Non-pharmacological methods of pain relief
There are a number of non-pharmacological forms of pain relief and coping strategies that can be used during labour. Those that are supported by the evidence would usually have been discussed or taught in antenatal sessions by midwives or independent practitioners.
The physiology related to methods such as hydrotherapy, transcutaneous electrical nerve stimulation and massage is based on stimulating sensory nerve endings in the skin and muscles, which affects the transmission of nerve impulses from nociceptors (pain receptors) in the contracting uterus at the spinal cord before they activate the higher centres of the brain for interpretation. The experience, particularly in the early stages of labour, can be relaxing as production of naturally occurring pain relieving endogenous opioids (e.g. beta-endorphins) increases to a level that modulates pain impulses, providing relief and a sense of euphoria.
Women may underestimate the effect of immersion or use of warm water during labour; however, it is beneficial and decreases the use of pharmacological methods for alleviating pain (Figure 79.1). While immersion in a warm bath or a birthing pool are common methods, there is also the option of using a warm shower. Birthing pools are available in midwifery-led birthing units and can be hired for use in the home. If the woman wants to use the pool to cope with her pain, there will need to be an initial discussion on her eligibility to do so. The option is usually only available for the woman who meets the criterion of low risk, that is an uncomplicated pregnancy, after 37 weeks’ gestation, and where spontaneous rupture of the membranes have occurred less than 24 hours before using the pool.
The midwife will also need to discuss and advise the woman on other safety issues, such as how to appropriately clean the bath or pool, keeping the water around 37.5°C and how to avoid slipping while using the shower or bath at home. The woman should be informed about what may happen if there is a deviation from the norm during labour, as any divergence from normality may mean that immersion has to be abandoned. She should also be sufficiently agile and able to rapidly exit the pool in case of any unexpected change in her condition or that of the fetus.
If the woman chooses to remain in water for her labour, maternal temperature should be checked hourly for possible pyrexia. The fetal heart should be intermittently auscultated with a water-proof Doppler ultrasound, as per the frequency and duration for any labour and according to the intrapartum guidelines.
As birth can often be sudden and rapid when water is used, the midwife should be skilled (or supported by a colleague who is competent) in facilitating birth in water, whether it is planned or unexpected.
Transcutaneous electrical nerve stimulation (TENS) involves applying electrode pads to the skin on either side of the spine between thoracic vertebrae 10 (T10) and lumbar vertebrae 1 (L1) and between the sacral vertebrae 1 (S1) and sacral vertebrae 4 (S4) (Figure 79.2).
The National Collaborating Centre for Women’s and Children’s Health (NCC-WCH) outline that TENS is ineffective in established labour therefore most women who choose to use TENS usually need to buy or hire them for home use in early labour. The midwife will need to advise women on how to obtain a device and demonstrate how and where to position the pads so she can apply it at home and use it effectively in the latent phase of labour. TENS must not be used if the woman is labouring in water.
An array of complementary and alternative therapies, as well as coping strategies exist with some being shown to improve perception of pain and positively impact on overall satisfaction with the experience of childbirth (Figure 79.3). There is evidence to suggest that acupuncture, acupressure, aromatherapy and hypnosis do work for some women but there is not enough research-based support to suggest that they should be offered as standard forms of pain relief or coping strategies within the NHS maternity service. Midwives should be familiar with methods used.
Women may consult a trained practitioner antenatally and be shown various methods. When a woman presents in labour and expresses a desire to utilise particular methods, the midwife should try and facilitate this; beginning with discussion ensuring that request are underpinned by policies and guidelines.
Mind–body interventions such as relaxation and focused breathing techniques to enable conscious awareness of muscular tension, together with music therapy for distraction are supported for use in national guidelines. Massage, particularly on the lower back area, also works to stimulate nerve impulses, which modulate pain signals from the uterus and should be encouraged if the woman wishes and can tolerate being touched in labour.
Each midwife needs to understand the evidence underpinning non-pharmacological methods of pain relief and be able to facilitate the recommended coping strategies in labour according to the woman’s requests. Birthing companions can also become involved in supporting the woman to utilise some of the techniques in labour.