Pain Management

Introduction

The aim of the study is focus on non-pharmacological pain treatment to relieve pain without medication. Using non-drug therapies can help to ease the pain and have a greater degree of cont|rol ov|er pa|in. Th|is could imp|rove the qual|ity of li|fe of the patients. The document will report on pa|in manag|ement and usage of no|n-pharma|cologic treatment. The searchable question is;

“Is utilization of non-pharmacologic pain management effective during labor process?”

Pain during the delivery process has been reported since ancient times. However, even with the current non-pharmacological resources for the relief of this symptom, it still constitutes a reality in obstetric services. Measures and resources for pain control during labor, as well as other types of pain, have been the subject of study and debate. Pain is characterized by an unplea|sant emoti|onal sens|ory experi|ence associated or rela|ted to act|ual or pote|ntial tis|sue injury (Treede, Rief, Barke, Aziz, Bennett, Benoliel, & Giamberardino, 2015). However, it is known that pa|in is also influenced by psychosocial and cultural factors, being of an individual nature. During the process of labor, pain can be described in two moments, in the first stage, the dilation phase, cau|sed by ute|rine contra|ctions and dila|tion of the cer|vix. In the expulsive period, together with these factors, there is the pressure that the fetus exerts on the pelvic structures, increasing its intensity (Klomp, Witteveen, de Jonge, Hutton, & Lagro-Janssen, 2017).

To assess the intensity and estimate the perceived pain, what has been referred by the woman in labor on a visual analog scale (VAS) has been used as an instrument for measuring or evaluating pain due to its easy applicability and understanding (Lehugeur, Strapasson, & Fronza, 2017). Other scales, such as numerical scales, verbal expression categories and non-numerical graphic representation, have also helped health professionals in pain assessment.

Current scientific advances in the obstetric area provided a better understanding of the mechanisms responsible for pain during the delivery process and thus, the perception of the painful stimulus can be reduced through pharmacological and non-pharmacological pain management (Treede, Rief, Barke, Aziz, Bennett, Benoliel, & Giamberardino, 2015). Among the pharmacological measures, the use of epidural or epidural analgesia combined with rachidian is routine (Smith, Levett, Collins, Armour, Dahlen, & Suganuma, 2018). Among the no|n-pharmac|ological measures known are herbal therapy, massages, chiropractic, acupuncture, aromatherapy, hydrotherapy, homeopathy and bioelectric or magnetic applications, ambulation, respiratory exercises and music therapy (Almushait, & Ghani, 2014). These therapies can reduce the use of allopathic measures and promote a feeling of well-being for women that provide satisfaction and reduces stress at the time of delivery.

Nevertheless, the use of no|n-pharma|cological strategies for pa|in control duri|ng lab|or is still present in the daily discussions between professionals, a fact that is probably associated with doubts about the efficacy of these techniques (Shah, 2020). In this perspective, this study aim|ed to demonstrate the efficacy of no|n-pharmac|ological pa|in rel|ief strategies dur|ing the delivery process.

PICOT Question

Patient/Population:

Population of the study is women undergoing labor.

Intervention:

Intervention proposed is non-pharmacological pain management during labor process.

Comparison:

Alternative compared are pharmacological and no|n-pharmac|ological meth|ods.

Outcome(s):

Outcomes are us|ed to ascertain the effective methods for pa|in manag|ement dur|ing lab|or process. It is used for applications in real time care settings.

Time:

Time taken is 1 week as the study incorporates the secondary analysis using previous primary literature on the non-pharmacological pain management during labor.

Methodology

The methodology used is a descriptive exploratory research of a bibliographic nature. The bibliographic research provides the analysis of the studies previously carried out and can show aspects that were not previously considered. It helps in generating new inquiries and possibly new studies (Salmon, 2017). In addition to offering aid for professional practice and collaborating to improve the assistance offered.

The searches were performed in March 2020 using the CINAHL  using the keywords/descriptors: “non-pharmacological treatment” or “pain treatment non pharmacologic” and “non-pharmacologic” “labor pain” or “Labor pain” and “Labor process” associated with “Pain”. These descriptors were chosen in order to obtain as many references as possible for analysis. The selected scientific production obeyed the following criteria: only scientific articles that report interventions of non-pharmacological strategies using a pain assessment instrument, classified as level of evidence II, written in English and availability of the complete scientific article in the databases (Burns, Rohrich, & Chung, 2011).

