Nonpharmacologic labor analgesia

Application of sharia childbirth innovation model in Indonesia: Perspective of midwives and staff of the Islamic Service Unit

BACKGROUND

The implementation of Sharia Model Childbirth (SMC) is in accordance with Fatwa Majelis Ulama Indonesia (MUI) no l07/DSN-MUI/X/2016 on the practice of sharia principles in health services. Sharia services in hospitals are general. This SMC innovation is specific and comprehensive, covering prenatal, delivery and postnatal. This model was implemented in 2017 but has never been qualitatively evaluated. The purpose of this study was to evaluate the application of SMC in the maternity services from the perspective of midwives and staff of the Islamic service unit.

MATERIALS AND METHODS

Applied qualitative research was conducted from 5 December 2021 to 31 January 2022. In-person in-depth interviews were conducted using semi-structured interview guidelines. Informants were taken from the midwives of the maternity room and the Islamic service installation until a fair saturation of data was achieved. Observational and documentation were conducted for the validity of the data. The data were analyzed thematically and presented in themes and sub-themes.

RESULTS

The results of the study were on the work procedures implemented, and the obstacles and shortcomings found. Most of the procedures and accompanying regulations had been implemented. Participants revealed obstacles and shortcomings in this innovative program. The major obstacle found was that the patient's right to choose a female medical officer was not fulfilled because of the type of teaching hospital it was and the lack of female medical staff. The shortcomings were in the reading of prayers and remembrances, the understanding of the contents of the manual, and the design of the delivery room, which did not maintain privacy.

CONCLUSION

Overall, SMC is being implemented, but there are obstacles and shortcomings in the implementation. Solutions and regulations in sharia services should urgently be found and enforced. The deficiencies in this innovative program must be corrected immediately.

A comparison of the effect of Swedish massage with and without chamomile oil on labor outcomes and maternal satisfaction of the childbirth process: a randomized controlled trial

PURPOSE OF STUDY

Massage is widely used as a traditional technique during labor and delivery. The aim of this study was to evaluate the effect of Swedish massage with and without chamomile oil on delivery outcomes.

METHODS

The present study was a randomized clinical trial on 154 primiparous pregnant women who were selected by random sampling method and divided into 3 groups: massage with chamomile oil (n = 53), massage without chamomile oil (n = 51), and control group (n = 50). Data collection tools included demographic and delivery information questionnaire, Visual Analogue Scale (VAS), maternal satisfaction with delivery scale, and Partograph form. In the two intervention groups, Swedish massage techniques (i.e., Effleurage, Petrissage, Vibration, and Superficial stroke) were performed with and without the use of chamomile oil since the active phase of labor (5 cm dilatation), while the control group received only routine labor care during labor.

RESULTS

Swedish massage with chamomile oil significantly reduced the labor pain score, reduced the length of active phase and the second stage of labor, and increased the score of maternal satisfaction with the labor process (P < 0.001). In addition, there was a significant relationship between the type of study groups and the type of delivery (P < 0.043).

CONCLUSION

The results of the study showed that using Swedish massage techniques with or without chamomile oil can improve labor outcomes. Swedish massage using chamomile oil was associated with better results compared to the same massage without using chamomile oil. Clinical trial code IRCT20200513047430N1.

Nonpharmacological labor pain management methods and risk of cesarean birth: A retrospective cohort study

BACKGROUND

Nonpharmacological labor pain management methods (NPLPMM) are noninvasive, low-cost practices that may play a role in reducing the rates of unnecessary cesarean birth. We aimed to evaluate whether the NPLPMM is associated with the mode of birth.

METHODS

We conducted a retrospective cohort study with clinical records of all women admitted for birth from January 2013 to December 2017. Records of women who had spontaneous labor or received induction or augmentation of labor during hospitalization were eligible for the study. We estimated the risk ratios for cesarean birth in general linear models using the Poisson regression with adjustments for the following variables: age, ethnicity, schooling, parity, gestational age, previous cesarean birth, spontaneous labor before admission, or induction/augmentation of labor.

RESULTS

Within the total of 3,391 medical records, 40.1% had the use of a nonpharmacological labor pain management method registered. Cesarean rate among the study population was 44.2%. The use of NPLPMM decreased the risk of cesarean birth by 78% (OR = 0.22; 95% CI 0.19-0.26). History of a previous cesarean birth (RR = 2.63; 95% CI 2.35-2.64), the lack of use of NPLPMM (RR = 2.46; 95% CI 2.22-2.72), and primiparity (RR = 2.09; 95% CI 1.86-2.34) were the strongest risk factors for cesarean birth in the cohort.

