Documente Academic
Documente Profesional
Documente Cultură
DEPARTMENT OF MIDWIFERY
BY JEMANESH DESTA
SEPTEMBER, 2020
DESSIE, ETHIOPIA
Contents
1. Introduction .......................................................................................................................................... 1
2. Non pharmacologiclal labour pain managment....................................................................................... 2
2.1 Water immersion ................................................................................................................................ 2
2.2 Relaxation and visualization ............................................................................................................... 3
2.3 Homeopathy and aromatherapy ........................................................................................................ 3
2.3.1 Mechanism of Essential Oils ........................................................................................................ 4
2.4 Massage and transcutaneous electrical nerve stimulation ................................................................ 4
2.5 Attention focusing and distraction ..................................................................................................... 5
2.6 Hypnosis .............................................................................................................................................. 5
2.7 Music and audio analgesia .................................................................................................................. 6
2.8 Bio feed back ....................................................................................................................................... 7
2.9 Acupuncture or acupressure............................................................................................................... 7
2.10 Continuous labour support ............................................................................................................... 8
2.11 Maternal movement and changes in position .................................................................................. 8
2.12 Reflexology ........................................................................................................................................ 8
3. Reference .................................................................................................................................................. 9
1. Introduction
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage. Labor Pain is a pain and discomfort associated
with the contraction of uterus during labor. The extent of pain elimination depends upon how
much the spinal cord is blocked. The use of analgesics and anesthetic agents may not be the first
choice for pain management for women in labor because of their potential side –effects.
Some of the non-pharmacological techniques which are frequently used during labor are:
Massage Therapy, Breathing and relaxation, hydrotherapy, Changing positions, hot and cold
applications & music therapy. The benefits of using non-pharmacological pain relief techniques
in labor are their attributes of being non-invasive, low-cost, simple, effective, and without
adverse effects(1)
Labor pain is complex and multifaceted, existing within an individual perception and context,
and arising from individual physiology, psychology and cultural perspectives. Notions of
‘normal labor’ differ depending on cultural background, spiritual practice and a woman’s
phenomenological experiences
The physiology of pain is usually considered within the realm of a pathological situation, with
connotations of distress and suffering. The functionality of pain is predominantly one of
protection and warning, labor pain must be differentiated from pathological connotations,
necessitating midwives to redefine it in the context of normal physiological birth.
The quality and intensity of discomfort during the process of labor can vary dramatically, and
requires support and reassurance to enable women to respond with confidence to the unknown
experience of labor
Throughout labor, pain manifests as visceral discomfort from nociceptors in the uterus and
cervix, developing into somatic pain as the perineal structures stretch and distend with
discomfort originating from pressure on the pudendal nerves. Translation of these sensations
occurs as stimulation reaches the thalamus, brain stem, and cerebellum, hypothalamic and limbic
systems, going through a process of transitory analysis with nociceptor impulses then becoming
modulated by the central nervous system .Endorphin release, prompted by certain nerve
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stimulation can translate ascending nociceptor information, counteracting the discomfort
experienced and decreasing the intensity of pain.
The most recent guidance recommends that women be offered the ‘opportunity to labour in water
for pain relief ’, although in practice this can be challenging to facilitate; there is variation in
accessibility and availability owing to differences in birthing environment and levels of
midwifery confidence.
Water immersion can be a useful tool in either the hospital or home setting, enabling women and
their partners to self-manage levels of discomfort. Midwifery advice to utilize water in the latent
phases of the birth process (2)
Bathing in labor confers no clear benefits for the laboring woman but may contribute to adverse
effects in the neonate It can be used as either :- shower, tub, whirlpool, birth pool.
Hydro thermic effect arises from water being a conductor of heat. The conduction of heat
through the skin and mucous membrane release muscle spasm and pain relief. Hydrokinetic
effect is the sensation of the abolition of gravity’ that is experienced during immersion .The
combined effect of the two leads to relaxation and reduced anxiety. (2)
Intradermal water blocks, also called intra cutaneous sterile water injections, decrease low back
pain during labor Estimates of the incidence of low back pain in labor range between 15% and
74% of all labors. Intradermal water blocks consist of 4 intradermal injections of 0.05- to 0.1-mL
sterile water (using a 1-mL syringe with a 25-gauge needle) to form 4 small blebs, 1 over each
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posterior superior iliac spine and 2 others placed 3 cm below and 1 cm medial to each of the first
sites. Exact locations of these do not appear to be critical to its success. (3)
Anxiety and fear cause an increase in pain owing to muscle tension. If the fear–tension–pain
syndrome cycle is to be broken, then women must be psychologically at ease without the
presence of fear for the impending labour. If they are not relaxed and free from fear, women may
experience the aforementioned ‘fear cascade’, occurring when they feel alone and unsupported
This can pave the way for catechol amines, cortisol and vasopressin’s, which disrupt oxytocin
production and cause physiological responses owing to maternal distress increasing levels of
adrenaline. Fear and adrenaline prompt a ‘fight or flight’ response, resulting in vasoconstriction
decreasing oxygenated blood to all non-essential organs, including the uterus. (2)
Aromatherapy is the use of essential oils derived from plants to increase the body’s sedative,
stimulate and relaxing substances. Essential oils are obtained by distillation and then mixed with
carrier oil such as grape seed, sweet almond and sesame, although carrier oils can also contain
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active ingredients such as aloe Vera. Oils can be inhaled using steam infusion or a burner, and
can also be used in a bath or for massage, which may be particularly effective in the intra partum
environment. (2)
The limbic system is the emotional Centre of the brain; it can influence the pulse rate, B.P,
respiration and response to stress.
