The measurement of pain during the first stage of labour

Transcription

1 University of Pretoria The measurement of pain during the first stage of labour Dr Mariatha Yazbek

2 Labour may impose severe pain during the first stage of labour and is experienced differently by women

3 Harmful effects of unrelieved pain to the patient and foetus in labour DOMAINS AFFECTED Endocrine Metabolic Cardiovascular SPECIFIC RESPONSES TO PAIN Adrenocorticotrophic hormone (ACTH), cortisol, antidiuretic hormone (ADH), epinephrine, norepinephrine, growth hormone (GH), catecholamines, renin, angiotensin II, aldosterone, glucagon, interleukin-1; insulin, testosterone Gluconeogenesis, hepatic glycogenolysis, hyperglycemia, glucose intolerance, insulien resistance, muscle protein catabolism, lipolysis Heart rate, cardiac output, peripheral vascular resistance, systemic vascular resistance, hypertension, coronary vascular resistance, myocardial oxygen consumption, hypercoagulation, deep vein thrombosis Respiratory Genitourinary Tidal volume and minute ventilation, alkalosis, hypoxemia Urinary output, urinary retention, fluid overload, hypokalemia, sodium bicarbonate Gastrointestinal Musculoskeletal Cognitive Immune Uterus Foetal implications Developmental Gastric and bowel movement, gastric acid secretion, carbohydrate intake (restricted dietary intake in labour) Muscle spasm, impaired muscle function, fatigue, immobility Reduction in cognitive function, mental confusion Depression of immune response Increase or decrease in uterine contractility, vasoconstriction, uterine blood flow, prolonged labour Oxygen, metabolic acidosis, late decelerations, foetal distress Behavioural and physiologic responses to pain, altered temperaments, altered development of the pain system, vulnerability to stress disorders, addictive behaviour, anxiety states Future pain Fear of future pain during pregnancy and labour

4 Barriers to labour pain assessment Within the healthcare system (disciplines) Healthcare professionals (under-, overestimate) Patient Legal/societal/cultural

5 Background There was a lady in labor, but the nurse told her she was pretending. She called the nurse and said, I am in pain, but the nurse shouted at her to be quiet, saying, When you were making the baby you enjoyed, so don t come and scream here. She told her to keep walking so that the baby could come quickly. The baby nearly fell while she was walking. The nurse again shouted at her telling her she wanted to kill her baby. Quality of care in South African Maternity services (Human Rights Watch 2011)

6 Pain assessment instruments Verbal Rating Scales (VRS) Numerical Rating Scale (NRS) Visual Analogue Scale (VAS) Wong-Baker FACES Pain Rating Scale Behavioural Scale McGill Pain Questionnaire (MPQ) The Coping With Labor Algorithm

7 Aim Develop a multidimensional labour pain assessment instrument that is valid and reliable structured; used by midwives and clinicians; not time consuming; comprehensive; specifically aimed at assessing pain during the first stage of labour; serve as a basis in assisting diagnosis of pain during labour; a data base against which pain relief can be measured; a basis for further referral and assessment.

8 Objectives Exploring the history of labour pain assessment and measurement. Exploring labour pain and the processes of labour. Exploring the barriers that may prevent labour pain from being assessed and relieved. Exploring the use of existing pain measurement instruments. Applying existing pain instruments to the woman in labour. Exploring the dimensions of pain. Developing a new instrument to allow: midwives and clinicians to recognise when labouring women need pain relief women to experience pain during labour without severe suffering

9 Research methods Mixed methods research Steps of instrument development (Blackburn & Waite) 1. Item generation 2. Item selection 3. Item description 4. Pilot testing 5. Analysis for reliability and validity 6. Refinement of the instrument 7. Testing Ethical consideration

10 Schematic presentation of the course of the research PHASE 1 INSTRUMENT DEVELOPMENT REFINEMENT OF THE LABOUR PAIN ASSESSMENT INSTRUMENT QUALITATIVE FOCUS GROUPS DATA ANALYSIS QUALITATIVE DELPHI TECHNIQUE First questionnaire DATA ANALYSIS COMPARISON OF FOCUS GROUPS AND FIRST DELPHI TECHNIQUE QUESTIONNAIRE INSTRUMENT ALTERATION QUALITATIVE DELPHI TECHNIQUE Second questionnaire PHASE 2 TESTING OF INSTRUMENT QUANTITATIVE ANALYSIS Testing of instrument Midwife questionnaire MIDWIFE QUESTIONNAIRE QUALITATIVE ANALYSIS Midwife questionnaire COMPARISON OF QUALITATIVE SECOND DELPHI TECHNIQUE AND MIDWIFE QUESTIONNAIRE PHASE 3 FINAL INSTRUMENT DEVELOPMENT OF IMPLEMENTATION GUIDELINES