DISCUSSION

The use of NPLPMM may be an effective strategy to reduce unnecessary cesarean birth. Further studies to identify the efficacy of each method may help health professionals to offer more appropriate methods at different stages of labor.

Effects of acupressure and shower applied in the delivery on the intensity of labor pain and postpartum comfort

BACKGROUND AND PURPOSE

Labour pain is a constantly increasing pain. This study thus aims to determine the effects of acupressure and shower on labour pain and postpartum comfort.

METHODS

In this randomized controlled trial (RCT), the control group consisted of 40 pregnant women, while the experimental groups consisted of 80 pregnant women in total. The experimental groups received routine labour care and either acupressure or showers upon reaching three cervical dilations (4-5, 6-7 and 8-10 cm). The control group only received routine labour care. A maternal information form (MIF), the Visual Analog Scale (VAS) and the Postpartum Comfort Questionnaire (PPCQ) were used to collect data.

RESULTS

Pain was significantly reduced in both of the experimental groups, in contrast to the control group, in all periods of the study (p < 0.001). Postpartum comfort also significantly increased in the experimental groups compared to the control group (p < 0.05).

CONCLUSION

Acupressure and showering are effective in reducing labour pain and increasing postpartum comfort. Midwives and nurses can therefore apply them as inexpensive and easy to administer methods for labour pain relief.

Beyond the epidural: Alternatives to neuraxial labor analgesia

Labor creates an intense pain experienced by women across the world. Although neuraxial analgesia is the most effective treatment of labor pain, in many cases, it may not be undesired, not available, or have contraindications. In addition, satisfaction with labor analgesia is not only determined by the efficacy of analgesia but a woman's sense of agency and involvement in the childbirth experience are also key contributors. Providing safe choices for labor analgesia and support is central to creating a tailored, safe, and effective analgesic treatment plan with high maternal satisfaction. Healthcare provider knowledge of various nonneuraxial analgesic options, including efficacy, contraindications, safe clinical implementation, and side effects of various techniques is needed for optimal patient care and satisfaction. Future rigorous scientific studies addressing all of these labor analgesia options are needed to improve our understanding. This review summarizes the current published literature for commonly available non-neuraxial labor analgesic options.

Women’s perceptions of the pain assessment and non-pharmacological pain relief methods used during labor: A cross-sectional survey

INTRODUCTION

The use of non-pharmacological pain relief methods and pain assessment scales during labor has received limited research attention. This study aimed to describe women’s perceptions of the pain assessment and non-pharmacological pain relief methods used during labor.

METHODS

A descriptive, cross-sectional survey was conducted. A convenience sample of women (n=204) from one Finnish maternity ward participated in the study. Women who had given birth were asked to respond to a validated questionnaire between November 2018 and February 2019. The statistical significance of observed differences was analyzed using the chi-squared test.

RESULTS

Less than half (46%) of the women who gave birth at the hospital were asked to assess the intensity of their pain on a pain assessment scale. The most commonly used non-pharmacological pain relief methods were encouragement (92%), the presence of a midwife (82%), and proper breathing technique that was taught by a midwife (81%). Aqua blisters (3%), reflexology (e.g. zone magnets, 5%), and music (9%) were the least commonly used non-pharmacological methods during labor. The participants’ experiences of fear and pain were significantly associated with the implementation of pain assessment.

CONCLUSIONS

Women’s pain was rarely evaluated by using a certain pain assessment scale. In addition, non-pharmacological pain relief methods were inadequately used during labor. More specifically, methods that required midwives’ own personal contributions were rarely offered to the women.

Effects of using epidural analgesia during delivery on maternal and infant outcomes

OBJECTIVES

To estimate the impact of epidural analgesia (EA) during delivery on maternal and infant outcomes.

DESIGN

This study was a prospective cohort study.

PARTICIPANTS

In total, 159 pregnant women in Women and Children's Hospital, School of Medicine, Xiamen university from Nov. 2019 to May 2020. Patients were randomly divided into EA group (n=80) and no analgesia group (n=79).

METHODS

The duration of labor, levels of umbilical arterial blood gas [pH and partial pressure oxygen (PaO2)], VAS, adverse events were evaluated to compare differences between EA group and no analgesia group, respectively.

