Paracetamol… Friend or Foe?
(June 2017)
As I slowly began to take more triage calls as a student midwife, I learnt the early standard ‘advice’ we would routinely give to women calling in early labour… “Have you had a bath and a couple of paracetamol?” being the primary line of defence in encouraging women to cope at home, away from the intervention and interference of the labour ward. The intention is of course pure, when everything is normal and if that is where she feels safe, then the best place for a woman to be in early labour is at home.
So what if the very thing that is intended to help women to cope with the latent phase of labour, is actually causing the latent phase to last longer?
I read a fascinating blog post by Midwife Undercover who had noticed an apparent increase in the length of the latent phase of labour and had consequently looked into the possibility that paracetamol was the culprit. As I read, I felt like I was experiencing an ‘eureka’ moment – paracetamol works by inhibiting prostaglandins! INHIBITING THEM! The midwives and student midwives among you, if you haven’t already considered this, may well be slapping your foreheads as I did when I read this. Prostaglandins are up there with Oxytocin in the mastermind partnership for the onset and continuation of an effective labour, and some have even argued they are even more important than oxytocin (O’Brien 1995). Could it be possible that the very tool we use to help to ‘normalise’ women, is ultimately increasing the burden on obstetric units with increased inductions and augmentations of labour?
In the hospital environment we use prostaglandin pessaries to induce the onset of labour and women are sometimes even suggested that having sex with their male partner may help to start the labour due to the prostaglandins present in sperm, coupled with the oxytocic effect of the encounter. We actively promote prostaglandin use in labour, whether it be synthetic or naturally occurring.
Curious, I began to ask women what they had used to cope at home while they were waiting for their labours to become established and in the past few months, three women stood out for me, one in particular had been faithfully taking regular paracetamol since she first started experiencing backache associated with irregular mild tightenings. Two weeks later, she felt she was experiencing the longest labour ‘ever’ and was facing induction of labour due to an ‘extended latent phase’.
Now of course the anecdotal evidence of a single midwife’s conversations is certainly not enough to base a change in practice upon so I started to look further, to see if I could find any further research to back up the hypothesis by the Undercover Midwife. Given the compelling nature of the information I have been surprised to find that no further research has been carried out, though as an aside it was interesting to discover research which suggested that intravenous paracetamol may be as effective as pethedine, though clearly with fewer side effects (Extended latent phase notwithstanding of course) (Elbohoty et al 2012). As fascinating as the results of a randomised controlled trial would be, the ethics of such a piece of research would almost certainly be untenable. The logistics of a retrospective study would probably present prohibitive challenges too.
Interestingly, NICE and RCM do not mention paracetamol at all in their advice for early labour care, both focussing on the importance of the midwifes role and non interventionist therapies such as warm baths, showers, massage, breathing and relaxation techniques, TENS and complementary therapies if the woman would like to use them – both careful to point out that the evidence is not always conclusive but if the woman feels they help then why not.
So why then, given the apparent absence of recommendation for it’s use, plus the recent question mark over whether it is actually inhibiting the progression of a normal labour, are we persisting in recommending it to women?
I would suggest that insufficient antenatal education is partly responsible, women are often very underprepared for the challenges of labour, surprised even, by the pain encountered. If her only understanding of pain is that it is something which needs to be fixed, then paracetamol and medicinal analgesia will be the obvious choice. The pains and sensations of the phases of labour and the normal physiological responses must be carefully taught – it is of course not just that the pain passes with an extraordinary prize at the end, but that the sensations are to be worked with as they cause the labour to move forward – Leap and Anderson (2008) talk extensively about working with rather than aiming to relieve pain, on the premise that the body produces endorphins in response to pain, which not only act as a natural analgesic, but also may stimulate oxytocin – necessary for the normal progression of labour (Walsh 2009).
The next thing I believe is that we simply don’t have the time to adequately cope with women presenting to us in the maternity unit in early labour. Far easier to suggest an easier fix and a solution which is understandable by a culture which believes all pain to be bad. In most obstetric units we simply don’t have the space to care for those women in early labour, nor the staff to facilitate early labour care. I have heard of some Trusts in the UK having ‘nests’ in which to give women a window of a few hours perhaps to learn some early labour techniques , but they seem to be in the minority. Midwifery led units and stand alone birth centres, if they were sufficiently staffed may well be able to stand in the gap for early labourers who don’t feel able to stay at home. Ultimately more midwives of course.
And finally is the reaffirmation of those early labour tricks we know as midwives to work and the building of our skills and confidence in relaying those techniques when we triage women over the phone. Presenting them as strong, powerful, viable and useful tools and not a wishy washy substitute for paracetamol. Empowering women to come off the phone with a life-raft of sorts, packed with things they can try, readily available in most homes; warmth, pressure and massage, good food, water, movement, music, support, a cosy bed, lovely smells… all of which may promote naturally occurring endorphins, oxytocin and a physiological labour.
References
http://undercovermidwife.blogspot.co.uk/2015/03/paracetamol-and-labour.html
O’Brien W (1995). The role of prostaglandins in labour and delivery. Clinical Perinatology. Dec, 22 (4), 973-84
Elbohoty A, Abd-Elrazek H, Abd-El-Gawad M, Salama F, El-Shorbagy M, Abd-El-Maeboud K (2012) Intravenous infusion of paracetamol versus intravenous pethidine as an intrapartum analgesic in the first stage of labor. Int J Gynaecol Obstet 118(1): 7–10. doi: 10.1016/j.ijgo.2012.01.025
NICE: https://www.nice.org.uk/guidance/cg190/ifp/chapter/The-early-stage-of-labour
RCM: https://www.rcm.org.uk/sites/default/files/Latent%20Phase_1.pdf
Walsh, D. 2009. Pain and epidural use in childbirth. RCM: Evidence based Midwifery. https://www.rcm.org.uk/learning-and-career/learning-and-research/ebm-articles/pain-and-epidural-use-in-normal-childbirth
So what if the very thing that is intended to help women to cope with the latent phase of labour, is actually causing the latent phase to last longer?
