Pain in Labor: Nonpharmacologic and Pharmacologic Management
Carol Burke
A woman’s experience of pain in labor is complex, multidimensional, unique to the individual, and may vary from labor to labor. Unlike an acute or chronic insult, pain during labor is usually not associated with a pathologic process. Labor is a normal, physiologic process that causes severe pain for most women. An appreciation of each woman’s unique experience of pain is possible when the perinatal nurse understands the physiologic and psychosocial factors influencing pain perception. This chapter will present the physiologic basis for pain, psychosocial factors influencing pain perception, pain management options, and nursing care for nonpharmacologic and pharmacologic methods during labor. For the majority of women in all societies and cultures, natural childbirth is likely to be one of the most painful events in their lifetime (Lowe, 2002). Pain in labor is not easily defined or simple to assess (Roberts, Gulliver, Fisher, & Cloyes, 2010).
During labor, responsibility for managing pain and providing comfort is shared by the laboring woman, nurses, physicians, certified nurse midwives (CNMs), and labor-support persons. Interventions exist along a continuum, from nonpharmacologic to pharmacologic. As healthcare professionals move along this continuum, the potential for complications and side effects increase. The goal of pain management during labor is to assist the woman in managing her pain without interrupting labor or doing harm to the woman or her fetus or newborn. Approaches to pain management in childbirth have addressed the sensory, affective, cognitive, and behavioral dimensions of pain, while more recently a multidimensional approach has been advocated, addressing all dimensions of labor pain (Lowe, 2002; Wesselmann, 2008). A study of low-risk women in labor concluded that four factors were critical to women’s experience of childbirth: (1) personal expectations, (2) the amount of support from caregivers, (3) the quality of the caregiver-patient relationship, and (4) the involvement in decision making (Hodnett et al., 2002).
PHYSIOLOGIC BASIS FOR PAIN
Most pain during childbirth results from normal physiologic events. During the first stage of labor, visceral pain results from uterine contractions leading to uterine muscle hypoxia; lactic acid accumulation; cervical and lower uterine segment stretching; traction on ovaries, fallopian tubes, and uterine ligaments; and pressure on the bony pelvis. Afferent pain impulses are carried along sympathetic nerve fibers entering the neuraxis between the 10th and 12th thoracic and first lumbar spinal segments. An additional somatic component arises from perineal stretching and pressure on the urethra, bladder, and rectum causing afferent pain impulses to fire late in the first stage and persist throughout the second stage. This pain is transmitted along the pudendal nerve carried along sympathetic nerve fibers entering the neuraxis between the second and fourth sacral spinal segments (El-Wahab & Robinson, 2011). Some women in labor experience continuous low-back pain that is distinct from uterine contractions. This pain may be related to pressure from the fetal occipital bone on the neural plexus and bony structures of the maternal spine and pelvis. The third stage is usually not particularly painful in comparison.
PHYSIOLOGIC RESPONSES TO PAIN
Pain during labor may result in anxiety and a stress response. Pain induces a physiologic stress response, which can precipitate widespread physiologic and
potentially adverse effects on the progress of labor and the well-being of the mother and fetus. Unrelieved anxiety and stress cause increased production of cortisol, glucagon, and catecholamines, which increase metabolism and oxygen consumption (Hawkins, 2010; Reynolds, 2011). Increased levels of catecholamines have been shown to cause uterine hypoperfusion and decreased blood flow to the placenta, resulting in uterine irritability, preterm labor, dystocia, and fetal asphyxia (Wesselmann, 2008). Increased adrenaline levels may prolong labor through beta-receptor-mediated uterine relaxation (Wesselmann, 2008). Due to the release of catecholamines, maternal tachycardia, hypertension, and a rise in cardiac output all increase myocardial workload and, hence, oxygen demand. Respiratory effects include hyperventilation leading to maternal hypocarbia and respiratory alkalosis. While these responses may be innocuous during the course of an uncomplicated labor, they can precipitate heart failure and even ischemia in women with poor cardiorespiratory reserve (El-Wahab & Robinson, 2011). Additionally, it has been suggested that postnatal depression may be less common among women who receive effective analgesia in labor (Flink, Mroczek, Sullivan, & Linton, 2009).
potentially adverse effects on the progress of labor and the well-being of the mother and fetus. Unrelieved anxiety and stress cause increased production of cortisol, glucagon, and catecholamines, which increase metabolism and oxygen consumption (Hawkins, 2010; Reynolds, 2011). Increased levels of catecholamines have been shown to cause uterine hypoperfusion and decreased blood flow to the placenta, resulting in uterine irritability, preterm labor, dystocia, and fetal asphyxia (Wesselmann, 2008). Increased adrenaline levels may prolong labor through beta-receptor-mediated uterine relaxation (Wesselmann, 2008). Due to the release of catecholamines, maternal tachycardia, hypertension, and a rise in cardiac output all increase myocardial workload and, hence, oxygen demand. Respiratory effects include hyperventilation leading to maternal hypocarbia and respiratory alkalosis. While these responses may be innocuous during the course of an uncomplicated labor, they can precipitate heart failure and even ischemia in women with poor cardiorespiratory reserve (El-Wahab & Robinson, 2011). Additionally, it has been suggested that postnatal depression may be less common among women who receive effective analgesia in labor (Flink, Mroczek, Sullivan, & Linton, 2009).
THE EXPERIENCE OF PAIN
Unique circumstances of every labor influence the experience of pain. Responsiveness of the cervix to uterine contractions is influenced by prior surgical or diagnostic procedures that compromise the integrity of the cervix. Prior surgical procedures may result in an incompetent cervix and shorter labor or cause scarring and adhesions, resulting in failure to dilate and protract labor. Many medical and nursing procedures are uncomfortable. Interventions such as pharmacologic agents used for cervical ripening, induction and augmentation of labor, vaginal examinations performed in the supine position, bed rest, amniotomy, tight external electronic fetal monitor (EFM) belts, and enemas may change the character of labor contractions and increase discomfort. Length of labor does not necessarily correlate directly with a woman’s perception of pain. Women with short labors may experience very intense pain due to frequent uterine contractions. Women with a fetus in a persistent posterior position report severe pain during and between uterine contractions.
