Tecnologias não invasivas de cuidado utilizadas por enfermeiras obstétricas: contribuições terapêuticas / Tecnologías de atención no invasiva utilizadas por las enfermeras obstétricas: contribuciones terapêuticas / Non-invasive care technologies used by obstetric nurses: therapeutics contributions

Resumo Objetivo descrever as contribuições terapêuticas da utilização de tecnologias não invasivas de cuidado, oferecidas por enfermeiras obstétricas, durante o trabalho de parto. Método estudo qualitativo e descritivo, com oito enfermeiras obstétricas da casa de parto do Rio de Janeiro. Os dados foram coletados de setembro a dezembro de 2018, através de entrevistas semiestruturadas, e submetidos à técnica de análise temática. Resultados para aliviar a dor e promover relaxamento, recorrem ao estímulo à participação do acompanhante e à respiração consciente, à aplicação da massagem, à promoção do ambiente acolhedor e ao uso da água morna e dos óleos essenciais. Para ativar o trabalho de parto, auxiliar na descida da apresentação e correção do posicionamento fetal, incentivam posicionamentos verticalizados e movimentos corporais, com alguns instrumentos. Conclusões e implicações para a prática tecnologias não invasivas de cuidado possuem contribuições terapêuticas e conformam um cuidado desmedicalizado, respeitoso e centrado na mulher, que promove a autonomia feminina.

Resumen Objetivo describir las contribuciones terapéuticas de la utilización de tecnologías de atención no invasivas que ofrecen las enfermeras obstétricas durante el trabajo de parto. Método estudio cualitativo y descriptivo, con ocho enfermeras obstétricas de una casa de partos de Río de Janeiro. Los datos fueron recolectados de septiembre a diciembre de 2018, a través de entrevistas semiestructuradas, y sometidos a la técnica de análisis temático. Resultados para aliviar el dolor y favorecer la relajación, se recurre a fomentar la participación del acompañante y la respiración consciente, la aplicación de masajes, la promoción de un ambiente acogedor y el uso de agua tibia y aceites esenciales. Para activar el trabajo de parto, facilitan en el descenso de la presentación y corrección del posicionamiento fetal, fomentan las posiciones verticales y los movimientos corporales, con algunos instrumentos. Conclusiones e implicaciones para la práctica las tecnologías de atención no invasiva tienen aportes terapéuticos y conforman un cuidado desmedicalizado, respetuoso y centrado en la mujer que promueve la autonomía femenina.

Abstract Objective to describe the therapeutics contributions of the use of non-invasive care technologies offered by obstetric nurses during labor. Method a qualitative and descriptive study, with eight obstetric nurses from a birthing center in Rio de Janeiro. Data were collected from September to December 2018, through semi-structured interviews, and subjected to thematic analysis technique. Results to relieve pain and promote relaxation, they resort to encouraging the companion's participation and conscious breathing, the application of massage, the promotion of a supportive environment and the use of warm water and essential oils. To activate labor, assist in descending the presentation and correction of fetal positioning, they encourage vertical positioning and body movements, with some instruments. Conclusions and implications for practice non-invasive care technologies have therapeutic contributions and form a not medicalized, respectful and women-centered care that promotes female autonomy.

Reviewing pain management options for patients in active labor.

Pain perception and preferences for pain management are unique to each woman in labor. This article provides an overview of the physiology of labor pain, discusses available nonpharmacologic and pharmacologic approaches to managing pain during active labor, and discusses potential benefits and risks for each option.

The effect of cognitive behavioral techniques using virtual reality on birth pain: a randomized controlled trial.

