Management of Labor Pain

1
Management of Labor Pain

• Anjani Reddy, PGY-1
• 1/12/09

2
Case Presentation

• 37 y/o G1P0 _at_ 38wks and 1day EGA, presents
  complaining of ctx q5 min for 6 hours
• PNI AMA neg. quad screen, declined amnio
• PMH none
• PSH none
• PObH none
• PGynHx no STIs/abnl PAPs/ovarian cysts/uterine
  fibroids
• Meds PNV
• All NKDA

3
Case Presentation

• VS stable
• Exam
• SVE 4/90/-1
• Category I tracing, ctx q 4-5min.
• During initial history taking, patient was asked
  what her preferences were with respect to pain
  management.
• Patient replied, What are my options?

4
Pain Pathways 1st stage

• Visceral/cramping pain during contractions
• Originates in the uterus and cervix
• Produced by distention of uterine/cervical
  mechanoreceptors and by ischemia of the
  uterine/cervical tissues
• Signal enters spinal cord from T10-L1
• Labor pain is referred to areas of skin supplied
  by those nerve roots, affecting the abdominal
  wall, lumbosacral region, iliac crests, gluteal
  areas, and thighs

5
Pain Pathways 2nd stage

• Somatic pain from distention of the vagina,
  perineum and pelvic floor
• Stretching of the pelvic ligaments
• S2-S4 (pudendal nerve)
• More severe than first stage
• Combination of
• Visceral pain from contractions
• Cervical stretching
• Somatic pain from distention
• Rectal pressure

6
Adverse Consequences of Labor Pain

• Hyperventilation
• Respiratory alkalosis could
• decrease ventilatory drive between contractions
• impair oxygen transfer to fetus (left shift of
  oxyhemoglobin dissociation curve)
• Uteroplacental vasoconstriction
• Neurohumoral Effects
• Increase in catecholamines and decrease in blood
  flow to the uterus, lowering fetal oxygenation,
  increasing bradycardia and acidosis
• Psychological Effects
• Unrelieved pain may cause postpartum
  psychological trauma, that could result in PTSD
  (prevalence of postpartum PTSD found to be 5.6)

7
Pain during labor and delivery

• the way pain is experienced is a reflection of
  the individuals emotional, motivational,
  cognitive, social, and cultural circumstances
• Pain of childbirth is likely to be the most
  severe pain that a woman experiences during her
  lifetime.
• Pain varies among women, and each labor of an
  individual may be different

8
Pain during labor and delivery

• Pain relief was NOT the most important factor
  influencing satisfaction with childbirth
• Study of 60 women with vaginal births found
  personal control was positively correlated with
  pt satisfaction
• Study of 100 women undergoing vaginal births
  found that satisfaction with pain relief was
  associated with a feeling of being in control and
  having input in the decision making process.

9
Approaches to management of labor pain

• Women should be involved in the decision-making
  process
• Can be accomplished by educating women about pain
  relief techniques
• Providing education BEFORE labor commences
  (rational decision-making is compromised at times
  of emotional and physical stress)

10
Approaches to management of labor pain

• Pharmacologic eliminate physical sensation of
  labor pain
• Non-pharmacologic prevent sense of suffering

11
Pharmacologic management of pain

• Introduced in the mid-nineteenth century
• Controversial-many believe that labor pain is a
  natural and necessary accompaniment of childbirth
• Medically unusual scenario no other circumstance
  in which it is considered acceptable to
  experience severe, pharmacologically relievable
  pain, while under direct medical care
• Therefore, ACOG supports the concept that
  maternal request alone is a sufficient medical
  indication for labor analgesia

12
Pharmacologic options

• Systemic analgesics
• Opioids, Opioids with mixed agonist-antagonist
  properties, PCA, Nonopioid agents, Inhalation
  agents
• Local injection techniques
• Pudendal, Paracervical block
• Neuraxial analgesia
• Epidural and spinal techniques

13
Systemic analgesics

• Opioids
• Morphine
• Fentanyl
• Meperidine
• Mixed opioid agonists-antagonists
• Nalbuphine
• Butorphanol
• Exert effects in the maternal brain, portion of
  dose crosses placenta, can cause decreased fetal
  heart rate variability and respiratory depression
  in the neonate
• Some argue that they produce relief by inducing
  somnolence rather than analgesia
• Also argued that doses high enough to manage pain
  cannot be reached, given side effect profiles.

