Oxford Handbook of Midwifery (62 page)

Working on the meridians located in the back is key. The Governing Vessel (GV) is the main source of Yang energy, which is required for labour to proceed effectively. By working on the GV the therapist can tap into and balance all of the energy sources in the body. The Bladder (BL) meridian located in the back is important to work on in the first stage of labour to relieve fear and anxiety. Sacral work is effective to relieve pain and tension, particularly on the sacral grooves, which helps to release energy to the uterus, perineum, and vagina.

If the woman feels comfortable for the therapist to work in the abdominal area, this has a direct link with the uterus and represents earth

energy, which helps the woman ground herself. Kidney One is located on

the underside of the foot, being the lowest point of the body; this point links to earth energy and is very grounding and calming.

Encouraging the birth partner to assist with some of the techniques enables the midwife to attend to other care commitments for the woman and provides a key role for involvement of the partner.

Recommended reading

Yates S (2003).
Shiatsu for Midwives
. London: Elsevier.

1
West Z (2001).
Acupuncture in Pregnancy and Childbirth
. London: Churchill Livingstone.

CHAPTER 12
Pain relief: non-pharmacological

254‌‌

Transcutaneous electrical nerve stimulation

Transcutaneous nerve stimulation (TENS) is a self-administered form of non-pharmacological pain relief that can be used throughout all stages of labour. The equipment can be hired or loaned by the pregnant woman for use at home before transfer to the labour ward.

Pain relief is thought to be activated by the passage of a mild electrical stimulus across the nerves of the spine at the level which transmits pain impulses from the uterus and cervix. This works in two ways by influencing the pain gate mechanism and stimulation of naturally occurring endorphins.

Electrodes in the form of adhesive pads are placed on either side of the spine and these are attached to a small control device by coated wires. Hand control buttons allows the user to select the power level required; as labour progresses a more intense level of stimulation can be selected as the contractions become longer, stronger, and more frequent. The device has a booster feature which can be operated throughout a contraction to obtain more pain relief and then a return to the selected programme once the contraction has subsided.

Effectiveness varies and is thought to be enhanced if the device is used from the earliest contractions onwards, before the labour becomes established. This enables the initial build up of endorphins to take effect

e.g. 40min, thus allowing the mother to gain benefit before strong contractions commence.

Instruction needs to be given to the woman and her birth partner regarding the placement of electrodes:

• One on either side of the spine just below the bra line, vertebral level T10–L1 and placed 3cm apart.
  
• One on either side of the spine, over the sacral dimples, vertebral level S2–S4 and placed 3cm apart.
  

  Advantages
  

• TENS is safe to use alongside other methods of pain relief such as nitrous oxide and oxygen, opiates and complementary therapies.
  
• Mother is in control.
  
• Non-invasive.
  

  

• No adverse effect on fetus.
  
• May reduce need for pharmacological analgesia.
  

  Disadvantages
  

• TENS cannot be used submerged in water or alongside epidural analgesia.
  
• There have been occasional reports of TENS possibly disrupting CTG tracings which midwives ought to be aware of.
  

  TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION
  

  255
  

  Recommended reading
  

  Johnson MI (1997). Transcutaneous electrical nerve stimulation in pain management.
  British Journal of Midwifery
  5
  (7), 400–5.
  

  Mainstone A (2004). Transcutaneous electrical nerve stimulus (TENS).
  British Journal of Midwifery
  

  12
  (9), 578–80.
  

  Rodriguez MA (2005). Transcutaneous nerve stimulation during birth.
  British Journal of Midwifery
  

  13
  (8), 8–9.
  

  Trout KK (2004). The neuromatrix theory of pain: implications for selected non-pharmacological methods of pain relief for labor.
  Journal of Midwifery and Women’s Health
  49
  (6), 482–8.
  

  

  Reprinted in:
  MIDIRS Midwifery Digest
  15
  (1), 73–8.
  

