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Evaluation of abdominal decompression during the first stage of labor
Evaluation of abdominal decompression during the first stage of labor HOWARD
SHULMAN,
STANLEY
J.
Brooklyn
and
New
M.D.
BIRNBAUM, York,
New
M.D. York
H E Y N s ,lp 2 in 1954, while working with a paralyzing drug (Scoline) during labor, found that there was rapid cervical dilatation following its administration. However, the agent caused respiratory distress, and patients receiving it had to have general anesthesia with assisted respirations. In 1955, Heyns designed an apparatus to imitate the effects of this drug. The abdominal wall was lifted by externally applied negative pressure to simulate an abdomen that had been paralyzed. The equipment consisted of a specially designed chair, pump, plastic airtight suit extending from neck to feet, and an incompressible fiber glass spacer over the abdomen. He postulated that the uterus at rest is angled backward. During a contraction it rises to eliminate this angle and forms a straight line with the vagina. A tense abdomen resisting these changes forces the uterus to expend energy to lift the abdomen and overcome its resistance. By paralyzing, or by applying negative pressure to the abdomen, the uterus can expend its energy more efficiently. This results in longer and less painful contractions since the abdominal wall is not stretched by the rising uterus. The original series comprised 100 patients, using external negative pressures of 40 to 50 mm. Hg. It was reported that contractions were longer and stronger, but less pain-
From New New
ful. Thus, 77 per cent of the patients had complete relief, and 72 per cent were delivered in less than 5 hours. This was sigsince 91 of the patients were nificant, primiparas, and no oxytocin was used. With the use of the same apparatus in another series,2 the first stage of labor was reduced by one half in 70 per cent of the primiparas, and there was substantial relief of pain in 90 per cent of the labors. Further work by the same author,4 employing vulva1 decompression during the second stage, showed improved fetal condition at birth. This was attributed to augmented placental blood flow and oxygenation. Scott and Loudon” with equipment made of disposable polythene tubing, modified the suit so that it extended from the axilla to above the knees. Negative pressures of 20 to 40 mm. Hg were applied to patients with ruptured membranes and 2 to 6 cm. dilatation. No oxytocin was employed. Pain relief was immediate. In fact, patients were no longer aware of the onset of contractions. No definite conclusions were reached, but the impression was that labor was significantly shortened. Quinn and McKeown5 used the original plastic suit of Heyns, but found that it caused pressure on the chest, prevented routine examinations, caused fluid to collect under the plastic, and immobilized the extremities. They fashioned a new suit extending from the axilla to the thigh. This was later simplified to a flexible steel mesh and plastic dome edged with foam rubber. With this apparatus, they concluded that
the Brookdale Hosgital, Brooklyn, York, and New York Hospital, York, New York.
Presented at the Brooklyn Gynecological Society, May,
1965.
421
422
Shulman
and
Birnbaum
Am.
evaluation of decompression was difficult, since it was not known how a given patient would have behaved in its absence. Their impression, however, was that labor was accelerated and pain lessened. Of 162 patients, there were 20 excluded as “failures.” Of the remainder, excellent relief of pain was achieved in 83 per cent of the primiparas and 88 per cent of the multiparas. The length of labor was substantially reduced in both groups. Faced with these optimistic reports, this study was designed to evaluate abdominal decompression during the first stage of labor employing a compact, easily applied apparatus.* The equipment consisted of a pump, flexible hose, and a transparent plastic shell with padded edges. The shell covered only the patient’s abdomen. Its edges were fitted ‘Emerson
Birtheez
June 1, 1966 J. Obst. & Gynec.
with plastic sheets that wrapped around the flanks, achieving an air-tight fit. The patient controlled the application of decompression by a hand switch. Twenty-five cases were picked at random from our delivery unit, 14 were multiparas. There were 12 ward and 13 private patients. Approximately half of our patients received oxytocin, which was not employed in earlier studies. Once labor was well established, the apparatus was applied after a brief explanation of the theory and technique of operation. The negative pressure was adjusted to the point that would relieve pain without causing undue pressure on the rib cage or symphysis pubis. Pain was evaluated objectively by the physician, and subjectively by the patient before application, using a 0 to 4+ scale. Following application, the patient was asked to alter-
Decompressor.