Table 16-1. DESCRIPTIONS OF PAIN EXPERIENCE DURING LABOR AND BIRTH | |||||||||
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As duration of intense pain increases, discouragement and fatigue increase, decreasing the woman’s ability to cope effectively with contractions. Fatigue may occur with a prolonged latent phase, as reported by the woman on admission that she has not slept well for days. Cultural differences with labor pain, acceptance, and personal control in pain relief render pain medication use during labor variable. The use of pain medication is lowest if women have a positive attitude toward labor pain and experience control over the reception of pain medication (Christiaens, Verhaeghe, & Bracke, 2010). Catastrophizing (where a person may think only in terms of negative thoughts about the pain and outcome) is associated with increased pain reports, even when coping strategies are being used (Escott, Slade, & Spiby, 2009).
Labor pain is an example of acute pain. It has a high degree of variability among individuals and at different points in labor. In a study of primiparous women during the first stage of labor, 60% described the pain during first stage of labor as unbearable, intolerable, extremely severe, and excruciating (Melzack, 1984). Descriptions of pain during the first and second stage of labor vary (Table 16-1). Some women describe a decrease in intensity during the second stage, perhaps because of maternal focus on pushing. Others experience more painful sensations, possibly because of the position of the fetus descending through the birth canal.
Many women experience intense pain in labor, which may increase in severity and duration over time. Childbirth pain is one of the most severe types of pain a woman will experience in her lifetime (Camann, 2005). When the McGill Pain Questionnaire was used to compare reports of intensity of pain for a variety of clinical experiences (e.g., chronic back pain, nonterminal cancer pain, phantom limb pain, sprains, fractures), only the pain associated with accidental amputation of a digit and causalgia pain caused more pain than labor (Niven & Gijsbers, 1989). It is clear that a woman’s expectation of her labor helps shape her experience, and the level of pain for many women is different from anticipated (Lally, Murtagh, Jacphail, & Thomson, 2008).
PSYCHOSOCIAL FACTORS INFLUENCING PAIN PERCEPTION
In addition to the physiologic factors that influence the perception of pain, psychosocial factors influence an individual’s experience. These factors include labor support, childbirth preparation, and the healthcare environment.
LABOR SUPPORT
Women identify labor support as a continuous presence by another, emotional support (reassurance, encouragement, and guidance), physical comforting, providing information, and guidance for the woman and her partner regarding decision making, facilitation of communication, anticipatory guidance, and explanations of procedures (Simkin & Bolding, 2004; Roberts et al., 2010). Providing for physical comfort includes offering a variety of nonpharmacologic and pharmacologic interventions. Emotional support includes behaviors such as giving praise, encouragement, and reassurance; being positive; appearing calm and confident; assisting with breathing and relaxation; providing explanations about labor progress; identifying ways to include family members in the experience; and treating women with respect (Bryanton, Fraser-Davey, & Sullivan, 1994; Sleutel, 2000). Methods of labor support are found in Display 16-1.
REGISTERED NURSE
It is the position of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) that supporting and caring for women during labor is best performed by a registered nurse (Display 16-2). Comprehensive nursing education, clinical patient-management skills, and previous experience make the registered nurse uniquely qualified to provide the professional care and complex emotional care women and families need during labor and birth (AWHONN, 2000). The perinatal nurse must be able to support the laboring woman and assist her in maximizing the potential of the woman’s birth plan. Multiple strategies may be necessary during the course of labor. Perinatal nurses should develop expertise in a variety of pain-management strategies.
Nurses may spend anywhere from 12.4% (Gale, Fothergill-Bourbonnais, & Chamberlain, 2001) to 58% (Miltner, 2002) of their time providing supportive care to patients, usually doing so in conjunction with some technical activity. Factors that have contributed to individual nurses spending less time with women include increased technology associated with giving birth, increased requests for epidural anesthesia, and institutional staffing patterns. As use of technology has expanded in obstetrics, the perinatal nurse has moved from providing hands-on comfort to monitoring the equipment, imputing data into the electronic medical record and relying on pharmacologic interventions. Technology, especially when coupled with epidural analgesia, requires the nurse to divide her focus between the woman and machines. If pharmacologic methods have been used, the woman’s pain may be lessened and the nurse may feel that her presence is no longer needed. The nurse may perceive that caring for a woman with an epidural is less physically and emotionally draining for the nurse than caring for a woman who is planning nonpharmacologic management. If the culture of the perinatal unit allows ease of access to neuraxial analgesia, nurses new to the specialty will have limited opportunity to learn about or use nonpharmacologic measures.
DISPLAY 16-1 Labor SupportEMOTIONAL SUPPORT
Companionship
Eye contact
Encouragement
Distraction
Reassurance
PHYSICAL COMFORT
Touch
Nourishment
Personal hygiene
Applications of heat or cold
Massage
Hydrotherapy
Position change
INFORMATION
Providing information
Offering advice
Coaching in breathing, relaxation techniques
Interpreting medical jargon
ADVOCACY
Supporting the woman’s decisions
Translating the woman’s wishes to others
SUPPORT FOR FAMILY MEMBERS
Role model labor support
Providing opportunity for breaks
Encouragement
It is important that the nurse recognizes the value of her presence and not be distracted by the technology. The registered nurse who understands the physiologic events of labor and has been educated about supportive care in labor should take the lead in providing
labor support and role model labor support behaviors for others present during labor and birth. Perinatal nurses should remain at the bedside when women are experiencing severe pain. This allows the nurse to provide support to the laboring woman and her partner. According to Chapman (2000), nurses who remained at the bedside, explained what was occurring with the labor, and included the expectant father were viewed by those fathers as providing the most support.
labor support and role model labor support behaviors for others present during labor and birth. Perinatal nurses should remain at the bedside when women are experiencing severe pain. This allows the nurse to provide support to the laboring woman and her partner. According to Chapman (2000), nurses who remained at the bedside, explained what was occurring with the labor, and included the expectant father were viewed by those fathers as providing the most support.
DISPLAY 16-2 Professional Nursing Support of Laboring WomenAWHONN maintains that continuously available labor support by a professional registered nurse is a critical component of achieving improved birth outcomes. The childbirth experience is an intensely physical and emotional event with lifelong implications. AWHONN views labor care and labor support as powerful nursing functions and believes it is incumbent on healthcare facilities to provide an environment that encourages the unique patient-nurse relationship during childbirth. Only the registered nurse combines adequate formal nursing education and clinical patient management skills with experience in providing physical, psychological, and sociocultural care to laboring women.
