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Maternal Care: Managing pain during labour


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Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

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Maternal Care: Managing pain during labour

  1. 1. 10 Managing pain during labourBefore you begin this unit, please take the PAIN RELIEF IN LABOURcorresponding test at the end of the book toassess your knowledge of the subject matter. Youshould redo the test after you’ve worked through 10-1 What is analgesia?the unit, to evaluate what you have learned. Analgesia means the relief of pain. Drugs used to relieve pain are called analgesics. Objectives Analgesics must not be confused with sedatives which do not relieve pain but only make the patient drowsy. When you have completed this unit you should be able to: 10-2 What is anaesthesia? • Explain the differences between Anaesthesia means the loss of all sensation, analgesia, anaesthesia and sedation. including pain. Local anaesthesia causes the • List the causes of pain in labour. loss of all sensation in that region of the body. • List which drugs can be given during With general anaesthesia the patient loses labour for analgesia. consciousness. • Ensure that a patient has adequate pain 10-3 What causes pain during labour? relief during labour. • List the dangers of the drugs which can Pain in labour is caused by: be used for pain relief. 1. Contractions. They progressively increase • Prepare a patient for general in duration and frequency during the first anaesthesia. stage of labour and become more painful. Contractions are most painful when the cervix is fully dilated and the patient has an urge to bear down. At first the pain is felt over the abdomen but later, when the cervix is nearly fully dilated, pain is felt in the lower back.
  2. 2. 206 MATERNAL CARE2. Cervical dilatation: This is due to uterine During labour, particularly during the latent contractions and pressure of the presenting phase and early in the active phase of the first part on the cervix. stage, patients may be encouraged to walk3. Vaginal examinations and procedures: around and not spend all the time in bed in Any vaginal examination is the labour ward. This reduces the amount uncomfortable and for many patients is of pain experienced during contractions. In also painful. This is particularly so when a addition, contractions will be more effective, forceps delivery, a vacuum extraction, or resulting in labour progressing faster. an episiotomy is performed. A calm, considerate and caring attitude fromThe amount of pain experienced by patients those who are attending the patient in labourin labour is very variable. Some patients have is important. Thorough but gentle clinicallittle pain, while others have severe pain, even examinations, rubbing the patient’s back andduring early labour. talking to her all do much to relieve the stress of labour and to some extent, the pain.10-4 What will make the pain worse? Most patients find it helpful to have someoneAnxiety, fear and uncertainty lower the pain with them during labour. A lay person or doulathreshold. This is particularly noticeable can fulfill this role perfectly well. A patientin primigravida patients, especially if they should be encouraged to have her partner,are very young. Pain increases the patient’s a family member, or someone else that sheanxiety, which in turn reduces her ability to knows well to stay with her during labour.tolerate pain. Antenatal preparation and emotional support10-5 What general measures help are important in reducing anxiety and painto reduce pain during labour? during labour.1. Knowledge of what to expect during labour. This important information should 10-7 Why is it important that labour be provided during antenatal visits to should be a positive experience? patients who will be experiencing labour for the first time. 1. The chances of breastfeeding successfully2. A pleasant environment and the support are increased. and encouragement of those who are 2. Patients will manage their infants with attending to the patient. greater confidence and master the art of3. The help and support of a family member, motherhood quicker. partner, friend, or doula is of great value.4. Allowing patients to walk around during 10-8 Why does a patient get pain relief labour. in labour if her lower back is rubbed? The nerve impulses that come from the lower10-6 Why is environmental and emotional back travel to the same spinal segments assupport important to a patient in labour? the nerves from the uterus and cervix. TheA patient should be prepared for her labour nerve impulses from the lower back, thereforeduring the antenatal period. Primigravidas partially block those from the uterus andmust be told in simple terms what is going to cervix. As a result, the pain of contractions ishappen during labour. Relaxation exercises experienced as less painful by the patient if herand breathing methods can help patients lower back is rubbed.prepare for labour, and should be taught aspart of antenatal care.