  CHAPTER 12
  Pain relief: non-pharmacological
  

  256‌‌
  

  Bach flower remedies during labour
  

  Childbirth presents an enormous physical and emotional challenge, conse- quently emotional reserves of strength and staying power may well be put to the test. The Bach flower remedies may help by assisting the mother to stay calm and work with her body, resulting in the release of endorphins and encephalins which greatly assist in the process of labour.
  

  Rescue Remedy is the most useful remedy for labour and can be sipped from a glass of water between contractions for the duration of labour. For dosages and administration, b see Bach flower remedies, pp. 128–130.
  

  Other remedies that may prove useful at this time are:
  

• Olive
  : may be useful when the woman is emotionally and physically exhausted, perhaps due to a long labour.
  
• Gorse
  : may help when there is a feeling of wanting to give up, cannot go on any longer.
  
• Beech
  : may help when there are feelings of intolerance towards birth partners and carers.
  
• Red chestnut
  : may be useful for overanxiety for the baby during labour and birth.
  
• Cherry plum
  : may help when there is fear of losing control, or behaving in an irrational way.
  
• Aspen
  : may help when apprehension or fear of the unknown is experienced.
  
• Clematis
  : for when there is too much detachment and distance from the process of birthing, possibly causing delay/disruption to progress.
  
• Impatiens
  : for feeling impatient and irritable with those around her or with the slow pace/progress of labour.
  
• White chestnut
  : may assist to relieve constant anxiety and worrying.
  
• Mimulus
  : for fear of pain, procedures, or the hospital environment.
  
• Walnut
  : may help in adjusting to the changes occurring during labour and birth, and extra protection to be able to cope better.
  
• Gentian
  : may help when there are feelings of despondency, perhaps because of slow progress or setbacks during labour.
  
• Willow
  : for feelings of self-pity and resentment.
  

  If the mother uses up less energy on anxiety and stress related to labour, she can then retain more energy to cope physically with labour.
  

  During labour, the calming effect of the remedies may also impact on the fetus in adjusting and coping with the stress of birth.
  

  

  Pain relief: pharmacological
  ‌‌
  

  Chapter 13
  

  257
  

  Nitrous oxide and oxygen administration
  258
  

  Opiates
  259
  

  

  Lumbar epidural analgesia
  260
  

  CHAPTER 13
  Pain relief: pharmacological
  

  258‌‌
  

  Nitrous oxide and oxygen administration
  

  This is a very good method to use in practice as:
  

• It is easily available to all midwives
  
• The woman controls it herself
  
• It works quickly, usually within three to four contractions
  
• It wears off quickly when administration stops
  
• It is safe to use in conjunction with other methods of pain relief
  
• It is useful as an aid to enhance coping strategies over ‘a rough patch’, or while waiting for other forms of pain relief to be effective.
  

  Method
  

  A mixture of N
  ₂
  O 50% and O
  ₂
  50% is delivered from a cylinder via Entonox
  ^®
  apparatus.
  

  How to use it
  

• Start use as soon as a contraction begins—to achieve maximum relief at the height of the contraction.
  
• You will need to palpate contractions and warn the woman to start breathing through the mask or mouthpiece (ask her preference!). A mask should cover the nose and mouth with a good seal. Listen to ensure that the valve is delivering the gas mixture correctly.
  
• The gas mixture should be inhaled throughout the contraction.
  
• It may take up to three contractions before good pain relief is experienced.
  
• Once started, onset of relief is usually within 20s.
  
• Recovery takes place between contractions. If the woman is too drowsy to operate the apparatus effectively, then no gas will be delivered and she will quickly recover. It is very unlikely to cause sleep or loss of consciousness.
  
• You may need to remind the woman that she does not need to inhale the gas mixture when there is no contraction.
  

  Disadvantages
  

• It may cause drowsiness, dizziness, and nausea.
  
• Some women do not like the odour.
  
• Use over more than 6h is not recommended.
  
• Some concern regarding the possibility of cross-infection and staff safety has arisen – however, is still considered a safe and simple