Table I _Before
After
application*
Objective
Objective
Subjective
application* I
Subjective
Primiparas +++ +++
C. M. F. B.
++t+
E. G.
if +++
tit t++
t+ i&f
+t+
-tit
ff-i t t++ tt +i +
P. A. J. M.
G. G. K. H.
tt ttt it+ t+
it-!ttt ttt ++
+ +++ ++ tt
B. s. c. M.
S. L. L. F.
it+ t++
++t ttt
+++
+
t
-t+t
it
+ ++ + ++ tt +t t+ t++ tt ttt ++ tt t+ ++
++ +t +t it+ tit t+ +t+ ++ ++ ++t t+ tt +t+ tt
tt
f ++ +
+ tt+ +
Multiparas
____
A. W. M. 0. D. D. R. MC. L. B. A. F. J. M. M. L. c. w. D. B. A. B. M. D. M. J. J. R.
*++tt-Very
severe
pain,
+tt--severe
pain,
+-moderate
pain,
tmild
+ if + + ttt +t t++ ++ 0 ttt + + +++ ++ pain,
and
O-none.
t Ai c f ++t ++ t +iti + t+t + tt +t+ t+
-
Volume Number
95 3
Abdominal
nate contractions with and without decompression. Relief was then evaluated objectively and subjectively as to whether the pain following decompression was unchanged, slightly improved, moderately improved, completely relieved, or worse than before. The patient was then allowed to keep the apparatus on for varying lengths of time, ranging from 10 minutes to 5 hours. The pains were then re-evaluated by the doctor and patient (using the 0 to pt scale) while the apparatus was in use. Negative pressure ranged from 25 to 70 mm. Hg. Upon removal of the apparatus the patient was asked whether she would request this form of pain relief again. Any comments made by the patient were recorded. The apparatus was kept in place (except for fetal heart observations) until the patient was ready for delivery, requested removal,
,
decompression
in labor
or the physician was able to make decision as to its effectiveness.
423
a definite
Results Our results are tabulated in Table I. Note that none of our 11 primiparas had complete relief of pain, and only 2 would have requested this form of analgesia again. Both of these patients were private patients of one of the authors (S. J. B.). One of these patients had training in “natural childbirth,” and used the apparatus for 4 hours with moderate objective and subjective relief of pain. She progressed from 5 cm. to 9 cm. dilation during this period, but eventually required 100 mg. Demerol and 0.4 scopolamine. The other patient used mg. the apparatus early in labor for only s/4 of an hour. Of the remaining 9 primiparas, only one
Consecutive Objective Worse Equal
pain
Moderate
improvement
contractions Subjective
I Equal Worse
pain
Equal
pain
Slight improvement Equal pain Moderate improvement Slight improvement
Slight improvement Moderate improvement Moderate improvement Moderate improvement
Moderate Moderate Moderate Moderate
improvement improvement improvement improvement
Slight Slight Moderate Moderate Slight Equal Equal Moderate Complete Equal Moderate Moderate Slight Moderate
Slight Slight Moderate Slight Slight Equal Equal Slight Complete Equal Moderate Moderate Equal Moderate
improvement improvement improvement improvement improvement pain pain improvement relief pain improvement improvement pain improvement
pain
improvement improvement improvement improvement
and
reuse
No No,
Slight improvement Equal pain Moderate improvement Equal pain
improvement improvement improvement improvement improvement pain pain improvement relief
Comments
shell could not be placed in position that would cause pain No, had moderate improvement early in labor, but when active labor began Yes, used early in labor No, patient not fully cooperative No, bothered by machine; did not want to push button No, originally slight improvement, later patient believed chine gave pain No, patient seemed improved but denied relief Yes No No
Undecided, difficulty in finding good position for dome Undecided, rapid labor Yes Undecided No, slight improvement coincidental with Demerol No No, pain over lower chest cage Undecided Yes, first complaint pain at full dilatation No, patient in active labor and no relief from pain No, pressure from inferior border of dome Yes No No, pain is less but pressure from machine is uncomfortable
not none
ma-
424
Shulman
and
June 1, 1%6 Am. J. Obst. & Cynec.
