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Neonatal pain assessment practices in the maternity ward (delivery room and postpartum ward): We can improve!
G Model
ARCPED-4659; No. of Pages 4 Archives de Pe´diatrie xxx (2018) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Research paper
Neonatal pain assessment practices in the maternity ward (delivery room and postpartum ward): We can improve! L. Calamy a,*, E. Walter-Nicolet b a b
Emergency department, hoˆpital Robert-Debre´, Assistance publique–Hoˆpitaux de Paris, 48, boulevard Se´rurier, 75019 Paris, France Department of neonatology, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 February 2018 Accepted 23 September 2018 Available online xxx
Background: Almost 20% of neonates experience pain during delivery or the period following birth. Aim: To describe the practices of pain assessment in the maternity wards in the greater Paris area, France. Methods: An e-mail questionnaire was sent to each practitioner in the 96 maternity units in ˆIle de France between December 2013 and February 2014. Results: In all, 63 (65%) questionnaires were completed. Pain was assessed in 43 (68%) maternity units, mostly using the French scale ‘‘e´chelle de douleur et d’inconfort du nouveau-ne´’’ (EDIN). In total, 20 maternity units (32%) reported no pain assessment, mainly because they considered it to be too timeconsuming, or because they argued that no pain scale was adequate; they relied on clinical signs or on the obstetric history for assessing and treating pain. About 40% of the maternity units using the EDIN scale judged it unsuitable for evaluating pain in term neonates in maternity units. Conclusion: This first regional study on pain assessment in the maternity ward showed that nearly two thirds of centers assessed pain. This rate may be overestimated because of the reporting method used. The EDIN scale is the most widely used tool but seems unsuitable especially for the delivery room setting. Studies should be conducted to test other tools for assessing neonatal pain in the delivery room.
C 2018 Published by Elsevier Masson SAS.
Keywords: Neonatal pain Evaluation Maternity
1. Introduction Newborns are exposed to pain in different settings. Even in the maternity ward, healthy neonates are exposed to pain for the first time. Studies have been published over the years raising concerns about the long-term consequences of pain during the neonatal period [1–4]. Epidemiological studies in neonatal intensive care units (NICU) have shown that pain is frequent, often undertreated and underevaluated [5–7]. In maternity hospitals (delivery room and postpartum ward), neonates are exposed to various painful situations. Some are inherent to birth and can lead to a pain state for several days (breech presentation, instrumental extraction, head or facial hematoma etc.) while others are procedure-induced and can occur both in the delivery room and in the postpartum ward. Procedure-induced pain is obvious and can be prevented and assessed with specific pain scales. However, aside from obvious situations of procedural pain, a neonatal pain state can be difficult to diagnose (because the symptoms are often paradoxical: * Corresponding author. E-mail address: L.Calamya*[email protected] (L. Calamy).
psychomotor inertia, prostration, immobility, feeding difficulties, absence of crying), especially in the maternity ward where newborns are supposed to be healthy. To our knowledge, to date no study has been published on the practices of pain assessment and treatment in the maternity setting. There are only few epidemiological studies of pain risk factors for newborns in maternity wards. According to the latest report of the French Health Ministry in 2016, there were 5% breech and 12% instrumental extractions, which were potential sources of pain [8]. In the United States in 2013, from all deliveries, there were 32.7% cesarean section deliveries and 3.3% operative vaginal deliveries (0.6% with forceps and 2.7% with vacuum devices) [9]. The detection and assessment of pain in all newborns are of clinical concern in order for adequate treatment to be offered. The aim of our study was to describe the practices of pain assessment in the maternity units of a highly populated French area. 2. Materials and methods An on-line 19-item questionnaire was sent by e-mail to one staff member among the heads of service, senior practitioners,
https://doi.org/10.1016/j.arcped.2018.09.001 C 2018 Published by Elsevier Masson SAS. 0929-693X/
Please cite this article in press as: Calamy L, Walter-Nicolet E. Neonatal pain assessment practices in the maternity ward (delivery room and postpartum ward): We can improve!. Archives de Pe´diatrie (2018), https://doi.org/10.1016/j.arcped.2018.09.001
G Model
ARCPED-4659; No. of Pages 4 L. Calamy, E. Walter-Nicolet / Archives de Pe´diatrie xxx (2018) xxx–xxx
2 Table 1 Items the questionnaire. Type of question General information
