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Management of Labor Pain. Anjani Reddy, PGY-1 1/12/09. Case Presentation. 37 y/o G1P0 @ 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

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Management of Labor Pain


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management of labor pain

Management of Labor Pain

Anjani Reddy, PGY-1

1/12/09

case presentation
Case Presentation
  • 37 y/o G1P0 @ 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
case presentation3
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 1 st stage
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
pain pathways 2 nd stage
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
adverse consequences of labor pain
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%)
pain during labor and delivery
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 delivery8
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
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 pain10
Approaches to management of labor pain
  • Pharmacologic – eliminate physical sensation of labor pain
  • Non-pharmacologic –prevent sense of suffering
pharmacologic management of pain
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
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
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
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
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
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
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
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
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
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
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
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
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 pain24
Approaches to management of labor pain
  • Pharmacologic – eliminate physical sensation of labor pain
  • Non-pharmacologic –prevent sense of suffering
non pharmacologic approach
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 approach26
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
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)
continuous labor support
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
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
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
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
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
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
movement during the 1 st stage
Movement during the 1st 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 2 nd stage
Movement during 2nd stage
  • Supine position found to be more painful than other positions
  • Kneeling position preferred to sitting position
touch and massage
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
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
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
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
music and audioanalgesia
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
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
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
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
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
case presentation continued
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
Resources
  • Ramin, S. Randomized Trial of Epidural vs. IV analgesia during labor. ObstetGynecol 1996 Nov; 86(5): 783
  • Lowe, NK. The nature of labor pain. Am J ObstetGynecol 2002; 186:So16
  • Goetzl, LM. ACOG Practice Bulletin. Clinical Management Guidelines for OB-Gyns Number 3, July 2oo2. Obstetric analgesia and anesthesia. ObstetGynecol 2002; 100:177.
  • Simkin, P. Comfort in Labor. Childbirth Connection.
  • www.utdol.com
  • www.pregnancytobaby.com/.../medical-treatments/
  • homepages.ed.ac.uk/asb/SHOA2/chpt2.htm
  • Creedy, DK. Childbirth and the development of acute trauma symptoms: incidence and contributing factors. Birth 2000; 27:104
  • Bricker, L. Parenteralopioids for labor pain relief: A systematic review. Am J ObstetGynecol 2002; 186:S094
  • Bucklin, BA. Obstetric anesthesia workforce survey: twenty-year update. Anesthesiology 2005; 103:645
  • Hodnett, ED. Home-like vs conventional institutional settings for virth. Cochrane Database Syst Rev 2005; CD000012
  • Ragnar, I. Comparison of the maternal experience and duration of labour in two upright delivery positions – a randomized controlled tril. BJOG. 2006; 113:165
  • Simkin, P. Nonpharmacologic relief of pain during labor: Systematic reviews of five methods. Am J ObstetGynecol 2002; 186:S131
  • DeClercq, ER. Listening to mothers II: Report of the Second National Survey of Women’s Childbearing Experiences. Childbirth Connection, New York 2006.
  • Mantle, F. The role of hypnosis in pregnancy and childbirth. Ch 10- Complementary Therapies for Pregnancy and Childbirth. 2nd Edition. BalliereTindall, New York 2000.
  • Cepeda MS. Music for pain relief. Chochrane Database Syst Rev 2006; CD004843
  • http://birthingnaturally.net/