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Intrapartum Care: Managing pain during labour

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Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters …

Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. Monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning

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  • 1. 6 Managing pain during labourBefore you begin this unit, please take the Analgesics must not be confused withcorresponding test at the end of the book to sedatives which do not relieve pain but onlyassess your knowledge of the subject matter. You make the patient drowsy.should redo the test after you’ve worked throughthe unit, to evaluate what you have learned 6-2 What is anaesthesia? Anaesthesia means the loss of all sensation, Objectives including pain. Local anaesthesia causes the loss of all sensation in that region of the body. With general anaesthesia the patient loses When you have completed this unit you consciousness. should be able to: • Explain the differences between 6-3 What causes pain during labour? analgesia, anaesthesia and sedation. Pain in labour is caused by: • List the causes of pain in labour. 1. Contractions: They progressively increase • List which drugs can be given during in duration and frequency during the first labour for analgesia. stage of labour and, therefore, become • Ensure that a patient has adequate pain more painful. Contractions are most relief during labour. painful when the cervix is fully dilated and • List the dangers of the drugs which can the patient has an urge to bear down. At first the pain is felt over the abdomen but be used for pain relief. later, when the cervix is nearly fully dilated, • Prepare a patient for general pain is felt in the lower back. anaesthesia. 2. Cervical dilatation: This is due to uterine contractions and pressure of the presenting part on the cervix.PAIN RELIEF IN LABOUR 3. Vaginal examinations and procedures: Any vaginal examination is uncomfortable and for many patients is6-1 What is analgesia? also painful. This is particularly so when a forceps delivery, a vacuum extraction orAnalgesia means the relief of pain. Drugs an episiotomy is performed.used to relieve pain are called analgesics.
  • 2. 106 INTRAPAR TUM CAREThe amount of pain experienced by patients A calm, considerate and caring attitude fromin labour is very variable. Some patients have those who are attending the patient in labourlittle pain, while others have severe pain, even is important. Thorough but gentle clinicalduring early labour. examinations, rubbing the patient’s back and talking to her all do much to relieve the stress6-4 What will make the pain worse? of labour and to some extent the pain.Anxiety, fear and uncertainty lower the pain Most patients find it helpful to have someonethreshold. This is particularly noticeable with them during labour. A lay person or doulain primigravid patients, especially if they can fulfill this role perfectly well. A patientare very young. Pain increases the patient’s should be encouraged to have her husband,anxiety, which in turn reduces her ability to a family member or someone else that shetolerate pain. knows well to stay with her during labour.6-5 What general or non pharmacological Antenatal preparation and emotional supportmeasures will contribute to are important in reducing anxiety and painreduce pain during labour? during labour.1. Knowledge of what to expect during labour. This important information should NOTE Rubbing a patient’s lower back is of great be provided during antenatal visits to help as the nerve impulses that come from patients that will be experiencing labour the skin over the lower back travel to the same for the first time. spinal segments as the nerve impulses from2. A pleasant environment and the support the cervix and uterus. The nerve impulses from the lower back, therefore, partially block those and encouragement of those who are from the uterus and cervix. As a result, the pain attending to the patient. of contractions is experienced as less painful3. The help and support of a family member, by the patient if the lower back is rubbed. partner, friend or doula is of great value.4. Allowing patients to walk around during labour. USE OF ANALGESICS6-6 Why are the environment and IN LABOURemotional support importantto a patient in labour? 6-7 Why do you need to give aA patient should be prepared for her labour patient analgesia during labour?during the antenatal period. Primigravidasmust be told in simple terms what is going to 1. As health workers, one of our primaryhappen during labour. Relaxation exercises responsibilities is to relieve pain andand breathing methods can help patients suffering. All too often pain duringprepare for labour, and should be taught as labour is regarded as part of a normalpart of antenatal care. process. Therefore, during labour patients should frequently be asked whether theyDuring labour, particularly during the latent need pain relief. If required, the mostphase and early in the active phase of the first appropriate and effective form of analgesiastage, patients may be encouraged to walk available must be given.around and not spend all the time in bed in 2. The relief of pain often allows labour tothe labour ward. This reduces the amount progress more rapidly by reducing theof pain experienced during contractions. In anxiety which is caused by pain. It isaddition contractions will be more effectiveresulting in labour progressing faster.
