Painless labour – Contemporary practices: Painless labour – Contemporary practices Dr. Tariq Other than techniques: Other than techniques These four factors make the greatest contribution to women's satisfaction in childbirth: having good support from caregivers having a high-quality relationship with caregivers being involved in decision-making about care having better-than-expected experiences, or having high expectations. Pain relief only becomes important for satisfaction in childbirth when expectations are not met (Hodnett 2002, a systematic review) Pain relief techniques: Pain relief techniques Water birthing Music Heat and cold Imagery Rhythmical movements Massage Relaxation Breathing Perineal massage Intra dermal injections of sterile water Narcotics Twilight sleep Entonox Lamaze technique Hypnotism Acupressure / Shiatsu Acupuncture Electro-acupuncture TENS Intrathecal narcotics Epidurals Non-pharmacological methods: Non-pharmacological methods Water birth: Water birth Soviet researcher Igor Charkovsky and French obstetrician Frederick Leboyer developed in 1960s Practices in United States, Canada, Australia, and New Zealand, as well as many European countries, including the United Kingdom and Germany By 2005, over 9000 hospitals in the US and more than three-quarters of all NHS hospitals (UK) provided this option (Dianne Garland. Waterbirth: An Attitude to Care) PowerPoint Presentation: Provides pain relief and a less traumatic birth experience for the baby Redistribution of blood volume, which stimulates the release of oxytocin and vasopressin (Katz 1990) Exerts gravitational pull Aid stretching of the perineum, slows crowning of the infant's head, reduces the use of episiotomy PowerPoint Presentation: a decrease in perinatal mortality (1.2 per 1,000 for waterbirth vs. 4 per 1,000 for conventional birth) during 1994-1996 in the UK Risks to the infant such as infection and water inhalation? "there are no valid reports of infants deaths due to water aspiration or inhalation" (Harper 2000) Slowed labor? A decrease in the intensity of contractions - a "5 centimeter" rule Maternal blood loss? - Difficult to assess. The amount of blood loss reduced due to lowering BP and heart rate. Music: Music ancient Greeks played soothing instrumental music to women in labour alters mood, reduces stress and promotes positive thoughts a trigger for a breathing response or as a cue for relaxation. used as a distraction Lamaze technique: Lamaze technique Prepared child birth, including relaxation techniques, breathing exercises etc. TENS: TENS TENS (transcutaneous electrical nerve stimulation stimulates the release of endorphins Most useful in labour before the pain becomes too intense drug dose requirements may be less Hypnotherapy : Hypnotherapy Mongan method (also known as HypnoBirthing), Hypnobabies, the Lamaze method, Natal Hypnotherapy and the GentleBirth program Useful for heartburn, high blood pressure and postnatal depression can significantly shorten labor, reduce pain and reduce the need for intervention, produced higher apgar scores, reduce the incidence of postpartum depression and increase the incidence of spontaneous deliveries (British Journal of Obstetrics and Gynaecology, 100(3), 221-226, 1993) Relaxation techniques : Relaxation techniques Providing a stress-free period during the antenatal period helping in preparing the woman and also in growth of the foetus. Decreasing the tension, fatigue, discomfort and pain of labour. It also increases the oxygen going to the baby. Helps in providing a stress-free period during pueperium (i.e.:after delivery). Thus helping in lactation and bonding between the couple and little one. PowerPoint Presentation: start by doing slow breathing. Body awareness / tension recognition Contract relax method Toes; feet; ankles; knees; thighs; buttocks; back; abdomen; chest; shoulders; fists; head; Clench teeth; face; eyebrows. Touch Relaxation - a conditioned reflex Breathing techniques: Breathing techniques In some women, relaxation alone may not be sufficient to counter the discomfort of labour. In such cases breathing techniques can be used to augment the efficacy of relaxation techniques used only