Non-Pharmacologic Pain Management During Labor

1. Non-Pharmacologic Pain Management During Labor Authored by: Karina Schaub, RNC, MN

2. Objectives • Identify several non-pharmacologic ways to help patients cope with labor pain • Know the contraindications for certain methods of pain relief • Identify several ways nurses can show support for the pt and their support people

3. Physiologic Responses to Pain • Release of Catecholamines • BP • HR • RR • Tension

4. Information to Discuss Upon Admission • Review Birth Plan • Discuss pain relief options and coping mechanisms • Advise support person • Discuss FHM standards

5. Empowering Women to Give Birth • Motivation • Encouragement • Position changes • Offer advice to support person • Physical Presence

6. Fetal Monitoring Standards per ACOG • Low risk patients: • 20 minute strip initially • Active Labor: during and 30 seconds after a contraction Q 30 min • 2nd Stage: during and 30 seconds after a contraction Q 15 min ** Always follow your hospital’s protocol

7. Fetal Monitoring Standards per ACOG • High risk patients: • 20 minute strip initially • Active Labor: during and 30 seconds after a contraction Q 15 min • 2nd Stage: during and 30 seconds after a contraction Q 15 min ** Always follow your hospital’s protocol

8. National Organization Support Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) American College of Obstetricians and Gynecologists (ACOG)

9. Research Study Support “The presence of a doula during labor… Lower use of analgesia, Lower C/S rate, Increased maternal satisfaction.” (Berghella, et al, 2008)

10. Personal Needs • Nutrition • Water • Ice chips • 120 cal/hr • Elimination

11. Non-Pharmacologic Coping Mechanisms Walking Swaying Rocking Chair Birthing Ball Changing Positions Squatting Bar Tub Rebozo Distractors Focal Point Visualization Music Aromatherapy Heat/Cold Massage Acupressure Hypnobirthing

12. Movement • Walking • Swaying • Hands & Knees

13. Using Props • Rocking Chair • Birthing Ball

14. Using Props • Squatting Bar • Put bed into chair position • Squat holding the bar • Pull on sheet

15. Using Props • Rebozo • Support with rebozo under arms to relax neck, shoulders, and back • Passive Movement Relaxation

16. Hydrotherapy “Liquid Epidural” • Less pain • Less muscle tension • Reduces effect of gravity on mother

17. Hydrotherapy Contraindications: • Maternal fever> 100.4 or suspected maternal infections • Amnionitis • Documented non-reassuring FHR • Condition requiring continuous EFM • Excessive vaginal bleeding • Epidural Anesthesia • Malpresentation • Other conditions at discretion of HCP

18. Hydrotherapy • Water temp mildly warm • Push fluids • Offer towel to drape over pt for privacy

19. Hydrotherapy • Decreases pain sensation • Less use of IM/IV/epidural analgesia • Fewer instrumental deliveries • Decreased incidence of cesarean sections • Decreased incidence of perineal trauma • Increased maternal satisfaction (Berghella, et al, 2008)

20. Does bath water enter vagina? • Research Study: Tampon placed in vagina before entering the water Potassium iodide solution placed in tub water No tampons reacted to the iodide until they were removed Conclusion: Bath water does NOT enter the vagina (Siegel, 1990)

21. Hydrotherapy after SROM • Waldenstrom. et al, 1992 – No differences in maternal or neonatal infections, asphyxia or resp problems. • Erolsspm. et al, 1996 - Pre-labor SROM – No differences in maternal or neonatal infection rate.

22. Perineal Massage • Starting at 34 wks • Almond oil 5-10 min daily • Perineal Massage 2nd stage • Warm pack 2nd stage (Berghella, et al, 2008)

23. Sterile Water Papules • Injection of Sterile Water in 4 areas • Burns x 30-90 seconds • Back pain relieved in 2-3 minutes • Pain relief x 2-3 hours • May be repeated ** Note – does not relieve contraction pain

24. Sterile Water Papules • MD, CNM, RN • Best to have 2 people inject at the same time • Tuberculin syringes, 0.3 ml of Sterile Water • Locate injection site over sacrum (4 injections)

25. Sterile Water Papules • Cleanse area with alcohol • Inject 0.15 ml of the Sterile Water intradermally in each site • Watch for a wheal to form

26. Using the Senses • Focal Point (sight) • Spot on the wall • Calming photo • Music (sound) • CD’s, IPOD, Headphones • Activates the right brain

