Case Background
The plan concerns a patient, Mrs T, who is a 26-year-old woman. She is having her first pregnancy and is at 40 weeks of gestation. Mrs T came to maternity triage, presenting with a history of moderate contractions that lasted between 30 and 40 seconds.
The patient states complaints of pain measured numerically as 5 on a scale from 0 to 10. Measures between 0 and 3 constitute mild pain, numbers from 4 to 6 mean moderate pain, and measures between 7 and 10 imply severe pain. As the patient measured her pain at 5, the pain was moderate.
The patient’s history did not reveal any underlying conditions or complications, and Mrs T does not have any allergies to any drugs. Internal examination showed that Mrs T was not in labour. Her cervix was closed, and the opening of the cervix was long and posterior, which implied that the labour was not in its early stages at the moment.
As a result, Mrs T was recommended to go home, wait for labour to begin, and return to the hospital later. The patient was also offered paracetamol for pain relief with a safety net for returning. However, Mrs T declined the presented pain relief option and requested an epidural.
It is clear from Mrs T’s situation that the main aim is to relieve the patient’s pain. While it may be impossible to avoid pain altogether during labour, the patient’s pain before labour can be reduced by 30% to shift from moderate to mild pain. Thus, it is expected that, after the suggested treatments, the patient would rate her pain between 0 and 3 on the 0-10 scale. This level of paint might be easier for Mrs T to endure while she is awaiting the start of labour.
The National Institute for Health and Care Excellence guidelines differentiate between pain relief before and during labour [1, 2]. Therefore, Mrs T cannot be treated as if she were in labour. Standard guidelines are to prescribe paracetamol for pain relief, which can be used in pregnant women, not in labour [1].
As the patient does not present with any prior medical history that would exclude this option, paracetamol is the first-line medication for the present scenario [1]. This option cannot be used because of the patient’s refusal. Mrs T wishes to be admitted to the hospital so that an epidural can be performed. However, this desire goes against the policy for first-line treatment of pain relief before labour [1]. Epidural is excluded from the standard guidelines as it is too early to use it, and it may have adverse consequences for the mother and the foetus [2].
The main factor increasing the complexity of this situation is the patient’s refusal to take the offered medication and the insistence on using more significant interventions. Mrs T may refuse other solutions, which makes the choice of alternative pain relief options difficult. Therefore, in the presented scenario, reviewing several options and presenting them to the patient is vital to achieve the desired aim.
Following the patient’s refusal to take paracetamol, one can offer two other medications: dihydrocodeine orally and pethidine intramuscularly (IM). However, while the patient may continue utilising dihydrocodeine at home, the choice of pethidine means that the patient has to be admitted. Moreover, a non-pharmacological option exists to use the transcutaneous electrical nerve stimulation (TENS) machine at home.
Options
Dihydrocodeine (Oral)
As noted in the patient’s case, the woman is not in labour currently and may go home to await the event. However, she also requests a more potent medication or option for treating her pain. Thus, an alternative pharmacological solution that fits these requirements is dihydrocodeine.
Dihydrocodeine tablets are oral medications used to treat moderate and severe pain [3]. They can be used during pregnancy and are a feasible option for the patient, but they present potential complications for the foetus. As such, after birth, the neonate may experience withdrawal symptoms and depressed respiration during and after labour [3]. Therefore, this option’s safety is questioned, and Mrs T should be informed of these consequences before administering the medication.
Nonetheless, the chosen opioid is likely to help achieve the established aim of reducing the patient’s pain. It is a prescription-only medicine that is appropriate for treating the patient’s pain, although it presents a risk of side effects for the baby [3]. As these issues may be addressed after labour and are not long-term, the option is appropriate without other pharmacological solutions for the patient to use at home [3]. The price of dihydrocodeine depends on the dosage and the brand producing and distributing the drug. The costs of dihydrocodeine tablets in the dosage of 30mg per tablet range from ÂŁ1 to ÂŁ8 per NHS indicative prices, and the cost ranges due to the package size [4].
Pethidine (IM)
The second pharmacological option in the scenario is pethidine, which is injected intramuscularly (IM). While this medication cannot be administered at home, it is an alternative to paracetamol because it aims to deal with moderate to severe pain [5]. The option of pethidine is feasible as it is used for treating pain during labour.