Because of their comprehensive education and experience, registered nurses are capable of providing highly skilled technical and complex emotional care. The registered nurse facilitates the childbirth process in collaboration with the laboring woman. The nurse’s expertise and therapeutic presence influences patient and family satisfaction with the labor and delivery experience. Women who are provided with continuously available support during labor experience improved labor and delivery outcomes compared with those who labor without a skilled support person. Such care can lead to the following:
Shorter labors
Decreased use of analgesia or anesthesia
Decreased operative vaginal delivery or cesarean section
Decreased need for oxytocin
Increased satisfaction with the childbirth experience
Professional registered nurses draw on a deep and broad base of nursing knowledge and clinical expertise to provide a level of care and support beyond that of lay personnel. They can effectively implement patient management strategies for low- and high-risk patients. The registered nurse can assess, plan, implement, and evaluate an individualized plan of care based on each woman’s physical, psychological, and sociocultural needs, including desires and expectations of the laboring process. The support provided by the professional registered nurse should include the following:
Assessment and management of the physiologic and psychologic processes of labor
Provision of emotional support and physical comfort measures
Evaluation of fetal well-being during labor
Instruction regarding the labor process
Patient advocacy—the clinical assessment and evaluation that results from collaboration among professional members of the healthcare team
Role modeling to facilitate family participation during labor and birth
Direct collaboration with other members of the healthcare team to coordinate patient care
In today’s healthcare environment, numerous factors may influence the nurse’s ability to provide bedside labor care:
A limited number of available experienced registered nurses
Limited financial resources
Rigid organizational processes and structures
Cumbersome documentation requirements
Decreasing reimbursement by third-party payers in the United States
AWHONN challenges healthcare facilities to continuously evaluate the impact of patient-nurse ratios on resource use, overall operating expenses, patient outcomes, and patient satisfaction. AWHONN also supports evaluation models that can measure the impact a registered professional nurse has on indirect cost savings, such as savings resulting from lower cesarean section rates, shorter labors, and fewer technologic interventions.
AWHONN encourages women and families to request labor support from a professional registered nurse or advanced practice nurse (e.g., clinical nurse specialist, CNM, or nurse practitioner) for labor and birth.
Studies on professional nursing care for laboring women are in progress. AWHONN supports continued research efforts to document the essential role of professional nursing labor support on maternal-newborn outcomes and the potential financial benefits of such support for the healthcare system.
CNM, certified nurse midwife.
From Association of Women’s Health, Obstetric and Neonatal Nurses. (2000). Professional nursing support of laboring women. Washington, DC: Author.
HUSBAND OR SIGNIFICANT OTHER
Labor support ideally is provided by a variety of individuals (Table 16-2). Qualitative research has demonstrated that one of the most significant aspects of the experience of labor for women is the presence of one or more support persons (Lavender, Walkinshaw, & Walton, 1999). Postpartum women report that one of the things contributing to a positive labor experience was the presence of a family member or friend in the room even if “they just sit there” (Lavender et al., 1999). At the time of admission, the laboring woman should identify family members or friends who will act as labor-support persons.
Fathers have an important role in providing physical and emotional support during childbirth. Chapman (1992) described three roles assumed by expectant fathers during labor without epidural analgesia or anesthesia:
Coaches actively assisted their partners during and after labor contractions with breathing and relaxation techniques. Coaches led or directed their
partners through labor and birth and viewed themselves as managers or directors of the experience.
Teammates assisted their partners throughout the experience of labor and birth by responding to requests for physical or emotional support or both. They sometimes led their partners, but their usual role was that of follower or helper.
Witnesses viewed themselves primarily as companions who were there to provide emotional and moral support. They were present during labor and birth to observe the process and to witness the birth of their child.
Table 16-2. PROVIDING LABOR SUPPORT | ||||||||||||||||||
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These roles were identified by organizing behaviors that partners were observed performing during labor or behaviors women described in interviews after birth. Most men in the study adopted the role of witness rather than teammate or coach (Chapman, 1992).
Chandler and Field (1997) report that witnessing their partners in severe pain caused men to feel helpless and fearful. They became discouraged when the comfort measures they tried did not help their partners. Ultimately, they felt they had failed in their role. These results contrast with the intentions of childbirth educators, who perceive themselves as preparing coaches and teammates for laboring women, and with perinatal nurses, who expect fathers and other family members to take a more active role in labor support.
The theoretical experience of expectant fathers when their partners received epidural analgesia or anesthesia is outlined in Display 16-3 (Chapman, 2000). During labor, critical experiences for men occurred at two points. In the holding-out phase of labor, before making the decision to receive an epidural, men experienced a sense of “losing her.” As pain became more severe, women underwent personality changes, becoming frustrated, irritable, exhausted, and panicky. These personality changes may be totally unfamiliar qualities that the men had never seen their partners demonstrate or demonstrate to the degree that they do while in labor. Women also gradually turn inward as they attempt to cope with the pain. Withdrawing into themselves causes women to be unable to communicate their needs and to become unresponsive to their partners’ attempts at labor support. Men feel increased levels of anxiety, helplessness, frustration, and emotional pain (Chapman, 2000). These findings are consistent with the work of Somers-Smith (1999), who found that fathers experience childbirth as a stressful event.
DISPLAY 16-3 Grounded Theory of the Expectant Father’s Epidural Labor Experience
Holding-Out Phase: During labor, when couples are planning to avoid an epidural or seeing how far they can get in labor without needing an epidural.
Surrendering Phase: The point at which the decision is made to receive an epidural, which is described as yielding to the need for an epidural, giving up, and feeling they have experienced all the pain they can handle and done everything they can to avoid an epidural.
Waiting Phase: Period of time after making the decision to receive an epidural until the anesthesia care provider arrives.
Getting Phase: Period of time when the anesthesia provider is present, making assessments, preparing equipment, and placing the epidural.
Cruising Phase: The time after the epidural has provided pain relief. Couples’ focus changes to rest and relaxation. Labor has gone from a stressful process to a calm experience. Both may fall asleep, due to exhaustion from the stress of coping with the pain of labor.
