Birth is a normal, healthy part of a woman’s life. This unexplainable happiness is usually accompanied by severe pain due to contractions.
Labour is a health state that most women aspire to, at some point in their lives. The first thought that comes to the mind of an expecting woman regarding her delivery is the pain of labour.
Labour is a normal physiological process, which while should be an occasion for rejoicing
2. FROM THE HOLY QURAN
IN THE NAME OF ALLAH THE
MOST BENEFICIENT THE MOST
MERCIFUL
“AND THE PAINS OF CHILDBIRTH DROVE
HER TO THE TRUNK OF A DATE PALM.
SHE SAID “ WOULD THAT I HAD DIED
BEFORE THIS, AND HAD BEEN
FORGOTTEN AND OUT OF SIGHT”.
3. Introduction
Birth is a normal, healthy part of a woman’s
life. This unexplainable happiness is usually
accompanied by severe pain due to
contractions.
Labour is a health state that most women
aspire to, at some point in their lives. The
first thought that comes to the mind of an
expecting woman regarding her delivery is
the pain of labour.
Labour is a normal physiological process,
which while should be an occasion for
4. CONTD…
The amount of pain a woman experiences is
influenced by many individual, physical,
emotional and environmental factors.
Most pain during childbirth results from
normal physiologic events.
If nurses understand the nature and effects of
pain during the labour process, they will be
better prepared to provide supportive care
physical comfort includes offering a variety of
Non-Pharmacologic and Pharmacologic
5. The Debate…
“Labor results in severe pain for many women.
There is no other circumstance where it is
considered acceptable for a person to
experience untreated severe pain, amenable to
safe intervention, while under a physician’s
care… Maternal request is a sufficient medical
indication for pain relief during labor.”
ACOG & ASA
6. What is labor?
• Labor = the act of uterine contractions
combined with cervical change
• Fetus is gradually pushed through the birth
canal (consisting of the cervix, vagina and
perineum)
• Placenta is extruded and uterus involutes
9. How does the uterus contract?
• The uterus is made from a weave of smooth
muscle (myometrium) covered by a smooth
cellular surface (serosa) – all formed by the
joining of the two original mullerian horns
• The cavity is hollow and lined by
vascular/stromal bed that is responsive to
hormonal stimulation (i.e. menstrual cycle)
11. What does the myometrium need
to contract?
• CALCIUM!
• Calcium channels allow influx which
through a cascade of events activates
myosin
• Smaller calcium supply comes from other
organelles (i.e.. Sarcoplasmic reticulum)
• These all play a part in how we can
manipulate labor!
14. Physiology of labour
Series of events that take place in the
genital organs to expel the viable products of
conception out of the womb through the
vagina into the outer world is called normal
labour.
15. STAGES OF LABOUR: divided into
4 stages.
First stage of labour – true labour
contractions
Second stage starts from full
dilatation of cervix till expulsion of
fetus.
Third stage begins after the
expulsion of fetus and ends with the
expulsion of placenta and
membranes.
Fourth stage is the stage of
20. The second stage of labor usually lasts about 90 minutes.
During this stage, the cervix opens sufficiently and the baby
begins to move down the birth canal. The mother pushes,
or bears down, in response to pressure against her pelvic
muscles. The crown of the baby’s head becomes visible in
the widened birth canal.
21. Nature of Labor Pain – 2nd
Stage
• Somatic pain
– Perineum
•Sharper and more
continuous
• Pressure or nerve entrapment
(caused by the fetus’ head)
– May cause severe back or leg
pain
22. Following the exit of the infant, the third stage of labor
occurs. The uterus continues to contract, expelling the
severed umbilical cord and placenta, called the afterbirth.
The third stage occurs within ten minutes of the baby’s birth.
23. As the head emerges entirely (left) the physician turns the
baby’s shoulders (right), which emerge one at a time with the
next contractions. The rest of the body then slides out
relatively easily, and the umbilical cord is sealed and cut.