However, at the same time, the patient under consideration is not in labour at the moment of the examination, and her labour may start later, requiring additional pain management. Additionally, the patient must be educated about the potential side effects of this opioid. Thus, while pethidine is commonly used for pregnant women and does not present many significant drawbacks, some precautions are necessary to consider [5, 6].
The use of pethidine can help reduce the patient’s pain. The injection can lower the pain score for several hours, allowing the patient to relax before laboring. Nevertheless, the patient must be admitted to receive the injection. The cost of pethidine solution for injections is approximately between ÂŁ4 and ÂŁ6 per the NHS indicative price [5]. The cost depends on the manufacturer, and a 1ml injection solution with 50mg of pethidine hydrochloride is provided.
TENS Machine
Finally, the last proposed solution – transcutaneous electrical nerve stimulation (TENS) – is non-pharmacological. A TENS machine uses electrical impulses to lower pain by affecting nerves [7]. The scholarship surrounding TENS finds the option safe for the mother and the foetus [7-9]. Moreover, this non-pharmacological solution is seen as an alternative to drugs as it does not require one to take strong medications with a variety of negative consequences. A TENS machine can be easily used by Mrs T at home, making it a feasible option for pain management before labour.
The use of the TENS machine to help with pelvic girdle and lower back pain has been effective in several research studies. Thus, it is likely that the patient’s pain may be reduced as a result. The option is also the most appropriate of the three suggested solutions because it is explicitly prescribed to women not in labour [7].
In contrast to other options, there are no indications that TENS leads to changing the woman’s labour date or significantly affecting other organs [7, 8]. TENS is a cost-effective option, as one TENS machine is required for the patient throughout the pain management course instead of purchasing medication [8]. The clinic will likely possess TENS machines, lowering the organization’s and the patient’s costs.
Analysis
Dihydrocodeine (Oral)
The evidence on the use of dihydrocodeine suggests that it can be used for moderate and severe pain in pregnant women [2]. As dihydrocodeine has similar effects to codeine, it is a weak opioid that has fewer potential side effects than more potent drugs of the same variety [3]. Mrs T presents as healthy and has no history that would require eliminating dihydrocodeine as a possible option. Nevertheless, the evidence for using dihydrocodeine as presented in human trials or in-depth research investigations is lacking.
Dihydrocodeine is viewed as an alternative to codeine, and the studies for the latter present similar results for pregnant patients [3]. There exist some studies that suggest the risk of neonatal respiratory depression as a result of using dihydrocodeine in the third trimester close to labour [3, 6]. Thus, Mrs T’s child is at increased risk of this condition, and precautions should be taken during labour to respond quickly to any health problems.
Pethidine (IM)
The investigation of pethidine injection use in women is mainly presented in studies of pregnant women going into labour. In these cases, the use of pethidine was effective in reducing pain, similar to such drugs as paracetamol [6]. At the same time, the complications related to the mother’s symptoms, such as nausea, vomiting, and dizziness, are present in women more often compared to those who use weaker oral drugs [5, 6].
A systematic review of pethidine safety during labour shows that the drug is safe for the foetus and the mother and does not cause any long-lasting effects on health if taken within appropriate dosages [5, 6]. A minimal dose of 25 mg is suggested as the best option for dealing with the patient’s pain [5]. As Mrs T refuses to take paracetamol for pain management, she should be advised about the adverse side effects of pethidine injections.
TENS Machine
Similar to the previous options, there exists a limited amount of evidence on the effectiveness of the TENS machine for reducing pain in pregnant women. For example, a randomised clinical trial has demonstrated that TENS was more effective in dealing with pain than paracetamol or physical exercise [7-9]. It has also been reported to help women reduce low back pain in the third trimester [7-9]. Some sources show decreased pain at the beginning of labour [7-9]. Thus, this non-pharmacological option suits patients not in labour during clinical visits.
Implementation Plan
Dihydrocodeine (Oral)
Based on the evidence, the patient can be prescribed a low dose of dihydrocodeine for pain management. This drug can come under such brand names as DHC Continus and DF118 Forte. Dihydrocodeine is also present in oral tablets with paracetamol, but they are excluded from the implementation plan due to the patient’s refusal to take the drug.
