Transcutaneous Electrical Nerve Stimulation for Pain Control During Labor and Delivery: A Case Report Donna L Keenan,

Linda Simonsen and Donald J McCrann PHYS THER. 1985; 65:1363-1364.

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Transcutaneous Electrical Nerve Stimulation for Pain Control During Labor and Delivery: A Case Report Donna L Keenan, Linda Simonsen and Donald J McCrann PHYS THER. 1985; 65:1363-1364.

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Transcutaneous Electrical Nerve Stimulation for Pain Control During Labor and Delivery
A Case Report
DONNA L. KEENAN, LINDA SIMONSEN, and DONALD J. McCRANN Key Words: Electric stimulation, Labor, Pain.

Transcutaneous electrical nerve stimulation (TENS) has been used to diminish postoperative pain1 and many forms of chronic pain2 with reportedly good results. There have been few reports of the use of TENS during childbirth in the physical therapy literature. Several European studies have reported good effects of TENS in the reduction of pain associated with labor and delivery.3-6 Because TENS is a noninvasive analgesic procedure and no maternal or fetal side effects have been encountered,3-5 a firsthand evaluation of this modality seemed appropriate. In this case study, we portray how TENS was used with one patient to prompt physical therapists and other health care providers to develop protocols and conduct research for use of this modality. Melzack and Wall's gate control theory of pain provides one theoretical foundation for TENS.7 According to this hypothesis, electrical stimulation of the large, afferent, high velocity fibers prevents the smaller, slow velocity, pain-carrying A delta and C fibers from transmitting pain signals to the higher brain centers. In keeping with Melzack's theory, high frequency, low intensity TENS blocks the transmission of nociceptive stimuli to the spinal cord.8 Labor and delivery are divided into three stages. Stage one begins with contractions of the uterus that efface and dilate the cervix and that cause pain receptors to be activated.9,10 The evoked impulses are transmitted by the afferent fibers through the uterine, pelvic, and hypogastric plexes and reach the spinal cord through dorsal roots at T10-L1. Once the cervix is fully dilated (10 cm), the second stage of labor begins; the contractions of the uterus and voluntary contractions of the abdominal muscles push the baby through the vaginal canal. Pain receptors are activated by dilation of the vagina, pelvic floor, vulva, and perineum. The evoked impulses are transmitted by afferent fibers through the pudendal nerves and reach the spinal cord through dorsal roots S2-4.9, 10 The third stage of labor is the delivery of the baby and the placenta. MATERIALS AND METHODS A Neuromod Selectra* TENS unit with dual channel output was used. As photographed by Robson,4 two EPC and
Ms. Keenan was Staff Physical Therapist, Maine Medical Center, Portland, ME 04102, when this paper was written. Address all correspondence to 597 Sawyer St, S Portland, ME 04106 (USA). Ms. Simonsen is Senior Physical Therapist, Maine Medical Center. Dr. McCrann is Acting Director of Perinatology, Department of ObstetricsGynecology, Maine Medical Center. This article was submitted February 17, 1984; was with the authors for revision 35 weeks; and was accepted March 21, 1985.

two Stemmen disposable electrodes were applied on the paraspinal muscles from T10-L1 and at S2 and S3, respectively. The thoracic-lumbar electrodes were controlled by channel I, and channel II controlled the sacral electrodes. During the trial, the unit was kept in a high frequency continuous mode and a spike wave form was used. Patient Data The patient was a 29-year-old woman; this was her first pregnancy and the gestation period was 42 weeks. The pregnancy had been uncomplicated except for the prolonged gestation, mild pregnancy-induced hypertension with edema, proteinuria, and a 16-kg (35 lb) weight gain. Her preparation for labor and delivery included attending a prepared childbirth class with instruction in Lamaze breathing and relaxation techniques and practice with the Neuromod Selectra TENS unit. Before childbirth, she also received instruction from one of us (D.L.K.) in the use of the Neuromod Selectra TENS unit in conjunction with Lamaze breathing and relaxation. TREATMENT AND RESULTS The patient had spontaneous rupture of the amniotic membranes four hours before admission to the hospital without spontaneous contractions. Labor was induced by intravenous oxytocin drip, and continuous external fetal monitoring was initiated through transabdominal ultrasound with a transabdominal tocodynamometer to record uterine contractions. No other medication, except for local anesthetic for an episiotomy, was administered during labor and delivery. The TENS unit was started after 2.5 hours of labor when contractions were two minutes apart and uncomfortable for the patient. The pulses per second were set at 85, and the intensity on channel I was adjusted to produce a comfortable "buzzing" sensation (Table). During uterine contractions, the intensity was increased to a level where a strong muscle contraction was achieved under the thoracic electrodes. Each uterine contraction could be felt by the patient as a strong pulling sensation in the lower abdominal area. The muscle contraction provided by the TENS unit was described as a deep pressure or massage that helped diminish the discomfort. The perceived strength of the uterine contraction was greater

* Model 7720, Medtronic Inc, 3055 Old Highway Eight, Minneapolis, MN 55440. Codman and Shurtleff, Inc, Pacella Park Dr, Randolph, MA 02368. Stemmen Laboratory, Inc, 1850 Whittier Ave, Costa Mesa, CA 92627.