In your maternity, for a term neonate, is pain evaluated with a validated pain scale? (Choose only one answer): yes, according to a protocol (go to question 5)/Yes, with no protocol (go to question 5)/No (go to question 4) If you answer ‘‘no’’ to question83, why? (multiplechoice answer): clinical presentation and obstetrical history are enough/No validated pain scales fit for the newborn in the maternity unit/It is too time-consuming If you answer this question, then send the questionnaire directly without answering any other questions If your answer ‘‘yes’’ to question84: in your maternity unit, the caregivers assess pain (only one answer): in the delivery room (go to pages 2 and 4)/in the postpartum ward (go to pages 2 and 4)/both (go to pages 2, 3 and 4) When do the caregivers assess pain in the delivery Evaluation in the delivery room or the room/postpartum ward? (multiple-choice answer) postpartum ward Is this evaluation traced? (Only one answer to choose) If pain is diagnosed, what do you do (multiple-choice answer) Which pain scales do you use in the delivery room Pain scales used (open-end answer) Which pain scales do you use in the postpartum ward (open-end answer) Do you think they are appropriate (choose only one answer) If not, why? (multiple-choice answer)
nurses, or midwife managers, of all 96 maternity units in the ˆIle de France, e.g., Paris region (12.6 million inhabitants). The questionnaire was structured into three parts: general practices of pain evaluation and where it took place as well as details of the delivery room and/or the postpartum ward (Table 1). We considered that a reliable evaluation was based on a validated pain scale and not on a subjective impression of pain. The questionnaire was sent in December 2013 followed by five reminders, by e-mail or phone call, until February 2014. All of the 96 maternity units were asked to take part in the study, whatever their level of perinatal care. The answers were treated anonymously. Approval for the study was obtained from the local ethics and research committee. The data were entered and processed with Excel (2010 Microsoft Corporation).
3. Results The answer rate was 65.6% (63/96): 36 senior doctors answered the questionnaire (57%), 23 midwives (37%), and four head nurses (6%). There were 15 (35%) level-1 maternity units, 21 (44%) level-2, and 15 (21%) level-3 units, according to the national classification of maternity units. We did not receive answers to the questionnaire from 14, 17, and two level-1, level-2, and level-3 wards, respectively. 3.1. Pain assessment and treatment Out of the 63 maternity units, 20 (32%) reported that they did not perform any pain assessment with a pain scale (seven level-1, seven level-2, and six level-3), whereas 43 (68%) reported that they did assess pain (15 level-1, 21 level-2, and seven level-3). Among the 20 maternity wards that did not perform pain assessment, 12 (60%) relied on clinical impression and/or obstetric history for judging pain, six (30%) considered that no pain assessment tool
Fig. 1. Reasons for evaluation in maternity units (delivery room and postpartum ward).
Fig. 2. Circumstances of pain evaluation in maternity units (delivery room or postpartum ward).
was useful, and 15% that assessing pain in the maternity ward was too time-consuming. If pain assessment was performed (43 maternity units), it was done both in the delivery room and in the postpartum ward (91%), or only in the postpartum ward (9%). Pain was assessed mainly in the case of clinical situations where there was a risk of pain (in the delivery room: 82% of maternity units; in the postpartum ward: 87% of the maternity units) or during painful procedures (in the delivery room: 49% of maternity units; in the postpartum ward: 64% of maternity units). Clinical signs of pain such as whimpering or prostration were not systematically followed by pain assessment (Figs. 1 and 2). Pain assessment was based on a specific protocol in only 10% of the delivery rooms and in 21% of the postpartum wards. Of the 43 maternity units in which pain was assessed, there was a protocol for pain treatment in 32 of them (74%). In the case of pain, nonpharmaceutical management, such as swaddling, reduced noise level, or non-nutritive sucking, was given in 35 of 43 (81%) maternity units and pharmaceutical treatment (acetaminophen) was administered according to the pain score in 34 of 43 maternity units (79%). Two of the 43 maternity units administered acetaminophen systematically for 24–48 hours without any adjustment to the pain score. Traceability of pain assessment was done in 33 of the 43 maternity units (76.7%).
Please cite this article in press as: Calamy L, Walter-Nicolet E. Neonatal pain assessment practices in the maternity ward (delivery room and postpartum ward): We can improve!. Archives de Pe´diatrie (2018), https://doi.org/10.1016/j.arcped.2018.09.001
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ARCPED-4659; No. of Pages 4 L. Calamy, E. Walter-Nicolet / Archives de Pe´diatrie xxx (2018) xxx–xxx
3.2. Pain assessment tools When pain assessment was carried out, the EDIN [10] (e´chelle douleur et inconfort du nouveau-ne´) pain scale was the one most often used: it was reported by 85% of the delivery rooms and 78% of the postpartum wards, followed by the DAN scale [11] (douleur aigue¨ du nouveau-ne´), in 12% and 20%, respectively. One maternity unit used the EVENDOL scale (e´valuation enfant douleur), a pain scale validated in the emergency department for children from birth to 7 years old, for both acute and prolonged pain [12], and in prehospital care, especially in medical transport of premature or ill neonates [13]. These pain scales were considered to be useful and suitable for use in maternity wards by 60% of the maternity units (26/43), but 40% of them (17/43) reported that the scales were not useful. The reasons given by six maternity units (35%) were: too timeconsuming, difficult to complete in the delivery room or postpartum ward. For 10 maternity units (59%), these scales were considered as inappropriate for term neonates in maternity wards.
