PHYSIOTHERAPY OPTIONS FOR COPING WITH LABOUR

• Labor – Uterine contractions that result in effacement and dilatation of the cervix.

• Braxton-Hicks – Uterine contractions NOT associated with cervical change.– Shorter in duration– Less intense– Over lower abdomen and groin– Resolve with ambulation

• Lightening – Descent of the fetal head into the pelvis

DEFINITIONS

• Preterm labor – Prior to 37 weeks

• Term – 37 to 42 weeks• Post dates – After 40 weeks

There are 3 stages of labour: • The First Stage begins with the onset of contractions

and ends when the cervix is fully dilated. Duration: primigravida = 8-12 h , multigravida = 6-8 h• The Second Stage begins after the cervix has fully

dilated and the baby’s head has moved down into the birth canal. It ends when the baby is born.

Duration: primigravida =1 -2h, multigravida = ½ h • The Third Stage involves the expulsion of the

placenta from the body

Duration: up to 30 minutes, however the average length of the third stage of labour is 10 minutes.

Role of physiotherapist during labour

• Relaxation• Breathing techniques• Positioning• Pain relief• Massage• Other coping strategies(hypnosis, warm water Bath, accupuncture)

RELAXATION • Breathing - Essential to most methods of relaxation;

taught concurrently• Physiological- Laura Mitchell Method (1963),jacobsons • Touch/massage- Kitzinger (1987)• Dissociation and unblocking -Noble (1996)

Passive relaxation practised within pregnancy is replaced by an alert but “non-striving” state of relaxation in labour [selective dissociation](releasing excess tension)

• Imagery • Hot water bath

Relaxation is an active, purposeful activity in which you consciously release tension. Relaxing your muscles helps to reduce physical tension and pain. It also provides a feeling of emotional well being which reduces anxiety and in turn reduces your sensitivity to pain.

Benefits for the mother-• During pregnancy- relaxation helps her to cope with the

physical, psychological and emotional discomfort of pregnancy.

• During labour –it allows body to function efficiently with the minimum of effort, energy is conserve and pain thresh hold is said to be increased.

two reasons for teaching relaxation to use in labour• 1. To prevent the mother becoming unduly tired,

thereby causing nervous ‘fatigue’• 2. To help the mother control her thoughts and feelings

or emotions• Jacobson used a tense–release approach that activates

both antagonists and agonists maximally. This approach is often used where rest is prescribed, the maximal contraction gaining maximal release. Concerns with regard to use of this approach during labour might be:

• the initiation of cramp• risks of hyperventilation• it has been known to induce anxiety/anger• it can exacerbate pain, especially back pain.

• The Mitchell method-Mitchell’s method activates only antagonists, and moderately; therefore there are not the same concerns as with Jacobson if using during labour Movements, once learnt, are performed in such a way that ‘trigger’ areas are put into positions of ease and comfort in a matter of seconds.

• Dissociation and unblocking-Noble says that relaxation is more than rest or stillness; it involves recognising and releasing excess tension – whatever the cause. The passive relaxation practised in pregnancy should be replaced by an alert, but ‘non-striving’, state of relaxation in labour. She describes a sequence of ‘dissociation’ – selective relaxation which develops the body’s ability to maintain a state of general release when one part of it (the uterus) is working hard. ‘Unblocking’ the muscular system and breathing freely can be a blissful release when tension has developed.

• Touch relaxation-Kitzinger discusses the concept of ‘touch relaxation’, where a woman relaxes towards the touch of her partner. However many women cannot bear to be touched during labour contractions, it can also increase tension if inappropriately applied or, if the person administering is tense, this may be relayed through to the woman.

• Whatever the approach chosen for use during labour it is essential that it ‘fits’ the woman’s needs. It is not advantageous to induce sleep when the woman is required to be alert and prepare for second stage, but sleep may conserve energy if there is a delay in progression.

• ASSESSMENT-So far as the physiotherapist is concerned, there must be an assessment of appropriateness of the approach used in order that it be advantageous to the woman.

• TEACHING TECHNIQUES-When teaching relaxation techniques consider the following:

• enablement – by choice of approach; reduced tension, ease and comfort, coping with the stress and pain of labour

• understanding – reasons behind the approach, the basic principles, and their effects

• beware – conflicting effects as a result of using a combination of techniques.