OBJECTIVE: This study was conducted to investigate the effects of cognitive behavioral techniques using virtual reality on birth pain. DESING: This study was planned as a double blind randomized controlled experimental study. SETTING AND PARTICIPANTS: It was conducted with 273 pregnant women who were randomized between July 2016 and June 2019 at maternity hospital located in eastern Anatolia, Turkey. METHODS: The study included 5 groups. (A: videos of newborn photographs with classical music, B: the video of the newborn photograph album, C: an introductory film of Turkey, D: only classical music, E: routine hospital care). The data were collected by using the "Personal Information Form", "Visual Analogue Scale", "Verbal Rating Scale" and "Virtual Reality". FINDINGS: Groups show homogeneity in terms of demographic and obstetric variables. It was found that mean Visual Analogue Scale posttest mean score of the group A was 4.98 ± 1.69; group B 4.96 ± 1.72; group C 5.96 ± 2.05; group D 5.60 ± 1.63 and group E 6.38 ± 1.86. Mean Verbal Rating Scale posttest score was found that group A was 2.64 ± 0.73, group B 2.70 ± 0.87, group C 3.18 ± 1.14, group D was 2.80 ± 0.86 and group E was 3.96 ± 1.01. It was obtained that the groups' mean Visual Analogue Scale and Verbal Rating Scale posttest mean scores was statistically significant (p<0.05). CONCLUSION: In this study, all cognitive techniques applied with virtual reality reduced labor pain during the active phase of labor. Especially the video of newborn photographs with classical music and newborn photograph album have been found more effective than other interventions evaluated in reducing labor pain. IMPLICATIONS FOR PRACTICE: Midwives can use these techniques to reduce birth pain.

Tecnologias de cuidado para o alívio da dor na parturição / Care techniques for pain relief in birthing / Tecnologías de cuidado para el alivio del dolor en la partición

Objetivo: este estudo objetivou conhecer as tecnologias de cuidado no alívio da dor no processo de parturição em um hospital de ensino. Método: pesquisa qualitativa e descritiva com 10 puérperas internadas em uma unidade materno-infantil no período de maio a junho de 2017. Os dados foram coletados por meio de entrevistas individuais e analisados conforme a Proposta Operativa de Minayo. Resultados: as puérperas que usaram as tecnologias de alívio da dor no processo de parturição julgaram como excelente e de grande valia os métodos para o alívio da dor. Conclusão: conclui-se que estas tecnologias são importantes para a autonomia e protagonismo da mulher e a vivência positiva do seu processo de parturição, sendo fundamental o investimento em outros métodos de alívio da dor, de modo a qualificar e tornar o parto mais prazeroso e menos traumatizante

Objective: this study aimed to identify the care technologies in pain relief in the birthing process in a teaching hospital. Method: qualitative and descriptive research, in which ten women in labor were hospitalized in a hospital maternal unit, from May to June 2017. Data were collected through individual interviews and analyzed according to Minayo's Operative Proposal. Results: postpartum women who used pain relief technologies in the birthing process considered the methods of pain relief as excellent and of great value. Conclusion: we concluded that these technologies are important for the autonomy and protagonism of women and the positive experience of their process of birthing, recognizing the importance of investing in other methods of pain relief, in order to qualify and make birthing process more pleasurable and less traumatic

Objetivo: este estudio objetivó conocer las tecnologías de cuidado en el alivio del dolor en el proceso de parturición en un hospital de enseñanza. Método: investigación cualitativa y descriptiva, en la que participaron diez puérperas internadas en una unidad materna hospitalaria, en el período de mayo a junio de 2017. Los datos fueron recolectados a través de entrevistas individuales, y analizados conforme a la Propuesta Operativa de Minayo. Resultados: las puérperas que usaron las tecnologías de alivio del dolor en el proceso de parturiado juzgaron como excelente y de gran valor los métodos para el alivio del dolor. Conclusión: se concluye que estas tecnologías son importantes para la autonomía y protagonismo de la mujer y la vivencia positiva de su proceso de parturión, siendo importantes inversiones en otros métodos de alivio del dolor, para calificar y hacer el parto más placentero y menos traumatizante

A Quality Improvement Initiative to Reduce Opioid Consumption after Cesarean Birth.

