Management of Labor Pain

1
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.

2
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 physicians care
  Maternal request is a sufficient medical
  indication for pain relief during labor.
• ACOG ASA

3
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

4
Nature of Labor Pain 1st Stage

• Visceral pain
• Diffuse abdominal cramping
• Uterine contractions

5
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

6
Trends

• Nulliparous
• More sensory pain during early labor
• Multiparous
• More intense pain during late 1st stage and the
  2nd stage
• Rapid fetal descent

7
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

8
Nonpharmacological Pain Relief

• Used by virtually all women
• (different degrees)

9
Continuous Labor Support

• Continuous labor support provided by a doula
  decreases the use of obstetric interventions.
• Doula lay woman trained in labor support

10
Continuous Labor Support

• Decreased
• Operative vaginal deliveries
• Cesarean deliveries
• Request for pain medication
• Fewer women have unsatisfactory births

11
Warm Water Baths

• Increasingly available
• Hospitals birth centers
• Recent survey (2002 - USA)
• 6 of women used warm water baths
• 49 found them very helpful

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Warm Water Baths

• No effect on the usage of epidural analgesia
• Short duration of pain relief
• Only effective while shes in the bath

13
Warm Water Baths Risks?

• No evidence of increased maternal or neonatal
  infection
• Labor may slow if used in early labor
• Less than 5cm dilation

14
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

15
Sterile-Water Injections

• Intradermal injections of sterile water in the
  sacral area
• Causes a burning sensation
• counterirritation
• Decreases back pain for 45-90 mins.

16
Sterile-Water Injections

• No decrease in request for pain medications
• Short duration
• No effect on abdominal labor pain

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Positions, Touch, Massage

• Limited evidence
• One study showed a decrease in the use of
  analgesia
• NO side-effects!

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Why are we looking to decrease the use of
medication?
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The Theory of Natural Birth
20
Unmedicated

• Body produces endorphins to cope with pain
• Babys endorphins raise when moms endorphins
  raise
• Medications decrease natural endorphins for both

21
Unmedicated

• Stimulates the babys 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 WBCs)
• Baby is more alert facilitates bonding

22
Unmedicated

• Oxytocin peaks just after an unmedicated birth
• Stimulates maternal behaviors
• P urposeful
• A nticipatory
• I ntermittent
• N ormal

23
Pharmacological Pain Relief
24
Parenteral Opioids

• Used in 39-56 of labors in US hospitals
• Despite common use and decades of research
• Insufficient data regarding safety and efficacy

25
Parenteral Opioids

• Subsequent use of epidural analgesia
• Adverse symptoms
• Nausea
• Drowsiness
• Inability to urinate
• Inability to participate in labor
• Cesarian
• Instrument-assisted vaginal delivery

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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

27
Parenteral Opioids - Infant

• Neonatal respiratory depression
• Decreased alertness
• Inhibition of sucking
• Lower neurobeharioral scores
• Delay in effective feeding
• Long-term effects cannot be excluded

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Further Research Needed

• Compare opioids with other methods
• Continuous support (doula)
• Hydrotherapy
• Pain experience
• Maternal satisfaction
• Adverse effects
• Labor neonatal

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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

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Epidural Analgesia

• Balance between pain relief and other goals
• Walking (1st stage)
• Pushing effectively (2nd stage)
• Minimizing side effects
• maternal and neonatal

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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

32
Walking Epidural

• Advantages
• Rapid onset of pain relief
• Potential for the intrathecal medication to
  suffice
• Likely to deliver in 2-3 hours

33
Epidural Analgesia - Effects

• Slows labor (1st and 2nd stages)
• Increases use of Pitocin
• oxytocin augmentation
• Increased perineal tears
• Increased instrument-assisted delivery
• forceps/vacuum extraction
• Increased cesarean (?)
• especially when administered early
• Maternal fever

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Concern

• Epidural-induced maternal fever
• Unnecessarily increases work-ups for neonatal
  sepsis
• Increased neonatal antibiotics

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Epidural Side Effects

• Common
• Hypotension
• Impaired motor function (inability to walk)
• Need for catheterization
• Uncommon (lt10)
• Pruritis
• Nausea vomiting
• Sedation

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Nitrous Oxide

• Widely used in most developing countries
• gt60 Finland and United kingdom
• Exception - USA

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Nitrous Oxide

• 50/50 blend nitrous oxide and oxygen
• Full effect 50 seconds after inhalation
• Usually self-administered as needed

38
Nitrous Oxide Side Effects

• Nausea
• Vomiting
• Poor recall of labor

39
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

40
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