PHYSIOLOGY OF PAIN IN LABOUR

K.W. Gondwe, 2009

Objectives
Define pain Describe of types of pain in labour Explain the gate theory and its relationship to labour pains Explain non-pharmacological and pharmacological management of pain in labour

PAIN
Pain is whatever the person says it is. Pain's an unpleasant sensation which may be associated with actual or potential tissue damage and which may have physical and emotional components Pain is very subjective and the degree varies in
Different women Same woman in successive labours Same woman at different time in the same labour

PAIN
Pain is describe by individual as being
Throbbing Slicing Burning Crushing Squeezing Cutting Pounding Pricking e.t.c

PAIN THRESHOLD AND TRANSMISSION

Pain threshold refers to the lowest level at which the brain perceives pain. Nociceptors are free nerve endings that generate pain impulses Nociception refers to causative factors for pain impulses i.e. somatic or visceral

TYPES OF PAIN IN LABOUR

There are two different kinds of labour
Somatic pain: related to pressure on and stretching of the birth canal as descent occurs Visceral pain: generally is experienced during active dilatation and is related to cervical stretching and uterine contraction intensity

VISCERAL PAIN
This pain is transmitted slowly through unmyelinated fibers and is felt as dull, diffuse, persistent or aching sensation Pain sensation transmitted thorough myelinated nerve fibers travel more rapidly and are perceived as localised sensations. During first stage nerve impulses enter the sympathetic chain at L1 to L5 then travel to the posterior roots of the X, XI, XII thoracic nerves up the spinal cord to the thalamus

 They may also be referred to the dermatomes of the same nerves and pain is felt in the skin, thighs, lower back and hips as well as hot spots of generalized aching. Some pain is pressure induced, some may be caused by fatigue and hypoxia of uterine muscles During labour areas of referred pain change location and if prolonged uterine fatigue may increase pain sensation

SOMATIC PAIN
Usually begins during the transition phase because descent is speeded Pressure of the fetus on the cervical, vaginal and perineal tissues is intense; first felt as need to bear down and this sensation may become overpowering These pain sensation travel through the pudendal nerves through the dorsal roots of the II, III, IV sacral nerves

 Pain is felt as contractions intensity rises 15 to 20mmHg above the resting tonus (above 25mmHg pressure on monitor strips).

GATE-CONTROL THEORY
This is important for understanding the approaches used in pain management. It was developed by Ron Melzack and Patrick Wall in 1962. Gate control theory asserts that activation of nerves which do not transmit pain signals, called nonnociceptive fibers, can interfere with signals from pain fibers, thereby inhibiting pain.

 Afferent pain-receptive nerves bring signals to the brain and comprise at least two kinds of fibers
a fast, relatively thick, myelinated "A" fiber (delta fibers) that carries messages quickly with intense pain, and a small, unmyelinated, slow "C" fiber that carries the longer-term throbbing and chronic pain.

Large-diameter A fibers are nonnociceptive (do not transmit pain stimuli) and inhibit the effects of firing by A and C fibers.

 The peripheral nervous system has centers at which pain stimuli can be regulated. Some areas in the dorsal horn of the spinal cord that are involved in receiving pain stimuli from A and C fibers, called laminae, also receive input from A fibers. The nonnociceptive fibers indirectly inhibit the effects of the pain fibers, by 'closing a gate' to the transmission of their stimuli. In other parts of the laminae, pain fibers also inhibit the effects of nonnociceptive fibers, thus 'opening the gate'.

 depending on the relative rates of firing of C and A fibers, the firing of the nonnociceptive fiber may inhibit the firing of the projection neuron and the transmission of pain stimuli The pain seems to be lessened when the area is rubbed because activation of nonnociceptive fibers inhibits the firing of nociceptive ones in the laminae. For example in transcutaneous electrical stimulation (TENS), nonnociceptive fibers are selectively stimulated with electrodes in order to produce this effect and thereby lessen pain.

 One area of the brain involved in reduction of pain sensation is the periaqueductal gray matter that surrounds the third ventricle and the cerebral aqueduct of the ventricular system. Stimulation of this area produces analgesia (but not total numbing) by activating descending pathways that directly and indirectly inhibit nociceptors in the laminae of the spinal cord.It also activates opioid receptorcontaining parts of the spinal cord.

