Define labor pain, non- pharmacological management, pain tolerance and endorphins Describe different non pharmacological strategies/methods used to manage discomfort during labor and delivery Identify advantages of non pharmacological management of discomfort during labor and delivery

1. Muhimbili University of Health & Allied
Sciences.
MW 603:01. ADVANCED INTRAPARTUM
AND POSTPARTUM
TOPIC: NON PHARMACOLOGICAL
MANAGEMENT OF DISCOMFORT DURING
LABOUR AND DELIVERY
PRESENTER: AURELIA TEMBA
FACILITATOR: DR AGNESS MASSAE
COORDINATOR: DR STELLAH MUSHY
DATE: 10/11/2023

2. Learning Objectives
At the end of this presentation participants will be able to;
Define labor pain, non- pharmacological management, pain tolerance
and endorphins
Describe different non pharmacological strategies/methods used to
manage discomfort during labor and delivery
Identify advantages of non pharmacological management of
discomfort during labor and delivery

3. CONT
 Outline barriers for provision of non pharmacological management in
our facilities
 Explain midwife's roles when providing non pharmacological
management during labor and delivery

4. INTRODUCTION
Labor pain often bring with anxiety and a host of other concerns for a
woman and her family .
The experience of labour is complex and subjective
Even if labour pain varies among individuals nearly 80% of pregnant
women worry labour pain during their pregnancy
Pain, anxiety and stress during labour and delivery cause an increase
release of catecholamine and cortisol used to regulate body’s stress
response

5. CONT
Pain, anxiety and stress during labour and delivery causes an increase
release of catecholamine and cortisol used to regulate body’s stress
response
Several factors affect a woman’s perception of labor making each
experience unique

6. CONT
Pain during labour is caused by;
• Contractions of the muscles of the uterus
• Stretching of the birth canal vaginal and uterine ligaments
• Pressure on the cervix ,bladder and bowels by babies presenting part

7. CONT
Factors affecting mothers response to labour pain are;
• Previous experiences with labour pain
• Cultural influences on expression of labour pain
• Support from care givers and family (pain management)
• Maternal fatigue anxiety and stress
• Preparation knowledge and confidence gained during ante natal period

8. CONT
WHO advocates labour pain management as a quality of care that
should be offered to all woman's during labour
 Labour pain may be worsened because of woman's tension anxiety
and fear
Non pharmacological management (NPM) approaches are largely
directed at increasing comfort ,enable the labouring woman to cope
with and preventing suffering without using of medication

9. CONT
NPM during labour and delivery strategies mostly used in our facilities
includes:
• Touching and massage
• Movement position changes
• Hydrotherapy
• Psychological Support

10. CONT
These strategies are used according to facility environment and
capacity
Midwives are the key players in provision of non pharmacological
management of discomfort during labour and delivery

11. CONT
Effective use of NPM to relief labour pain is believed to;
• Increase satisfaction
• Reduce anxiety, stress and fear among women during labour
• Ensure positive labour experience to women

12. DEFINITION OF TERMS
Labour pain is pain experienced as a result of uterine contraction
during child birth (Dictionary.com 2020)
Discomfort defined as a negative physical/emotional state causing
unpleasant feelings or sensations (Research gate.com 2022)
Pain tolerance refers to how much pain a person can reasonably
handle or maximum amount or level of pain a person can tolerate or
bear (Science direct.com 2021)

13. CONT
Non pharmacological management of discomfort during labour
and delivery refers to approaches used to increase comfort ,promote
rest, facilitate the woman's coping with the labour pain and to prevent
suffering without the use of medication ( Lowdermilk 2014)
 Endorphins are chemicals that the body naturally produces to cope
with pain ,stress or anxiety ( Medical News 2023)

14. Non pharmacological management of
comfort during labour and delivery
Breathing exercises
Massage and touching
Hypnosis
Aromatherapy
Audio analgesia
 Birthing ball

15. CONT
 Beverages
 Psychological support
Movement and position
Counter pressure
Hydrotherapy
Focus and distraction
Environmental condition

16. BREATHING EXERCISES
Women are instructed to take deep breathing during contractions and
after the contractions as well
Women are informed to inhale slowly through nose ( 6-7 seconds)
and exhale through mouth
Promote relaxation of the abdominal muscles by increase the size of
abdominal cavity
 It facilitate oxygen flow to the uterus and fetus
Provide sense of well being and control

17. CONT
It facilitate oxygen flow to the uterus and fetus
Provide sense of well being and control
Used to increase abdominal pressure and thereby assist in expelling
the fetus as well to relax the pelvic muscles to prevent precipitate
expulsion of the fetal

18. MASSAGE AND TOUCHING
Touch and massage have been an integral part of the traditional care
process for women in labor.
 Touch can be as simple as holding the woman’s hand or touching any
part of the body during contractions
 Touch is used to communicate caring, reassurance, and concern, it is
important that the woman’s preferences for touch
Women who perceive touch during labor as positive have less pain,
anxiety, and need for pain medication

19. CONT
Purposeful massage of the head, hand, back, and foot also
communicate caring
Massage is very effective in reducing tension and enhancing comfort
Receptors in the brain receive the sensation of pleasure from massage
blocking painful stimuli of labor
Combining massage with aromatherapy oil or lotion enhances
relaxation both during and between contractions

20. MASSAGE WOMAN IN LABOUR

21. APPLICATION OF HEAT
Application of heat includes warmed blankets, warm compresses,
heated rice bags, a warm bath or shower, or a moist heating pad can
enhance relaxation and reduce pain during labor.
Heat relieves muscle ischemia and increases blood flow to the area of
discomfort.
 Heat application is effective for back pain caused by a posterior
presentation or general backache from fatigue.

22. COLD APPLICATION
Cold application such as cold cloths, frozen gel packs, or ice packs
applied to the back, the chest, and/or the face during labor may be
effective in increasing comfort when the woman feels warm.
They also may be applied to areas of musculoskeletal pain.
 Cooling relieves pain by reducing the muscle temperature and
relieving muscle spasms

23. HYPNOSIS
Hypnosis is a state of deep mental and physical relaxation that enables
a person to focus intensely on thought or feeling, blocking outside
distractions
 Hypnosis techniques used for labor and birth place an emphasis on
enhancing relaxation and diminishing fear, anxiety, and perception of
pain.

24. CONT
Current evidence suggests that hypnosis seems to reduce fear, tension,
and pain during labor and to raise the pain threshold
 Women using this technique report a greater sense of control over
painful contractions and a higher level of satisfaction with their
childbirth experience

25. AROMATHERAPY
Aromatherapy uses oils distilled from plants, flowers, herbs, and trees
to promote health and to treat and balance the mind, body, and spirit.
Can be administered in variety ways like oil during massage, in hot
water as a bath or a drop in warm face cloth
 These essential oils are highly concentrated, and can be mixed with
lotions or creams before they are applied to the skin (e.g., for a back
massage).
Reduces stress and tension during labour, promote relaxation and
reduce pain and enhance the feeling of well being

26. AUDIO-ANALGESIA
Music, recorded or live, can provide a distraction, enhance relaxation,
and lift spirits during labor, thereby reducing the woman’s level of
stress, anxiety, and perception of pain.
It can be used to promote relaxation in early labor and to stimulate
movement as labor progresses.

27. CONT
Music can help to create a more relaxed atmosphere in the birth room,
leading to a more relaxed approach by health care providers .
Women should be encouraged to prepare their musical preferences in
advance .

28. BIRTHING BALL
Is a large exercise ball that woman in labor sit on to perfom
movement such as rocking and pelvic rotation
It is a newest pieces of birthing equipment
Sitting on the ball keeps the baby properly aligned in the pelvis
Encourages pelvic mobility
Help the baby the descent of the baby
Help the laboring woman to shift her weight, rock the pelvis and find
a comfortable positions to labor in more easily

29. BIRTHING BALL

30. BEVERAGES AND WATER
Labouring women are encouraged to stay well hydrated
Encourage them to drink enough water and liquid source diet like
juice ,hot tea, milk mtori or porridge according to the woman’s
preference
 Beverages acts as other source of energy during process of labour as
labour process takes a lot of energy similar to running a marathon

31. PSYCHOLOGICAL SUPPORT
Mostly used approach, done through:
• Providing information on labour process
• Counselling women on labour pain,
• Providing reassurance
• Providing good care and attention
• Support and consolation to mothers in labour including birth
companion

32. MOVEMENT AND POSITION CHANGES
Women during labour are encouraged to walk during labour
Labouring women tend to find upright positions most comfortable like
sitting standing and walking, others choose lying down position as
labour advances
 Upright position (walking, sitting, kneeling, or squatting) promote
the descent of the fetus caused by gravity force

33. CONT
Movement during labour help labour process by the simple effects of
gravity and change the shape of pelvis and allow the baby to move
During labour women should be educated on different delivery
position as women prefers according to facility environment

36. C0UNTER PRESSURE
Counter pressure is steady pressure applied by a support person to the
sacral area with a firm object (e.g., tennis ball) or the fist or heel of the
hand. Pressure can also be applied to both hips squeeze) or to the
knees .
Counter pressure lifts the occiput off these nerves, thereby providing
pain relief.

37. CONT
• It helps the woman cope with the sensations of internal pressure and
pain in the lower back , especially helpful when back pain is caused by
pressure of the occiput against spinal nerves when the fetal head is in a
posterior position.