Stimulation of the limbic system triggers release of encephalin (natural pain killers), endorphins
(natural opioids), serotonin (natural sedatives) which leads to:- restful, balanced mood,
awareness of senses, maintenance of body temperature. In effect - scent can help to relax and
reduce anxiety
3. Internal method :- In the U.K., oral and rectal routes are not advocated except under the
direction of medical practitioners. Perineal lavage (lavender or chamomile) can be used post-
partum. (4)
Massage is manipulation of the body’s soft tissues, and during the intra partum period massage
techniques in different areas can aid relaxation and soothe the woman.
For a woman experiencing lower back ache, lumbosacral massage may be soothing, whereas for
a woman feeling tense and anxious, shoulder massage may enable relaxation
The efficacy of massage suggests that massage leads to increased vagal activity, therefore
reducing maternal pulse rate, blood pressure and cortisol levels, also improving blood flow and
oxygenation of tissues .
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and active phases of labour. TENS is hypothesized to complement the release of endogenous
endorphins, mediating the experience of pain and may reduce the length of labour by suppressing
catecholamine release. (2)
TENS seems to have a satisfactory pain reducing properties through the labor. The pain
characteristics and woman satisfaction during labor and episiotomy were intermediate; better
analgesic than paracetamol, while inferior to pethidine. Nevertheless, the adverse maternal and
fetal outcomes of TENS are significantly lower than pethidine. The superior safety profile
together with the ease of use, women self-administration, availability and reduced cost make
TENS an ideal choice for labor analgesia. (5)
Attention focusing may be accomplished by deliberate intentional activities on the part of the
labouring woman. Examples include attention to verbal coaching, visualization and self-
hypnosis, performing familiar tasks (such as grooming and eating), concentration on a visual,
auditory, tactile, or the stimulus, and patterned breathing. While patterned breathing continues to
be taught in many childbirth education programs, no controlled studies have evaluated its
effectiveness. The results of a small study of patterned breathing suggest that it may increase the
mother’s fatigue if begun too early in labor, and should be restricted to active labour
Distraction may be a more passive form of attention focusing, with stimuli from the environment
(television or a walk out of doors) or from other people drawing a woman’s attention away from
her pain. It does not require as much mental concentration as deliberate attention-focusing
measures, and is probably ineffective when pain is severe. Attention focusing and distraction are
usually used in combination with other strategies. (6)
2.6 Hypnosis
Hypnosis it is defined as ‘a temporarily altered state of consciousness, in which the individual
has increased suggestibility’. Under hypnosis, a person demonstrates physical and mental
relaxation, increased focus of concentration, ability to modify perception, and ability to control
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normally uncontrollable physiological responses, such as blood pressure, blood flow, and heart
rate.
Hypnosis is used in two ways to control pain perception in childbirth: self - hypnosis and
posthypnotic suggestion. Most hypnotherapists teach self-hypnosis, so that women may enter a
trance during labor and reduce awareness of painful sensations.
Among the techniques used are: relaxation; visualization (helping the woman imagine a pleasant,
safe scene and placing herself there, symbolizing her pain as an object that can be discarded, or
picturing herself as in control or free of pain); distraction (focusing on something other than
thepain); and glove anesthesia (through suggestion, creating a feeling of numbness in one of her
hands, and then spreading that numbness wherever she wishes by placing her numb hand on the
desired places of her body). The woman is taught to induce these techniques herself; only rarely
do hypnotherapists accompany their clients in labour. (6)
Broadly, music therapy procedures are structured as either receptive or active. Receptive music
therapy frequently accompanies other forms of therapy, incorporating music chosen by the
patient in consultation with a qualified music therapist. The musical interventions are often
selected to arouse specific emotions, which, in turn, allow the patient to more easily access,
recall, and interrogate memories with the goal of understanding the role those memories play in
the patient’s current circumstances.