Birnbaum
had significant objective relief of pain after decompression (a difference of at least 2t on the pain scale). Subjectively, one reported pains significantly worsened. It is of interest that results differed when the patients were asked to evaluate successive single contractions. Here again, no patient achieved complete relief, and 5 patients noted no change or an increase in pain intensity. The remainder had slight or moderate relief. Three patients were bothered by pressure from the shell or did not want to bother pushing the switch. The duration of labor ranged from 5% hours to 18 hours with an average of 9% hours. Seven of the 11 primiparas received oxytocic drugs. The change in cervical dilation during decompression ranged from 1 to 4 or 5 cm. Of the 14 multiparas, only 3 would request this method of analgesia in the future, although 4 more were undecided. Only one patient had significant and objectively complete relief in this group. This patient was again a private patient of one of the authors (S. J. B.). She had some “natural childbirth” training. She employed decompression for 11/1 hours and first complained of pain when fully dilated. A second patient had good subjective relief during If/2 hours of use, but was undecided about using this technique in the future. When evaluating consecutive contractions, 4 multiparas noted no change, one had complete relief, and 9 reported mild or moderate relief. While 7 patients would not request decompression again, 2 showed moderate improvement either subjectively or objectively. The 4 undecided patients showed either slight or moderate improvement. Thus 6 dissatisfied patients still had some relief from the decompression. Four multiparas were bothered by the bubble. Their reasons for dissatisfaction were similar to the primiparous group. The duration of labor averaged 6.5 hours, with two labors 4 hours or less. Four patients received oxytocin. The change in cervical dilation during
application ranged from 2 to 6 cm. There was one case of prolapsed cord during decompression, but this could not be related to the apparatus. There was no other abnormality of labor or delivery, and the newborn infants were in no way affected by the decompression. Comment Of our 25 patients, only 5 (20 per cent) were satisfied enough with abdominal decompression to request it again. Furthermore, 2 of these were patients with training childbirth,” who might have in “natural done well with any regimen. In the combined group there were only 5 patients (20 per cent) who had significant (more than 2+ change) objective or subjective relief of discomfort. On the other hand, 7 patients not only were unrelieved, but were bothered by the pressure of the bubble rim. Six patients received no analgesic medication during labor. In only 2 of these could pain relief be attributable to the apparatus. It was because of these poor initial results that we suspended our study after 25 cases. It was our impression that there was little or no effect on the duration of labor. There were no ill effects noted in the fetus. The one serious obstetrical complication (prolapsed cord) did not appear to be related to the procedure, since this patient used the apparatus for only f/2 hour and requested its removal because of rim pressure. Summary 1. Twenty-five patients in active labor were selected at random and subjected to intermittent abdominal decompression during the first stage of labor. 2. Only 5 (20 per cent) patients were satisfied enough with the relief obtained to request this procedure again. Upon subjective and objective evaluation using a pain scale of 0 to 4+, only 5 patients had a significant (at least a 2+ difference) relief during contractions. Thus, abdominal decompression does not appear to be an adequate technique of analgesia in our obstetric patients.
Volume Number
95 3
Abdominal
decompression
in labor
425
REFERENCES
1. 2. 3. 4.
Heyns, 0. S.: M. Proc. South Africa 5: 121, 1959. Heyns, 0. S.: J. Obst. & Gynaec. Brit. Emp. 66: 220, 1959. Heyns, 0. S.: Lancet 2: 91, 1959. Heyns, 0. S.: Develop. Med. Child. & Neurol. 4: 473, 1962.
5. 6.
Quinn,
L.
L.,
OBST.
& GYNEC.
Scott, 1181,
D. B., 1960.
Linden Brooklyn,
and McKeown, R. A.: AX 83: 458, 1962. and Loudon, J. D.: Lancet
Boulevard and Rockaway New York 11212
Parkway
J. 1:
SHULMAN,
STANLEY
J.
