Table Of ContentHolistic Pain
Management in
Pregnancy
What RNs, APRNs, Midwives
and Mental Health
Professionals Need to Know
Theresa Mallick-Searle
Editor
123
Holistic Pain Management in Pregnancy
Theresa Mallick-Searle
Editor
Holistic Pain Management
in Pregnancy
What RNs, APRNs, Midwives and Mental
Health Professionals Need to Know
Editor
Theresa Mallick-Searle
Division of Pain Medicine
Stanford Health Care
Redwood City, CA, USA
ISBN 978-3-031-06321-3 ISBN 978-3-031-06322-0 (eBook)
https://doi.org/10.1007/978-3-031-06322-0
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
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Preface
In conducting my research for this book, along with my personal experiences as a
registered nurse for over 25 years and a nurse practitioner in pain management for
over 20, caring for patients with chronic and acute pain during pregnancy, I discov-
ered a real need in the community to provide a practical education guide for the
advanced practice registered nurse, bedside and clinic nurse, and Midwife. My
objective is to provide the reader with the most up-to-date clinical information
available on assessment and management of pain during pregnancy, applying a nur-
turing and holistic approach to the patient. An overview to the scope of the need,
including a discussion on the use of opioids and the incidence of opioid use disorder
will be covered. Things that you can do to help your patient in preparation for a
healthy pregnancy will be reviewed, including optimization of diet, nutrition, fit-
ness, mental health, and stabilization of chronic pain conditions. A few of the most
common pain conditions that can present or worsen with pregnancy will be evalu-
ated, including low back pain, pelvic girdle pain, migraine, and fibromyalgia.
Redwood City, CA, USA Theresa Mallick-Searle
v
Contents
1 Introduction to Pain in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Theresa Mallick-Searle
2 Background and Medication Overview . . . . . . . . . . . . . . . . . . . . . . . . . 9
Theresa Mallick-Searle
3 Opioids and Opioid Use Disorder (OUD) in Pregnancy . . . . . . . . . . . . 27
Theresa Mallick-Searle
4 Nutrition and Microbiome: In Preparation for Pregnancy . . . . . . . . . 33
Cynthia Belew
5 Behavioral Management for Pain in Pregnancy . . . . . . . . . . . . . . . . . . 79
Valerie W. Jackson, Iulia Gambro Irina Ivan, and Karen Choe
6 Musculoskeletal Pain during Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . 97
Laurel Short and Shannon DeSalvo
7 Migraine in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Theresa Mallick-Searle and Maureen Moriarty
8 Fibromyalgia/Generalized Body Pain during Pregnancy . . . . . . . . . . . 141
Theresa Mallick-Searle
9 Use of Nerve Blocks and Neuromodulation in Pregnancy . . . . . . . . . . 153
Theresa Mallick-Searle
10 Complementary Treatments in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . 163
Theresa Mallick-Searle
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
vii
Introduction to Pain in Pregnancy 1
Theresa Mallick-Searle
Pain is as common to being human as breathing. Pain is a physiologic response to
the exposure of noxious stimuli that is built into our DNA [1]. Pain is protective; the
“pain response” is what helps us escape or remove ourselves from potential further
harm or even death. Our current understanding as to the pathophysiology of pain is
broken down into four distinct phases: transduction, transmission, perception, and
modulation (Fig. 1.1). It is through these phases that pain is experienced [2].
Transduction occurs at the point of tissue insult, where primary afferent neurons are
activated by a noxious stimulus, such as a burn. Transmission occurs when the nerve
impulses are transmitted from the periphery (site of injury) to the dorsal horn of the
spinal cord. Perception occurs as part of the ascending pain pathway, when the
nerve impulse ascends to the regions of the brain responsible for pain perception
(somatosensory cortex, insular cortex, prefrontal cortex, anterior cingulate cortex,
thalamus, amygdala, nucleus accumbens). Finally, modulation occurs in parallel to
the activation of the ascending and descending pathways. Where within the periph-
ery, the spinal cord, and in the brain, chemical changes are occurring in the nervous
system to bring about homeostasis and reduce the noxious impact of the pain
response [2].
To best set the stage for a robust discussion about pain in pregnancy, we will
spend some time here defining some basic concepts in pain. Pain is generally defined
as being acute or chronic. Acute pain is pain that is anticipated, generally has a
known cause, and is short-lived. Chronic pain is maintained pain that general out-
lasts its protective benefit, often has multiple causes, is associated with much emo-
tional suffering and disability, is ongoing or recurrent, and continues beyond the
anticipated time of tissue healing (3–6 months) [3]. A newer term that has been
T. Mallick-Searle (*)
Division of Pain Medicine, Stanford Health Care, Redwood City, CA, USA
e-mail: [email protected]
© The Author(s), under exclusive license to Springer Nature 1
Switzerland AG 2022
T. Mallick-Searle (ed.), Holistic Pain Management in Pregnancy,
https://doi.org/10.1007/978-3-031-06322-0_1
2 T. Mallick-Searle
4 Perception in the brain
(modulation occurs)
5 Descending pathway
(down regulation)
3 Transmission along
spine up to brain
1 Injury (modulation occurs)
2 Transmission along
mixed fiber neurons
(modulation occurs)
Fig. 1.1 Neuromechanisms of pain. (Adapted from CORE-REMS: Pain Management and
Opioids: Balancing Risks and Benefits. WWW.CORE- REMS.ORG)
Table 1.1 Types of pain [5, 6]
Nociceptive/inflammatory Nociplastic Neuropathic
• Pain in response to injury or • Pain arising from altered • Pain that develops when the
stimuli; typically acute nociceptive function; nervous system is damaged;
typically chronic typically chronic
• Examples: postoperative • Examples: fibromyalgia, • Examples: postherpetic
pain, sports injuries, irritable bowel neuralgia, trigeminal neuralgia,
arthritis, sickle cell disease, syndrome, nonspecific distal polyneuropathy,
mechanical low back pain low back pain neuropathic low back pain
coined, to define pain presentation is “high-impact chronic pain.” This term is used
to define chronic pain that is experienced with such regularity that it interferes in
patients’ lives (work, social, self-care activities) on most days or every day during
the last 6 months [4]. There are three types of pain characteristics which are descrip-
tive and to some degree may identify sources of ongoing stimulus: neuropathic,
nociceptive, and nociplastic (Table 1.1). Nociceptive pain is defined as pain that is
related to insult of somatic or visceral tissues due to trauma or inflammation.