14
Meperidine (Demerol)

• Dose 25-50mg IV, 50-100mg IM
• Onset 5min IV, 40min IM
• Duration 2-3hrs
• Side effect profile respiratory depression,
  serotonergic crisis, seizures, and metabolite
  activity in the neonate for up to 2.5 days

15
Morphine

• Dose 2-5mg IV, 40min IM
• Onset 3-5min IV, 20-40min IM
• Duration 3-4hr
• Side effects Greater respiratory depression in
  mother/infant than Demerol

16
Fentanyl

• Dose 25-50mcg IV, 100mcg IM
• Onset 1-3min IV, 7-10min IM
• Duration 1-2hrs IM
• Side effects respiratory depression
• Remifentanil is in the same subclass same
  onset, but metabolized quickly, thus, should not
  cause respiratory depression

17
Mixed Agonist-Antagonists

• Butorphenol, Nalbuphine, Pentazocine, and
  buprenorphine
• Dose ceiling effect in terms of respiratory
  depression (can intensify analgesia without
  increasing respiratory depression).
• Besides opioid side effects, also have
  psychomimetic effects
• Less frequently used, mixed properties thought to
  diminish efficacy

18
Other systemic analgesics

• PCA pump
• Antiemetics Hydroxyzine and promethazine
• Nitrous Oxide used in UK. Self-administered.
  Short acting. Inexpensive, easy to administer,
  safe for mother and fetus/neonate, and improved
  analgesia compared to opioids.
• Ketamine, Benzos, and Barbituates have been used
  to improve sleep during early labor, or for
  sedative purposes.
• Scopolamine used for twilight sleep in early
  20th century. Rarely used today.

19
Neuraxial Techniques

• Used by more than 70 of women who give birth in
  hospitals with greater than 1500 deliveries per
  year
• Spinal vs. Epidural techniques
• Immediate onset vs lower side effect profile
• Side effects include hypotension, fever, HA,
  numbness, and infection

20
Epidural

• Continuous infusion of
• Local anesthetic (Bupivacaine or Ropivacaine)
• Opioid (usually lipid soluble Fentanyl or
  Sufentanyl
• /-Epinephrine (works on alpha 2 receptors)

21
Pudendal Nerve Block

• Alleviates pain arising from vaginal and perineal
  distention
• Used as a supplement for epidural analgesia if
  the sacral nerves are not sufficiently
  anesthetized
• Provide analgesia for low forceps delivery

22
Systemic vs. Regional analgesia

• Systematic Review found
• Opioids provided limited pain relief, only
  slightly better than placebo
• Epidural analgesia provided better pain relief
  than parenteral opioids
• Epidural analgesia assoc with longer duration of
  labor, increased Pitocin augmentation, more
  instrumental deliveries
• Effect on c-section rate varied by study

23
Randomized trial of Epidural vs IV Demerol
analgesia for the initial treatment of labor pain

• 1,330 pts
• Increased rate of c-section delivery secondary to
  dystocia in the epidural anesthesia group (OR
  1.98, 9 vs 5)
• Epidural associated with
• Increased pain relief (60 vs 22)
• Increased chorioamnionitis (23 vs 5)
• Increased Pitocin use (32 vs 23)
• Increased low forceps delivery (8 vs 1)

24
Approaches to management of labor pain

• Pharmacologic eliminate physical sensation of
  labor pain
• Non-pharmacologic prevent sense of suffering

25
Non-pharmacologic approach

• Goal is to eliminate her sense of
• Perceived threat to body and/or psych
• Helplessness, loss of control
• Distress
• Insufficient resources for coping with the
  situation
• Fear of death of the mother or baby

26
Non-pharmacologic approach

• Pain is a side effect of a normal process
• Goal is NOT to make the pain disappear
• Instill self-confidence, sense of mastery and
  well-being
• So that pain is neither feared, nor focused on
• Women who feel that they have successfully coped
  with the pain and stress of labor note that they
  were able to transcend their pain and experience
  a sense of strength and profound psychologic and
  spiritual comfort during labor.

27
Birth Environment

• Promotes sense of comfort and privacy
• Comfort aids
• Places to walk, bathe, and rest
• Study comparing hospital vs home births found
  hospital births were associated with higher pain
  ratings
• Systematic review of randomized trials of
  home-like versus conventional institutional
  settings for birth
• Increased likelihood of not using intrapartum
  analgesia/anesthesia (RR1.19, 95 CI 1.07-1.21)
• Request same setting the next time (RR1.81, 95
  CI 1.65-1.98)
• Express satisfaction with intrapartum care
  (RR1.14, 95 CI 1.07-1.21)

28
Continuous Labor Support

• Nonmedical care of laboring women throughout
  labor and delivery by a trained person
• Supportive companion during labor can help with
  pain and anxiety
• Multiple studies have shown that doulas
• Half the risk of unplanned c-sections
• Half the risk of instrumental delivery
• Significantly shorten labor

29
Water Immersion

• Warm water, deep enough to cover the womans
  abdomen
• Enhances relaxation, reduces labor pain
• Body temperature should be monitored
• Few minutes to hours in the first stage of labor
• Randomized trials show
• Significant reduction in pain (via pain score or
  decreased narcotic use)
• No increase in infection rates (even c ROM)

30
Intradermal Water Blocks

• Incidence of low back pain in labor is 15-74
• Etiologies include asynclitism, fetal OP
  position, referred uterine pain, lumbopelvic
  characteristics
• Endorphins release thought to be responsible for
  pain relief
• Randomized trials have found
• Significant decrease in severe LBP
• Relief lasts 45 -120 minutes

31
Intradermal Water Block

• 4 intradermal injections of .05-.1mL sterile
  water with a 25 gauge needle. Over each posterior
  superior iliac spine and two 3cm below and 1cm
  medial to the first sites.
• Burning during injection, therefore, given during
  ctx.