BACKGROUND: One in 300 opioid naïve women become addicted to opiates after cesarean birth. After cesarean, women are often prescribed more opiates at discharge than necessary, resulting in increased opportunity for diversion. PURPOSE: To improve use of comfort strategies and nonopioid medications to decrease the amount of opioids required postoperatively and prescribed at discharge, in women who gave birth via cesarean. METHODS: An interdisciplinary workgroup was convened to assess data on opioid use, prescribing practices at discharge, and nurses' use of alternative comfort strategies from January to March 2018. A comfort bundle was designed to include standardized use of preoperative acetaminophen, postoperative comfort education, simethicone, postoperative gum chewing, and abdominal binders. Nurses and healthcare providers were educated on the initiative. Data were reevaluated and compared with preintervention data assessing for improvement and adherence to the bundle components. RESULTS: There was a 61% reduction in morphine milliequivalents given to women after cesarean birth between the first quarter in 2018 and the fourth quarter in 2018. Comparing March with December, 2018 data, adherence to each bundle component improved. The percentage of women receiving less than 20 tabs of oxycodone at discharge increased from 26.3% to 96.7%. IMPLICATIONS FOR NURSING PRACTICE: Nurses should evaluate comfort options provided after cesarean birth and educate women about use of nonopioid pain relief strategies. A standardized process to address pain and comfort after cesarean birth may decrease exposure to opioids while maintaining comfort.

Effect of Change in Position and Back Massage on Pain Perception during First Stage of Labor.

BACKGROUND: Labor is one of the most painful events in a women's life. Frequent change in positions and back massage may be effective in reducing pain during the first stage of labor. AIM: The focus of this study was to identify the impact of either change in position or back massage on pain perception during first stage of labor. DESIGN: A quasi-experimental study. SETTING: Teaching hospital, Kurdistan Region, Iraq, November 2014 to October 2015. SUBJECTS: Eighty women were interviewed as a study sample when admitted to the labor and delivery area and divided into three groups: 20 women received frequent changes in position (group A), 20 women received back massage (Group B), and 40 women constituted the control group (group C). METHODS: A structured interview questionnaire to collect background data was completed by the researcher in personal interviews with the mothers. The intervention was performed at three points in each group, and pain perception was measured after each intervention using the Face Pain Scale. RESULTS: The mean rank of the difference in pain scores among the study groups was as follows after the first, second, and third interventions, respectively: group A-52.33, 47.00, 49.2; group B-32.8, 30.28, 30.38; group C-38.44, 42.36, 41.21. There were significant differences between groups A, B, and C after the first, second, and third interventions (p1 = .011, p2 = .042, p3 = .024). CONCLUSIONS: Back massage may be a more effective pain management approach than change in position during the first stage of labor.

Satisfação das puérperas atendidas em um centro de parto normal / Satisfaction of puerperal women attended in a normal birth center

Objetivo: analisar a satisfação das puérperas atendidas em um Centro de Parto Normal. Método: estudo qualitativo, descritivo e exploratório, realizado com 20 puérperas. Os dados foram produzidos por entrevistas semiestruturadas, guiadas por um roteiro com perguntas abertas e fechadas, gravadas e transcritas na íntegra, e analisados pela técnica de Análise de Conteúdo na modalidade Análise Temática. Os resultados foram apresentados em categorias temáticas. Resultados: constatou-se satisfação das puérperas com a assistência recebida, sobretudo pelo apoio contínuo das enfermeiras obstetras, uso de tecnologias não invasivas para alívio da dor, estímulo à autonomia e direito à acompanhante. Enalteceram ainda o ambiente por ser privativo, seguro e calmo. Conclusão: as puérperas mostraram-se satisfeitas em relação ao atendimento oferecido pelo Centro de Parto Normal devido à adesão às boas práticas preconizadas pela Organização Mundial de Saúde, legitimando-se como local apropriado para o parto e nascimento.

Women's autonomy in the process of labour and childbirth: integrative literature review. / Autonomia feminina no processo de parto e nascimento: revisão integrativa da literatura.