  3. 3. MANAGING PAIN DURING LABOUR 207USE OF ANALGESICS • When patients have painful contractions with slow progress duringIN LABOUR the active phase of the first stage of labour, e.g. with an occipito-posterior position.10-9 Why do you need to give a 2. In the second stage of labour:patient analgesia during labour? • When an episiotomy is done.1. As health workers, one of our primary • When an instrumental delivery is done. responsibilities is to relieve pain and 3. In the third stage of labour: suffering. All too often pain during • When an episiotomy or perineal tear is labour is regarded as part of a normal repaired. process. Therefore, during labour patients should frequently be asked whether they 10-12 What methods of providing need pain relief. If required, the most analgesia can you use? appropriate and effective form of analgesia 1. General measures, as mentioned in available must be given. sections 10-5 and 10-6.2. The relief of pain often allows labour to 2. Specific methods: progress more rapidly by reducing the • Opiates, e.g. pethidine. anxiety which is caused by pain. It is • Inhalational analgesia, i.e. nitrous oxide well known that anxiety may cause poor with oxygen. progress during labour. • Local anaesthesia. • Epidural anaesthesia. The relief of pain is very important and must • General anaesthesia. receive careful attention when a patient is cared for during labour. 10-13 Which analgesic drug is commonly used in the first stage of labour?10-10 Should all patients receive analgesia? Pethidine. This drug is a powerful analgesic but commonly causes nausea and vomiting as a sideNo. Some patients have little pain in labour effect. Pethidine also produces some sedation.and, therefore, may not need an analgesic.Other patients feel that they are able totolerate the pain of uterine contractions, 10-14 What drug is often givene.g. by concentrating on their breathing, and together with pethidine?choose not to have analgesia. It is important Promethazine (Phenegan) or hydroxyzineto consider the patient’s wishes when deciding (Aterax). They combine well with pethidinewhether or not to give analgesia. However, for three reasons:most patients do need analgesia during labour. 1. They have a tranquillising effect which makes the patient feel more relaxed.10-11 When do you give analgesia 2. They have an anti-emetic effect, reducingto a patient in labour? the nausea and vomiting caused by1. In the first stage of labour: pethidine. • When patients ask for pain relief. 3. They increase the analgesic effect of • When patients experience painful pethidine. 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.
  4. 4. 208 MATERNAL CARE10-15 What are the actions of pethidine? given. Obese patients weighing more than 75 kg must not receive more than 75 mg.It is a powerful analgesic which causes An intravenous infusion must first bedepression of the central nervous system. started before the drug is given.Large doses can therefore cause respiratorydepression. A drop in blood pressure mayalso occur. Pethidine crosses the placenta 10-18 How close to full dilatationand can cause respiratory depression in the may pethidine be given?newborn infant who may, therefore, need There is no limit to how late in labourresuscitation at birth. pethidine can be given. If the patient needsMorphine, which is less commonly used, has analgesia she should be given the appropriatesimilar actions and side effects to pethidine. dose. However, if she receives pethidine within six hours of delivery, the infant may have NOTE Pethidine and morphine may temporarily respiratory depression at birth. affect the cardiotocogram with the fetal heart rate tracing showing loss of beat-to-beat variation. Pethidine may be given late in labour if needed. An overdose of pethidine may cause respiratory 10-19 How often may pethidine depression in both the mother and her infant. be given in labour? If an adequate dose of intramuscular pethidine10-16 How is pethidine usually given is given, it is usually not necessary to repeatand how long is its duration of action? the drug within four hours. (In South Africa1. The intramuscular route: registered nurses are allowed by law to give • This is the commonest method of 100 mg pethidine by intramuscular injection giving pethidine, especially with a during labour, without a doctor’s prescription, cervical dilatation of less than 7 cm. and to repeat the injection after an interval of • Pain relief will be experienced