The College at Brockport: State University of New York Digital Commons @Brockport Senior Honors Theses Master's Theses and Honors Projects 5-6-2015 Perceptions of Labor and Delivery Clinicians on Non-Pharmacological Methods for Pain Relief During Labor Amanda Rose Cochrane The College at Brockport, [email protected] Follow this and additional works at:http://digitalcommons.brockport.edu/honors Part of theMaternal, Child Health and Neonatal Nursing Commons, and theNursing Midwifery Commons Repository Citation Cochrane, Amanda Rose, "Perceptions of Labor and Delivery Clinicians on Non-Pharmacological Methods for Pain Relief During Labor" (2015).Senior Honors Theses. 94. http://digitalcommons.brockport.edu/honors/94 This Honors Thesis is brought to you for free and open access by the Master's Theses and Honors Projects at Digital Commons @Brockport. It has been accepted for inclusion in Senior Honors Theses by an authorized administrator of Digital Commons @Brockport. For more information, please [email protected]. Running head: PERCEPTIONS OF LABOR AND DELIVERY CLINICIANS ON NON-PHARMACOLOGICAL Perceptions of Labor and Delivery Clinicians on Non-Pharmacological Methods for Pain Relief During Labor A Senior Honors Thesis Submitted in Partial Fulfillment of the Requirements for Graduation in the Honors College By Amanda Rose Cochrane Nursing Major The College at Brockport May 6, 2016 Thesis Director: Susan E. Lowey, PhD, RN, CHPN, Assistant Professor, Department of Nursing Educational use of this paper is permitted for the purpose of providing future students a model example of an Honors senior thesis project. PERCEPTIONS OF LABOR AND DELIVERY CLINICIANS ON NON-PHARMACOLOGICAL 2 Chapter I: Introduction There has been a movement from natural birthing to medical birthing with the development of modern technology. A natural childbirth is typically considered to be free of pharmacological intervention, where as a medicalized birth often uses pharmacological methods for pain relief and assisted delivery techniques. This change has resulted in medical intervention during labor being at an all time high in the United States. Pharmacological methods of pain relief are often one of the first interventions that the health care team uses. In order to labor with minimal pharmacological interventions for pain relief, or pain medications, mothers need continuous support and complimentary or alternative medicine (CAM) to help them cope with the pain. Unfortunately, there is a stigma around “natural” birthing, or birthing without medical interventions, that causes people to associate it with home births. In order to increase the number of “natural births” occurring in the United States, it is crucial to find a way to promote the use of these alternative methods in a setting where expectant mothers can feel safe, like the hospital setting. The goal of this study is to describe the perceptions of labor and delivery clinicians regarding non-pharmacological methods for pain relief during labor. Although there are several enticing areas of study pertaining to this topic, this study looks specifically at the question: “What are the barriers to the use of non-pharmacological methods for pain relief during labor in the hospital setting?” Without knowledge of what prevents the use of these methods, it is impossible to overcome the barriers and enact change. Also, many people are unaware of the multitude of options for non-pharmacological pain relief during labor. Recognizing the barriers is the first step in addressing the question, “How can hospitals increase the use of non- pharmacological pain relief methods during labor?” This study will further the understanding of PERCEPTIONS OF LABOR AND DELIVERY CLINICIANS ON NON-PHARMACOLOGICAL 3 current methods used for pain relief during labor, explore the incidence of and attitude towards non-pharmacological pain intervention use and perceived facilitators and barriers to the use of these methods. Ultimately, the research findings will be used to propose ways to increase women’s access to a more natural childbirth in the hospital setting. For the purposes of this study, “labor and delivery clinicians” will include midwives, providers and nurses. Non-pharmacological methods for pain relief during labor include supportive measures such as hydrotherapy or the use of water for pain relief, the use of a birthing ball, massage, therapeutic touch, music, aromatherapy, doula support, heat and cold application, visualization and frequent position changes. These are just a few examples of the many techniques available to laboring mothers. This descriptive qualitative study was conducted through individual, semi-structured interviews with three different clinicians. All clinicians who participated in the study work with laboring mothers as nurses, midwives or obstetricians. The questions asked addressed the current methods for pain relief being used where the clinicians worked, frequency of use of alternative methods for pain relief, what specific methods they see being used, their personal beliefs on these methods and why they think these methods are not used more often. This data was analyzed and themes were revealed regarding how often these methods are used, what clinicians believe is preventing their use and how the clinician’s role in labor affects their ability to use alternative methods. Through studies like this, ways can be found to discuss and implement as natural of a birth for the mother as possible while reserving more medical interventions for high-risk deliveries and emergency situations. This is an important area of study in nursing because overcoming the barriers to natural childbirth in the hospital setting may require policy change, PERCEPTIONS OF LABOR AND DELIVERY CLINICIANS ON NON-PHARMACOLOGICAL 4 increased insurance coverage for a number of the techniques, enhanced prenatal education on the choices available to laboring women and a shift in the culture of many hospitals. Chapter II: Review of Literature