OBJECTIVE: To identify the available evidence in scientific literature on healthcare practices that interfere with the autonomy of Brazilian women in the labour and delivery process. METHOD: The search for papers was conducted in the databases LILACS, Scopus and PubMed, between 1996 and 2015, according to a guiding question and exclusion criteria, resulting in the selection of 22 papers to compose the analytic body. RESULTS: The main practices that favoured the exercise of women's autonomy were out-of-hospital care practices; care practices of support and comfort; and educational care practices. By contrast, the practices that limited autonomy were authoritarian care practices; standardised or routine care practices; care practices that intensify the painful sensation of childbirth; and impersonal and cold care practice. CONCLUSION: There was an alarming contrast between the daily healthcare routine and ministerial recommendations.

The Effect of Acupressure Applied to Point LI4 on Perceived Labor Pains.

Controlling labor pain is one of the basic goals for caregivers during the birthing process. There are many pharmacological and nonpharmacological methods that are used for controlling pain and helping the mother to cope with pain and have a favorable labor. The study was planned as a randomized, controlled experimental study to detect the effect of acupressure applied to Point LI4 on perceived labor pains. The study sample comprised 88 pregnant women (44 acupressure group, 44 control group), who complied with the study guidelines, agreed with the conditions of the study, and signed the informed consent. Acupressure was applied to the study group when cervical dilatation reached 4 to 5 cm and again when cervical dilation was 7 to 8 cm. Acupressure was applied to Point LI4 on both the hands at the same time from the beginning to the end of the contraction (16 times). Evaluation with the visual analog scale was made 6 times: when the pregnant woman was first admitted to the hospital, before and after acupressure, and within 2 hours after delivery. The control group received routine care. There were statistically significant differences between the groups in subjective labor pain scores (P < .0001). There was a significant difference between the groups in terms of total duration of labor. As shown from our study, applying acupressure to Point LI4 was found to be effective in decreasing the perception of labor pains and shortening the labor (P < .05). Mothers were pleased with this treatment, but they found it insufficient to control their pain.

Autonomia feminina no processo de parto e nascimento: revisão integrativa da literatura / Autonomía femenina en el proceso de parto y nacimiento: revisión integradora de la literatura / Womens autonomy in the process of labour and childbirth: integrative literature review

RESUMO Objetivo Identificar as evidências disponíveis na produção científica acerca das práticas de assistência à saúde que interferem no exercício da autonomia das mulheres brasileiras no processo de parto e nascimento. Método A busca dos artigos foi desenvolvida nas bases de dados LILACS, Scopus e PubMed, no período entre 1996 e 2015, tendo como eixo orientador a questão norteadora e os critérios de exclusão, sendo selecionados 22 artigos como corpus de análise. Resultados Foram evidenciadas como práticas que favorecem o exercício da autonomia feminina: práticas assistenciais extra-hospitalares; práticas assistenciais de apoio e conforto; e práticas assistenciais educativas. Em contrapartida, revelaram-se como práticas limitantes ao exercício da autonomia: práticas assistenciais autoritárias; práticas assistenciais padronizadas ou rotineiras; práticas assistenciais que intensificam a sensação dolorosa do parto; e prática assistencial impessoal e fria. Conclusão Revelou-se uma situação de alerta relativa ao grande descompasso existente entre o cotidiano assistencial e as recomendações ministeriais.