Chapman, L. L. (2000). Expectant fathers and labor epidurals. MCN: The American Journal of Maternal Child Nursing, 25(3), 133-139.
The second and most dramatic phase for men sharing the experience of labor is during the cruising phase. After the epidural has provided relief from the pain of labor, men describe a sensation of “she’s back.” The laboring woman again is aware of her surroundings and is interacting with those around her. From a man’s perspective, labor has gone from a stressful event to a calm experience. Rather than describing their experience in terms of the role they assumed during labor and the frustration and disconnected feelings they had as labor intensified and women’s behavior changed (Chapman, 1991, 1992), these men described their experience by the degree of frustration they felt before the epidural and the degree of enjoyment after the epidural (Chapman, 2000). It is important that childbirth educators present this content, discuss this process, and teach men in their classes about the emotions they can expect to witness and experience during labor.
DOULA
There is increased interest in the role of the professional or lay labor-support person (doula), who is present during labor in addition to the perinatal nurse. The movement toward professional or lay labor support is a result of the inability of perinatal nurses to provide women with the support they want during labor and the recognition that husbands or significant others do not always make the best coaches during labor. Being in a hospital and seeing one’s wife in labor may be very stressful for some fathers (Klaus, Kennell, & Klaus, 2002). Childbirth education programs have traditionally provided training labor-support persons. However, the assumption that the husband or significant other makes the best coach may not be accurate (Chapman, 1992). It is important for the father of the baby to be present during the labor and birth, but the presence of a doula may be what the laboring woman needs.
Table 16-3. DIFFERENTIATING THE ROLES OF THE NURSE AND THE DOULA | ||||||||||||||||||||||||
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Labor-support persons, or doulas, with a variety of credentials and levels of education, assist women and their partners during pregnancy, birth, and the postpartum period. “A doula is a supportive companion (other than a friend or loved one) who is professionally trained to provide labor support” (Gilliland, 2002, p. 762). Most often seen during labor, their main goal is to ensure that the woman feels safe and confident (Ballen & Fulcher, 2006). A doula remains continuously at the side of the woman to provide emotional support and physical comfort (Klaus et al., 2002). While not provided by all programs, a unique aspect of the doula role occurs postpartum, usually after discharge from the hospital. During a home visit, the doula is able to make time to review with the new mother her labor and birth experience with the goal of creating a satisfying birth experience. “The doula allows the woman to reflect on her experience, fills in gaps in her memory, praises her, and sometimes helps reframe upsetting or difficult aspects of the birth” (Ballen & Fulcher, 2006, p. 305). Table 16-3 contrasts the role of a doula with that of the perinatal nurse.
In a meta-analysis of 11 clinical trials in which continuous support by a doula was compared with traditional intermittent support of a labor and delivery nurse, continuous support was associated with significantly shorter labors; decreased use of analgesia, oxytocin, and forceps; and decreased cesarean births (Scott, Berkowitz, & Klaus, 1999). In a culture in which women experience traditional labor without their husbands, those accompanied by a female support person had significantly shorter labors, less use of analgesia and oxytocin, and fewer admissions to the neonatal intensive care unit (NICU) (Mosallam, Rizk, Thomas, & Ezimokhai, 2004). Women who had the benefit of a doula during labor expressed significantly less emotional distress and had higher self-esteem at 4 months postpartum than women who had attended a traditional Lamaze class (Manning-Orenstein, 1998). When low-income pregnant women were randomized to be accompanied in labor by their family and a trained doula or just family members, those in the experimental group had significantly shorter labors and greater cervical dilation at the time of epidural anesthesia (Campbell, Lake, Falk, & Backstrand, 2006).
Doulas (also known as labor assistants, birth companions, labor support specialists, professional labor assistants, and monitrices) may be volunteers or paid and are available through a variety of programs, either hospital based, community based, or as a private, contracted service. Hospital- and community-based programs are often available to underserved populations, women who may be newly emigrating, or women who might be alone during childbirth (e.g., adolescents, incarcerated women). Individual hospitals or community-based healthcare agencies may be involved in training doulas, or there are national organizations where training and certification are available (Display 16-4). Services of a doula are generally arranged by the expectant couple or presented as an available option by a healthcare agency before labor.
The husband or significant other, family members and friends, and/or a doula should be welcomed and encouraged to provide labor support. The presence of one or all of these additional individuals does not decrease the ultimate responsibility of the perinatal nurse but instead adds to a positive birth experience. Labor support, when provided by nursing personnel, a partner, family members, or friends, affects a woman’s perception of labor (Lowe, 2002; Wright, McCrea, Stringer, & Murphy-Black, 2000). In a meta-analysis of 15 clinical trials, continuous support from a nurse, CNM, or lay person resulted in decreased operative vaginal birth, cesarean birth, 5-minute Apgar scores less than 7, and use of medication for pain relief (Hodnett, Gates, Hafmeyr, & Sakala, 2003). In a systematic review of the literature, Hodnett (2000) found the attitudes and behaviors of caregivers are a stronger influence on satisfaction with childbirth than many other factors. Women who received continuous support during labor are less likely to request intrapartum analgesia, require an operative birth, or report dissatisfaction with their childbirth experience (Hodnett et al., 2003).
DISPLAY 16-4 Associations That Train and Certify DoulasALACE (Association of Labor Assistants & Childbirth Educators) http://www.alace.org
CHILDBIRTH EDUCATION SPECIALISTS http://www.childbirtheducation.net
DONA (Doulas of North America International) http://www.dona.org
CHILDBIRTH INTERNATIONAL http://www.childbirthinternational.com
INTUITIVE DOULA http://www.intuitivedoula.com
ICEA (International Childbirth Education Association) http://www.icea.org
Adapted from Ballen, L. E., & Fulcher, A. J. (2006). Nurses and doulas:
Complementary roles to provide optimal maternity care. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35(2), 304-311.
