Pain Management in Labor
Advice to Pregnant Women About Labor Pain Relief
by Jennifer N. Ayers-Gould, BA LPN ICCE
When preparing for and anticipating birth, most women will undoubtedly have questions and concerns about the pain of labor. They have heard the horror stories of their friends and relatives and the analogies that giving birth is like passing a watermelon out of your mouth. Women are bombarded with stories about the miracle of drugs and epidurals for pain relief and how they could have never done it without help from pain medications and their "savior" physicians and anesthesiologists. It is no wonder that women who have never before birthed are scared to death that they will not be able to handle the pain of childbirth and are in utter trepidation when thinking about what it will feel like.
Yes, birth can be painful. For some women, it can even be pleasurable! The sensations which accompany labor and birth are primal feelings of your body opening up and preparing for the emergence of a new human being into the world. Fear and mistrust of the birthing process can be the greatest contributors to one's perception of pain. This is not the pain which accompanies a stubbed toe or a broken arm, this is pain with a purpose. Labor pains do not signal that something is wrong that needs to be fixed. It is pain which urges a women to open, trust, and surrender to it.
The single most important thing a woman can do is trust in the process of birth; trust that her body was made to birth; listen to her body and follow its cues. When a woman surrenders to birth, steps out of the way, and allows her body to do what it needs to do, she will experience less pain during labor. Knowing and believing that birth is not a medical procedure, but a natural unfolding of the process of life will allow one to be open and accepting of the sensations which accompany childbirth. Understanding the process and having complete faith in oneself eliminates fear which creates the tension which magnifies the perception of pain.
It amazes me that when a woman becomes pregnant, she takes great precautions to avoid anything which may harm the baby: alcohol, drugs, radiation, excessive temperature changes, over-exertion, etc., but as soon as she begins to experience any discomfort in labor, without a second thought is asking (or begging) for narcotics to dull the pain. Is she not still pregnant? Does she not consider that whatever pharmacological agents that enter her body will also have an effect on her unborn child? Why all of a sudden is it "safe" to expose the baby to these harmful agents? And particularly at a time when the baby needs to be fully strengthened and alert for the work of leaving his mother's body and adapting to life on his own? Not only does every (unnecessary) intervention have an effect on the child, but also impacts the mother's experience of birth. By numbing ourselves to the powerful and empowering sensations of birth, we are becoming detached from our physical-spiritual-emotional beings. When we dull the pain of childbirth, we are also dulling the myriad of other sensations which accompany birth.
The sensations of childbirth call us to be submissive to the awesome power of life. Labor waves, like great ocean swells, sweep over us and overtake us. They humble us in their magnitude, call us to surrender to their pull and flow with their mighty power. The pain sensations cause our bodies to react by releasing hormones which will naturally put us in a state of higher consciousness, a sort of "birth euphoria.." The hormones also effect our babies and stimulate them in preparation for their transition to extrauterine life. This is not senseless torture, this is truly purposeful pain.
When women understand the sensations of labor and birth, accept the process as normal and natural, trust in their bodies to give birth, approach childbirth without fear, and stop allowing the misinformation of our overly-technocratic society to adversely affect them, they will be able to integrate the pain of birth into the process of birth; the process of birth into the process of life. They will be able to see that what we are told must be fixed was never broken at all.
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Therapies for Labor and
Americans spent nearly $14 billion on alternative therapies in 1998 and there were more alternative health care provider visits than primary health care visits (McFarlin, Gibson, O'Rear, & Harman, 1999). Complimentary and alternative therapies are the fastest growing areas of healthcare. The main difference between conventional medicine and complimentary medicine is the inclusion of the emotional, spiritual, and physical components of well-being; complimentary methods utilize the client's own energy to enhance the healing potential. The inclusion of complimentary therapies in maternity care vastly increases the choices available to women throughout pregnancy and childbirth (Tiran & Mack, 2000).
The gate theory of pain control is described as a transfer of nerve impulses, pain sensations, which travel along a sensory nerve pathway; according to the gate theory, only one sensation can travel on the pathway at a time. If the sensory pathway is occupied by a sensation caused by stroking, massaging, hot water, electrical stimulation, or pressure the pain sensation is effectively blocked from getting to the brain and being perceived as pain (Lowdermilk, et al, 2000).
Acupuncture and Acupressure
The ancient, traditional, Chinese art of acupuncture is the process of inserting thin needles in the body at any one, or more, of the 2000 specific points thought to control, correct, or alter various aspects of body function. The obstetric use of acupuncture is used most readily by midwives and has gained popularity over the last 20 years (Beal, 1999). The first deliveries recorded that utilized acupuncture for pain relief, were done in 1972 in England. In addition to intrapartum and postpartum pain relief, many women find acupuncture useful for relieving pregnancy discomforts such as nausea, headache, hemorrhoids, and backache. The World Health Organization sites sufficient evidence supporting the therapeutic effects of acupuncture for it to be considered as an important part of primary health care and that it should be fully integrated with conventional medicine (Tiran & Mack, 2000).
