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Labor analgesia: We need to better understand and educate our obstetric patients
Journal of Clinical Anesthesia 41 (2017) 42–43
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
Editorial
Labor analgesia: We need to better understand and educate our obstetric patients Nitrous oxide has long been an option for labor analgesia in the United Kingdom. It has only been over the last few years, however, that it has become available on some Labor and Delivery units in the United States with many others now considering whether to offer it as another analgesic choice for laboring women. Limited data are available regarding the efficacy of nitrous oxide labor analgesia. In this issue of the Journal of Clinical Anesthesia, Sutton, et al. provide useful information that may assist anesthesiologists and obstetricians who are adopting its use on their units. They offer a profile of parturients at their institution who chose nitrous oxide analgesia and those who ultimately converted from nitrous oxide to epidural analgesia [1]. It is particularly noteworthy that in this retrospective review the majority of women who utilized nitrous oxide were nulliparous women who desired a “nonmedical birth.” Labor induction and augmentation were found to be associated with conversion to epidural analgesia. While this information is useful for the practicing anesthesiologist, it also highlights that interpretation of these results requires an understanding of the psychology of the study participants. Most importantly, it also emphasizes that both anesthesiologists and obstetricians have room for improvement when educating our nulliparous patients about the labor and delivery experience and their options for labor pain management. Although the majority of scientific studies do not require an understanding of the psychology of the study subjects, some do to properly interpret the results. A classic example of this requirement occurred in 2009 when a study was published investigating the effect of general versus neuraxial anesthesia for cesarean delivery on childhood learning disabilities. The study was conducted because it was hypothesized that general anesthesia for cesarean delivery may be associated with the development of a learning disability [2]. There was no difference in the incidence of learning disabilities between the infants born by cesarean delivery with the mother receiving general anesthesia and the infants born by vaginal delivery. The use of general anesthesia for cesarean delivery did not increase the risk of a childhood learning disability. More importantly, the infants born to mothers who received neuraxial anesthesia for cesarean delivery had a lower incidence of developing a learning disability. While it may be concluded from these results that cesarean delivery performed with neuraxial anesthesia is protective, subsequent research has established that neuraxial labor analgesia does not have a protective effect [3]. However, if one understands the psychology of the parturient who chooses neuraxial anesthesia for cesarean delivery, the results begin to make sense. During the time period from which the data for this study were obtained, most parturients would receive general anesthesia for cesarean delivery. Those receiving neuraxial anesthesia chose it because it allows one to be awake and remember the birth. It stands to reason that those who choose neuraxial anesthesia are more likely to breast feed, read to the child, and overall
http://dx.doi.org/10.1016/j.jclinane.2017.05.011 0952-8180/© 2017 Elsevier Inc. All rights reserved.
be more actively involved with the child. It is more probable that these factors lowered the risk of learning disabilities as compared to the anesthesia used for cesarean delivery. Another recent investigation of nitrous oxide for labor analgesia also highlights the need to understand the psychology of the study participants. In this study, patients who received only nitrous oxide for labor analgesia and reported poor analgesic efficacy still rated their satisfaction with their analgesic care highly [4]. Clearly there were other psychologic factors at play in these women's perceptions of their labor experience. The same concept applies to the current study. It is no surprise that the majority of patients choosing nitrous oxide are nulliparous. Nulliparous patients have not experienced labor and are unsure about the experience. As such, they are unaware of the pain associated with labor and assume that nitrous oxide will be helpful. It is not that nulliparous patients prefer nitrous oxide, rather it is that nulliparous patients are unaware of the labor experience and the pain involved. In fact, most of these women were hoping to have a nonmedical birth. It is interesting that those nulliparous women who ultimately chose to convert from nitrous oxide to epidural analgesia were more likely than those using only nitrous oxide to have indicated an initial preference for a medicated birth. It seems that perhaps those who initially expressed a desire for a nonmedical birth considered the self-administration of nitrous oxide less medicated than epidural analgesia. Again there is psychology at play here that needs to be understood in order to properly interpret the study results. And certainly the results provide evidence that clearly there is room for improvement in educating our obstetric patients about their options for labor analgesia. The concept of a nonmedical or natural childbirth may be traced to Dr. Grantly Dick Read. Dr. Read was an obstetrician who published the book, Childbirth Without Fear. Dr. Read preached that childbirth was not intended to be painful. Pain was a result of fear and the lack of a supportive environment in which to deliver. His viewpoint of obstetric anesthesia is clear when one considers his description of obstetric anesthesia: “Walt Disney could hardly do justice to the Silly Symphony of Obstetric Analgesia” [5]. Many nulliparous patients are unprepared for the pain of childbirth and do not have an understanding of the severity of the pain involved. They also are extremely unprepared for the increased strength and discomfort associated with the initiation of oxytocin to augment or to induce labor. Again, improved patient education before arrival on the labor and delivery unit could go a long way towards providing more realistic expectations about labor and improving nulliparous women's labor experiences. We have all seen the disappointment and sense of failure expressed by some women who initially preferred a nonmedical birth and then chose some form of analgesia. Better education efforts on our part might prevent at least some of these patients from experiencing these negative emotions.