The chosen product for the patient is dihydrocodeine 30mg tablets with the active ingredient of dihydrocodeine tartrate. These tablets are taken orally with or after a meal. The adult dose for dihydrocodeine is one tablet every four to six hours, with no more than six tablets in 24 hours [4]. Acknowledging the patient’s pregnancy, choosing the lowest dose of one tablet every six hours with food is recommended.
There is no need for additional baseline assessment or tests, as the patient’s history does not reveal any potential complications. Nevertheless, it is vital to monitor Mrs T’s health and her labour to ensure the lack of negative consequences and provide alternative treatment options if the chosen pharmaceutical option does not prove effective. The patient is to be advised against using such medications as antihistamines, sedatives, sleeping aids, and other prescription pain medicines, as they increase the effect of codeine and may pose a threat to her health [4]. Moreover, the patient should report to the office if the medicine is not working. She should be strongly advised not to take more drugs than prescribed and warned about such symptoms as sleeping problems, dizziness, nausea, and disorientation.
Pethidine (IM)
If the chosen plan focuses on pethidine, the patient should receive a single IM injection and be admitted to the clinic. Pethidine injection solutions come in 50 mg of pethidine hydrochloride per 1 ml solution or 100 mg per 2 ml solution. The lowest possible dosing is chosen for the patient as a single IM injection of 25mg (0.5ml) [5]. The nurse will administer the injection, and the patient must be monitored to prevent or mitigate any complications.
Similar to the previous pharmacological option, there exists a risk of adverse effects on the foetus in the form of respiratory depression in the infant after birth [5]. The assessment of the patient showed no difficulties with the pregnancy and no prior history of respiratory issues, but additional care should be taken to monitor the patient during labour. The safety net includes clinical observation and the restriction to the single lowest dose possible. Moreover, the patient should be informed about potential side effects, such as dizziness, nausea, and vomiting.
TENS Machine
The TENS machine is given to the patient with instructions on how to use it. The patient may place larger electrode pads on the lower back [9]. However, due to the movement of the electrical current, the patient should be warned not to put the pads on the front and back of the body simultaneously. After placing the pads, the patient should turn the machine on and turn the dial so she can feel the tingling sensation, which does not cause pain.
Sessions can last for 30 minutes initially, possibly lengthening them if no discomfort occurs [9]. The patient may adjust the dials as necessary, but be cautious of pain from using the machine. Finally, Mrs T must be instructed to remove the pads only after turning off the device. The follow-up includes any potential patient complaints, such as discomfort or the lack of positive changes in pain management. The safety net includes choosing pharmacological options or adjusting the TENS machine.
References
NICE. Antenatal care. London: The National Institute for Health and Care Excellence; [2022]. Web.
NICE. Intrapartum care for healthy women and babies. London: The National Institute for Health and Care Excellence; [2022]. Web.
Specialist Pharmacy Service. Using opioids for pain relief during pregnancy [Internet]. London, SPS; [2022]. Web.
NICE. Dihydrocodeine tartrate: medicinal forms [Internet]. London: The National Institute for Health and Care Excellence; [2022]. Web.
NICE. Pethidine hydrochloride [Internet]. London: The National Institute for Health and Care Excellence; [2022]. Web.
WHO Reproductive Health Library. WHO recommendation on opioid analgesia for pain relief during labour [Internet]. Geneva: World Health Organization, The WHO Reproductive Health Library; [2022]. Web.
Fiat F, Merghes PE, Scurtu AD, Almajan Guta B, Dehelean CA, Varan N, et al. The main changes in pregnancy—therapeutic approach to musculoskeletal pain. Medicina. 2022;58(8):1115.
Kapoor H. Transcutaneous electrical nerve stimulation (TENS) – renewal of interest for labour analgesia. J Anaesthesiol Clin Pharmacol [Internet]. 2022 Aug [cited 2022 Dec 14]; 0(0): n.p. Web.
Oxford Health NHS. TENS machine in pregnancy [Internet]. Oxford, NHS; [2022]. Web.