Acupressure is similar to acupuncture, however, no needles are used; rather, the hands, fingers and/or thumbs are used to create pressure over the same stimulation points. Shiatsu, Japanese for finger pressure, can relieve symptoms of pregnancy such as, breathlessness, hemorrhoids, nausea and vomiting, carpal tunnel syndrome, heartburn, edema, coughs, urinary frequency, cramps, insomnia, lumbar-sacral pain, headaches, and fatigue (Tiran & Mack, 2000).In spite of the potential benefits of acupuncture and acupressure, and the growing interest in complimentary and alternative therapies, very few hospital systems integrate either treatment modality; women seeking them must seek independent practitioners and gain permission to utilize the treatments in their chosen birth site (Beal, 1999).
Warm water, in the form of a Jacuzzi bath, shower, or a simple warm soak are methods of hydrotherapy. Warm water has been used for it's healing powers for centuries, and it has been found effective in managing the discomforts of the first and second stages of labor. Hydrotherapy is an economical and drug free method of utilizing the gate theory mechanism of pain reduction. Basically, the hot water competes with the pain impulses for neuropathway access. Hot water effectively blocks the sensation of pain while allowing the woman's body to relax and allow her body to work at moving the baby closer to birth (Teschendorf & Evans, 2000).
There are virtually no side effects with hydrotherapy; women and fetus may experience tachycardia if the water is too hot; the baseline fetal heart rate can rise 10-20 beats per minute during the bath, but return to baseline within 30 minutes after the bath. The water temperature should be monitored closely and maintained between 96° and 98°F. Most women report a more satisfying birth experience and better pain tolerance when the tub is used during labor (Teschendorf & Evans, 2000). It is important to mention that getting in the tub too soon, before labor is really active, could slow labor progress (Simkin, 1995). Infection control protocols are used to reduce the potential of infection (Teschenforf & Evans, 2000).
Transcutaneous Electrical Nerve Stimulation
Transcutaneous Electrical Nerve Stimulation (TENS) utilizes electrical impulses that are sent to the skin and may work by increasing endorphins at the sight if stimulation. The laboring woman controls the intensity of the electrical stimulation via the battery operated control device that she holds in her hand. A tingling sensation at the site of the electrode elicits the gait response as the neuropathways sense the tingling rather than the sensation of discomfort. There are relatively no side effects, however, TENS units may cause interference with electronic fetal monitoring. The benefit is that some women find great relief and are able to delay or avoid epidural anesthesia by using them (Simkin, 1995).
Subcutaneous Water Papules
Subcutaneous Water Papules are a method of pain relief using a similar principal to TENS. This was established in Scandinavia and is not wide spread in North America. This technique may help some women avoid pain meds. Injecting sterile water just under the skin on the lower back causes four small papules. The strategically placed papules provide pressure and employ the gate method of pain reduction. There is a stinging sensation for 20 to 30 seconds after each injection. Subcutaneous Water Papules are primarily used for relief of low back pain and pressure in labor (Simkin, 1997).
More Complimentary Therapies
The practice of aromatherapy is an ancient art and the term "aromatherapy" was first used in the 1920's. Over the last 10-15 years aromatherapy has been gaining in popularity. Women benefit from massage with essential oils that have therapeutic properties. Some of the oils that are used in labor and delivery are used as adjuncts to conventional pain relief measures and they include: clary sage, lavender, mandarin, and jasmine; they may be added to massage lotions, used to scent the room, or added to the bath. Only a those with experience and knowledge of the effects produced should use essential oils with pregnant or laboring women (Tiran & Mack, 2000).
Hypnosis is a state of deep relaxation that offers a sense of extreme well-being. When hypnosis is used in labor the perception of pain can be greatly reduced. If the client truly believes that it will work for her, and she has practiced her method of induction adequately, it can be a truly remarkable source of pain relief (Tiran & Macke, 2000).
The founder of Hypno-birthing TM is Marie Mongan; her philosophy is, that every woman instinctively knows how to birth, and that when fear is replaced with knowledge, and a faith that her body will work the way it was designed to work, her birth will be experienced with satisfaction and fewer interventions. Through a series of classes, the woman learns about the natural flow and rhythm of labor, breathing patterns, and visualizations; the goal is to reach a sense of profound relaxation through fear release and self hypnosis enabling her to have a safe, satisfying birth (Mongan, 1998). Dr. Goldman, a practitioner of Hypno-birthing says, " The goal is not painless childbirth but to be in control from start to finish" and "to have a warm picture of labor as apposed to [a picture of'] panic" (Kelomattox, 1999).
Cold and Heat
The use of cold and heat provides a very inexpensive comfort measure. Heat feels great on an achy back. Warm compresses to the perineum help avoid tears and episiotomies. Heating pads, hot water bottles, or homemade hot packs can be very effective. A hot pack can be made by filling a cotton sock with rice, adding a bit of lavender oil, if you like; then tie it closed and warm it in the microwave for a few minutes; the warmth and smell of lavender is appreciated by many. After the birth, cold packs to the perineum decrease swelling and provide a local numbing effect (Simkin, 1997).