about 30 four hours or more.) minutes after administration and the duration of action will be about four hours, although this varies from patient NALOXONE to patient.2. The intravenous route: • This method may be used if the patient 10-20 How should you treat requires analgesia urgently and the respiratory depression due to cervix is already 7 cm or more dilated. pethidine in a newborn infant? • Pain relief is experienced within five Naloxone (Narcan) is a specific antidote to minutes and the duration of action will pethidine (and morphine) and will reverse the be about two hours. effects of the drug.10-17 What dose of pethidine If a patient was given pethidine duringshould be given? labour, and delivers an infant who does not breathe well after birth, the infant should be1. The intramuscular route: 2 mg/kg body given naloxone (Narcan). The correct dose of weight. Therefore, 100 to 150 mg is usually naloxone is 0.1 mg/kg (i.e. 0.25ml/kg). A 1 ml given. Patients weighing less than 50 kg ampoule contains 0.4 mg naloxone. Therefore, must receive 75 mg. an average-sized infant requires 0.75 ml while2. The intravenous route: 1 mg/kg body a large infant up to 1 ml naloxone. Do not weight. Therefore, 50 to 75 mg is usually give naloxone to asphyxiated infants whose
  5. 5. MANAGING PAIN DURING LABOUR 209mothers have not received pethidine (or promethazine (Phenegan) or hydroxyzinemorphine). Naloxone will not reverse the (Aterax) together with pethidine will providerespiratory depression caused by barbiturates sufficient sedation for a restless patient. The(e.g. phenobarbitone), benzodiazepines (e.g. dose is 25 mg promethazine (Phenegan) andValium) or a general anaesthetic. 100 mg hydroxyzine (Aterax).Research has shown that the previously There is no role for sedation with diazepamrecommended dose (0.01 mg/kg) of neonatal (Valium) and barbiturates. Sedatives mayNarcan is tenfold too low. The use of neonatal also cross the placenta and sedate theNarcan must, therefore, be stopped and infant. Diazepam (Valium) can cause severereplaced with adult Narcan. respiratory depression in the infant and this effect is not reversed by naloxone. Infants who do not breathe well after delivery should only receive naloxone if their mothers INHALATIONAL were given pethidine or morphine during labour. ANALGESIA10-21 How should naloxone be given?Usually naloxone is given to a newborn 10-24 What inhalationalinfant by intramuscular injection into the analgesia is available?anterolateral aspect of the thigh. The drug will The most commonly used inhalationalreverse the effects of pethidine. Meanwhile, it analgesic is Entonox. This is a mixture of 50%is important to continue ventilating the infant. nitrous oxide and 50% oxygen. It is usuallyNaloxone can also be given intravenously. supplied in cylinders and is breathed in byThe drug acts more rapidly when given the patient through a mask when she needsintravenously, e.g. into the umbilical vein. pain relief.10-22 Is a single dose of The advantages of Entonox are:naloxone adequate? 1. It is safe for mother and fetus.Yes. A single dose of naloxone is almost always 2. It is short acting.adequate to reverse the respiratory depression 3. It acts quickly.caused by pethidine. The action lasts about The disadvantages of Entonox are:30 minutes. Some infants may becomelethargic after 30 minutes and may then 1. It is expensive.require a second dose of naloxone. 2. It requires special apparatus for administration. 3. It is not always effective because the patient needs to start inhaling the gas as soon asSEDATION DURING the contraction starts for the analgesicLABOUR effect to be present during the peak of the contraction. Many patients start the inhalation too late.10-23 Are sedatives useful in labour? 4. Patients often hyperventilate and get ‘pins and needles’ in their face and hands.In practice there are very few indicationsfor the use of sedatives in labour. If apatient is restless or distressed, it is almostalways because of pain and she thereforeneeds analgesia. The tranquillising effect of
