Sarah Lavonne:
Hi, I am Sarah Lavonne, and I'm so glad you're here. Here at Bundle Birth, we believe that your life has the potential to make a deep, meaningful impact on the world around you. You, as a nurse, have the ability to add value to every person and patient you touch. We want to inspire you with the resources, education, and stories to support you to live your absolute best life, both in and outside of work. But don't expect perfection over here. We're just here to have some conversations about anything, birth, work, and life, trying to add some happy to your hour as we all grow together. By nurses, for nurses, this is Happy Hour with Bundle Birth Nurses.
I remember the first time that I had seen a TENS used in labor. It was definitely at my Beverly Hills hospital. I'd never seen a TENS. I'd barely seen a doula at my very first hospital in East LA. And this patient had come in with a doula. She was a home birth transfer and had her TENS machine, and this lady was locked in with this thing. And sure enough, she needed a little bit of pitch. She sort of stalled a little bit out at home. Her contraction were eight minutes. How I remember that? Don't ask me why, but I do remember her having this TENS machine on, and she was obsessed. And I felt like it was so interesting for me to watch her engage with it. And it sort of gave her something to do. She was so in the zone, and she used it for her entire labor.
She never required any pharmacological medication to help her cope with labor, and she did it. And so I really hadn't seen too many other experiences with a TENS unit, and so it really wasn't until I started doing research for the physiologic coping class for our Move Learning Retreat in 2023. That was the theme of learning. Next theme of learning will be different. But what I wanted to do was expand on the physiologic birth class and really look at pain in labor, understanding that none of the physiology works if they're not coping. If they're fully flailing around and completely out of control and losing their minds and fully traumatized by the experience, none of the physiologic birthing stuff that we teach is ever going to be effective. And so I wanted to know, is there a way to hack the labor pain so that the patient can cope better?
And how do we equip us as nurses to understand the physiology of pain, how it works in the body, and how therefore, we can help support the patient to cope better, leading to obviously potentially for less interventions, less of a poor experience, and ultimately hopefully a vaginal birth and the patient getting what they want. And so as a part of that, that led me down a rabbit hole where I ended up looping back into the land of learning about use of a TENS machine during labor. And so that is what this episode is about. It's going to be your little mini class on a TENS. I do dream about doing an actual class on TENS use in labor. It's in the docket. There's a lot of other things in the docket in the meantime. And so I want to teach you what is the TENS, what's it used for, why does it potentially work, what's the evidence say, how to use it, what is its contraindications, and how it might be potentially something that you could bring as a change project and/or add to your comfort carts on your unit.
Because I think the more choice that we can give our patients, the more options we give them, the more in control they feel, and we know that that correlates with birth satisfaction. So what is a TENS machine? TENS actually stands for Transcutaneous Electrical Nerve Stimulation. My first experience with a TENS personally was after a back injury. So I actually injured my back three times on the job and was out at various times, and then I got into a car accident which left me in physical therapy for a year working with this pain of my back. And the TENS was one of those things that I felt like was when he did the TENS versus just a chiropractic adjustment, it really, really helped me, and then also helped with the pain in the moment. And so of course, my curious brain got going crazy, and so I did actually learn about TENS during the time. And really what it is, if you've never tried it before, it's this basically low voltage electrical stimulation.
So I know it's like electrical nerve stimulation, but it's basically this buzzing electricity that goes through these leads. And imagine the sticky stickers like what we use for the EKG. It's like big pads like that. And really the surface area does matter, so they're pretty large, that in the case of labor are placed on the back, and they send these electrical buzzing, is the best way that I can describe it, from cords that come from a little machine. And the patient has the ability to increase or decrease the stimulation. But what it does is that it sends this electrical nerve stimulation in various places based on wherever the stickers are placed.
And it really goes into the gate control theory. So the reason why this may be effective, and I'll tell you the evidence in a second, and the theory behind it is the gate control theory. And so really what the gate control theory is is that we basically have this pathway of pain. So imagine there's pain, there's a painful stimuli somewhere in the body, and then there's this pathway for that pain signal to get to the brain. So if you imagine on a spectrum, there's pain at one end, your brain on the other, and then there are certain things that we can do. And the key with the gate control theory is non painful stimuli. So that non painful input basically gets in the way and dulls the sensation as the pain sensation travels to the brain. So by the time that sensation gets to the brain, it's less painful.