24. Fourth Stage of Labor
• Stage 4
– Immediate period after placental delivery
– Uterus contracts to close off venous sinuses
and slow bleeding
– Watch for signs of post-partum hemorrhage
25. • The Apgar score is a score given at one, five and ten
minutes after the birth of a child. A score of 7-9 is
normal.
• Bonding is the closeness (caring and concern) for
another.
• Feeding, touching and playing are the three basic
elements of bonding.
• Factors that negatively affect bonding are: very
expensive child, very cross or colicky child, wife is
sick, mother refuses sexual advances of father, if
child looks like someone the parents do not like.
26. PHYSIOLOGY OF LABOUR PAIN
The first symptom to appear in first stage of labour
is painful intermittent contractions. This pain is felt
anteriorly with simultaneous hardening of the
uterus. Initially the pain is not strong enough and
come at various intervals of 15-30 min with duration
of about 30 sec. The pain starts from the abdomen,
back and then radiates to thigh.
27. Causes of Pain in Labor
Stage One
Stretching of the cervix
during dilation & effacement
Uterine Anoxia/ Myometrial hypoxia
Stretching of the
uterine ligaments
28. Causes of Pain in
Labor
Stage
Two
Distention of the vagina and
Perineum
Compression of the nerve
ganglia in cervix & lower uterus
Pressure on urethra, bladder,
rectum during fetal descent
Traction on and stretching of
the perineum
29.
30.
31. PAIN RELIEF MEASURES
Normal labour may be easy and trouble free
provided a rational approach is made with
the beginning of pregnancy. Pain can be
relieved by various measures:
Sedatives and analgesics.
Epidural analgesia.
Inhalation agents.
Alternative and
contemporary modalities.
32. Methods of Pain Relief
• Non pharmacologic
– Childbirth methods
• Breathing Techniques
• Relaxation Techniques
• Touch
• Focusing attention on one object
– Effleurage
35. CONTD…
There are several measures used for
relieving pain during labour.
Alternative and contemporary
modalities are one among them; it
refers to all those therapies not
provided by the conventional
methods. These modalities boosts up
the confidence of the women, hence
36.
37.
38. CONTD….
Alternative and contemporary
modalities are simple, safe and
inexpensive.
It considers the human body as the sum
total of its physical, mental, social and
spiritual dimensions. It has no side
effects.
Remedies are based on natural
ingredients thereby advocating a
drugless cure. Alternative modalities
40. GATE CONTROL THEORY
• It implies that a non-painful stimulus can
block transmission of a noxious stimulus.
• It is based on the premise that the gate
modulates the pain impulses.
• There are three types of nerve fibres: A-
Delta fibres(sharp pain), C fibres(dull pain),
A-Beta fibres(light touch).
• The substantia gelatinosa acts as the
modulating gate.
• A-Delta and C firbres open the gate and A-
Beta fibres close the gate.
• Alternative modalities activate the A-Beta
43. AROMA THERAPY
Aromatherapy is the science of using highly
concentrated essential oils or essences distilled from
plants in order to utilize their therapeutic
properties.
stimulates the chemoreceptor sites in the naso-
pharynx and directly affects the hypothalamic-
pituitary, adrenal axis.
Administration includes putting drops in a pillow, in
a bath.
Important essential oils
(1) Lavender Oil
(2) Neroli Oil
(3) Rose Oil
46. TOUCH AND MASSAGE:
Therapeutic touch in labour is to communicate
caring and reassurance.
Painful uterine contractions can be treated by the
application of pressure with the hands to the
women’s back, abdomen, hips, sacrum etc.
Touch and massages stimulates the body to release
endorphins which are natural pain killing and mood
lifting hormones.
Massage is thought to have physiological basis,
blocking pain impulses by increasing A-fiber
transmission or by stimulating large diameter nerve
fibers to close a gate of pain, stimulating circulation
with resultant increased oxygenation to tissues and
facilitating the excretion of toxins through the
47.