  6. 6. 210 MATERNAL CARE10-25 Which patients should 10-29 What are the risks ofpreferably use Entonox? local anaesthesia?A patient requiring analgesia for the first time 1. Too much local anaesthetic is dangerousin advanced labour, where the delivery is and may cause convulsions. Theexpected within an hour. maximum dose of a 1% solution of lignocaine (Xylocaine) for a patient of10-26 Does Entonox have any average size is 20 ml.serious side effects? 2. A local anaesthetic can cause convulsions if it is injected into a vein in error.No. Entonox is completely safe and cannot beused in excessive doses. The maximum safe dose of lignocaine is 3 mg/kg body weight. One ml of a 1% lignocaine solution contains 10 mg lignocaine. Entonox is a completely safe analgesic. An overdose, or intravenous injection, of a local anaesthetic may cause convulsions.LOCAL ANAESTHESIA 10-30 What is the duration of10-27 What is a local anaesthetic? action of lignocaine?Local anaesthetics are drugs which are injected Lignocaine results in loss of sensation in theinto the tissues and which result in a loss infiltrated area for 45 minutes. If the maximumof all sensation in the injected area. Local dose has already been given but more localanaesthetics often give a burning sensation anaesthetic is required, a further 10 ml of 1%which lasts one to two minutes while they are lignocaine may be given after 30 minutes.being injected. The patient should be warnedabout this before starting the injection.Lignocaine (Xylocaine) is the local anaesthetic EPIDURAL ANAESTHESIAused most commonly. Although available indifferent concentrations it is best to only usethe 1% solution. The possibility of giving an 10-31 What are the indicationsoverdose will then be reduced. for epidural anaesthesia? 1. When there is poor progress during the10-28 When should you use active phase of the first stage of labour,a local anaesthetic? e.g. due to an occipito-posterior position. 2. When ineffective uterine contractions areThere are two main indications for local present, prior to starting oxytocin.anaesthesia in labour: 3. When it is important to prevent bearing1. When performing an episiotomy, or when down before a patient’s cervix is fully repairing an episiotomy or perineal tear. dilated, e.g. with a preterm infant or a2. When performing a pudendal block. The breech presentation. local anaesthetic acts on the pudendal 4. Caesarean sections may also be done under nerves, and is usually given before an epidural anaesthesia. instrumental delivery. This is the ideal form of local anaesthesia as it offers the patient complete pain relief. Unfortunately special training and equipment are necessary for giving epidural anaesthesia
  7. 7. MANAGING PAIN DURING LABOUR 211and, therefore, it is only available in most level emetic (prevents vomiting) which speeds2 and 3 hospitals. up the emptying of the stomach and increases the tone of the lower oesophagus.10-32 What special nursing care is required The drug acts for about two hours.following an epidural anaesthetic? 3. The gastric acid must be neutralised by an antacid before the induction of general1. There is a danger of hypotension following anaesthesia. Usually 30 ml of a 0.3 molar the administration of the first and each solution of sodium citrate is given. If further dose of the local anaesthetic. The induction of anaesthesia is not started patient’s blood pressure must be taken within 30 minutes of the sodium citrate every five minutes for 30 minutes following being given, the 30 ml dose should be each dose of the local anaesthetic. repeated.2. Depending on the amount of anaesthesia achieved, patients often cannot pass urine. NOTE Sodium citrate is cheap and can be A Foley catheter is therefore often required made up by any pharmacist. It is an electrolyte until the effect of the anaesthesia wears off. solution and therefore preferable to other antacids which contain particles that can cause a chemical pneumonitis if the drug is aspirated.GENERAL ANAESTHESIA CASE STUDY 110-33 What are the dangers for apregnant or postpartum patient when A patient and her husband present at thereceiving a general anaesthetic? maternity hospital. She is 26 years old,Any pregnant or postpartum patient who gravida 2 para 1 and at term. Her antenatalreceives a general anaesthetic has a very high course has been normal and her routinerisk of vomiting and aspirating her stomach observations on admission are also normal.contents because: The fetal presentation is cephalic with 2/51. Stomach emptying is delayed. of the fetal head palpable above the pelvic2. The tone of the sphincter in the lower brim. The membranes rupture spontaneously oesophagus is reduced. and her cervix is found to be 5 cm dilated on3. The intra-abdominal pressure is increased. vaginal examination. The patient is relaxed and does not find her contractions painful.Patients who have been starved