I have a visual of this in our Physiologic Coping class, which by the way, you can get, and you can learn all about this in visible form. You can see me on camera talking about all this. But regardless that, if you imagine... And actually, I do give you this example. If you want to bang your knuckles on a hard table and bang them really hard to the point where it hurts, again, use at your own discretion, what do we naturally do when we were to bang a hand or stub a toe? You naturally want to rub the area, right? And in fact, my niece and nephew had been staying with me, and Riley had hit her arm on something and she was holding her arm. And so I went over and I just started vigorously rubbing the area, and she kind of looked at me all like, oh, it's fine, and then stopped crying. And it was no big deal anymore. And again, maybe she would've stopped crying, but the idea is that when you create a non-painful distraction, the signal to the brain is dulled.
So a lot of times for the gate control theory, that is rubbing, that could be pressure. What do we do when we bang ourselves? We hold the place, we put pressure on it, and that decreases the capability of that signal getting to the brain. Cold also helps with gate control theory, but the goal is to reduce the pathway to the brain. And TENS is another way that is a way to stimulate the area, whatever area that is, to decrease the chance of the full painful stimuli getting and reaching the brain. Now, let's be very clear, and I talk about this in Physiologic Coping too, is that when we look at the evidence on pain reduction in labor, which I love, of course, so I pull up the Cochrane. So there's this Cochrane review on pain management for women in labor, an overview of systematic reviews, which is from 2012, so it's old. But it hasn't really been redone ever since, and so this is the most recent we have on this specific thing.
So when we look at pain management of what works and what may work and what has insufficient evidence on it, it sort of splits it up in these things. But let's be clear, when we're looking at pain management in labor, the question we need to ask when we're looking at these articles is, are we looking for pain relief, or are we looking for pain cessation, meaning to remove the pain? Because if we look at these systematic reviews, what do they tell us? They tell us everything that we already know that makes all the sense in the world. And why did we pay for research studies on this?
What works for pain management is an epidural and inhaled anesthesia to effectively manage pain. Mind you, they may have adverse outcomes or adverse effects, but that's what works for labor pain management. Well, of course, if you're trying to manage the pain and remove the pain, then of course that's what's going to work. And so then what they say is, what might work is water immersion, relaxation, acupuncture, massage, local nerve blocks like sterile water injections, non-opioid drugs, sedatives. And so that may work, but when we're talking about it working or not, it's not really meant to have full pain relief. I'm not going to throw you in a tub and expect for your contractions to go away and you no longer feel them. That's not really the goal, unless it is the goal. And that's where, for me, I had this aha moment as I was going through the literature on pain relief and labor.
It's like, is the goal pain relief? Because Cochrane definitely seems to think so, but is that the patient's goal? And then that leads us into, what is our own bias around pain and labor? Because there's sort of these two theories, and this comes from Leap and Anderson, and I do talk about this extensively in the Physiologic Hoping class, which, by the way, is probably my favorite class I've ever taught and put together. But the idea of pain relief is this concept of, in your brain, of what you think is that pain is abnormal and unnecessary. And so if you believe in pain relief, in that theory, then you're always going to believe that the benefits of anesthesia will always exceed the risk. That is the goal. Why wouldn't you get an epidural? The goal is to be pain-free. That's what I'm here for. And let's think about how we're trained as birth professionals.
We're very much trained as birth professionals to relieve the pain. It's the sixth vital sign, right? But in labor it's so different. And so the goal then would be to consider shifting your brain to more of a working with pain model. And that assumes that pain has a physiologic role in birth, and that when they're properly prepared and supported, they have endogenous analgesic substances that support them to work with the pain. And so when we think about our goals or we look at these systematic reviews, if the goal is working with the pain, then any intervention that helps the patient work with the pain versus provide full pain relief is valid. And often, what are we hearing in our practice when we talk about getting in the water or even our spiky balls? Which by the way, our spiky balls are like the one thing that when I'm at births are like... They get so attached to them. It works very, very well, and that's because it helps release endorphins, or a TENS unit, right?