Brooklyn
and
New
M.D.
BIRNBAUM, York,
New
M.D. York
H E Y N s ,lp 2 in 1954, while working with a paralyzing drug (Scoline) during labor, found that there was rapid cervical dilatation following its administration. However, the agent caused respiratory distress, and patients receiving it had to have general anesthesia with assisted respirations. In 1955, Heyns designed an apparatus to imitate the effects of this drug. The abdominal wall was lifted by externally applied negative pressure to simulate an abdomen that had been paralyzed. The equipment consisted of a specially designed chair, pump, plastic airtight suit extending from neck to feet, and an incompressible fiber glass spacer over the abdomen. He postulated that the uterus at rest is angled backward. During a contraction it rises to eliminate this angle and forms a straight line with the vagina. A tense abdomen resisting these changes forces the uterus to expend energy to lift the abdomen and overcome its resistance. By paralyzing, or by applying negative pressure to the abdomen, the uterus can expend its energy more efficiently. This results in longer and less painful contractions since the abdominal wall is not stretched by the rising uterus. The original series comprised 100 patients, using external negative pressures of 40 to 50 mm. Hg. It was reported that contractions were longer and stronger, but less pain-
From New New
ful. Thus, 77 per cent of the patients had complete relief, and 72 per cent were delivered in less than 5 hours. This was sigsince 91 of the patients were nificant, primiparas, and no oxytocin was used. With the use of the same apparatus in another series,2 the first stage of labor was reduced by one half in 70 per cent of the primiparas, and there was substantial relief of pain in 90 per cent of the labors. Further work by the same author,4 employing vulva1 decompression during the second stage, showed improved fetal condition at birth. This was attributed to augmented placental blood flow and oxygenation. Scott and Loudon” with equipment made of disposable polythene tubing, modified the suit so that it extended from the axilla to above the knees. Negative pressures of 20 to 40 mm. Hg were applied to patients with ruptured membranes and 2 to 6 cm. dilatation. No oxytocin was employed. Pain relief was immediate. In fact, patients were no longer aware of the onset of contractions. No definite conclusions were reached, but the impression was that labor was significantly shortened. Quinn and McKeown5 used the original plastic suit of Heyns, but found that it caused pressure on the chest, prevented routine examinations, caused fluid to collect under the plastic, and immobilized the extremities. They fashioned a new suit extending from the axilla to the thigh. This was later simplified to a flexible steel mesh and plastic dome edged with foam rubber. With this apparatus, they concluded that
the Brookdale Hosgital, Brooklyn, York, and New York Hospital, York, New York.
Presented at the Brooklyn Gynecological Society, May,
1965.
421
422
Shulman
and
Birnbaum
Am.
evaluation of decompression was difficult, since it was not known how a given patient would have behaved in its absence. Their impression, however, was that labor was accelerated and pain lessened. Of 162 patients, there were 20 excluded as “failures.” Of the remainder, excellent relief of pain was achieved in 83 per cent of the primiparas and 88 per cent of the multiparas. The length of labor was substantially reduced in both groups. Faced with these optimistic reports, this study was designed to evaluate abdominal decompression during the first stage of labor employing a compact, easily applied apparatus.* The equipment consisted of a pump, flexible hose, and a transparent plastic shell with padded edges. The shell covered only the patient’s abdomen. Its edges were fitted ‘Emerson
Birtheez
June 1, 1966 J. Obst. & Gynec.
with plastic sheets that wrapped around the flanks, achieving an air-tight fit. The patient controlled the application of decompression by a hand switch. Twenty-five cases were picked at random from our delivery unit, 14 were multiparas. There were 12 ward and 13 private patients. Approximately half of our patients received oxytocin, which was not employed in earlier studies. Once labor was well established, the apparatus was applied after a brief explanation of the theory and technique of operation. The negative pressure was adjusted to the point that would relieve pain without causing undue pressure on the rib cage or symphysis pubis. Pain was evaluated objectively by the physician, and subjectively by the patient before application, using a 0 to 4+ scale. Following application, the patient was asked to alter-
Decompressor.