CHILDBIRTH PREPARATION
An awareness of the childbirth preparation and skills that the woman and her partner are prepared to use are helpful when planning nursing support strategies during labor. The desire for pain relief during labor varies in women with a spectrum from natural childbirth to the most invasive technique (e.g., neuraxial analgesia). Prenatal education should provide information on an assortment of pain management and coping skills to hopefully meet the expectations of the woman. Most pregnant women have concerns about labor process and their ability to handle painful contractions. Childbirth classes provide an opportunity to help women understand and let go of fears about labor and birth and begin to develop confidence in their ability to give birth. Antenatal education in preparation for childbirth is available in a number of formats including in a classroom, online, and through video display. Content and bias varies depending on the author and presenter of the material. Both pharmacologic and nonpharmacologic pain relief methods may be presented as alternatives or complimentary to each other, which may influence the woman’s coping ability and choice. The common goal of all birthing classes is to provide the knowledge and confidence to give birth and to make informed decisions. Anxiety-reducing strategies and a variety of coping techniques integrated into the physiology of the birth process will provide an aid to pain management. Guidelines from 2008 from the National
Institute for Clinical Excellence (NICE; 2008) reviewed studies from the United States, the United Kingdom, and Australia and recommend preparation for labor and birth to include information about coping with pain in labor and the birth plan. Knowledge regarding pregnancy, birth, and parenting issues is increased following attendance at antenatal classes, and the wish to receive this information is a strong motivator for attending classes. Classes need to include information about decision making, including both informed consent and the women’s right to an informed refusal. For the woman, it takes courage and confidence to communicate effectively with the healthcare team and her provider in making clear her expectations of labor and birth (Lothian, 2005).
Institute for Clinical Excellence (NICE; 2008) reviewed studies from the United States, the United Kingdom, and Australia and recommend preparation for labor and birth to include information about coping with pain in labor and the birth plan. Knowledge regarding pregnancy, birth, and parenting issues is increased following attendance at antenatal classes, and the wish to receive this information is a strong motivator for attending classes. Classes need to include information about decision making, including both informed consent and the women’s right to an informed refusal. For the woman, it takes courage and confidence to communicate effectively with the healthcare team and her provider in making clear her expectations of labor and birth (Lothian, 2005).
A broad range of nonpharmacologic behavioral strategies including controlled breathing, relaxation, positioning, and massage are usually presented in both the Lamaze and Bradley courses (Table 16-4). The Lamaze® philosophy, also known as psychoprophylaxis, teaches that birth is a normal, natural, and healthy process. The goal of Lamaze® is to explore all the ways women can find strength and comfort during labor and birth. It is based on the Pavlovian concept of conditioned reflex training. Classes focus on relaxation techniques, but they also encourage the mother to condition her response to pain through training and preparation. This conditioning is meant to teach expectant mothers constructive responses to the pain and stress of labor as opposed to tensing muscles in response to pain. The basis of Lamaze® childbirth preparation is the belief that pain during childbirth leads to fear and tension, which increases the experience of pain. As fear and anxiety heighten, muscle tension increases, inhibiting the effectiveness of contractions, increasing discomfort, and further heightening fear and anxiety. Other techniques are also used to decrease a woman’s perception of pain such as distraction (a woman might be encouraged, for example, to focus on a special object from home or a photo) or massage by a supportive coach. Lamaze® courses are neutral regarding the use of drugs and routine medical interventions during labor and delivery and educate mothers about their options so informed decisions can be made. Nonpharmacologic and pharmacologic pain-management strategies provide women with specific techniques they can use to cope with the discomfort of labor, thereby increasing their feelings of control.
Table 16-4. COMPARISON OF PRENATAL EDUCATION CLASSES | ||||||||||||
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The Bradley Method® (also called “Husband-Coached Birth”) places an emphasis on a natural approach to birth and on the active participation and teamwork with the baby’s father as the birth coach. A major goal of this method is the avoidance of medications unless absolutely necessary. Other topics include the importance of good nutrition and exercise during pregnancy, relaxation techniques (such as deep breathing and concentration on body signals) as a method of coping with labor, and the empowerment of parents to
trust their instincts to become active, informed participants in the birth process. The course is traditionally offered in 12 sessions. Although Bradley® emphasizes a birth experience without pain medication, the classes do prepare parents for unexpected complications or situations, including emergency cesarean birth. After the birth, immediate breastfeeding and constant contact between parents and baby are stressed.
trust their instincts to become active, informed participants in the birth process. The course is traditionally offered in 12 sessions. Although Bradley® emphasizes a birth experience without pain medication, the classes do prepare parents for unexpected complications or situations, including emergency cesarean birth. After the birth, immediate breastfeeding and constant contact between parents and baby are stressed.
Hospital-based classes are offered in the third trimester and welcome the involvement of a birth companion during classes. The hospital-based prenatal class presents content seemingly biased to that particular institution and may focus primarily on the medical model. Usually a tour of the facility is included in the classes. Carlton et al. (2005) question whether some hospital-based education serves to socialize women about the “appropriate” ways of giving birth rather than educating them.
There is a relationship between women’s expectation of labor and their actual experience of labor (Green, 1993). Women who expect breathing and relaxation techniques to work are more likely to find them helpful. Women who wish to avoid medications can be successful with the help of educational preparation, their support system, and perinatal nurses who respect that plan. The labor admission assessment should include questions related to the type and amount of childbirth preparation (e.g., classes, reading, video tape viewing). As part of the admission assessment, the nurse should ask about the couple’s plans for pain management during labor and whether this subject was discussed with her obstetric provider. Asking about their plans and goals validates their efforts to prepare for labor and birth. Nurses should assure the woman and her support persons that the couple’s goals are understood and that achievement is a shared objective. Nurses have a responsibility whenever possible to facilitate an experience for each couple that matches their expectations (Carlton, Callister, & Stoneman, 2005). Knowledge and skills learned in childbirth-preparation classes are enhanced when the nurse present during labor and birth believes in and actively supports the couple as they apply these principles.
HEALTHCARE ENVIRONMENT
Every perinatal unit takes a unique approach to caring for laboring women. A culture develops over time and is accepted by most of those working within the department as a reflection of their values and beliefs. Cultural differences may be as significant as the availability of labor, delivery, recovery, and postpartum rooms (LDRPs) or as subtle as the routine initiation of intravenous fluids on admission. These practices reflect the evolution of intrapartum care within a particular institution. Unit culture extends to treatment of pain and influences the woman’s perception of pain. Nurses who value nonpharmacologic approaches to pain management use these techniques in clinical practice.
