Pain Management in Pregnancy
Part I
Introduction: Pain and pregnancy
Pain is an occurrence that almost always occurs at one time or the other during the antepartum, intrapartum or postpartum period during the obstetric sojourn of the woman. Different factors result in the development of pain which is most severe during the intrapartum period. It is important for the woman to be offered modalities of abolishing or reducing the pain to the barest minimum in order to reduce the psychological and emotional trauma that excessive pain might cause the birthing mother.
Moreover, it is important to give the laboring patient sufficient and exhaustive information about the various available modalities of labor analgesia, both pharmacological and non-pharmacological with their corresponding advantage and disadvantages so that the patient might make an informed decision based on the choices that has been presented to her.
Pain management during labor should not be undertaken without due consideration for the potential benefits and the inherent risks both to the fetus and the mother. It is important to take extra caution when administering pharmacological agents intrapartum more importantly in cases of preterm delivery bearing in mind that the preterm infant has a reduced capacity to metabolize these pharmacological agents.
A
Pain in the antepartum patient
Potential sources of pain in the antepartum patient include low back pain that occurs when the pregnancy is close to term. This is as a result of relaxation of the lower back interspinous ligaments so as to make more room for the fetus to pass through the birth canal.
There can also be pain in the lower limbs as a result of the increasing size of the fetus thereby compressing on adjourning structures. This can lead to compression of the nerves supplying the muscles of the lower limb, giving rise to pain.
Pain in the intrapartum patient
In the intrapartum patient, the major cause of pain is the regular uterine contractions that occur during the process of labor. These contractions are rhythmic and painful and as labor progresses, the frequency and duration of each contraction increases. Therefore, as labor progresses, the patient feels increasing intensity of pain.
There could also be pain as a result of some obstetric interventions like the administration of episiotomy in order to widen the birth canal for easy passage of the fetus.
Pain in the postpartum patient
The postpartum patient may also feel abdominal pain attributed to involution of the uterus especially during the first few days postpartum. Also, pain could also result from surgery in patients that have undergone caesarean section.
B
Intrapartum pharmacologic pain management
Narcotics
Opioid have been available for use in the management of obstetric pain for over a century although there is not enough evidence on the safety and efficacy of opioid for labor pain management (Elbourne & Wiseman, 2006). However, researchers have reported modest intrapartum pain relief. Narcotics also cause sedation, which has been said to produce some form of "therapeutic rest" for patients who experience excruciating pain in the early latent phase of labor or even irregular pattern of uterine contraction that can lead to exhaustion. It is important to note that narcotics administered during the active phase of labor will not completely abolish the labor pains. Rather, it would allow the patient to better cope with the anxiety and the pain. Of all the drugs in the opioid class of analgesics, there is no one that has been proven to have a superior analgesic effect or side effect profile other than the fact that the meperidine has been associated with increased incidence of nausea and vomiting (Bricker & Lavender, 2002). However, there is limited information on the effect of individual opioid on maternal-infant bonding and breastfeeding. It is important to educate the patient on the effect of administered narcotics on neonatal respiration pattern and early neonatal behavior especially breastfeeding (it has been shown that all opioid in significant doses have the ability to impair early breastfeeding). Side effects include sedation, dysphoria, nausea and vomiting. There can also be pruritus, amnesia in high doses and respirator depression in the mother. To this end, it has been advocated that the patient should not be left alone immediately after administration of a narcotic but rather, the patient should be monitored for up to 30 minutes following the administration of the last dose of narcotic.
It is also important to note the effect of opioid on fetal heart rate variability for up to 1 hour and also decrease in baseline fetal heart rate by up to 15 beats per minute. There has been respiratory depression and sedation of the newborn following administration of narcotics (Elbourne & Wiseman, 2006).
Some important precautions have been advised in the use of narcotics. They include the fact that the patient should be informed that the narcotics will not remove the experience of pain completely. However, it would allow the patient to be able to manage the labor more comfortably. Moreover, in preterm labor, narcotics should be used with caution, bearing in mind that the infant will be more sensitive to the effect of the narcotic due to impaired metabolism of the drug leading to persistence of the drug in the infant's system.
There can also be a delay in emptying of gastric content when parenteral narcotics are administered, thereby increasing the risk of potential maternal aspiration and regurgitation. Therefore it is important to be cautious when parenteral narcotics are administered to patients who may end up having a caesarean delivery (Elbourne & Wiseman, 2006).
A representative opioid is Morphine. Morphine has duration of action of 4 hours with a maternal half life of 1 hour and a neonatal half life of up to 6 hours. When compared to another narcotic, Meperidine, it has less side effect of nausea. Morphine has a more sedating action than fentanyl, another narcotic (Elbourne & Wiseman, 2006).
A number of non-pharmacological relaxation techniques and comfort measures are available and are routinely offered to patients in labor. However, there is wide variation among women as regards the effectiveness of these techniques what works for a patient may not be useful in other patients (Elbourne & Wiseman, 2006).
Labor Support
Labor support entails the continuous presence of trained personnel who is skilled in the area of providing emotional and physical support including encouragement to the patient throughout the process of labor. Investigators have shown that continuous labor support has the potential of reducing the need for analgesia and operative birth and women displayed more satisfaction with the birthing experience (Hodnett et al, 2002). The use of this non-pharmacological modality of pain management will reduce the need for the use of pharmacological agents to manage pain. The advantage is that it would prevent the occurrence of potential complications to the infant like respiratory depression. Since infants that have respiratory depression initially have low APGAR scores and are more likely to be associated with interventions like emergency resuscitation. Also, the initial mother-child bonding experience may not be achieved if the activity of the infant is initially reduced (Simkin, 1995).
Positioning
Certain positions have been proven to increase comfort during labor. These positions include walking, standing, sitting, squatting, and side-lying. As with most other non-pharmacological modalities of pain management, this method also depends on individual patients. The patient needs to identify the particular position that suits her best before she can have relief from pain of labor. Moreover, the use of some devices like birthing ball, birthing rope and birthing stool have also been advocated. As it has been mentioned earlier, the need for pharmacological agents to manage pain is reduced when the non-pharmacological techniques are used (Simkin, 1995).
Part II
A: Specific Variables
It is important for the woman to make an informed decision about the different modalities of management of pain in the intrapartum period. However, such information must be personalized to each patient according to their clinical history and findings on examination. Some of these factors include religious belief, Co-morbidities (hypertension, heart failure, goiter etc) and psychological / psychiatric conditions, among other things. for the deeply religious Christian individual who believes that the pain of labor has been pronounced on mankind and each woman is meant to go through the pain, it is important to give scientific facts and information to back up the claim that such a woman may chose to have a painless delivery if she so desires. It is also important to get the written consent of such a patient before any form of analgesia is administered to them. However, some of these patients are willing to accept non-pharmacological modalities of pain management as opposed to pharmacological methods. For individuals that have medical conditions, it is mandatory to offer them analgesia so that the pain would not aggravate their medical condition and lead to morbidity both on the part of the mother and the infant. Patients who have Sickle cell disease needs to be offered adequate analgesia so that the individual does not suffer a crisis as a result of the pain. Likewise, the individual with hypertensive heart disease needs to have adequate analgesia so that the blood pressure will not rise to a dangerous level because of excessive pain.
Also, the mental status of the patient needs to be considered in choosing an appropriate form of analgesia. For instance, a woman with schizophrenia may not agree to non-pharmacological modalities of pain management.
B: Educating the patient
Non-pharmacologic modalities that I would discuss include Labor Support and Positioning.
Labor Support
The specific points I would teach to the patient about this method includes the fact that Labor support as a non-pharmacological modality of pain management can also be used in conjunction with pharmacologic agents. I would want to let the patient to realize that this modality is not mutually exclusive of other methods (Simkin, 1995). Research has shown that pharmacological modalities may not completely abolish the labor pains therefore Labor support would be a good adjunct to whatever pharmacologic modality is being considered. I would also want to make the patient realize that individuals who have engaged the services of individuals to provide Labor support during the process tend to have a more satisfying bathing experience when compared to other individuals who did not have Labor support (Simkin, 1995). I would also want to tell the patient that Labor support can be provided by either a trained personnel or a family member, this is because some patients would want their spouses to be present when they are going through the labor experience.
Positioning
For the patient to successfully utilize this modality of pain management, it is important that the patient tries out the various positions before deciding to assume one particular position so that the best position can be utilized (Simkin, 1995). Moreover, it is important for the patient to realize that non-pharmacological modes of pain management differ in efficacy from one individual to another. I would want to encourage the patient to chose another modality if they do not feel relieved after tying out a particular position.
In conclusion, pain management is an important aspect of the labor process that gives a lot of concern to the modern woman who wishes to have a relatively pain-free labor. It is the duty of the health care professional to provide exhaustive information to the patient so that they can make informed decisions on the modality of pain relief they desire in order to have an excellent birthing experience. Also, the advantages and disadvantages of the various modalities should be discussed with the patient and the clinician make the best decision in the best interest of the mother and her soon to be born infant and also to the satisfaction of the clinician.
References
Simkin P (1995). Reducing pain and Enhancing Progress in Labor: A Guide to Non-Pharmacological Methods for Maternity Caregivers. Birth 1995; 22:161-170
Hodnett ED, Lowe NK, Hannah ME et al (2002). Effectiveness off Nurses as Providers of Birth Labour Support in North American Hospitals. JAMA 2002; 288(11):1373-81
Elbourne E, Wiseman RA (2006) Types of Intramuscular Opioids for maternal pain relief in labour. Cochrane Database of Systematic Reviews 2006; (4): CD001237
Bricker L, Lavender T (2002). Parenteral Opioids for Labor Pain Relief: A Systematic Review. Am J Obstet Gynecol, 186 (5): S94-109