And so when we look at the evidence that said that there was little difference between groups for most of the comparisons, examining pain intensity, satisfaction, or assisted vaginal birth. This comes from Cochrane in 2013. When I read something like that, what do we expect our doctors to be telling us? Well, there's no evidence on it, and then we throw it out the window. Whereas we have to look at the big picture of birth satisfaction, of... Even there's a 2020 study by Daniel Benson and Hoover that said in 78% of cases, the TENS helped with pain and 72% of people would use it again. Is that enough to be able to offer this on our units? Is it potentially something that has so low risk? And actually, the number one thing that people ask is, does it interfere with our monitoring?
It shouldn't interfere with your monitoring, maybe a Monica. But again, you don't know until you try. And if it interferes, then it interferes, and then you don't do it, right? But either way, is there satisfaction? And is their ability to work with the pain enough for us to be able to offer this as an option for our patients? That's the question I'm going to pose. So as we learn about the TENS in labor, we know that it comes from a gate control theory. I'm going to read you just a component from UpToDate because UpToDate has a very quick and easy quick and dirty little piece on TENS, and then I'm going to explain to you a little bit more from my experience, and how to use it and whatnot. So they say that TENS is the transmission of low voltage electrical impulses from a handheld battery powered generator to the skin via surface electrodes.
So TENS units are specifically designed for use for laboring patients. And they should be, by the way. And we just got ours in stock, which I'll tell you about later. And are available for rent, without a doctor or midwife's order, in drug stores and medical equipment companies in many countries. Most TENS units allow the wearer to adjust frequency, intensity, and waveform, which is lovely. That's more control. Anytime that we can give more control to our patients, it correlates with burst satisfaction. What is some of the other evidence on TENS use in labor? So UpToDate mentions a 2023 systematic review, which was 10 randomized trials including 1,214 pregnant people. They compared TENS for management of labor pain with routine care and concluded that the TENS was more effective than routine care in decreasing labor pain scores. However, the significance of this amount of pain reduction is less clear.
A subsequent trial that randomly assigned 46 low risk laboring persons to either TENS or usual care reported an 11 point reduction or 10% in pain levels after treatment and five hour longer mean time until initiation of medication in the TENS group. And that really goes to delaying epidurals and having less exposure to medical interventions, which is correlated with better outcomes. So some other things that I found in the evidence was it helps increase oxytocin and endorphin release and helps decrease cortisol, which is our stress response. Anytime we lower our stress response in labor, that's going to help speed up labor. Hello. In one study, they found a shorter first and second stage of labor, potentially because the patient was more relaxed. Reduce pain scores, less anxiety, help postpone other pharmacological interventions. And the goal, and really the common denominator was to start it earlier than labor. So that later or late early labor timeframe was always the best, three centimeters on, again, if you're not checking them, but an early labor before things get too intense because it sort of has this building effect where it gets more and more effective over time.
Now, some patients don't love it. I actually had a birth, goodness, a month ago, and we got the TENS out and she had bought it for her labor from us. And we put it on, and she was like, "Oh. Oh no. Oh no." And very quickly, it came off. Great. We know we tried. It was one more intervention. She did love a spiky ball though, I will say. She was one of the ones that actually gave her my spiky ball. She was so attached to it. What do we know about contraindications? So what are the contraindications for a TENS unit are on the maternal side? If they're preterm, preeclamptic, eclamptic, it's a no. If they have a pacemaker or they have TB, any malignant tumors, hypotension, skin wound or rash where the pads are going to be placed, which is on their middle and lower back, if they have a seizure disorder or a history of spinal rod surgery, then it would be fully contraindicated. Now for labor, some contraindications would be if they're in the shower or the bath, it cannot be used well wet.
So the patient needs to be dry. If they're a little sweaty, just dry them off to get them stuck. And if they continue to sweat, just kind of dab them with their gown or with a towel or something. But otherwise, it can not get wet. It's electric. If they have a fever or if they have an epidural. When it's unnecessary, if they have an epidural. Let's be clear. All right? And if they have a medical implant, we want to make sure that we get a doctor's order. Because depending on where that metal implant is, not ideal.
