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Pain control

Extracted from Survival Guide to Midwifery, 2nd Edition (2012) Diane M. Fraser and Margaret A. Cooper, Oxford; Churchill Livingstone: 2012. Courtesy Elsevier

A clear distinction should be made between the traditional goal of pain relief and control of pain in labour. The aim should be to give the woman control of pain rather than trying to eradicate it. This may require a multifaceted approach that includes pharmacological and non-pharmacological methods.

Non-pharmacological methods of pain control

  • Breathing and relaxation techniques
  • Massage
  • Hydrotherapy
  • Aromatherapy
  • Transcutaneous electrical nerve stimulation (TENS)
  • Reflexology
  • Homeopathy
  • Music therapy
  • Acupuncture
  • Herbal medicine

A Cochrane review of studies involving acupuncture, acupressure, aromatherapy, massage and relaxation techniques found that acupuncture reduced the need for analgesia; women taught self-hypnosis had decreased need for pharmacological analgesia; no differences were seen for women receiving aromatherapy. Few other complementary therapies have been subjected to scientific study. In the UK, the National Institute for Health and Care Excellence suggests that breathing and relaxation techniques, and massage, may be helpful and have no side effects. Women should be offered the option of being in water during labour as this helps with pain. Acupuncture, acupressure or hypnosis are not available on the NHS, but women can use these techniques if they wish. Starting to use a TENS machine once the woman is in established labour will not help with pain.

Pharmacological methods of pain control

  • Opiate drugs. Frequently used during childbirth because of their powerful analgesic properties. The most commonly used are those listed below. All have similar pain-relieving properties, but they also have side effects, including nausea, vomiting and drowsiness in the mother, and depression of the baby's respiratory centre at birth.
  • Pethidine: usually administered intramuscularly in doses of 50 - 150 mg; takes about 20 minutes to have an effect
  • Diamorphine: usual dose is 10mg given via intramuscular injection
  • Meptazinol: usually given in doses of 100 - 150 mg intramuscularly
  • Inhalation analgesia. The most commonly used inhalation analgesia in labour is a premixed gas comprising up to 50% nitrous oxide and 50% oxygen, administered through a piped system or via an Entonox apparatus. It takes effect within 20 seconds, with maximum efficacy occurring after about 45-50 seconds.
  • Regional (epidural) analgesia. A local anaesthetic is injected into the epidural space of the lumbar region, usually between vertebrae L1 and L2, or L2 and L3, or between L3 and L4. Continuous infusion of local anaesthetic (bupivacaine) and opioids (usually fentanyl) is administered via a syringe pump. Midwives top up the epidural block by giving a further dose as prescribed by the anaesthetist. The midwife is personally responsible for ensuring she is competent to carry out the procedure, and should be aware of possible complications and their immediate treatment.

The Practising Midwife featured articles

Cochrane Corner: Inhaled analgesia for pain management in labour 2012; 15(9): 42 - 43 Author: Declan Devane

Optimising Endorphins 2012; 15(10): 33 - 35 Mavis Kirkham, Margaret Jowitt

Cochrane Corner: Early versus late initiation of epidural analgesia for labour 2014; 17(11): 30 - 32 Valerie Smith

Cochrane Corner: Oral analgesia for relieving post-caesarean pain 2016; 18(6): 34 - 36 Valerie Smith

Further reading

Royal College of Midwives. (2012) Evidence Based Guidelines for Midwifery-Led Care in Labour: Understanding pharmacological pain relief. https://www.rcm.org.uk/sites/default/files/Understanding%20Pharmacological%20Pain%20Relief_0.pdf

Tidy C. (2015). Pain relief in labour (Professional reference). http://patient.info/doctor/pain-relief-in-labour

NICE (2014). Intrapartum care for healthy women and babies (CG190) - Information for the public. https://www.nice.org.uk/guidance/cg190/ifp/chapter/pain-relief

 

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