WK3: Pain in labour and midwifery team practice

Question 1

What is the role of the midwife in managing pain in labour?

Answer 1

• Educate women + family on pain and their optinos
• Normalise labour pains
• ‘It is not somwhting that we need to take away’
• Pain is effective contractions
• painful contracts bring baby on
• Pain can be different in every lanout and baby
• We work with the pain rather than against it to ensure the women copes best
• Western culture has a sway to the removal of pain in labour. I.e. epidural use

Difference between nursing and midwifery is significant when thinking about pain. Nurses try to relieve it

Question 2

Describe pain in the context of child bearing.

Answer 2

• Complex
• Personal
• Subjective (is what the woman says it is)
• Multifactorial
• Influenced by psychological, biological, economic and sociocultural factors (it is because of these that s it so different for everyone)
• A normal part of the physiological factors
• Healthy pain: gols is not to remove it but to support the women experiencing it

Question 3

Explain the impact fear (internal influence) has on labour pain and the midwife role in mitigating this.

Answer 3

• Antagonist to oxytocin is cortisol and adrenaline hormones (fear-related)
• Consider environmental factors that reduce these and induce cortisole
• Women have a deep engrained fear of labour and birth= increases the perception of pain.
• Fear, anxiety and loss of control are associated with increased use of pharmacological pain relief and does not help or remove the pre-existing fear/anxiety (can have long term effects)

Midwives role: to reduce women’s fear and anxiety and communicate in the way that women believe in their abilities (promote courage)

Question 4

Explain the gate pain theory.

Answer 4

What they propose:
Any nerve signal can go to one of two places to go to the brain. Either inhibitory interneurons or transmission cells.
*nocioceptors detect pain
* mechano receptors detect touch, pressure …
- Mechanoreceptors when stimulated increase inhibitory interneuron on the pain signals
= close the gate to your brain preventing the reception of pain.

Any nerve signals can go to one of two destinations while on the way to the brain. Either the;
Transmission cells= pick of the signal and take it to the brain
Inhibitory interneurons= that it would pass through the first and have the activity less intense.

• Theory based on the existence of a ‘gate’ that could facilitate/inhibit transmission of pain signals
• Brain exerts ‘downward’ control over our experience of pain by influencing the amount of pain stimulation allowed to pass a ‘gate’ in spinal cord
  - i.e we experience greater levels of pain if more stimuli is let through the gate
  Degree of pain experienced depends on amount of information that gets through the gate to the brain influenced by:
  1. Where the pain starts (in peripheral pain fibres)
  2. Activity in other peripheral fibres (i.e. carrying competing information)
  3. Messages coming from brain (distractions)

Question 5

What are some non pharmacological pain relief options that ‘close the gate’ and what are their potential benefits and hrams?

Answer 5

rubbing painful site
acupuncture
Hot water
Ice packs
TENS machine
Comb (touch receptor in hand becomes focus point of comb, rhythmic to keep doing, some acupressure points in the hand)
Repeatedly count down from 10
Bounce on a ball for repetition

Benefits: they increase inhibitory interneurons on the pain pathway, thus loading the pain pathway and decreasing the perceived pain (a double negative).

Exercise, distractions and stress can release the body’s own painkillers
E.g. endogenous opiates such as endorphins

Question 6

What factors impact a woman’s pain perception?

Answer 6

• Consider what triggers the gate to shut?
  (action of the synapse at the dorsal horn before the pain signals travel to the brain)
• Past experience
• Meaning of situation
• Attention to the pain (focous else where/distraction or attention else where)
• Anxiety (cortisole, stress)
• Anticipation
• Culture
• Expectations
• Suggestion (support person/midwife suggests that the pain is good and normal)

Question 7

What factors affect the perception of pain?