11 Phase 1: Instrument development and refinement Item generation Delineation of the content area Identification of the various dimensions of the measurement content areas Item selection Intensity Quality Behaviours/Physiological parameters Fatigue threshold Psychosocial/Emotional status Item description

12 Labour pain assessment tool Hospital: Private / Provincial Ethnicity: White / Black or coloured / Asian or Indian Social background: High income / Middle income / Lower income Support: None / Husband or partner / Midwife or doula / Other Age: Gravity: Parity: Onset of labour: h Suggested time of assessment: - Admission - 3-4cm cervical dilatation - 7-8cm cervical dilatation - Before and 1 hour after administration of pain medication - Any other time when in suspected severe pain Time Cervical dilatation Method of pain relief Length of labour Score Intensity Quality Aching Miserable Discomforting Tender Annoying Sore Hurting Tiring Agonising Intense Exhausting Horrible Unbearable Excruciating Overwhelming Behaviour Physiological parameters Happiness Excitement Relaxation Muscular tension Restlessness Rising Anxiety Crying out Nausea / vomiting Uncontrolled anxiety Amnesia Fatigue Threshold Normal activity Normal eating Normal voice Active / Tired Liquid intake Little talking Fatigue / Sleepiness No eating / drinking Irritability Confused Psychosocial Emotional status Good support Interact normal Anticipation Some fear Rely on support More focussed Frustrated Fear to be alone Little / no support Interact difficult Discouraged Horror when alone Patient rating no pain: :unbearable

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14 Stage 1: Focus group interviews Population Lecturers in Midwifery Midwives representing the private and provincial hospital sectors Midwives in private practice Clinicians (obstetricians) representing the private and provincial sectors Sample Obtained a qualification in midwifery or obstetric Worked/lectured in Midwifery or Obstetrics two years prior to participation

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16 Stage 2: Delphi Technique Two rounds of open-ended questionnaires Population and sample Most senior persons teaching Midwifery at all South African universities Data Collection First questionnaire original labour pain assessment instrument Second questionnaire evaluate face and content validity of altered instrument/confirm changes

17 Altered Labour pain assessment instrument Give a rating of 0, 1 or 2 for each Midwife rating that describes your patient s labour pain best before the patient rates her own pain. Suggested time of assessment: Date 12/8/ /8/ Admission Time - Assessment of the progress of labour - Before administration of pain relief - One hour after administration of pain relief Cervical dilatation - Method of pain relief -Any other time when in suspected severe pain Method of pain relief Length of active labour 15h00 4cm Walking Shower 19h00 8cm Pethidine Atarax 1 hour 5 hours Midwife rating Intensity of pain 0 2 Quality of pain Behaviours / Physiological Parameters Fatigue Threshold Psychosocial / Emotional status Aching Miserable Discomforting Tender Annoying Happiness Excitement Relaxation Normal activity Normal eating Normal voice Normal breathing Support sufficient Interact normal Anticipation Some fear Sore Hurting Tiring Agonising Intense Muscular tension Restlessness Rising Anxiety Active/Tired Liquid intake Little talking Rapid breathing Rely on support More focussed Frustrated Fear for unknown Exhausting Horrible Unbearable Excruciating Overwhelming Crying out Nausea/vomiting Uncontrolled anxiety Fatigue/Sleepiness No eating/drinking Irritability Uncontrolled breathing Support not effective Interact difficult Discouraged Fear to be alone Total midwife rating 3/10 8/10 /10 /10 Patient rating no pain: :unbearable 4/10 9/10 /10 /10

18 A schematic presentation of the course of the research PHASE 1 INSTRUMENT DEVELOPMENT REFINEMENT OF THE LABOUR PAIN ASSESSMENT INSTRUMENT QUALITATIVE FOCUS GROUPS DATA ANALYSIS QUALITATIVE DELPHI TECHNIQUE First questionnaire DATA ANALYSIS COMPARISON OF FOCUS GROUPS AND FIRST DELPHI TECHNIQUE QUESTIONNAIRE INSTRUMENT ALTERATION QUALITATIVE DELPHI TECHNIQUE Second questionnaire PHASE 2 TESTING OF INSTRUMENT QUANTITATIVE ANALYSIS Testing of instrument Midwife questionnaire MIDWIFE QUESTIONNAIRE QUALITATIVE ANALYSIS Midwife questionnaire COMPARISON OF QUALITATIVE SECOND DELPHI TECHNIQUE AND MIDWIFE QUESTIONNAIRE PHASE 3 FINAL INSTRUMENT DEVELOPMENT OF IMPLEMENTATION GUIDELINES