PAIN TOLERANCE
Pain is a culturally bound phenomenon. When a patient expresses pain, the form that expression takes is related to what her culture has taught her is appropriate. Pain tolerance may be defined as the level of stimuli at which the laboring woman asks to have the stimulation stopped. In labor, it is the point at which a woman requests pharmacologic pain relief or increased comfort measures. Descriptive words such as mild, moderate, and severe do not provide a measure of pain tolerance because laboring women may describe pain as severe but may not request pain medication. A woman’s pain tolerance or the length of time she is able to go without medication may be increased by the use of nonpharmacologic pain management techniques (O’Sullivan, 2009).
The Joint Commission (TJC; 2011), in 2001, established pain management standards for healthcare organizations, which require that patients (1) have appropriate assessment and management of pain, (2) are screened for pain during the initial assessment and reassessed periodically, and (3) are educated about pain management. Many hospitals use a rating scale to quantify the pain from 0 to 10, with a response of 4 or greater requiring intervention and 10 being excruciating pain. TJC does not mandate this particular rating scale but rather that their standards are followed.
Most hospitals have adapted one of the many available standardized pain assessment tools. Those used in adult populations, for the most part, require that the patient rate the intensity of pain she is experiencing. They are useful because there is some objectivity added to assessing and documenting phenomena that are very subjective. What these simplistic tools cannot tell the nurse is how the pain is being interpreted or translated by the woman in labor. What is her perception of the pain and how much is she suffering during labor? Only by being present and really listening, observing, and empathizing with a woman during labor can the nurse begin to understand what the experience of pain is for her and what interventions might be helpful to provide some relief (King & McCool, 2004). There is still a need for research to find a suitable assessment instrument for the evaluation of labor pain (Bergh, Stener-Victorin, Wallin, & Martensson, 2011).
Roberts et al. (2010) developed and implemented an alternative tool to the 0 to 10 rating scale, called The Coping with Labor Algorithm, which qualifies the woman’s ability and internal consciousness as coping or not coping with her labor. Signs of coping include rhythmic motion, breathing patterns, and stating she is coping. Noncoping cues include lack of concentration, crying, and stating she is no longer coping. Both
pathways incorporate nursing and supportive actions. The coping algorithm was found to be useful in the hospital setting and is being evaluated in other hospitals for ease of use and applicability. The Coping with Labor Algorithm has passed a Joint Commission survey.
pathways incorporate nursing and supportive actions. The coping algorithm was found to be useful in the hospital setting and is being evaluated in other hospitals for ease of use and applicability. The Coping with Labor Algorithm has passed a Joint Commission survey.
Although pain may be quantified, it is only one component of a woman’s overall experience of labor and delivery. Personal satisfaction is not always correlated with the level of pain and should be included in the evaluation of pain (Tournaire & Theau-Yonneau, 2007). Research has shown that alternative coping techniques may improve a women’s sense of control and satisfaction with childbirth (Kimber, McNabb, McCourt, Haines, & Brocklehurst, 2008). Helping women cope with labor through methods to impact the affective component and decrease the sensory component may be viewed as ineffective by clinicians supportive of the pharmacologic model (Lowe, 2002).
THE NONPHARMACOLOGIC MODEL
The nonpharmacologic model views childbirth as a unique individual experience and a normal physiologic process that involves pain. The goal is to eliminate the suffering, helplessness, distress, and loss of control. This model will not provide complete pain relief, but allows techniques that allow a woman to cope with her labor pain; therefore, it is inaccurate to use terms such as pain relief when referring to these interventions. Alternatively, the complete removal of pain does not always convert to a more satisfying experience. A woman’s ability to actively participate in her labor can transform the experience from suffering to active participation and confidence in her ability to cope with the aid of her support system. The nonpharmacologic model is appealing to women and caregivers who are interested in reducing labor pain without creating potentially serious side effects and high costs. It includes a wide variety of techniques to address both physical sensations of pain and to prevent suffering by addressing the emotional and spiritual components of care (Simkin & Bolding, 2004). Ultimately, it is a nurse’s role to support the laboring woman to make informed choices that achieve a woman’s vision of birth, while ensuring the safety of both the mother and infant. Few randomized, controlled clinical trials exist validating all these techniques. Some interventions, such as positioning, counter-pressure, heat and cold, touch, massage, and injections of sterile water, may decrease pain. Other interventions, such as relaxation, imagery, focusing, breathing techniques, and music, more likely benefit a woman by decreasing anxiety, improving overall mood, and increasing the individual’s sense of control in a painful situation (McCaffery & Pasero, 1999).
 FIGURE 16-1. Frequency of nonpharmacologic use during labor. (Adapted from Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. [2007]. Listening to mothers II: Report of the second national U. S. survey of women’s childbearing experiences. Journal of Perinatal Education, 16(4), 15-17.) |
Women choose pain-management strategies based on their previous experience with pain, what they learned in prenatal classes and from primary healthcare providers’ recommendations, and listening to what worked for family members and friends. The advantage of nonpharmacologic pain management strategies is their simplicity and relative ease to initiate, the sense of control women receive when they actively manage their pain, the lack of serious side effects, and the fact that they do not generally add additional costs to the birth process (Simkin & O’Hara, 2002). Also, nonpharmacologic interventions do not require additional medical interventions and provide the opportunity for the woman’s significant others to be involved in the birth experience. The 2006 “Listening to Mothers II Survey” noted that 69% of the mothers used some type of nonpharmacologic intervention during labor (Declercq, Sakala, Corry, & Applebaum, 2007) (Fig. 16-1).
There are three classifications of nonpharmacologic methods or comfort measures that can be used to decrease or alter painful sensations associated with labor and birth: (1) measures to reduce painful stimuli, (2) methods that activate peripheral sensory receptors to block transmission of painful stimuli, and (3) cognitive techniques that enhance inhibitory neural pathways, thereby reducing a woman’s negative psychologic reaction to pain (Table 16-5).
