Oxford Handbook of Midwifery (60 page)

Recommended reading

National Collaborating Centre for Womens’s and Children’s Health (2007).
NICE Guidelines for Intrapartum Care
—
Care of Healthy Women and Their Babies During Childbirth
. London, RCOG Press.

1. Thacker S, Stroup D, Peterson H (2003). Continuous electronic fetal monitoring during labour. (Cochrane review). In:
   Cochrane Library
   , Issue
   1
   . Oxford: Update Software.
   
2. National Institute of Clinical Excellence (2001).
   The Use of Electronic Fetal Monitoring
   . London: NICE. Available at: M www.nice.org.uk.
   
3. Hillan E (1991). Electronic fetal monitoring—more problems than benefits?
   MIDIRS Midwifery
   

   Digest
   :
   1
   (3), 249–51.
   

4. Walsh D (2001). Midwives and birth technology: the debate that’s overdue.
   MIDIRS Midwifery Digest
   :
   11
   (3), S3–S6.
   
5. Harrison J (1999). Fetal perspectives on labour.
   British Journal of Midwifery
   7
   (10), 643–7.
   
6. Alfrevic Z, Devane D, Gyte G (2006). Continuous cardiotocography (CTG) as a form of elec- tronic fetal monitoring (EFM) for fetal assessment during labour.
   Cochrane Database of Systematic Reviews
   , 2011 Issue 2. The Cochrane Collection. London: John Wiley and Sons Ltd.
   
7. Walsh D (2007).
   Evidence-based Care for Normal Labour and Birth
   . London: Routledge.
   
8. Thacker S (1997). Lessons in technology diffusion: The electronic fetal monitoring experience.
   

   Birth
   24
   (1), 58–60.
   

9. Hindley C (2001). Intrapartum electronic fetal monitoring in low risk women: a literature review.
   Journal of Clinical Excellence
   3
   , 91–9.
   
10. Walsh D (2001). Midwives and birth technology: the debate that’s long overdue.
    MIDIRS Midwifery Digest
    :
    11
    (3)Supp 2, S3–S6.
    

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    Pain relief:
    ‌‌
    

    non-pharmacological
    

    Chapter 12
    

    241
    

    Massage
    242
    

    Homoeopathic remedies for labour and birth
    244
    

    Breathing awareness
    246
    Hypnosis and visualization
    247
    Aromatherapy during labour
    248
    Reflexology during labour
    250
    

    

    Acupuncture in labour and childbirth
    252
    Transcutaneous electrical nerve stimulation
    254
    Bach flower remedies during labour
    256
    

    CHAPTER 12
    Pain relief: non-pharmacological
    

    242‌‌
    

    Massage
    

    The basis of massage is touch, which many midwives incorporate into their care of the labouring woman. Regular massage from 36 weeks and during labour has been shown to reduce levels of stress hormones in women.
    ¹
    Professional massage involves the use of vegetable oils, using basic reme- dial techniques. The three basic strokes are:
    

    • Effleurage
      : long, smooth strokes used at the beginning and end of a treatment.
      
    • Kneading
      : both hands work together, alternately picking up and squeezing the muscle, resulting in a kneading movement.
      
    • Frictions
      : using the thumbs, fingers, or heels of the hand; these strokes are used to penetrate deep muscle tissue.
      

      Essential oils may be added to enhance the therapeutic effect. Care should be taken to ensure that the use of essential oils are not contraindicated, that the midwife is trained in their use and is familiar with safety precautions (b see Aromatherapy, pp. 122–6, and Aromatherapy during labour, p. 248).
      

      Physiological and psychological benefits
      

    • Improves the circulation.
      
    • Relaxes the muscular system.
      
    • Stimulates diuresis and reduces oedema.
      
    • Stimulates the lymphatic system.
      
    • Speeds up the elimination of waste products.
      
    • Encourages the production of endorphins.
      
    • Aids digestion.
      
    • Aids sleep.
      
    • Enhances mental and physical relaxation.
      
    • Encourages release of emotional tension.
      
    • Encourages communication.
      

      However, precautions do need to be taken prior to a massage session, to address general and pregnancy-specific contraindications. Awareness of the woman’s medical and obstetric history should always be considered and consent needs to be obtained beforehand.
      

      General contraindications
      

      Massage should not be given, or caution should be taken, under the fol-
      lowing circumstances:
      

    • After a meal or alcohol; allow at least 1–2h before massage
      
    • If there is infection, pyrexia, or inflammation
      
    • If there has been recent injury or surgery
      
    • Varicose veins: work very gently over these areas
      
    • Thrombophlebitis
      
    • Carcinoma: exert no direct pressure over the diseased site
      
    • Sciatica: take extreme caution in the affected area
      
    • Burns, bruising, and open wounds
      
    • Sensitive skin: take care with these patients.
      

MASSAGE

243

Pregnancy-specific contraindications

Avoid:

1
McNabb MT, Kimber L, Haines H, McCourt C (2006). Does regular massage from late preg- nancy to birth decrease pain perception during labour and birth? – A feasibility to investigate a programme of massage, controlled breathing and visualization, from 36 of pregnancy until birth.
Complementary Therapies in Clinical Practice
12
(3), 222–31.

CHAPTER 12
Pain relief: non-pharmacological

244‌‌

Homoeopathic remedies for labour and birth

Homoeopathic remedies can contribute a great deal to supporting women physically and emotionally throughout labour and birth. It enables a woman to be empowered to progress through this physiological event without resort to chemical drugs and unnecessary interventions. It pro- vides another option for care that is not harmful to the mother or the fetus. An informed woman may wish to self-medicate (comprehensive birth kits are available), or a woman may choose to be attended by a homoeopath who has gained permission prior to labour, or the midwife may be qualified in homoeopathy. For general principles of homoeopathy, b see Homoeopathy, p. 120.

