User:AntonioZDiaz/Pain management during childbirth

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Pain management during childbirth is the treatment or prevention of pain that a pregnant person may experience during labor and delivery. The amount of pain a pregnant person feels during labor depends partly on the size and position of their baby, the size of their pelvis, their emotions, the strength of the contractions, and their outlook. It is common for pregnant persons to be concerned about how they will cope with the pain of labor and delivery. Childbirth is different for each pregnant person and predicting the amount of pain experienced during birth and delivery can not be certain.

Some pregnant persons do fine with natural methods of pain relief alone. Many pregnant persons blend natural methods with medications and medical interventions that relieve pain. Building a positive outlook on childbirth and managing fear may also help some pregnant persons cope with the pain. Labor pain is not like pain due to illness or injury. Instead, it is caused by contractions of the uterus that are pushing the baby down and out of the birth canal. In other words, labor pain has a purpose.

History[edit]
Prior to the 20th century, childbirth predominantly happened in the home, without access to any medical interventions for pain management. Childbirth was a leading cause of death for pregnant persons, and many were fearful of the process, creating a large desire for pain management. But despite the demands of pregnant persons, little relief was offered before the mid-19th century. Chemical anesthesia during labor was first introduced in 1847, receiving support from persons who can get pregnant and reluctance from physicians. Anesthesia's use was popularized in 1853 by Queen Victoria's decision to use chloroform for pain relief during the birth of her eighth child.

In the early 20th century, a drug-induced state known as "twilight sleep" was developed by Carl Gauss and Bernhardt Kronig, two doctors in Freiburg, Germany. The procedure, especially when performed by untrained doctors, had a number of risks and side-effects. Its rise and fall coincided with both first-wave feminism and the anti-German sentiment that arose during World War I.

In 1956, Pope Pius XII approved the use of painless childbirth; the 1960s saw the rise of epidural analgesics for pain management.

Preparation
Preparation for childbirth can affect the amount of pain experienced during childbirth. Some examples of preparation strategies include childbirth classes, consults with healthcare providers, and coping strategies. Interaction with friends and family can also alleviate concerns.

In addition to the many medications that are administered during childbirth, many pregnant persons manage pain using a range of coping strategies. This provides people who are giving birth the opportunity to mentally prepare for an often painful event. Many people have inherent coping methods, but there have been recent articles researching their efficacy and implementation. After a review of several articles, Escott et al. suggested the following recommendations for systematic evaluation in the context of antenatal education are made: "(i) Increase the range of coping strategies currently utilized to include cognitive based strategies. (ii) Help pregnant persons identify and understand the nature of their own coping styles and preferences, including any unhelpful patterns of pain catastrophizing. (iii) Help pregnant persons develop their own unique set of coping strategies for labor. (iv) Strengthen feelings of coping self-efficacy by practice in class and reinforcement by the class teacher. (v) Develop implementation intentions which account for the changing context of childbirth and (vi) Actively develop prompting and reinforcement of use of identified coping strategies by birth partners. These are the first steps to prepare for child birth and often happen before medication is used."

Educational interventions are also helpful in reducing pain during childbirth. A specific child-birth class that has been researched and evaluated is the “Bonapace Method.” This is an educational intervention that aims to reduce pain during childbirth. This method uses both the pregnant person’s significant partner in addition to pain control techniques. These pain control techniques are based on three neurophysiological pain models: 1. The Gate control theory; 2. CNS control through cognitive structuring and breathing; and 3. Hyperstimulation of acupressure trigger points. Essentially, the partner will massage pressure points on sensitive areas of the body including the hand, calf and sacrum. This is intended to distract the brain from pain from contractions.

The efficacy of this method was studied in a multicenter case control study. It showed that compared to a traditional childbirth training program, pregnant people using the Bonapace Method had a lower pain perception in terms of both unpleasantness and intensity. Pregnant people looking to reduce pain during labor through educational interventions should consider looking into the Bonapace Method and figure out if it is right for them.