Answer 7

• Birthing environment (home vs hospital)
• Trust in womans innate ability to give birth
• Level of invasive procedures occurred
• Level of invasive procedures
• Type and length of labour (precip vs long labout)
• Fatigue
• Ability to express pain without judgement
• Feelings of control (not so much in controlling labour, but being in control fo what is done)= indice feelings of safety

Question 8

How can a midwife assist a woman when choosing pain management

Answer 8

Based on;
- Every women is very individual
- Philosophical approach to birth (is she interested in intervention free? Does she understand why she wants this?)
- What is her attitude to pain (accepting or traumatised)
- Experience withp pain management in the past
- Individual prejudice
- Influenced by close others, especially partner
- offer her all options and give the benefits and risks
- understand her birth plan/preferences as early as possible so you can support her choices when it gets difficult.

Question 9

What are some non-pharmacological pain relief options?

Answer 9

Comfort inducing measures
- Positioning, mobility, posture
- Use of water, heat, cold, showers, water immersion
- Massage, pressure * Encouragement
- Aromatherapy
- Meditation
- Affirmations
- Music
- Involvement of partners and other support people
- Relaxation-guided imagery

Others
- TENS
- Sterile water injections
- Acupuncture/Acupressure
- Homeopathy

Question 10

Explain the non-pharmacological pain management of water immersion including its risks and benefits.

Answer 10

Water immersion includes a shower, and bath.
- around 35%
- submerge/cover over abdomen
- reduced pain perceived by women
- Can reduce the length of labour as it increase oxytocin and reduces stress hormones

Key benefits
- Heat relieves muscle spasm- therefore pain
- Relieves the effects of gravity and discomfort of pelvis
- Reduces anxiety
- Increase of natural opiates
- Reduces catecholamine secretion
- Woman feels in greater control
- similar to warm compress it promotes streaching of the perineum thus, reducing tear risks/severity

Complications
- cant use if have IV antibiotics, CTG monitored,
- infection
- pyrexia

Question 11

Explain the non-pharmacological pain management of hypnosis/calm birth including its risks and benefits.

Answer 11

What is it?
- a method of managing pain and anxiety during childbirth, involving various therapeutic relaxation techniques
e.g. deep breathing and visualization

Benefits
- avoid pharmacologically pain relief options that come with other side effects
- greater maternal satisfaction

Complications/risks
- mother ay not remember first moments with baby as is still in the zone

The role of the midwife
- Protect the environment
- Respect woman’s choices
- Respect what she requests including the language you use.

Does it work?
- May be effective in reducing pain, increasing vaginal birth and reducing use of oxytocin
- Greater maternal satisfaction

Question 12

Explain the non-pharmacological pain management of TENS amchine birth including its risks and benefits.

Answer 12

Transcutaneous Electrical Nerve Stimulation
- Electrical pulses prevent the pain signals from the uterus and cervix from reaching your brain
- Also stimulates the release of endorphins
- Best if used early in labour (Hamilton 2003)
- Insufficient evidence that it is more effective than placebo or other forms of pain management, no evidence of harm
- Anecdotal evidence = highly effective to a point
- Gives her something to do= distraction

Question 13

What are the general benefits of non-pharmacological pain relief?

Answer 13

• Relatively safe
• Don’t interrupt balance of physiology, oxytocin production/progress of lanour
• Promote woman’s control of the process= promotes feeling safe
• Don’t interfere with woman’s memory of the process (unlike opiates do)
• Able to be participated in by other members of the support team
• Promotes sense of achievement
• Does not negatively impact baby (babys ability to BF, breathing etc)

Question 14

What factors do non-pharmacological pain relief options rely on?

Answer 14

• Motivation to try them and keep trying them
• Physiology working
• Well woman
• Well-informed staff and support people
• Minimal interference (with light and assessments from the medical team)
• Trust in the process/ Mindset

Question 15

What are the three main pharmacological pain relief options for labour?

Answer 15

1. morphine
2. epidural analgesia
3. N2O:O2

Question 16

Explain the use of N2O:O2 and the risks and benefits of it.