The effectiveness of nonpharmacologic pain-management strategies can be explained by Melzack and Wall’s (1965) early work on the gate control and the processes responsible for the transmission of pain. The first process is explained by the structure of the central nervous system, which is composed of large and small sensory nerve fibers. Impulses are carried by the spinal cord from the site of the stimuli to the cerebral cortex, where impulses are interpreted. Small, thinly myelinated, or unmyelinated fibers transport impulses such as pressure and pain from the uterus, cervix, and pelvic joints. Large myelinated fibers transport impulses from the skin. Because passage along large fibers occurs more quickly, it is possible for cutaneous stimulation to block or alter painful impulses. Based on this premise, tactile stimulation in the form of touch or massage is often used effectively during labor. The second process is stimulation of the reticular activating system in the brain stem. The reticular activating system interprets auditory, visual, and painful sensory stimuli. When the cerebral cortex focuses on auditory or visual stimulation, painful stimulation is less able to pass through the “gate.” Many forms of distraction are used during labor to decrease pain perception.
Table 16-5. NONPHARMACOLOGIC METHODS TO CONTROL PAIN | ||||||||
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Melzack (1999) has reevaluated the Gate Control Theory, adding to it the possibility of multiple influences within the brain, a neuromatrix that is ultimately responsible for how each individual perceives pain. These other influences include past experiences, cultural conditioning, emotional state, level of anxiety, understanding of the labor process, and the meaning that the current situation has for the individual are used by the cerebral cortex to interpret a sensation as painful. Just as thoughts and emotions can increase pain, they can also increase feelings of confidence and control, decreasing painful sensations. Prenatal education and labor support are effective pain-management strategies because they enhance maternal confidence and a sense of control.
CUTANEOUS PAIN RELIEF TECHNIQUES
Maternal Position and Movement
Women naturally choose positions of comfort and are more likely to change position during early labor. Modern technology (e.g., EFM, intravenous tubing and catheters, automatic blood pressure monitors, fetal scalp electrodes) and pharmacologic use may interfere with a woman’s ability to find a comfortable position and frequently restricts her to bed. Many nurses and physicians encourage bed rest for labor because it helps them feel more in control of the situation, and they believe it may be safer for the woman and fetus. However, it is possible to use most of the technology available in obstetrics without maintaining continuous bed rest. An upright position can be accomplished in a recliner, rocking chair, or birthing bed adjusted to a chair position. EFM telemetry units, transducers that can be submerged in water, or intermittent auscultation of the fetal heart rate (FHR) can be used to evaluate fetal response to labor while the woman is ambulating or using hydrotherapy. Women should be encouraged to change their position frequently during labor. Changing position alters the relationship between the fetus and pelvis and the efficiency of uterine contractions (Zwelling, 2010). Table 16-6 lists a variety of positions available to women in labor along with the benefits of each. Maintaining a horizontal position during labor is associated with decreased blood flow and may increase uterine muscle hypoxia, resulting in the increased perception of pain associated with uterine contractions (Mayberry et al., 2000). Molina, Sola, Lopez, and Pires (1997) noted decreased pain in vertical as compared with horizontal positions before 6 cm of dilation.
Women report less pain in an upright position during the second stage of labor than women in a semi-Fowler’s or semi-recumbent position (AWHONN, 2008). Upright positions during labor cause more intense and frequent contractions and more rapid cervical dilation. Changing position in labor and including some upright positions
may result in more efficient labors (Cluett & Burns, 2009). Women may initially resist suggestions to change position or may find new positions uncomfortable. When encouraging a woman to change position, the nurse should provide extra support and encouragement and suggest that she remain in the new position through several contractions before deciding whether it is comfortable. In the absence of any staff instructions, women moved about in bed, but only a small percentage chose upright positions or ambulation during either the first or second stage (Cluett & Burns, 2009).
may result in more efficient labors (Cluett & Burns, 2009). Women may initially resist suggestions to change position or may find new positions uncomfortable. When encouraging a woman to change position, the nurse should provide extra support and encouragement and suggest that she remain in the new position through several contractions before deciding whether it is comfortable. In the absence of any staff instructions, women moved about in bed, but only a small percentage chose upright positions or ambulation during either the first or second stage (Cluett & Burns, 2009).
Table 16-6. LABOR POSITIONS | ||||||||||||||||||||||||||||
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Pillows should be used generously to maintain positions and to support extremities. When a side-lying position is used, pillows can be placed behind the back and between the knees. In a semi-Fowler’s position, pillows can be placed under knees or arms. Shorter women sitting in a chair may find that a pillow or stool under their feet decreases stretching of leg muscles. Women who labor with the baby’s head in an occipital-posterior position report significantly less back pain when using hands-and-knees positioning (Zwelling, 2010). Positioning and movements in labor
are recommended for other purposes than comfort, such as rotating an asynclitic fetus and correcting slow progress in dilation or descent.
are recommended for other purposes than comfort, such as rotating an asynclitic fetus and correcting slow progress in dilation or descent.
Birthing Ball
Standard physiotherapy balls routinely used in physical therapy and exercise programs have permeated the labor setting. The woman can maintain an upright position by sitting on the ball or kneeling on the bed with her arms and chest draped over the ball. The rotation of the ball helps the mother to sway her hips side to side or in a circle. This movement helps to stretch her body and align a fetus from an asynclitic position. The birthing ball can facilitate position changes and be used as a comfort tool for women in labor. A woman can sit on it and rock or lightly bounce to decrease perineal pressure. She can also lean over the ball, decreasing back pain with an occiput posterior position. Birthing balls are one of the best tools for facilitating an upright position and can be used with an epidural only with assistance and support.
Touch and Massage
Touch in the form of hand holding, stroking, embracing, or patting communicates caring and reassurance. Cultural influences and personal factors may affect individual responses to touch; however, touch is universal and may soothe and reassure the laboring woman.
In hospitals, nurses have varying comfort levels with touch and may be more likely to advise support persons to provide the intervention. Usual touch by the nurse (only as necessary to perform clinical procedures) is different than comforting (nonclinical) touch. Perinatal nurses and others who provide support during labor use touch consciously and unconsciously throughout labor to communicate their support and presence, to relieve muscle tension, and to decrease the pain of labor. The interventions of touch and massage have not undergone sufficient scientific study to provide clear conclusions regarding benefits and risks. Some women appreciate touch and massage in labor, and these simple interventions may relieve pain and anxiety. The reaction of each woman should guide the nurse in the acceptability and value of these soothing measures (Declercq et al., 2007).
