About the Author: This article was written by Marion Costin-Ford, Independent Midwife, East Midlands
The information in this article is correct at date of publication: June 2010.
Opinions expressed by the author are not necessarily those of the publisher or editorial staff.
Having a baby is quite possibly the most important event in a woman’s life, and for many women, the focus of pregnancy is planning for labour and birth.
Midwifery is the only medical profession where we regard pain in a positive way. It is a major signal of an imminent birth and spurs us on to prepare for it. It is also the awakening for the mother-to-be that they will soon be meeting up with their baby, and they must also prepare for their birth journey.
It is important to use good current research based evidence when advising women who are making these choices, as it will help them to have honest expectations of their birth experience. It is also important to encourage women to embrace the concept of labour and birth, than to fear it, as fear itself can increase pain levels, so a good understanding of what is available to help women through their labour is essential to help them make the right decisions
The Birth Plan
Making a well informed and flexible birth plan can be an invaluable tool during labour and birth. Not only does it help women think about how they would like their labour to progress, but also involves their birth partner, who she may want to act as her advocate when she is focusing on her labour. This also has the advantage of informing Healthcare Professionals, so that they can hopefully facilitate the woman’s choices and preferences.
It is very easy to have an information overload when considering choices, as it seems that everybody wants to get in on the act. Mums and family may offer age old advice, and whilst some friends may give positive accounts of their labours, others may wear their birth experiences like medals of honour.
There is never a shortage of Pregnancy and Birth magazines, showing pictures of women with perfect bumps in between the adverts for the latest maternity wear and baby products, and in this technological age, information can be found from a global level at the click of a mouse.
What is most important, is to make sure that women are guided towards, current and credible information to help them make their choices. Women need to be flexible and realistic about their birth plan. Availability of staff and resources can change by the minute in a busy Maternity unit and there may be restrictions or delays which can influence how the labour progresses and birth plan choices.
Most women report that they were not sure how they were going to cope with their first labour, so exploring the alternatives in advance will provide an understanding of how other pain relief options work, particularly for first time mothers.
Methods of pain relief
Everybody is unique in their perception of pain and how they cope. Therefore, it is important to get the right information about what is available.
The following guide covers the most popular methods of pain relief for labour and birth.
Things that help during early / latent phase of labour
The latent phase of labour is defined by N.I.C.E1 as ‘a period of time, not necessarily continuous, when there are painful contractions, and there is some cervical change, including cervical effacement’. In simpler terms, this means that the body is getting ready to go into established labour.
Some women establish their labours more quickly than others, the latent phase can last a few hours or a few days. As there is no way of predicting when the active phase of labour will start, it is a good idea to discuss coping and distraction techniques with women to help them prepare for what could be quite a long wait.
Relaxation CD’s can help the body and mind cope with this phase, and can be used all the way through labour and birth. In preparation for hospital, it may be ideal to transfer to an MP3 player, as not all units have CD players, and headphones will reduce the noise from elsewhere in the delivery suite.
Warm baths (not too hot) have a good calming effect and help relieve pain. Showers are also useful, particularly for back pain. A plastic stool or garden chair can be put in the shower so the Mum-to-be can sit with the water running on her back.
Paracetomol can help with contraction pain in the early stages of labour. It can be taken safely during pregnancy. Two tablets (1 gram) can be taken every four hours, but NO MORE than four doses should be taken within 24 hours. It is important that the woman makes a note of what she has taken- and when, so that any other drugs can be given safely at a later stage.
Recording special TV programmes and saving special DVD’s for the occasion is something that can be prepared beforehand. Anticipation of something new to watch is a great distraction technique and can while away many hours of waiting for both the woman and her birth companion.
Squeezing stress balls can divert the tension from the shoulders and head when having contraction in early labour. It also has the added advantage of giving the birth partner’s hands a rest. This can be used throughout labour.
Keeping mobile during labour is also important and adopting different positions. Birthing balls are a comfortable way of getting into a position where the pelvic outlet can open more to help baby’s head engage.
Women need to know the importance of regular nutrition and hydration. The body has a strenuous job to do and women may not feel like eating when labour establishes. Regular emptying of the bladder will help keep the baby’s head as low in the pelvis as possible.