  • 3. MANAGING PAIN DURING LABOUR 107 well known that anxiety may cause poor • Opiates, e.g. pethidine. progress during labour. • Inhalational analgesia, i.e. nitrous oxide with oxygen. • Local anaesthesia. The relief of pain is very important and must • Epidural anaesthesia. receive careful attention when a patient is cared • General anaesthesia. for during labour. 6-11 Which analgesic drug is commonly6-8 Should all patients in used in the first stage of labour?labour receive analgesia? Pethidine. This drug is a powerful analgesic butNo. Some patients have little pain in labour commonly causes nausea and vomiting as a sideand, therefore, may not need an analgesic. effect. Pethidine also produces some sedation.Other patients feel that they are able totolerate the pain of uterine contractions, e.g. 6-12 What drug is often givenby concentrating on their breathing, and together with pethidine?choose not to have analgesia. It is importantto consider the patient’s wishes when deciding Promethazine (Phenegan) or hydroxyzinewhether or not to give analgesia. However, (Aterax). They combine well with pethidinemost patients do need analgesia during labour. for three reasons: 1. They have a tranquillising effect which6-9 When do you give analgesia makes the patient feel more relaxed.to a patient in labour? 2. They have an anti-emetic effect, reducing the nausea and vomiting due to pethidine.1. In the first stage of labour: 3. They increase the analgesic effect of • When patients ask for pain relief. pethidine. • When patients experience painful uterine contractions during a normal The dose of promethazine is 25 mg and labour. hydroxyzine is 100 mg, irrespective of the • When patients have painful amount of pethidine given. contractions and in addition require oxytocin stimulation of labour. 6-13 What are the actions of pethidine? • When patients have painful It is a powerful analgesic but causes depression contractions with slow progress during of the central nervous system. Large doses can, the active phase of the first stage of therefore, cause respiratory depression. A drop labour, e.g. with an occipito-posterior in blood pressure may also occur. Pethidine position. crosses the placenta and can cause respiratory2. In the second stage of labour: depression in the newborn infant who may, • When an episiotomy is done. therefore, need resuscitation at birth. • When an instrumental delivery is done.3. In the third stage of labour: Morphine, which is less commonly used, has • When an episiotomy or perineal tear is similar actions and side effects to pethidine. repaired. Pethidine and morphine may temporarily affect the cardiotocogram with the fetal heart rate6-10 What methods of providing tracing showing loss of beat-to-beat variation.analgesia can you use?1. General measures as mentioned in sections An overdose of pethidine may cause respiratory 6-5 and 6-6 above. depression in both the mother and her infant.2. Specific methods:
  • 4. 108 INTRAPAR TUM CARE6-14 How is pethidine usually given and 6-17 How often may pethidinehow long is its duration of action? be given in labour?1. The intramuscular route: If an adequate dose of intramuscular pethidine • This is the commonest method of is given, it is usually not necessary to repeat giving pethidine, especially with a the drug within four hours. (In South Africa cervical dilatation of less than 7 cm. registered nurses are allowed by law to give • Pain relief will be experienced about 30 100 mg pethidine by intramuscular injection minutes after administration and the during labour, without a doctor’s prescription, duration of action will be about four and to repeat the injection after an interval of hours, although this varies from patient four hours or more.) to patient.2. The intravenous route: • This method may be used if the patient NALOXONE requires analgesia urgently and the cervix is already 7 cm or more dilated. • Pain relief is experienced within five 6-18 How should you treat minutes and the duration of action will respiratory depression due to be about two hours. pethidine in a newborn infant? Naloxone (Narcan) is a specific antidote to6-15 What dose of pethidine pethidine (and morphine) and will reverse theshould be given? effects of the