48. Latent Phase:
In a 10ml bottle =pour 4drops of lavender+ 2 drops
of neroli +add vegetable oil.
Massage temples, forehead and chest and advice to
take deep breaths.
Active Phase:
In 10ml bottle pour 6 drops lavender+ 1drop
neroli+1drop rose oil + add vegetable oil.
Massage and advice to breathe and relax.
50. BREATHING EXERCISES
The theory behind breathing patterns is that the
thought process is redirected from the painful
response. Breathing exercises should be done at
the beginning and at the end of each contraction.
Some of the breathing exercises are:
(1)Slow breathing
(2)Light accelerated breathing:
(3)Variable transition breathing:
(4)Slow relaxed abdominal breathing
51. Procedure:
Fill a small tuberculin syringe with sterile water
Identify the posterior superior iliac spine and
mark them.
Approx. 3 to 4 cm down and 1 to 2 cm in
identify other two points and mark them.
During a contraction inject a small amount of
sterile water into the skin raising a bleb
Repeat at the other three sites as quickly as
possible.
During the injection the woman will feel a
sharp stinging pain.
The stinging will fade in 10 to 15 sec.
Avoid back massage after the water block as it
could shorten the duration of action.
Procedure:
Fill a small tuberculin syringe with sterile water
Identify the posterior superior iliac spine and
mark them.
Approx. 3 to 4 cm down and 1 to 2 cm in
identify other two points and mark them.
During a contraction inject a small amount of
sterile water into the skin raising a bleb
Repeat at the other three sites as quickly as
possible.
During the injection the woman will feel a
sharp stinging pain.
The stinging will fade in 10 to 15 sec.
Avoid back massage after the water block as it
could shorten the duration of action.
INTRA-DERMAL WATER BLOCKS
52. INTRA-DERMAL WATER BLOCKS
It is a new technique for non-narcotic pain relief.
With slight modifications it can be used in labour,
especially for posterior positions.
.
59. HYDROTHERAPYOne of the safest and most effective forms of
pain relief in labour is the immersion in deep
water or a warm shower.
Hydrotherapy has been used for relaxation,
healing and pain relief for centuries. It relieves
the stretching sensations of ligaments and areas
associated with posterior presentation.
Mode of action
There are three factors that contribute to the
benefit of hydrotherapy: heat, buoyancy and
massage.
Immersion in water results in increased
circulation.
The buoyancy of water creates a weightless
feeling and promotes relaxation
One of the safest and most effective forms of
pain relief in labour is the immersion in deep
water or a warm shower.
Hydrotherapy has been used for relaxation,
healing and pain relief for centuries. It relieves
the stretching sensations of ligaments and areas
associated with posterior presentation.
Mode of action
There are three factors that contribute to the
benefit of hydrotherapy: heat, buoyancy and
massage.
Immersion in water results in increased
circulation.
The buoyancy of water creates a weightless
feeling and promotes relaxation
60. CONCLUSION
Alternative and contemporary modalities
are the techniques which imparts a sense
of well being in an individual with the
desired effect. The main advantage is that
it can be discontinued at any time without
any side effects. Midwives should possess
adequate knowledge about these
modalities.
61.
62.
63. Bishop Score
ParameterScor
e
0 1 2 3
Position Posterior Intermediat
e
Anterior -
Consistency Firm Intermediat
e
Soft -
Effacement 0-30% 40-50% 60-70% 80%
Dilation <1 cm 1-2 cm 2-4 cm >4 cm
Fetal station -3 -2 -1, 0 +1, +2
64. Cervical Ripening
• Mechanical
– Stripping (or sweeping) of the fetal membranes
– Placement of hygroscopic dilators within the
endocervical canal
– Insertion of a balloon catheter above the
internal cervical os (with or without infusion of
extra-amniotic saline)
• Pharmacologic
– Prostaglandins
• Prostaglandin E2-cervidil
• Prostaglandin E1-misoprostil
65. After the initiation of labor…
• Factors responsible for the ongoing labor
process include:
– Oxytocin
– Prostaglandins (PGF2-alpha, thromboxane,
PGE1,E3)
– Endothelin (by receptor-PLC coupling via
nifedipine sensitive channels)
– Epidermal Growth Factor
67. Stages of Labor
• First stage – Latent and active labor
• Second stage – Descent with pushing to
delivery of baby
• Third stage – Delivery of placenta
• Fourth stage – involution of the uterus
69. Stages of Labor
• Stage 1 (Latent Phase)
– Uterus and cervix prepare for active labor
– Dilatation up to 4 cm
– Variable length of time
70. Stages of Labor
• Stage 1
– The “Active” Phase – rapid cervical dilatation
from 4 centimeters to 10 centimeters (or
complete dilatation). Varies for nulliparous vs.