Herbal remedies are the earliest form of medicine and have been a historical part of many cultural healing traditions. Until the 1800's people routinely consulted herbalists for health care (Tiran & Macke, 2000). Herbs are used medicinally to cure many illnesses and it is important to remember that herbs are medications. Herbs can have side effects just like other drugs; they must be taken with respect and it would be best if the use of herbs were shared with health care providers. Tiran & Mack, (2000) report that the World Health Organization calculated that 75% of the world's population uses traditional medicine and most cultures use herbs for the transitional moments of dying and being born.
An increase in the use of herbal therapies has brought about additional education needs for many health care providers. The health care provider should be knowledgeable and current with herbal medicine. The main principals of herbal medicine are; holism, an entire body approach to health care; individuality, a treatment plan tailored to the specific client; diversity, many philosophies are accepted; empowerment, the consumer takes responsibility for their own healing; and connectedness, a connection to the earth and plants used to create the herbal remedies.
Historically herbs have been used for childbearing by various cultures; the safety and efficacy of their use has not been well documented. Herbs are used in pregnancy as antiemetics, to augment labor, slow bleeding, encourage lactation and much more. Certified Nurse Midwives (CNM) and Certified Professional Midwives (CPM) are more likely to use herbs. The most common herbs used by CNM's are herbs to facilitate labor; 64% of CNM's responding to a recent study said that they used blue cohosh, 45% used black cohosh, and 93% used castor oil, to stimulate labor; and raspberry leaf to enhance uterine tone, and evening primrose oil to expedite cervical ripening. More reporting of statistical data surrounding the safety and efficacy of such practices would make more CNM's comfortable with the practice (Beal, 1999).
Carolyn Rafferty, RN, BSN
Sterile Water Injections for Relief of Back Pain in Labor
Regardless of the various comfort measures available; such as hydrotherapy, massage, acupressure, counter pressure and position changes; some women find the pain of back labor difficult to bear. Therefore, many women today are turning to the epidural for the relief they need. However, the epidural comes with many risks to both mom and the baby. Is there any more natural alternative?
In 1965, Melzack and Wall introduced what is now known as the "Gate Control Theory" which suggests that nerve cells from touch fibers can actually close the gate on pain signals to the brain, thus giving the perception of minimized pain. Therefore, for a woman in labor, the brain has the ability to influence the course of her labor and her perception of pain.
In 1975, Melzack and Fox determined that the perception of pain could be altered by introducing a brief period of pain. This, in turn, would alleviate the chronic back pain. An example of this theory is the use of a TENS (transcutaneous electrical nerve stimulation) unit. The TENS unit sends pulses which interrupts the brain's awareness of pain and may also cause a release of endorphins which is the body's natural pain coping mechanism.
Then in 1989, Lytzen, Cederberg, and Moller-Nielsen presented their study on "Relief of low back pain in labor by using intracutaneous nerve stimulation (INS) with sterile water papules" in a medical journal. This study included 83 women with lower back pain during the first stage of labor. These women were given injections of sterile water intracutaneously over the sacrum. All but six of the women noticed instant and complete pain relief which lasted up to three hours. The procedure could then be repeated. Sixty-seven of the eighty-three were pleased with the results.
Trolle, Moller, Kronborg and Thomsen introduced their study of "The effect of sterile water blocks on low back labor pain" in the American Journal of Obstetrics and Gynecology in 1991. This study contained 272 women complaining of severe low back pain. The women were randomly assigned to receive either a sterile water injection or a saline solution block. There was a significantly higher degree of analgesic relief for those in the sterile water group (89.4%) than those in the saline group (45%). No adverse effects were noted and the patient satisfaction was high.
The woman's back is cleansed. Then 0.1-0.15cc of sterile water is injected intradermally into four places on the women's sacrum. Preferably, the procedure should be done with two people doing the injections simultaneously. The injections cause an intense burning sensation which lasts 30-90 seconds. Relief from the procedure should be noticed in 2-3 minutes. Because of the intensity of the pain, the woman should have constant support and encouragement during the time of the injections.
Sterile water injections is an excellent alternative for pain relief due to back labor. Even though it may not provide relief from contraction pain, often once the back pain is alleviated, the laboring women can cope better with her labor. Likewise, often the relaxation of the back can assist in the proper decent and positioning of the baby, leading to a shorter labor. With no known side effects and no medications entering the body, sterile water injections may become the choice for the relief of back labor for many laboring women.
Fox E.J., Melzack R. "Transcutaneous electrical stimulation and acupuncture: comparison of treatment for low-back pain." Pain 1976 Jun;2(2) :141-8.
Lytzen T, Cederberg L, Moller-Nielsen J. "Relief of low back pain in labor by using intracutaneous nerve stimulation (INS) with sterile water papules." Acta Obstet Gynecol Scand, 1989.
Melzack R, Wall, P. "Pain mechanisms: A new theory." Science, 150 (1965) 971-979.
Trolle B, Moller M, Kronborg H, Thomsen S. "The effect of sterile water blocks on low back labor pain." Am J Obstet Gynecol. 1991 May;164(5 Pt 1):1277-81.
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