the measurement of pain during the first stage of …...dr mariatha yazbek labour may impose severe...

University of Pretoria

The measurement of pain during the first

stage of labour

Dr Mariatha Yazbek

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

Harmful effects of unrelieved pain to the patient and foetus in labour

DOMAINS AFFECTED SPECIFIC RESPONSES TO PAIN

Endocrine Adrenocorticotrophic hormone (ACTH), cortisol, antidiuretic

hormone (ADH), epinephrine, norepinephrine, growth hormone

(GH), catecholamines, renin, angiotensin II, aldosterone,

glucagon, interleukin-1; insulin, testosterone

Metabolic Gluconeogenesis, hepatic glycogenolysis, hyperglycemia, glucose intolerance, insulien resistance,

muscle protein catabolism, lipolysis

Cardiovascular Heart rate, cardiac output, peripheral vascular resistance, systemic vascular resistance,

hypertension, coronary vascular resistance, myocardial oxygen consumption,

hypercoagulation, deep vein thrombosis

Respiratory Tidal volume and minute ventilation, alkalosis, hypoxemia

Genitourinary Urinary output, urinary retention, fluid overload, hypokalemia, sodium bicarbonate

Gastrointestinal Gastric and bowel movement, gastric acid secretion, carbohydrate intake (restricted dietary

intake in labour)

Musculoskeletal Muscle spasm, impaired muscle function, fatigue, immobility

Cognitive Reduction in cognitive function, mental confusion

Immune Depression of immune response

Uterus Increase or decrease in uterine contractility, vasoconstriction, uterine blood flow, prolonged

labour

Foetal implications Oxygen, metabolic acidosis, late decelerations, foetal distress

Developmental 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

Within the healthcare system (disciplines)

Healthcare professionals (under-, overestimate)

Patient

Legal/societal/cultural

Barriers to labour pain assessment

„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)

Background

• 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©

Pain assessment instruments

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.

Aim

• 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

Objectives

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

Research methods

Schematic presentation of the course of the research INSTRUMENT DEVELOPMENT PHASE 1

REFINEMENT OF THE LABOUR PAIN ASSESSMENT INSTRUMENT

QUALITATIVE

FOCUS GROUPS

QUALITATIVE DELPHI TECHNIQUE First questionnaire

DATA ANALYSIS DATA ANALYSIS

COMPARISON OF FOCUS GROUPS AND FIRST

DELPHI TECHNIQUE QUESTIONNAIRE

INSTRUMENT ALTERATION

QUALITATIVE DELPHI TECHNIQUE Second questionnaire

PHASE 2 TESTING OF

INSTRUMENT

MIDWIFE

QUESTIONNAIRE

QUANTITATIVE ANALYSIS

Testing of instrument

Midwife questionnaire

QUALITATIVE ANALYSIS


COMPARISON OF QUALITATIVE SECOND DELPHI

TECHNIQUE AND MIDWIFE QUESTIONNAIRE

PHASE 3 FINAL INSTRUMENT

DEVELOPMENT OF IMPLEMENTATION GUIDELINES

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

Phase 1: Instrument development

and refinement

Labour pain assessment tool

Hospital: Private / Provincial Suggested time of assessment:

Ethnicity: White / Black or coloured / Asian or Indian - Admission

Social background: High income / Middle income / Lower income - 3-4cm cervical dilatation

Support: None / Husband or partner / Midwife or doula / Other - 7-8cm cervical dilatation

Age: _____ Gravity: ____ Parity: ____ - Before and 1 hour after administration of pain medication

Onset of labour: ____h____ - Any other time when in suspected severe pain

Time

Cervical dilatation

Method of pain relief

Length of labour

Score 0 1 2

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: 1---2---3---4---5---6---7---8---9---10 :unbearable

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

Stage 1: Focus group interviews

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

Stage 2: Delphi Technique

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

- 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

12/8/2009 12/8/2009

15h00 19h00

4cm 8cm

Walking

Shower

Pethidine

Atarax

1 hour 5 hours

Midwife rating 0 1 2

Intensity of pain

0

2

Quality of pain

Aching

Miserable

Discomforting

Tender

Annoying

Sore

Hurting

Tiring

Agonising

Intense

Exhausting

Horrible

Unbearable

Excruciating

Overwhelming

1

2

Behaviours /

Physiological

Parameters

Happiness

Excitement

Relaxation

Muscular tension

Restlessness

Rising Anxiety

Crying out

Nausea/vomiting


1

2

Fatigue Threshold

Normal activity

Normal eating

Normal voice

Normal breathing

Active/Tired

Liquid intake

Little talking

Rapid breathing

Fatigue/Sleepiness

No eating/drinking

Irritability

Uncontrolled breathing

0

1

Psychosocial /

Emotional status

Support sufficient

Interact normal

Anticipation

Some fear

Rely on support

More focussed

Frustrated

Fear for unknown

Support not effective

Interact difficult

Discouraged

Fear to be alone

1

1

Total midwife rating

3/10 8/10 /10 /10

Patient rating no pain: 0---1---2---3---4---5---6---7---8---9---10 :unbearable

4/10

9/10

/10

/10

A schematic presentation of the course of the research INSTRUMENT DEVELOPMENT PHASE 1