19 Phase 2 : Testing of the final instrument Population Two provincial and four private hospitals in Gauteng Patients expected to have a normal vaginal delivery/trial of labour Sample Purposive sample Labour pain is a fairly homogenous experience within the population of women who deliver a baby Permission from hospitals in writing Patients in the active phase of labour fortuitously chosen Sample size of patients from each sector

20 Inclusion criteria All patients where an uncomplicated labour was expected and were experiencing pain Patients had to undergo a part of or the entire active stage of labour Exclusion criteria Patients receiving an epidural Medical complications e.g., pre-eclampsia, cardio respiratory disease, diabetes Antepartum haemorrhage Maternal pyrexia Abnormal lie or presentation Preterm labour (< 36 completed weeks) Postterm ( > 42 completed weeks) Meconium stained liquor Foetal distress Prolonged rupture of membranes (> 24 hours) Multiple pregnancy Cervical dilatation of 8 to10 cm (patients in the transitional phase of labour are about to deliver and do not qualify for pain relief)

21 Cervical dilatation and pain scores cm Mean cervical dilatation First pain assessment n = 41 Second pain assessment n = 40 Third pain assessment n = 16 Method of pain relief and type of hospital PAIN RELIEF METHOD PRIVATE PATIENTS 100% PROVINCIAL PATIENTS 100% No pain relief 11 44% Nondrug Massage Walking Breathing 1 1 5% 5% 3 12% Water 4 20% Anaesthesia Entonox Buscopan Pethidine and Aterax % 5% 40% 11 44% Regional techniques Epidural 4 20% TOTAL n = % n = %

22 Mean length of active labour Hours First assessment n = 19 Second assessment n = 32 Third assessment n = 13 Mean length of active labour in private and provincial hospitals 8 Hours (n = 10) 2.33 (n = 9) 5.61 (n = 18) 2.64 (n = 4) 4.5 (n = 6) 3.86 (n = 7) Private hospitals Provincial hospitals First assessment Second Third assessment assessment

23 Total mean pain ratings Total rating Total mean pain ratings 0 First assessment n = 44 Second assessment n = 44 Third asssessment n = 20 Comparison of total mean pain ratings to cervical dilatation ASSESSMENT TOTAL MEAN PAIN RATING MEAN CERVICAL DILATATION (cm) First Second Third 4.41 (n = 44) 6.86 (n = 44) 7.63 (n = 20) 3.85cm (n = 41) 5.88cm (n = 40) 6.94cm (n = 16) INCREASE cm

24 Total mean midwife and patient pain ratings Total rating First assessment n = Second assessment Third asssessment Total midwife pain rating Total patient pain rating n = 44 n = 20 Paired t-test of the total mean midwife and patient pain ratings PAIRED DIFFERENCES: MIDWIFE AND PATIENT PAIN RATINGS MEAN OBSERVED t VALUE (t) DEGREES OF FREEDOM (df) SIGNIFICANC E LEVEL (p) Pair 1: Total midwife - patient rating Pair 2: Total midwife - patient rating Pair 3: Total midwife - patient rating

25 Correlation coefficient Perfect correlation between mean midwife pain rating and mean patient pain rating would be 1.00 (r and 1.00). Paired samples correlations = Strong relationships First mean midwife and mean patient pain rating:.794 Second mean midwife and mean patient pain rating:.741 Third mean midwife and mean patient pain rating:.70

26 QUANTITATIVE ANALYSIS Statistician at the University of Johannesburg assisted with frequencies and tabulations. Items with a mean score of below six on the seven-point Likert scale discarded or modified. Midwife completed, second Delphi technique sample (n = 50) PRIVATE HOSPITAL MIDWIVES PROVINCIAL HOSPITAL MIDWIVES Mean items of the labour pain assessment instrument (n=49) Lowest rating: Highest level of agreement: 6.27 (instructions) 6.96 (patient rating)

27 Overall structure of the instrument OVERALL STRUCTURE OF THE INSTRUMENT YES NO N Quick and easy to implement Cover all aspects of labour pain Specifically aimed at the needs and problems for whom it was designed for Use acceptable to the patient Structured Useful during the first stage of labour Assist with the formation of a pain assessment diagnosis Comments and suggested alterations (n=5) COMMENTS AND SUGGESTED ALTERATIONS If possible labour to be pain free or to reduce stress level of it or else good results won t be achieved. Leave more space to indicate pain relief administration. Leave out suggested times of assessment. Indicate/Write assessment of patient in active phase of labour. Pain should also be rated immediately after birth when the patient is more calm. Vital signs.