multiparous patients
• Nulliparous – 1.2 cm/hr
• Multiparous – 1.5 cm/hr
71. Stages of Labor
• Stage 2 “Pushing”
– Starts from complete dilatation to delivery of
the fetus
– Variable depending on parity maternal forces
– Fetus has to make it’s way through the curves
of the pelvis
72. Third Stage of Labor
• Stage 3
– From delivery of the fetus to delivery of the
placenta
– Variable amounts of time for placental
extrusion but generally within the first 20-30
minutes
– Medications can be used to augment placenta
delivery and post-partum bleeding
74. Occiput posterior (OP) presentation
• Approximately 10% of
deliveries
• Face is looking up
towards the ceiling
versus the floor
• Fetus must perform
opposite
flexion/extension
maneuvers to navigate
the birth canal
76. What can we do when labor is
not progressing?
• Natural methods
– Rupture of membranes
– Walking
– Nipple stimulation
– Position change
– Herbs (used as abortifacients)
77. Medical treatments for protracted
labor
• Augmentation of contractions with Pitocin
• Anesthesia
• Repositioning of fetal head
• Assistance with vacuum or forceps
78. Considerations for Operative
Vaginal Delivery
• Maternal Criteria
– Adequate analgesia
– Lithotomy position
– Bladder empty
– Clinical pelvimetry must be adequate in
dimension and size
– Consent
79. Considerations
• Fetal criteria
– Vertex presentation
– Fetal head engaged in the pelvis
– Position of fetal head must be known
– ? Presence of caput or molding
80. Considerations
• Other criteria
– Cervix fully dilated
– Membranes ruptured
– No placenta previa
– Experienced operator
– Capability to perform an emergent cesarean
delivery if needed
81. How far we’ve come…
• Addition of
anesthesia, antisepsis
and sterile technique
• Closure of uterine
incisions vs.
hysterectomy
• Significant reduction
in mortality after
1940’s –Why?
What are the characteristics of contractions and how these related to labor progress?
What are the causes of pain during the first stage of labor?
What are the causes of pain during the second stage of labor?
What are methods of non-pharmacologic pain relief in providing general comfort?
Several midwifery pearls involve the use of non-pharmacologic approaches to pain management in labor. These include ambulation and freedom of movement, hydrotherapy during the active phase of labor, and continuous support of the woman in labor. All of these approaches are supported by research (ACNM, 2014).
Hydrotherapy is beneficial and safe for laboring women.
Historically hydrotherapy was not used in labor due to the concern that it would increase the risk for maternal and/or fetal infection in the setting of ruptured membranes. However, the use of a warm tub bath to soothe the pain of labor has become a common practice in the past two decades and has been extensively studied.
In a review of 8 randomly controlled trials involving 2939 women, researchers demonstrated that immersion in water during labor was associated with a statistically significant decrease in the use of anesthesia and a decrease in reported pain. No adverse maternal or neonatal outcomes were reported.
Water immersion can facilitate the neuro-hormonal interactions of labor, alleviate pain, improve uterine perfusion, and enhance labor progress (Ginesi & Niescierowicz, 1998a, 1998b).
If you don’t have a tub, you can always use the shower.
