ch12

SECOND EDITION OF THE ALARM INTERNATIONAL PROGRAM SYLLABUS

CHAPTER 12

ANALGESIA FOR LABOR

Learning Objectives: Recognize the role of non pharmacological pain relief in labor List available pharmacological methods of pain relief Describe the proper techniques used in pain relief labor

12.0.1 Support Measures in Labor

Physiological discomforts will accentuate labor pain and need to be relieved. Maintenance of mobility and frequent position changes are helpful. Fear and anxiety are major contributors to pain and should be dealt with taking into account unique personality and cultural factors. Some comfort measures include: Encourage and facilitate position changes and mobility Reduce fear and anxiety Facilitate appropriate rest Provide a labor companion

Companion Support in Labor

The presence of a labor companion to provide physical contact and encouragement to the mother, has been shown to reduce the length of labor and decrease the use of analgesia and the need for labor interventions. Other studies have addressed the effect of the continuous presence of a professional care provider.

Non-Pharmacological Pain Relief

It must be recognized that non-pharmacological pain relief varies from country to country. The wishes of the patient must be determined to ensure the most comfortable birthing experience.

Pharmacologic Methods - Systemic

Sedatives and tranquilizers were used regularly in the past but now are used primarily in small doses in early labor only.

NarcoticsNarcotics are used routinely in many centres. The agent used is dependent primarily on the caregiver’s preference. Narcotics may be given intramuscularly or by repetitive intravenous boluses. The intravenous route has the advantage of a rapid effect when needed. Narcotics may be usefully combined with an antiemetic. Narcotics may cause decreased fetal heart rate variability and neonatal respiratory depression. Respiratory depression in the newborn may be easily treated with repeated doses of naloxone.

12.0.2 Peripheral Nerve Blocks

Pudendal Nerve BlockThese are used for analgesia of the perineum in the second stage of labor. This form of analgesia can be very useful and should be considered when other regional analgesia is not available. Local anesthesia with epinephrine allows administration of larger volumes with greater effectiveness and limits systemic levels in the mother and transfer to the fetus.

ALARM INTERNATIONAL * Chapter 12 - Analgesia for Labor * 130


Perineal InfiltrationGenerous and widespread infiltration should be used. Use of an agent with epinephrine is helpful. Care should be taken not to inject intravascularly and the toxic dose of the agent being used must be known.

Regional Anaesthesia


Epidural Block

Epidural block can provide effective pain relief throughout all stages of labor and delivery.

Epidural anaesthesia has been reported in some studies to have a negative effect on the progress of labor and to increase operative delivery rates. Co-founders such as a large number of nulliparous women who experienced prolonged labors or malposition of the fetal head bias these studies.

The hormonal response to pain includes a rise in endogenous catecholamines. The effective relief of pain lowers epinephrine concentrations resulting in improved uterine contractions and possibly improved placental perfusion.

A particular benefit of epidural analgesia exists for women with dystocia of labor due to hypotonic contractions whose labor will require augmentation. Provision at this point of more effective pain relief is truly humane and permits augmentation and subsequent vaginal delivery.

High dose motor block epidurals may lead to prolongation of second stage. This may be due to the blockage of the natural increase in oxytocin that occurs in the second stage of labor. Oxytocin augmentation may be necessary if contractions are too infrequent or ineffective. Paralysis of the pelvic floor musculature may result in persistent fetal head malposition. “Walking” and low dose epidurals lead to less motor blockade and therefore less head malposition and a shorter second stage.

Discontinuing an epidural in the second stage to allow effective pushing is disadvantageous. The sudden return of pain is often worse than if there hadn’t been relief provided at all. The woman may be so distracted and distressed by pain that she cannot push effectively.

Facts about Epidurals

Epidurals effectively relieve pain First stage progress is unaltered or enhanced High motor block epidurals prolong the second stage progress Second stage management may be altered to ameliorate epidural effect

delayed pushing extending time limits for second stage placental blood flow and fetal well-being are preserved or enhanced

Epidurals and the Second StageManagement Options

Don’t stop the epidural Avoid early intervention with operative delivery Continue the epidural and allow more time Continue the epidural and use oxytocin


12.0.3 Summary:

The type of pain relief should always be individualized after a complete discussion with the pregnant woman. Women should enter the labor process fully appraised of all available pain relief options.


ch12

Documents