QUALITATIVE

FOCUS GROUPS







PHASE 2 TESTING OF

INSTRUMENT

MIDWIFE

QUESTIONNAIRE










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 25-50 patients from each sector

Phase 2 : Testing of the final instrument

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)

Cervical dilatation and pain scores

Method of pain relief and type of hospital

3.85

5.88

6.94

0

2

4

6

8

10

cm

Mean cervical dilatation

First pain

assessment

n = 41

Second pain

assessment

n = 40

Third pain

assessment

n = 16

PAIN RELIEF

METHOD

PRIVATE PATIENTS 100% PROVINCIAL

PATIENTS

100%

No pain relief 11 44%

Nondrug

Massage

Walking

Breathing

Water

1

1

4

5%

5%

20%

3

12%

Anaesthesia

Entonox

Buscopan

Pethidine and Aterax

1

1

8

5%

5%

40%

11

44%

Regional techniques

Epidural

4

20%

TOTAL n = 20 100% n = 25 100%

Mean length of active labour

Mean length of active labour in private and provincial

hospitals

4.154.31

3.47

0

1

2

3

4

5

First assessment

n = 19

Second assessment

n = 32

Third assessment

n = 13

Hours

3.86 (n = 7)

2.64 (n = 4)2.33 (n = 9)

4.5 (n = 6)5.61 (n = 18)4.5 (n = 10)

0

2

4

6

8

First assessment Second

assessment

Third assessment

Hours

Private

hospitals

Provincial

hospitals

Total mean pain ratings

Comparison of total mean pain ratings to cervical dilatation

4.41

6.86 7.63

0

2

4

6

8

10

First assessment

n = 44

Second assessment

n = 44

Third asssessment

n = 20

Total rating Total mean

pain ratings

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 3.22 3.09cm

Total mean midwife and patient pain ratings

Paired t-test of the total mean midwife and patient pain

ratings

3.95

6.45

7.35

4.86

7.277.9

0

2

4

6

8

10

First assessment

n = 44

Second

assessment

n = 44

Third

asssessment

n = 20

Total rating

Total

midwife

pain

rating

Total

patient

pain

rating

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


rating


rating

-.909

-.818

-.550

-3.346

-3.325

-1.502

43

43

19

.002

.002

.150

Correlation coefficient

Perfect correlation between mean midwife pain

rating and mean patient pain rating would be

1.00 (r +1.00 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


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)

Mean items of the labour pain assessment instrument (n=49)

Lowest rating: 6.27 (instructions)

Highest level of agreement: 6.96 (patient rating)

PRIVATE HOSPITAL

MIDWIVES

PROVINCIAL HOSPITAL

MIDWIVES

20 30

Overall structure of the instrument

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.”

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

47

50

49

49

49

47

48

3

1

1

1

3

1

50

50

50

50

50

50

49


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 RELIABILITY

Design validity

Face and content

validity

Criterion-related validity

Instrument validity

Internal validity

Sample and sample variability

Number of items or observers

Instrument

Time between testing

Schematic presentation of the course of the research

INSTRUMENT DEVELOPMENT PHASE 1


QUALITATIVE

FOCUS GROUPS







PHASE 2 TESTING OF

INSTRUMENT

MIDWIFE

QUESTIONNAIRE










YAZBEK LABOUR PAIN SCORE Date:

SUGGESTED TIME OF ASSESSMENT:

Admission

Assessment of the progress of labour

Before administration of pain relief

One hour after administration of pain relief

Any other time when in suspected severe pain

Time:

Cervical dilatation:

Method of pain relief:

Length of active labour:

MIDWIFE

RATING 0 1 2

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


FATIGUE

Normal activity

Normal eating

Normal voice

Normal breathing

Active/Tired

Liquid intake

Little talking

Rapid breathing

Fatigue/Sleepy

No eating/drinking

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: 0---1---2---3---4---5---6---7---8---9---10 :unbearable

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

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.

• 7-10

The pain is severe. Some patients may need pharmacological

methods of pain relief.

Schematic presentation of the course of the research INSTRUMENT DEVELOPMENT PHASE 1


QUALITATIVE

FOCUS GROUPS







PHASE 2 TESTING OF

INSTRUMENT

MIDWIFE

QUESTIONNAIRE










the measurement of pain during the first stage of …...dr mariatha yazbek labour may impose severe...

Documents