AUXILIARY
PAIN RELIEF DURING SUCTION CURETTAGE
Arthur G. Shapiro, M.D., F.A.C.O.G. Barry Cohen, M.D., F.A.C.O.G.
Departments of Obstetrics-Gynecology and Anesthesiology University of Miami School of Medicine Miami, Florida
ABSTRACT
Three groups of patients who were undergoing suction curettage with a paracervical block were studied for the effect of pain relief using an ancillary analgesic in the form of self-administered methoxyflurane or headphones with stereophonic music. The results indicated that the headphones produced less tension and anxiety and therefore, less complaint of pain than the control group. Methoxyflurane did not show any improvement in pain relief but was at times associated with an amnesic response to the procedure and less post-abortion cramping.
Accepted
for publication
JANUARY
1975
September 25,
VOL.
11 NO. 1
1974
25
CONTRACEPTION
INTRODUCTION
In the last few years, out-patient suction curettage has become an acceptable, safe method for termination of pregnancy in the first trimester. Most abortion facilities use a paracervical block for analgesia. This study was undertaken to see if there was any advantage to using additional analgesia in the form of self-administered methoxyflurane or stereophonic headphones.
MATERIALS AND METHODS
Suction curettage was carried out at the University of Miami Hospital, Out-Patient Department, on patients between 6 and 12 weeks gestation. The patients were studied in a randomized fashion in three groups: (a) control, (b) self-administered methoxyflurane and (c) stereophonic headphones. All patients were exposed to identical preoperative screening procedures including history, physical and laboratory examination and contraceptive counseling. Neither the patient nor her individual counselor knew in advance which ancillary anesthesia, if any, would be used. All patients received 10 milligrams of Valium* orally, which was administered approximately one to two hours before the procedure. At the start of the procedure, a paracervical block was administered using a total of 2Occ of 1% Carbocaine** Thereafter, the patient received either: (a) no further analgesia, (b) self-administered methoxyflurane or The methoxyflurane was administered using a Pentec (c) stereophonic headphones. Mark II (manufactured by Cyprane, Ltd., Keighley, England)? The machine was set at 0.5, which is equal to 0.5 volume per cent and the concomitant oxygen flow rate was set at five liters er minute. The stereophonic headphones used iiere llianuracturedby Panasonic (RP (Matsushita Electric Corporation of America) model # RF60. The type of music was left to the patient's discretion. The amount of pain was judged on the basis of the patient's response to the abortion procedure. For each case, analgesia was scored by the patient, physician, nurse and counselor.
*Valium (R) - Roche Labs, Nutley, New Jersey (R) - Winthrop Labs, New York **Carbocaine +Supplied courtesy of Abbott Labs, North Chicago,
26
Illinois
JANUARY
1975 VOL. 11 NO. 1
CONTRACEPTION
The scoring was defined as follows:
Patient Score
Staff Score
"Absolutely no pain" or "minimal cramping"
0
No observable of pain
signs
1+
Some movement or grimace during the procedure
"I had some pain"
2+
Moderate amount of pain
"It really hurt--very uncomfortable"
3+
Severe pain, no relief
"Very painful-Excruciating"
RESULTS
The three groups were similar on the basis of race and parity (Tables I and II). The control and the methoxyflurane groups appear to have the same incidence of pain (Table III); among the 24 patients with no pain in the methoxyflurane group, 10 also experienced amnesia from the procedure. In addition, the patients who were in the methoxyflurane group had fewer complaints of post-abortion cramping in the recovery room. The group using the headphones had less than half the incidence of pain than the other two groups. In addition, all of the staff felt that the patients in this group were much better able to relax than the other two groups. TABLE I
DISTRIBUTION
OF THE PATIENT POPULATION ACCORDING
Control
Methoxyflurane
TO RACE
Stereo Music
White
30
25
30
Black
9
15
17
Spanish
7
Total
JANUARY 1975
46
VOL. 11 NO. 1
6
5 45
53
27
CONTRACEPTION
TABLE II
DISTRIBUTION
OF THE PATIENT POPULATION ACCORDING
Control
Methoxyflurane
TO PARITY
Stereo Music
Primipara
28
21
25
Multipara
18
24
28
Total
46
45
53
TABLE III
AMOUNT OF PAIN RELIEF OBTAINED IN EACH OF THE THREE GROUPS TESTED
Severity of Pain
28
0
1+
2+
3+
Control Number Percentage
24 52
13 28
7 15
2 5
Methoxyflurane Number Percentage
24 53
9 20
9 20
3 7
Stereo Music Number Percentage
45 05
5 9
3 6
0 0
JANUARY
1975 VOL. 11 NO. 1
CONTRACEPTION
DISCUSSION
