Wednesday, April 25, 2012

Pain Management

The Cochrane Pregnancy and Childbirth Group is consumer driven. They have recently identified pain relief as a topic of utmost importance to women in our country. They state that women experience pain associated with childbirth in varying degrees of intensity. This pain is experienced quite individually and is influenced by physiological and psychosocial factors. Ultimately, maternal satisfaction with the birthing experience should lead to less post partum depression and better coping with and adjustment to motherhood.  They funded a study to provide an evidence-based summary of the safety and the efficacy of pain management. Evidence was collected from 312 randomized, controlled trials.

Fifteen childbirth pain managements were identified for this study. They include: no treatment/ placebo, hypnosis, biofeedback, sterile water injection, water immersion, aromatherapy, various relaxation techniques including yoga and music, acupuncture and acupressure, massage, reflexology, TENS, inhaled analgesia, opioid drugs and non-opioid drugs, local nerve blocks and epidural. Effect  of the interventions were included and ranged from satisfaction with pain relief ( based on  intensity of pain ), sense of control in labor and satisfaction with the entire childbirth experience.  Safety of interventions ranged from effect on infant/ maternal interaction, breastfeeding, assisted vaginal birth, cesarean section, adverse effects on both mother and baby, admission to NICU, Apgar score at less than five minutes and poor long-term infant outcomes.

More studuies of pharmacological as opposed to non-pharmacological interventions were included. Pharmacological methods did relieve pain and did have side effects. Epidural, combined spinal epidural and inhaled nitrous oxide and oxygen relieved pain better than opioids. Epidurals are associated with risk of low blood pressure, urine retention and fever. Increased use of forceps, shivering, tinnitus, and respiratory or cardiovascular depression may occur. Effect on breastfeeding was found uncertain. Combined spinal epidurals provided faster relief than traditional epidurals but caused increased itching, sweating and tingling. Inhaled nitrous oxide was found to cause nausea and drowsiness but showed minimal toxocity and was eliminated from both mother and infant rapidly. Non-opioids, like NSAIDS relieved pain for short periods of time. Opioids cross the placenta and showed to provide less relief than epidurals. They cause variable fetal heartrates, decreased awareness, neonatal respiratory depression and hypothermia. They cause maternal sedation, hypoventilation, urine retention and impaired capacity for decision making.

Non-pharmacological methods are seen more with midwife-led births and where there is continual intrapartum support. These methods are meant to break the fear-pain-tension cycle and to work within the framework of the idea that childbirth associated pain is normal and that coping skills and management is appropriate. Studies of these non-pharmacological methods are lesser and more incomplete than pharmacological studies.

The conclusion is that as part of a childbirth preparation program, clients should be made aware of all methods of pain management and their efficacy and side effects. Women should be made to feel free to choose methods based on information, physiological and psychosocial perceptions of the experience and should lead to maternal satisfaction and good maternal and fetal outcomes.