PAIN MANAGEMENT Prepared by Mr’s :raheegeh Awni

1. PAIN MANAGEMENT Prepared by Mr’s :raheegeh Awni

2. Method of Grantly Dick-Read This method is based on the idea that fear and anticipation of pain arouse natural protective tensions in the body, psychic as well as muscular. Fear stimulates the sympathetic nervous system and causes the circular muscle of the cervix to contract. 10/5/2014 2

3. The longitudinal muscles of the uterus then have to act against increased cervical resistance, causing tension and pain. According to Dick-Read, prenatal courses and training reduce fear, overcome ignorance, and build a woman's self-confidence. instructions Exercises that strengthen certain muscles and relax others. Breathing techniques that will enable the woman to relax in the first stage of labor and work effectively with muscles used during delivery. Explanations of the value of improved physical health and emotional stability.

4. Psychoprophylactic or Lamaze Method Psychoprophylactic childbirth. The woman is taught to replace responses of restlessness, fear, and the loss of control with more useful activity. The mother-to-be is taught exercises that strengthen the abdominal muscles and relax the perineum. Breathing techniques to help the process of labor are practiced. 10/5/2014 4

5. The coach serves as a conditioned stimulus using the sound of his or her voice, use of particular words, and repetition of practice. Medications are not encouraged for pain relief. Relaxation is the core component. Increased tolerance to pain is accomplished by decreased mental anxiety and fear.

6. The Bradley Method of Delivery Commonly referred to as coached childbirth, Involves the concepts of leading, guiding, supporting, caring, and fostering specific skills and confidence. Coaches attend classes and learn to help the woman long before labor begins. 10/5/2014 6

7. In one study, Kennell and associates (1991) randomly assigned 412 nulliparous women in labor to either continuous emotional support from an experienced companion or to monitoring by an inconspicuous observer who did not interact with the laboring woman. • The cesarean delivery rate was significantly lower in the continuous support group compared with that of the hands-off monitored group (8 versus 13 percent), as was the frequency of epidural analgesia for vaginal delivery (8 versus 23 percent).

8. Management of Discomfort Pain is unpleasant ,complex, highly individualizedphenomenon with both emotional and sensory component The pain and discomfort of labor have tow origins visceral, somatic. Visceral pain : in the first stage of labor, located in the lower portion of the abdomen, the pain from cervical changes, distention of the lower uterine segment and uterine ischemia

9. 2) Somatic pain : pain is intense, sharp ,burning and will localized ,result from stretching and distention of perineal tissue and the pelvic floor. Pain during the 3ed stage of labor are similar to that experienced early in the first stage of labor.

10. PRINCIPLES OF PAIN RELIEF • In a scholarly review, Lowe (2002) emphasized that the experience of labor pain is a highly individual reflection of variable stimuli that are uniquely received and interpreted by each woman individually. • These stimuli are modified by emotional, motivational, cognitive, social, and cultural circumstances. • The complexity and individuality of the experience suggest that a woman and her caregivers may have a limited ability to anticipate her pain experience prior to labor. • Thus, choice among a variety of methods and individualization of pain relief is desirable.

11. Factor influencing pain response 1-physiological 2-phychosocial 3-enviromental

12. Physiologic factor -The women with history of dysmenorrhea may experience increased pain during childbirth - upright position during labor decreased pain and increase comfort when compared with the supine potion. -endorphins: higher level may increase the ability of women in labor to tolerate acute pain and reduce their irritability and anxiety.

13. culture • It is important to recognize that although women behavior in response to pain may vary according to her cultural background. • it may not accurately reflect the intensity of the pain she is experiencing

14. Anxiety Excessive anxiety and fear increase catecholamine secretion, result in more pelvic pain stimuli reaching the brain, this in turn magnifies pain perception. (lowe,2002) Catecholamines are neurotransmitters. They include dopamine, norepinephrine, and epinephrine. These proteins help transmit signals in your body and brain.

16. Previous experience • Women with first experience may not have develops effective pain coping strategies, and the nature of previous childbirth may affect woman's responses to pain.

