Analgesia in Analgesia in Labour for Labour for

UndergraduatesUndergraduates

Max Brinsmead MB BS PhD Max Brinsmead MB BS PhD

May 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 TechniquesAnaesthetic Techniques

– Epidural AnaesthesiaEpidural Anaesthesia– Spinal (talk to an anaesthetist about this)Spinal (talk to an anaesthetist about this)– Paracervical Block (no longer practised)Paracervical Block (no longer practised)– Pudendal Block (talk to an obstetric Pudendal Block (talk to an obstetric

registrar)registrar)– Perineal infiltration (not covered in this talk)Perineal infiltration (not covered in this talk)

Pain in LabourPain in Labour

80 – 90% of women describe their pain 80 – 90% of women describe their pain in labour as “very severe” or in labour as “very severe” or “intolerable”“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 does not correlate either with the pain of labour or with satisfaction with of labour or with satisfaction with analgesiaanalgesia

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 of labour and is presumably mediated by labour and is presumably mediated by endorphinsendorphins– ““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

Position in LabourPosition in Labour

Pain is greatest when the patient lies Pain is greatest when the patient lies on her backon her back

Patients should be encouraged to Patients should be encouraged to adopt a position of comfortadopt a position of comfort

There is evidence that remaining There is evidence that remaining upright and mobile improves labour upright and mobile improves labour efficiencyefficiency

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

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 None showed any reduction in pain or

use of further analgesiause of further analgesia Some actually showed an increase in Some actually showed an increase in

pain scorespain scores

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

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 Please note that this does not mean “water

births”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

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 With the exception of satisfaction if the education

is provided by the same person who provides is 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

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 – Causes dizziness/light headedness in 5 –

36%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

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 2This can interfere with her ability to cooperate in the 2ndnd stage of labourstage 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 This drug is often misused in neonatal

resuscitation & has not been shown to be resuscitation & has not been shown to be effective by RCTeffective 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 However, because of the wide individual variation in metabolism...variation in metabolism...

It is my view that no woman should be denied It is my view that no woman should be denied her her FIRSTFIRST dose of a narcotic at any stage in dose of a narcotic at any stage in labourlabour

Intrapartum Epidural Intrapartum Epidural AnaesthesiaAnaesthesia

The most effective form of pain relief availableThe most effective form of pain relief available Modern agents that limit motor block and with Modern agents that limit motor block and with

the addition of a narcotic by continuous the addition of a narcotic by continuous infusion gives the best resultsinfusion gives the best results

There is evidence that there is improved There is evidence that there is improved placental function (gas exchange and cord pH)placental function (gas exchange and cord pH)

Reduces maternal blood pressureReduces maternal blood pressure– Useful if the woman is pre eclampticUseful if the woman is pre eclamptic– Will reduce the risk of eclampsiaWill reduce the risk of eclampsia

The Cons of Epidural The Cons of Epidural AnaesthesiaAnaesthesia

Requires a skilled anaesthetic serviceRequires a skilled anaesthetic service There are side effects and some risksThere are side effects and some risks It lengthens the second stage of labourIt lengthens the second stage of labour

– And the need for assisted deliveryAnd the need for assisted delivery– But should not increase the requirement for CSBut should not increase the requirement for CS

Reduces maternal mobilityReduces maternal mobility Requires IV access and fetal monitoringRequires IV access and fetal monitoring

– Particularly when oxytocin augmentation is Particularly when oxytocin augmentation is usedused

Side Effects & Risks of Side Effects & Risks of Epidural AnaesthesiaEpidural Anaesthesia

Maternal hypotensionMaternal hypotension ShiveringShivering Reduced capacity for mobilisation in labourReduced capacity for mobilisation in labour Risk of dural puncture and severe headache Risk of dural puncture and severe headache

about 1%about 1%– May require a “blood patch”May require a “blood patch”

Bladder function compromisedBladder function compromised– Catheter commonly requiredCatheter commonly required– May cause some incontinence for some weeks afterMay cause some incontinence for some weeks after

Epidural haematoma, abscess & nerve Epidural haematoma, abscess & nerve damage very raredamage very rare

Does NOT cause long-term backacheDoes NOT cause long-term backache