Volume 65 / Number 9, September 1985

1363

when the TENS unit was turned off, and the patient elected to continue using the TENS unit. Channel II and the sacral electrodes were also tried. The smaller area of the Stemmen electrode, however, produced a sharp, stinging sensation. Because this was uncomfortable for the patient, the use of this channel was discontinued. The EPC electrodes were not applied to the sacral area because the patient was able to maintain a comfortable, relaxed state during each contraction by using only channel I. The TENS unit was used during two hours of active labor: the early transition phase (2-8-cm dilation) while the patient sat in a rocking chair and the late transition phase (8-10-cm dilation) while the patient was in a side-lying position in bed. Pain was kept at a tolerable level during both stages by the TENS-produced muscle contraction, total body relaxation, and breathing techniques. During the early transition stage, the patient herself could easily adjust the intensity of the unit according to the strength of the uterine contraction. The intensity was decreased to the lowest comfortable level between contractions to minimize accommodation to the stimulation (Table). During the late transition stage, when uterine contractions became very strong and close together, increased patient concentration was required and she no longer could control the TENS intensity herself. Instead, the therapist adjusted the intensity by observing the behavior of the patient and uterine contractions recorded on the fetal monitor. As labor progressed to the second stage (full dilation of the cervix), the uterine contractions became farther apart and less intense. During this stage, the patient had to push effectively with the abdominal muscles and, therefore, needed to concentrate on and experience the full strength of the uterine contraction. The muscle contraction produced by the TENS unit was too distracting to allow this concentration; therefore, the TENS unit was discontinued after 2.5 hours. Contrary to some reports that the TENS unit disrupted the fetal ECG signal from internal fetal monitors,5 the TENS unit did not produce any artifact in the fetal heart-rate tracing produced by ultrasound with the external monitor.
DISCUSSION

TABLE Transcutaneous Electrical Nerve Stimulation Pulse Rate and Intensity of Channel 1 Time Since Application of TENS Unit* (hr)

Stimulation Factors

0
Pulse rate (pps) Intensity between uterine contractions (% output) Intensity during uterine contractions (% output)

0.5 85 35 55

1 85 65 80

1.5 85 80 99

2 99 70 85

2.5 99 85 99

85 25 38

* The TENS unit was applied 2.5 hours after induction of labor.

In this trial, only one channel of the unit was used. Because of the strength of the uterine contractions and accommodation to the stimulation, the patient was using the full output of channel I at the end of the transition phase. A second set of EPC electrodes instead of the smaller Stemmen electrodes applied to the sacral area may be helpful to increase the comfortable sensation from the TENS stimulation. In this trial, TENS was discontinued during the second stage of labor. If discomfort was experienced between contractions during this stage, a low level of stimulation could be maintained. This low level would not mask the strength of the uterine contractions and would allow the patient to push effectively with the abdominal muscles. For TENS to be used successfully during childbirth, the patient must understand the use of the unit before beginning labor. Theory of pain control and application of the unit could be taught as part of a prepared childbirth class. Under the supervision of class instructors, patients could simulate conditions during childbirth by practicing total body relaxation and breathing techniques in combination with low intensity stimulation through electrodes placed on an extremity to avoid stimulation near the baby without fetal monitoring. 1364

The TENS could then be started in early labor and the intensity controlled by the patient through the active phase of stage one. In our case study, a health professional had to control the intensity during the transition phase (8-10 cm). A physical therapist or a labor room nurse who has been educated in the use of this modality can provide this service or supervise the patient's labor coach, who can control the unit if necessary. Physical therapists may also wish to instruct patients in TENS use in childbirth education classes. According to the literature, the effectiveness of TENS for pain control in labor is equivocal.3-6 The patient in this case report, however, was more comfortable using TENS than when the unit was turned off. Lamaze breathing and relaxation is an accepted practice during most labor and delivery. Therefore, we chose to evaluate the effectiveness of TENS in addition to these pain reduction measures. The use of a subjective rating scale during labor and delivery would be helpful to evaluate pain control in future studies. The favorable results of this case study and the benign nature of this modality suggest that TENS could effectively complement other methods of pain control for childbirth. Controlled studies with large numbers of patients, however, are needed to evaluate possible long-term fetal effects and to develop protocols for the use of TENS during labor and delivery. Obstetrical physicians will delay general acceptance of this modality until appropriate studies have proved its efficacy and safety. Acknowledgment. The authors wish to thank Mary Hutchinson, RN, for her assistance in this case study.
REFERENCES 1. Smith MJ: Electrical stimulation for relief of musculoskeletal pain. The Physician and Sportsmedicine 11(5):47-55,1983 2. Melzack R: Prolonged relief of pain by brief, intense, transcutaneous somatic stimulation. Pain 1:357-373,1975 3. Augustinsson LE, Bohlen P, Bundsen P, et al: Pain relief during delivery by transcutaneous electrical nerve stimulation. Pain 4:59-65,1977 4. Robson JE: Transcutaneous nerve stimulation for pain relief in labour. Anesthesia 34:357-361,1979 5. Bundsen P, Peterson LE, Selstam U: Pain relief in labor by transcutaneous electrical nerve stimulation: A prospective matched study. Acta Obstet Gynecol Scand 60:459-468,1981 6. Neshein Bl: The use of transcutaneous nerve stimulation for pain relief during labor: A controlled clinical study. Acta Obstet Gynecol Scand 60:1316,1981 7. Melzack R, Wall PD: Pain mechanism: A new theory. Science 150:971973,1965 8. Stratton SA: Role of endorphins in pain modulation. The Journal of Orthopedic and Sports Physical Therapy 3:200-205,1982 9. Bonica JJ: Principles and Practice of Obstetric Analgesia and Anesthesia: Fundamental Considerations. Philadelphia, PA, F A Davis Co, 1967, vol 1 10. Bonica JJ: The nature of pain in parturition. Clin Obstet Gynecol 2:499516,1975 PHYSICAL THERAPY