Introduction to Labor Pain Labor is a dynamic process that most women go through during childbirth. As a woman’s labor progresses and changes, so does the pain that accompanies it. The perception of pain is influenced by a variety of factors including the woman’s culture, her individual ability to cope with pain, her body, her surroundings and her support systems. In order to adequately assist laboring mothers who are coping with labor pain so that they can achieve the most gratifying birthing experience, health care workers need to thoroughly understand labor pain. There are several factors that influence a woman’s perception of labor pain. A woman’s culture, ethnicity, level of education, preparation for childbirth, previous pain experiences and ability to cope all affect her ability to manage the pain of labor (Zwelling, Johnson, & Allen, 2006). It is impossible to change a woman’s culture, ethnicity or previous experiences with pain, but health care workers can educate and prepare laboring mothers to cope with the pain. In Japan, childbirth is considered a woman’s number one contribution to society, so feeling the pain and successfully coping with it is considered admirable (Behruzi, Hatem, Goulet, & Fraser, 2014, p. 14). In the United States, on the other hand, women often want to feel the least amount of pain possible. Socio-cultural views like these ultimately affect the definition of “coping” with labor as well as the methods used to cope. Non-pharmacological methods for pain relief do not remove the pain entirely, but helps to empower laboring mothers to cope with the pain they are experiencing in a more natural way. PERCEPTIONS OF LABOR AND DELIVERY CLINICIANS ON NON-PHARMACOLOGICAL 5 In order to understand how to reduce labor pain non-pharmacologically, it is imperative to know how pain physiologically occurs. In the first stage of labor, pain is a result of the lower uterus distending, the cervix stretching during dilation and the baby’s descent causing pressure on nerves and surrounding tissues (Zwelling et al., 2006, p. 365). The pain of the uterine contractions spreads to the stomach, lower back, hips, thighs and gluteal muscles. As the uterus contracts, ischemia also causes pain (Almushait & Ghani, 2014, p. 5). During the second stage of labor, the vagina distends and the tissues around the pelvic floor and perineum stretch (Zwelling et al., 2006, p. 365). The pain of labor is also affected by the baby’s position, how quickly it descends into the birth canal, the position of the mother, how tired she is, and the length and frequency of the contractions. The laboring mother and her support people need to be educated on what is happening in her body that is causing pain so that she can cope better with it. Understanding exactly what the pain is from can also help health care workers to choose an appropriate method of relieving the pain non-pharmacologically. A woman’s perception of pain can be affected by a woman’s emotional state as well. Throughout labor, a woman often becomes anxious which results in her body secreting more catecholamines, also known as fight or flight hormones. Catecholamine impairs the secretion of the hormone that helps with uterine contractions, oxytocin, while increasing pain perception (Zwelling et al., 2006, p. 366). Therefore, as the mother becomes more stressed her pain increases and her contractions become weaker. Any variation from the mother’s birth plan or unexpected occurrences during labor will place more stress on the mother. This is why it is important to prenatally prepare the mother to adapt as her labor evolves so that she knows what to expect and can apply methods for pain relief accordingly. The light, noise, room temperature, equipment and atmosphere of the birthing facility all affect pain perception, as well. Creating a PERCEPTIONS OF LABOR AND DELIVERY CLINICIANS ON NON-PHARMACOLOGICAL 6 soothing, home-like environment will help to relax the mother, thus reducing pain. Removing as much stress from the birthing process as possible will decrease the mother’s perception of pain and encourage contractions. Labor pain is as dynamic as labor itself, and can change frequently. It is important to discuss the mother’s birthing preferences, goals and concerns often because they may change as her pain level progresses. No single technique will help all mothers, or even the same mother throughout labor, which is why each mother needs an individualized plan that is re-evaluated as her labor progresses (Brown, Douglas, & Flood, 2001, p. 6). In order to prepare women for their changing needs and desires, it is important to educate them on the several options available so they can make stress free decisions as their pain transforms. Methods for Pain Relief There are two main classifications of pain relief methods: pharmacological and non- pharmacological. The goal of non-pharmacological methods is to increase the ability of the woman to cope with pain, where as the goal of pharmacological methods for pain relief is to relieve labor pain (Jones, et al., 2013, p. 1). Some examples of current pharmacological methods used frequently in labor include inhaled nitrous oxide and oxygen, non-opioid drugs or sedatives, epidural anesthesia (EA), combined spinal-epidurals, local anesthetic nerve blocks and parenteral opioids. In general, pharmacological methods tend to manage pain effectively but can have adverse effects on the mother and on delivery outcomes. Non-pharmacological methods, on the other hand, have been shown to improve the management of pain with few negative effects, but minimal research has been conducted on these methods to prove their efficacy. Labor and delivery clinicians may be less educated on non-pharmacological methods for pain relief during PERCEPTIONS OF LABOR AND DELIVERY CLINICIANS ON NON-PHARMACOLOGICAL 7 labor, which results in an overall poor understanding of its benefits. This gap in literature is why it is important to research the role of non-pharmacological methods for pain