4. Discussion To our knowledge, this is the first study, conducted in a large French region, to report specifically on pain assessment practices in maternity wards. Our results show that pain assessment is not a systematic practice, as one third of the Paris area maternity units reported no pain assessment. In addition, we found that the EDIN pain scale is the most widely used, even if it is not always considered as the more suitable. Several studies have been conducted regarding the setting of the NICU, showing a wide variation of pain evaluation rates [5,6,14,15]. In a Brazilian study conducted in a third-level public hospital for high-risk pregnancies, pain assessment in the NICU was done always/frequently by 30.8% of doctors and 35.7% of nurses before any educational intervention [15]. In a Canadian pediatric teaching hospital, pain scores were documented in 55% of charts in the previous 24 h [14]. The Europain study showed that 58.5% of tracheal ventilated neonates, 45% of noninvasive ventilated neonates, and 30.4% of neonates on spontaneous ventilation received pain assessments [6]. In France, these rates were 90% and 87%, respectively, for the first two categories [6]. The choice of a pain scale is not easy in neonatology as there is no gold standard like the Visual Analogue Scale for adults and only a hetero-evaluation can be performed. The EDIN pain scale was primarily developed to assess prolonged continuous pain in preterm infants in NICUs and conventional neonatal units; this scale also assesses stress and discomfort. The DAN scale is validated only for painful procedures in neonates. The EDIN score reflects the presence of wellbeing or pain during observation of the newborn for several hours [10]. It was the tool most often used in maternity wards despite the fact that some difficulties have been highlighted during validation studies in maternity wards [16,17]. In the initial validation study of 76 preterm infants with a mean gestational age of 31.5 weeks, conducted in the NICU context, the internal consistency was 0.94 (alpha coefficient) [10]. A validation study for EDIN was conducted in the postpartum ward of a French maternity unit on 160 newborns between 4 and 12 hours of age [16]. The scores obtained in the presumed term group were significantly higher than those obtained in the presumed preterm group, supporting the construct validity of EDIN [16]. The inter-rater reliability was found to be good (kappa = 0.61 for the total score) but the internal consistency was found to be limited (alpha = 0.62). In the Debillon report, the authors recommend observing the baby for several hours [10], which is difficult to perform in the maternity wards, especially in
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the delivery room. In our study, 40% of the maternity units that used the EDIN score considered that this scale was not very useful, mainly because it was difficult to complete in the delivery room or the postpartum ward (35%) and/or was unsuitable for term neonates in the maternity wards (59%). Some items of the EDIN score, especially sleep and quality of relationship, need several hours of observation and some knowledge of the patient, which makes this scale difficult to use in the delivery room. It seems easier to employ the EDIN score in the postpartum ward, with the option of allowing time for a longer observation period and repeating the assessment. It is feasible that parents could be taught to use the EDIN score, but the emotional context of the birth would probably interfere with their assessment. The final validation should be made by a caregiver, and an initial elevated score should alert caregivers to change their attitude toward the neonate. The DAN scale, validated for procedural acute pain, should not be used for prolonged continuous pain [11]. Despite several assessment tools being available, it is still clear which is the best scale for assessing pain in neonates, especially in the delivery room. A tool such EVENDOL, which was initially designed and validated to assess pain in the context of pediatric emergency settings, for both acute or prolonged pain may be useful [12]. This tool has demonstrated its clinical utility from birth to 7 years of age, and in various neonatal situations. Beltramini’s study, which comprised 422 children including 150 newborns, showed that EVENDOL is a quick, easyto-use, and discriminant instrument for the assessment of pain [13]. A French multicentric study to assess the reliability of EVENDOL for term neonates in the maternity ward is currently underway. An obstacle for pain assessment in the delivery room can also be the lack of training of midwives and pediatricians in using pain scales, and the current habit of subjective judgment without using a relevant objective tool. In our study, the traceability of pain was correct when assessment was performed. This good rate is perhaps due to the reporting form of our study. The best way to determine the real rate would be a review of the medical files. Despite an apparently high pain assessment rate, a specific assessment protocol was available in only 10% of all maternity units, and pain was mostly assessed in cases of potential painful situations (breech presentation, instrumental extraction, head or face hematoma etc.). Pain treatment relied on a protocol in 74% of the ‘‘evaluating maternity wards’’ while the others relied on clinical signs only. Studies have shown that the implementation of a specific neonatal pain protocol increases pain treatment and pharmacologic interventions [15,18,19]. In maternity units, most neonates are healthy, but caregivers must be aware of painful situations for some newborns and attentive to unusual behavior. This study showed encouraging results regarding pain assessment in maternity units in the Paris region, even if it was much lower than in the French NICUs and still insufficient. Our study had several limitations as it was declarative: the assessment rates were probably overestimated. Only one person in each center answered the questionnaire and his or her response might not reflect the reality of the center. A study conducted on a ‘‘given day’’ or an observational study would better reflect the reality. Epidemiological studies on pain in maternity units, with the same systematic data collection as the EPIPPAIN study [7], have not been performed to date and may be useful.