All right? Now, for us, one of our requests, and this comes from the Elle TENS world, so the TENS that we have stocked... And actually, we import them. We're one of the only ones that import them from the UK. TENS use other places in the world is extremely standard. In fact, I have a client, I had a client, she's now no longer pregnant, but I had a client in the UK. And everybody, when they get pregnant, they get a TENS machine. And they use it throughout their labor, they use it throughout their pregnancy, and even into the postpartum period, and they get this specific one made for labor. Now in the US, there aren't very good ones, to be honest. And the ones on Amazon, one, they're not powerful enough, two, the electrodes are too small, and three, they're not specifically designed for labor. And so when I was looking for one for my practice or to offer my patients when they would ask me about it, we just realized that the best one out there is this Elle TENS.
And so I couldn't really find one, and so we decided to import them ourselves. So we've just recently restocked these in our stores. So if you are looking for one for yourself, for a friend, or for your unit, we do have the electrodes and we do have the Elle TENS machines. They just need to be wiped down, and they're specifically designed for labor. And so as with the manufacturer recommendations and expectations, it would be to not put the electrodes on the abdomen. We're never putting it on the abdomen. And then obviously this goes for any tape allergy. If they're allergic to the electrodes or the adhesive on them, obviously it would be contraindicated, but that's really it. Now, again, this is not for use for an epidural. It ideally is placed earlier, but what an incredible offering to help also just even build trust with your care team.
How often is the stigma in the hospital that we are so medical focused, or we're pushing an epidural, we have an agenda versus... So many of you, I love your comfort carts that you've put together and been stocking, even our spiky balls or breathing beads, or other things like the twinkle lights and candles in these, or the Starlight projector. That was such a fun thing to see you guys pick up and take. That came from one of my births that I was at where one of the dads during COVID was like... He took his job very seriously and was like, "I got this star projector, and it was so gorgeous in the room." And so it sort of took off. And so what a fun thing to add to your kids to offer choice, offer pain relief, not full relief, but an ability to work with the pain even more.
So what do you do? In the case of a TENS, I would be curious to know how many of you have used at TENS before. And in fact, we'll post a post on Instagram related to TENS, and you can tell us your experience there. I'll be watching, and we can comment back and forth. That'd be really fun to hear what your experience has been. I know for me, it's been somewhat mixed, but when it works, it works. And it may not work with every patient, but when it does work, what an incredible option for them. I also had a birth last month that she was locked in with her machine. And what I love about the Elle TENS is that it does have this burst button where once it's on, when they have a contraction, they can press the burst button and it gives this extra zap or extra intensity. And then when it's over, they unclick it. So not only does it help them cope with the discomfort, but it also gives them something to do and that distraction can help them with the pain.
And so how does it work? Basically, you would talk to the patient, you would get an order from your doctor if you need one/just make sure everyone's on the same page that you're not going to do anything or apply something without a policy procedure. If you don't have a policy procedure, then you get a doctor's order. Once that's all good, talk to the patient, give some patient education, make sure that they're cool with it. Once you do your whole informed consent thing, you're going to clean the back and make sure that it's super dry. And then you get four electrodes. And the electrodes are like... Think about like the EKG pads that we have, the little stickers with the knob on it that you plug in the EKG machine.
Basically it's like triple as long, so these long rectangular pads. And one of them, they're going to go on either side of the spine, starting with the top of the first ones right at the bra line. And so that is placed, if you want the medical location for it, it's going to be placed around T10 to L1, and then the other one at S2 to S4, so in the sacrum area. So you're placing it with the top of them at the bra line on either side of the spine, and then the other two on either side of the spine. And I usually do about one-ish fingers to two above the butt crack. So find the butt crack, go about a centimeter to two above that, and then the bottom part of the electrodes land there going up the sides of the spine. So you have four electrodes on the side.
And again, on this Instagram post, I'll show you this. The other thing is we do have a free TENS sample policy in our store. So I'll link that down below as well for you to look at the literal step-by-step. If you're trying to bring this to your unit, take that to your unit, adapt it for your unit, have at it, enjoy, and come to us for your tens machines. And so you'll put these four stickers on their back, and then ideally... So there's two channels on the L tens. Ideally, what you're doing is you're plugging in one channel to the upper back and another channel to the lower back so that they can adjust the intensity of the upper back, maybe being less than the lower, or vice versa, but they have that control. You want to make sure that your unit is off before you plug anything in, but you can plug in one channel to the top, the other channel to the bottom, and then you hand the patient the machine. They have full control. You're not doing it for them. And they can turn it on.