drug.1. The intramuscular route: Two mg per kg If a patient was given pethidine during body weight. Therefore, 100 to 150 mg is labour, and delivers an infant who does not usually given. Patients weighing less than breathe well after birth, the infant should be 50 kg must receive 75 mg. given naloxone (Narcan). The correct dose of2. The intravenous route: One mg per kg Narcan is 0.1 mg/kg (i.e. 0.25ml/kg). A 1 ml body weight. Therefore, 50 to 75 mg is ampoule contains 0.4 mg naloxone. Therefore, usually given. Obese patients weighing an average sized infant requires 0.75 ml while more than 75 kg must not receive more a large infant up to 1 ml naloxone. Do not than 75 mg. An intravenous infusion must give naloxone to asphyxiated infants whose first be started before the drug is given. mothers have not received pethidine (or morphine). Naloxone will not reverse the6-16 How close to full dilatation respiratory depression caused by barbituratesmay pethidine be given? (e.g. phenobarbitone), benzodiazepines (e.g.There is no limit to how late in labour Valium) or a general anaesthetic.pethidine can be given. If the patient needs Research has shown that the previouslyanalgesia she should be given the appropriate recommended dose (0.01 mg/kg) of Neonataldose. However, if she receives pethidine within Narcan is tenfold too low. The use of Neonatalsix hours of delivery, the infant may have Narcan must, therefore, be stopped andrespiratory depression at birth. replaced with adult Narcan. Pethidine may be given late in labour if needed. Infants who do not breathe well after delivery should only receive naloxone if their mothers were given pethidine or morphine during labour.
  • 5. MANAGING PAIN DURING LABOUR 1096-19 How should naloxone be given? INHALATIONALUsually naloxone is given to a newborn ANALGESIAinfant by intramuscular injection into theanterolateral aspect of the thigh. The drug willreverse the effects of pethidine. Meanwhile, it 6-22 What inhalationalis important to continue ventilating the infant. analgesia is available?Naloxone can also be given intravenously.The drug acts more rapidly when given The most commonly used inhalationalintravenously, e.g. into the umbilical vein. analgesic is Entonox. This is a mixture of 50% nitrous oxide and 50% oxygen. It is usually supplied in cylinders and is breathed in by6-20 Is a single dose of naloxone adequate? the patient through a mask when she needsYes. A single dose of naloxone is almost always pain relief.adequate to reverse the respiratory depression The advantages of Entonox are:caused by pethidine. The action lasts about30 minutes. Some infants may become 1. It is safe for mother and fetus.lethargic after 30 minutes and may then 2. It is short acting.require a second dose of naloxone. 3. It acts quickly. The disadvantages of Entonox are:SEDATION IN LABOUR 1. It is expensive. 2. It requires special apparatus for administration.6-21 Are sedatives useful in labour? 3. It is not always effective because the patient needs to start inhaling the gas as soon asIn practice there are very few indications the contraction starts for the analgesicfor the use of sedatives in labour. If a effect to be present during the peak ofpatient is restless or distressed, it is almost the contraction. Many patients start thealways because of pain and she, therefore, inhalation too late.needs analgesia. The tranquillising effect of 4. Patients often hyperventilate and get ‘pinspromethazine (Phenegan) or hydroxyzine and needles’ in their face and hands.(Aterax) together with pethidine will providesufficient sedation for a restless patient. The 6-23 Which patients shoulddose is 25 mg promethazine (Phenegan) and preferably use entonox?100 mg hydroxyzine (Aterax). A patient requiring analgesia for the first timeThere is no role for sedation with diazepam in advanced labour, where the delivery is(Valium) and barbiturates. Sedatives may expected within an hour.also cross the placenta and sedate theinfant. Diazepam (Valium) can cause severerespiratory depression in the infant and this 6-24 Does entonox have anyeffect is not reversed by naloxone. serious side effects? No. Entonox is completely safe and cannot be used in excessive doses. Entonox is a completely safe analgesic.