Non-pharmacological[edit]
Many methods help pregnant persons relax and make pain more manageable. A review of the effectiveness of non-medical approaches to pain relief found that water immersion, relaxation methods, and acupuncture relieved pain. These and other non-pharmacologic pain management options are further discussed below.


 * Breathing and relaxation techniques
 * Relaxation methods may be helpful in reducing the risk of assisted vaginal births.
 * Warm showers or baths
 * Massage
 * Many types of massage can be used during various stages of labor. Literature suggests light touch or stroke massage techniques may aid in the release of oxytocin, which may help stimulate contractions and facilitate cervical dilatation. Various types of massage may also help soothe and distract from the pain of labor.
 * Warm or cold compresses, such as heat on lower back or cold washcloth on forehead
 * Applying warm compresses, especially to the lower back area, while the cervix is dilating may help reduce pain during the first stage of labor and may even help to decrease the length of labor itself, however, the evidence supporting this is limited.
 * Changing positions while in labor (stand, crouch, sit, walk, etc.)
 * Use of a labor ball
 * Using a labor ball during childbirth first began in the 1980s. It is best used during the first stage of labor. Evidence suggests using a birthing ball can facilitate pain relief by supporting the perineum and providing gentle stimulation to the area during cervical dilatation. It may also aid in fetal descent through various positioning exercises and with gravity.
 * Listening to music
 * Although little evidence supports music as an effective method in decreasing pain, it may provide a distraction or assist in creating a more positive birth experience which may ultimately decrease the chance of negative postpartum outcomes.
 * Acupuncture
 * The use of acupuncture may be associated with fewer assisted vaginal births and caesarean sections. This relates to the neurophysiological pain models described above in the preparation section.
 * Continuous supportive care of a loved one, hospital staff member, or doula
 * The presence of a doula or support attendant may decrease the need for pharmacological pain control and increase the likelihood of spontaneous vaginal births as opposed to cesarean section. A positive support person may also assist in creating an environment leading to a more positive birth experience.
 * Other methods include hypnosis, biofeedback, sterile water injection, aromatherapy, and TENS, however there are limited studies that demonstrate the effectiveness of in reducing pain during labor and delivery by using these methods.

Water and childbirth[edit]
Main article: Water birth

According to the American Office of Women's Health, laboring in a tub of warm water, also called hydrotherapy, helps pregnant persons feel physically supported, and keeps them warm and relaxed. It may also be easier for laboring pregnant persons to move and find comfortable positions in the water.

Water immersion during the first stage of labor may help decrease the need for analgesia and possibly shorten the duration of labor, however, there is limited data to suggest that water immersion during the second and third stages of labor significantly reduce the use of pharmacologic interventions.

In waterbirthing, a pregnant persons remains in the water for delivery. The American Academy of Pediatrics has expressed concerns about delivering in water because of a lack of studies showing its safety and because of the rare but reported chance of complications.

Medical and pharmaceutical methods of pain control[edit]
Physicians, nurse practitioners, physician assistants, nurses and midwives will typically ask the pregnant person in labor if there is a need of pain relief. Many pain relief options work well when given by a trained and experienced clinician. Clinicians also can use different methods for pain relief at different stages of labor. Still, not all options are available at every hospital and birthing center. Depending on the health history of the pregnant person, the presence of allergies or other concerns, some choices will work better than others.

Opioids[edit]
There are many methods of pain relief during labor. Opioids are a type of analgesia that is commonly used during childbirth to assist in pain relief. They can be injected directly into the muscle in the form of a shot or put into an IV. These medications may cause unwanted side effects like drowsiness, itching, nausea, or vomiting to the laboring pregnant person. Although they are short acting in the laboring pregnant person, it takes longer for an infant to clear these medications. All opioids can cross the placenta and may poorly affect the baby by causing problems with heart rate, breathing, or brain function. For this reason, opioids are not given close to delivery. They can be beneficial in early labor, however, since they can help dull pain, but do not impair the pregnant person's ability to move or push. Their use also does not seem to be linked to a higher chance of cesarean sections. There are many things to consider when deciding to use opioids during a delivery and these options, as well as the risks and benefits, should be discussed early in the first stage of labor with a trained medical professional.