28 QUALITATIVE ANALYSIS Wording of instructions not clear enough Leaving out suggested times of assessment. Indicating assessment of the patient in active labour Date indicated Enlarging the method of the pain relief block Midwife analysis compared to second Delphi round analysis VALIDITY Design validity Face and content validity Criterion-related validity Instrument validity Internal validity RELIABILITY Sample and sample variability Number of items or observers Instrument Time between testing

29 Schematic presentation of the course of the research PHASE 1 INSTRUMENT DEVELOPMENT REFINEMENT OF THE LABOUR PAIN ASSESSMENT INSTRUMENT QUALITATIVE FOCUS GROUPS DATA ANALYSIS QUALITATIVE DELPHI TECHNIQUE First questionnaire DATA ANALYSIS COMPARISON OF FOCUS GROUPS AND FIRST DELPHI TECHNIQUE QUESTIONNAIRE INSTRUMENT ALTERATION QUALITATIVE DELPHI TECHNIQUE Second questionnaire PHASE 2 TESTING OF INSTRUMENT QUANTITATIVE ANALYSIS Testing of instrument Midwife questionnaire MIDWIFE QUESTIONNAIRE QUALITATIVE ANALYSIS Midwife questionnaire COMPARISON OF QUALITATIVE SECOND DELPHI TECHNIQUE AND MIDWIFE QUESTIONNAIRE PHASE 3 FINAL INSTRUMENT DEVELOPMENT OF IMPLEMENTATION GUIDELINES

30 YAZBEK LABOUR PAIN SCORE Date: SUGGESTED TIME OF ASSESSMENT: Time: Admission Cervical dilatation: Assessment of the progress of labour Before administration of pain relief Method of pain relief: One hour after administration of pain relief Any other time when in suspected severe pain Length of active labour: MIDWIFE RATING INTENSITY QUALITY Aching Miserable Discomforting Tender Annoying Sore Hurting Tiring Agonising Intense Exhausting Horrible Unbearable Excruciating Overwhelming BEHAVIOUR & PHYSIOLOGIC Happiness Excitement Relaxation Muscular tension Restlessness Rising anxiety Crying out Nausea/Vomiting Uncontrolled anxiety FATIGUE Normal activity Normal eating Active/Tired Liquid intake Fatigue/Sleepy No eating/drinking Normal voice Normal breathing Little talking Rapid breathing Irritability Uncontrolled breathing PSYCHOSOCIAL & EMOTIONAL Support sufficient Interact normal Anticipation Some fear Rely on support More focussed Frustrated Fear of unknown Support ineffective Interact difficult Discouraged Fear to be alone TOTAL /10 /10 /10 /10 PATIENT RATING: no pain: :unbearable

31 Phase 3: Guidelines to implement the labour pain assessment instrument Pain diagnosis Planning: Common goals Common language Common knowledge Regular communication Teach midwives how to use the instrument Comfort goals Pain relief goals Setting pain relief measures when: The patient has a pain rating of 4 or more The frequency and intensity of contractions suddenly increase One hour after pain relief

32 Labour pain ratings and suggested pain relief 0-3 The pain is mild and the patient should cope. 4-6 The pain is moderate. Some patients may need pain relief. Nonpharmacological methods such as massage should be offered first The pain is severe. Some patients may need pharmacological methods of pain relief.

33 Schematic presentation of the course of the research PHASE 1 INSTRUMENT DEVELOPMENT REFINEMENT OF THE LABOUR PAIN ASSESSMENT INSTRUMENT QUALITATIVE FOCUS GROUPS DATA ANALYSIS QUALITATIVE DELPHI TECHNIQUE First questionnaire DATA ANALYSIS COMPARISON OF FOCUS GROUPS AND FIRST DELPHI TECHNIQUE QUESTIONNAIRE INSTRUMENT ALTERATION QUALITATIVE DELPHI TECHNIQUE Second questionnaire PHASE 2 TESTING OF INSTRUMENT QUANTITATIVE ANALYSIS Testing of instrument Midwife questionnaire MIDWIFE QUESTIONNAIRE QUALITATIVE ANALYSIS Midwife questionnaire COMPARISON OF QUALITATIVE SECOND DELPHI TECHNIQUE AND MIDWIFE QUESTIONNAIRE PHASE 3 FINAL INSTRUMENT DEVELOPMENT OF IMPLEMENTATION GUIDELINES