RESULTS

The duration of the first stage of labor was shorted in the total stage (P=0.002) and the first stage of labor (P=0.001) in EA group compared with no analgesia group. The second stage of labor and third stage of labor, levels of umbilical arterial blood gas and 1min Apgar score in neonates were similar in EA and no analgesia groups (All P>0.05). After adjusting age, pre-pregnancy BMI, and past and present medical history, the VAS was low in EA group compared with no analgesia group when the uterine orifice was completely open [odds ratio (OR)=0.001, 95% confidence interval (CI):0.001-0.002], 8h post-delivery (OR=0.508, 95%CI:0.264-0.977) and 24h post-delivery (OR=0.321, 95%CI:0.167-0.617). EA increased the proportion of adverse events occurring 5 min post-delivery (χ2=10.137, P=0.001), while decreased the proportion of adverse events occurring 24h post-delivery (χ2=4.750, P=0.029).

LIMITATIONS

In terms of the effects of EA on neonates, we only measured the 1 min Apgar score of neonates.

CONCLUSIONS

EA might be a promising pain relief method for pregnant women. The results of our study might give a reference for the use of EA during delivery in clinic.

Does TENS Reduce the Intensity of Acute and Chronic Pain? A Comprehensive Appraisal of the Characteristics and Outcomes of 169 Reviews and 49 Meta-Analyses

Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. Materials and Methods: We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. Results: We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors' conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. Conclusions: Our appraisal reveals examples of meta-analyses with 'sufficient data' demonstrating benefit. There were no examples of meta-analyses with 'sufficient data' demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with 'insufficient data' and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward.

Oxycodone for pain management in the latent phase of labour - A pragmatic trial

BACKGROUND

Parenteral opioids are used for pain relief in labour but there are little data for oxycodone in this context. The aim of this study was to evaluate the efficacy, foetal exposure and safety of subcutaneous oxycodone in the latent phase of labour.

METHODS

This pragmatic trial included 76 parturients, who received subcutaneous oxycodone for pain relief in the latent phase of labour according to the hospital protocol: an initial dose 0.1 mg/kg, and a second dose, 0.05 mg/kg, could be administered four hours later. Pain intensity and pain relief were assessed using a numerical rating scale of 0-10. After delivery, blood samples from the maternal and umbilical veins were collected, and plasma concentrations of oxycodone and its main metabolites were quantified using UPLC-MS/MS. The Apgar scores and maternal and neonatal adverse effects were recorded.

RESULTS

The foetal exposure at birth was low, the median oxycodone and oxymorphone umbilical vein plasma concentrations were 1.2 ng/mL (range 0.21-7.8) and 0.14 ng/mL (0-0.26), respectively. Pain scores decreased substantially, from a median pain score of 7/10 before oxycodone to median scores of 5/10 at 30 minutes after administration, 5/10 at 60 minutes and 6/10 at 120 minutes. The median Apgar score was 9 (range 2-10) at 1 minute and 9 (6-10) at 5 minutes. Maternal adverse effects were mild, and there were no oxycodone-related neonatal adverse effects.

CONCLUSION

Subcutaneous oxycodone provided effective analgesia during the latent phase of labour. Newborn exposure at birth was low, and oxycodone was well-tolerated.

Comparing the effect of auricular acupressure and body acupressure on pain and duration of the first stage of labor: study protocol for a randomized controlled trial

BACKGROUND

Labor pain is one of the leading causes of fear of childbirth. Acupressure is a non-pharmacological pain relief method that has shown promising results in relieving this pain. The present study is designed to compare the effects of body acupressure at multiple points and auricular acupressure on the pain and duration of labor.

METHODS/DESIGN

In a randomized controlled trial, 90 primigravida women who attend for childbirth will be randomly assigned to one of three groups (intervention groups of either body acupressure or auricular acupressure; control, consisting of routine care). Computer-generated six-block randomization techniques will be used to determine the allocation sequence with a 1:1:1 ratio. To hide the allocation, the type of intervention will be written according to the generated sequence and put in opaque envelopes; these as well as questionnaires will be encoded. The pain score for all participants will be measured at the peak uterine contraction at 4-cm cervical dilation and at 10-cm dilation based on a visual analog scale (VAS). The duration of the active phase of labor in these groups will be recorded too. Data will be imported into SPSS-16 software. First, normality of the data distribution will be investigated. To compare labor duration among the research groups, ANOVA will be used, which will be followed, in case of significance, by the Scheffe post hoc test. Furthermore, Chi-squared test will be used to compare the categorized demographic variables and ANOVA or Kruskal-Wallis tests will be used to compare the quantitative variables in the studied groups. A significance level of 0.05 is considered significant.

DISCUSSION

In this study the effect of auricular acupressure and body acupressure on pain and duration of first stage of labor will be compared.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials, IRCT20180218038789N1. Registered 2018-03-04; pre result.