There will be no electric signal when they turn it on, but you'll choose the first channel and just have them slowly increase the intensity until it gets to a place... And I usually tell them that it's where you're like, ooh, and then go down one, where it's almost painful, and then back off by one so that there's enough stimulation, but not... It should never be painful or sharp. And then do the exact same thing with the channel number two for the lower half. It's so interesting to me. Some patients I've had, they love it super high. And other ones, they barely have any sensation. For me, I can't even feel it at that level, but whatever. They're like, "Oh, no, no, that's fine. That's good." So to each his own and their own sensitivity. And then that's on. It stays. It goes constantly. Now, again, you want to teach them about that burst button. So when the contraction comes, they press the burst. It does sort of... I usually like to warn them that it can kind of like, whoa... They got to...
That's a lot first. And then after the contraction's over, then they would turn it off. Sometimes they forget, so you might need to remind the partner to help remember to turn it off in between. If they have it on the whole time, it's not a big deal. But ideally what happens is when you remove the burst button, it has that dull sensation so that they have access to more of the tense stimulation during the contraction. Otherwise, it sort of starts continuously dulling the sensation. They don't have anywhere else to go from there. So once the leads are placed, you've trained the patient, then they labor with it. Now, if you were to ever get an epidural, want to get in the shower, or sometimes they're just like, "I'm over it," then fine, take it off.
But more often than not, I like to put it around their neck so that they're not dropping it, it doesn't fall, and then it's easy access. They can take it with them to the bathroom as they go to the bathroom, walk around. It ends up becoming this supplement to their toolbox to really help them cope through labor. At one of my recent births, I had a patient who she used it early on in labor. She's the one that if you take our physiologic birth rental with your hospital, I tell the story of her birth because I'd literally come off of her birth going almost straight into teaching an eight-hour physiologic birth class. And she had the most supportive provider and wanted to go without an epidural. She'd done it the first time. This was my second birth with her. And we put on the TENS, and that girl was locked in. We did acupressure points. She breathed through labor. She moved through labor.
And really, it was the combination of those things, and the spiky ball, that got her to the end. But what I loved about it was we almost forgot that it was happening, and she really sort of stopped using the burst button through the contraction towards transition. It was enough there, but the moment that baby was out, she was like, "Ah, ah, get it off." All of a sudden, her sensation came back. And the TENS was really sensitive to her because she no longer needed it, which to me was just a really interesting... Again, I'm drawing conclusions here, but from my own experience was like, huh, I wonder how much it actually was working because it helped dull her senses and didn't even feel that intense during her labor. But the moment the baby was out, she was done and over it, which I obviously love.
So if you are looking for a change project and you don't know how to do that, we do have a leading change class available on our site. It's actually on sale right now for the rest of the year. If you want to sort of have help in how to pursue a change on your unit, how to get the right people involved. If you don't have a policy, we have a free policy. If you're looking to stock your unit or maybe your own labor and birth, we now do have them in our store. We do recommend using the electrodes from Elle TENS, that allows for the warranty to still apply if you use it with your electrodes. I think you can, but just keep in mind that the warranty no longer applies if you use it with the other electrodes. But consider what are the options that your hospital has for pain relief and labor. And that is one of our jobs.
As much as it may feel annoying to some of you to have those patients that come in with the long birth plan, that want to go without epidural, we also are called to a higher standard of being able to offer a toolbox of tools. How good does it feel for the patient to be feeling out of control or there's no hope, and they look to you and say, "What else can I do?" And you go, "I got lots of tricks up my sleeve"? TENS maybe being one of them. Other options being other of them. If you're looking for training on how to help patients cope with labor, we have a Coping with Labor class. If you want to learn more about the physiology behind coping, you can come to our Physiologic Coping class that's on demand on the site. There's so many options for you.
Ultimately, what I want is for our patients to have choice, and I know that that's what you want as well. And TENS may be one way to help decrease their pain and offer choice through labor, empowering them to have a more positive birth experience. Thanks everyone for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us both if you subscribe, rate, leave a raving review and share this episode with a friend. If you want more from us, head to bundlebirthnurses.com or follow us on Instagram. Now it's your turn to take what you learned to today and try one new coping measure to help support your patients in helping them manage their pain in labor. We'll see you next time.