In the first search, 615 references were found, which were pre-selected from the abstracts and / or titles. From this total, 15 references were selected, 3 of them were not available online and rest was fully available online, and one study was repeated. The rest were excluded as they were review or update studies, they did not present evidence grade II or an instrument to assess pain, they were performed during the prenatal period or they used a qualitative approach. The final sample was made up of 10 articles.

In the descriptive analysis, the articles were characterized by author, year of publication, name of the newspaper, title and type of non-pharmacological strategy used for pain management. The full texts of the articles were carefully read to verify the use and effects of non-pharmacological strategies during the pain management. Then they were grouped into two categories: Pain relief during labor, and Evidence after the applic|ation of no|n-pharmaco|logical strate|gies.

Results

The ten artic|les chose were publi|shed in scholarly databases in English. As th|is rev|iew aim|ed to demonstrate the efficacy of no|n-pharmaco|logical strategies, only articles that presented level of evidence II were selected, as they are controlled studies possible to reproduce and rigorous methodology, which are indicated for treatment and prevention studies (Newnham, & Kirkham, 2019). The humanization movement of childbirth assistance worldwide was able to influence the search for these measures, since promoting pain relief during childbirth is closely related to guaranteeing safety to the woman in labor in the painful process, and consequently with a healthy delivery. The assistance provided to the pregnant woman and the mother in labor must take into account humanistic aspects that incorporate social, cultural and economic issues of this woman and her family (Newnham, & Kirkham, 2019).

Although it is a recommendation of the World Health Organization, the implementation of non-pharmacological strategies to alleviate the discomforts derived from pain during the delivery process, adherence to this practice has been influenced by the philosophy of the delivery care institution (Smith, et al, 2018). In European countries such as France and Denmark, pregnant women are encouraged to give birth naturally and to receive non-pharmacological pain relief practices (Smith, et al, 2018). The establishment of such measures in these services can optimize the assistance offered to the woman in labor, as well as to the pregnant woman during the prenatal period, as a way of humanizing health services (World Health Organization, 2018). It is important to encourage the practice of normal delivery without interventions as well as also guarantee adequate humanized assistance to the pregnant woman during the prenatal period, childbirth and post-childbirth (Busch, Moretti, Travaini, Wu, & Rimondini, 2019). It will promote women's autonomy allowing them to experience this process in a less traumatic and unpleasant way.

Pain relief during labor

The articles selected to demonstrate the efficacy of pain relief during the delivery process used the strategies: acupuncture, transcutaneous electrical stimulation, and muscle relaxation and breathing exercises. Acupuncture is described in three articles found, but only two presented results on the application of this strategy. The other only compares the use of meperidine in women in labor who received acupuncture, and it was analyzed as this is an opioid used in obstetrics as a pain reliever in the woman in labor. At the beginning of the sessions, the pain score was significant and higher in the patients in the group who received acupuncture (intervention group) than the score found in the women in labor in the control group.

At the beginning of the sessions, the pain score was significant and higher in the patients in the group who received acupuncture (intervention group) than the score found in the women in labor in the control group. Two hours after the start of the sessions, the pain score in the intervention group, 56.51 (52.63-60.39), was significantly lower than that found in the control group, 69.61 (65.99-73.84) (p < 0>

Although the two studies had similar characteristics regarding the chosen points, inclusion criteria and instrument for pain assessment (VAS), which varies from 1 to 10, the number of participants was greater in the first study presented, being 74 participants in the intervention group and 70 control group, in which the needles were inserted at points used for the application of injectable solutions. The other study analyzed consisted of 90 participants placed in three different groups of equal numbers, being an acupuncture application group, an acupuncture pretend group, which used points, normally used for injection drug application, and a third control group.

The application of the breathing and relaxation techniques of Dick Read and Fernand Lamaze also showed no relief of pain during labor. The intensity of pain reported through the VAS increased according to the progression of cervical dilation, showing no statistically significant difference in any of the phases, latent phase (p = 0.21), active phase (p = 0.11) and transition (p = 0.49). The pain score in the experimental group was higher than that seen in the control group in all phases, except in the transition phase, in which the maximum VAS score was reported for both groups.