5. Conclusion Pain must be assessed at least once a day for each patient in hospital, as stated in several public health codes and the French guidelines for hospitalized patients. A newborn becomes a patient as soon as he or she comes into the world, and their pain has to be
Please cite this article in press as: Calamy L, Walter-Nicolet E. Neonatal pain assessment practices in the maternity ward (delivery room and postpartum ward): We can improve!. Archives de Pe´diatrie (2018), https://doi.org/10.1016/j.arcped.2018.09.001
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ARCPED-4659; No. of Pages 4 L. Calamy, E. Walter-Nicolet / Archives de Pe´diatrie xxx (2018) xxx–xxx
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evaluated and treated. Progress in the quality of care is feasible and requires specific pain protocols in all units as well as specific training. There are much more babies in the maternity units than in NICUs and their pain also has to be considered. A more accurate scale should be developed or scales like the EVENDOL should be validated for neonates–but the currently available tools are useful and should be used. Disclosure of interest The authors declare that they have no competing interest. Acknowledgments The authors thank Elisabeth Fournier-Charrie`re (Pain evaluation and treatment department, Biceˆtre Hospital, Assistance publique-Hoˆpitaux de Paris) for her help and advice in the design of this study and in the writing of this article. References [1] Vinall J, Grunau RE. Impact of repeated procedural pain-related stress in infants born very preterm. Pediatr Res 2014;75:584–7. [2] Brummelte S, Grunau RE, Chau V, et al. Procedural pain and brain development in premature newborns. Ann Neurol 2012;71:385–96. [3] Taddio A, Shah V, Gilbert-MacLeod C, et al. Conditioning and hyperalgesia in newborns exposed to repeated heel lances. JAMA 2002;288:857–61. [4] Taddio A, Goldbach M, Ipp M, et al. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995;345:291–2. [5] Boyle EM, Courtois E, Eriksson M, et al. Pain assessment in ventilated and nonventilated neonates in NICUs across the UK: European pain audit in neonates (Europain). Arch Dis Child Fetal Neonatal Ed 2014;99 Suppl 1:A53.
[6] Carbajal R, Eriksson M, Courtois E, et al. Sedation and analgesia practices in neonatal intensive care units (EUROPAIN): results from a prospective cohort study. Lancet Respir Med 2015;3:796–812. [7] Carbajal R, Rousset A, Danan C, et al. Epidemiology and treatment of painful procedures in neonates in intensive care units. JAMA 2008;300:60–70. [8] Inserm DREES. Enqueˆte nationale pe´rinatale. Les naissances et les e´tablissements. Situation et e´volution depuis 2010; 2016, www.epope´-insermfr/ wp-content/uploads/2017/10/ENP2016_rapport_completpdf. [9] Martin JA, Hamilton B, Osterman MJ, et al. Births: final data for 2013. Natl Vital Stat Rep 2015;64:1–65. [10] Debillon T, Zupan V, Ravault N, et al. Development and initial validation of the EDIN scale, a new tool for assessing prolonged pain in preterm infants. Arch Dis Child Fetal Neonatal Ed 2001;85:F36–41. [11] Carbajal R, Paupe A, Hoenn E, et al. DAN: une e´chelle comportementale d’e´valuation de la douleur aigue du nouveau-ne´. Arch Pediatr 1997;4:623–8. [12] Fournier-Charriere E, Tourniaire B, Carbajal R, et al. EVENDOL, a new behavioral pain scale for children ages 0 to 7 years in the emergency department: design and validation. Pain 2012;153:1573–82. [13] Beltramini A, Galinski M, Chabernaud JL, et al. Pain assessment in children younger than 8 years in out-of-hospital emergency medicine: reliability and vlidity of EVENDOL Score. Pediatr Emerg Care 2016. http://dx.doi.org/10.1097/ PE.C.0000000000000953 [Epub ahead of print]. [14] Harrison D, Joly C, Chretien C, et al. Pain prevalence in a pediatric hospital: raising awareness during pain awareness wek. Pain Res Manag 2014;19:e24– 30. [15] Aymar CL, Lima LS, Santos CM, et al. Pain assessment and management in the NICU: analysis of an educational intervention for health professionals. J