relief in labor. The Current Birthing Process The birthing process has evolved considerably over time. The cesarean section rate rose 60% between 1996 to 32.9% in 2009, but are currently remaining steady around 32.7% in 2013 (Hamilton, Martin, Osterman, & Curtin, 2014, p. 7). This change over a thirteen year time span is drastic and shows how childbirth has devolved from a natural, healthy aspect of womanhood, into a medicalized process that requires intervention. Birth plans are often disregarded when mothers enter the hospital setting and surrender to the medical version of childbirth. Too often mothers are being treated with increased interventions and epidurals instead of being coached and empowered to cope with the pain. In order to reverse this medicalized child birth trend, the current issues need to be clearly identified. As childbirth has shifted from the home to the hospital setting, the perspective of childbirth in the United States (U.S.) has also changed. In many countries, pregnancy is equated with a pathology that needs to be fixed by doctors instead of a natural part of being a woman (Behruzi et al., 2010). Pregnancy is not an illness, but rather a normal, natural and healthy time in a woman’s life. In order to decrease this stigma around childbirth, healthcare workers need to return control to laboring mothers, empower them and emphasize that childbirth is not a sickness that needs to be medically managed. Despite Japan’s more natural approach to childbirth, their low infant mortality rate is competitively rated with the U.S. and is a mere 2.7 per 1000 live births (Behruzi et al., 2010). Japan was even listed as the “best place to give birth in 2009 (Behruzi et al., 2010, p. 3).” These statistics show that a medicalized birth is not the only way to PERCEPTIONS OF LABOR AND DELIVERY CLINICIANS ON NON-PHARMACOLOGICAL 8 have a safe birth. The larger question here is how can the U.S. revert back to a primarily natural birthing process and convey that women are capable of delivering their children. Although many components have contributed to this shift from natural childbirth to medical childbirth, no one factor can be held solely responsible. These changes can be summarized as such: “As the place of birth shifted from home to hospital during the first half of the 20th century, numerous changes in care such as the use of narcotics or anesthesia, high patient-to-nurse ratios, connections to intravenous lines, electronic monitors, and other devices, made it safer or more convenient if the woman remained in bed (Simkin & O'hara, 2002, p. S148).” Although these changes over time are not directly related to the birth rate statistics, they do show a striking transformation in the birthing process itself. These changes were not entirely based on the evidence of best practices. The reality is that there is often not enough staff, a growing rate of cesarean sections and inductions, a higher litigation risk, less vaginal births after cesareans, an “unprecedented” amount of elective cesarean sections and frequently “under- empowered” labor nurses (Zwelling et al., 2006, p. 365). Instead of focusing on the laboring mother and her family, care often revolves around speedy deliveries to maximize the use of limited staff members and the rapid turnover of hospital beds. As the number of cesarean sections increases, so does the number of repeat cesarean sections. The more repeat cesarean sections a woman has, the higher risk she has of intraoperative complications, placental attachment and risk of uterine rupture (Eriksen, Nohr, & Kjcergaard, 2011). Epidural use and cesarean delivery rates cannot increase endlessly without negative consequences. Another rate that is increasing is the number of mothers receiving epidural anesthesia for childbirth. In the United Kingdom 19% of mothers get EAs which is minimal compared to the 61% in the United States and 75% in France (Behruzi et al., 2010, p. 11). This change in pain PERCEPTIONS OF LABOR AND DELIVERY CLINICIANS ON NON-PHARMACOLOGICAL 9 control methods reflects the shift towards a more medicalized childbirth process. In a study in Japan, every obstetrician interviewed agreed that EA should only be used if the mother has extreme anxiety or high blood pressure. In the United States, on the other hand, EA is used for any mother that requests it unless it is contraindicated. Having more strict qualifications for EA use would greatly reduce the incidence of negative side effects as well as prevent the cascade of medical interventions that results from their use. Although epidurals greatly reduce labor pain, they can have negative side effects that many women are unaware of. They alter the body’s ability to push the newborn down the birth canal by inhibiting skeletal muscles which ultimately slows down labor progression and lengthens or stops the 2nd stage of labor entirely (Alexander, Lucas, Ramin, McIntire, & Leveno, 1998). The slowed dilation and lengthened labor time has been found to increase the rate of operative deliveries and result in an increased need for oxytocin to speed up contractions (Alexander et al., 1998). Ultimately, the laboring mother will need more oxytocin overall to achieve the same rate of cervical dilation than those who do not receive an epidural. This results in the woman needing more interventions to obtain the same amount of progress that a woman with less interventions would achieve naturally, and shows how medicalized childbirth runs on the hospital policy schedule instead of revolving around the women’s physiological clock. Epidurals can also result in hypotension and decrease the fetal heart rate , requiring continuous monitoring of the mother and baby. Women who receive EA also have lower levels of natural oxytocin in their bodies after delivery which results in an increased risk of post partum hemorrhage. This evidence reinforces how imperative it is to look at a woman’s natural response to childbirth and how these medical interventions are affecting these responses.