I read a fascinating blog post by Midwife Undercover who had noticed an apparent increase in the length of the latent phase of labour and had consequently looked into the possibility that paracetamol was the culprit. As I read, I felt like I was experiencing an ‘eureka’ moment – paracetamol works by inhibiting prostaglandins! INHIBITING THEM! The midwives and student midwives among you, if you haven’t already considered this, may well be slapping your foreheads as I did when I read this. Prostaglandins are up there with Oxytocin in the mastermind partnership for the onset and continuation of an effective labour, and some have even argued they are even more important than oxytocin (O’Brien 1995). Could it be possible that the very tool we use to help to ‘normalise’ women, is ultimately increasing the burden on obstetric units with increased inductions and augmentations of labour?
In the hospital environment we use prostaglandin pessaries to induce the onset of labour and women are sometimes even suggested that having sex with their male partner may help to start the labour due to the prostaglandins present in sperm, coupled with the oxytocic effect of the encounter. We actively promote prostaglandin use in labour, whether it be synthetic or naturally occurring.
Curious, I began to ask women what they had used to cope at home while they were waiting for their labours to become established and in the past few months, three women stood out for me, one in particular had been faithfully taking regular paracetamol since she first started experiencing backache associated with irregular mild tightenings. Two weeks later, she felt she was experiencing the longest labour ‘ever’ and was facing induction of labour due to an ‘extended latent phase’.
Now of course the anecdotal evidence of a single midwife’s conversations is certainly not enough to base a change in practice upon so I started to look further, to see if I could find any further research to back up the hypothesis by the Undercover Midwife. Given the compelling nature of the information I have been surprised to find that no further research has been carried out, though as an aside it was interesting to discover research which suggested that intravenous paracetamol may be as effective as pethedine, though clearly with fewer side effects (Extended latent phase notwithstanding of course) (Elbohoty et al 2012). As fascinating as the results of a randomised controlled trial would be, the ethics of such a piece of research would almost certainly be untenable. The logistics of a retrospective study would probably present prohibitive challenges too.
Interestingly, NICE and RCM do not mention paracetamol at all in their advice for early labour care, both focussing on the importance of the midwifes role and non interventionist therapies such as warm baths, showers, massage, breathing and relaxation techniques, TENS and complementary therapies if the woman would like to use them – both careful to point out that the evidence is not always conclusive but if the woman feels they help then why not.
So why then, given the apparent absence of recommendation for it’s use, plus the recent question mark over whether it is actually inhibiting the progression of a normal labour, are we persisting in recommending it to women?
I would suggest that insufficient antenatal education is partly responsible, women are often very underprepared for the challenges of labour, surprised even, by the pain encountered. If her only understanding of pain is that it is something which needs to be fixed, then paracetamol and medicinal analgesia will be the obvious choice. The pains and sensations of the phases of labour and the normal physiological responses must be carefully taught – it is of course not just that the pain passes with an extraordinary prize at the end, but that the sensations are to be worked with as they cause the labour to move forward – Leap and Anderson (2008) talk extensively about working with rather than aiming to relieve pain, on the premise that the body produces endorphins in response to pain, which not only act as a natural analgesic, but also may stimulate oxytocin – necessary for the normal progression of labour (Walsh 2009).
The next thing I believe is that we simply don’t have the time to adequately cope with women presenting to us in the maternity unit in early labour. Far easier to suggest an easier fix and a solution which is understandable by a culture which believes all pain to be bad. In most obstetric units we simply don’t have the space to care for those women in early labour, nor the staff to facilitate early labour care. I have heard of some Trusts in the UK having ‘nests’ in which to give women a window of a few hours perhaps to learn some early labour techniques , but they seem to be in the minority. Midwifery led units and stand alone birth centres, if they were sufficiently staffed may well be able to stand in the gap for early labourers who don’t feel able to stay at home. Ultimately more midwives of course.
And finally is the reaffirmation of those early labour tricks we know as midwives to work and the building of our skills and confidence in relaying those techniques when we triage women over the phone. Presenting them as strong, powerful, viable and useful tools and not a wishy washy substitute for paracetamol. Empowering women to come off the phone with a life-raft of sorts, packed with things they can try, readily available in most homes; warmth, pressure and massage, good food, water, movement, music, support, a cosy bed, lovely smells… all of which may promote naturally occurring endorphins, oxytocin and a physiological labour.
References
http://undercovermidwife.blogspot.co.uk/2015/03/paracetamol-and-labour.html
O’Brien W (1995). The role of prostaglandins in labour and delivery. Clinical Perinatology. Dec, 22 (4), 973-84
Elbohoty A, Abd-Elrazek H, Abd-El-Gawad M, Salama F, El-Shorbagy M, Abd-El-Maeboud K (2012) Intravenous infusion of paracetamol versus intravenous pethidine as an intrapartum analgesic in the first stage of labor. Int J Gynaecol Obstet 118(1): 7–10. doi: 10.1016/j.ijgo.2012.01.025
NICE: https://www.nice.org.uk/guidance/cg190/ifp/chapter/The-early-stage-of-labour
RCM: https://www.rcm.org.uk/sites/default/files/Latent%20Phase_1.pdf
Walsh, D. 2009. Pain and epidural use in childbirth. RCM: Evidence based Midwifery. https://www.rcm.org.uk/learning-and-career/learning-and-research/ebm-articles/pain-and-epidural-use-in-normal-childbirth
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