Management of Labor Pain
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Transcript Management of Labor Pain
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