RESUMEN Objetivo Identificar la evidencia disponible en la literatura científica acerca de las prácticas de atención de salud que interfieren con el ejercicio de la autonomía de las mujeres brasileñas en el proceso de parto y el nacimiento. Método La búsqueda de artículos se desarrolló en las bases de datos LILACS, Scopus y en PubMed, en el período comprendido entre 1996 y 2015, con el principio rector de los rectores criterios de interrogación y exclusión, y seleccionó 22 artículos como un corpus de análisis. Resultados Hemos puesto de relieve las prácticas que favorecen el ejercicio de la autonomía de la mujer: las prácticas de atención ambulatoria; prácticas de apoyo y consuelo; prácticas educativas y atención. Por el contrario se han demostrado como una limitación del ejercicio práctico de la autonomía: las prácticas de atención autoritarias; prácticas de cuidados estandarizados o de rutina; cuidado prácticas que mejoran la sensación dolorosa del parto; y la práctica de la atención impersonal y fría. Conclusión Se puso de manifiesto una situación de alerta en el gran desajuste entre su vida cotidiana y recomendaciones ministeriales.

ABSTRACT Objective To identify the available evidence in scientific literature on healthcare practices that interfere with the autonomy of Brazilian women in the labour and delivery process. Method The search for papers was conducted in the databases LILACS, Scopus and PubMed, between 1996 and 2015, according to a guiding question and exclusion criteria, resulting in the selection of 22 papers to compose the analytic body. Results The main practices that favoured the exercise of women’s autonomy were out-of-hospital care practices; care practices of support and comfort; and educational care practices. By contrast, the practices that limited autonomy were authoritarian care practices; standardised or routine care practices; care practices that intensify the painful sensation of childbirth; and impersonal and cold care practice. Conclusion There was an alarming contrast between the daily healthcare routine and ministerial recommendations.

Experiences and perceptions of Ghanaian midwives on labour pain and religious beliefs and practices influencing their care of women in labour.

BACKGROUND: Beliefs surrounding pain during childbirth has biblical foundations that contribute to labour pain being viewed as a natural phenomenon. Contemporary health care promotes evidence-based labour pain management but the faith of the midwife may influence her midwifery practice regarding labour pain management. Therefore this study sought to gain in-depth insight into the experiences and perceptions of midwives regarding labour pain and the religious beliefs and practices influencing their care of women in labour in Ghana. METHODS: The design of the study was an interpretive phenomenology using individual in-depth interviews. The study participants were 27 Ghanaian female midwives of various religious backgrounds. Interviews were conducted in English, audio-taped and transcribed verbatim. Colaizzi's qualitative analysis procedures were employed concurrently with data collection. RESULTS: Three major themes were generated: religious beliefs about labour pain, religious practices in labour and religious artefacts used in labour. The midwives' faith and their experiences during their midwifery practice were inter-connected. The midwives believed labour pain was natural and religious practices are important to prevent complications. Religious artefacts used in labour included anointing oil and water, necklaces, rubber bands, bracelets, stickers and beads. CONCLUSION: It is important that midwives provide an enabling environment for women in labour to practice their faith and they should employ context-appropriate strategies to effectively manage labour pain that takes into account the religious beliefs and practices of women.

Perceptions of labour pain management of Dutch primary care midwives: a focus group study.

BACKGROUND: Labour pain is a major concern for women, their partners and maternity health care professionals. However, little is known about Dutch midwives' perceptions of working with women experiencing labour pain. The aim of this study was to explore midwives' perceptions of supporting women in dealing with pain during labour. METHODS: We conducted a qualitative focus group study with four focus groups, including a total of 23 midwives from 23 midwifery practices across the country. Purposive sampling was used to select the practices. The constant comparison method of Glaser and Straus (1967, ren. 1995) was used to gain an understanding of midwives' perceptions regarding labour pain management. RESULTS: We found two main themes. The first theme concerned the midwives' experienced professional role conflict, which was reflected in their approach of labour pain management along a spectrum from "working with pain" to a "pain relief" approach. The second theme identified situational factors, including time constraints; discontinuity of care; role of the partner; and various cultural influences, that altered the context in which care was provided and how midwives saw their professional role. CONCLUSION: Midwives felt challenged by the need to balance their professional attitude towards normal birth and labour pain, which favours working with pain, with the shift in society towards a wider acceptance of pharmacological pain management during labour. This shift compelled them to redefine their professional identity.