• the ‘whole’ – combination of different coping strategies, (positioning, breathing, massage, etc.); relaxation alone is not generally enough to cope with the intensity of the ‘wave’.

• flexibility – venue, positioning, noise, pillows and blankets for comfort

• practice – to enable learning to take place, • motivation – ‘breeds’ success; feedback – encouragement, praise• confidence – physiotherapist, and mother-to-be; the freedom to

change position if not at ease• long term – once acquired, a skill for ‘life’• safety – the ‘emotional reaction’; recovery must be slow and

gradual; inhale, stretch. Return to standing must be staged: lying to side lying, to prone kneeling, to kneeling (with support), to standing. Discussion should take place with regard to the ‘experience’.

BREATHING TECHNIQUES

Benefits/Purpose of Breathing Techniques• Provides Oxygen- to mother, baby, and hard

working uterus. Well oxygenated muscles function more effectively and efficiently.

• Reduces Pain.• Relaxation- Rhythmic breathing promotes physical

relaxation by reducing muscle tension, and promotes emotional relaxation by reducing anxiety.

• Distraction- by helping the mother concentrate and focus on breathing instead of her contractions.

• During labour there is considerable increase in oxygen requirement. more alveolar ventilation is necessary that will lead to hyperventilation. due to hyperventilation, level of carbon dioxide falls.

• This cause respiratory alkalosis, leading to decrease in calcium ionization, which can affect nerve conductivity.

EFFECT OF HYPERVENTILATION

SIGN AND SYMPTOM

• Dizziness, eventual uncounciousness

• Numbness and tingling in the lips and extremities.

CAUSES

• Cerebral hypoxia due to constriction of cerebral vessels and reduced blood pressure.

• Changed in ionized calcium caused by alkalosis which affect nerve conduction.

With Every Breathing Technique…• Take a cleansing breath at the beginning and end

of the technique.• Release all muscle tension. Melt into your position.• Think positive, peaceful, calming, and

strengthening thoughts and/or visualizations.• Focus on releasing physical and emotional tension

with every out breath.• If wanted use movement- walk, sway, rock,

bounce.• If wanted make low noises- chant, sing, or moan

on exhale.

Cleansing Breath (Organizing Breath)• The Purpose- To give a boost of oxygen, focus you

on the breathing technique, promote physical/ emotional relaxation, and acts as signal to your therapist that your contraction is beginning/ending.

• When- Use this technique at the beginning of a contraction, before you start a breathing pattern and at the end of a contraction, after your breathing pattern.

• How- Take in a deep inhale filling your lungs as full as you can, and release/exhale with a yawn.

BREATHING AND CONTRACTIONS-There are three phases:• preparatory phase – the time between contractions, the start of a new contraction, and the gradual build up• action phase – the build up in strength and intensity, reaching a ‘peak’• recovery phase – receding from the peak, and recovering ready to prepare again for the next one.

• First stage-Deep, slow, easy breathing – pausing between expiration and inspiration – may be all that some women use in the first stage. Most, however, will be unable to maintain this and a modification will be needed. Untrained women may either hold their breath or uncontrollably hyperventilate when contractions progressively become stronger and more painful. The respiratory response to exercise and effort is for breathing to become faster.

• This can be introduced as gentle ‘feather’ or ‘candle’ breathing. They could imagine that an ostrich feather or a candle is in front of their faces, and that they are very gently breathing in and out so that the feather or candle flame would barely move on the outward breath.

• Each contraction will still start with the outward, relaxing, welcoming breath and continue with slow, deep, calm breathing; There should still be a momentary ‘pause’ between the outward and inward breath and respiration should be as slow and deep as is comfortable

Breathing Techniques for First Stage Labor

Slow Breathing (Relaxed Chest Breathing, Abdominal Breathing)Begin by doing one cleansing breath. Inhale slowly

and comfortably. Exhale slowly and comfortably through your mouth with slightly pursed lips. This breathing is very comfortable, relaxed and similar to the breathing you do when you sleep. End your breathing technique with a cleansing breath.

Light Breathing (Hee Hee Breathing)Begin by doing one cleansing breath. Start your breathing like slow breathing and as the contraction intensifies your breathing becomes quicker and shallower. Let your contraction guide the rate of your breathing. Making noise during the exhale helps relieve tension and creates more focus. If you choose to make noise, keep it a low noise like ‘heeee’ or ‘hooo’. As your contraction subsides, return breathing back to the slow breathing technique. End your breathing technique with a cleansing breath.