Table I _Before
After
application*
Objective
Objective
Subjective
application* I
Subjective
Primiparas +++ +++
C. M. F. B.
++t+
E. G.
if +++
tit t++
t+ i&f
+t+
-tit
ff-i t t++ tt +i +
P. A. J. M.
G. G. K. H.
tt ttt it+ t+
it-!ttt ttt ++
+ +++ ++ tt
B. s. c. M.
S. L. L. F.
it+ t++
++t ttt
+++
+
t
-t+t
it
+ ++ + ++ tt +t t+ t++ tt ttt ++ tt t+ ++
++ +t +t it+ tit t+ +t+ ++ ++ ++t t+ tt +t+ tt
tt
f ++ +
+ tt+ +
Multiparas
____
A. W. M. 0. D. D. R. MC. L. B. A. F. J. M. M. L. c. w. D. B. A. B. M. D. M. J. J. R.
*++tt-Very
severe
pain,
+tt--severe
pain,
+-moderate
pain,
tmild
+ if + + ttt +t t++ ++ 0 ttt + + +++ ++ pain,
and
O-none.
t Ai c f ++t ++ t +iti + t+t + tt +t+ t+
-
Volume Number
95 3
Abdominal
nate contractions with and without decompression. Relief was then evaluated objectively and subjectively as to whether the pain following decompression was unchanged, slightly improved, moderately improved, completely relieved, or worse than before. The patient was then allowed to keep the apparatus on for varying lengths of time, ranging from 10 minutes to 5 hours. The pains were then re-evaluated by the doctor and patient (using the 0 to pt scale) while the apparatus was in use. Negative pressure ranged from 25 to 70 mm. Hg. Upon removal of the apparatus the patient was asked whether she would request this form of pain relief again. Any comments made by the patient were recorded. The apparatus was kept in place (except for fetal heart observations) until the patient was ready for delivery, requested removal,
,
decompression
in labor
or the physician was able to make decision as to its effectiveness.
423
a definite
Results Our results are tabulated in Table I. Note that none of our 11 primiparas had complete relief of pain, and only 2 would have requested this form of analgesia again. Both of these patients were private patients of one of the authors (S. J. B.). One of these patients had training in “natural childbirth,” and used the apparatus for 4 hours with moderate objective and subjective relief of pain. She progressed from 5 cm. to 9 cm. dilation during this period, but eventually required 100 mg. Demerol and 0.4 scopolamine. The other patient used mg. the apparatus early in labor for only s/4 of an hour. Of the remaining 9 primiparas, only one
Consecutive Objective Worse Equal
pain
Moderate
improvement
contractions Subjective
I Equal Worse
pain
Equal
pain
Slight improvement Equal pain Moderate improvement Slight improvement
Slight improvement Moderate improvement Moderate improvement Moderate improvement
Moderate Moderate Moderate Moderate
improvement improvement improvement improvement
Slight Slight Moderate Moderate Slight Equal Equal Moderate Complete Equal Moderate Moderate Slight Moderate
Slight Slight Moderate Slight Slight Equal Equal Slight Complete Equal Moderate Moderate Equal Moderate
improvement improvement improvement improvement improvement pain pain improvement relief pain improvement improvement pain improvement
pain
improvement improvement improvement improvement
and
reuse
No No,
Slight improvement Equal pain Moderate improvement Equal pain
improvement improvement improvement improvement improvement pain pain improvement relief
Comments
shell could not be placed in position that would cause pain No, had moderate improvement early in labor, but when active labor began Yes, used early in labor No, patient not fully cooperative No, bothered by machine; did not want to push button No, originally slight improvement, later patient believed chine gave pain No, patient seemed improved but denied relief Yes No No
Undecided, difficulty in finding good position for dome Undecided, rapid labor Yes Undecided No, slight improvement coincidental with Demerol No No, pain over lower chest cage Undecided Yes, first complaint pain at full dilatation No, patient in active labor and no relief from pain No, pressure from inferior border of dome Yes No No, pain is less but pressure from machine is uncomfortable
not none
ma-
424
Shulman
and
June 1, 1%6 Am. J. Obst. & Cynec.
