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Anjani Reddy, PGY-1
1/12/09
Case Presentation
 37 y/o G1P0 @ 38wks and 1day EGA, presents
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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
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?”
Pain Pathways –
st
1
 Visceral/cramping pain during
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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
stage
Pain Pathways –
 Somatic pain from distention
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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
nd
2
stage
Adverse Consequences of Labor
Pain
 Hyperventilation
 Respiratory alkalosis could
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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%)
Pain during labor and delivery
 “the way pain is experienced is a reflection of the
individual’s 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
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.
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)
Approaches to management of
labor pain
 Pharmacologic – eliminate physical sensation of labor
pain
 Non-pharmacologic –prevent sense of suffering
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
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
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.
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
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
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
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
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.
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
Epidural
 Continuous infusion of:
 Local anesthetic
(Bupivacaine or
Ropivacaine)
 Opioid (usually lipid
soluble Fentanyl or
Sufentanyl
 +/-Epinephrine (works
on alpha 2 receptors)
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
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
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%)
Approaches to management of
labor pain
 Pharmacologic – eliminate physical sensation of labor
pain
 Non-pharmacologic –prevent sense of suffering
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
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.”
Birth Environment
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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)
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
Water Immersion
 Warm water, deep enough to cover the woman’s
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)
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
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.
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
So many positions, so little time!
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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
Movement during the
st
1
stage
 16 controlled trials:
 Less pain while standing/sitting, compared to supine
 Compared to lying on one’s side, less pain while sitting,
until 6cm, then less pain while lying on one’s side
 Vertical and side lying positions were accompanied by
more progress than the supine position
 High satisfaction associated with the option of walking
Movement during
nd
2
stage
 Supine position found to be more painful than other
positions
 Kneeling position preferred to sitting position
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!
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
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!!
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
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77% found these helpful
22% did not
 Study of British women using relaxation techniques:
88% found techniques helpful
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
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
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
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
Transcutaneous Electrical Nerve
Stimulation
 Low voltage impulses to the
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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
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 patient’s
pain control and provide long-term pain relief
 This option was presented to the patient again, and
patient agreed with epidural analgesia
 7:30PM: Epidural placed
 12:30PM: Unplanned C/S performed 2/2 “non-
reassuring heart tones”
Resources
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http://birthingnaturally.net/