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Labor Support & Non-Pharmacologic Pain Management

Linda Robinson, MSN, RNC

Clinical Nurse Specialist, Northwest Hospital

Spring 2016

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Greek physician, 1st Century

“soothe pains by touching with warm hands and afterwards drench pieces of cloth with warm, sweet olive oil an put them over the abdomen as well as the labia and keep them saturated with the warm oil for some time, and one must also place bladders filled with warm oil alongside.”

HistoryMedical men may oppose for a time the

superinduction of anesthesia in parturition, but they will oppose it in vain; for certainly our patients themselves will force use of it upon the profession. The whole question is, even now, one merely of time”.

Sir John Simpson

History 1900’s doctor’s attending about 50% of births

Midwives took care of women who could not afford a doctor

Women started being attracted to hospitals as they offered pain relief

Women’s movement

Births move to hospitals

Scopolomine, twilight sleep 1914

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Labor results in severe pain for many

women. There is no other

circumstance where it is considered

acceptable for a person to experience

untreated severe pain, amenable to

safe intervention, while under a

physician’s care. In the absence of a

medical contraindication, maternal

request is a sufficient medical

indication for pain relief during labor.

ACOG, 20025

ObjectivesDiscuss the uniqueness of labor pain and

factors of pain response

Discuss the roles of nursing, doulas and

family in labor support

Discuss positions and movements for comfort

Discuss resources for effective coping during

labor without using pain-relieving medications

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Goals Safety for mom and baby

Emotionally satisfying

Physiologic approach

Vaginal birth

Empowering experience

Can we predict who will

have pain?

Level of Fear is related to her level of

preparation

Degree of fatigue

Anxiety

Her ability to distraction

Tension PainMore preparation showed a decreased pain

perception and less use of analgesia but an

increase in her level of confidence~

Lowe, 2002

Fear What does this mean for

you?

Labor Support Practices

Be Present

Reduce Anxiety

Consider Environment

Be PresentSpending time with the patient allows you to see

her needs and emotions as they change over time

In the active phase, she may become dependent

on others and express wavering self confidence.

Emotional support----use of voice, words, touch;

be aware of how your body language, tone of

voice, choice of words are making an

impression upon your patient and family

Environment

Allow for privacy

Fluids and Nutrition

Reduce noise; use music

Proper lighting, Proper temperature

Discomforts associated with the

technology of birth. 19

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Continuous Support in

Labor reduces the risk of:

medication use

longer labors

operative vaginal birth

C-Section

5 minute Apgar less than 7

(Hodnett, 2003, 2004)

Doula - “in service of”

Shorter labors

Less need for oxytocin to speed up

labor

Reduced use of forceps

Less post-partum depression

Mother more satisfied with birth

Women request less pain meds and epidurals

Informational support

Breathing

Relaxation

Imagery

Focal Point

Care of the partner

More ResourcesMovement

Positioning

Hypnosis - Hypnobirthing

TENS unit

Sterile Water Blocks

Acupuncture

Application of Heat or Cold

Hydrotherapy

Movement in LaborDecreases pain

Facilitates maternal-fetal circulation

Changes quality of contractions

Decreased length of labor

Facilitates fetal descent

Decreased perineal trauma

POSITIONS

FOR

LABOR

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Hypnosis

Is a state of attentive and focused concentration

During trance-like state, therapeutic suggestions can be given

Possible Benefits

Hypnosis

Shorter 1st stage

More spontaneous deliveries

Higher APGAR scores

Reduced perception & awareness of pain

Few side effects and risks

Possible Benefits of

Hypnosis

More satisfying birth experience

Less tension and anxiety

Less Analgesia & Epidural use

Can empower the woman

She may become very self-sufficient

Limits of Hypnosis

Most beneficial results to “good”

subjects (about 25% of population)

Variable skill and experience of the

hypnotherapist

5-31% may experience mild

dizziness, nausea & headache, r/t

failure to dehypnotize properly

TENS - Transcutaneous

Electrical Nerve

Stimulation

Low voltage electrical impulses are administered through flat electrodes applied to the skin.

Most useful early in labor

Most useful for back pain

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TENS - benefitsMay provide some beneficial pain

relief in early labor

Non-invasive

Mom can be mobile

Doesn’t interfere with labor

If fail, can use other methods

TENS – Drawbacks

Can interfere with fetal monitor

Requires education of patient

and staff

Finding institutional support for

use of TENS can be a hurdle

Sterile Water

Blocks2 intracutaneous injections are made on each

side of back about 2 cm below and 1 cm

medically to superior iliac spines.

