Knowledge and use of sterile water injections amongst midwives in the United Kingdom: A cross-sectional study

Simple Yet Effective-Sterile Water Injections to Treat Labor Pain in the Transport Environment

Sterile water injections (SWI) is a nonpharmacologic pain relief option to treat back pain in labor. This case report describes and discusses the use of SWI in the context of an obstetric retrieval of a 29-year-old woman who was transferred by the Royal Flying Doctor Service South Eastern Section. It provides an overview of SWI, discusses the relevance for medical transport, and offers suggestions for medical transport professionals.

The barriers to offering non-pharmacological pain management as an initial option for laboring women: A review of the literature

INTRODUCTION

Many women use pharmacological or non-pharmacological pain management (NPPM) during childbirth, however, evidence shows the usage rates of pharmacological pain management are increasing. The shift towards a biomedical approach to birth care opposes the enduring midwifery philosophy of trusting the woman and her body. Identifying midwives’ beliefs and attitudes towards perceived and actual barriers to offering NPPM as an initial option will provide insight into the factors that affect this.

METHODS

This review of the literature sought to understand midwives’ beliefs and attitudes towards the barriers to offering NPPM as an initial option for laboring women. Peer-reviewed journals were searched for primary research that met the inclusion criteria and explored midwives’ beliefs and attitudes towards the barriers to offering NPPM as an initial option for laboring women. Included studies were evaluated for quality according to the Critical Appraisal Skills Programme (CASP) checklists.

RESULTS

Thirteen qualitative studies met the inclusion criteria and four main themes of barriers to midwives offering NPPM emerged: health system-related, health facility-related, health practitioner-related, and health consumer-related barriers.

CONCLUSIONS

The review of the literature highlighted there are barriers that prevent or delay the initial utilization of non-pharmacological methods of pain management in labor by midwives. These findings can be used as a platform to inform further research into this topic.

Midwives and women's experiences of Sterile Water Injections for back pain during labour: An integrative review

BACKGROUND

/ OBJECTIVE: This integrative review summarises original research that explores the experiences and perceptions of midwives and women using sterile water injections (SWI's) during labour.

DESIGN

Integrative review.

METHODS

A robust search strategy was conducted using the following databases: Scopus, Cumulative Index to Nursing and Allied Health (CINAHL), Ovid Medline and PubMed. All articles were assessed for quality using the Joanna Briggs Institute Critical Appraisal Tools (2017) scoring. Whittemore and Knafl's (2005) five stage approach was used to analyse the primary literature related to midwives and women's experiences of sterile water injections (SWI's) for back pain during labour.

FINDINGS

A total of 291 articles were retrieved and 13 papers were included in this review (four qualitative including one case report and nine quantitative) that fulfilled the inclusion criteria. Three overarching themes were identified: 'Assessment, perception and communication of pain', 'Techniques of administration of SWI's' and 'Barriers and resistance to using SWI's'. The 'Assessment, perception and communication of pain' theme included four subthemes: 'balancing the expectation of the injection pain against pain relief'; 'using appropriate language to prepare women'; 'rapid onset and increased pain relief with SWI's in comparison to saline'; and 'midwives high considerations for using SWI's as a form of pain relief'. The 'Techniques of administration of SWI's' theme included two subthemes: 'intradermal is better than subcutaneous injections'; and, 'four injections is better than one'. The 'Barriers and facilitators to using SWI's' theme included four subthemes: 'guidelines and evidence'; 'level of experience'; 'midwifery philosophy challenges'; and 'resistance from colleagues'. For example, 'midwifery philosophy challenges' included midwives being conflicted about providing an invasive, painful procedure as counter-intuitive to supporting women through the pain of labour. Midwives need opportunities to learn and develop skills for using SWI's. Women described feeling more empowered during their labour and appreciated the use of SWI's including the rapid onset of pain relief and the absence of side effects. The ability for women to exert some control over their pain whilst still being able to experience the physical sensations of labour and birth was important.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The review supports the evidence for the use of SWI's however, there is limited evidence available and more information needs to be provided about the benefits of this non-pharmacological technique for back pain during labour. Generalised guidelines are needed to ensure consistent practice in the provision of care for women experiencing back pain during labour.

Promotion on labor process and relief of the low back pain by relaxing pelvic muscle with Shangliao (BL 31) point injection in women using epidural analgesia during labor: A randomized, controlled, clinical trial

BACKGROUND

The purpose of this study was to explore the effects of combing Shangliao point injection with epidural analgesia on labor pain and birth process in women with low back pain and the possible mechanisms.

METHODS

93 consecutive women were randomized to receive either Shangliao point injection combined with epidural analgesia or epidural analgesia. Another 14 women were recruited to explore the mechanisms and the transperineal ultrasound was performed accordingly.