Arnica

The most commonly used remedy for childbirth is arnica. This remedy is used extensively for emotional and physical trauma, so therefore is an invaluable remedy for labour and the early postnatal period. It can be taken during labour and immediately following birth (preferably before the cord is cut) to minimize the general effects of trauma and to assist with pain relief. Taken for a few days after the birth, arnica will aid healing and help with after pains.

Other common remedies

• Aconite
  : for anxiety and fearfulness at any time during labour, but especially before labour and afterwards where there has been a sudden or traumatic birth.
  
• Belladonna
  : for severe, distressing, and spasmodic pains. The woman feels like she wants to escape. The face is hot, red, and flushed, often accompanied by a headache.
  
• Caulophyllum
  : for exhaustion and slow progress in labour. Helps to establish regular and effective contractions.
  

  0 This should not be taken during pregnancy as it is a powerful uterine tonic and may initiate premature labour.
  

• Chamomilla
  : for unbearable pain and extreme irritability.
  
• Cimicifuga
  : for sharp, shooting pains in all directions and failure to progress. A feeling of wanting to give up accompanied by anxiety and possibly hysteria.
  

  •
  Gelsemium
  : the uterus feels heavy, sore, and squeezed, with pains
  

  radiating to the back. There may be fear, trembling, and weakness, especially in the transition stage.
  

• Pulsatilla
  : for an erratic, changeable, and tearful emotional state. The pains tend to be cutting and tearing, and move around. The remedy helps to establish regular contractions and restores emotional balance.
  
• Sepia
  : a sensation of the uterus being dragged down and heavy. Experienced by women in the second stage of labour at the crowning of the head. The overwhelming urge to bear down feels like the muscles of the pelvic floor are stretched beyond their limits. The woman is usually irritable, indifferent, and self-absorbed.
  
• Nux vomica
  : for irritability, chilliness, and finding fault with carers.
  

  HOMOEOPATHIC REMEDIES FOR LABOUR AND BIRTH
  

  245
  

  Recommended reading
  

  Geraghty B (1997).
  Homoeopathy for Midwives
  . London: Churchill Livingstone.
  

  Lockie A, Geddes N (1992).
  The Women’s Guide to Homoeopathy
  . London: Hamish Hamilton. Moskowitz R (1992).
  Homoeopathic Medicines for Pregnancy and Childbirth
  . Berkeley, California:
  

  

  North Atlantic Books.
  

  CHAPTER 12
  Pain relief: non-pharmacological
  

  246‌‌
  

  Breathing awareness
  

  Women are encouraged to become aware of their own breathing pat- terns and how adjustments can be made during labour and birth to help relieve tension and aid coping skills. A non-directive approach to breathing awareness ensures that the mother follows instinctual cues for working with her contractions. This prevents hyperventilation and enables more efficient exchange of oxygen and carbon dioxide.
  

• SOS breathing—Sigh Out Slowly. The outgoing breath is a naturally relaxing part of respiration; extending the outgoing breath will help to counteract hyperventilation. Inhalation naturally follows exhalation and therefore there is no need to emphasize breathing in.
  
• Pant Pant Blow or Puff Puff Blow breathing is a modification of panting, for the end of the first stage and transition, where there may be a premature urge to push.
  
• Panting—breathing out short/light breaths to help at crowning, allowing the baby’s head to be born slowly and to help minimize perineal trauma. Care should be taken not to breathe in this way for long periods as this can lead to hyperventilation and lightheadedness.
  

  Valsalva’s manoeuvre
  : continued use of this technique is no longer recommended. Involves fixed diaphragm, closed epiglottis and breath holding, usually commenced at the beginning of contraction. Leads to increased intrathoracic pressure; decreased venous blood return to the heart; reduced cardiac output;
  ¹
  less O
  ₂
  from lungs; lowered arterial pressure and reduced O
  ₂
  to placenta.
  ²
  

  Disadvantages
  

• Prolonged decrease of O
  ₂
  to fetus.
  
• Lower cord pH.
  
• Fetal heart rate abnormalities.
  
• Lower Apgar score.
  
• More vaginal wall damage.
  
• Oedema of maternal face.
  
• Burst blood vessels.
  
• Headache.
  
• Maternal hypoxia.
  
• Maternal exhaustion.
  
• Undermines women’s own natural birthing instincts.
  

•
Ignores the optimum timings for pushing within a contraction—the extra surges that occur up to 3–4 times during a contraction.

1. Thompson A (1995). Maternal behaviour during spontaneous and directed pushing in the second stage of labour
   . Journal of Advanced Nursing
   22
   , 1027–34.
   
2. Bosomworth A, Bettany-Saltikov J (2006). Just take a deep breath.
   MIDIRS Midwifery Digest
   

16
(2), 157–65.

HYPNOSIS AND VISUALIZATION

247‌‌

Hypnosis and visualization

Hypnosis is a naturally induced state of relaxed concentration—a state of union between the mind and body that communicates suggestions to the subconscious mind. The subconscious mind governs what we think and feel, while influencing the choices that we make. In essence, it can control pain. The aim of hypnosis and visualization is to equip the woman with supportive techniques that will help her prepare and cope with labour and birth. These techniques consist of self-hypnosis, guided visu- alization, and breathing methods. The philosophy of hypnosis maintains that when fear, stress, and tension are absent, then the woman can utilize her natural instincts more effectively, resulting in a more calm and ful- filling birth experience.
¹

Women using hypnosis have been compared with controls using traditional breathing and relaxation techniques. It was found that those in the hypnotically prepared group experienced: