1. Analgesia in Labour for Undergraduates Max Brinsmead MB BS PhD May 2015

2. This Talk Pain in Labour Pain in Labour –Who gets it and how bad –Pain & satisfaction with the birth experience –The role of endorphins Non – Pharmacological Options 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

3. This Talk (2) Pharmacological Options Pharmacological Options –Nitrous oxide by inhalation –Narcotics Advantages and Disadvantages Advantages and Disadvantages Choice of drug, dose and route Choice of drug, dose and route –Sterile Water by Injected Papule Anaesthetic Techniques Anaesthetic Techniques –Epidural Anaesthesia –Spinal (talk to an anaesthetist about this) –Paracervical Block (no longer practised) –Pudendal Block (talk to an obstetric registrar) –Perineal infiltration (not covered in this talk)

4. Pain in Labour 80 – 90% of women describe their pain in labour as “very severe” or “intolerable” 80 – 90% of women describe their pain in labour as “very severe” or “intolerable” Pain does not correlate with... 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 Satisfaction with “the birth experience” does not correlate either with the pain of labour or with satisfaction with analgesia

5. Pain in Labour (2) Patient’s rating of pain in labour and satisfaction with analgesia VARIES according to when they are studied: 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 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

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

7. Position in Labour Pain is greatest when the patient lies on her back Pain is greatest when the patient lies on her back Patients should be encouraged to adopt a position of comfort Patients should be encouraged to adopt a position of comfort There is evidence that remaining upright and mobile improves labour efficiency There is evidence that remaining upright and mobile improves labour efficiency

8. Breathing & Relaxation Limited studies show benefit Limited studies show benefit Harmless to mothers and babies Harmless to mothers and babies Provided that prolonged breath-holding is avoided Provided that prolonged breath-holding is avoided

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

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

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

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

13. Transcutaneous Electrical Nerve Stimulation (TENS) Has been studied in 10 RCTs Has been studied in 10 RCTs None showed any reduction in pain or use of further analgesia None showed any reduction in pain or use of further analgesia Some actually showed an increase in pain scores Some actually showed an increase in pain scores

14. Aromatherapy Has been studied in one RCT Has been studied in one RCT Found no effect on pain or the need for other analgesia Found no effect on pain or the need for other analgesia And no effect on the rate of spontaneous birth And no effect on the rate of spontaneous birth

15. Labouring in Water Studies consistently show that women who have access to water (bath or shower) resort to epidural anaesthesia less frequently 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... 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

16. Antenatal Education Reported pain in labour is influenced by a patient’s expectations 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... 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

17. Role of a Support Person Rates of spontaneous birth are possibly increased... Rates of spontaneous birth are possibly increased... –and length of labour is reduced by One to one care from an empathetic person One to one care from an empathetic person This can be provided by a female companion or “doula” 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 Whether this role can be taken by a patient’s male partner has not be confirmed

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

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

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

21. 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 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 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... 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 It is my view that no woman should be denied her FIRST dose of a narcotic at any stage in labour

22. Intrapartum Epidural Anaesthesia The most effective form of pain relief available The most effective form of pain relief available Modern agents that limit motor block and with the addition of a narcotic by continuous infusion gives the best results Modern agents that limit motor block and with the addition of a narcotic by continuous infusion gives the best results There is evidence that there is improved placental function (gas exchange and cord pH) There is evidence that there is improved placental function (gas exchange and cord pH) Reduces maternal blood pressure Reduces maternal blood pressure –Useful if the woman is pre eclamptic –Will reduce the risk of eclampsia

23. The Cons of Epidural Anaesthesia Requires a skilled anaesthetic service Requires a skilled anaesthetic service There are side effects and some risks There are side effects and some risks It lengthens the second stage of labour It lengthens the second stage of labour –And the need for assisted delivery –But should not increase the requirement for CS Reduces maternal mobility Reduces maternal mobility Requires IV access and fetal monitoring Requires IV access and fetal monitoring –Particularly when oxytocin augmentation is used

24. Side Effects & Risks of Epidural Anaesthesia Maternal hypotension Maternal hypotension Shivering Shivering Reduced capacity for mobilisation in labour Reduced capacity for mobilisation in labour Risk of dural puncture and severe headache about 1% Risk of dural puncture and severe headache about 1% –May require a “blood patch” Bladder function compromised Bladder function compromised –Catheter commonly required –May cause some incontinence for some weeks after Epidural haematoma, abscess & nerve damage very rare Epidural haematoma, abscess & nerve damage very rare Does NOT cause long-term backache Does NOT cause long-term backache