17. Childbirth preparation • The (gate-control theory of pain) help to explain why the pain relief techniques taught in child birth preparation class work to relive the pain of labor. • -pain sensation travel along sensory nerve pathways to brain, (massage, music etc) help in reducing or completely blocking the capacity of nerve pathways to transmit pain .

18. support • A woman satisfaction with her child birth experience is primarily influenced by the attitudes an behaviors of her caregivers, including the caregivers ability to communicate and to be helpful supportive accepting and kind, continuous support significantly relives pain improves outcomes, decrease complication of labor.

19. enviroment • The quality of the environment can influence woman's ability to cope with the pain. • women prefer to be cared by familiar caregiver in a comfortable homelike setting. • Environment should be safe, private, space for movement (light, noise,temprature) adjusted according to woman ‘s preference.

20. Non pharmacologic managementof discomfort Pain relief during labor

21. Nonpharmacologic methods • include psychoprophylaxis (Lamaze method), emotional support, • massage, • hydrotherapy, • transcutaneous electrical nerve stimulation (TENS), • acupuncture, • hypnosis. • These techniques tend to work best early in the first stage of labor when the pain is least intense.

22. Research finding • RCT: The study findings was that 30min of yoga practice of at least three times per week for 10 week is an effective complementary means for facilitating maternal comfort, decreasing pain during labor and 2hr post delivery and shortening the length of labor . • This result provides evidence of the benefit of using yoga as an alternative midwifery intervention to improve the quality of maternal and childe health care.

23. music reduces sensation and distress of labor pain. • In a RCT, the effect of music on sensation and distress of pain was examined in that primiparous women during the active phase of labor (2003). • Results of the hypotheses is that music would reduce both the sensation and distress of pain was supported, the music group had significantly less sensation and also distress of pain than did the control group over the 3hr post test.

24. Result: • soft music decreased both sensation and distress of active labor pain in the first 3hr. • It also delays increase in distress of pain for an hour, the sedative quality of the music helped women to relax and distract themselves from increasingly sever pain.

25. Intradermal water block • intradermal water block involves the injection of small amount of sterile water (.5-1 ml) by using a fine needle .25 gauge into four locations in the lower back to relieve back pain. • 1 over posterior superior iliac spine and 2 other placed 3cm below and 1cm medial to each of the first site, • ( ID ) water blocks are effective in decreasing labor pain and suffering. • Stinging will occur for about 20-30 seconds after injection.

26. Effectiveness of this method may be related to mechanisms of counter irritation ( reducing localized pain in one area by irritating the skin in an area nearby. It can be repeated.

28. Touch and massage • Massage: is the intentional and systematic manipulation of the soft tissue of the body to enhance health and healing. • On trials include systematic review studied 90 women , the women's blood pressure and the number of expression of anxiety significantly decrease in the touch group. • The second trial of massage = 28 randomized women to receive either usual care or massage of head, neck, hand, and feet by their partner for 20minutes\hr for 5hr during labor, this reduces the women's pain and anxiety and improves their mood.

29. Acupuncture and acupressure • Is a component of traditional Chinese medicine, done by the insertion of fine needles into the skin at a combination of specific point along meridians (channels of energy called Qi,” chee”) in the body, followed by routine ,heating or electrical stimulation, and the placement of needles depends on degree and location of pain, stage of labor, level of fatigue, tension, anxiety.

30. Total 598 women, between those women randomly allocated to acupuncture and control group, women report of pain were significantly lower in the acupuncture group in all 3trials, and maternal satisfaction was high.

31. Breathing techniques • To provide distraction, thereby reduce the perception of pain and help woman maintain control during the contraction. • It can promote relaxation of abdominal muscle and increase the size of abdominal cavity. • In second stage, breathing is used to increase abdominal pressure and help in expelling the fetus. • Instruction to simple breathing for those who are unprepared is useful.

32. Touch and massage • Are beneficial in relieving labor pain. • Touch as holding woman’s hand s and stroking her body. • Therapeutic touch enhance relaxation, reduce anxiety, and reliefs pain.