Indeed, the alleviation of pain and the reduction of anxiety which can exacerbate pain appear to
be the most promising use of music therapy. Music therapy improved both sleep and quality of
life for 65 patients with acute or chronic back pain listening to specific types of music reduced
pain and anxiety in patients undergoing hemodialysis. (7)
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2.8 Bio feed back
Biofeedback is a non-invasive therapy which should be administered after a medical consultation
has ruled out serious symptoms or an underlying chronic disorder. It is given to women during
labour to reduce the perception of pain during labour.
It is an alternative approach that aims to allow women to gain control over their body responses,
for example by concentrating on their rate, rhythm and type of breathing, and has been used as a
behavioral therapy for multiple health problems, including pain. The purpose of the review was
to see whether biofeedback, taught in prenatal classes, would have an effect in relieving pain
during labour. (9)
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combination of specific points .it provides an effective alternative to pharmacologic pain relief. It
may be useful for those women who want to avoid or delay pain medications or in settings where
pain medication. (10)
2.12 Reflexology
Reflexology is an ancient natural therapy which uses subtle energies of the feet to balance and
harmonise the being, so that he or she may attain and maintain health and wellbeing. To put it
simply everything that happens in the being is reflected in the feet, and everything that happens
in the feet is reflected in the body. Reflexology offers a woman in labour a very unobtrusive and
gentle method of pain control.
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Corresponding reflexes for the uterus, fallopian tubes, ovaries and pelvic region are situated in an
area around the ankle bones and can be stimulated by massage, using either circular movement
with the thumb and forefinger or press and hold method. In labour, for pain relief there are five
reflex zones used:-
1. Entire being: General massage to the whole foot to relax the mother and encourage inner
stillness.
2. “Solar Plexus” (centre of energy): Using bimanual hold technique with the thumb on the solar
plexus zone, rest fingers naturally and hold for 1-10 minutes to aid relaxation.
3. Chest: Using the lung press (metatarsal press) to influence regular breathing.
4. Adrenal glands: Using technique to sedate, thumb press and rotate counter clockwise. This
helps to lower adrenaline output and encourage endorphin release.
5. Pelvis: Using the techniques of pelvic stretches to relax the pelvis. (11)
3. Reference
1. Amshu Dhaka , Shrooti Shah, et,al .assessment of knowledge on non-pharmacological
methods of pain relief during labour among nurses working in maternity and children
hospital Nepal, jcmc/ vol 7/ no. 3/ issue 21/ jul-sep, 2017.
2. Ruth Alexandra Sanders, Kathryn Lamb, Non-pharmacological pain management
strategies for labor: Maintaining a physiological outlook, British Journal of Midwifery,
Vol 25, No 2, February 2017
3. Penny Simkin, PT, and April Bolding, PT, Update on Non pharmacologic Approaches to
Relieve Labor Pain and Prevent Suffering, by the American College of Nurse-Midwives ,
Volume 49, No. 6, November/December 2004)
4. Jackson J. Aromatherapy. London:Darling Kindersly, 1986)
5. Hanan A. A. Farra, Hatem S. Shalab, The Safety and Efficacy of Transcutaneous Nerve
Stimulation (TENS) in Reducing Vaginal Delivery Labor Pain: Randomized Controlled
Clinical Trial, Published: May 11, 2020)
6. Witoon Prasertcharoensuk MD* Jadsada Thinkhamrop MD,MS, Non-Pharmacologic
Labour Pain Relief, J Med Assoc Thai 2004; 87(Suppl 3): S203-6)
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7. Guenther Bernatzkya, Michaela Prescha,et,al. Emotional foundations of music as a non-
pharmacological pain management tool in modern medicine, Neuroscience and
Biobehavioral Reviews, 2011
8. Janula raju1, Mahipal Singh2, effectiveness of biofeedback as a tool to reduce the
perception of labour pain among primigravidas: pilot study, Turkish journal of family
medicine and primary care (tjfmpc) ▪ www.tjfmpc.com ▪ vol. 7, no.3 ▪ September 2013
9. Irma Marcela Barragán Loayza1, Ivan Solà2, et,al. Biofeedback for pain management
during labour, New, published in Issue 6, 2011.)
10. Penny Simkin, PT, and April Bolding, PT, Update on Non pharmacologic Approaches to
Relieve Labor Pain and Prevent Suffering, by the American College of Nurse-Midwives ,
Volume 49, No. 6, November/December 2004)
11. Habanananda T. Non- pharmacological pain relief in labour. Journal-Medical Association
of Thailand. 2004 Oct;87:S194-202)
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