Patterned Breathing (Hee-Blow Breathing, Lamaze Breathing)

• Begin by doing one cleansing breath. Breath in quick and shallow breathes. For three exhales make a quick ‘hee’ noise, one exhale make a slow “hoo’ noise. Repeat three quick, shallow ‘hees’ and one slower “hoo’ until contraction subsides. End your breathing technique with a cleansing breath.

Variable Breathing ( Transitional Breathing, Take Charge Routine)

• Begin by doing a cleansing breath. This is just like patterned breathing except that you vary anywhere from one to four ‘hee’ exhales with one ‘hoo’ exhale. For the take charge routine the therapist tells you how many ‘hee’ breathes to take per ‘hoo’ by holding up a finger for a ‘hee; breath and fist for a ‘hoo’ breath. End your breathing technique with a cleansing breath.

• It can be helpful to think in terms of each contraction as a mountain – as the contraction is building in intensity you climbing up one side of the mountain, as the contraction peaks you are at the top of the mountain, and as the contraction disappears you are coming down the other side of the mountain.

• As you feel each contraction coming and building in intensity, try to maintain your awareness of the breath. Don’t stop breathing and don’t hyperventilate. Your breathing will become faster and more shallow as the contraction becomes more painful and you come closer to the peak, but stay with it, breathing in, breathing out. Know that the contraction will peak and end. Take it one contraction at a time, once a contraction is gone it’s gone forever and you are one step closer to meeting your baby.

• As soon as you aware that the contraction has peaked and the pain is fading away, Relax, Release and Let Go. Focus your awareness on the out breath – long steady, sighing out breaths as you come down the other side of the contraction. Slow it down. Follow the out breath down into the cervix and pelvic floor.

Second stage

• The length of time that a women is actively ‘pushing’ should be monitored and the physiotherapist must be aware of local procedures with regard to this phase so that she can communicate this accurately to the women she is preparing.

Prolonged ‘pushing’ will have the following physiological effects:1. There is an initial large rise in blood pressure.2. Venous compression in the chest and abdomen will increase intrathoracic and intra-abdominal pressure and therefore blood flow back to the heart is reduced.3. A fall in cardiac output and blood pressure follows.4. Dizziness results, the Valsalva manoeuvre is released, and cardiac output returns to normal.5. Placental blood flow is reduced, which can be reflected in foetal heart decelerations.

• BREATHING AND ‘PUSHING’-Breathing awareness can be used to facilitate pushing. The woman can be trained to breathe in, then slowly out on exertion (e.g. during defaecation) so that it will become instinctive to ‘breathe’ out as she pushes, and to maintain the push at the same time as she breathes in. Each push should last about 5 to 10 seconds, and each contraction may demand three to four pushes. The deep inhalation provides mother and foetus with a good supply of oxygen. Exhalation on exertion works with the muscular contraction of the uterus to best effect. It is absolutely essential that the push is ‘felt’ through the perineum.

BREATHING & PUSHING

• ask the mother to place her index finger over epigastrium, take a breath in & feel the expansion in this area.

• fix the ribs & increase the intrathoracic pressure, with inspiration bear down & diaphragm will then act as a

piston directed downwards towards the fundus.

• place the other hand on the waist feel it expand sideways & become aware of the forward bulging of the lower abd.muscle & the relaxation of the pelvic floor.”open the door for the birth of baby”

• Relaxation of the jaws should explain to the patient.

• The direction of the push is downward under the pubic bone.

• Breath hold for only 6-7sec. To minimize any adverse effect on the fetus due to a prolonged pushing maneuver.

• several pushes may be necessary during contraction. b/w contraction sigh out, rest & relax.

Breathing Techniques for Second Stage Labor

Pant-Blow• This breathing technique is used when it is necessary to

keep from pushing. This may happen if you get a strong urge to push before full dilation, as your baby’s head is crowning, or when your caregiver feels it is needed.

• This is the only breathing technique that you do not do a cleansing breath at the start.

• Breathe as if blowing out a candle over and over again, use quick shallow blows until urge to push subsides. End with a cleansing breath.

