Melomed Articles


14 February 2019 - Dr. Aneeqah Hendricks

Management of pain in labour


A. INTRODUCTION
Labour and delivery is a time of intense pain, which is often influenced by the psychological, emotional, social, cultural and physiological state of the mother. Multiple methods of alleviating pain during the birthing process are currently available. Whether you choose pharmacological methods such as morphine or an epidural, or non-pharmacological methods (water, hypnotism, acupuncture, acupressure to make labour easier, be prepared for some degree of pain or discomfort. 

Maternal physiological responses to labour pain may influence maternal and foetal well-being and labour progress. Pain, stress and anxiety cause release of stress hormones such as Cortisol and β-endorphins.The sympathetic nervous sytem response to pain leads to a marked increase in circulating catecholamines that can adversely affect uterine activity and uteroplacental blood flow. Effective pain management attenuates or eliminates these responses. 

B. PHARMACOLOGICAL (MEDICATION)
Most commonly used are Entonox (gas), opiates (Morphine and Pethidine) and Epidural. Many women end up relying on some type of method to reduce the physical pain of childbirth. As you prepare for labour, it is important to become familiar with the pain medications that are available, how they work, their risks and their benefits.

The Pros and Cons of using pain-relieving drugs in labour:

ENTONOX
PROS
  • It works quickly
  • It leaves the system quickly
  • Self administered, more control for patient
  • Helps focus the breathing
  • No known side effects to the fetus
  • Can be used at home or in the birth pool
  • CONS
  • Can make you feel nauseous
  • Can make you feel dizzy, not with it' and out of control
  • Long term effects on baby unknown

  • PETHIDINE, MORPHINE
    PROS
  • Acts as a sedative, relaxes and calms
  • Takes the edge off the pain
  • Works quickly
  • Can help you rest, best given in early labour
  • CONS
  • Can cause nausea and vomiting
  • Mobility may be reduced therefore can slow labour
  • Interferes with endorphin production
  • Increased risk of intervention
  • Interferes with prolactin( milk production hormone)
  • Crosses through to the baby and if given too close to birth can affect baby's breathing and sucking 

  • EPIDURAL
    PROS
  • Provides total pain relief when effective
  • Does not cause drowsiness
  • Lowers blood pressure
  • CONS
  • Reduced mobility
  • You will need an IV line
  • Can slow labour
  • Increased risk of intervention and instrumental delivery 
  • Will need a urinary catheter
  • Can cause itching and severe headache


  • C. NON PHARMACOLOGICAL
    Hypnosis:  With a little practice throughout pregnancy, women learn the process of becoming deeply relaxed and free of fear so the uterine muscles can work with minimal pain.  

    Acupuncture/acupressure involves applying pressure to specific points in the  body , to provide pain relief and encourage an efficient labour.

    TENS (Transcutaneous Electrical Nerve Stimulation) provides relief for the first stage of labour (25-60% effective). Also good for backache. Machines can be bought or hired.

    Therapeutic Touch Or Massage: The purpose of therapeutic touch in labour is to communicate caring and reassurance. Painful contractions of the uterus can be treated by the application of pressure with the hands to the womans back, abdomen, hips, thighs, sacrum or perineum

    Anxiety is reported to be reduced in patients who receive reassuring touch. In a retrospective study of 30 patients, 77% experienced less pain' when they were touched during labor, and 40% reported less need for pain medication.
     
    MOVEMENT: whatever feels comfortable egg bouncing gently on Pilates ball.
    Heat: sitting in warm bath.

    DOULA
    Having A Doula: Their Benefits And Purpose
    The word doula is a Greek word meaning women's servant. Women have been serving others in childbirth for many centuries and have proven that support from another woman has a positive impact on the labor process.

    What is a doula?
    A doula is a professional trained in childbirth that provides emotional, physical, and educational support to a mother who is expecting, is experiencing labor, or has recently given birth. The doula's purpose is to help women have a safe, memorable, and empowering birthing experience.

    What does a doula do?
    Most doula-client relationships begin a few months before the baby is due. During this period, they develop a relationship in which the mother feels free to ask questions, express her fears and concerns, and take an active role in creating a birth plan.

    Doulas do not provide any type of medical care. However, they are knowledgeable in many medical aspects of labor and delivery.

    As such, they can help their clients gain a better understanding of the procedures and possible complications in late pregnancy or delivery.


    During delivery, doulas are in constant and close proximity to the mother. They have the ability to provide comfort with pain-relief techniques including breathing techniques, relaxation techniques, massage, and laboring positions. Doulas also encourage participation from the partner and offer reassurance.

    After the birth, many labor doulas will spend time helping mothers begin the breastfeeding process and encouraging bonding between the new baby and other family members.

    What are the benefits of having a doula?
    Numerous studies have documented the benefits of having a doula present during labor. A recent Cochrane Review, Continuous Support for Women During Childbirth, showed a very high number of positive birth outcomes when a doula was present. With the support of a doula, women were less likely to have pain-relief medications administered and less likely to have a cesarean birth. Women also reported having a more positive childbirth experience.1

    Other studies have shown that having a doula as a member of the birth team decreases the overall cesarean rate by 50%, the length of labor by 25%, the use of oxytocin by 40%, and requests for an epidural by 60%. 2

    The key to choosing a doula is to find a person with whom you feel comfortable.
    Questions to Ask a Potential Doula:
  • What training have you had?
  • What services do you provide?
  • What are your fees?
  • Are you available for my due date?
  • What made you decide to become a doula?
  • What is your philosophy regarding childbirth?
  • Would you be available to meet with me before the birth to discuss my birth plan?
  • What happens if for some reason you are not available at the time I give birth?

  • W.O.M.B.S  stands for Women Offering Mothers Birth Support and they are the Doula association in Cape Town.
    Contact them to find  a suitable doula.

    Melomed labour ward staff encourages doula support in pregnancy and labour and they doula and husband is allowed to be in delivery room.

    D. CONCLUSION
    Write down your wishes in your birth plan, but remember that you should keep an open mind. You may find that you want more pain relief than you'd planned, or your doctor or midwife may suggest more effective pain relief to help the delivery.

    Ask your midwife or doctor to explain what's available so that you can decide what's best for you.
    Whether you decide to use pain relief during labour, there are a number of techniques that will help you be more relaxed, which can help you to cope with the pain.



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