Non-Pharmacological Relief Measures in Labor Dr. Bethany Brown, DNP, CNM,WHNP, EFM-C, Sexual Health counselor/Educator

Non-Pharmacological Measures Counter pressure Effleurage (light circular massage) Massage Walking, rocking, movement-frequent position changes! Heat/cold TENS Acupressure Water therapy Intradermal water injections Aromatherapy Breathing techniques Music Imagery Hypnosis biofeedback

Summary of the Evidence Most non-pharmacological methods of pain management are non-invasive, appear to provide benefits, and are safe to the mother and baby In future trials, usual care needs to be more clearly defined and relevant outcomes such as measures of pain need to be assessed. Providers need to gain expertise in the use of non-pharmacological pain relief techniques and integrate into practice and hospital settings. Non-pharmacological relief measures help women cope with labor better, especially psychosocially. Chaillet, N., Belaid, L., Crochetiere, C. et al. Non-pharmacological approaches for pain management during labour compared to usual care: a meta-analysis. Birth 2014. 41, 122-137.

Sterile Water Injections

Pushing Positions with Epidural Squat Towel/Sheet Pull All 4’s (in various ways) https://youtu.be/j_qU6QL3NO0 Another Labor position video to share with patients: https://youtu.be/heswj-Hw5TU http://www.babycenter.com/2_positions-to-ease-labor-pain_3656514.bc

Summary of the Evidence Women should choose from a variety of positions in which to labor and push in, but supine and lithotomy should not be used. Delayed pushing for women with epidurals, especially when the fetal position is high or not anterior, increases the chance of having a spontaneous vaginal birth Directing women when and how to push should be considered an intervention to be used only when indicated because spontaneous pushing is usually safer for the mother and fetus. Kopas, M.L. (2014). A Review of Evidence-Based Management of Second Stage Labor. Journal of Midwifery & Women’s Health, 59(3), 264-276.

Summary of the Evidence Incidence and severity of perineal trauma may be reduced by warm perineal compress, gentle massage, and slow crowning of fetal head. It is unclear whether time limits to duration of second stage of labor improve outcomes, but it is reasonable to consider operative birth when birth is not imminent after a nulliparous women has been pushing longer than 2 hours or has complete dilation for more than 4 hours, or after a multiparous women has been pushing longer than one hour or has complete dilation for more than 2 hours. Kopas, M.L. (2014). A Review of Evidence-Based Management of Second Stage Labor. Journal of Midwifery & Women’s Health, 59(3), 264-276.

#1 pain relief in labor MOVEMENT (even with a epidural!) Is shorter labor and distraction which is accomplished through= MOVEMENT (even with a epidural!)

References American College of Obstetricians and Gynecologists (the College) and the Society for Maternal-Fetal Medicine, Caughey AB,Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014;210(3):179-193. Bleich AT, Alexander JM, McIntire DD, Leveno KJ. An analysis of second-stage labor beyond 3 hours in nulliparous women. Am J Perinatol. 2012;29(9):717-72 Chaillet, N., Belaid, L., Crochetiere, C. et al. Non-pharmacological approaches for pain management during labour compared to usual care: a meta-analysis. Birth 2014. 41, 122-137. Fraser WD, Marcoux S, Krauss I, Douglas J, Goulet C, Boulvain M. Multicenter, randomized, controlled trial of delayed pushing for nulliparous women in the second stage of labor with continuous epidural analgesia. The PEOPLE (Pushing Early or Pushing Late with Epidural) Study Group. Am J Obstet Gynecol. 2000;182(5):1165-1172. Gillesby E, Burns S, Dempsey A, Kirby S, Mogensen K, Naylor K, Petrella J, Vanicelli R, Whelan B. Comparison of delayed versus immediate pushing during second stage of labor for nulliparous women with epidural anesthesia. J Obstet Gynecol Neonatal Nurs.2010;39(6):635-644. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2012;5:CD002006 Hals E, Oian P, Pirhonen T, et al. A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstet Gynecol. 2010;116(4):901-908. Kemp E, Kingswood CJ, Kibuka M, Thornton JG. Position in the second stage of labour for women with epidural anaesthesia.Cochrane Database Syst Rev. 2013;1:CD008070.  Kopas, Mary Lou. A review of evidenced-based practices for management of the second stage. Journal of Midwifery & Women's Health, 2014. (59) 3. Osborne K, Hanson L. Directive versus supportive approaches used by midwives when providing care during the second stage of labor. J Midwifery Women's Health. 2011;57(1):3-11 Priddis H, Dahlen H, Schmied V. What are the facilitators, inhibitors, and implications of birth positioning? A review of the literature.Women Birth. 2012;25:100–106 Ramphul M, Kennelly M, Murphy DJ. Establishing the accuracy and acceptability of abdominal ultrasound to define the foetal head position in the second stage of labour: A validation study. Eur J Obstet Gynecol Reprod Biol. 2012;164(1):35-39. Roberts J, Hanson L. Best practices in second stage labor care: Maternal bearing down and positioning. J Midwifery Womens Health. 2007;52(3):238-245