Answer 16

N2O:O2 gas replaced oxygen in your lungs, thus reducing the O2 given to your brain which prevents the perception of pain.

Benefits
- Acts rapidly, expired rapidly (breathing in 10sec ot get into blood and work and takes out 10 secs to be expired on expiration)
- Attached to a blender so you can change the strength e.g. 20% N2O: 80% O2
- No effect of uterine contractility
- mederate respiratory effort may decrease
- women do not lose sense of the present moment

Risks/complications
- Complete absorption through the placenta although, is rapidly cleared from fetal system when inhalation stops
- uteroplacental perfusion (encourage normal breathing)
*it is important that between contractions she isnt having gas
- Can produce nausea and vomiting, poor recall of labour/ “out of it” feeling (impacts on memory of experience)

Question 17

Explain the use of narcotics/morphine and the risks and benefits of it.

Answer 17

Benefits
- works directly on opioid receptors in the central nervous system, and reduces feelings of pain by interrupting the way nerves signal pain between the brain and the body.

Risks
Side effects for the woman
- Resp depression
- CNS depression
- Vomiting
- Reduced heart rate
- Euphoria
- droziness
- Hypotension
- Reduced output
- Thermoreulation depression
- Relaxation of smooth muscles= decreased contractions
- Reduced gut motility (constipation after birth)

Side effects for baby
- Resp depression/recuss
- Crosses placenta rapidly and absorbed by fetus it isn’t able to be removed quickly= babys have difficulty breast feeding for the first few weeks of life.

Question 18

Explain the use of an epidural and the risks and benefits of it.

Answer 18

by injecting an anesthetic into the epidural space around your spine so that it can stop pain signals from traveling from your spine to your brain.

Benefits
- “Numbing” affect
- should not feel anything (sharp and temp) from breasts down
- Can still feel pressure

Risks
- headache (related to the posture and change in pressure in epidural space)
- fetal bradycardia
- hypotension
- back pain at site of insertion for 3-6 months
- Neuropraxia= numbness or nerve damage. up to1/1,000.
- shivering
- pruritus
- need for IDC
- Inadequate anaglesis e.g. one sided
- failed process and need for replacing it

Increases the likelihood of
- Continuous fetal monitoring
- IV Fluids
- Augmentation
- BP and other frequent obs
- Usually restricted to bed
- IDC
- Increased risk of fetal distress, instrumental birth and delayed second stage
- all of which increase risk for C/S
- IV fluids to prevent hypotension
- augmentation of labour as it is lileyt to stall
- Restricted to be on back
- Increased monitoring
- IDC
- Increased risk of instrumental birth, delayed second stage
- Increased risk of C/s

Question 19

What does an epidural cause hypotension?

Answer 19

• Results of action on sympathetic nervous system
• Cases vasodilatory effect on peripheral circulation because of blocking of sympathetic nerves
• Pooling of the circulation in the periphery
  = Hypotension

Fetal compromise- hypotension and hypoxia

Question 20

What is the midwifes role in the insertion of an epidural?

Answer 20

Information to women preferably during the antenatal period

Assistance with procedure
- Positioning of woman
- Set-up including IV therapy/canulate
- Help for anaesthetist

Observations
- 5-10 min for 30 minutes then 1/2hourly (risk o hypotension)
- CTG

Change of position
- To up right may not allow epidural to work

Care of bladder (IDC)

Top-ups or care of continuous infusion

Careful, contemporaneous documentation
- Partogram
- Epidural chart
- CTG
- Progress notes

Question 21

What are key midwifery practice points when caring for a women with an epidural?

Answer 21

• allow for 1 hour of passive descent when fully dilated
• change positions
• do detmatones to assess epidural effect (should not be higher than T5 as this risks resp depression)
• Bromage score= how much moto0r black they have. e.g. 3= completely move their feed- 0= none/full felxion of keen sand feet
• continually assess blood pressure
• ## manage temp e.g. not to many blankets

Question 22

What are some external and internal factors that impact the way a women perceives pain in labour?

