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Definition of Pain and Description of Labour Pain
Pain is defined as a bothering sensory feeling or emotional experience and is variably described as irritating, sore, stinging, aching, throbbing, or unbearable feeling (Patel 2010). There are two categories of pain, including nociceptive and neuropathic (Macintyre & Schug 2007). Macintyre and Schug (2007) explained these categories in detail. The first category is nociceptive pain—a common category reported in clinical settings. This type of pain occurs due to trauma, tissue damage or inflammation that stimulates sensory nerve endings called nociceptors. Intense peripheral nociceptive stimuli will increase excitability of the nervous spinal cord, leading to central sensitisation in the presence of subsequent pain stimuli, increased intensity and lower pain threshold. Macintyre and Schug (2007) also described two types of nociceptive pain: somatic and visceral pain. Somatic pain may be experienced as sharp, hot or stinging pain that is localised to the area of injury. Visceral pain is dull, cramping or colicky pain that is poorly localised. Visceral pain can also be referred to other areas, with associated symptoms, such as nausea and vomiting. The second category is neuropathic pain. It results from serious injury or disease of the peripheral or central nervous system. Injury leads to developing central sensitisation and hyper excitability of damaged peripheral nerves. Therefore, the patient may experience sensory loss, motor weakness, bowel or bladder sphincter abnormalities, reflex change, pain in area of sensory loss, alteration in skin colour, temperature and texture, and sweating. The resulting pain often responds poorly to pharmacological treatment (opioids). Neuropathic pain can be a part of acute pain following surgery or serious trauma.
Many authors Baker et al. (2001) agree that labour pain is the most excruciating form of pain is that associated with human childbirth. Wong (2009) highlighted that during childbirth; the first and second stages of labour represent and correspond to two different types of pain. The first type of pain experienced during the first stage of labour occurs due to uterine contractions that lead to dilatation of the cervix. This pain consequently is visceral accounting for sensations from the mechanical distension of the cervix and the lower uterine segment. These sensations are transmitted through the L10 nerve root and are often felt as back pain. The second type of pain is experienced during the second stage of labour that occurs due to accentuated distension of the uterus and cervix plus stretching of the structures of the pelvic floor and decent of the fetal head. Wong (2009) clarified that this type of pain is felt though the distribution of the pudendal nerve.
Mander (2000) and Simkin (2000) pointed out that psychology or the contribution of psychologists had never been considered crucial in the domain of antenatal education when it evolved. Therefore, the field has failed to take advantage of crucial developments in comprehending how the psychological aspects impact the two notable aspects related to birth experiences, experiences linked to fear and pain. It can be gathered that the description of pain during labour may vary from other conditions, where it indicates that pathology and variation need to be considered carefully. They also suggested that some studies describe the essence of childbirth pain despite there existing limited yet contrasting proof to show that the pain during labour differentiates from other severe pain conditions.
Assessment and Management of Labour Pain
The estimated birth rate worldwide in 2014 is 18.7 births/1,000 populations, 255 worldwide births per minute or 4.3 births every second (CIA 2014). This means that the world should be on track to achieve the 2015 Millennium Development Goal to improve maternal care, recognising that women’s experience of child birth pain is a primary step in improving maternal care. Positive birth experiences leave enjoyable and pleasant memories. Transmission of positive pain free stories from women who experienced a peaceful spontaneous birth before will encourage women with their first pregnancy to prefer vaginal birth (Beigi et al. 2010).
Accurate assessment and reassessment of acute pain, such as labour pain, is the key for successful pain management (Breivik et al. 2008). Using a validated and reliable tool is necessary for pain management and satisfying clients. Breivik et al. (2008) indicated that acute pain can be assessed both at rest and during movement using one-dimensional tools, such as the visual analog scale and numeric rating scale. They emphasised that the visual analog scale and the numeric rating scale are equally sensitive and superior to a four-point verbal categorical rating scale. The authors also highlighted that the numeric rating scale from 0–10 (‘no pain’ to ‘worst pain’) is more practical than other scales and can determine the intensity of pain accurately.
Patients are usually asked to rate their pain scores at rest time. Assessment of pain during physical activity, such as mobility and deep breathing, is considered a strong indicator of analgesic efficacy. Therefore, nurses have to score pain both at rest and with activity. They also have to assess pain level during the period of treatment. Frequency of assessment depends on the chosen model of pain relief and client response. Poorly controlled pain indicates the need for frequency of assessment and close observation (Macintyre & Schug 2007; ICSI 2008).