  • 6. 110 INTRAPAR TUM CARELOCAL ANAESTHESIA 6-28 What is the duration of action of lignocaine? Lignocaine results in loss of sensation in the6-25 What is a local anaesthetic? infiltrated area for 45 minutes. If the maximumLocal anaesthetics are drugs which are injected dose has already been given but more localinto the tissues and which result in a loss anaesthetic is required, a further 10 ml of 1%of all sensation in the injected area. Local lignocaine may be given after 30 minutes.anaesthetics often give a burning sensationwhich lasts one to two minutes while they arebeing injected. The patient should be warned EPIDURAL ANAESTHESIAabout this before starting the injection.Lignocaine (Xylocaine) is the local anaesthetic 6-29 What are the indicationsused most commonly. Although available in for epidural anaesthesia?different concentrations it is best to only usethe 1% solution. The possibility of giving an 1. When there is poor progress during theoverdose will then be reduced. active phase of the first stage of labour, e.g. due to an occipito-posterior position.6-26 When should you use 2. When ineffective uterine contractions area local anaesthetic? present, prior to starting oxytocin. 3. When it is important to prevent bearingThere are two main indications for local down before a patient’s cervix is fullyanaesthesia in labour: dilated, e.g. with a preterm infant or a1. When performing an episiotomy, or when breech presentation. repairing an episiotomy or perineal tear. 4. Caesarean sections may also be done under2. When performing a pudendal block. The epidural anaesthesia. local anaesthetic acts on the pudendal This is the ideal form of local anaesthesia nerves, and is usually given before an as it offers the patient complete pain relief. instrumental delivery. Unfortunately special training and equipment are necessary for giving epidural anaesthesia6-27 What are the risks of and, therefore, it is only available in most levellocal anaesthesia? 2 and 3 hospitals.1. Too much local anaesthetic is dangerous and may cause convulsions. The 6-30 What special nursing care is required maximum dose of a 1% solution of following an epidural anaesthetic? lignocaine (Xylocaine) for a patient of 1. There is a danger of hypotension following average size is 20 ml. the administration of the first and each2. A local anaesthetic can cause convulsions if further dose of the local anaesthetic. The it is injected into a vein in error. blood pressure must be taken every fiveThe maximum safe dose of lignocaine minutes for 30 minutes following eachis 3 mg/kg body weight. One ml of a 1% dose of the local anaesthetic.lignocaine solution contains 10 mg lignocaine. 2. Depending on the amount of anaesthesia achieved, patients often cannot pass urine. A Foley’s catheter is, therefore, often An overdose, or intravenous injection, of a local required until the effect of the anaesthesia anaesthetic may cause convulsions. wears off.