Interventions can be used by the perinatal nurse or other labor-support person to relieve back labor. These techniques include counter-pressure, bilateral hip pressure (e.g., double-hip squeeze), and the knee press (Simkin, 1995). These maneuvers are performed by applying localized pressure to reduce sacroiliac pain resulting from strain on sacroiliac ligaments caused by mechanisms of labor. Counter-pressure requires application of enough force to meet the intensity of pressure from the fetal occipital bone against the sacrum (Fig. 16-2). Steady pressure from the heel of a support person’s hand or another firm object counteracts the strain against the sacroiliac ligaments caused by the fetal occiput (Simkin, 1995).
 FIGURE 16-2. Firm counter-pressure of the fists on the lower back. |
Massage is the manipulation of the soft tissues of the body to enhance health and healing. Massage has been used to decrease fatigue, tension, emotional distress, and chronic and acute pain. Purposeful use of massage is employed during labor as a relaxation and stress-reduction technique. This technique is effective at reducing pain because it functions as a distraction, may stimulate cutaneous nerve fibers that block painful impulses, and stimulates the local release of endorphins (Gentz, 2001; Huntley, Coon, & Ernst, 2004). In two randomized controlled trials, where the experimental group received several massages during labor, self-reports of anxiety levels were the same in both groups, while nurses reported observing significantly less behavioral manifestations of pain (Chang, Wang, & Chen, 2002) and pain scores were significantly less during early and active labor (Chang, Chen, & Huang, 2006).
All forms of massage are accomplished with moderate pressure, activating large myelinated nerve fibers. Because habituation can occur, decreasing the beneficial effects of massage, the type of stroke and location should vary during labor. In a randomized controlled trial during which partners provided massage during labor, women reported significantly less pain and anxiety (Field, Hemandez-Reif, Taylor, Quintino, & Burman, 1997). Relaxation and massage have been shown to be factors in promoting labor progress, decreasing pain perception, and increasing the woman’s ability to cope with labor (Zwelling, Johnson, & Allen, 2006).
Hydrotherapy
Hydrotherapy, or the use of warm water as a complimentary nonpharmacologic pain relief technique, may be desired and effective for the woman in labor. It is capable of promoting relaxation and decreasing pain without the risks caused by other treatments. Benfield, Herman, Katz, Wilson, and Davis (2001) published a small study of laboring women at 4-cm cervical dilation noting a therapeutic effect of decreased anxiety at 15 minutes of warm water immersion with an added benefit of decreased pain and anxiety at 60 minutes compared to nonbathers. A randomized controlled study of 108 women found the pain index scores among women who used the immersion bath were significantly lower than in those women without immersion (daSilva, deOliveira, & Nobre, 2009). Kiani (2009) concluded that a warm water pool can be an effective way to decrease labor pain and alleviate suffering especially during the first and second stages of labor. Numerous positive benefits have been shown by use of hydrotherapy (Cluett & Burns, 2009) and are listed in Display 16-5.
Positive benefits of water immersion include ease of positioning, buoyancy, hydrostatic pressure, and thermal relaxation. Hydrotherapy allows freedom of movement and helps facilitate maternal participation leading to a more normal labor process. Buoyancy in the tub allows for an almost weightless feeling, and women may have more opportunity to move during labor, which enhances progress due to the ease of movement. Using water immersion and covering the abdomen with warm water, the hydrostatic pressure of the water provides stability and relieves some of the pain associated with uterine contractions. In addition, hydrostatic pressure moves fluid from the extravascular to the intravascular spaces reducing blood pressure and edema and promoting diuresis (Florence & Palmer, 2003). Warm water provides soothing stimulation of nerves in the skin, promoting vasodilatation, reversal of sympathetic nervous system response, and a reduction in catecholamine production (Florence & Palmer, 2003). Hydrotherapy is postulated to provide pain relief through the perception of warmth by the nerve receptors in skin. These nerve impulses travel to the cerebral cortex and initiate the gate mechanism, thereby decreasing pain perception. The potential combined effects of these changes are postulated to result in increased intravascular volume, improved uterine perfusion, decreased pain, decreased blood pressure due to vasodilatation, increased relaxation, and shortened labor (Simkin & O’Hara, 2002). The water temperature should be maintained between 36°C and 37°C (96.8°F and 98.6°F) to promote relaxation and maintain warmth. Warmer water may raise both maternal and fetal temperature and may lead to fetal tachycardia and elevated neonatal temperature (Simkin & O’Hara, 2002). Maternal effects of hydrotherapy include weakness, dizziness, nausea, tachycardia, or hypotension. These are usually related to an increase in body temperature or dehydration. Cool liquids should be provided to the mother to maintain her comfort, and hourly monitoring of the water temperature will help to maintain optimal temperature.
DISPLAY 16-5 Benefits of Hydrotherapy
Pain and anxiety relief
Increased diuresis
Decreased edema
Decreased blood pressure
Enhanced fetal rotation due to increased buoyancy
Faster cervical dilation
Less use of intramuscular and intravenous medication
Less use of epidural anesthesia
Fewer operative births (vacuum and forceps)
Less perineal trauma
Fewer episiotomies
A repeated concern regarding the safety to the fetus is whether hydrotherapy can be used with ruptured membranes. Water does not enter the vagina during tub bathing. This topic has been studied with no increase in the incidence of chorioamnionitis, postpartum endometritis, neonatal infections, or need for antibiotics (Zwelling et al., 2006; Eriksson, Mattsson, & Ladfors, 1997).
Safety considerations including rapid draining of the water and movement to the birthing bed must be planned when immersion is used. A safety huddle including the woman and her support person, nurses, and provider staff should occur prior to entry to the tub, which includes expectations of duration of hydrotherapy, need for emergent exit, and avoidance of injury from falls. Tubs may be ordinary bathtubs, water-saving reclining tubs, or portable tubs. The manufacturer’s recommendations and the hospital’s infection control department are sources for appropriate cleaning and safety requirements.
If water immersion is not an option, hydrotherapy may be achieved in the form of a warm shower spray using a flexible hand-held unit guided by the mother, her support person, or the nurse. Aiming at the lower uterine segment, the warm stream of water may help to relieve the stretching sensations of the ligaments and promote local vasodilatation that facilitates muscle relaxation and reduces pain of tense muscles (Mackey, 2001). Significant others supporting the woman in labor can assist her by holding the shower wand and adjusting the temperature as needed. The mother may stand or sit in the shower on a supportive bench or chair as tolerated and desired, even for long periods of
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