The American Society for Pain Management Nursing (ASPMN) (2012) describes a strategic goal that calls for ‘continuous improvement in the knowledge base of current and future health care providers’ as a clinical education that guarantees effective pain management. The management of labour pain is important in the maternity context of birth. Managing labour pain is complicated and requires assessment, reassessment, and constant observation by midwives. However, three main barriers to successful pain management have been identified (Soyannwo 2010; Mander 2010). Firstly, there is the staff culture of difficulty in dealing with women in pain. This barrier is aggravated by midwives’ intolerance of noisy birth environment. Midwives recognise that pain is one of the basic aspects of the labour process. Based on this reality, it is proposed that midwives tolerate and cope with women and women’s reactions. Midwives should differentiate between acceptable physiological labour pain that requires presence and pathological labour pain that requires pharmacological treatment to prevent unwanted complications. Secondly, the midwives’ knowledge and understanding of the meaning of labour pain is important. If midwives were able to interpret pain, this would facilitate supportive care and women’s long term satisfaction. What is supportive and effective for women may be a little more frustrating to others. Thirdly, there is the lack of unobserved and unrecorded aspects of midwifery practices, particularly pain, as it is the most manageable intervention in labour. Midwifery interventions have to be witnessed, and educational interventions are required (Soyannwo 2010; Mander 2010).
Klomp et al. (2014) emphasised that midwives have to know pain management approaches taken by most women in order to help women to handle their pain during childbirth. The three management approaches found in Klomp et al. (2014); the pragmatic natural, the deliberately uninformed and the planned pain relief approaches. The pragmatic natural approach is used by women who are confident in their ability to handle labour pain without the need for pain relief if labour is normally progressing, but at the same time, they valued pharmacological pain relief when required. The deliberately uninformed approach is employed by women who want to receive information in moderation and prefer to observe how things turn out. The planned pain relief approach is implemented by women who definitely need to have pain relief at the beginning of childbirth.
Chaillet et al. (2014) conducted a meta-analysis on the effectiveness of non-pharmacological approaches to pain relief during labour compared to usual care. They found that non-pharmacological approaches to relief labour pain can help women cope with labour pain, contribute to reduction in medical interventions and benefit women and infants without causing harm. Specifically, non-pharmacological approaches based on Gate control (water immersion, massage, ambulation, positions) and diffuse noxious inhibitory control (acupressure, acupuncture, electrical stimulation and water injections) are associated with reduction in epidural analgesia, reducing labour pain and increasing maternal satisfaction. Whereas the non-pharmacological approaches based on CNS control (education, attention deviation, support) are associated with increased epidural, instrumental delivery, use of oxytocin, duration of labour, neonatal resuscitation and less satisfaction with childbirth. Chaillet et al. also found that the most effective method of non-pharmacological approaches to pain relief is continuous support, which reduces obstetric interventions.
Childbirth is supposed to be a normal process, but the pain associated with it can be severe so as to need pain relief. Epidural analgesia is considered the most effective form of pain relief during labour, but their effects on the progress of labour and obstetric outcome remains debatable (Nafisi 2006; Bhattacharya, Wang & Knox, 2006; Anu et al. 2011). A randomised) investigated the effect of epidural lidocaine analgesia on duration of the second stage of labour and obstetric outcomes among nulliparous parturient in Iran. The results of the investigation showed that the lumber epidural analgesia had a minimal effect on spontaneous delivery as it does not prolong duration of labour; it does not increase oxytocin augmentation; it does not increase the rates of vacuum assisted or cesarean births; and it does not affect the neonatal APGAR scores. Furthermore, Nafisi found that the pain level was low during the active phase of the first stage and during the second stage of labour in the epidural group; the incidence of hypotension among the epidural group was high, and the incidence of nausea and vomiting was not different (epidural 6% vs meperdine 4%) between both groups.
Different findings were revealed through a population based epidemiological study (Bhattacharya, Wang & Knox 2006) on all deliveries recorded at the Aberdeen Maternity Data Bank over 16 years. It was found in this study that most women (41.54 %) used opioids to relieve pain, 33.13 percent of women received Entonox only or no analgesia, and a minority of women had an epidural (15.5%). The women who received an epidural had a longer gestational period (5.5days), a higher incidence of pregnancy related complication (43.03%), increased incidence of induced labour (42.7%), a longer duration of labour (31.1hrs), and elevated rates of instrumental (43.2%) and cesarean births (29%) compared to women who received opioids, Entonox only or no analgesia. However, it was determined in this study that the poorest neonatal outcomes were found among mothers who used opioids analgesia compared to other groups. The still birth rate was 1.03 percent, an Apgar score of 7 or less at 1 minute was 13.5 percent and at 5 minutes was 2.4 percent of births. The researchers (Bhattacharya et al. 2006) in this study referred to literature to present a suggestive explanation for poor neonatal outcomes, which they explained could be related to timing and dosing of opioids injection. Another possible explanation is that the data were collected from deliveries recorded over 16 years where resuscitation techniques were less developed. Recently, Anu et al. (2011) found that maternal side effects, such as nausea, vomiting, drowsiness and hypotension are low; neonatal respiratory depression is not significantly reported, but there is a significant prolongation in the second stage of labour in the epidural tramadol group than the intravenous one.
Women´s Experiences of pain and Satisfaction with Care
The absence of pain does not mean absence of negative emotional reaction ‘suffering’. When women feel angry during labour, unable to control their pains and feel hopeless, they may develop child birth related posttraumatic stress syndrome. Midwives should recognise that if a woman has any option of pain relief, she still needs professional support that enhances labour progression (Simkin & Hull 2011). Simkin & Hull (2011) advised midwives to listen to women’s concerns, prepare them for labour and minimise the likelihood of loneliness, disrespect and intolerable pains