during contraction PowerPoint Presentation: “SLOW PACED” Breathing “MODIFIED-PACE” Breathing: Combination of slow and modified paced breathing: “Patterned – paced” Breathing: (Pant – blow) Breath holding while pushing: Acupressure: Acupressure For relieving head / neck and upper backache apply circular pressure on the muscles at the top of the shoulder in vertical line with the nipples near the back. Massaging the center of the sole, below the ball of the feet will relax the lower body. To relieve low backache, pelvic discomfort or pain, press firmly in an inward direction on either side of the vertebral column, below the waist level. Circular pressure is applied during contraction and intermittent pressure between contractions. PowerPoint Presentation: The ball of the thumbs is the part that is used to put the pressure. Do not use your nails or the tip of the thumb apply the pressure in a circular motion to release the pressure point when the pregnant women exhales and then one must transfer to another acupressure point Large areas of the body include the shoulder point, the buttock point and the thighs Acupuncture: Acupuncture Traditional Chinese therapy Releases endorphins and enkephalins Electro-acupuncture : Electro-acupuncture a significant difference in the concentration of β-endorphin (β-EP) and 5-hydroxytryptamine (5-HT) in the peripheral blood between the two groups at the end of the first stage (p = 0.037; p = 0.030) producing a synergism of the central nervous system (CNS) with a direct impact on the uterus through increasing the release of β-EP and 5-HT into the peripheral blood. (Fan Qu, Jue Zhou. Electro-Acupuncture in Relieving Labor Pain. Evid Based Complement Alternat Med. 2007 March; 4(1): 125–130.) Physical therapy: Physical therapy Massage Counter pressure Hot and Cold Compresses Light stroking or “Effleurage” Massage: Massage Touch has been associated with the power of healing since the beginning of civilisation a source of counter-stimulation Examples; Therapeutic massage (eg: shiatsu), perineal massage Methods of touch and massage : Methods of t ouch and massage lightly stroking the abdomen vigorously firm stroking where it hurts most firm circular massage using the palm of the hand over the centre of the back or sacrum. rhythmical squeezing and letting go of the shoulder muscles a long stroke down the length of the back, buttocks and down the back of the legs stroking across the forehead, down the neck and down the arms simply holding hands! Shiatsu: Shiatsu Japanese form of therapeutic massage. Shiatsu means ‘finger pressure’. Similar to acupuncture. Pain-relieving pressure points (‘tsubo’) are stimulated without the use of needles Distraction : Distraction using music listening to jokes playing cards Intra dermal injections of sterile water : Intra dermal injections of sterile water intense stinging followed by relief of backache for 60 – 90 minutes may be due to release of endorphins or by counterirritation 0.1 ml of sterile water is injected into four locations on the lower back, two over each posterior superior iliac spine (PSIS) and two 3 cm below and 1 cm medial to the PSIS. The injections should raise a bleb below the skin. Simkin PP, O'Hara M. Nonpharmacologic relief of pain during labor: systematic eviews of five methods. Am J Obstet Gynecol 2002;186(Suppl 5): S131-59 . Twilight sleep : Twilight sleep known and more or less used since 1903 "Freiburg Method," "Dammerschlaf" of Gauss "scopolamine-morphine" method of obstetric anesthesia Monitoring: pupils, pulse, respiration, character of the uterine contractions and the character of the fetal heart action "memory tests" Cochrane review : Cochrane review We found evidence that acupuncture and hypnosis may help relieve labour pain There is insufficient evidence about the benefits of music, massage, relaxation, white noise, acupressure, aromatherapy No evidence about the effectiveness of massage or other complementary therapies ( Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative therapies for pain management in labour. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD003521. DOI: 10.1002/14651858.CD003521.pub2 ) Pharmacological methods: Pharmacological methods Narcotics: Narcotics Morphine / pethidine / nalbuphine etc. Most common method Intra muscular (in the buttocks / arms) injections or intravenous injection (in a drip form or through an IV line) of analgesics and sedatives appear to have limited effect on labor pain , used mainly in earlier stages when the pain is not so intense. PowerPoint Presentation: can cause nausea and depress respiration in laboring women readily cross the placenta and can depress newborn breathing and affect behavior may be associated with addictive and self-destructive behaviors in the exposed child later in life (Bricker and Lavender 2000, a systematic review). Entonox: Entonox Oxygen and nitrous oxide mixture (50% each)-inhaled to get rid of pain Safe to both mother and baby, but not very effective, good amount of pain persists PowerPoint Presentation: Percentages of women using pain relief (based on the reports of the National Birthday Trust surveys) 1946 1958 1970 1984 1990 Chloroform 17 0 0 0 0 Nitrous oxide and air 16 56 2 0 0 Nitrous oxide and O 2 0 0 52 54 60 Trilene 0 25 7 0 0 Pethidine 0 56 69 36 37 Epidural or spinal 0 3 9 17 18 Non-drug pain relief 0 1 2 13 58 No pain relief 68 34 2 2 NR BMJ. 1999 April 3; 318(7188): 927–930. PowerPoint Presentation: Figure Percentage of women using nitrous oxide by distribution of numbers of labour units in Britain BMJ. 1999 April 3; 318(7188): 927–930. Nerve blocks: Nerve blocks A pudendal nerve block with lignocaine plus an infiltration of the perineum with local anaesthetic for low cavity, forceps, or vacuum extraction Regional techniques: Regional techniques 6 to 10 percent of mothers had no pain relief (analgesia) during labour in 2001, compared to 11 to 33 percent in 1992 An anesthesiologist was involved in 95 percent of cases Regional analgesia, including epidural, spinal or combined epidural-spinal techniques, accounted for 76 percent of the aesthesia services provided in the larger hospitals, and for 57 percent of services in the smaller hospitals (Source: Newswise) PowerPoint Presentation: First lady anaesthetised for labour in United States was Fanny Longfellow wife of famous American poet Henry Wadsworth Longfellow. She wrote- “This is certainly the greatest blessing of this age.” PowerPoint Presentation: Epidural analgesia blocks the pain carrying nerve impulses to the brain. As the concentration of the analgesic is controlled, contractions can be felt but pain not experienced In severe pain, adrenalin is released A relaxant effect in the uterus and it sometimes hastens delivery which may otherwise be prolonged due to severe pain PowerPoint Presentation: Differentiation of regional blocks (usually done by anaesthetist) and field blocks (commonly performed by obstetrician) BMJ. 1999 April 3; 318(7188): 927–930. PowerPoint Presentation: Percentage of women using various methods of pain relief and whether they found them helpful BMJ. 1999 April 3; 318(7188): 927–930. PowerPoint Presentation: Lack of proper set up (including training of doctors & para-medical staffs) Ignorance of expected mother and their family members Doctors and midwifery staffs should be more sympathetic to deal with the intense pain felt by expected mother Intrathecal narcotics: Intrathecal narcotics Subarachnoid morphine sulphate 1.5 mg abolished pain during the first stage of labour. Pain in the second stage was abolished in four patients and lessened in three During the early puerperium, pain at the site of the episiotomy was much reduced Side effects included itching of the face, nausea and vomiting, and frontal headache (P V Scott, F E Bowen, P Cartwright, B C Rao, D Deeley, H G Wotherspoon, I M Sumrein. Intrathecal morphine as sole analgesic during labour. Br Med J. 1980 August 2; 281(6236): 351–355.) PowerPoint Presentation: Percentage of women wishing to use epidural at next delivery BMJ. 1999 April 3; 318(7188): 927–930. General anaesthesia : General anaesthesia For caesarean sections about 30% of elective procedures, and 40% of emergency procedures in UK the risks of inhaling gastric contents and of airway problems In Pakistan, incidence varies widely from 12-82% PowerPoint Presentation: Questions & Comments?