RESULTS

The main result duration from epidural analgesia to baby delivery was significantly shorter in epidural analgesia and saline injection group than that in epidural analgesia group 307.0 (175.0-445.0) min VS 369.0 (254.0-563.0) min (P = 0.02). The verbal numerical rate scaling score in low back during the first contraction was significantly decreased 5.0 (4.0-7.0) after Shangliao point injections (P < 0.001). The consumption of ropivacaine per hour was significantly less in epidural analgesia and saline injection group than in epidural analgesia group (-0.4 mg, 95%CI: -0.1 to -1.8; P = 0.03). The angle of progression and anteroposterior diameter of the levator hiatus at rest and during valsalva were significantly increased after shangliao point injection (7.10°, 95%CI, 1.50~12.70; P = 0.02); (9.10°, 95%CI, 3.60~14.58; P < 0.01); (0.27 cm, 95%CI, 0.03~0.51; P = 0.03); (0.30 cm, 95%CI, 0.13~0.48; P < 0.01).

CONCLUSIONS

Shangliao point injection could shorten the time to baby delivery and rapidly relieve low back pain in addition to epidural analgesia, that may attribute to its function of relaxing the pelvic floor muscles and promote fetal head progress.

Caesarean delivery rates and analgesia effectiveness following injections of sterile water for back pain in labour: A multicentre, randomised placebo controlled trial

BACKGROUND

About a third of women experience severe back pain during labour. Injecting small volumes of intracutaneous sterile water into the lumbar region can be used to relieve this pain, however the procedure is controversial and previous reviews call for high quality trials to establish efficacy. We evaluated the impact on birth outcomes and analgesic effects of sterile water injections.

METHODS

A multicentre, double-blind trial undertaken between December 2012 and December 2017 in one British and 15 Australian maternity units. Women experiencing severe back-pain in labour were assigned (1:1) by an independently generated randomisation schedule stratified by site to injections of either sterile water or saline placebo. Participants and caregivers were blinded to group allocation. The primary outcome was caesarean delivery rate. Main secondary outcomes included at least 30% or 50% reduction in self-reported pain scores at 30, 60 and 90 minutes after treatment. Intention to treat analysis were used and the level of significance for the multiple clinical outcomes was set at p<0.001 with the Bonferroni correction applied. The study is registered with the ACTRN Registry number, ACTRN1261100022195.

FINDINGS

Between December 9, 2012, and December 15, 2017, 1166 women were recruited and randomised: 587 women received sterile water injections (SWI) and 579 a saline placebo. Seven women in the SWI group and 12 in the placebo group were excluded as consent was not completed, leaving 580 and 567, respectively, included in the analysis. The proportions of caesarean delivery were 17·1% (82 of 580) in the SWI group and 14·8% (82 of 567) in the placebo (RR 1·16, 95% CI 0·88-1.51; p = 0·293). At 30 min post treatment 60·8% (330 of 543) of women in the SWI group reported a 30% reduction in self-reported pain compared to 31·4% (163 of 520) placebo (RR 1·94, 95% CI 1·68-2·24; p=<0·001) and 43·3% (235 of 534) SWI reported a 50% reduction versus 18·1% (94 of 520) placebo (RR 2·39, 95% CI 1·95-2·94; p=<0·001). The analgesic effect of SWI compared to placebo remained significant at 60 and 90 min post-treatment. There were no significant differences in other maternal or neonatal outcomes.

INTERPRETATION

Compared to placebo, injections of sterile water did not reduce rates of caesarean delivery. For the main secondary outcome of pain relief the intervention did result in significantly more women reporting at least 30% and 50% reduction in pain for up to 90 min. Water injections have no effect on birth outcomes though can be an effective treatment for the relief of labour-related back pain.Funded by the National Health and Medical Research Council.

Comparative Analgesic Effects of Intradermal and Subdermal Injection of Sterile Water on Active Labor Pain

Background

The labor pain is one of the factors encouraging pregnant women for cesarean section delivery. Recently, intradermal and subdermal injection of distilled water has shown to be effective in improving this pain.

Objectives

The present study aimed to determine which method has a greater impact on labor pain reduction.

Methods

In this double-blind, randomized clinical trial, 121 nulliparous women with a gestational age of ≥ 37 weeks were randomly divided into three groups: (1) 0.5 cc sterile water injection subdermally at four sacral points with insulin needles (n = 40); (2) 0.5 cc sterile water injection intradermally (n = 39); and (3) needle contact with the mentioned points as the placebo (n = 42). Before the intervention, the VAS score was measured for labor pain, and it was repeated 10, 30, 60, and 90 min after the intervention. The results were compared between the three groups.

Results

Before the intervention, the mean VAS pain score had no significant difference between the three groups. However, 30, 60, and 90 min after the intervention, the mean pain score was significantly lower in the intradermal and subdermal injection groups than in the control group (P = 0.001); however, the difference between the intradermal and subdermal injection groups was not significant.

Conclusions

The injection of distilled water by either intradermal or subdermal method was associated with a significant reduction in the pain score during labor, but there was no difference between these two methods in terms of decreasing labor pain. As sterile water injection is a safe, effective, and low-cost method, it is proposed to increase the knowledge of midwives and obstetricians about this method.