Editorial
This lack of familiarity also influences the pain associated with the physiologic process of labor. This point was proven in 1981 when Melzack et al., reported on women's experience of labor using the McGill Pain Questionnaire [6]. The pain experienced by nulliparous women during their first birth was more intense than the pain experienced by multiparous patients. A means to decrease this pain in nulliparous women is to attend prepared childbirth classes. Education about the birthing process was shown by Melzack to result in a statistically and clinically significant reduction in pain scores. It is unclear in the current study what the knowledge base was for study participants about labor and the pain involved. It is important, however, to effectively manage the pain of labor as it may induce an unreasonable fear of subsequent childbirth. The fear of childbirth is known as tokophobia. Women suffering from tokophobia may seek sterilization or termination if they should subsequently become pregnant. Education about childbirth accompanied with effective analgesia that supports the patient's desires will help avoid the development of tokophobia [7]. Pregnant patients deserve honest education about the labor process and the pain involved. While some providers feel that such a discussion might exacerbate a woman's labor pain experience by placing both the idea and fear of pain in the patient's mind, it actually liberates women by providing realistic expectations, thereby allowing them to plan ahead for the most appropriate form of analgesia. This study by Sutton et al. reminds anesthesiologists that many parturients, especially nulliparous parturients, arrive on the labor suite uninformed of the upcoming process with its inherent pain. Furthermore, some of them consider the use of nitrous oxide analgesia to be a less medicated birth than use of epidural analgesia. These fallacies can only be corrected if anesthesiologists participate in childbirth education and take the lead in educating women before they arrive on the labor and delivery unit about their
43
options for labor pain management. It is only with such involvement that nulliparous women will arrive already equipped with a realistic understanding of the labor process and its associated pain as well as reasonable expectations regarding their options for its management.
References [1] Sutton C, Butwick A, Riley E, Carvalho B. Nitrous oxide for labor analgesia: utilization and predictors of efficacy. Journal of Clinical Anesthesia. [2] Sprung J, Flick RP, Wilder RT, et al. Anesthesia for cesarean delivery and learning disabilities in a population-based birth cohort. Anesthesiology 2009;111:302–10. [3] Flick RP, Lee KM, Hofer RE, et al. Neuraxial labor analgesia for vaginal delivery and its effects on childhood learning disabilities. Anesth Analg 2011;112:1424–31. [4] Richardson MG, Lopez BM, Baysinger CL, Shotwell MS, Chestnut DH. Nitrous oxide during labor: maternal satisfaction does not depend exclusively on analgesia effectiveness. Anesth Analg 2017;124:548–53. [5] Caton D. Who said childbirth is natural? The medical mission of Grantly Dick Read. Anesthesiology 1996;84:955–64. [6] Melzack R, Taenzer P, Feldman P, Kinch RA. Labour is still painful after prepared childbirth training. CMA Journal 1981;125:357–63. [7] Hofberg K, Brockington I. Tokophobia: an unreasoning dread of childbirth. Br J Psychiatry 2000;176:83–5.