With Every Push…• Curl around your baby by tucking your chin and

curling your shoulders forward.• Release tension in your bottom, perineum, and

thighs.• Visualize baby easily moving down and out.• Completely relax your body in-between pushing

efforts.• Breath normal in-between pushing efforts

Spontaneous Bearing Down (Expulsion Breathing)

• Breath comfortably until the urge to push becomes irresistible. Next take a deep breath and hold it or slowly release it while bearing down for 5-7 seconds. After bearing down, release any remaining oxygen and breath comfortably until the next strong urge- then repeat. You may bear down 2-4 times in one contraction. End with a cleansing breath. Some women find it helpful to grunt, moan, or make low noises while bearing down.

Directed Pushing ( Hospital Pushing)• This breathing technique is common if the

mother has no or low urge to push. Breath comfortably until your caregiver asks you to push. Next take a deep breath and hold it or slowly release it while bearing down for 5-7 seconds. After bearing down, release any remaining oxygen. Take a breath or two and repeat until caregiver asks you to rest. End with a cleansing breath.

BREATHING DURING LABOUR

• according to Williams & Booth (1985)

1st stage

Easy breathing- a little slower & deeper then usual.

Transitional stageBreathing to prevent pushing “fairly deep breathing” to move the diaphragm up &down together with a sharp blow out through relaxed lip

2nd stage

1 or 2 deep breaths in & out, then hold making the diaphragm “piston go down” repeat when breath runs out, after a gulp of air.

POSITIONING

• Because of the anteversion of the uterus during first stage contraction, many women find that they instinctively need to lean forward on same sort of support, some like to rotate or rock their pelvis.

• Leaning forward facilitates ante version.• Women should be encouraged to change position

during first stage of labour• The knee chest position is sometimes helpful in

assisting the elimination of the anterior lip of cervix.

Moving during contractions or changing positions between contractions often adds to your comfort and improves labor progress. Walking, rocking, swaying, and other movements can be part of your rhythmic ritual for handling contractions.

• Positions attended during 1st stage are

• Sitting with head &shoulder resting on a table.

• Standing leaning against a wall either facing or with back support.

• Stride sitting across a chair resting the head & arms on the back.

• On all four on floor supported by partner, standing, resting head on his shoulder.

2. POSITIONING DURING 2ND STAGE OF LABOUR.

Commonly used positions are

• Lithotomy

• Dorsal (recumbent)

• Lateral & semirecument

Massage in labour

• It is probable that the soothing sensory inputs from stroking, effleurage and kneading activates the gate closing mechanism at spinal level.

• Area of massage back,(deep kneading over painful area, double handed kneeding over SI joint., effleurage from sacro coccygeal area, up and over the illiac creast, slow, rhythmical longitudinal stroking, from occiput to coccyx can relieve tension.

• Perineal massage

Pain relief in labourComfort Measures• Having a support person at your side helps keep you focused• Relaxation and breathing techniques help control anxiety and

pain throughout labor and are best learned in childbirth education classes

• Distraction such as music or TV in early labor• Imagery is picturing yourself in a peaceful place• Massage and use of cold packs ease muscle tension• Your labor nurse will suggest other methods of easing your

early labor pain• When contractions are closer together and stronger, rest in

between, taking slow deep breaths

• Touch and massage including the use of creams and oils, heat and cold, and counter pressure.

• Being active during labour rather than staying in bed. Position changes like walking, squatting, sitting, the hands and knees position and using a birthing ball can all be helpful.

• Pleasing surroundings with the use of music, dim lights and aromatherapy.

• Use of a warm water bath or shower may help reduce labour pain.

• Sterile water injections: involves injecting small amounts of sterile water into the skin in the lower part of the back. This can help women in early labour who have back pain.

• Hypnosis and acupuncture may be helpful in some women during labour.

Types of Pain Relief

• There are two types of pain relieving drugs, analgesics and anesthetics.

• An anesthesiologist will work with you and your health care team to select the best method for you.

• Analgesia is the relief of pain without total loss of feeling or muscle movement. These drugs do not always stop pain completely, but do lessen it.

• Anesthesia is blockage of all feeling, including pain. General anesthesia causes you to lose consciousness. Regional anesthesia removes all feeling of pain from specific parts of the body while you remain conscious.

Systemic Analgesics

• These medications are often given as injections into a muscle or vein to lessen pain without causing you to lose consciousness. They act on the entire nervous system rather than a specific area. Epidurals may be given for additional pain relief. Side effects of systemic analgesics are mostly minor in nature, and may cause nausea (can be treated with another medication), drowsiness, or trouble concentrating. Systemic analgesics are not given right before delivery because they may slow the baby’s reflexes and breathing at birth.