Waiting for labour to establish can be an uncomfortable and frustrating time but if everything is normal, the safest and most comfortable place for a woman to be during this time is at home. However, it should be made clear when the hospital or Midwife should be called.
The main reasons for calling during latent phase, or before labour has started are:
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· Rupture of membranes
· Vaginal bleeding
· Experiencing pain that is constant
· Reduced fetal movement
· Not coping well with contractions
· Concern that something isn’t normal for that particular Woman
· Contractions are regular and no more than 5 minutes apart
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Women usually recognise when the latent phase changes to the onset of established labour, but it should be re-enforced that if they need advice, that they can contact the Maternity Unit at any time.
Drug free pain relief options throughout labour
Relaxation / Hypnosis for childbirth
Hypnosis for childbirth is a method of deep relaxation which, in order to be most effective, requires good support from a birth partner in order to achieve the best result.
It works by learning techniques of self hypnosis, which by-pass the logical part of the brain, in order to train the subconscious part to interpret pain as a different sensation. Carefully selected vocabulary is used, such as ‘rush’ or ‘surge’ rather than ‘pain’ or ‘contraction’ in order for the brain to convert the feeling into something more manageable. This method can be used throughout labour and birth, and is an excellent method if planning home birth, as the woman is in control of the environment she is in, i.e. noise and interruption.
To get the most out of this method, it is important to be surrounded by like-minded people, as some birth partners may feel awkward about the narrative they will use to support their partners and if in hospital, some staff may not have a good understanding of the technique. Even though more and more Midwives are expanding their knowledge in this field, it is always a good idea to have a good birth preference guide, and if possible, let the unit know beforehand that the woman is planning to use hypnosis. It may also be asking if a Midwife working at the hospital is training in hypnotherapy
There are many types of relaxation and hypnosis courses available privately. Even the most popular and well known courses can differ from practitioner to practitioner.
The most popular courses such as Hypnobirthing and Natal Hypnotherapy last about 5 weeks and cost between £200 and £300 per couple, depending on practitioner and location.
It is always best to seek a recommendation from someone who has used these methods before, and if needed, travel a little further or pay a little extra to get the best possible course.
There are also many relaxation / hypnosis CD’s on the market, which are a more affordable option. They are not as intense as the attended courses, but are particularly effective for relaxation during the last days of anticipation whilst waiting for labour to start, and also a great companion during the latent/establishing phase of labour.
Water Therapy / Birth Pool
Labour and birth in water is nothing new. Although it has become more popular over the last 20 years, the original concept was developed in the 1960s by Igor Tjarkovsky, a Soviet Researcher6. In the 1980s, Innovative Obstetrician Michel Odent started using the method at his Birth Centre in Pithiviers, France7. He is seen by many, as the person who made water birth as popular as it is today.
Water has a therapeutic and calming effect and as long as labour is progressing normally, can be used effectively both at home and in hospital. In early labour, it is best to use a normal sized bath or shower as getting into the pool too early can slow labour down.
Temperature is very important as water that is too hot can increase the maternal heart rate, and in turn increase the baby’s heart rate. Normally the water is kept at body temperature around 37 degrees C. Baby can be born underwater safely, as the first breath is taken when the baby’s face feels the cool air of the outside world.
Birth pools can be hired from about £200 for a rigid sided one. Inflatable pools can be bought for as little as £60, but are small and only meant to have a single use.
Many things need to be considered when planning to use a pool at home including where the safest and most convenient place is for the pool when filled, the size of the water heater, as the pool will need topping up and emptying during and after the birth. Also to consider the weight of the water in the pool especially if it is situated upstairs.
It is also very important to make sure that the Midwife who is attending the birth is trained, confident and competent in the use of water for labour and birth.
TENS Machine
TENS stands for Transcutaneous Electronic Nerve Stimulation, and is a simple and drug free method of pain relief. Originally used in the 1970’s to help alleviate back pain, it was increasing interest in its effectiveness during labour2. That has made it an increasingly popular choice.