  • 7. MANAGING PAIN DURING LABOUR 111GENERAL ANAESTHESIA which contain particles that can cause a chemical pneumonitis if the drug is aspirated.6-31 What are the dangers for apregnant or postpartum patient when CASE STUDY 1receiving a general anaesthetic?Any pregnant or postpartum patient who A patient and her husband present at thereceives a general anaesthetic has a very high maternity hospital. She is 26 years old, gravidarisk of vomiting and aspirating stomach 2 para 1 and at term. Her antenatal course hascontents because: been normal and her routine observations on admission are also normal. The fetal1. Stomach emptying is delayed. presentation is cephalic with 2/5 of the fetal2. The tone of the sphincter in the lower head palpable above the pelvic brim. The oesophagus is reduced. membranes rupture spontaneously and her3. The intra-abdominal pressure is increased. cervix is found to be 5 cm dilated on vaginalPatients who have been starved must be examination. The patient is relaxed and doesmanaged in the same way as patients who have not find her contractions painful. She isrecently eaten. During a general anaesthesic, admitted to the labour ward and given 100 mgthe risk of the patient vomiting is particularly pethidine and 100 mg hydroxyzine (Aterax)high during intubation and extubation. by intramuscular injection as she is already in the active phase of the first stage of labour. Her husband is asked to wait outside the6-32 What precautions must be labour ward. It is suggested that he go hometaken preoperatively that will for a while as the infant is unlikely to be bornreduce the dangers of vomiting? during the next five or six hours.1. A patient who may require a general anaesthetic should be kept nil per mouth 1. Has the patient been correctly managed? (i.e. she should be starved).2. Metoclopramide (Maxalon) 20 mg (two No. She did not require analgesia. Not all ampoules) should be given intravenously patients need analgesia during labour. Some 15 minutes before the induction of general patients experience little pain during labour anaesthesia. Metoclopramide is an anti- while others handle the pain of contractions emetic (prevents vomiting), it speeds up with no difficulty. emptying of the stomach and it increases the tone of the lower oesophagus. The drug 2. What would have been the correct acts for about two hours. management of this patient?3. The gastric acid must be neutralised by The patient should have been reassured that an antacid before the induction of general her labour was progressing normally. She anaesthesia. Usually 30 ml of a 0.3 molar should have been encouraged to walk about solution of sodium citrate is given. If and not spend all the time in bed. Analgesia induction of anaesthesia is not started need not be given routinely to all patients in within 30 minutes of the sodium citrate active labour. being given, the 30 ml dose should be repeated. 3. Do you agree with the handlingSodium citrate is cheap and can be made up of the patient’s husband?by any pharmacist. It is an electrolyte solutionand, therefore, preferable to other antacids No. Most patients prefer to have someone they know well remain with them during labour. Her
  • 8. 112 INTRAPAR TUM CAREhusband should have been encouraged to stay very painful while the pain in turn makes herwith her if that was what the patient wanted. even more anxious.4. What should the husband do if he 2. What should have been donestays with his wife during labour? during the antenatal period to avoid the present situation?Simply being there is reassuring to thepatient. He can help to keep her relaxed and Receiving good information about thecomfortable. Furthermore, he can be shown process of labour at antenatal visits, attendinghow to rub her back during contractions. antenatal exercise classes and visiting the labour ward during the last weeks of5. Is it of any value to rub a patient’s pregnancy would have resulted in a far moreback during contractions, or is it relaxed patient in labour.only an ‘old wife’s tale’ that has noplace in modern midwifery? 3. What should have been done in the labour ward to reduce her anxiety?Rubbing a patient’s lower back is of great helpas the nerve impulses that come from the skin She should have experienced a pleasantover the lower back travel to the same spinal atmosphere in the labour ward withsegments as the nerve impulses from the cervix understanding and encouragement from theand uterus. The nerve impulses from the lower staff. They should have reassured her thatback, therefore, partially block those from everything was under control and that therethe uterus and cervix. As a result, the pain of was no reason for her to be frightened. Thecontractions is experienced as less painful by staff themselves should appear confident,the patient if the lower back is rubbed. relaxed and caring. It is important that a family member or friend of the patient’s remain with her.CASE STUDY 2 4. Should the doctor prescribe 10 mgA 16-year-old patient presents in labour at of intravenous diazepam (Valium)term after a normal pregnancy. She is very because the patient is unmanageable?anxious, does not co-operate with the labour No. Sedatives, especially diazepam, should beward staff and complains of unbearable pain