FACTORS AFFECTING PAIN PERCEPTION Worry and anxiety Insecurity Fear Ignorance Fatigue Intense heat or cold Poor general physical condition Malnutrition and starvation Infection Continuous pain or severe pain experienced over an extended period (hypertonic contraction or in prolonged labour

Culture Parity Education Marital stability Childbirth preparation Past experiences Race Unplanned or planned pregnancy

NON-PHARMACOLOGICAL PAIN MANAGEMENT

Touch: most women respond positively to touch.

Effleurage refers to light rhythmic stroking over the womans abdomen in rhythm with breathing during contractions and aids in relaxing muscles Counter pressure against the sacrum Backrub over the sacral area and buttocks every two hours or less Foot massage Acupressure for additional endorphin response and relief of painful sensation

 Warm bath or shower for relaxation Breathing techniques

Dilatation less than 3cm: woman feels for onset of contraction and takes a deep breath through the nose and out through pursed lips. She should focus on slow chest breathing (6 to 9 per minute). When contraction is over she takes a final deep breath in and blows the contraction away through pursed lips. She may focus on an object or close her eyes Dilatation 4 to 7cm: change to shallower, lighter breaths (no more than 16/min). Ask her to slowly raise her abdomen when breathing in (this moves the abdomen away from the contracting uterus

 Cervical dilatation 8 to 10:women has difficulties concentrating on breathing. Ask the woman to breath 3 times and then puff (as if blowing out a candle) out to blow away the contraction (breath, breath, breath, puff) NB. avoid hyperventilation which can result in alkalosis, discourage early pushing

Do not leave the woman alone. A support person: husband or close relation may be used. Talk with support person and give them reassurance, nourishment, rest elimination. Remember they need to be comfortable for them to provide adequate support. Minimize adverse environmental stimuli: control glaring lights, decrease traffic flow and noise in birth setting

 Remind mother that to select the best position in which she feels comfortable. Encourage walking in early labour. The mother can also stand, lean against the wall or over a chair or support person, sit on a chair. Provide privacy and space with adequate room temperature and ventilation Talk of contractions and not pains Relax and get as near to the womans level as possible. Sit by the bedside. Do not tower over her

 Adjust the labour bed to provide comfortable position i.e. semi fowlers. The woman should never be flat on her back. Use pillows to support all dependent parts. Use comfort measures such as cold cloths, ice chip, backrubs, baths or shower Chat with the woman in-between contractions. Do not distract her during a contraction. WAIT. Assure the mother that she is doing well with kind voice Remind mother to urinate frequently

 Encourage rest in between contractions Keep her bedding clean, dry without wrinkles or kinking During actual birth trust and work with the woman. The goal is pelvic floor release and relaxation it is not an athletic contest. Encourage series of quick breaths holding for five seconds while pushing with grunting sounds or expiratory vocalizations. Give her verbal support i.e. beautiful, go with it, you are doing fine.

PHARMACOLOGICAL MANAGEMENT
Pharmacological includes use of pain management

Analgesia: brings loss of pain sensation by raising pain threshold for pain perception. Analgesics are the agent used and they relieve pain without causing unconsciousness Anesthesia: use of agents to bring loss of sensation

 Systemic analgesia
narcotic analgesic compounds: meperedine, morphine , pethidine. Make sure that naloxone is available incase neonate exhibits respiratory depression, hypotonia, lethargy, and delay in temperature regulation Analgesic potentiator: i.e. phenobarbitone, promethazine. These may be given together with the narcotic to reduce the risk of narcotic effects from high doses Nerve block analgesia and anesthesia: chemically related to cocaine i.e. 0.5-1% lidocaine, bupivacaine, e.t.c. in case of depressive effects atropine, oxygen and supportive measure should be available

 Local infiltration anesthesia: used with episiotomy i.e. 1% lidocaine, chloroprocaine. Epinephrine can be added to the solution to control bleeding Pudendal block: useful in second stage and administered 20 to 30 minutes before perineal anesthesia is needed, but may result into loss of the bearing down reflex. Spinal anesthesia: local anesthetic used for C/S. Epidural block: relieves pain of uterine contractions and delivery both vaginal and abdominal by injecting anesthetic in the epidural (peridural) space

 Paracervical block: relieves pain from cervical dilatation and distension of LUS

Inhalation analgesia General analgesia

When to give narcotics in labour

Maternal assessment
Mother should be willing Vital signs should be stable

Fetal assessment
FHR between 120 and 160 and reactive Fetus is term Meconium staining not present

Labour assessment
Contraction pattern well established Cervix less than 6cm (4-5 in prims and 3-4 in multips) Fetal presenting part engaged Progressive descent of presenting part with no complication

YEBO