Pediatr (Rio J) 2014;90:308–15. [16] Bordin C, Leclaire M, Demeester A. L’e´chelle de douleur et d’inconfort du nouveau-ne´ (EDIN). E´tude de validite´ portant sur 160 nouveau-ne´s en maternite´ entre 4 et 12 heures de vie. Sage-Femme 2012;11:120–7. [17] Lassauge F, Gauvain-Picard A, Paris I. Validite´ de construit de l’e´chelle de douleur et d’inconfort du nouveau-ne´ (EDIN). Douleur Analgesie 1998;11:173–7. [18] Deindl P, Unterasinger L, Kappler G, et al. Successful implementation of a neonatal pain and sedation protocol at 2 NICUs. Pediatrics 2013;132:e211–8. [19] McKechnie, Levene M. Procedural pain guidelines for the newborn in the United Kingdom. J Perinatol 2008;28:107–11.
Please cite this article in press as: Calamy L, Walter-Nicolet E. Neonatal pain assessment practices in the maternity ward (delivery room and postpartum ward): We can improve!. Archives de Pe´diatrie (2018), https://doi.org/10.1016/j.arcped.2018.09.001
ARCPED-4659; No. of Pages 4 Archives de Pe´diatrie xxx (2018) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Research paper
Neonatal pain assessment practices in the maternity ward (delivery room and postpartum ward): We can improve! L. Calamy a,*, E. Walter-Nicolet b a b
Emergency department, hoˆpital Robert-Debre´, Assistance publique–Hoˆpitaux de Paris, 48, boulevard Se´rurier, 75019 Paris, France Department of neonatology, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 February 2018 Accepted 23 September 2018 Available online xxx
Background: Almost 20% of neonates experience pain during delivery or the period following birth. Aim: To describe the practices of pain assessment in the maternity wards in the greater Paris area, France. Methods: An e-mail questionnaire was sent to each practitioner in the 96 maternity units in ˆIle de France between December 2013 and February 2014. Results: In all, 63 (65%) questionnaires were completed. Pain was assessed in 43 (68%) maternity units, mostly using the French scale ‘‘e´chelle de douleur et d’inconfort du nouveau-ne´’’ (EDIN). In total, 20 maternity units (32%) reported no pain assessment, mainly because they considered it to be too timeconsuming, or because they argued that no pain scale was adequate; they relied on clinical signs or on the obstetric history for assessing and treating pain. About 40% of the maternity units using the EDIN scale judged it unsuitable for evaluating pain in term neonates in maternity units. Conclusion: This first regional study on pain assessment in the maternity ward showed that nearly two thirds of centers assessed pain. This rate may be overestimated because of the reporting method used. The EDIN scale is the most widely used tool but seems unsuitable especially for the delivery room setting. Studies should be conducted to test other tools for assessing neonatal pain in the delivery room.
C 2018 Published by Elsevier Masson SAS.
Keywords: Neonatal pain Evaluation Maternity
1. Introduction Newborns are exposed to pain in different settings. Even in the maternity ward, healthy neonates are exposed to pain for the first time. Studies have been published over the years raising concerns about the long-term consequences of pain during the neonatal period [1–4]. Epidemiological studies in neonatal intensive care units (NICU) have shown that pain is frequent, often undertreated and underevaluated [5–7]. In maternity hospitals (delivery room and postpartum ward), neonates are exposed to various painful situations. Some are inherent to birth and can lead to a pain state for several days (breech presentation, instrumental extraction, head or facial hematoma etc.) while others are procedure-induced and can occur both in the delivery room and in the postpartum ward. Procedure-induced pain is obvious and can be prevented and assessed with specific pain scales. However, aside from obvious situations of procedural pain, a neonatal pain state can be difficult to diagnose (because the symptoms are often paradoxical: * Corresponding author. E-mail address: L.Calamya*[email protected] (L. Calamy).