Self-administered methoxyflurane has been used for post-operative pain, labor and instrumental vaginal delivery (1,2,3). The apparent lack of analgesic benefit by methoxyflurane in this study may be partly explained by the tremendous overlay of anxiety as displayed by the patients during their pre-abortion interviews. Furthermore, because of the very nature of the drug (high lipid solubility; slow uptake and distribution), adequate blood levels On the are not achieved within the short time span of an abortion procedure. other hand, during labor, the intermittent use of methoxyflurane over a longer period of time allows for the accumulation of blood levels adequate enough to produce an analgesic effect (2). For this reason, methoxyflurane is probably not an ideal agent for short operative procedures. Nitrous oxide 50% and oxygen, in a premixed cylinder*, administered on demand may have been more effective as an analgesic; however, this gas mixture has not been approved for clinical use by the U.S. Food and Drug Administration. Certainly, its characteristics are such as to provide excellent short-term analgesic and would be the only practical self-administered delivery system for nitrous oxide analgesic in an out-patient setting. Headphones with stereophonic music for relief of pain has been used for many yearn indentists' offices. This present study seems to indicate its successful adaptability to out-patient abortion analgesia. The headphone music was observed to create a state of detachment and relaxation in virtually all of the patients in this group. Patients who were nervous and difficult to examine during the pre-operative screening pelvic examination were noted to become relaxed and cooperative when the headphone music was administered in the procedure room. In addition, the headphone music tended to drown out the noise of the suction machine and thereby kept the patients unaware that the curettage had actually begun. There is no doubt that anxiety heightens any amount of pain which a patient Therefore, it is most important that the physician. nurse and counselor experiences. Moreover, this try to allay any of the patient's fears about the abortion procedure. study seems to indicate that one simple way of helping to allay the patient's anxiety would be the administration of an auditory stimulus in the form of headphones with stereophonic music.
* Entonox - Puritan Oxygen Corp., Kansas City, Missouri
JANUARY 1975
VOL. 11 NO. 1
29
CONTRACEPTION
REFERENCES
1.
Yakaitis, R.W. Cooke, J.E. and Redding, J.S.: Self-administered methoxyflurane for post-operative pain: effectiveness and patient acceptance. Anesth Analg 51: 208-212, 1972.
2.
Latto, I.P. Rosen, M. and Molloy, M.J.: Absence of accumulation of methoxyflurane during intermittent self-administration for pain relief in labor. Br J. Anaesth 44: 391-399, 1972.
3.
Fielding, M.E. and Hurry, D.J.: Analgesia in instrumental vaginal delivery by the intermittent self-administration of methoxyflurane using a disposable Br J. Anaesth 44: 386-389, 1972. vaporizer.
30
JANUARY 1975
VOL. 11 NO. 1
PAIN RELIEF DURING SUCTION CURETTAGE
Arthur G. Shapiro, M.D., F.A.C.O.G. Barry Cohen, M.D., F.A.C.O.G.
Departments of Obstetrics-Gynecology and Anesthesiology University of Miami School of Medicine Miami, Florida
ABSTRACT
Three groups of patients who were undergoing suction curettage with a paracervical block were studied for the effect of pain relief using an ancillary analgesic in the form of self-administered methoxyflurane or headphones with stereophonic music. The results indicated that the headphones produced less tension and anxiety and therefore, less complaint of pain than the control group. Methoxyflurane did not show any improvement in pain relief but was at times associated with an amnesic response to the procedure and less post-abortion cramping.
Accepted
for publication
JANUARY
1975
September 25,
VOL.
11 NO. 1
1974
25
CONTRACEPTION
INTRODUCTION
In the last few years, out-patient suction curettage has become an acceptable, safe method for termination of pregnancy in the first trimester. Most abortion facilities use a paracervical block for analgesia. This study was undertaken to see if there was any advantage to using additional analgesia in the form of self-administered methoxyflurane or stereophonic headphones.
MATERIALS AND METHODS
Suction curettage was carried out at the University of Miami Hospital, Out-Patient Department, on patients between 6 and 12 weeks gestation. The patients were studied in a randomized fashion in three groups: (a) control, (b) self-administered methoxyflurane and (c) stereophonic headphones. All patients were exposed to identical preoperative screening procedures including history, physical and laboratory examination and contraceptive counseling. Neither the patient nor her individual counselor knew in advance which ancillary anesthesia, if any, would be used. All patients received 10 milligrams of Valium* orally, which was administered approximately one to two hours before the procedure. At the start of the procedure, a paracervical block was administered using a total of 2Occ of 1% Carbocaine** Thereafter, the patient received either: (a) no further analgesia, (b) self-administered methoxyflurane or The methoxyflurane was administered using a Pentec (c) stereophonic headphones. Mark II (manufactured by Cyprane, Ltd., Keighley, England)? The machine was set at 0.5, which is equal to 0.5 volume per cent and the concomitant oxygen flow rate was set at five liters er minute. The stereophonic headphones used iiere llianuracturedby Panasonic (RP (Matsushita Electric Corporation of America) model # RF60. The type of music was left to the patient's discretion. The amount of pain was judged on the basis of the patient's response to the abortion procedure. For each case, analgesia was scored by the patient, physician, nurse and counselor.
