A 31-year-old healthy nulliparous patient at 40 + 2 weeks’ gestation presented to the Labor & Delivery Unit in spontaneous labor. She was under the care of a midwife and strongly desired natural childbirth. On admission, she was accompanied by her husband and her doula. She presented her nurse with a written birth plan that detailed several requests for her labor experience, including nonpharmacologic pain management. She wanted to begin in the birthing tub and use hypnotherapy techniques during her labor.
Patients may present to labor and delivery with plans to employ several nonpharmacologic methods of relaxation and pain mitigation during their labor.
Many of these techniques are entirely compatible with neuraxial or pharmacologic analgesia.
Anesthesiologists should strive to understand the variety of options available, maintain respect for the patient’s goals, and facilitate a satisfying and safe labor experience for the patient.
This patient’s case represents a common clinical scenario encountered on labor and delivery units. Some obstetric patients are motivated to experience labor with little or no medical intervention. As anesthesiologists, it is important for us to acknowledge their goals, recognize alternative methods of analgesia, and appreciate that many of these methods are still compatible with conventional anesthetic interventions. Often the patient’s satisfaction with the childbirth process does not necessarily correlate with pain control.1 The efficacy of these complementary or alternative medicine (CAM) techniques is difficult to evaluate scientifically; nonetheless, they are widely accepted by many patients and incorporated into their birth plans.2–5
The use of birthing tubs or whirlpools has increased in popularity, and many hospitals have this equipment available for laboring patients (Figure 8.1). Women may choose to labor in the tub, and some may also deliver while submerged in water (based on institutional policy). Water immersion provides a warm, soothing environment for the parturient and is thought to increase relaxation and decrease the perception of pain, although the exact mechanism of analgesia is unknown.6
Several benefits of water immersion have been identified, in addition to its potential analgesic effects. Parturients who participate in hydrotherapy have been shown to have shorter labors, fewer tears and episiotomies, fewer obstetric interventions (e.g., amniotomy, pharmacologic augmentation), and lower analgesic requirements (pharmacologic or regional).3 Studies have not shown a decreased incidence of instrumental or operative deliveries in these patients, however. A randomized, controlled trial (RCT) has shown that water immersion may be helpful in early labor to manage labor dystocia.7 It is difficult to objectively assess the true analgesic effects of water immersion given the inability to provide it in a blinded fashion, and patients who seek water immersion therapy may be highly motivated to undergo natural childbirth.
Laboring with water immersion does not preclude the patient from using other methods of analgesia. Although parturients are generally not permitted to have an epidural while in the tub, they may choose to labor initially using water immersion and then ask for an epidural after they leave the tub. Other laboring techniques also may be used simultaneously with water immersion, such as hypnobirthing and massage. Water-compatible monitors allow for continuous fetal heart rate monitoring even while the patient is submerged in water.
Certain patients may not be eligible for hydrotherapy. Relative contraindications, based on institutional policy, may include premature labor, ruptured membranes, and the presence of meconium, infection, or vaginal bleeding. Another important consideration is the sanitation of the tub, water, and hose equipment. Bacteria such as Pseudomonas aeruginosa and Klebsiella pneumoniae have been cultured from these labor whirlpools and pose an infection risk for both the mother and the neonate.8
Water immersion is generally considered safe in low-risk parturients undergoing uncomplicated vaginal deliveries.9 Caregivers who oversee patients laboring with hydrotherapy must be aware of its risks and promote proper sanitation of equipment. Although there is not sufficient data to determine the true analgesic effect of water immersion, many women report great satisfaction while laboring with hydrotherapy.
Acupuncture and Acupressure
Acupuncture is a form of traditional Chinese medicine based on the belief that energy, or Qi (pronounced “chi”), flows along channels in the body called meridians (Figure 8.2). Acupuncture theory holds that many medical conditions result from the disruption of this energy flow and that the insertion of fine needles along these meridians helps to restore the harmony of Qi. No anatomic correlations between the meridians and Western medicine exist, but the efficacy of acupuncture may be related to its interaction with the neuroendocrine system.3
Acupuncture has been used to treat a variety of medical conditions, including infertility and hyperemesis gravidarum. Data suggest that acupuncture, in conjunction with moxibustion (the burning of mugwort adjacent to the tip of the fifth toe), may help to convert a breech fetus to vertex.10 There are also several uses for acupuncture during labor, such as induction of labor and treatment of nausea and pain.11
The true efficacy of acupuncture is difficult to assess because of the inability to blind both patients and acupuncturists. A meta-analysis of 10 RCTs showed that acupuncture did not significantly decrease pain scores in comparison with minimal acupuncture (placing needles in areas that are not acupoints).12 However, other studies using placebo or sham acupuncture (mimics acupuncture without actually inserting needles) demonstrated a decrease in use of pharmacologic or regional analgesia in the patients who received acupuncture.13 A further study that randomized 36 patients to receive electroacupuncture versus placebo found that the women receiving acupuncture had decreased pain intensity, greater relaxation, and increased levels of B-endorphin and 5-hydroxytryptamine in blood samples.14
Hypnosis is considered a scientifically accepted method of analgesia. Parturients may opt to practice various forms of hypnosis during labor, including self-hypnosis, instructor-guided hypnosis, and the use of audio recordings. These techniques help to put the patient in a state of focused concentration, in which she is unaware of, although not completely blinded to, her surroundings. Many hypnotic techniques use “softer” words than usual medical terminology to ease the patient into a relaxed state. For example, using the word release rather than rupture, blossom rather than dilate, and tightening rather than pain can help to comfort patients.15
Positron emission tomography (PET) has shown that hypnosis modulates pain by suppression of neural activity in the anterior cingulate gyrus.16 Hypnosis requires a motivated patient, as well as prenatal preparation. It is generally a well-received practice given its noninvasive nature and compatibility with other analgesic techniques, including regional anesthesia.