Prevalence and intensity of pain during diagnostic hysteroscopy in women attending an infertility clinic: analysis of 489 cases

Objective

To investigate the prevalence and intensity of pain perception during diagnostic hysteroscopy in women and potential related factors.

Methods

A total of 489 women were investigated at an infertility clinic. Fluid diagnostic hysteroscopy was performed without analgesia or anesthesia by gynecologists with different levels of experience in operative hysteroscopy, using a 2.9mm rigid scope. The Visual Analog Scale was used to score pain intensity after vaginal speculum insertion and after hysteroscopy. Data collected included age, ethnicity, body mass index, history of infertility and endometrial surgery (curettage and/or hysteroscopy), smoking habits, and hysteroscopy diagnosis. Only the state of anxiety was assessed by the State-Trait Anxiety Inventory given to each patient before the procedure.

Results

Hysteroscopy median (25^th to 75^th) Visual Analog Scale scored 3.3 (3 to 5), and 41.7% of the women referred Visual Analog Scale score ≥4. Median (25^th to 75^th) State-Trait Anxiety Inventory score was 42 (38 to 45), and 58.3% of the women referred State-Trait Anxiety Inventory score >40. Hysteroscopy Visual Analog Scale score was significantly correlated to surgeon experience and to vaginal speculum insertion but not to State-Trait Anxiety Inventory score, ethnicity or abnormal hysteroscopic findings.

Conclusion

Diagnostic hysteroscopy was mostly perceived as a mild discomfort procedure by most women. Nevertheless, in a considerable number of cases, women perceived hysteroscopy as painful. Pain perception was linked to individual pain threshold and surgeon experience, but not to pre-procedural anxiety state levels, ethnicity or abnormal hysteroscopic findings.

Non-Neuraxial Labor Analgesia: Options

Although it is the most effective method to treat labor pain, neuraxial analgesia may be undesired, contraindicated, unsuccessful, or unavailable. Providing safe choices for labor pain relief is a central goal of health care providers alike. Consequently, knowledge of the efficacy, clinical implementation, and side effects of various non-neuraxial strategies is needed to provide appropriate options for laboring patients. In addition to nonpharmacologic alternatives, inhaled nitrous oxide and systemic opioids represent two broad classes of non-neuraxial pharmacologic labor analgesia most commonly available. This review summarizes the current published literature for these non-neuraxial labor analgesic options.

The Effect of Epidural Analgesia Alone and in Association With Other Variables on the Risk of Cesarean Section

Introduction:

Epidural analgesia (EA) is the most widespread pharmacologic method of labor pain relief. There remains disagreement, however, regarding its adverse effects. The objective of this study was to determine the effect of EA administration on the risk of cesarean delivery and its causes (e.g., stalled labor, risk of loss of fetal well-being, among others) and the degree to which this effect may be modulated by mother-, newborn-, and labor-related variables.

Method:

A retrospective cohort observational study was conducted including all deliveries in a Spanish public hospital between March 2010 and March 2013 ( N = 2,450; EA = 562, non-EA = 1,888).

Results:

Risk of a cesarean section was significantly increased by EA administration (odds ratio [ OR] = 2.673; p < .0001). The percentage of cesarean deliveries due to the risk of loss of fetal well-being was significantly higher in the EA (47.8%) versus non-EA group (27.5%; OR = 1.739; p = 0.0012,). The EA-associated risk of cesarean section was not significantly modified as a function of maternal age or parity, fetal position, newborn weight, weeks of gestation, or sedation administration alone. However, these variables in combination may increase the risk. We present multivariate models for each group that account for these variables, allowing for estimation of the risk of a cesarean delivery if EA is administered.

Conclusion:

EA is associated with an increased risk of cesarean delivery. Other variables in combination (maternal age or parity, fetal position, newborn weight, weeks of gestation, or sedation administration) may increase this risk.

Mindfulness-Based Interventions During Pregnancy: a Systematic Review and Meta-analysis

This systematic review aims to assess the effect of mindfulness-based interventions carried out during pregnancy exploring mindfulness and mental health outcomes. A systematic review was conducted to appraise the current literature on the subject area. Inclusion and exclusion criteria were agreed and after reviewing titles, abstracts and full papers, 14 articles met the inclusion criteria and were included in the review. The quality of included articles was checked using the Quality Assessment Tool for Quantitative Studies. Pooled results of the randomised controlled trials (RCTs) reporting outcomes on anxiety, depression and perceived stress indicated no differences between the mindfulness intervention group and the control group. Pooled results of the non-RCTs reporting anxiety, depression and perceived stress showed a significant benefit for the mindfulness group. Mindfulness as an outcome was assessed in four RCTs for which the pooled results show a significant difference in favour of the mindfulness intervention when compared to a control group. The pooled results of the four non-RCTs also indicate a significant difference following mindfulness intervention. Results suggest that mindfulness-based interventions can be beneficial for outcomes such as anxiety, depression, perceived stress and levels of mindfulness during the perinatal period. Further research would be useful to explore if such benefits are sustained during the post-natal period.