Local Anesthesia• Local anesthesia provides numbness or loss of

sensation to a limited area such as when an episiotomy is performed to widen the vaginal opening. It does not lessen the pain of contractions. Local anesthesia rarely affects the baby and has no side effects once the numbness wears off.

Regional Analgesia• Epidural analgesia, spinal block and combined spinal-

epidural block are all types of regional analgesia used to decrease labor pain. They are popular for childbirth as they provide excellent pain relief, while allowing you to remain alert and awake. Very little medication reaches the baby.

EPIDURAL ANESTHESIA• commonly called an epidural block,

causes some loss of feeling in the lower part of your body.

• An epidural block is given in the lower back into a small area called the epidural space. It contains nerve fibers, some of which carry pain sensations to the brain. You will be asked to sit or lie very still with your back curved outward and to stay in this position until the procedure is completed. You can move when it’s done but you will not be able to walk around.

• Pain relief usually begins within 10-20 minutes after the medication has been injected through the epidural catheter. Although an epidural will make you more comfortable, you may still be aware of your contractions. You may notice temporary numbness, heaviness or weakness in your legs. Your anesthesiologist can adjust the degree of numbness for your comfort and to assist in labor and delivery. These sensations will subside during the first few hours after delivery

Side Effects and Risks of an Epidural

• A drop in your blood pressure can occur. This may slow your baby’s heartbeat. Your baby’s heart rate will be monitored closely. To decrease this risk, you will first be given fluids through an intravenous line, instructed to lie on your left side, medications administered as needed, and some oxygen by mask may be given to you.

• Shivering may be associated with an epidural, although this can occur without one. Warm blankets will help.

• After delivery your back may be sore for a few days.

• Some women (1-2 in 100) may experience a “spinal” headache after an epidural. You can reduce the risk of this happening by holding very still during insertion of the epidural needle. If a headache does occur, it usually subsides within a few days. If the headache does not stop or if it becomes severe, an epidural blood patch may be needed to help the headache to go away. The blood patch involves taking blood from the arm and injecting this into the epidural space with quick relief in many cases.

• Mild itching is a side effect of narcotic medications and is easily treated.

• When an epidural is given late in labor or a lot of anesthetic is used, it may be hard to bear down and push your baby through the birth canal. Adjusting the dose can help with this.

• A small percent of women will develop a fever during labor, especially women having their first baby, long labor, and with epidural anesthesia. The reason is unknown, but very unlikely reflects true infection in mother or baby. In some cases, the pediatrician may do some tests on the baby to rule out any possibility of infection.

• Serious complications are very rare. If the anesthetic medication enters a vein in the epidural space you may experience dizziness, rapid heartbeat, a funny taste and numbness around the mouth. If the medication enters the spinal fluid, it can affect your chest muscles and make breathing difficult. As with any needle placement, rare significant risks include infection or bleeding in the epidural space or nerve injury

• Spinal Block, like an epidural, is an injection in the lower back. Once the drug is injected, pain relief occurs right away. A spinal usually is given only once during labor, so it is best suited for a time close to delivery. A spinal block can be used for a cesarean delivery or a vaginal birth where forceps or vacuum extraction is indicated. Spinal blocks can cause the same side effects as an epidural block and are treated in the same way.

• General Anesthesia puts you to sleep (makes you lose consciousness) so you do not feel pain. General anesthesia is used when a regional block is not possible or is not the best choice for medical or other reasons. It can be started quickly and is often used for emergency cesarean delivery. Food or liquids in the woman’s stomach cause a major risk during general anesthesia. Labor usually causes undigested food to stay in the stomach. During unconsciousness, this food can come back into the mouth and go into the lungs causing damage. To avoid this, you may be told not to eat or drink once labor has started. After you are asleep, your anesthesia provider will place a breathing tube into your mouth and windpipe for the duration of surgery, which is removed as you waken.

MEDICATIONS (PHARMACOLOGIC TECHNIQUES)

• Nitrous Oxide is an anesthetic gas. It is given together with oxygen through a facemask. You hold the mask and start inhaling the gas mixture just before a contraction begins.

• Pain relief occurs within two or three breaths but will disappear 3 to 5 minutes after you stop breathing the gas. Because its effect disappears so rapidly, nitrous oxide is very safe and does not make your baby sleepy.