O cuidado de enfermagem vivenciado por mulheres durante o parto na perspectiva da humanização / Nursing care experienced by women during the child-birth in the humanization perspective / La asistencia de enfermaría experimentado por las mujeres durante el parto en perspectiva de humanización

Objetivo: conhecer as vivências das puérperas sobre o cuidado de enfermagem durante o trabalho de parto e parto no que tange a humanização. Método: estudo exploratório-descritivo com abordagem qualitativa, realizado com doze mulheres que aguardavam atendimento em um serviço especializado de Minas Gerais. As informações foram coletadas a partir de um roteiro semiestruturado e analisadas pela Técnica de Análise de conteúdo na modalidade Temática. Resultados: as vivências das puérperas sobre a atuação humanizada da enfermagem são ambíguas, destacam-se a comunicação e o emprego de técnicas não farmacológicos para alívio da dor, todavia, constatam-se a realização de procedimentos provenientes do modelo biomédico. Conclusão: evidenciou-se a necessidade de reformulação na assistência de enfermagem à mulher no parto em prol de ações que reduzam intervenções desnecessárias e devolva à mulher o seu protagonismo.(AU)

Objective: to know the mothers' experiences about the nursing care during the child-birth labor and childbirth regarding the humanization. Method: an exploratory-descriptive study with qualitative approach, conducted with twelve women who were waiting for attendance in a specialized service from Minas Gerais. The information were collected through a semi-structured guide and analyzed by the technique analyzing the contents in the theme mode. Results: the mothers' experiences about the humanized nursing act are ambiguous, and it is noteworthy the communication and the job of the no-pharmacological techniques for the pain relief, however, were found the procedures performances coming from the biomedical model. Conclusion: it was evident the needs for a reformulation in the child-birth nursing assistance to women in favor of actions reducing unnecessary interventions and giving back to the women her main role.(AU)

Objetivo: conocer las experiencias de las madres sobre los cuidados de enfermería durante el parto en relación a la humanización. Método: estudio cualitativo exploratorio-descriptivo, realizado con doce mujeres en espera de tratamiento en un servicio especializado de Minas Gerais. Se recogió a la información de un guión semi-estructurado y analizado por la técnica de análisis de contenido en el modo temático. Resultados: las experiencias de las madres sobre el desempeño humanizado de la enfermería son ambiguos, destacamos la comunicación y el uso de técnicas no farmacológicas para aliviar el dolor, sin embargo, se dan cuenta para llevar a cabo los procedimientos del modelo biomédico. Conclusión: se demostró la necesidad de reformular los cuidados de enfermería para las mujeres en parto a favor de acciones para reducir las intervenciones innecesarias y devolver a la mujer su papel.(AU)

Cuidados de enfermagem à mulher com dor do parto: transformações a partir da pesquisa-ação participativa / Nursing care for women with pain in childbirth: changes from participatory action research / Cuidados de enfermería para las mujeres con dolor en el parto: cambios con respecto a la investigación-accíon participativa