27. Using the Senses • Aromatherapy (smell) • Clary Sage: Anxiety, Fatigue, Stress • Jasmine: Confidence, Fatigue, Stress • Lavender: Anxiety, Irritability, Stress • Peppermint: Fatigue, Relaxes urinary meatus • Rose: Anxiety, Stress

28. Using the Senses • Heat/Cold (touch) • Cool cloth • Fan • Warm tub • Massage (touch) • Back • Feet • Tennis Ball

29. Mind over Matter • Distractors • TV • Children playing • Cleaning • Visualization • Visualize a favorite place where you can think of smells, sounds, feelings…

30. Breathing patterns Slow deep breaths 1st Stage Feeling pushy but can’t push yet? Pant – short quick breaths out Breathing Rhythm inLabor

31. Acupressure • For Nausea/Vomiting • Inner Gate or Neiguan P6 Pressure Point

32. Acupressure • Pain relief during labor • Hegu li-4 pressure point

33. Hand Reflexology • Pressure on the balls of the hand and finger tips • Can use in both hands

34. Acupressure • Cervical Dilation • Sanyinjiao SP-6

35. Hypnobirthing • Childbirth method using mind/body and meditation science • Deep relaxation • Eliminate Fear, Tension, and Pain • Techniques improve immune and nervous system function in preparation for birth: • Teaches to recognize and release fears in labor • Teaches to extend natural labor pain management

36. Conclusion • Combine different techniques based on your assessment of pt’s needs • Provide rationale behind the various methods of pain relief • Let the pt and family know that you are there for them

37. Questions?

38. References Berghella, V., Baxter, J., & Chauhan, S. (2008). Evidence-based labor and delivery management. American Journal of Obstetrics and Gynecology. 445-454. Retrieved February 1, 2011 from www.AJOG.org. Birthing Ball. [Online Image] Retrieved June 23, 2009 from http://www.birthease.co.uk/birthease_shop/Shop-Products/Birth-Birthing-Ball/Birth-Birthing-Ball-Large-Image.jpg. Buckle, J. (2000). Aromatherapy for Health Professionals. Cervical Dilation Acupressure. [Online Image] Retrieved June 22, 2009 from http://acupuncture.rhizome.net.nz/acupressure/images/sp-6_2.gif. Childbirth Instructor Magazine. (1997). The Moaning Option. 2nd Quarter Dougans, I. (2003). Reflexology: The Complete Illustrated Guide to Therapeutic Foot Massage for Health and Well-being. Intradermal Injection. [Online Image] Retrieved June 23, 2009 from http://www.hivandhepatitis.com/0_images_2008/tb_hosp2.gif Jonquil, S. (1997). Midwifery Today. Sterile Water Blocks for Back Pain in Labor. Kunz, K. & Kunz, B. (2003). Reflexology: Health at your fingertips. 120-121. Labor Bathtub. [Online Image] Retrieved June 23, 2009 from http://www.discoversanmiguel.com/images2010/Twin-Cities-Labor-Tub.jpg

39. References Cont’d Labor Squatting Bar. [Online Image] Retrieved June 23, 2009 from http://www.google.com/imgres?imgurl=http://www.wpahs.org/womenshealth/clinical/services/images/OBtour_25_001.jpg&imgrefurl=http://crispy-not-crunchy.blogspot.com/2009/08/littlests-birth-story.html&usg=__8786P5Mwt3BMFqt3IBMMGJwmpiU=&h=188&w=240&sz=38&hl=en&start=7&itbs=1&tbnid=UM0yN02DhWKrGM:&tbnh=86&tbnw=110&prev=/images%3Fq%3Dlabor%2Bsquatting%2Bbar%26hl%3Den%26sa%3DN%26gbv%3D2%26ndsp%3D20%26tbs%3Disch:1 Mongan, Marie. (2006). Hypnobirthing: The Mongan Method. Pfeil, Aerlyn, CPM. (2007). Sterile Water Papules for Back Labor Relief. Sterile Water Papule Injection Sites. [Online Image] Retrieved May 3, 2009 from http://www.scielo.br/img/revistas/rba/v56n5/en_12f1.gif. Tisserand, R. (1977). Healing Arts Press. Art of Aromatherapy. Trolle, B., Moller, M., Kronberg, H. & Thomsen, S. (1991). American Journal of Obstetrics and Gynecology. The Effects of Sterile Water Blocks on Low Back labor Pain.