The application of transcutaneous electrical stimulation (TSE) in two groups of 11 participants each, without application of electrodes in the paravertebral region at the level of the tenth thoracic vertebra (T 10 / L 1) and the second sacral vertebra (S2) did not present a significant result in pain relief during the development of labor when it was evaluated by means of VAS (p = 0.86) (Smith, et al, 2018).

In another study conducted by Shahoei, Shahghebi, Rezaei, & Naqshbandi, (2017), accompanying four groups of 10 participants each, the use of two models of pain relief electrodes, Plate and Silver Spike Point (SPP), was compared with their respective control groups  (Bedwell, Dowswell, Neilson, & Lavender, 2011). The mean pain found was 8.5 ± 1.5, showing a statistically significant difference between the control group and the group treated with SPP model electrodes after 10 (p = 0.005), 30 (p = 0.001), 60 (p = 0.007) and 120 minutes (p = 0.02), and only after 10 minutes of stimulation using Plate-type electrodes (p = 0.04) (Bedwell, Dowswell, Neilson, & Lavender, 2011). In this last study, the points chosen for application of the electrodes were first and second sacrum holes (B 31 and 32), different stimulation points from those described in the first study (Shahoei, et al, 2017).

Evidence after the application of non-pharmacological strategies

Other benefits derived from the application of non-pharmacological strategies that deserve to be addressed in this review were evidenced, which are represented in the subcategories shown below.

Use of analgesic drugs

The use of meperidine was compared with the application of acupuncture. Among the women in labor who did not receive acupuncture, 37% used meperidine. Regarding the group in which the technique was applied, 11% required the administration of this opioid, a result considered statistically significant (p <0>

The proportion of women who needed analgesic drugs was lower among the participants who used TSE, the use of the Silver Spike Point model being statistically significant (p <0>

Another interesting benefit found was the time between pain assessment and the administration of combined analgesia. When the pain score is greater than or equal to 6 in the VAS, epidural-associated spinal anesthesia was indicated and the time required for this indication was greater for the group that received application of the TSE, mean of 90 minutes, compared to the control group. The mean of installation of the combined analgesia was 30 minutes (Smith, et al, 2018).

Oxytocics administration

The use of acupuncture in women with dilation ? 4 cm and the presence of three contractions in the period of 40 seconds and needles inserted at points LI4, UB32, UB60, SP6, ST36, LIV3, GB34, HT7 decreased the doses of oxytocin administered (p = 0.001) (Mosquera, Luces, Onandia, & Tizón, 2016).

A second study also showed that the proportion of women who needed oxytocin to increase contractions during the course of labor was lower among those who received this ENF when compared to the acupuncture pretend and control groups, being 50%, and 76.6%,  respectively (p = 0.03) (Nwanodi, 2016).

Length of the labor process

The process of labor begins with the latent phase, in which the pattern of contractions and the painful process are minor. The duration of this phase presented a statistically significant difference when muscular and respiratory relaxation techniques were implemented, observing an average of 84.7 ± 37.10 minutes for the control group and the experimental group of 145.26 ± 96.57, (p = 0.01) (Lehugeur, et al, 2017).

After the latent phase, the active phase begins, which corresponds to the increase in uterine contractions, cervical dilation and descent of the fetus through the maternal pelvis. In parturients who received acupuncture, the duration of the active phase of the labor process was significantly shorter (p <0>

Discussion

The analysis of the published studies showed that only three non-pharmacological strategies were applied according to level of evidence II. Other non-pharmacological strategies are described in the literature, although their application forms did not show a significant level of evidence in practice. The need to carry out controlled clinical trials is perceived so that the efficacy of other strategies, such as cryotherapy, ambulation, music therapy and others, are validated and incorporated into obstetric care.

Regarding pain relief, not all the non-pharmacological strategies were effective, but the use of analgesic drugs and the administration of oxytocin in the women in labor were decreased. In addition to this, another interesting aspect is that no adverse events were reported harmful to the woman in labor and the fetus.