*Valium (R) - Roche Labs, Nutley, New Jersey (R) - Winthrop Labs, New York **Carbocaine +Supplied courtesy of Abbott Labs, North Chicago,
26
Illinois
JANUARY
1975 VOL. 11 NO. 1
CONTRACEPTION
The scoring was defined as follows:
Patient Score
Staff Score
"Absolutely no pain" or "minimal cramping"
0
No observable of pain
signs
1+
Some movement or grimace during the procedure
"I had some pain"
2+
Moderate amount of pain
"It really hurt--very uncomfortable"
3+
Severe pain, no relief
"Very painful-Excruciating"
RESULTS
The three groups were similar on the basis of race and parity (Tables I and II). The control and the methoxyflurane groups appear to have the same incidence of pain (Table III); among the 24 patients with no pain in the methoxyflurane group, 10 also experienced amnesia from the procedure. In addition, the patients who were in the methoxyflurane group had fewer complaints of post-abortion cramping in the recovery room. The group using the headphones had less than half the incidence of pain than the other two groups. In addition, all of the staff felt that the patients in this group were much better able to relax than the other two groups. TABLE I
DISTRIBUTION
OF THE PATIENT POPULATION ACCORDING
Control
Methoxyflurane
TO RACE
Stereo Music
White
30
25
30
Black
9
15
17
Spanish
7
Total
JANUARY 1975
46
VOL. 11 NO. 1
6
5 45
53
27
CONTRACEPTION
TABLE II
DISTRIBUTION
OF THE PATIENT POPULATION ACCORDING
Control
Methoxyflurane
TO PARITY
Stereo Music
Primipara
28
21
25
Multipara
18
24
28
Total
46
45
53
TABLE III
AMOUNT OF PAIN RELIEF OBTAINED IN EACH OF THE THREE GROUPS TESTED
Severity of Pain
28
0
1+
2+
3+
Control Number Percentage
24 52
13 28
7 15
2 5
Methoxyflurane Number Percentage
24 53
9 20
9 20
3 7
Stereo Music Number Percentage
45 05
5 9
3 6
0 0
JANUARY
1975 VOL. 11 NO. 1
CONTRACEPTION
DISCUSSION
Self-administered methoxyflurane has been used for post-operative pain, labor and instrumental vaginal delivery (1,2,3). The apparent lack of analgesic benefit by methoxyflurane in this study may be partly explained by the tremendous overlay of anxiety as displayed by the patients during their pre-abortion interviews. Furthermore, because of the very nature of the drug (high lipid solubility; slow uptake and distribution), adequate blood levels On the are not achieved within the short time span of an abortion procedure. other hand, during labor, the intermittent use of methoxyflurane over a longer period of time allows for the accumulation of blood levels adequate enough to produce an analgesic effect (2). For this reason, methoxyflurane is probably not an ideal agent for short operative procedures. Nitrous oxide 50% and oxygen, in a premixed cylinder*, administered on demand may have been more effective as an analgesic; however, this gas mixture has not been approved for clinical use by the U.S. Food and Drug Administration. Certainly, its characteristics are such as to provide excellent short-term analgesic and would be the only practical self-administered delivery system for nitrous oxide analgesic in an out-patient setting. Headphones with stereophonic music for relief of pain has been used for many yearn indentists' offices. This present study seems to indicate its successful adaptability to out-patient abortion analgesia. The headphone music was observed to create a state of detachment and relaxation in virtually all of the patients in this group. Patients who were nervous and difficult to examine during the pre-operative screening pelvic examination were noted to become relaxed and cooperative when the headphone music was administered in the procedure room. In addition, the headphone music tended to drown out the noise of the suction machine and thereby kept the patients unaware that the curettage had actually begun. There is no doubt that anxiety heightens any amount of pain which a patient Therefore, it is most important that the physician. nurse and counselor experiences. Moreover, this try to allay any of the patient's fears about the abortion procedure. study seems to indicate that one simple way of helping to allay the patient's anxiety would be the administration of an auditory stimulus in the form of headphones with stereophonic music.
* Entonox - Puritan Oxygen Corp., Kansas City, Missouri
JANUARY 1975
VOL. 11 NO. 1
29
CONTRACEPTION
REFERENCES
1.
Yakaitis, R.W. Cooke, J.E. and Redding, J.S.: Self-administered methoxyflurane for post-operative pain: effectiveness and patient acceptance. Anesth Analg 51: 208-212, 1972.
2.
Latto, I.P. Rosen, M. and Molloy, M.J.: Absence of accumulation of methoxyflurane during intermittent self-administration for pain relief in labor. Br J. Anaesth 44: 391-399, 1972.
3.
Fielding, M.E. and Hurry, D.J.: Analgesia in instrumental vaginal delivery by the intermittent self-administration of methoxyflurane using a disposable Br J. Anaesth 44: 386-389, 1972. vaporizer.
30
JANUARY 1975
VOL. 11 NO. 1