Answer 22

Internal
- fears
- past experiences

External
- adrenaline indcing envrionment
- whether she want into labour herself or not!!
- the way her support people feel and interaction/speak about pain

Question 23

How does a midwife use pain relief strategies in an ethical and legal way?

Answer 23

Ethical
- ensure you support the womens wishes
- unbiased

Legal
- practice within their scope
- referral for prescription
- document

Question 24

Define collaborative practice in midwifery?

Answer 24

A care principle and model of care that focouses on a strong relationship between the woman, midwife and the interprofessional team that is based on communication, trust and enables the provision of safe and women-centered care.
- enables the woman to be an active participant in their care.

Principles
- places the woman at the centre of her own care. Promoting cultural needs
- woman choose care that is based on the best evidence and is appropriate for themselves
- enables informed decision-making based on information sharing of all their options
- based on reciprocal communication and sensitive language to develop trust
- underpin by safety and quality practice
- respect and value for each other to meet each others needs
- commitment to joint education and training
- maximise a women continuity of care
- provides clear roles and responsibility for effective care.

Question 25

Who might midwife collaborate with in woman centered care?

Answer 25

Collab with;
- Aboriginal health workers or strong women workers
Doulas
Midwives
Obstetricians
hospital personnel
district medical officers

Question 26

What is the scope of practice for a midwife?

Answer 26

• The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant.

This care includes;
- preventative measures
- the promotion of normal birth
- the detection of complications in mother and child
- the accessing of medical care or other appropriate assistance
- the carrying out of emergency measures.
- health counselling and education, not only for the woman, but also within the family and the community.

• This work should involve antenatal education and preparation for parenthood and may extend to;
• women’s health
• sexual or reproductive health
• child care.

A midwife may practise in any setting including the home, community, hospitals, clinics or health units (ICM, 2017)

Midwifery care is centred on promoting and protecting pregnancy, labour, birth and early postnatal period as a normal, physiologic process

When a woman does not fall within this category (of normal birth care), due to current or past circumstances, it is the role of the midwife to assess whether referral for consultation or transfer of clinical responsibility is necessary

This may require input from another professional or a formal referral

Question 27

Describe the difference between consultation and referral as per the ACM National midwifery guidelines.

Answer 27

• it exists to provide an evidenced-based framework for collaboration between midwives and doctors when caring for women
• Outline specific clinical situations and categories and process for referral

Referal= when care fall out of midwifes scope
Consultation= to seek advice for decision making

Outlines that;
- Consultation is the seeking of professional advice from a qualified, competent source and making decisions about shared responsibilities for care provision.
- Referral is the transfer of primary health care responsibility to another qualified health service provider health professional.

Question 28

Choose wether a referral or discussion/consultation is necessary for the following conditions?
Previous classical C/S
Referral
Previous GDM
Type 1 DM
Hypothyroidism
Hx of PPH
Multiple pregnancy
Symphysis pubis dysfunction
Oxytocin infusion during labour
Maternal temp 38C postpartum

Answer 28

Previous classical C/S
- Referral

Previous GDM
- Discuss

Type 1 DM
- Refer

Hypothyroidism
- Consult

Hx of PPH
- Consult or Refer

Multiple pregnancy
- Refer

Symphysis pubis dysfunction
- Discuss

Oxytocin infusion during labour
- Consult

Maternal temp 38C postpartum
- Consult

Question 29

What does successful collaboration look like?

Answer 29

• The woman must remain the centre of the process and be actively involved in decision-making
• Open communication between all parties
• The woman’s values and philosophical beliefs need to be respected and upheld
• Mutual trust and respect between all those involved

Question 30

What are some barriers of collaboration?

Answer 30

• Competitive approach between professionals and healthcare institutions
• Lack of continuity of care or carer
• Poor communication
• Hierarchical environment or imbalance of power/authority
• Woman is not kept at the centre