Pain Relief Management During pregnancy (Brief discussion)

Pregnancy occurs as the result of the female gamete oocyte merging with the male gamete, spermatozoa, in a process referred to, in medicine, as fertilization, or more commonly knowledge as conception. Pregnancy is defined as the carrying of one or more offspring known as a fetus or embryo, inside the womb of a female (wiki encyclopedia, 2007). In pregnancy period,  physiology of whole body is dramatically changed due to fall and rise of gonadotrophins as a result various physiological abnormalities are seen, among them pain is a prominent symptom. Pain in pregnancy is a difficult area owing to need to balance the best interests of the mother and the fetus or neonate.

    pain in pregnancy is a fraught area and concern about maternal, fetal and neonatal well being.There are many causes behind the pain during pregnancy and commonly described as physiological, pathological and idiopathic ,among them physiological cause is taken as the most common cause.
Many women may experience occasional bouts of lower abdominal pain during pregnancy. While frightening at best abdominal pain during pregnancy is usually a normal and harmless condition. Normal abdominal pain during pregnancy can sometimes suggest more serious problems. For example: ectopic pregnancy, miscarriage, preterm labor etc (Brann, 2004).    

          Other potential sources of pain may include postural dysfunction related to pregnancy, diastasis rectus abdominalis (DRA) misalignment in the pelvic girdle, and poor body mechanics (Jeffcoat, 2008).  The primary responsibility of nurse is to assess and management of pain especially in pregnant women due to the seriousness of maternal and fetal health. The control of pain is guided by analgesic ladder which is presented by WHO in 1996. In the hospital nurse should involved in pain management team. In final point this paper will briefly describes about pain management in pregnancy through non pharmacological and pharmacological interventions.

              

Nonpharmacological management of pain in pregnancy should always be considered before embarking upon pharmacological therapy with its potential risk to the women, the fetus and the neonates. Nonpharmacological techniques alone can provide adequate analgesia for many women, but they require the investment of time and energy on the part of women and therapist particularly where training in the technique is required. Unfortunately, this can place excessive demands upon limited sources. However these techniques can be very satisfying for the women, giving her control over her own management in her home environment and allowing her to have what might commonly be perceived as more natural pregnancy. By the contrast in acute, severe pain it may be necessary to achieve rapid pharmacological control before it is possible for the patient to co- operate with the non pharmacological options (Roche & Hughes, 1999).Nonpharmacological techniques for controlling acute and chronic pain in pregnancy includes various methods. First of all nurse can use the psychological interventions to relief pain in pregnant woman. Number of simple psychological interventions can improve a client’s pain control by:

Ø    Reducing anxiety, stress and muscle tension.

Ø    Distraction ( distraction plays a role in pain manage by pushing      awareness of pain out of central cognition) 

Ø    Increasing control and pain-coping mechanisms.

Ø    Improving general well- being (Zarnegar &Daniel, 2005).

In pregnant women pain relief management by psychological interventions can be most important techniques and nurse should apply this techniques. Most of all during pain assessment nurse should create trusting therapeutic relationship with clients and play instrumental role in reducing anxiety and helping pregnant women /other clients to cope with pain (Carr &Mann, 2003). Nurse can help to create trusting relationships by:

              i.   Listening to the clients.

              ii. Believing the client’s pain experience (Seers, 1996).

              iii. Acting as patient’s advocating.

             iv. Providing patients with appropriate physical and emotional support.

               .

          In addition relaxation is another Nonpharmacological (psychological) intervention to relief pain in pregnant women. Although scientific evidence for the effectiveness of relaxation technique is limited(carrol & Seers  1998) however a number of studies have shown benefits for clients experiencing pain (Sloman et al; 1994; Good et al 1999, Lang et al ,2000). Payne (1995) describes several relaxation techniques ranging from simple breathing technique to progressive muscle relaxation and more complex technique. For example sciatic pain /lower back pain / hip pain this pain in pregnant women can be managed by some relaxation exercises  (Jeffcoat, 2008). Here are some exercises

·  Have her lift, her head off the floor. Do not have her lift up the shoulders.

·  Feel with your finger if there is a separation occurring.

·  Then place your finger in the same position and check two inches above the umbilicus and two inches below the umbilicus.

· A one to two finger separation is normal. If there is more than a two separation at any of the levels, then your patient has diastasis recti and prepare for another exercise.