Regina Y. Fragneto, M.D.⁎ Robert Gaiser, M.D. University of Kentucky College of Medicine, Department of Anesthesiology, United States ⁎Corresponding author at: UK Chandler Medical Center, 800 Rose Street, Department of Anesthesiology, Lexington, KY 40536, United States. E-mail address: [email protected] (R.Y. Fragneto). 5 May 2017 Available online xxxx
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
Editorial
Labor analgesia: We need to better understand and educate our obstetric patients Nitrous oxide has long been an option for labor analgesia in the United Kingdom. It has only been over the last few years, however, that it has become available on some Labor and Delivery units in the United States with many others now considering whether to offer it as another analgesic choice for laboring women. Limited data are available regarding the efficacy of nitrous oxide labor analgesia. In this issue of the Journal of Clinical Anesthesia, Sutton, et al. provide useful information that may assist anesthesiologists and obstetricians who are adopting its use on their units. They offer a profile of parturients at their institution who chose nitrous oxide analgesia and those who ultimately converted from nitrous oxide to epidural analgesia [1]. It is particularly noteworthy that in this retrospective review the majority of women who utilized nitrous oxide were nulliparous women who desired a “nonmedical birth.” Labor induction and augmentation were found to be associated with conversion to epidural analgesia. While this information is useful for the practicing anesthesiologist, it also highlights that interpretation of these results requires an understanding of the psychology of the study participants. Most importantly, it also emphasizes that both anesthesiologists and obstetricians have room for improvement when educating our nulliparous patients about the labor and delivery experience and their options for labor pain management. Although the majority of scientific studies do not require an understanding of the psychology of the study subjects, some do to properly interpret the results. A classic example of this requirement occurred in 2009 when a study was published investigating the effect of general versus neuraxial anesthesia for cesarean delivery on childhood learning disabilities. The study was conducted because it was hypothesized that general anesthesia for cesarean delivery may be associated with the development of a learning disability [2]. There was no difference in the incidence of learning disabilities between the infants born by cesarean delivery with the mother receiving general anesthesia and the infants born by vaginal delivery. The use of general anesthesia for cesarean delivery did not increase the risk of a childhood learning disability. More importantly, the infants born to mothers who received neuraxial anesthesia for cesarean delivery had a lower incidence of developing a learning disability. While it may be concluded from these results that cesarean delivery performed with neuraxial anesthesia is protective, subsequent research has established that neuraxial labor analgesia does not have a protective effect [3]. However, if one understands the psychology of the parturient who chooses neuraxial anesthesia for cesarean delivery, the results begin to make sense. During the time period from which the data for this study were obtained, most parturients would receive general anesthesia for cesarean delivery. Those receiving neuraxial anesthesia chose it because it allows one to be awake and remember the birth. It stands to reason that those who choose neuraxial anesthesia are more likely to breast feed, read to the child, and overall
http://dx.doi.org/10.1016/j.jclinane.2017.05.011 0952-8180/© 2017 Elsevier Inc. All rights reserved.
be more actively involved with the child. It is more probable that these factors lowered the risk of learning disabilities as compared to the anesthesia used for cesarean delivery. Another recent investigation of nitrous oxide for labor analgesia also highlights the need to understand the psychology of the study participants. In this study, patients who received only nitrous oxide for labor analgesia and reported poor analgesic efficacy still rated their satisfaction with their analgesic care highly [4]. Clearly there were other psychologic factors at play in these women's perceptions of their labor experience. The same concept applies to the current study. It is no surprise that the majority of patients choosing nitrous oxide are nulliparous. Nulliparous patients have not experienced labor and are unsure about the experience. As such, they are unaware of the pain associated with labor and assume that nitrous oxide will be helpful. It is not that nulliparous patients prefer nitrous oxide, rather it is that nulliparous patients are unaware of the labor experience and the pain involved. In fact, most of these women were hoping to have a nonmedical birth. It is interesting that those nulliparous women who ultimately chose to convert from nitrous oxide to epidural analgesia were more likely than those using only nitrous oxide to have indicated an initial preference for a medicated birth. It seems that perhaps those who initially expressed a desire for a nonmedical birth considered the self-administration of nitrous oxide less medicated than epidural analgesia. Again there is psychology at play here that needs to be understood in order to properly interpret the study results. And certainly the results provide evidence that clearly there is room for improvement in educating our obstetric patients about their options for labor analgesia. The concept of a nonmedical or natural childbirth may be traced to Dr. Grantly Dick Read. Dr. Read was an obstetrician who published the book, Childbirth Without Fear. Dr. Read preached that childbirth was not intended to be painful. Pain was a result of fear and the lack of a supportive environment in which to deliver. His viewpoint of obstetric anesthesia is clear when one considers his description of obstetric anesthesia: “Walt Disney could hardly do justice to the Silly Symphony of Obstetric Analgesia” [5]. Many nulliparous patients are unprepared for the pain of childbirth and do not have an understanding of the severity of the pain involved. They also are extremely unprepared for the increased strength and discomfort associated with the initiation of oxytocin to augment or to induce labor. Again, improved patient education before arrival on the labor and delivery unit could go a long way towards providing more realistic expectations about labor and improving nulliparous women's labor experiences. We have all seen the disappointment and sense of failure expressed by some women who initially preferred a nonmedical birth and then chose some form of analgesia. Better education efforts on our part might prevent at least some of these patients from experiencing these negative emotions.