TENS machines do not take the pain away, rather they stimulate the body`s natural system and allow the user to retain control.
The method uses Melzeck’s Pain Gate Theory3 whereby a small amount of electrical current delivered by electrodes to the skin can block painful impulses, at the same time, stimulating the natural production of endorphins, the body’s natural pain relief.
The controlled current is delivered through four electrodes which are applied to the skin and are placed at points on the lower back. A small tingling sensation can be felt, and when needed during a contraction, a pulse of current can be delivered to give extra relief.
This method cannot be used in water and should never be used during pregnancy until signs of labour have started. All modern machines are small, portable and usually take common sized batteries. Prices start from around £65 for a good quality machine, and many companies hire them for a five or six week period from about £25.
Some maternity units around the country may have a TENS machine that can be used, but the electrodes are single use and there may be a charge, usually around £5 to replace them.
Systematic clinical reviews4 have found little evidence to prove that TENS is an efficient method of pain relief, but many women have found it to be very beneficial, particularly in the early stages of labour. Combined with other methods of pain relief during the later stages of labour, this method can be an excellent birth companion.
Medical pain relief options throughout labour
ENTONOX (Gas and Air)
Entonox is the registered name of a mixture of 50% nitrous oxide and 50% oxygen, which is commonly used for labour and birth. Although its effects were discovered in the late 1800s, it was not commercially used until further research showed its effectiveness when mixed together in the same cylinder in the early 1960s5.
The gas mixture is breathed continuously through a mouthpiece and demand valve, and although its use has to be instigated by a qualified HCP, its use is controlled by Mum.
Entonox is usually effective approximately 30 seconds after it is commenced, and will leave the system approximately 30 seconds afterwards. This means that its effectiveness in relieving pain relies on the timing of the person using it. Women can feel light headed and dizzy, but it is a popular method of pain relief, particularly after labour has established and contractions become more frequent and last for longer.
Entonox can be used for home birth, but must only be used in the presence of a Midwife or Doctor. Constant use can cause a dry throat and tiredness, therefore, regular sips of fluid and rest are recommended.
It is not advisable to use Entonox during the second stage of labour, as the sensation of pushing can be inhibited by its use and it isn’t possible to push and breathe Entonox at the same time. The flexibility of its use means that Entonox can be used during the third stage of labour and during any post birth procedures which can cause discomfort, i.e. repairing a damaged perineum or vaginal examinations.
Opioid Analgesia
Commonly used opioids such as Meptid or Pethidine, give a sedative effect, which can help women cope with the effects of labour, especially if long. Although there is some pain relief with these drugs, they have a strong calming effect that can sometimes make the woman feel out of control, which in turn can have a negative effect on its analgesic properties. It can also make the woman feel nauseous, therefore an anti –emetic, such as Cyclizine or Phenergan are given at the same time.
The drug passes through the placenta and can have differing effects on the baby, which the mother needs to consider. Midwives and HCP’s caring for the Mother may ask if they can assess progress of labour before administering Opioids, as it can have negative effects on the baby if birth is considered imminent within the next few hours.
Both anecdotal evidence from Midwives and qualitative research has suggested that babies tend to be sleepier and slower to establish feeding after Pethidine was used in labour8 and in rare cases can cause respiratory depression at birth, requiring an antidote drug to be given to baby to reverse the effects.
Different units use different Opioid drugs, which seems to depend on Consultant preference or tradition9. Although Meptid and Pethidine are from the same generic family, their administration doses are different:
Pethidine is usually given in a 100mg dose universally, and lasts about 6 hours
Meptid is given around 2 hourly and the dose is calculated by the woman’s weight.
Midwives are restricted to the amount of drug they are allowed to prescribe, but this amount is based on the average amount needed during labour and birth.
This should be taken into consideration if a home birth is planned.
Epidural Anaesthesia
This method is very effective for women who are finding it difficult to cope with labour using other sources of pain relief. Pain relieving drugs are given through a small plastic tube into a space between the vertebrae, which bathes the nerves which are sending the pain messages to the brain. Epidurals in normal labour remove the pain, but sometimes pressure can still be felt during contractions.