       In the same way physiotherapist can also help the management of pain in pregnancy through feedback on posture, muscle relaxation techniques, exercise programs, prophylactic back care classes and aids such as walking frames uterine support pillow and the wide sacroiliac belts used in the management of pubic symphysis diastasis. Walking aids are used to facilitate maximum mobilization in the best possible posture. Massage is useful in most pain problems encountered in pregnancy but, since massage is time consuming it is most profitable to teach a willing family member to assist with or perform this (Roche &Hughes, 1999). Similarly transcutaneous electrical nerve stimulation is another method of pain relief management in pregnancy. Transcutaneous electrical nerve stimulation is through to work by sending a weak electrical current through the skin to stimulate the sensory nerve ending. Depending on the stimulation parameters used, transcutaneous is thought to modulate pain impulses by closing the gate to pain transmission within the spinal cord by stimulating the release of natural pain relieving chemicals in the brain and spinal cord (King, 1999). Up to 70%of patient obtains an analgesic effect, which can be sustained for six months. Transcutaneous electric nerve stimulation reduces the use of analgesics (Roche & Hughes 1999). Whereas there is limited scientific evidence for the effectiveness of transcutaneous nerve stimulation. Despite this, many health care professionals use transcutaneous electrical nerve stimulation for variety of chronic pain condition and the support the view that this is a useful form of analgesia (Walsh 1997). In contrast, transcutaneous electrical nerve stimulation has not found to improve the control of acute pain following surgery (McQuay et al, 1997).

 Secondly acupuncture hypnotherapy and application of heat therapy is also beneficial to relief pain in pregnancy. Acupuncture is provided by some physiotherapists, general practitioners, and acupuncture specialists as well as pain specialist. Acupuncture is used for variety of pain syndrome in pregnancy including headache, back pain and nerve entrapments. It is believed to work in part by stimulating release of body’s own natural opioids. Although there is also limited scientific evidence for the pain relieving effect of acupuncture, largely due to the controlled studies (Ezzo et al. 2000), it is used and has an important role in pain management in pregnancy. In the same way hypnotherapy/ self hypnosis also another method to manage pain in pregnancy and we can use occasionally for chronic severe pain in pregnant patients. In general, this option is useful only in subject who are easily hypnotized. The success of this technique is depends upon time investment a high degree of concentration severe training sessions and a skilled hypnotherapist (Roche &Hughes, 1999). Just as… so most patient will gain a degree of pain relief from the local application of heat, this can be in the form of a hot water bottle a micro waved wheat pillow or a hot bath. There is much anecdotal and some scientific evidence to support the usefulness of heat as an adjunct to other pain treatments (Akin et al 2001; Nadler et al 2002; Robinson et al 2002). Heat works by:

Ø  Stimulating thermo receptors in the skin and deeper tissues, thereby reducing the sensitivity to pain by closing the gate system in spinal cord.

Ø  Reducing muscle spasm.

Ø  Reducing the viscosity of synovial fluid which alleviates the painful stiffness during movement and increase joint range (Carr &Mann 2000b).

Many patients have myofacial pain, which respond well to heat and passive stretching. Heat should not be used in conjunction with epidural analgesia or nerve blocks, owing to risk of burns in the presence of impaired thermal perception (Roche &Hughes 1999). In the final point Nonpharmacological techniques are unquestionably effective and safe interventions to pain relief management in pregnancy. The optimal pain control is likely to be achieved by combining Nonpharmacological techniques with pharmacological. Despite the lack of research evidence to support the effectiveness of many Nonpharmacological techniques, their benefits to patients and families could not be underestimated. 

Next, nurse can use the gentle humor to relief client’s pain. Pasero (1998) suggest that many patients find gentle humor an effective way of coping with pain. Humor may be particularly helpful prior to pain procedure as it can have a lasting effect. During assessment of pain in pregnant women nurses can provide humorous tapes, books and video unlike in clinical setting (Dougherty &Lister, 2008).  In another hand patient information and education about pain can make all the difference between effective and ineffective pain relieve. Information /education help to reduce anxiety and enables patients to make informed decisions about their care ( Hayward, 1975, Taylor, 2001). Pregnant women should be given specific information about why pain control is important, what to expect in term of pain relief, how they can participate in their management and what to do if pain is not controlled. Some caution is required, however because not all patient respond positively to the same level of information. Patient with high level of anxiety may find that detailed information can increase their pain and influence their pain control. To overcome this, patient can be given a choice of whether or not they receive simple or detailed information (Mitchell, 1997)

Pharmacological management of pain in pregnancy is equally important as none pharmacologically. When prescribing in pregnancy the risk to the developing fetus as well as to the mother need to be considered. Selecting drugs with long safety record and paying attention to the timing of exposure, the drug dose and duration of drug use will minimize these risks. The control of pain is by analgesic ladder which was presented by WHO in 1996. The simple principles are such that pharmacological interventions begins on the first step of ladder and proceeds upward as and when the pain reaches a higher level and the current analgesia is no longer effective. It is important to make an assessment of each pain separately; since the pain may need to be managed in a different manner one analgesic intervention will rarely be sufficient. Often the best practice is to combine the baseline analgesia with an appropriate adjuvant treatment in order to achieve maximum pain control.