Epidural and spinal blocks[edit]
Further information: Epidural administration

Further information: Spinal anaesthesia

An epidural is a procedure that involves placing a tube (catheter) into the lower back, into a small space below the spinal cord. Small doses of medicine can be given through the tube as needed throughout labor. With a spinal block, a small dose of medicine is given as a shot into the spinal fluid in the lower back. Spinal blocks usually are given only once during labor. Epidural and spinal blocks allow most pregnant persons to be awake and alert with very little pain during labor and childbirth. With an epidural, pain relief starts 10 to 20 minutes after the medicine has been given. The degree of numbness felt can be adjusted. With spinal block, good pain relief starts right away, but it only lasts one to two hours.

Although movement is possible, walking may not be if the medication affects motor function. An epidural can lower blood pressure, which can slow the baby's heartbeat. Fluids given through IV are given to lower this risk. Fluids can cause shivering. But pregnant persons in labor often shiver with or without an epidural. If the covering of the spinal cord is punctured by the catheter, a bad headache may develop. Treatment can help the headache. An epidural can cause a backache that can occur for a few days after labor. An epidural can prolong the first and second stages of labor. If given late in labor or if too much medicine is used, it might be hard to push when the time comes. An epidural increases risk of assisted vaginal delivery.

Pudendal block[edit]
Further information: Pudendal anesthesia

In this procedure a doctor injects numbing medicine into the vagina and the nearby pudendal nerve. This nerve carries sensation to the lower part of the vagina and vulva. This method of pain control is only used late in labor, usually right before the baby's head comes out. With a pudendal block, there is some pain relief but the laboring pregnant person remains awake, alert, and able to push the baby out. The baby is not affected by this medicine and it has very few disadvantages.

Inhaled analgesia[edit]
Further information: Inhalational anaesthetic

Another form of pharmacologic pain relief available for a laboring person is inhaled nitrous oxide. This is typically a 50/50 mixture of nitrous oxide with air that is an inhaled analgesic and anesthetic. Nitrous oxide has been used for pain management in childbirth since the late 1800s. The use of inhaled analgesia is commonly used in the UK, Finland, Australia, Singapore and New Zealand, and is gaining in popularity in the United States.

Although this method of pain control does not provide as much pain relief as an epidural, there are many benefits to this type of analgesia. Nitrous oxide is inexpensive and can be used safely at any stage of labor. Inhaled analgesia provides pregnant persons with mild pain relief while allowing them to maintain mobility and have less monitoring than would be required with an epidural. It is also useful in early labor to assist with pain relief and it can be used in conjunction with other non-pharmacologic pain methods such as birthing balls, position changes, and even possibly water birth. The gas is self-administered so the laboring person has full control of how much gas they wishes to inhale at any given time.

Nitrous oxide has the added benefit of limited side effects. Some laboring persons who use this method may experience some dizziness, nausea, vomiting, or drowsiness, however, since dosing is determined by the patient, once these symptoms begin they can limit their use. The gas takes effect quickly, but also lasts a short period of time so the laboring person must hold the mask to their face in order to benefit from the effects of analgesia. There is very little effect to the baby since it is quickly eliminated by the baby as soon as it begins breathing. Evidence does not suggest any clinically significant risk factors in the use of nitrous oxide gas as opposed to other methods of pain management both non-pharmacologic and pharmacologic in terms of Apgar score or cord blood gas. There is also limited evidence to determine whether there are any increased occupational risks to the healthcare provider associated with the use of nitrous oxide.

Pain management after childbirth[edit]
Perineal pain after childbirth has immediate and long-term negative effects for the person who gave birth and their babies. These effects can interfere with chestfeeding and the care of the infant. The pain from injection sites and possible episiotomy is managed by the frequent assessment of the report of pain from the person who gave birth. Pain can come from possible lacerations, incisions, uterine contractions and sore nipples. Appropriate medications are usually administered. Routine episiotomies have not been found to reduce the level of pain after the birth.