Epidurals can only be sited by an Anaesthetist, but can be maintained by Midwives who have been suitably trained. The drug administration is more commonly being given through patient controlled devices, but can be topped up manually if there is reduced effect.
Even though the majority of women have no side effects, like all clinical procedures, having an epidural can have its risks, even though they are very rare. Headaches can be caused by Dural Tap (a leakage of spino-cerebral fluid into the epidural space) which, if severe, can be relieved by another small procedure to block the hole. Other side effects can be prolonged loss of sensation in parts of the lower limbs, weakness in the limbs and back problems.
Epidurals tend to lower blood pressure (monitored continuously throughout labour) and this is controlled by an intravenous infusion of fluid running at the same time. After the birth, the plastic tube is usually removed from the back as soon as pain relief is no longer needed, and the effects of an epidural usually wear off in about 2 hours.
There are restrictions of movement when an epidural has been sited. The limbs are generally too weak to support standing, which means that the woman is confined in her movements. Due to the strength of the drugs given, continuous monitoring of the baby is also essential. This method can also slow down the progress of labour, and there is an increased risk of an assisted birth e.g. ventouse, forceps.
Although all Consultant Led Maternity Units have a team of Anaesthetists, it is not always possible to have an epidural when it is requested, as there may be emergencies happening in other parts of the unit. It is important to consider other methods which can be used if the woman is waiting for an anaesthetist to become available.
Summary of methods of pain relief available
Method
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Self Caring
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HCP administered
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Available on NHS
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Available Privately
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Relaxation /Hypnosis for childbirth
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Yes
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n/a
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No
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Yes
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Tens Machine
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Yes
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If required
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At some units
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Yes
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Entonox (gas and air)
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No
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Yes
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At all units
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n/a
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Birth pool
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Yes
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Yes
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At some units
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Yes
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Opioid Analgesia (Pethidine/ Meptid)
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No
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Yes
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At all units
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n/a
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Epidural Anaesthesia
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No
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Yes
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At Consultant units only
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n/a
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Conclusion
There are many factors that shape a woman’s perception of pregnancy, labour and birth. Whether they be the antenatal class they attend, the well meaning advice from relatives, the websites they visit in the internet, or the deep roots of their culture. There are various methods of pain relief which can help women cope with pain in labour. Her birth plan can inform the midwife looking after her as to what she wants and she in turn can inform her of what is available to help her cope.
Regardless of all the information available, women see us as the ‘experts’ and hopefully build a relationship of mutual trust during their pregnancy journey. The way that we give information can be swayed, either by our own experiences or observing the experience of others.
What we must always remember is that, whatever they decide, it is the woman’s choice, and we must be prepared to give them the best impartial information and advice available in order to successfully support those in our care.
References1. NICE, NICE Clinical Guideline 55 -Intrapartum care p.24, NCC-WCH Publications, London, 2007. Available at: www.nice.org.uk [Accessed February 2010].
2. Blincoe A. TENS Machines and Their Use in Managing Labour Pain. British Journal of Midwifery. 2007; vol 15, no 8: 516.
3. Melzeck R. Pain Mechanisms, A new theory: Science. 1965; vol.150, no.699: 972.
4. Tunstall M. Obstetric Analgesia. The use of a fixed nitrous oxide and oxygen mixture from one cylinder. Lancet.1961; Vol. 28; no. 2: 964.
5. Dowswell T, Bedwell C, Lavender T, Neilson JP. Transcutaneous Electrical Nerve Stimulation (TENS) for Pain Relief in Labour: Cochrane Database Systematic Review. 2009; Vol.15; no.2, ref.CD007214.
6. Sidenbladh E. Water Babies: London, A & C Black, 1994: 27.
7. Odent M. Birth Reborn: Cambridge, University Press, 2005: 46.
8. Hunt S. Pethidine: love it or hate it? : MIDIRS Midwifery Digest. 2002; vol.12, no. 3: 365.
9. Tuckey J., Prout R., Wee M. Prescribing intramuscular opioids for labour analgesia in consultant-led maternity units: a survey of UK practice: International Journal of Obstetric Anesthesia. 2008; vol.17, no.1: 5.