When using analgesic ladder drugs and therapies from the initial step, which are of some benefits for patient, are continued when additional drugs from subsequent steps are commenced. Thus by continuing Nonpharmacological therapy, the consumption of analgesic drugs can be reduced, and by continuing nonopioid analgesics, the consumptions of opioids analgesics can be reduced. On the other hand the first trimester of pregnancy is the time of greatest risk to the developing fetus; hence non pharmacological interventions are the mainstays of analgesic therapy. For those women who cannot be supported in second trimester with Nonpharmacological therapies alone, local anesthetics, paracetamol, clonidine patches and opioids can be added to their treatment regimen (Roche &Hughes 1999).

      When we use pharmacological interventions to manage pain in pregnancy we can use the local pharmacological therapy, selected systemic non steroidal anti inflammatory drugs and  opioids. First of all we must choose the local pharmacological therapy to relief pain in pregnancy because this therapy produces lower plasma drug concentrations than systemic and hence is associated with fewer concerns regarding adverse effect to the mother and fetus (Smith & Aronson 2001). Local anesthesia and steroid injections may achieve analgesia for several weeks. We can use a mixture of equal volumes of 1% lignocaine and 0.5% bupivacaine with 10 mg of triamcilone up to a maximum volume of 20ml. this is useful in the treatment of nerve entrapments, coccydynia, and postoperative wound neuromas, from both cesarean section and episiotomies (Roche &Hughes 1999).    The nonsteroidal anti inflammatory drugs (NSAIDS) which are safe for pregnancy are also beneficial  in pregnancy and have shown to provide better pain relief than paracetamol combination actions to acute pain (McQuay et al; 1997). These drugs can be used alone or in combination with both opioids and non opioids analgesics. Here is a list of analgesics which are safe to use in pregnancy:

Drugs Paracetamol Amitriptyline Mexeletene Aspirin/NSAIDS Clonidine Orphenadrin

Category B D B D B C

Comments The pharmacokinetic of paracetamol is similar in pregnant state to in non pregnant state. There are no reports to congenital abnormalities attributed to paracetamol. maternal paracetamol over dose cause fetal hepatotoxicity leading to fetal death Limb reduction abnormalities have been reported in women using Amitriptyline in first trimester of pregnancy. However half a million second and third trimester of pregnancies in which Amitriptyline has been used. There are no any reports of fetal abnormalities. No data In the third trimester of pregnancy, the use of aspirin/ NSAIDS premature closure of ductusarteriosus and subsequent pulmonary hypertension. There is also a risk of neonatal hemorrhage. Low dose NSAIDS causes oligohydraminous in second trimester. There are no reports of congenital abnormalities by using clonidine during pregnancy. No data.

Source: Pain review 1999 vol. 6 pp. 244

For the short term control of acute pain when opioids are necessary, intravenous morphine is frequently used via patient controlled analgesia (PCA) pump. Morphine has the advantage that a variety of short and long acting oral preparations are available to facilitate conversion to oral therapy. Pathidine also used, but its use is associated with the potential for the accumulation of a neuroexitatory metabolites and its oral preparations are all short acting. For longer term use methadone is the opioids of choice in pregnant women. It is an orally active mu-opioid receptor agonist, and methadone is also an N-methyl –D aspirate (NMDA) receptor antagonist, which may add its efficacy in neurogenic pain states. Methadone is the long acting opioids whereas morphine, diamorphine and   Pathidine are short acting opioids.  Long acting opioids results in withdrawal episodes in the mother which are associated with fetal distress, premature labor and fetal loss. The improvement in neonatal outcome with methadone use compared that of short acting opioids may be due in part to the reduction recurrent withdraw. 

                                                      

                                    Conclusion:

The pain in pregnancy is fraught area and concern about maternal fetus or neonate. Pregnant women present to nurses or other health practitioners for analgesia because they are concerned about the effects of drug on the developing fetus. Failing to assist these women in making analgesic choice may result in them obtaining in appropriate drugs from nonprescription sources or from well meaning friends or relatives. Safe analgesia can be provided to pregnant women. Nonpharmacological options should be explored, using a multidisciplinary approach before offering analgesic drugs. It is nurse’s duty to provide these drugs in systemic manner, with a thoughtful explanation of the relevant risks to the women and the fetus, allowing her to make informed decisions about managing her pain. 

                                                   

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