Evidências científicas apontam o excesso de intervenções prejudiciais na atenção às mulheres durante o parto, causando desconforto e dor. O uso de métodos não invasivos e não farmacológicos para alívio da dor do parto implica na participação efetiva da equipe de enfermagem. Objetivo geral: transformar o cuidado de enfermagem às mulheres durante o parto, por meio da utilização de métodos não farmacológicos para alívio da dor. Objetivos específicos: sensibilizar profissionais de enfermagem para o cuidado à mulher com dor do parto; analisar a percepção das profissionais de enfermagem sobre o parto; descrever o conhecimento sobre o cuidado às mulheres por meio do uso de métodos não farmacológicos de alívio da dor e construir coletivamente uma proposta de estratégias para a utilização de métodos não farmacológicos para alívio da dor do parto. Metodologia: estudo descritivo de natureza qualitativa utilizando a abordagem da pesquisa-ação participativa em saúde. Participaram do estudo 18 profissionais de enfermagem de um hospital na Bahia. Os dados foram organizados no software Atlas.ti, categorizados e analisados. Resultados: As participantes percebem o parto normal como experiência positiva; a dor do parto foi descrita como intensa, porém naturalizada; conhecem métodos não farmacológicos de alívio da dor e o definem como um cuidado qualificado. Bola, cavalinho, massagem, banho, deambulação, musicoterapia e aromaterapia foram os métodos mais citados e também utilizados pelas participantes. As dificuldades para realização do cuidado são insuficiência de pessoal; ambiente inadequado; despreparo de profissionais e de acompanhantes; e dificuldade na interação da equipe. As estratégias desenvolvidas foram: oficina de capacitação para o uso dos métodos não farmacológicos de alívio da dor, alocação de espaço destinado ao uso dos métodos pelas mulheres em trabalho de parto, elaboração e divulgação local de tecnologias educativas sobre estes métodos. Ao final da pesquisa, verificamos que o total de mulheres atendidas que utilizaram métodos não farmacológicos para alívio da dor dobrou, em relação à média dos seis meses anteriores, passando de 10% para 23%. Conclusão: A experiência evidencia a importância da utilização da abordagem participativa como mediadora de transformações nas práticas de cuidado em saúde, tanto do ponto de vista da melhoria da qualidade do cuidado prestado às mulheres, como na criação e fortalecimento de vínculos entre as profissionais. A pesquisa possibilitou, ainda, aprofundamento da integração ensino-serviço e maior inserção social do Programa de Pós-graduação em Enfermagem.(AU)

Effective non-pharmacological birth interventions.

Midwifery expertise is in 'normal' birth. What constitutes 'normal' is debatable, but well embedded within 'normal' are the birth plans of women who aspire to give birth without using drugs. To give birth without drugs for many may seem undesirable or intolerable, especially to those whose cultural references to birth have been overwhelmingly negative, fearful or risk-obsessed. However, significant numbers of women have confidence in their innate ability to birth their babies and are rightfully concerned about the undesirable side effects of pharmacological interventions. As well as providing wider choice for women, looking for alternative ways of addressing pain and progress in labour enhances birth attendants' knowledge and becomes a delightful journey of discovering the ancient and modern arts of midwifery. Shared here are a collection of ideas to contribute to the toolkit of knowledge about non-pharmacological interventions.

The power of environment.

In Ten tips for normal birth, the Royal College of Midwives (RCM) (2014) advocates the building of nests; creating an environment that helps women to feel safe and secure during birth, as this can improve women's experiences and likelihood of normal birth. Furthermore, a private, undisturbed and dark environment, where women feel calm and safe can promote the release of oxytocin, the hormone responsible for uterine contractions and thought to promote the release of the pain relieving hormones endorphins (Uvnas Moberg 2003). When this is not achieved, women can experience fear-tension-pain syndrome, impeding labour progress and causing increased levels of pain (Dick-Read 2013). In addition, birth space has the potential to encourage the promotion of normality through providing space to mobilise, and alternative furniture to enable upright birth positions. Midwives should help women to create a birth space in which they feel safe, calm and secure, to promote normality and increase the incidence of normal birth (RCM 2014).

The rise of remifentanil and the decline of midwifery autonomy.

Since the 1980s epidural analgesia has been considered the gold standard for pain relief in labour. Over the past decade there has been a growing trend in UK maternity units to offer remifentanil PCA as a fast, safe alternative for women where epidural analgesia is contraindicated. Increasingly more obstetric units and anaesthetists are extending the use of remifentanil and in many units it is now preferred over central neuroaxial blocks (Stocki et al 2014). It would appear that remifentanil is being hailed as the panacea for labour pain. Whilst discussion around the use and effects of remifentanil is very well documented in anaesthetic journals, there is very little midwifery research around this subject. Following a review of the current evidence, this article will explore the use of remifentanil in labour, consequences for women and neonates and implications for midwifery practice.