used very rarely because they may result induring contractions. She bears down with severe respiratory depression in the infant atevery contraction even though the cervix is birth. This complication is not reversed by theonly 4 cm dilated. The patient is told to behave commonly available drugs at delivery.herself. She is informed that the worst partof labour is still to come and is scolded for 5. What would have been the correctbecoming pregnant. As she is a primigravida, management of labour for thisshe is promised analgesia when her cervix patient, beside reassurance?reaches 6 cm dilatation. She should have been encouraged to1. Why is the patient frightened? concentrate on her breathing during contractions. In addition she should have beenBecause she is unprepared for labour and given adequate analgesia as soon as possible.does not know what to expect. In addition,she is in a strange environment and the staffare unfriendly and aggressive. Being anxiousresults in her experiencing her contractions as
  • 9. MANAGING PAIN DURING LABOUR 1136. What form of analgesia should 4. What would be the best route ofhave been given to this patient? administering the pethidine to this patient?The ideal form of analgesia for this patient The pethidine should preferably be givenwould have been an epidural anaesthetic as intravenously. Pain relief will then be obtainedit provides complete pain relief. Alternatively in five minutes and the effect of the drugshe should have been given pethidine and should last two hours.promethazine (Phenegan) or hydroxyzine(Aterax) by intramuscular injection. The 5. The infant is delivered 45 minutestranquillising effect of promethazine or after the pethidine is given. Whathydroxyzine would have helped to lessen her complication of the drug may beanxiety. present in the infant at delivery? The infant may have respiratory depression andCASE STUDY 3 as a result may not breathe adequately at birth. 6. How should the infant be managedCervical dilatation in a multigravid patient if the breathing is inadequatein labour at term progresses from 3 cm to (i.e. the infant has asphyxia)?8 cm in four hours. Now for the first timeshe complains that her contractions are very The infant must be resuscitated with artificialpainful. The doctor informs the midwife that respiration provided via a face mask orshe is progressing fast and that her cervix will endotracheal tube. Naloxone (Narcan) cansoon be fully dilated. He adds that the patient be given to the infant to reverse the effect ofmust just continue without analgesia for the the pethidine. Naloxone is usually given bylast two hours as the delivery will soon be over. intramuscular injection. However, it acts more rapidly if it is given into the umbilical vein.1. Do you agree with thepatient’s management?No. The patient needs analgesia and the most CASE STUDY 4appropriate form of analgesia should beoffered to her. A multigravid patient, who has had two previous Caesarean sections, is booked for an elective Caesarean section under2. What would be the best form of general anaesthesia at 39 weeks gestation.analgesia to offer this patient? The patient is admitted to hospital at 07:00,Entonox (nitrous oxide with oxygen) as it having had nothing to eat since midnight.works rapidly and is completely safe. She also She is prepared for surgery at 08:00. As theonly needs analgesia for a short time as her patient has been kept ‘nil by mouth’ no drugcervix will soon be fully dilated. to prevent vomiting during intubation and extubation is given. Only an intravenous3. If Entonox is not available or if infusion is started and a Foley’s catheterthe patient is unable to use Entonox passed before she is moved to theatre.correctly, what other form ofanalgesia should be considered? 1. Do you agree that a drug to prevent vomiting is not needed as the patient hasPethidine and promethazine (Phenegan) or had nothing to eat or drink for eight hours?hydroxyzine (Aterax). No. All pregnant patients are at risk of vomiting during general anaesthesia even if
  • 10. 114 INTRAPAR TUM CAREthey have taken nothing by mouth during the anaesthesia. It is an anti-emetic, it increasespast few hours. the stomach emptying time and raises the sphincter tone of the lower oesophagus. These2. Why should a pregnant patient who effects will reduce the danger of vomiting. Anhas not eaten overnight still be at risk of antacid should also be given before the generalvomiting during a general anaesthetic? anaesthetic. The drug of choice is 30 ml of a 0.3 molar solution of sodium citrate.Because her stomach has a delayed emptyingtime, the lower oesophageal tone is reduced 4. Both these drugs are given at 07:45.and she has a raised intra-abdominal pressure. However, due to a delay, the patient is only taken to theatre at 08:30. Is it3. What preventative measures should have necessary to repeat either of these drugs?been carried out during the pre-operativepreparation of the patient for theatre? The metoclopramide (Maxalon) acts for two hours so need not be repeated. However, theMetoclopramide (Maxalon) 20 mg (two sodium citrate acts for only 30 minutes and,ampoules) must be given intravenously therefore, must be repeated before the start of15 minutes before the induction of the anaesthetic.