• Narcotics are drugs used to ease the pain associated with labour contractions. They promote sleep, help to reduce the intensity of painful contractions and lessen anxiety. Narcotics can cause side effects such as nausea and vomiting, excessive sleepiness, and slower breathing. In addition, narcotics given during labour can affect the baby’s breathing in the first few hours of life. Although rarely needed, a drug called Narcan can be given to your baby to reverse the effects of narcotics.

• Narcotics used for labour: • 1. Morphine (more-feen) is given through an intravenous

(IV) infusion or it can be injected under the skin or into muscle. Pain relief takes effect within 5 - 30 minutes and lasts 4 - 6 hours.

• 2. Fentanyl (fen-ta-nyl) is a shorter acting narcotic, given as a single dose. Pain relief takes effect within 2 - 3 minutes and lasts 30 - 60 minutes.

• 3. Remifentanil (rem-e-fen-tan-nil) is a very short acting narcotic. It is always given via Patient Controlled Analgesia (PCA) into your IV. This medication is rapidly effective within 1 - 2 minutes but only lasts 5 minutes. For this reason, in addition to self-administration, the PCA will be programmed to provide a continuous background infusion of remifentanil. Because this drug lasts only a short time, it is less likely to affect the baby’s breathing at birth.

The Use of TENS in Labour

Benefits of using TENS in labour• TENS is a form of non-invasive pain relief• TENS has no harmful effects on either the

mother or baby • TENS does not restrict your ability to move

about in labour• TENS can be applied at home during early labour• Other pain relief options can still be used if TENS

does not provide you with adequate pain relief

Modes of stimulation

• Two of the TENS parameters are used for labour.These are burst train TENS and brief intense TENS.

• Burst Train TENS-This is characterised by low-frequency bursts (4 Hz) of higher-frequency stimulation. This type of stimulation has the properties of both conventional TENS and acupuncture-like TENS. Conventional TENS has its effects by the stimulation of the A and A fibres to inhibit the C-fibre-mediated pain sensations presynaptically at spinal segmental level.

• Conventional TENS may take 5–10 minutes before pain relief is experienced. Acupuncture-like TENS will produce analgesia that is long lasting but may take about 30 minutes of stimulation before the effects are noted. This latency before onset of analgesia is due to the theorised mechanism of effect. It is thought that the stimulation affects the descending control mechanisms at both spinal and supraspinal levels by the production of opiate-mediated systems activated by the stimulation of A nerve fibres.

• Brief Intense TENS This is characterised by a high frequency (100 Hz),a long pulse duration (150s) and the highest intensity that can be tolerated by the patient. It is best used for short periods of time (i.e. 10–15 minutes) owing to the fatigue generated in the nerves from this intense type of stimulation. The effect can be almost instantaneous owing to the localised blocking of nerve conduction

• These two modes of stimulation are used for the specific instance of labour because they suit the specific nature of labour pain.

• Labour pain consists of dull, aching period-type pains that are due to stretching of and pressure on the abdominal and pelvic viscera; these include the structure of the uterus, cervix, walls of the vagina and the pelvic floor muscles and fascia.

• Visceral pain is conducted to the spinal segment via C fibers and this type of pain is best tolerated by the use of endorphin mechanisms and closing the pain gate. This is why burst train TENS is used all the time during labour.

• Brief intense TENS is also used as it acts quickly and has a strong counterirritant and nerve-blocking effect; this makes it suitable for the increased pain experienced during contractions

• Most TENS units that are used specifically for labour have these two types of stimulation. The burst train mode is the type of stimulation used all the time during labour and the brief intense mode is activated by the use of a press button mechanism when the woman experiences the beginnings of a contraction. The brief intense mode is then de-activated by pressing the same boost button so that the burst train mode is resumed

Placement of the electrodes• The electrodes can be placed either over the relevant

vertebral segments that receive nociceptive information from the painful areas or over the area that is giving pain.

• During the first stage, labour pain information, when pain is at its most intense, will be entering segments T10–L1. The information from the parasympathetic nerves and the pudendal nerve arrives at the spinal segments S2–S4. When choosing electrodes these will need to be long enough to cover these spinal segments. Each pair of electrodes will be placed on either side of the spinal column, one pair covering either side of the spinous processes of T10–L1 and the other pair covering either side of the spinous processes of S2–S4.