must be She is admitted to the labour ward and givenmanaged in the same way as patients who have 100 mg pethidine and 25 mg promethazinerecently eaten. During a general anaesthesic, by intramuscular injection as she is alreadythe risk of the patient vomiting is particularly in the active phase of the first stage of labour.high during intubation and extubation. Her husband is asked to wait outside the labour ward. It is suggested that he go home10-34 What precautions must be for a while as the infant is unlikely to be borntaken preoperatively that will during the next five or six hours.reduce the dangers of vomiting?1. A patient who may require a general 1. Has the patient been correctly managed? anaesthetic should be kept nil per mouth No. She did not require analgesia. Not all (i.e. she should be starved). patients need analgesia during labour. Some2. Metoclopramide (Maxalon) 20 mg (two patients experience little pain during labour ampoules) should be given intravenously while others handle the pain of contractions 15 minutes before the induction of general with no difficulty. anaesthesia. Metoclopramide is an anti-
  8. 8. 212 MATERNAL CARE2. What would have been the correct only 4 cm dilated. The patient is told to behavemanagement of this patient? herself. She is informed that the worst part of labour is still to come and is scolded forThe patient should have been reassured that becoming pregnant. As she is a primigravida,her labour was progressing normally. She she is promised analgesia when her cervixshould have been encouraged to walk about reaches 6 cm dilatation.and not spend all the time in bed. Analgesianeed not be given routinely to all patients inactive labour. 1. Why is the patient frightened? Because she is unprepared for labour and3. Do you agree with the handling does not know what to expect. In addition,of the patient’s husband? she is in a strange environment and the staff are unfriendly and aggressive. Being anxiousNo. Most patients prefer to have someone they results in her experiencing her contractions asknow well remain with them during labour. Her very painful while the pain in turn makes herhusband should have been encouraged to stay even more anxious.with her if that was what the patient wanted. 2. What should have been done4. What should the husband do if he during the antenatal period tostays with his wife during labour? avoid the present situation?Simply being there is reassuring to the Receiving good information about thepatient. He can help to keep her relaxed and process of labour at antenatal visits, attendingcomfortable. Furthermore, he can be shown antenatal exercise classes and visitinghow to rub her back during contractions. the labour ward during the last weeks of pregnancy would have resulted in a far more5. Is it of any value to rub a patient’s relaxed patient in labour.back during contractions, or is it onlyan ‘old wives’ tale’ that has no 3. What should have been done in theplace in modern midwifery? labour ward to reduce her anxiety?Rubbing a patient’s lower back is of great help She should have experienced a pleasantas the nerve impulses that come from the skin atmosphere in the labour ward withover the lower back travel to the same spinal understanding and encouragement from thesegments as the nerve impulses from the cervix staff. They should have reassured her thatand uterus. The nerve impulses from the lower everything was under control and that thereback partially block those from the uterus and was no reason for her to be frightened. Thecervix. As a result, the pain of contractions is staff themselves should appear confident,experienced as less painful by the patient if the relaxed and caring. It is important that alower back is rubbed. family member or friend of the patient’s remain with her.CASE STUDY 2 4. Should the doctor be informed about the unmanageable patientA 16-year-old patient presents in labour at and be asked to prescribe10 mg ofterm after a normal pregnancy. She is very intravenous diazepam (Valium)?anxious, does not co-operate with the labourward staff and complains of unbearable pain No. Sedatives, especially diazepam, should beduring contractions. She bears down with used very rarely because they may result inevery contraction even though the cervix is severe respiratory depression in the infant at
  9. 9. MANAGING PAIN DURING LABOUR 213birth. This complication is not reversed by the only needs analgesia for a short time as hercommonly available drugs at delivery. cervix will soon be fully dilated.5. What would have been the correct 3. If Entonox is not available or ifmanagement of labour for this the patient is unable to use Entonoxpatient, beside reassurance? correctly, what other form of analgesia should be considered?She should have been encouraged toconcentrate on her breathing during Pethidine and promethazine (Phenegan) orcontractions. In addition she should have been hydroxyzine (Aterax).given adequate analgesia as soon as possible. 4. What would be the best route of6. What form of analgesia should administering the pethidine to this patient?have been given to this patient? The pethidine should preferably be givenThe ideal form of analgesia for this patient intravenously. Pain relief will then be obtainedwould have beeen an epidural anaesthetic as in five minutes and the effect of the drugit provides complete pain relief. Alternatively should last two hours.she should have been given pethidine andpromethazine (Phenegan) or hydroxyzine 5. The infant is delivered 45 minutes(Aterax) by intramuscular injection. The after the pethidine is given. Whattranquillising effect of promethazine or complication of the drug may behydroxyzine would have helped to lessen her present in the infant at delivery?anxiety. The infant may have respiratory depression and as a result may not breathe adequately at birth.CASE STUDY 3 6. How should the infant be managed if the breathing is inadequateCervical dilatation in a multigravida patient (i.e. the infant has asphyxia)?in labour at term progresses from 3 cm to8 cm in four hours. Now for the first time The infant must be resuscitated with oxygenshe complains that her contractions are very and artificial respiration provided via a facepainful. The midwife informs her that she is mask or endotracheal tube. Naloxone (Narcan)progressing fast and that her cervix will soon must be given to the infant to reverse the effectbe fully dilated. She adds that the patient must of the pethidine. Naloxone is usually given byjust continue without analgesia for the last two intramuscular injection. However, it acts morehours as the delivery will soon be over. rapidly if it is injected into the umbilical vein.1. Do you agree with thepatient’s management? CASE STUDY 4No. The patient needs analgesia and the mostappropriate form of analgesia should be A multigravida patient, who has had twooffered to her. previous Caesarean sections, is booked for an elective Caesarean section under general anaesthesia at 39 weeks gestation. The patient2. What would be the best form of is admitted to hospital at 07:00, having hadanalgesia to offer this patient? nothing to eat since 24:00 the previous night.Entonox (nitrous oxide with oxygen) as it She is prepared for surgery at 08:00. As theworks rapidly and is completely safe. She also patient has been kept nil per mouth, no drug
  10. 10. 214 MATERNAL CAREto prevent vomiting during intubation and 3. What preventative measures should haveextubation is given. Only an intravenous been carried out during the pre-operativeinfusion is started and a Foley catheter passed preparation of the patient for theatre?before she is moved to theatre. Metoclopramide (Maxalon) 20 mg (two ampoules) should have been given1. Do you agree that a drug to prevent intravenously 15 minutes before the inductionvomiting is not needed as the patient has of anaesthesia. It is anti-emetic, it increaseshad nothing to eat or drink for eight hours? the stomach emptying time, and raises theNo. All pregnant patients are at risk of sphincter tone of the lower oesophagus. Thesevomiting during general anaesthesia even if effects will reduce the danger of vomiting. Anthey have taken nothing by mouth during the antacid should also be given before the generalpast few hours. anaesthetic. The drug of choice is 30 ml of a 0.3 molar solution of sodium citrate.2. Why should a pregnant patient whohas not eaten overnight still be at risk of 4. Both these drugs are given at 07:45.vomiting during a general anaesthetic? However, due to a delay, the patient is only taken to theatre at 08:30. Is itBecause her stomach has a delayed emptying necessary to repeat either of these drugs?time, the lower oesophageal tone is reducedand she has a raised intra-abdominal pressure. The metoclopramide (Maxalon) acts for two hours so need not be repeated. However, the sodium citrate only acts for 30 minutes and, therefore, must be repeated before the start of the anaesthetic.