Management of Labor
Pain
Adapted from:
The Nature and Management of Labor Pain:
Parts I. Am Fam Phys 2003; 68(6); 1109-12.
The Nature and Management of Labor Pain:
Parts II. Am Fam Phys 2003; 68(6); 1115-20.
The Debate…
“Labor results in severe pain for many
women. There is no other circumstance
where it is considered acceptable for a
person to experience untreated severe pain,
amenable to safe intervention, while under a
physician’s care… Maternal request is a
sufficient medical indication for pain relief
during labor.”
ACOG & ASA
Nature of Labor Pain

Pain is subjective

Complex interaction of influences




Physiologic
Psychosocial
Cultural
Environmental
Expectations are often confirmed…
 Anxiety and fear = higher experience of pain
 Confidence in her ability to cope
*Safe and positive birth environment
Nature of Labor Pain –
1st Stage

Visceral pain


Diffuse abdominal cramping
Uterine contractions
Nature of Labor Pain –
2nd Stage

Somatic pain

Perineum


Sharper and more continuous
Pressure or nerve entrapment (caused by
the fetus’ head)

May cause severe back or leg pain
Trends…

Nulliparous


More sensory pain during early labor
Multiparous

More intense pain during late 1st stage and
the 2nd stage

Rapid fetal descent
What determines maternal
satisfaction?




Pain relief
Quality of relationship with caregiver
Participation in decision making
Home-like birth environment
Caregivers with whom they are acquainted
personally
Nonpharmacological Pain
Relief
Used by virtually all women
(different degrees)
Continuous Labor Support
Continuous labor support provided by a
doula* decreases the use of obstetric
interventions.
*Doula – lay woman trained in labor support
Continuous Labor Support
Decreased…
 Operative vaginal deliveries
 Cesarean deliveries
 Request for pain medication
*Fewer women have unsatisfactory births
Warm Water Baths
Increasingly available

Hospitals & birth centers
Recent survey (2002 - USA)
 6% of women used warm water baths
 49% found them very helpful
Warm Water Baths

No effect on the usage of epidural
analgesia

Short duration of pain relief

Only effective while she’s in the bath
Warm Water Baths – Risks?


No evidence of increased maternal or
neonatal infection
Labor may slow if used in early labor

Less than 5cm dilation
Warm Water Baths –
Recommendations

Seem to be safe and effective for limited
periods
Wait for active labor
 Maintain water at or below body temp
 Limit bath time to 1-2 hours

Sterile-Water Injections
Intradermal injections of sterile water in
the sacral area

Causes a burning sensation


counterirritation
Decreases back pain for 45-90 mins.
Sterile-Water Injections

No decrease in request for pain
medications


Short duration
No effect on abdominal labor pain
Positions, Touch, &
Massage

Limited evidence

One study showed a decrease in the use of
analgesia
NO side-effects!
Why are we looking to
decrease the use of
medication?
The Theory of
“Natural Birth”
Unmedicated


Body produces endorphins to cope with
pain
Baby’s endorphins raise when mom’s
endorphins raise

Medications decrease natural endorphins for
both
Unmedicated

Stimulates the baby’s adrenal glands

“fight or flight” – helps to adapt to life outside
of the uterus
Helps baby breathe
 Increases blood flow to baby
 Stimulates immune system (increased WBC’s)
 Baby is more alert – facilitates bonding

Unmedicated

Oxytocin peaks just after an unmedicated
birth

Stimulates maternal behaviors
P urposeful
A nticipatory
I ntermittent
N ormal
Pharmacological Pain
Relief
Parenteral Opioids

Used in 39-56% of labors in US hospitals
Despite common use and decades of
research…

Insufficient data regarding safety and efficacy
Parenteral Opioids


Subsequent use of epidural analgesia
Adverse symptoms






Nausea
Drowsiness
Inability to urinate
Inability to participate in labor
Cesarian
Instrument-assisted vaginal delivery
Parenteral Opioids
vs. Epidural





Less pain relief and satisfaction with pain
relief (all stages)
Lower rate of oxytocin augmentation
Shorter stages of labor
Fewer cases of malposition
Fewer instrument-assisted deliveries
Parenteral Opioids - Infant

Neonatal respiratory depression
Decreased alertness
Inhibition of sucking
Lower neurobeharioral scores
Delay in effective feeding

Long-term effects cannot be excluded




Further Research Needed

Compare opioids with other methods


Continuous support (doula)
Hydrotherapy
 Pain
experience
 Maternal satisfaction
 Adverse effects
•
Labor & neonatal
Epidural Analgesia

Effective pain management
“There is no other circumstance where it is
considered acceptable for a person to experience
untreated severe pain…”
ACOG & ASA
Epidural Analgesia

Balance between pain relief and other
goals…



Walking (1st stage)
Pushing effectively (2nd stage)
Minimizing side effects

maternal and neonatal
“Walking Epidural”


aka CSE Combined Spinal Epidural
Intrathecal opioid injection before
continuous epidural infusion
*Often are unable to walk…


Substantial motor blockade
Need continuous fetal monitoring
“Walking Epidural”
Advantages:
 Rapid onset of pain relief
 Potential for the intrathecal medication to
suffice

Likely to deliver in 2-3 hours
Epidural Analgesia - Effects


Slows labor (1st and 2nd stages)
Increases use of Pitocin



Increased perineal tears
Increased instrument-assisted delivery


forceps/vacuum extraction
Increased cesarean (?)


oxytocin augmentation
especially when administered early
Maternal fever
Concern

Epidural-induced maternal fever


Unnecessarily increases work-ups for neonatal
sepsis
Increased neonatal antibiotics
Epidural – Side Effects
Common:
 Hypotension
 Impaired motor function (inability to walk)
 Need for catheterization
Uncommon (<10%):
 Pruritis
 Nausea & vomiting
 Sedation
Nitrous Oxide

Widely used in most developing countries

>60% Finland and United kingdom

Exception - USA
Nitrous Oxide



50/50 blend nitrous oxide and oxygen
Full effect 50 seconds after inhalation
Usually self-administered as needed
Nitrous Oxide – Side Effects



Nausea
Vomiting
Poor recall of labor
Issue of Choice

Women in the USA have less options than
women in Canada and the UK
“It is unclear if the high use of epidural
analgesia is a true preference…”
What determines maternal
satisfaction?




Pain relief
Quality of relationship with caregiver
Participation in decision making
Home-like birth environment
Caregivers with whom they are acquainted
personally