psychomotor inertia, prostration, immobility, feeding difficulties, absence of crying), especially in the maternity ward where newborns are supposed to be healthy. To our knowledge, to date no study has been published on the practices of pain assessment and treatment in the maternity setting. There are only few epidemiological studies of pain risk factors for newborns in maternity wards. According to the latest report of the French Health Ministry in 2016, there were 5% breech and 12% instrumental extractions, which were potential sources of pain [8]. In the United States in 2013, from all deliveries, there were 32.7% cesarean section deliveries and 3.3% operative vaginal deliveries (0.6% with forceps and 2.7% with vacuum devices) [9]. The detection and assessment of pain in all newborns are of clinical concern in order for adequate treatment to be offered. The aim of our study was to describe the practices of pain assessment in the maternity units of a highly populated French area. 2. Materials and methods An on-line 19-item questionnaire was sent by e-mail to one staff member among the heads of service, senior practitioners,
https://doi.org/10.1016/j.arcped.2018.09.001 C 2018 Published by Elsevier Masson SAS. 0929-693X/
Please cite this article in press as: Calamy L, Walter-Nicolet E. Neonatal pain assessment practices in the maternity ward (delivery room and postpartum ward): We can improve!. Archives de Pe´diatrie (2018), https://doi.org/10.1016/j.arcped.2018.09.001
G Model
ARCPED-4659; No. of Pages 4 L. Calamy, E. Walter-Nicolet / Archives de Pe´diatrie xxx (2018) xxx–xxx
2 Table 1 Items the questionnaire. Type of question General information
In your maternity, for a term neonate, is pain evaluated with a validated pain scale? (Choose only one answer): yes, according to a protocol (go to question 5)/Yes, with no protocol (go to question 5)/No (go to question 4) If you answer ‘‘no’’ to question83, why? (multiplechoice answer): clinical presentation and obstetrical history are enough/No validated pain scales fit for the newborn in the maternity unit/It is too time-consuming If you answer this question, then send the questionnaire directly without answering any other questions If your answer ‘‘yes’’ to question84: in your maternity unit, the caregivers assess pain (only one answer): in the delivery room (go to pages 2 and 4)/in the postpartum ward (go to pages 2 and 4)/both (go to pages 2, 3 and 4) When do the caregivers assess pain in the delivery Evaluation in the delivery room or the room/postpartum ward? (multiple-choice answer) postpartum ward Is this evaluation traced? (Only one answer to choose) If pain is diagnosed, what do you do (multiple-choice answer) Which pain scales do you use in the delivery room Pain scales used (open-end answer) Which pain scales do you use in the postpartum ward (open-end answer) Do you think they are appropriate (choose only one answer) If not, why? (multiple-choice answer)
nurses, or midwife managers, of all 96 maternity units in the ˆIle de France, e.g., Paris region (12.6 million inhabitants). The questionnaire was structured into three parts: general practices of pain evaluation and where it took place as well as details of the delivery room and/or the postpartum ward (Table 1). We considered that a reliable evaluation was based on a validated pain scale and not on a subjective impression of pain. The questionnaire was sent in December 2013 followed by five reminders, by e-mail or phone call, until February 2014. All of the 96 maternity units were asked to take part in the study, whatever their level of perinatal care. The answers were treated anonymously. Approval for the study was obtained from the local ethics and research committee. The data were entered and processed with Excel (2010 Microsoft Corporation).
3. Results The answer rate was 65.6% (63/96): 36 senior doctors answered the questionnaire (57%), 23 midwives (37%), and four head nurses (6%). There were 15 (35%) level-1 maternity units, 21 (44%) level-2, and 15 (21%) level-3 units, according to the national classification of maternity units. We did not receive answers to the questionnaire from 14, 17, and two level-1, level-2, and level-3 wards, respectively. 3.1. Pain assessment and treatment Out of the 63 maternity units, 20 (32%) reported that they did not perform any pain assessment with a pain scale (seven level-1, seven level-2, and six level-3), whereas 43 (68%) reported that they did assess pain (15 level-1, 21 level-2, and seven level-3). Among the 20 maternity wards that did not perform pain assessment, 12 (60%) relied on clinical impression and/or obstetric history for judging pain, six (30%) considered that no pain assessment tool
Fig. 1. Reasons for evaluation in maternity units (delivery room and postpartum ward).
