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 physician’s 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

12. Warm Water Baths • No effect on the usage of epidural analgesia • Short duration of pain relief • Only effective while she’s 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

17. Positions, Touch, & Massage • Limited evidence • One study showed a decrease in the use of analgesia NO side-effects!

18. Why are we looking to decrease the use of medication?

19. The Theory of “Natural Birth”

20. Unmedicated • Body produces endorphins to cope with pain • Baby’s endorphins raise when mom’s endorphins raise • Medications decrease natural endorphins for both

21. 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

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

26. 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

28. Further Research Needed • Compare opioids with other methods • Continuous support (doula) • Hydrotherapy • Pain experience • Maternal satisfaction • Adverse effects • Labor & neonatal

29. 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

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

31. “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

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

35. Epidural – Side Effects Common: • Hypotension • Impaired motor function (inability to walk) • Need for catheterization Uncommon (<10%): • Pruritis • Nausea & vomiting • Sedation

36. Nitrous Oxide • Widely used in most developing countries • >60% Finland and United kingdom • Exception - USA

37. 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