How is TENS used

In order to manage your pain more effectively it is important to use TENS as early in labour as possible. TENS is more effective if you use it in combination with other coping strategies such as relaxation, positioning and massage.The TENS electrodes need to be positioned over the nerve pathways which transmit pain messages from the uterus and cervix during labour. Electrodes should be positioned on mother back, paravertebrally over dermatomes T10-L1, for second stage additional electrodes over the S2-S4.

• Initially, you may wish to start with the Channel 2 electrodes placed either side of the spine just above the waist.

• As your labour progresses or if you are experiencing lower back or pelvic pain you can start using the Channel 1 electrodes which are placed either side of the lower spine below the waist

• The Channel 1 and Channel 2 electrodes can be used at the same time if needed.

Once the electrodes are in position, check that the booster switch is turned off or set to minimum before turning the machine on. Slowly increase the intensity until you feel a tingling sensation under the electrodes - it should feel strong but comfortable. During contractions you can increase the intensity further by using the booster control on the TENS unit. As labour progresses, the intensity may need to be increased because your body gets used to the sensation of TENS.

Safety limits

foetus was most at risk if:• the electrodes were placed abdominally• the woman was thin, having only 1 inch of

abdominal fat• the foetus was occipitoposterior

Practical considerations in the use of TENS• Ideally women should be introduced to the TENS unit

during a class with a health professional, preferably a physiotherapist. It should be clearly stated that

• the unit should not be placed over the carotid sinus (the anterior neck)

• the unit should not be placed over the area where a pacemaker has been fitted

• the electrodes and the TENS unit should be removed before going into the bath or birthing pool

• the unit should only be used for the woman herself, and for her labour, unless she has been given instructions otherwise by a health professional

• Specific precautions include:• TENS should not be used in the bath or in the

shower• Women who have metallic implants or an

implanted electronic device, (e.g. a cardiac pacemaker) should not use TENS

• TENS should not be used whilst driving a car• TENS should not be used prior to the 37th week of

your pregnancy unless advised by your doctor or physiotherapist

• TENS must be turned off before applying or removing the electrodes

VARIATIONS IN LABOUR

• FIRST STAGE-The powers• Hypotonic contractions Weak, infrequent

hypotonic contractions with slow progress may necessitate oxytocin infusion.

• Hypertonic contractions Very powerful, frequent hypertonic contractions can lead to precipitate labour and delivery, and possible foetal distress. The mother should try to remain calm and relaxed, and will probably need to use lighter, quicker breathing.

• Induction of labour If the cervix is unripe, prostaglandins in one form or another will be administered. This may be followed by artificial rupture of the membranes (ARM) and intravenous oxytocin. Mothers must be warned that prostaglandins can give rise to unpleasant, ‘colicky’ contractions (TENS may be helpful), and that induced or accelerated contractions will be stronger, possibly more painful, and with shorter resting intervals than those of normal labour. In addition the woman may be immobilised by drips and monitoring equipment. She will need extra support and may require additional analgesia

The passages

• Cephalopelvic disproportion The pelvis is too small for the foetus. Squatting may help overcome this in the second stage.

• Cervical dystocia There is failure of the cervix to dilate.

• Placenta praevia This can obstruct descent.

The passenger• Occipitoposterior presentations These account for

approximately 30% of labours. An aching, ‘boring’ backache will be apparent; it may persist between contractions. The first stage of labour can be long-drawn-out, with irregular contractions. The mother will be more comfortable in positions that take the weight of her uterus away from her back (e.g. prone kneeling); between contractions, pelvic rocking and circling may help alter pressure within the pelvis. Deep back massage or pressure, heat or ice packs and resting in a warm bath may relieve discomfort. The foetus may rotate or be delivered face to pubes. An epidural anaesthetic may be necessary

• Breech birth Labour may be no different to a vertex presentation, but is likely to be actively managed with epidural anaesthetic in most hospitals. Pelvimetry and an ultrasound scan at 38 weeks will attempt to identify women whose babies will need delivery by elective caesarean section.

• Malpositions or malpresentation These may be associated with an obstruction, such as disproportion or placenta praevia

SECOND STAGE

• Episiotomy • Ventouse delivery This is the method of choice

for assisted delivery as there is thought to be less risk of damage to mother and baby. A cap, attached to a suction pump, is fitted on to the baby’s head whilst in the birth canal, and held in place by suction.

• Forceps delivery • Caesarean delivery

THIRD STAGE

• Lacerations and tears• Retained placenta• Post partum Hemorrhage