Fig. 2. Circumstances of pain evaluation in maternity units (delivery room or postpartum ward).
was useful, and 15% that assessing pain in the maternity ward was too time-consuming. If pain assessment was performed (43 maternity units), it was done both in the delivery room and in the postpartum ward (91%), or only in the postpartum ward (9%). Pain was assessed mainly in the case of clinical situations where there was a risk of pain (in the delivery room: 82% of maternity units; in the postpartum ward: 87% of the maternity units) or during painful procedures (in the delivery room: 49% of maternity units; in the postpartum ward: 64% of maternity units). Clinical signs of pain such as whimpering or prostration were not systematically followed by pain assessment (Figs. 1 and 2). Pain assessment was based on a specific protocol in only 10% of the delivery rooms and in 21% of the postpartum wards. Of the 43 maternity units in which pain was assessed, there was a protocol for pain treatment in 32 of them (74%). In the case of pain, nonpharmaceutical management, such as swaddling, reduced noise level, or non-nutritive sucking, was given in 35 of 43 (81%) maternity units and pharmaceutical treatment (acetaminophen) was administered according to the pain score in 34 of 43 maternity units (79%). Two of the 43 maternity units administered acetaminophen systematically for 24–48 hours without any adjustment to the pain score. Traceability of pain assessment was done in 33 of the 43 maternity units (76.7%).
Please cite this article in press as: Calamy L, Walter-Nicolet E. Neonatal pain assessment practices in the maternity ward (delivery room and postpartum ward): We can improve!. Archives de Pe´diatrie (2018), https://doi.org/10.1016/j.arcped.2018.09.001
G Model
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3.2. Pain assessment tools When pain assessment was carried out, the EDIN [10] (e´chelle douleur et inconfort du nouveau-ne´) pain scale was the one most often used: it was reported by 85% of the delivery rooms and 78% of the postpartum wards, followed by the DAN scale [11] (douleur aigue¨ du nouveau-ne´), in 12% and 20%, respectively. One maternity unit used the EVENDOL scale (e´valuation enfant douleur), a pain scale validated in the emergency department for children from birth to 7 years old, for both acute and prolonged pain [12], and in prehospital care, especially in medical transport of premature or ill neonates [13]. These pain scales were considered to be useful and suitable for use in maternity wards by 60% of the maternity units (26/43), but 40% of them (17/43) reported that the scales were not useful. The reasons given by six maternity units (35%) were: too timeconsuming, difficult to complete in the delivery room or postpartum ward. For 10 maternity units (59%), these scales were considered as inappropriate for term neonates in maternity wards.
4. Discussion To our knowledge, this is the first study, conducted in a large French region, to report specifically on pain assessment practices in maternity wards. Our results show that pain assessment is not a systematic practice, as one third of the Paris area maternity units reported no pain assessment. In addition, we found that the EDIN pain scale is the most widely used, even if it is not always considered as the more suitable. Several studies have been conducted regarding the setting of the NICU, showing a wide variation of pain evaluation rates [5,6,14,15]. In a Brazilian study conducted in a third-level public hospital for high-risk pregnancies, pain assessment in the NICU was done always/frequently by 30.8% of doctors and 35.7% of nurses before any educational intervention [15]. In a Canadian pediatric teaching hospital, pain scores were documented in 55% of charts in the previous 24 h [14]. The Europain study showed that 58.5% of tracheal ventilated neonates, 45% of noninvasive ventilated neonates, and 30.4% of neonates on spontaneous ventilation received pain assessments [6]. In France, these rates were 90% and 87%, respectively, for the first two categories [6]. The choice of a pain scale is not easy in neonatology as there is no gold standard like the Visual Analogue Scale for adults and only a hetero-evaluation can be performed. The EDIN pain scale was primarily developed to assess prolonged continuous pain in preterm infants in NICUs and conventional neonatal units; this scale also assesses stress and discomfort. The DAN scale is validated only for painful procedures in neonates. The EDIN score reflects the presence of wellbeing or pain during observation of the newborn for several hours [10]. It was the tool most often used in maternity wards despite the fact that some difficulties have been highlighted during validation studies in maternity wards [16,17]. In the initial validation study of 76 preterm infants with a mean gestational age of 31.5 weeks, conducted in the NICU context, the internal consistency was 0.94 (alpha coefficient) [10]. A validation study for EDIN was conducted in the postpartum ward of a French maternity unit on 160 newborns between 4 and 12 hours of age [16]. The scores obtained in the presumed term group were significantly higher than those obtained in the presumed preterm group, supporting the construct validity of EDIN [16]. The inter-rater reliability was found to be good (kappa = 0.61 for the total score) but the internal consistency was found to be limited (alpha = 0.62). In the Debillon report, the authors recommend observing the baby for several hours [10], which is difficult to perform in the maternity wards, especially in
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the delivery room. In our study, 40% of the maternity units that used the EDIN score considered that this scale was not very useful, mainly because it was difficult to complete in the delivery room or the postpartum ward (35%) and/or was unsuitable for term neonates in the maternity wards (59%). Some items of the EDIN score, especially sleep and quality of relationship, need several hours of observation and some knowledge of the patient, which makes this scale difficult to use in the delivery room. It seems easier to employ the EDIN score in the postpartum ward, with the option of allowing time for a longer observation period and repeating the assessment. It is feasible that parents could be taught to use the EDIN score, but the emotional context of the birth would probably interfere with their assessment. The final validation should be made by a caregiver, and an initial elevated score should alert caregivers to change their attitude toward the neonate. The DAN scale, validated for procedural acute pain, should not be used for prolonged continuous pain [11]. Despite several assessment tools being available, it is still clear which is the best scale for assessing pain in neonates, especially in the delivery room. A tool such EVENDOL, which was initially designed and validated to assess pain in the context of pediatric emergency settings, for both acute or prolonged pain may be useful [12]. This tool has demonstrated its clinical utility from birth to 7 years of age, and in various neonatal situations. Beltramini’s study, which comprised 422 children including 150 newborns, showed that EVENDOL is a quick, easyto-use, and discriminant instrument for the assessment of pain [13]. A French multicentric study to assess the reliability of EVENDOL for term neonates in the maternity ward is currently underway. An obstacle for pain assessment in the delivery room can also be the lack of training of midwives and pediatricians in using pain scales, and the current habit of subjective judgment without using a relevant objective tool. In our study, the traceability of pain was correct when assessment was performed. This good rate is perhaps due to the reporting form of our study. The best way to determine the real rate would be a review of the medical files. Despite an apparently high pain assessment rate, a specific assessment protocol was available in only 10% of all maternity units, and pain was mostly assessed in cases of potential painful situations (breech presentation, instrumental extraction, head or face hematoma etc.). Pain treatment relied on a protocol in 74% of the ‘‘evaluating maternity wards’’ while the others relied on clinical signs only. Studies have shown that the implementation of a specific neonatal pain protocol increases pain treatment and pharmacologic interventions [15,18,19]. In maternity units, most neonates are healthy, but caregivers must be aware of painful situations for some newborns and attentive to unusual behavior. This study showed encouraging results regarding pain assessment in maternity units in the Paris region, even if it was much lower than in the French NICUs and still insufficient. Our study had several limitations as it was declarative: the assessment rates were probably overestimated. Only one person in each center answered the questionnaire and his or her response might not reflect the reality of the center. A study conducted on a ‘‘given day’’ or an observational study would better reflect the reality. Epidemiological studies on pain in maternity units, with the same systematic data collection as the EPIPPAIN study [7], have not been performed to date and may be useful.
5. Conclusion Pain must be assessed at least once a day for each patient in hospital, as stated in several public health codes and the French guidelines for hospitalized patients. A newborn becomes a patient as soon as he or she comes into the world, and their pain has to be
Please cite this article in press as: Calamy L, Walter-Nicolet E. Neonatal pain assessment practices in the maternity ward (delivery room and postpartum ward): We can improve!. Archives de Pe´diatrie (2018), https://doi.org/10.1016/j.arcped.2018.09.001
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evaluated and treated. Progress in the quality of care is feasible and requires specific pain protocols in all units as well as specific training. There are much more babies in the maternity units than in NICUs and their pain also has to be considered. A more accurate scale should be developed or scales like the EVENDOL should be validated for neonates–but the currently available tools are useful and should be used. Disclosure of interest The authors declare that they have no competing interest. Acknowledgments The authors thank Elisabeth Fournier-Charrie`re (Pain evaluation and treatment department, Biceˆtre Hospital, Assistance publique-Hoˆpitaux de Paris) for her help and advice in the design of this study and in the writing of this article. References [1] Vinall J, Grunau RE. Impact of repeated procedural pain-related stress in infants born very preterm. Pediatr Res 2014;75:584–7. [2] Brummelte S, Grunau RE, Chau V, et al. Procedural pain and brain development in premature newborns. Ann Neurol 2012;71:385–96. [3] Taddio A, Shah V, Gilbert-MacLeod C, et al. Conditioning and hyperalgesia in newborns exposed to repeated heel lances. JAMA 2002;288:857–61. [4] Taddio A, Goldbach M, Ipp M, et al. Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995;345:291–2. [5] Boyle EM, Courtois E, Eriksson M, et al. Pain assessment in ventilated and nonventilated neonates in NICUs across the UK: European pain audit in neonates (Europain). Arch Dis Child Fetal Neonatal Ed 2014;99 Suppl 1:A53.
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Please cite this article in press as: Calamy L, Walter-Nicolet E. Neonatal pain assessment practices in the maternity ward (delivery room and postpartum ward): We can improve!. Archives de Pe´diatrie (2018), https://doi.org/10.1016/j.arcped.2018.09.001