Editorial
This lack of familiarity also influences the pain associated with the physiologic process of labor. This point was proven in 1981 when Melzack et al., reported on women's experience of labor using the McGill Pain Questionnaire [6]. The pain experienced by nulliparous women during their first birth was more intense than the pain experienced by multiparous patients. A means to decrease this pain in nulliparous women is to attend prepared childbirth classes. Education about the birthing process was shown by Melzack to result in a statistically and clinically significant reduction in pain scores. It is unclear in the current study what the knowledge base was for study participants about labor and the pain involved. It is important, however, to effectively manage the pain of labor as it may induce an unreasonable fear of subsequent childbirth. The fear of childbirth is known as tokophobia. Women suffering from tokophobia may seek sterilization or termination if they should subsequently become pregnant. Education about childbirth accompanied with effective analgesia that supports the patient's desires will help avoid the development of tokophobia [7]. Pregnant patients deserve honest education about the labor process and the pain involved. While some providers feel that such a discussion might exacerbate a woman's labor pain experience by placing both the idea and fear of pain in the patient's mind, it actually liberates women by providing realistic expectations, thereby allowing them to plan ahead for the most appropriate form of analgesia. This study by Sutton et al. reminds anesthesiologists that many parturients, especially nulliparous parturients, arrive on the labor suite uninformed of the upcoming process with its inherent pain. Furthermore, some of them consider the use of nitrous oxide analgesia to be a less medicated birth than use of epidural analgesia. These fallacies can only be corrected if anesthesiologists participate in childbirth education and take the lead in educating women before they arrive on the labor and delivery unit about their
43
options for labor pain management. It is only with such involvement that nulliparous women will arrive already equipped with a realistic understanding of the labor process and its associated pain as well as reasonable expectations regarding their options for its management.
References [1] Sutton C, Butwick A, Riley E, Carvalho B. Nitrous oxide for labor analgesia: utilization and predictors of efficacy. Journal of Clinical Anesthesia. [2] Sprung J, Flick RP, Wilder RT, et al. Anesthesia for cesarean delivery and learning disabilities in a population-based birth cohort. Anesthesiology 2009;111:302–10. [3] Flick RP, Lee KM, Hofer RE, et al. Neuraxial labor analgesia for vaginal delivery and its effects on childhood learning disabilities. Anesth Analg 2011;112:1424–31. [4] Richardson MG, Lopez BM, Baysinger CL, Shotwell MS, Chestnut DH. Nitrous oxide during labor: maternal satisfaction does not depend exclusively on analgesia effectiveness. Anesth Analg 2017;124:548–53. [5] Caton D. Who said childbirth is natural? The medical mission of Grantly Dick Read. Anesthesiology 1996;84:955–64. [6] Melzack R, Taenzer P, Feldman P, Kinch RA. Labour is still painful after prepared childbirth training. CMA Journal 1981;125:357–63. [7] Hofberg K, Brockington I. Tokophobia: an unreasoning dread of childbirth. Br J Psychiatry 2000;176:83–5.
Regina Y. Fragneto, M.D.⁎ Robert Gaiser, M.D. University of Kentucky College of Medicine, Department of Anesthesiology, United States ⁎Corresponding author at: UK Chandler Medical Center, 800 Rose Street, Department of Anesthesiology, Lexington, KY 40536, United States. E-mail address: [email protected] (R.Y. Fragneto). 5 May 2017 Available online xxxx