Positive results are accredited in the application of non-pharmacological strategies during the delivery process that can be intensified if these are associated and implemented during prenatal care. In this period, the pregnant woman will be able to familiarize herself with different strategies that will be proposed by the delivery assistance unit and also through the understanding of their application and the option of choosing the method that best suits her. Just as the health professional may establish a closer relationship with the pregnant woman, favoring the client / professional relationship. In this way, the guarantee of control of the pain of the pregnant woman during the delivery process, through non-pharmacological strategies that present scientific evidence of efficacy, will favor a humanized obstetric assistance with the promotion of safety and quality.

Relevance for clinical practice

The relevant therapies can be used in conjunction with clinical practices based on their effectiveness. The non-pharmacological practices are not effective by themselves but can be combined with the pharmacologic treatment. He|at hel|ps to decre|ase pa|in and mus|cle spa|sms. Applying he|at to the ar|ea for 20 to 30 min|utes ev|ery 2 ho|urs is helpful. Massage before entering labor can help relax muscle tension and ease pain. After labor process, spinal cord stimulation can be helpful to use an electrode with safe, lig|ht elect|rical sign|als to rel|ax the ner|ves th|at cau|se the pa|in.

Overall, ten studies were found that evaluated different non-pharmacological treatments for chro|nic pa|in in MS patients. The treatm|ents evalu|ated were: transcut|aneous electr|ical neurostimulation, direct transcranial stimu|lation, transcr|anial random noise stimul|ation, reflexology, psychotherapy and hydrotherapy. These studies used diffe|rent meth|ods to meas|ure pa|in and oth|er outco|mes. There was al|so variation in the comparison groups.  There is a ve|ry lo|w lev|el of evide|nce regarding the us|e of an|y non-pharmacolo|gical treatment for chro|nic pa|in in MS patients. The overall qual|ity of the stud|ies was considered ve|ry low, as ma|ny inclu|ded on|ly a sma|ll number of partici|pants, in addition to showing oth|er methodol|ogical problems. Mo|re resea|rch studies of goo|d method|ological qua|lity and a larger num|ber of partic|ipants are need|ed to deter|mine the effecti|veness of these treat|ments.

References;

Lehugeur, D., Strapasson, M. R., & Fronza, E. (2017). Non-pharmacological management of relief in deliveries assisted by an obstetric nurse. Journal of Nursing UFPE on line, 11(12), 4929-4937.

Almushait, M., & Ghani, R. A. (2014). Perception toward non-pharmacological strategies in relieving labour pain: An analytical descriptive study. J Nat Sci Res, 4(2).

Busch, I. M., Moretti, F., Travaini, G., Wu, A. W., & Rimondini, M. (2019). Humanization of Care: Key Elements Identified by Patients, Caregivers, and Healthcare Providers. A Systematic Review. The Patient-Patient-Centered Outcomes Research, 1-14.

Bedwell, C., Dowswell, T., Neilson, J. P., & Lavender, T. (2011). The use of transcutaneous electrical nerve stimulation (TENS) for pain relief in labour: a review of the evidence. Midwifery, 27(5), e141-e148.

Burns, P. B., Rohrich, R. J., & Chung, K. C. (2011). The levels of evidence and their role in evidence-based medicine. Plastic and reconstructive surgery, 128(1), 305.

Shah, S. R. (2020). Augmentation and Management of Labor. In Labour Room Emergencies (pp. 213-223). Springer, Singapore.

Klomp, T., Witteveen, A. B., de Jonge, A., Hutton, E. K., & Lagro-Janssen, A. L. (2017). A qualitative interview study into experiences of management of labor pain among women in midwife-led care in the Netherlands. Journal of Psychosomatic Obstetrics & Gynecology, 38(2), 94-102.

Shahoei, R., Shahghebi, S., Rezaei, M., & Naqshbandi, S. (2017). The effect of transcutaneous electrical nerve stimulation on the severity of labor pain among nulliparous women: A clinical trial. Complementary therapies in clinical practice, 28, 176-180.

Mosquera, L. P., Luces, A. L., Onandia, M. G., & Tizón, E. B. (2016). Transcutaneous Electrical Nerve Stimulation (TENS) for Pain Management During Labor. Revista de enfermeria (Barcelona, Spain), 39(11-12), 27-32.

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