32
Maternal Movement and Positioning

• 76 of hospitalized laboring women do not walk
  around. Limited movement was secondary to
• Connections (IVs, tocometers, BP cuffs,
  catheters)
• Pain medications
• Instructed not to by medical staff

33
So many positions, so little time!

• Knee-Chest
• Dangle
• Hands and Knees
• Labor Dance
• The Lift
• The Lunge
• Rocking
• Side Lying
• Squatting
• Toilet Sitting
• Tug of War
• Walking and Swaying
• Semi-prone

• Rhythmic ritual for handling contractions
• Pelvic dimensions vary with different maternal
  positions, ameliorating labor pain
• Certain positions are specifically helpful when
  back pain is the primary cause for discomfort

34
Movement during the 1st stage

• 16 controlled trials
• Less pain while standing/sitting, compared to
  supine
• Compared to lying on ones side, less pain while
  sitting, until 6cm, then less pain while lying on
  ones side
• Vertical and side lying positions were
  accompanied by more progress than the supine
  position
• High satisfaction associated with the option of
  walking

35
Movement during 2nd stage

• Supine position found to be more painful than
  other positions
• Kneeling position preferred to sitting position

36
Touch and Massage

• Touch communicates caring, concern, reassurance,
  and love
• Massage enhances relaxation and reduces pain
• Have been found to decrease pain, anxiety and
  blood pressure
• Shown to improve mood, and sense of support
• NO harmful effects!

37
Application of Heat and Cold

• Personal choice
• Place one or two layers of cloth to protect
  against skin damage and intact sensation is a
  prerequisite
• Heat
• Applied to back, lower abdomen, groin, perineum
• Relieves pain, chills, stiffness, muscle spasm,
  and increases extensibility of connective tissue
• Cold
• Applied to back, chest, face
• Relieves pain, muscle spasm, inflammation and
  edema

38
Childbirth Education

• Reading, classes, office visits
• Information on the process of labor and birth,
  typical pain experience, and options for pain
  management should be provided for pregnant women
  and partners/supports.
• Provision of education PRIOR to labor!!

39
Relaxation and Breathing

• Rhythmic breathing patterns that promote
  relaxation, and distract women from labor pain
• Enhance sense of control
• Survey of women who gave birth in the US in 2005
• 49 used breathing techniques
• 77 found these helpful
• 22 did not
• Study of British women using relaxation
  techniques 88 found techniques helpful

40
Music and Audioanalgesia

• Few studies, with small sample sizes and
  inadequate controls
• Cochrane review on the effect of music on acute
  pain
• Small reduction in pain intensity levels and
  opioid requirements

41
Aromatherapy

• Use of concentrated oils distilled from plants
• Use is increasing
• Some sources note that they are potent as
  pharmacological drugs and should be used with
  caution
• One uncontrolled prospective study
• 8058 women
• Lavender, rose or frankincense used under
  supervision of midwives
• Used to decrease fear, anxiety, pain, nausea and
  vomiting
• Half of women found it helpful
• 1 reported nausea/headache as side effect

42
Acupuncture/Acupressure

• Acupressure is a simpler alternative to
  acupuncture, pressure applied with fingers or
  small beads at acupuncture points
• Both have shown to lead to lower use of
  pharmacologic pain relief
• Acupuncture has been shown to increase relaxation
  in laboring patients

43
Hypnosis

• a state of deep physical relaxation with an
  alert mind, in this state, the subconscious mind
  can be more readily accessed
• Self hypnosis glove anesthesia, time
  distortion, imaginative transformation
• Significant reduction in analgesic use
• Contraindicated in women with history of psychosis

44
Transcutaneous Electrical Nerve Stimulation

• Low voltage impulses to the skin via surface
  electrodes
• Rentals available w/o rx
• Paravertebrally at T10-L1 and S2-4
• Woman controls intensity and sensation patterns
• Increases endorphins
• Randomized trials showed
• Decreased and later introduction of pain meds
• Reduction of pain scores was shown in some
  studies

45
Case Presentation Continued

• 6PM Patient admitted.
• Options discussed. Patient expressed interest in
  systemic analgesics
• Preference presented to OB staff
• OB staff felt epidural analgesia would improve
  patients pain control and provide long-term pain
  relief
• This option was presented to the patient again,
  and patient agreed with epidural analgesia
• 730PM Epidural placed
• 1230PM Unplanned C/S performed 2/2
  non-reassuring heart tones

46
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