Does not need to be precise placement

A fine needle used to inject 0.1 ml of sterile

water at each point.

A small white papule surrounded by a red zone

should be produced.46

Sterile Water

Injections - BenefitsInstant and complete relief of low

back pain in many women.

Pain relief lasted as long as 3 hours

Less pain than TENS users

May help women attain a goal of birth

without an epidural

Sterile Water

Injections - Drawbacks

Stinging pain can last 30 seconds

Short Acting

Warn her and help her focus during administration.

Use helper and inject two at a time

Acupressure

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Application of Heat

Increased local blood flow

Increased local skin and muscle temperature

Increased tissue metabolism

Decreased muscle spasm

Relaxation of tiny muscles in the skin

Elevated pain threshold

Application of Cold

Decreased local blood flow

Decreased local skin and muscle temperature

Decreased tissue metabolism

Decreased muscle spasm

Slowed transmission of impulses, leading to decreased sensation, numbing effects

Be careful!

Weakness

Dizziness

Nausea

Maternal or fetal tachycardia

Maternal hypotension

To Prepare

Childbirth Classes

Hypnosis

Acupuncture

TENS unit

Self-education

How could you empower her to

enhance her ability to cope with

labor?

Positive attitude re childbirth.

Faith in her

Emphasize Fundamental strategies for which

she has control.

Let her know she has control by choosing to

focus on coping strategies versus the pain.

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Scene: Woman in early labor,

breathing at peak of contractions,

appears relaxed.

What does she need?

Praise, Praise, Praise, Praise, Praise

Reassurance, Reassurance

Express Confidence in her ability

Mom is well, baby is well and process is going well.

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Scene: Woman in early labor,

her back is hurting.

Positions

Back Massage

Hip Press

TENS unit

Sterile Water Injections

Scene: First time mother in early labor.

Strategies to encourage labor.Fluids, Oral with calories

Position change

Upright positions

Walking, Showering, Rocking, Dancing

Reassurance and Praise

Focus her on coping.

Active Labor Signs

Intense contractions, requiring her

full attention from beginning to end.

Facial flushing

Frequent q 2-4 minute contractions

Decreased ability to talk/chat

Decreased ability to self analyze and

objectively plan strategies to cope.

Active Labor HelpRecognize it, let her know her progress

Reassure her about labor progress

Reassure her that these sensations are normal

Consider all or part of Take Charge Routine

Guide partner in coaching strategies

When to consider

another method?

Her birth-plan states epidural, so when

eligible

At her request, when eligible, if desire

for pain medications was wait-and-see,

or neutral.

Long hard labor and a delivery is not

expected within 1-2 hours, and patient

requests.

When to try longer?

Normal progress, delivery expected within 1-2

hours

In early labor, she is just beginning to

experience active labor. She wanted natural

childbirth, but has not started to utilize a coping

strategy. Teach and support, then reevaluate.

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The Take Charge Routine

Routinefrom Penny Simkin, The Birth Partner.

She hits an emotional low

Despair, crying

Wants to give up

Very tense and cannot relax

The Take Charge Routinefrom Penny Simkin, The Birth Partner.

Remain calm (touch and voice)

Stay close

Anchor her. Hold her shoulders or her head in your hands - gently, confidently , firmly - or hold tightly in your arms

Make eye contact - “open your eyes and look at me”

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The Take Charge Routinefrom Penny Simkin, The Birth Partner.

Change the ritual she has been using

during contractions: - position, breathing.

Help pace her breathing

Encourage her every breath. “Breathe

with me, that’s the way, just like that.

Good, stay with it, breathe with me, look

at me, just like that, it’s going away. Good.

Good. Now a deep breath and let it go.

Good work.” 69

The Take Charge Routinefrom Penny Simkin, The Birth Partner.

Talk to her between contractions -

“what is helping? Let me help you

more. Take a deep breath and look at

me with the beginning of the next

contraction.”

Repeat yourself.

References Zwelling. E. (2010). Overcoming the Challenges:

Maternal Movement. American Journal of Maternal Child Nursing 35:2, March-April.

Positions for Labor & Birth by Simkin and Anchetta

http://www.transitiontoparenthood.com//ttp/parented/pain/positions.htm