acupuncture (n = 496), one audio-analgesia (n = 24), two trials acupressure (n = 172), one aromatherapy (n = 22), five trials hypnosis (n = 729), one trial of massage (n = 60), and relaxation (n = 34). The trials of acupuncture showed a decreased need for pain relief (relative risk (RR) 0.70, 95% confidence interval (CI) 0.49 to 1.00, two trials 288 women). Women taught self-hypnosis had decreased requirements for pharmacological analgesia (RR 0.53, 95% CI 0.36 to 0.79, five trials 749 women) including epidural analgesia (RR 0.30, 95% CI 0.22 to 0.40) and were more satisfied with their pain management in labour compared with controls (RR 2.33, 95% CI 1.15 to 4.71, one trial). No differences were seen for women receiving aromatherapy, or audio analgesia. Acupuncture and hypnosis may be beneficial for the management of pain during labour; however, the number of women studied has been small. Few other complementary therapies have been subjected to proper scientific study.

Knowledge and decision-making for labour analgesia of Australian primiparous women

Objective to assess and investigate knowledge of labour pain management options and decision-making among primiparous women. Design a semi-structured guide was used in focus groups to gather pregnant women's knowledge concerning labour analgesia. Attitudes to labour and pain relief, knowledge of pain relief, trustworthiness of knowledge sources, and plans and expectations for labour pain relief were investigated. Setting a major tertiary obstetric hospital in metropolitan Sydney, Australia. Participants twenty five primiparous women, who were 25 weeks or more gestation, and planning a vaginal birth. Findings although women considered themselves knowledgeable, they were unable to describe labour analgesic risks or benefits. There was a large discrepancy between perception and actual knowledge. The main source of knowledge was anecdotal information. Late in pregnancy was considered the ideal time to be given information about labour analgesia. Women described their labour pain relief plans as flexible in relation to their labour circumstances; however, most women wanted to take an active role in decision-making. Key conclusions the large discrepancy between perceived knowledge and actual knowledge of the likely consequences of labour analgesia suggests that women rely too heavily on anecdotal information. Implications for practice clinicians should be aware that some women overestimate their knowledge and understanding of analgesic options, which is often based on anecdotal information. Standardised labour analgesia information at an appropriate time in their pregnancy may benefit some women and assist health-care providers and women to practice shared decision-making.

L'analgésie péridurale obstétricale contrôlée par la patiente : en pratique

Objectives Update on patient controlled epidural analgesia for labour. Study design Literature review of the recent data on local anaesthetics, additional analgesics and of publications on the various protocols used. Data collection Pubmed database ( www.ncbi.nlm.nih.gov/entrez/query.fcgi) was checked with the following key words: PCEA, labour, opioids, clonidine. The abstracts of the ASA meetings from 2000 to 2005 were also examined. Results Patient controlled epidural analgesia (PCEA) is the method of choice for optimal labour pain management. The advantages of this technique are numerous. Some of them are established: consistent reduction in overall local anathetic requirement, less motor blockade, safety of the technique and team workload reduction. A better adequacy with the analgesic requirements and an increase in overall patient satisfaction are frequently retrieved, provided that the choice of the analgesics and the PCEA parameters are adequately chosen. Conclusion The use of PCEA improves the quality of analgesic management offered to the parturients who are more and more willing to have a “more natural” childbirth. The PCEA gives them more autonomy and, in fine, enables them to better enjoy this unique event. The main barrier to a more widespread diffusion of PCEA in many institutions remains the financial issue, although a well-selected device and low cost disposables allow a reduction of indirect costs by decreasing care giver workload.

Anesthésie ďune parturiente en travail, atteinte ďurticaire pigmentaire

To report the anesthetic management of labour pain and Cesarean section in a patient with urticaria pigmentosa at risk for systemic mastocytosis. CLINICAL: A 37-yr-old patient with a history of urticaria pigmentosa and an allergic reaction to a local anesthetic agent was seen in consultation at 36 weeks gestation. She previously tested negative for an allergy test to lidocaine. Recommendations to avoid systemic mastocytosis included: avoidance of histamine-releasing drugs, using lidocaine for labour epidural, and regional anesthesia in case of a Cesarean section. The patient presented at term in labour. Intravenous fentanyl was used for early labour, followed by a combined spinal-epidural. The spinal contained lidocaine and fentanyl, but because of pruritus, the epidural infusion contained lidocaine only. Most likely because of tachyphylaxis to lidocaine, an epidural bolus of lidocaine with epinephrine failed to provide adequate anesthesia for a Cesarean section. The block was supplemented with nitrous oxide by mask, with fentanyl postdelivery. Postoperative pain control was managed with an epidural infusion of lidocaine and fentanyl for three days. The patient was discharged without complications four days postsurgery.Proper allergy testing prior to pregnancy is important to help the management of labour pain and anesthesia for Cesarean section in a patient at risk for systemic mastocytosis.

Providing Developmentally Competent Care for Adolescents During Labor and Birth

In 2002 there were nearly half a million births in the United States to adolescent girls 19 or younger. Although nurses strive diligently to provide culturally competent care to women of differing ethnic backgrounds sometimes nurses can forget that developmentally competent care is also essential for providing optimal care to adolescents. A review of the literature found few studies documenting adolescent responses to labor and birth. Thurman and Hulsey documented adolescents preferences for and use of labor pain management and found that significantly less primiparous adolescents choose regional anesthesia compared to older primiparous women but the researchers could not explain why. Low et al contrasted adolescents experiences of childbirth with the experiences reported by adults. They found that adolescents put limited time into planning for their birth have a greater focus on planning for the baby and use the media as a significant source of information. Work has been done on providing social support to teens during pregnancy but little research has been published on providing support to adolescents during labor and birth. (excerpt)

Perception of labour pain among the Yoruba ethnic group in Nigeria

SummaryIn Nigeria, it is generally assumed that labour is well tolerated and pain relief is not usually considered an important part of intra-partum care. This prospective study was carried out to assess mothers' perception of labour pain and determine any factor that may influence it. During the period of study, 281 women who delivered at Wesley Guild Hospital Ilesa, Nigeria were interviewed within 2 h of delivery to assess the severity of labour pain and desire for analgesia. Perception of labour pain was assessed using a 3-point verbal rating. The majority (68.3%) of women described labour pain as severe with only 5.3% describing it as mild. More than 86% of the women would want the pain relieved. Perception of pain was not influenced by age, parity and educational level. Management of pain in labour should form an important part of intra-partum care as is the case in developed countries.