33. Hypnosis: • Is state of deep physical relaxation with an alert mindproducing alpha wave, hypnosis for child birth is almost always self-hypnosis. • the hyptherpist teaches the women to induce the hypnotic state in her self during labor, sometime her partner is thought to relief techniques are “glove anesthesia”, and imaginative transformation in which the pain is acceptable, and contraction are seen as surges of energy that cause only alight pressure sensation. • “The body can't tell the difference between imagination and reality.”

34. It emphasizes on enhancing relaxation and diminishing fear, anxiety and perception of pain. • The woman receives posthypnotic suggestions as ‘’ you will be able to push out easily.’’

35. A total of 172 women participated in the 3trial, one trial found a decrease in use of anesthesia, one trial elevated maternal satisfaction with child birth and reported increase satisfaction in the hypnosis group.

36. Transcutaneous nerve stimulation (TENS) • involves placement of two pairs of flat electrodes on either side of woman’s thoracic and sacral spine. • These electrodes provide continuous low intensity electrical impulses stimuli from pattery-operated device. • During labor, the woman increases stimulation from low to high intensity by turning control knobs on the device. • electrode is placed at level of T1, S2, S4.

38. Aromatherapy: • Is the sciences of using highly concentrated essentials oils or essences distilled زيوت عطرية from plants in order to utilize their therapeutic properties . • herbal teas and vapors. • Lavender clary sage and bergamot promote relaxating,camomile oil.

39. lavender

40. Clary sage

41. camomile

42. Bergamot clay

43. On large, uncontrolled prospective study reported on the use effectiveness of aromatherapy over an 8 year period during this time 8050 women received aromatherapy during labor (to reduce, fear, anxiety, pain ,nausea, vomiting, to enhance women's sense of well-being and to improve contraction. • Mother and midwifes reported on the effectiveness of the oil in accomplishing the purpose for which it was given.

44. Application of heat and cold Heat applied to the women's back, lower abdomen, groin and perineum, to relief pain, and to relieve chills, decrease joint stiffness, reduce muscle spasm, heat is contraindicated if a women has a fever, or prone to hemorrhage, and not used in regions of impaired sensation (analgesia, or anesthesia) Cold: is applied on the women's back, chest or face during labor cold has the additional effect of relieving muscle spasm and reducing inflammation and edema. Study; Appling ice massage to 49 women hand the result revealed significant reduction in pain when measured on a visual analog scale.

45. Continuous labor support Is refer to non –medical care of the laboring women throughout labor and birth by trained person, include (continuous presence, emotional support, physical comforting. information and guidance,nonmidical information and advice) -15 RCTs,including 12,791 women, labor support was provided by Varity of people. The meta analysis revealed that women were less likely to experience analgesia instrumental delivary,cesarean birth, and report satisfaction.

46. Bath in labor Immersion in warm deep enough to cover the woman’s abdomen is used to enhance relaxation, reduce labor pain, and promote progress. - finding of prospective cohort studies found that decrease in pain upon entering the water followed slow rise in pain score.

47. music • Music, tapped or live, enhances relaxation during labor, thereby reducing stress, anxiety and the perception of pain. • It can be used to promote relaxation in labor and to stimulate movement as labor progresses.

48. Pharmacologic management of labor discomfort

49. Systemic analgesia • The major pharmachologic method for relieving labor pain. • Cross maternal blood-brain barrier to provide central analgesic effect. • They also cross through placenta.

50. ANALGESIA AND SEDATION • PARENTERAL AGENTS: • 1- opoid agonist analgesia • Meperidine and Promethazine. Meperidine, 50 to 100 mg, with promethazine, 25 mg, may be administered intramuscularly. • . Meperidine readily crosses the placenta, and the half-life is approximately 13 hours or longer in the newborn. • These analgesia decreased gastric emptying • And increase nausea and vomiting. • Its depressant effect in the fetus follows closely behind the peak maternal analgesic effect.