Max Brinsmead MB BS PhD May 2015 Analgesia in Labour Max Brinsmead MB BS PhD May 2015

This Talk Pain in Labour Non – Pharmacological Options Who gets it and how bad Pain & satisfaction with the birth experience The role of endorphins Non – Pharmacological Options Position for labour Breathing and relaxation Massage and Touch Distraction and Music Acupuncture and Hypnosis Transcutaneous Electrical Nerve Stimulation (TENS) Other methods e.g. Aromatherapy Labouring in Water The role of antenatal education The role of a support person

This Talk (2) Anaesthetic Techniques (not considered) Pharmacological Options Nitrous oxide by inhalation Narcotics Advantages and Disadvantages Choice of drug, dose and route Sterile Water by Injected Papule Anaesthetic Techniques (not considered) Epidural and Caudal Spinal Paracervical Block Pudendal Block Perineal infiltration

Pain in Labour 80 – 90% of women describe their pain in labour as “very severe” or “intolerable” Pain does not correlate with... Age Education Social class Satisfaction with “the birth experience” does not correlate either with the pain of labour or with satisfaction with analgesia Only 60% of women are “moderately satisfied” with their analgesia and 20% still rate their pain as “severe”

Pain in Labour (2) Patient’s rating of pain in labour and satisfaction with analgesia VARIES according to when they are studied: In labour Immediately postpartum Several weeks postpartum This is due to the amnesic effects of labour and is presumably mediated by endorphins “Nature’s opiates” Which are elevated by pregnancy and... Highest in labour

Pain in Labour (3) Patient’s reaction to the pain of labour will vary according to her expectations Personal Cultural The continuum ranges from... “No woman needs to suffer” Therefore it is our role to remove it completely To... It is “natural” or “ordained” And a “part of the experience” Most women are somewhere in between so your role is to establish rapport and find out where they are

Pain in Labour (4) Because a sense of control is important In providing analgesia carers of labouring women need to... Examine their own beliefs and values Respect a patient’s right to choose Because a sense of control is important And what correlates with satisfaction with labour is the attitude and support provided by the carer

Position in Labour Pain is greatest when the patient lies on her back Patients should be encouraged to adopt a position of comfort There is evidence that remaining upright and mobile improves labour efficiency Mobility may be encouraged by the use of Birth Balls... But RCTs have not been done

Breathing & Relaxation Limited studies show benefit Harmless to mothers and babies Provided that prolonged breath-holding is avoided So patients who wish to use this should be supported

Massage & Therapeutic Touch Has been studied by RCT Shown to reduce the pain of labour Reduces anxiety and stress And resulted in better mood and less postnatal depression in one study

Distraction & Music Has been studied by one RCT Reduces both the pain and distress from pain Harmless to mothers and babies

Acupuncture and Acupressure Has been studied in 4 RCTs Reduces the need for pharmacological pain relief and epidural anaesthesia Reduces the need for augmentation of contractions But not the rate of spontaneous birth

Hypnosis Has been studied in 5 RCTs Reduces the need for pharmacological pain relief And the need for augmentation of contractions

Transcutaneous Electrical Nerve Stimulation (TENS) Has been studied in 10 RCTs None showed any reduction in pain or use of further analgesia Some actually showed an increase in pain scores So this method should not be offered But I allow TENS by patients who wish to do so

Aromatherapy Has been studied in one RCT Found no effect on pain or the need for other analgesia And no effect on the rate of spontaneous birth But I allow aromatherapy by patients who wish to do so

Labouring in Water Studies consistently show that women who have access to water (bath or shower) resort to epidural anaesthesia less frequently Please note that this does not mean “water births” Does not affect any other outcome... Length of labour Rate of SVD Infant outcomes (Apgars etc) Maternal trauma (to the perineum) Infant or maternal infection But keep temperature <37.50 C And keep it clean

Antenatal Education Reported pain in labour is influenced by a patient’s expectations So preparation for childbirth is one important component of antenatal care However antenatal education does not influence... The use of analgesia in labour Length of labour Rate of SVD, assisted birth & need for Caesarean Infant outcomes (Apgars etc) Any measure of maternal outcome With the exception of satisfaction if the education is provided by the same person who provides intrapartum care

Role of a Support Person Rates of spontaneous birth are possibly increased... and length of labour is reduced by One to one care from an empathetic person This can be provided by a female companion or “doula” Whether this role can be taken by a patient’s male partner has not be confirmed But it is a shame if his only role at a birth is to protect his wife from uncaring midwives!

Nitrous Oxide by Inhalation (Entonox) Is a weak analgesic agent That “takes the edge off” the pain of labour Rapidly effective and rapidly excreted Can be used anywhere (including in water) Has no effect on the progress of labour Causes dizziness/light headedness in 5 – 36% Success in its use is all about timing And this requires a little practice NICE recommends that Entonox be available to all labouring women

Narcotic Analgesics Intensively used and studied for >50 years But there are only a few placebo-controlled RCTs Is a relatively poor analgesic agent when compared to epidural anaesthesia Causes nausea and drowsiness in women This can interfere with her ability to cooperate in the 2nd stage of labour Should always be administered with an anti emetic drug Which actually enhances its analgesic effects The main problem is its potential to cause respiratory depression in the neonate And a reluctance to feed which can last several days

Neonatal Depression from Narcotics Depends on maternal metabolism of the drug And this varies from woman to woman But the effect is “dose related” and... Because the breakdown metabolites of Pethidine are also a respiratory depressant in the neonate The greatest potential for harm comes from repeated doses Whilst the effect can be totally reversed by Naloxone... This drug is often misused in neonatal resuscitation & has not been shown to be effective by RCT

Neonatal Depression from Narcotics (2) Because early studies suggested that the transplacental passage of narcotics is greatest in the first 2 hours after maternal administration Most midwifery and obstetric texts counsel against their use if delivery is expected within 2 hours However, because of the wide individual variation in metabolism... It is my view that no woman should be denied her FIRST dose of a narcotic at any stage in labour But beware of the mother who goes to sleep when she should be pushing!

Narcotic Analgesia Choice of Agent, Dose & Route of Administration There are a large number of studies available Some suggest small advantages for Diamorphine & Meptazinol over Pethidine But the best outcomes are achieved by the PCA administration of an intravenously administered short-acting narcotic e.g. Remifentanil Where such resources are not possible... There is quite a lot to be said for the use of Pethidine 50 mg IV and 50 mg IM Provided the IM injection is not into subcutaneous fat Upper arm is recommended over lower limb Why do the ED docs always use SC morphine?

Sterile Water by Injection The intradermal injection of 0.1 ml of sterile water into 1 – 4 sites of lumbosacral skin has been shown by RCT to reduce back ache in labour by up to 60% for up to 2 hrs Causes a “bee sting” like pain Presumably works by “inhibitory gate control” Useful for the patient with an OP When an epidural is not possible Not endorsed by NICE

Sterile Water by Injected Papules

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