Examples of nociceptive pain would be childbirth or chronic axial low back pain.
Neuropathic pain is defined as pain related to insult of peripheral and/or central
1 Introduction to Pain in Pregnancy 3
nerves. Examples of neuropathic pain would be diabetic peripheral neuropathy or
lumbar radiculopathy. Nociplastic pain, a new term introduced by the International
Association for the Study of Pain (IASP) in 2017, defined as pain without identifi-
able nerve or tissue insult, thought to result from persistent neuronal dysregulation.
An example of nociplastic pain is fibromyalgia [5].
After 40 years, the IASP introduced a revised definition of pain, in the hopes that
it would lead to improved assessment and management of those with pain. The new
definition is: “An unpleasant sensory and emotional experience associated with, or
resembling that associated with, actual or potential tissue damage” [7]. This revised
definition was put forth to try and encapsulate the subjective and objective nature of
pain. A reflection that:
• Pain is always a personal experience that is influenced to varying degrees by
biological, psychological, and social factors.
• Pain and nociception are different phenomena. Pain cannot be inferred solely
from activity in sensory neurons.
• Through their life experiences, individuals learn the concept of pain.
• A person’s report of an experience as pain should be respected.
• Although pain usually serves an adaptive role, it may have adverse effects on
function and social and psychological well-being.
• Verbal description is only one of several behaviors to express pain; inability to
communicate does not negate the possibility that a human or a nonhuman animal
experiences pain [7].
Pregnancy and childbirth are essential to the existence of any species. In humans,
ethnicity and cultural influences play a powerful role in the experience. Although
we will not spend a lot of time in the discussion of cultural influences on the pain
experience, I think that it is important to examine some common cultural influences
on pain management. Having a better understanding of the role that ethnicity and
culture play in pain, pregnancy, and childbirth will provide the healthcare provider
with greater insights to the best, acceptable treatment approaches compatible with
the patient’s beliefs and needs. There has been much written about the influence that
culture and ethnicity have on the pain experience [8–12]. Additionally, there have
been writings published on the influence of culture and ethnicity on pregnancy and
childbirth [13–16]. What is lacking in the literature is a combined examination of
the role that cultural influences directly have on the pain experience in pregnancy.
We can surmise that when the cultural beliefs and practices of the individual are
supported and respected by the healthcare community, then there is much more
harmony during the pregnancy. However, when the mainstay of the healthcare com-
munity conflicts with the values and culture of the individual, this can lead to not
only a negative experience for the pregnant female, but also possibly worsen the
pain experience.
The experience of a healthy pregnancy, safe childbirth, and successful bonding
during the perinatal period is what we all strive for in the care of our patients. With
many other critical aspects of care to be knowledgeable about and competent to
4 T. Mallick-Searle
provide, often the importance of making pain management a priority gets over-
looked. Pain during pregnancy is common, and its management is complex. Poorly
managed pain can result in adverse maternal outcomes such as depression, sleep
deprivation, hypertension, as well as poor fetal outcomes [17–19]. Advanced prac-
tice registered nurses (APRNs), nurses, and midwifes need to have a basic under-
standing of patient assessment and the basics of a pain history. If there is a history
of chronic pain and substance use, the assessment needs to be expanded to include
a standard pain history and assessment.
Aspects of a complete pain history include the follow:
• Pain assessment (Fig. 1.2): descriptors (location, intensity, severity, quality,
duration, variations), treatments trialed, effects of pain on physical, emotional,
psychosocial function, and examination (focus of general observation, musculo-
skeletal, neurological, cutaneous) [20].
• Inclusion of past medical and treatment history (Fig. 1.3): nonpharmacologic
strategies trialed and effectiveness, pharmacologic strategies trialed and effec-
tiveness, relevant illness, and past and current opioid use [21].
• Complete social and psychological history (Fig. 1.4).
The use of validated pain assessment tools (Fig. 1.5) can help structure the evalu-
ation and expedite the process. Commonly use assessment tools in pain manage-
ment include the brief pain inventory (BPI), 5-As, chronic pain grade questionnaire
(CPG), PEG three-item scale [22].
We will cover the risk assessment that should be covered in patients with an opi-
ate use disorder, substance abuse disorder, or you considering for chronic opioid
use, in Chap. 3.
Description of Pain
Onset/ Variations/
Location Intensity Quality
Duration Patterns/Rhythms
What Relieves the Pain?
What Causes or Increases the Pain?
Effects of Pain on Physical, Emotional, and Psychosocial Function
Patient’s Current Level of Pain and Function
Fig. 1.2 Pain assessment