Implementation of a Hydrotherapy Protocol to Improve Postpartum Pain Management

INTRODUCTION

A growing number of women are seeking alternatives to traditional pharmacologic pain management during birth. While there has been an extensive array of nonpharmacologic options developed for labor, there are limited offerings in the postpartum period. The purpose of this quality improvement project was to implement a hydrotherapy protocol in the early postpartum period to improve pain management for women choosing a nonmedicated birth.

PROCESS

The postpartum hydrotherapy protocol was initiated in a certified nurse-midwife (CNM) practice in an urban academic medical center. All women who met criteria were offered a 30-minute warm water immersion bath at one hour postpartum. Pain scores were assessed prior to the bath, at 15 minutes after onset, and again at the conclusion (30 minutes). Women who completed the bath were also asked to complete a brief survey on their experience with postpartum hydrotherapy.

OUTCOMES

In women who used the bath (N = 45), there was a significant reduction in pain scores (P < .001) between the onset of the bath and scores at both 15 minutes and 30 minutes. There was no significant difference between pain scores at 15 minutes and 30 minutes (P = .97). Of those women who completed a survey (n = 43), 97.7% reported both that the bath reduced their pain and improved their birth experience. One hundred percent reported they would use it again in another birth.

DISCUSSION

This project demonstrated successful implementation of a hydrotherapy protocol as an alternative or adjunct to medication for early postpartum pain management that significantly reduced pain and improved the birth experience for those who used it. It offers a nonpharmacologic alternative where there have traditionally been limited options.

The characteristics of women who use hypnotherapy for intrapartum pain management: Preliminary insights from a nationally-representative sample of Australian women

OBJECTIVES

This manuscript presents a preliminary examination of the characteristics of women who choose intrapartum hypnosis for pain management.

DESIGN

Cross-sectional analysis of 2445 women (31-36 years) from a sub-study of the Australian Longitudinal Study on Women's Health (ALSWH), employing Fisher exact tests.

SETTING

Australia.

MAIN OUTCOME MEASURES

Use of intrapartum hypnosis, or hypnobirthing, for pain management during labour and birth.

RESULTS

Women using hypnobirthing were more likely to have consulted with an acupuncturist or naturopath, or attended yoga/meditation classes during pregnancy (p<0.0001). Use of CM products such as herbal medicines, aromatherapy oils, homoeopathy, herbal teas or flower essences (p<0.001) was also more common amongst these women. Women choosing hypnotherapy for intrapartum pain management less commonly identified as feeling safer knowing that an obstetrician is providing their care (p<0.001), and were more likely to labour in a birth centre or in a community centre (i.e. at home).

CONCLUSIONS

This analysis provides preliminary analysis into an as yet unexamined topic in contemporary maternity health service utilisation. The findings from this analysis may be useful for maternity health professionals and policy makers when responding to the needs of women choosing to use hypnotherapy for intrapartum pain management.

Anxiety at outpatient hysteroscopy

This review summarises current understanding and research on the association between anxiety and outpatient hysteroscopy. Women undergoing hysteroscopy suffer from significant levels of anxiety, with repercussions on pain perception, success rates and satisfaction. Using validated tools such as the Spielberger State-Trait Anxiety Index (STAI) or the Hospital Anxiety and Depression Scale (HADS) in the outpatient hysteroscopy setting, average state anxiety scores similar or greater than those measured before more invasive procedures under general anaesthesia have been consistently reported. This clearly suggests a significant gap between our clinical viewpoint of what is "minimally invasive" and patients' expectations. In spite of its potential role of confounder in studies on pain-reduction interventions, we found that patient anxiety was evaluated in only 9 (13 %) out of a sample of 70 randomised controlled trials on outpatient hysteroscopy published since 1992. Factors such as trait anxiety, age, indication and the efficiency of the clinic can be correlated to state anxiety before hysteroscopy, but more robust data are needed. Promising non-pharmacological interventions to reduce anxiety at hysteroscopy include patient education, communication through traditional or multimedia approaches, interaction and support during the procedure and music listening.