38. HYDROTHERAPY
Bathing, showering, and jet hydrotherapy (whirlpool baths) with
warm water are non pharmacologic measures that can promote
comfort and relaxation during labor
The warm water stimulates the release of endorphins, relaxes fibers to
close the gate on pain, promotes better circulation and oxygenation
and helps to soften the perineal tissues.

39. CONT
It helps the woman cope with the sensations of internal pressure and
pain in the lower back , especially helpful when back pain is caused by
pressure of the occiput against spinal nerves when the fetal head is in a
posterior position.

40. FOCUS AND DISTRACTION
Rely on labourig woman’s ability to focus and uses mind diverting
activities
Inhibit release of stress hormone caused by fear and anxiety
Done by vision of a pleasant scene or visualizing what is actually
happening such as the cervical opening or baby is moving down
Distraction is done by using stimuli from the that will draw attention
away from your pain

41. ENVIRONMENTAL CONDITION
 Birth is affected by every sense in the body.
 By giving special attention to all the senses we can bring harmony to
the mother as a whole
For the visual sense, try dimming the lights or using candles to bring a
soft glow to the birth environment
Presence of privacy , good room temperature ,availability of bed
sheets pillows and running water has effects on labour process

42. CONTINOUS LABOUR SUPPORT (DOULA)
Also known as birth companion
Do not have any qualifications but a doula training course
They provide continuous support physically and emotionally
throughout child birth including reassurance, changing position
breathing massage and relaxation
Can help a woman during postpartum period
However its important to note that a doula is not a substitute for a
midwife since doula do not have any medical training

43. ADVANTAGES OF NON PHARMACOLOGICAL
MANAGEMENT
Cost effective
Non invasive
Promote women’s sense of control over pain
Safe with no or few side effects
Reduce analgesia consumption

44. CONT
Decreasing cesarean section
Increase satisfaction of care
Increase hospital delivery birth
Shortening labour process
Decrease number of birth asphyxia and trauma

45. EFFECTS OF NOT MANAGING LABOUR PAIN
Increase rate of anxiety and stress during labour
Decreased blood floor in uterus
Increase rate of cesarean section
Fetal hypoxia
Post traumatic disorder/syndrome
Prolonged labour

46. CONT
• Increase urinary and perineal trauma
• Vasoconstriction of uterine muscles

47. BARRIERS TO IMPLEMENT NON
PHARMACOLOGICAL MANAGEMENT
Women’s unwillingness
Lack of knowledge for some health care providers
Time constraints
Unsupportive facility environment
Midwives misconception about it ( not effective method)
Midwives unacceptance of the methods ( time consuming, excessive
workload)

48. SUMMARY
Labour pain is a universal concern for woman and women’s
experience of pain during labour varies greatly
Labour although a natural and physiological, but also psychological
challenge for most women
The most common emotional that accompany labour includes
excitement, fear, anxiety and uncertainty

49. CONT
Pain intensity increases with progression of labour ad depends on the
fetal size, passage through birth canal and maternal threshold levels of
pain
Addressing pain relief during labour and delivery is a way of
promoting a satisfactory birth experience by reducing stress anxiety
fear and a healthy reproductive outcome for women

50. CONT
Non pharmacological management of comfort during labour and
delivery are non invasive, cheap and simple
Midwives uses various non pharmacological methods to relieve labour
pain

51. CONT
Midwives uses various non pharmacological methods to relieve labour
pain, these include changing positions, deep mouth breathing exercises
providing psychological support and performing sacral massage
 Midwives reported some myths and fear that prevented the optimal
use of non pharmacological management approaches including
knowledge gap which shows the need the designing an intervention to
fill the gap

52. MIDWIVE’S ROLES IN PROVISION OF NON
PHARMACOLOGICAL MANAGEMENT
Be knowledgeable on different non pharmacological management of
discomfort strategies
Conduct assessment of woman in labour to exclude those with
complications
Educate the woman during labour and delivery advantages of using
them during labour process
Prepare conducive environment for labourig woman

53. CONT
Provision of non pharmacological management to labouring women
for positive labour outcome
Helping the mother to practice non pharmacological management
strategies as woman’s preference and availability at health facility

54. REFERENCES
Franser, D. M., Cooper, M.A., & Nolte A.G.W. (2014). Myles Text
Book for Midwives. 16th edition, London: Churchill Livingston
 DC DUTTA’S (2015) Textbook Of Obstetrics including
Perinatology and Contraception ,7TH revised edition
Lowdermilk P.C.A (2012) Maternity and Women Health care 10th
edition

55. CONT
Dorkas L. Mwakawanga ,Lillian T. Mselle,Nathanael Sirili. Use of
non pharmacological methods in managing labour pain ,experience
nurse-midwives in selected 2 district hospitals in eastern Tanzania,
2020
 https:/www.sciencedirect.com
https:/www.researchgate.com