Birnbaum
had significant objective relief of pain after decompression (a difference of at least 2t on the pain scale). Subjectively, one reported pains significantly worsened. It is of interest that results differed when the patients were asked to evaluate successive single contractions. Here again, no patient achieved complete relief, and 5 patients noted no change or an increase in pain intensity. The remainder had slight or moderate relief. Three patients were bothered by pressure from the shell or did not want to bother pushing the switch. The duration of labor ranged from 5% hours to 18 hours with an average of 9% hours. Seven of the 11 primiparas received oxytocic drugs. The change in cervical dilation during decompression ranged from 1 to 4 or 5 cm. Of the 14 multiparas, only 3 would request this method of analgesia in the future, although 4 more were undecided. Only one patient had significant and objectively complete relief in this group. This patient was again a private patient of one of the authors (S. J. B.). She had some “natural childbirth” training. She employed decompression for 11/1 hours and first complained of pain when fully dilated. A second patient had good subjective relief during If/2 hours of use, but was undecided about using this technique in the future. When evaluating consecutive contractions, 4 multiparas noted no change, one had complete relief, and 9 reported mild or moderate relief. While 7 patients would not request decompression again, 2 showed moderate improvement either subjectively or objectively. The 4 undecided patients showed either slight or moderate improvement. Thus 6 dissatisfied patients still had some relief from the decompression. Four multiparas were bothered by the bubble. Their reasons for dissatisfaction were similar to the primiparous group. The duration of labor averaged 6.5 hours, with two labors 4 hours or less. Four patients received oxytocin. The change in cervical dilation during
application ranged from 2 to 6 cm. There was one case of prolapsed cord during decompression, but this could not be related to the apparatus. There was no other abnormality of labor or delivery, and the newborn infants were in no way affected by the decompression. Comment Of our 25 patients, only 5 (20 per cent) were satisfied enough with abdominal decompression to request it again. Furthermore, 2 of these were patients with training childbirth,” who might have in “natural done well with any regimen. In the combined group there were only 5 patients (20 per cent) who had significant (more than 2+ change) objective or subjective relief of discomfort. On the other hand, 7 patients not only were unrelieved, but were bothered by the pressure of the bubble rim. Six patients received no analgesic medication during labor. In only 2 of these could pain relief be attributable to the apparatus. It was because of these poor initial results that we suspended our study after 25 cases. It was our impression that there was little or no effect on the duration of labor. There were no ill effects noted in the fetus. The one serious obstetrical complication (prolapsed cord) did not appear to be related to the procedure, since this patient used the apparatus for only f/2 hour and requested its removal because of rim pressure. Summary 1. Twenty-five patients in active labor were selected at random and subjected to intermittent abdominal decompression during the first stage of labor. 2. Only 5 (20 per cent) patients were satisfied enough with the relief obtained to request this procedure again. Upon subjective and objective evaluation using a pain scale of 0 to 4+, only 5 patients had a significant (at least a 2+ difference) relief during contractions. Thus, abdominal decompression does not appear to be an adequate technique of analgesia in our obstetric patients.
Volume Number
95 3
Abdominal
decompression
in labor
425
REFERENCES
1. 2. 3. 4.
Heyns, 0. S.: M. Proc. South Africa 5: 121, 1959. Heyns, 0. S.: J. Obst. & Gynaec. Brit. Emp. 66: 220, 1959. Heyns, 0. S.: Lancet 2: 91, 1959. Heyns, 0. S.: Develop. Med. Child. & Neurol. 4: 473, 1962.
5. 6.
Quinn,
L.
L.,
OBST.
& GYNEC.
Scott, 1181,
D. B., 1960.
Linden Brooklyn,
and McKeown, R. A.: AX 83: 458, 1962. and Loudon, J. D.: Lancet
Boulevard and Rockaway New York 11212
Parkway
J. 1: