pain management during labor & second stage of labor

Pain management during labor &

Second stage of labor

Objectives At the end of this presentation student will be able

to :Identify the etiology of pain during labor and birth Identify types of labor support and advanced nursing roles in normal labor and delivery care Define Of Second Stage Of Labor. Discuss The Mechanism Of Labor Discuss Cultural and social aspects of labor and delivery. Analyze labor and delivery care in Jordan.

Etiology of pain during labor

Basic factors for pain in childbirth: physical and emotional.

1. physical pain in labor is caused by: Muscle cramps/ uterine contraction. Stretching of cervix and perineum . Medical tests and procedures (pelvic exams,IVs, catheterization,

and so forth) Position of the baby and pressure of presenting part on tissue like

bladder,urethra,back,lower colon

Etiology of pain during labor

2. Emotional FactorsMany negative emotions can actually increase your perception of

pain: Fear of pain Fear of the unknown Anxiety Self-doubt Lack of education Exhaustion Dehydration Hunger

Non pharmacological strategiesEmotional support Instructional/informational supportAdvocacy support Pharmacological strategies

Labor support

Endorphin

Natural pain killer produced from pituitary gland released during stressful events or in moment of grate pain it is responsible for euphoric feelings known as “runner’s high” and “adrenaline rush “ .

It secretion triggered by consumption of certain food “chochlate,chili peppers” also triggered by massage therapy or acupuncture .

1. Nonpharmacologic strategies

1. Support from a Doula or coach Is a women who experienced in childbirth but without

professional credentials , who guides and assist women in labor . Having a doula can increase women self-esteem as well as

decrease rate of oxytocin augmentation ,epidural anesthesia and cesarean birth .

Doula can be women husband,mother,father..etc

2. Water therapy(hydrotherapy )

Standing under warm shower or soaking in tube of warm water , the temperature of water used should be between 35-37c .

Several study have investigated the risk of using hydrotherapy with rupture membrane findings have shown no increase in chorioamnionitis , post partum indometraitis,neonatal infection or antibiotic use

( tournaire & theau-yonneau,2007,zwelling et al ,2006)

No limit to the time women can stay in bath and often they are encouraged to stay in it as long as desired


In randomized controlled trial (RCT) to determine the efficacy of warm showers on parturition pain and the birth experiences of women during the first stage of labor

participants in the experimental group received warm shower bath interventions full body or lower back shower, participants could spend 5 minute complete bath 15 minutes directing shower water toward any body region that felt most comfortable. Facilities allowed participants to stand and sit as desired. Water was constantly monitored and maintained at a temperature of 37◦C. Participants in the control group received standard care.

women who participated in warm showers reported significantly lower VAS pain scores at 4-cm and 7-cm cervical dilations, and higher birth experiences than the control group.

warm showers are a cost-effective, convenient, easy to perform ,non-pharmacological approach to pain reduction. This intervention helps women in labor to participate fully in the birthing process, earn continuous caregiver support, feel cared for and comforted, and have a more positive overall

experience.

(Lee, Liu, Lu, & Gau, 2013)

3. Transcutaneous electrical nerve (TENS) stimulation

Two paired of electrodes attached to women back T10-L1 .

Low- intensity electrical stimulation is given continuously or applied by women herself as a contraction begin .

Block afferent fibers and preventing pain to travel from uterus to spinal cord synapses , and facilitate release of endorphin


Can be effective as epidural anesthesia

Not available in our hospital.

Carries no risk to the mother and fetus

Women can refuse to being “tied down “ to equipment


4.Acupuncture Based on concept that illness result from an imbalance of

energy , to correct the imbalance needles are inserted into the skin at specific body points , activation of these point lead to release of endorphins .

Helpful in first stage of labor


A randomized controlled trial was conducted with 607 healthy women in labor at term who received acupuncture, TENS, or

traditional analgesicsTo compare the effect of acupuncture with transcutaneous electric

nerve stimulation (TENS) and traditional analgesics for pain relief and relaxation during delivery.

Primary outcomes: were the need for pharmacological and invasive methods, birth experience and satisfaction with delivery.

Secondary outcomes : were duration of labor, use of oxytocin, mode of delivery, postpartum hemorrhage, Apgar score, and umbilical cord pH value.

(Borup, Wurlitzer, Hedegaard, Kesmodel, & Hvidman, 2009)

Result Use of pharmacological and invasive methods was significantly lower in

the acupuncture group (acupuncture vs traditional, p < 0.001; acupuncture vs TENS, p = 0.031).

Acupuncture did not influence the duration of labor or the use of oxytocin.

Mean Apgar score at 5 minutes and umbilical cord pH value were significantly higher among infants in the acupuncture group compared with infants in the other groups.

CONCLUSIONSAcupuncture reduced the need for pharmacological and invasive methods

during delivery. Acupuncture is a good supplement to existing pain relief methods.

(Borup, Wurlitzer, Hedegaard, Kesmodel, & Hvidman, 2009)

5.AcupressureApplication of pressure or massage to heel of the

hand ,fist or pads of the thumb and fingers


1. Nonpharmacologic strategies6. Therapeutic touch and massage Based on concept that body contains energy field when

increased lead to health and when decreased lead to illness touch and massage work to relive pain by increase level of

endorphins Effleurage is a form of therapeutic touch of gentle abdominal

massage

7.Application of Heat and Cold

Heat Application :• Effective in relief back pain and raises the pain threshold. • To increase blood flow and relieves muscle ischemia. • increases relaxation

Cold application: • Applied to the back, chest, and face to increase comfort• slowing transmission of pain.

1 .Nonpharmacologic strategies

1. Nonpharmacologic strategies9.Aromatherapy Their used based on the principle that the sense of smell

plays a significant role in over all health , when essential oil inhaled it’s molecule transported via olfactory system to the brain and the brain respond to particular aroma with emotional responses , when applied externally they absorbed to the skin and then carried throughout circulation .

The oils may be massaged into the skin, in a bath or inhaled using a steam infusion or burner

A randomized controlled trial was conducted to determine the effect of lavender

aromatherapy on pain intensity perception and intrapartum outcome in primiparous women

The aroma group received 0.1 ml of lavender essential oil mixed with 1 ml of distilled water via tissues attached to their gowns close to their nostrils. Meanwhile, the control group received 2 ml of distilled water in a similar way.

Pain intensity perception was measured by Visual Analogue Scale (VAS) before the intervention and at 30 and 60 minutes afterwards

(Kaviani, Azima, Alavi, & Tabaei, 2014)

Result The mean of pain intensity perception in the aroma group was

lower than that of the control group at 30 and 60 minutes after the intervention (p←0.001).

ConclusionThis study revealed that aromatherapy decreased the labour pain,

but did not affect the duration of labour phases

Kaviani, Azima, Alavi, & Tabaei, 2014

9. Hypnosis Hypnosis is an altered state of conscious and awareness focus of attention to reduce awareness of the external

environment.

For childbirth, hypnosis is often used to focus attention on feelings of comfort or numbness as well as to enhance women's feelings of relaxation and sense of safety.


1. Nonpharmacologic strategies10. Sterile water injections (SWI) Sterile water injections (SWI) are an effective method for the relief

of back pain in labour. The procedure involves a small amount of sterile water (0.1 ml to 0.2 ml) injected under the skin at four locations on the lower back (sacrum).

1 .Nonpharmacologic strategies The injections cause a brief but intense stinging sensation, lasts

for about 30 seconds and then wears off completely.

To distract from the stinging sensation the injections are done during a contraction by two midwives.

SWI provides effective pain relief for up to two hours.

http://www.matermothers.org.au/hospitals/mater-mothers-private-brisbane/labour-and-birth/switch/about-sterile-water-injections





Benefits of SWI often immediate effect no effect on mother’s state of consciousness no effect on baby does not limit mobility does not adversely affect labour progress is a simple procedure that can administered by midwife can be repeated as needed

case report

• The woman was given sterile water injections and required no additional pain relief to cope with labor. The pain relief effect, measured by the VAS, was very powerful and she described her experience in highly positive terms.

• The method is a good alternative for women who do not want pharmacological pain relief during childbirth

(Ma°rtensson,2010)

Evidence :Intradermal Water Block

The evidence concluded that it was effective but it was based only on 4

studies they found suitable for analysis: Ader et al compared sterile water to saline. Sterile water worked better but

there was no difference in the requirement for pethedin (Demerol)

Trolle et al compared sterile water to saline and found it twice as effective (89% vs. 45%).

Martensson et al compared 0.1cc of intradermal water, 0.5 cc of subcutaneous water, and 0.1 cc of subcutaneous saline. The two water groups were equally effective and superior to the saline.

Labreque et al. compared sterile water injections to TENS and to standard care (massage, etc.) Water worked better than the other two, but there was no difference in epidural requests, and fewer women said they would choose it again.

11.Biofeedback use thinking and mental process (focus)to control body

response, to change the response of the stress and pain

Women who are interesting in using this method must attend several sessions during pregnancy to condition themselves to regulate their pain response

If women response to pain during contraction with frowning and breath holding her partner use verbal feedback to help her to relax


12. Double Hip Squeeze The double hip squeeze changes the shape of the pelvis and

releases tension on the sacroiliac joints. Place hands on each side below iliac crest and over gluteal

muscle with fingers pointing toward midline.



12.Birthball

Definition: The ability of subject participate and share in the laboring client’s

feelings (Sauls, 2004).

Emotional LSB assist to occupy the client’s mind with positivethoughts and diminish or block feelings of fear, and anxiety

2. Emotional LSB

1. Nursing PresenceNursing presence is defined as being with the client rather than

performing tasks on the client and as complete physical, emotional, psychological, and spiritual engagement between nurse and client.

Nursing presence includes: high level of nursing skill. being open honest. nonjudgmental with the client. listening carefully to her needs and concerns.

2. Emotional LSB

2.partner carePractice in Jordan

Companionship or social support during labour has been shown to be one of the most beneficial practices in maternity care( Hodnett E,2007)

None of the public hospitals in Jordan allowed the presence of a birth companion including the husband during labour and birth.

Evidence show that : mothers who had received support during labour were significantly less likely to have pharmacological pain relief.and significantly more likely report a good birth experience

Shaban et al., 2011

2. Emotional LSB

Instruction and information on all aspects of labor and birth provide clients with an opportunity to be a part of the decision-making process, which fosters a positive birth experience.

Verbal communication must be culturally sensitive

3. Instructional/Informational LSB

Advocacy includes protecting the client, attending to needs, and assisting in making choices related to health care; this requires the establishment of a therapeutic relationship. Being an advocate for the client, the nurse empowers the client to give birth with dignity.

4. Advocacy LSB

1. Narcotic analgesic (opioid analgesic) Act by decrease sensation of pain . Used for their analgesic effect , all drugs in this category cause

CNS depression , respiratory depression .

Narcotic analgesic includes: pethidine (meperidin) , fentanyl remifentanil, morphine, tramadol

pethedin is the most commonly used analgesic in labor because it has additional sedative and antispasmodic actions , these make it effective not only for reliving pain but also for relaxing cervix and providing feeling of euphoria and well-being

Narcotic antagonist : naloxon (Narcan)

Pharmacological strategies

Advantages and disadvantages of narcotic (opioid ) administration

Advantagesan increased ability for a woman to cope with labor The medications may be nurse-administeredIt has no amnesic effect but create a felling of well-being or euphoria

Disadvantages Frequent occurrence of uncomfortable side effects, such as nausea and vomiting, pruritus, drowsiness, and neonatal depressionPain is not eliminated completely

pharmacological strategies

Intrathecally (spinal) narcoticRefer to injection into spinal cord

Opioid used alone: Ex: fentanyle 1.30-3hr with Multipara morphine 4-7 hr with Nullipara or women with history of long

labor Excellent pain relief for labor pain they take effect 15-30min and last 4-7hrDon’t cause maternal hypotension or affect VS Women can fell contraction but no pain , her ability to bear down during second stage of labor is preserved because the bushing reflex is not lost and her motor power remain intact


2. AnesthesiaThe use of medication to partially or totally block all sensation to an area of

the body• Local anesthesia Reduce ability of local nerve fiber to conduct pain Used to numb the perineum just before birth to allow for episiotomy and

repair• Regional anesthesia

injection of local anesthetic agent such as tetracaine or bupivacine to block specific nerve pathways that supply a particular organ or area of the body

spinal analgesia epidural analgesia combined spinal epidural

• General anesthesia Intra Venous Analgesia Inhalational Analgesia


1.Spinal (subarachnoid)anesthesia local anesthetic agent such as (bupivacine or ropivacaine) injected In subarachnoid space through 3dr ,4th or 5th lumber interspaces by using lumber puncture technique .

Anesthesia mixed with CSF, used on elective and emergent CS birth not suitable of vaginal birth because it useful for shorter and simpler procedures.

Anesthesia normally raise to level of T10 , up to umbilicus and including both legs.



Complication hypotension from sympathetic blockage lead to impaired

placental perfusion and ineffective breathing pattern may occur during spinal anesthesia

Turn the women to her left side I.V fluid administration to increase blood volume Vasopressin to increase BPO2 may be used Check V/S every 5-10min

pharmacological strategiesComplication spinal headacheOccur because continuous leakage of CSF from the needle insertion

site or by instillation of air into CSF , shift in pressure of CSF cause strain in vertebral meanings.

Incidence reduced by using of : small-gauge needle Increase fluid intake to replace spinal fluid

pharmacological strategiesIf headache occurred : Ask women to lie flat Administer analgesic Blood patch technique : withdraw 10ml of venous blood and

then immediately injected into the epidural space over spinal injection site , injected blood clot and seals of any further leakage of CSF .

2.Epidural anesthesia Anesthetic agent placed inside

epidural space at :L4-5L3-4L2-3 Block not only nerve roots in

the space but also sympathetic nerve fibers that travel with them


Patient control epidural analgesia The newest method is the using PCA that will be programmed specially for the

patient by anesthesiologist indwelling catheter and programmed pump that allow women to control the dose of analgesic , this method provide optimal analgesia with higher maternal satisfaction and enhance sense of control during labor. (saito et al,2005)


IT is more difficult to insert epidural catheter when the women is obese , morbidly obese patients are more likely to have failed

epidural placement and accidental Dural puncture. (valleyo,2007)


Advantages of Epidural anesthesiaWomen remain alert and more comfortable Able to participate and achieve good relaxation Airway reflex remain intact Gastric empty not delay Blood loss not excessive The most effective pain relief.Fetal complication are rare but may occur


Disadvantages of Epidural anesthesia

• Hypotension

• Urinary retention

• Backache

• soreness where the needle is inserted

• nausea and vomiting

• epidural may prolong second stage of labor ,pushing more difficult and additional interventions such as Pitocin, forceps, vacuum extraction or cesarean might become necessary

• baby might experience respiratory depression, fetal malpositioning, and an increase in fetal heart rate variability


epidural analgesia appears to be effective in reducing pain during labour.

women who use this form of pain relief are at increased risk of having an instrumental delivery

having an epidural was also associated with a longer second stage of labour, more use of augmentation of labour, more frequent very low blood pressure readings, problems passing urine, fever, and being unable to move for a period of time after the birth

What evidence say about epidural analgesia Cochrane Database of Systematic Reviews

The use of epidural anesthesia is associated with a significant increase in maternal temperature and in the incidence of intrapartum maternal fever.

(Passini, Amorim, Almeida, & Barros, 2011)

Sever hypotension (systolic BP 100mmHg or less or more than 20% decrease from base line blood pressure ) as a result of sympathetic block can be an outcome of epidural block .

(anim-somuah,smyth,&howell,2008)

What evidence say about epidural analgesia Cochrane Database of Systematic Reviews

delay the administration of epidural analgesia in nulliparous women until cervical dilatation reaches 4 cm to 5 cm and that other forms of analgesia be used until that time to avoid suppressing the progress of labor

2002, the American College of Obstetricians and Gynecologists

It is recommended that the administration of systematic opioid analgesia be delayed until labor is well established.

(creehan,2008)

Women in labor most no longer reach a certain level of cervical dilatation or fetal station before receiving epidural analgesia.

(aab&acog,2007,cunningham et al ,2010)

Time of adminestration of epidural analgesia

3. Combined spinal-epidural analgesia CSE• Combination of opioid and local anesthesia injected inside spinal cord and in

subarachnoid space , used to block pain transmission without compromising motor ability

• It is associated with greater incident with FHR abnormalities than epidural analgesia alone


Inhalational analgesiaduring labour involves the self-administered inhalation of

sub-anaesthetic concentrations of agents while the mother remains awake and her protective laryngeal reflexes remain intact


inhalational analgesia• N2O does not interfere with

uterine contractions.

• No effect on fetus too.

• Premixed nitrous oxide &oxygen.

• N2O 50% and O2 50%

• ENTONOX-cylinders with a capacity of 500 L are available.

• Inhalation should begin 45 seconds before the onset of pain.


inhaled analgesia appears to be effective in reducing pain intensity and in giving pain relief in labournitrous oxide appears to result in more side effects compared with flurane derivatives. Flurane derivatives result in more drowsiness when compared with nitrous oxide. nitrous oxide appears to result in even more side effects such as nausea, vomiting, dizziness and drowsiness

(Trudy Klomp, Leanne Jones, Di Nisio.2012)Cochrane Database

What evidence say about inhaled anelgesia

Begins with fully cervical dilation (10 cm) and complete effacement (100%) and ends with the baby’s birth.

Duration of second stage

Multiparous women 1-2hr

Nulliparous women 2-3hr


Second stage consist of 2phases: 1. latent phase: baby begins its journey through the birth canal, or

vagina, to the outside. The power for this movement is provided by the contracting uterus, the diaphragm, and the abdominal and respiratory muscles of the mother. With each contraction the baby's head moves down until part of the baby's head is visible at the entrance of the birth canal .


2. Active phase(delivary mother's pushing produces crowning , fetal station +1

The mother continues to push until the entire head is delivered

The shoulders emerge next, first one and then the other

Finally, the medical attendant slowly eases the rest of the body out of the birth canal and the baby is born.


The mechanisms of labor, also known as the cardinal movements refer to the changes in position of fetal head during its passage through the birth canal.

Engagement DescentFlexionInternal Rotation ExtensionExternal Rotation Expulsion

Cardinal Movements in Labor

Vaginal birth video

Nursing care during second stage Sign that suggest onset of second stage • 1. felling of urge to bush or need for bowel

movement• 2. sudden appearance of sweat on upper lip • Episodes of vomiting • Increase bloody show• Checking of extremities • Increase restlessness • Involuntary bearing down

Perform every 5-30 min v/s Assess every 5-15min FHRAssess every 10-15min vaginal show and signs of fetal descent and maternal appearance Assess every contraction and bearing down effort

Nursing care during second stage

Fundal pressure Use of fundal pressure is not advised because there is no standard

techniques available for this maneuver also no current legal or regulatory standard exist for it’s use and no evidence related to it effectives in facilitating a safe vaginal birth is available.(simbson,2008)

Nursing care during second stage

When the fetal head reaches the pelvic floor most women experience the urge to bear down or push. Monitor women’s breathing.

Should not hold breath more than 5 to 7 sec.

Remained her to take deep breathing

Bearing Down (pushing)

THE “OLD WAY” pushing immediately at 10 cm regardless of whether the woman has an urge to push.

closed-glottis pushing (Valsalva's Maneuver).

woman lies in the supine Lithotomy position. These techniques have the potential to cause harm to the

mother and baby.

(AWHONN,2010)

When and how to push

This is when a woman, who in the second stage of labor or the "pushing stage" has coached to push. Instructs woman to hold her breath and push for 10 counts/seconds.

But holding breath for 10 seconds not good during pushing.

Because of: increase intrathoracic and cardiovascular pressure. reducing cardiac output. inhibiting perfusion of the uterus and the placenta. resulting in fetal hypoxia.

Closed Glottis pushing/Valsalva's Maneuver

The Best Way A better approach based on current evidence is to delay pushing until the woman feels the urge to push.

The latent phase is an ideal time to allow the woman to rest in preparation for pushing efforts at the appropriate time.

When the time is right for pushing? the best approach based on current evidence is to encourage the

woman to do whatever comes naturally.

(AWHONN,2010)

When and how to push

• The benefits of delayed pushing include less fetal heart deceleration , fewer forceps and vacuum assisted birth , less perenial damage

• The longer length of second stage doesn’t associated with poor neonatal outcomes , as long as fetal status during this time is normal.

(berghella et al ,2008 ,brancato,church,&ston,2008)

Reaserch evidence

Reaserch evidence

• More effective bearing down effort conserve maternal energy and reduce the risk of operational vaginal birth.

(robert,2002,simbson&james,2005)

Based on this evidence it is essential that prenatal nurse advocate for the practice of delayed and spontaneous

bearing down effort.

Positioning is an important component of safe and effective pushing.

upright position or lateral position works better than supine positioning.

Forcing women's legs back against their abdomen during pushing should be avoided because this results in stretching the perineum

and increases the risk of perineal lacerations.

International Journal of Gynecology and Obstetrics (2012)

Position & Pushing

small cut in the vaginal opening to prevent tearing during delivery.

This is often a routine procedure in primigravidas.

episiotomy is a painless procedure done just before the baby's head is born.

Episiotomy

Episiotomy is routinely practiced in 67% of the hospitals in Jordan .

Sweidan et al., (2008)

Perineal (episiotomy) Classified as one of the practices that is frequently used and should be avoided as a routine.

Khresheh et al., (2009)

Practice in Jordan for Episiotomy

There should be a policy of restricted episiotomy (episiotomy only when necessary).

There is no evidence that a policy of routine episiotomy resulted in significant:

Reductions in laceration severity. pain. pelvic organ prolapse. better maternal outcomes.


Episiotomy

Episiotomy at first vaginal delivery significantly and independently increased the risk of repeated episiotomy and spontaneous perennial tears in subsequent delivery. (Lurie,2012)

Avoiding routine episiotomy in unnecessary condition would increase the rate of intact perineal and minor perineal trauma and reduce postpartum delivery pain with no adverse affect nether on maternal nor neonatal morbidities .(shahraki,2011)

Evidence show that :

Episiotomy and laceration repair should always be

performed under adequate perineal anesthesia.

such as: epidural. local infiltration.


Episiotomy

A comparison of labor and birth outcomes in Jordan with WHO guidelines

Pain relief (pethedin) 44% one of the practices that is frequently used inappropriately.

Low Apgar Score Admission to NICU Interrupts mother–baby bonding and disrupts breast

feeding initiation. Respiratory depression for both mother and infant.

Perineal (episiotomy) 53% Classified as one of the practices that is frequently used and should be avoided as a routine.

Khresheh et al., (2009)

Cultural Differences Among Birthing Women

The Russian Culture Russian women prefer to be alone during labor and birth. They view labor and birth as a private experience. They prefer not to have their partners present because

they were afraid for their husbands!


The Russian Culture Using female relatives at the birth instead of the

husband is a common practice.

This is popular among many women in Arabic cultures as well as traditions of Pacific Islanders, Cambodians, Chinese, Filipinos, Indonesians, and Koreans


The Chinese culture Chinese women are encouraged to avoid heavy

manual ,encourage rest. Infant boys are considered more valuable than infant girls. The Chinese avoid “cold” foods such as bean sprouts and

bananas because they believe it increases the risk of miscarriage.


In the Chinese culture, eating during labor is the norm. When asking for water, they prefer warm water. If given ice chips

they are not eaten for fear of upsetting the hot-cold balance. They may not choose to use ice on episiotomies for this reason Upsetting the hot-cold balance is thought to cause arthritis in old

age. The “Sitting Month” is the month after delivery where

women are encouraged to rest and recover.


African Culture It is typical for the woman to deliver while squatting on the

ground surrounded by female relatives. Squatting is representative of the mother’s connection with the earth.

Midwives only get paid if delivery is successful. Some relatives act as midwives.

In the Yoruba tribe, in Nigeria, the name given to the child must reflect circumstances around the birth.

References Lee, Nigel, Webster, Joan, Beckmann, Michael, Gibbons, Kristen, Smith,

Tric, Stapleton, Helen, & Kildea, Sue. (2013). Comparison of a single vs. a four intradermal sterile water injection for relief of lower back pain for women in labour: A randomised controlled trial. Midwifery, 29(6), 585-591.

Lee, Shu-Ling, Liu, Chieh-Yu, Lu, Yu-Yin, & Gau, Meei-Ling. (2013). Efficacy of warm showers on labor pain and birth experiences during the first labor stage. Journal Of Obstetric, Gynecologic, And Neonatal Nursing: JOGNN / NAACOG, 42(1), 19-28. doi: 10.1111/j.1552-6909.2012.01424.x

Wang, FuZhou, Shen, XiaoFeng, Guo, XiRong, Peng, YuZhu, Gu, XiaoQi, & Group, The Labor Analgesia Examining. (2009). Epidural Analgesia in the Latent Phase of Labor and the Risk of Cesarean Delivery: A Five-year Randomized Controlled Trial. Anesthesiology, 111(4), 871-880 810.1097/ALN.1090b1013e3181b1055e1065.

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Cochrane Pregnancy and Childbirth Group’s Trials Register (31 January 2012)

Thorp, James A., Hu, Daniel H., Albin, Rene M., McNitt, Jay, Meyer, Bruce A., Cohen, Gary R., & Yeast, John D. (1993). The effect of intrapartum epidural analgesia on nulliparous labor: A randomized, controlled, prospective trial. American Journal of Obstetrics and Gynecology, 169(4), 851-858. doi: http://dx.doi.org/10.1016/0002-9378(93)900

Zhang, Jun, Klebanoff, Mark A., & DerSimonian, Rebecca. (1999). Epidural analgesia in association with duration of labor and mode of delivery: A quantitative review. American Journal of Obstetrics and Gynecology, 180(4), 970-977. doi: http://dx.doi.org/10.1016/S0002-9378(99)70669-1.

http://dx.doi.org/10.1016/0002-9378(93)900

http://dx.doi.org/10.1016/S0002-9378(99)70669-1

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http://www.facebook.com/l.php?u=http://edinfo.med.nyu.edu/mc/culture/Preganacy.html&h=FAQHJTs4P

http://www.facebook.com/l.php?u=http://2008gamesbeijing.com/chinese-pregnant-women-paint-olympic-mascots-on-their-stomachs/&h=fAQGMc9JV

http://www.facebook.com/l.php?u=http://2008gamesbeijing.com/chinese-pregnant-women-paint-olympic-mascots-on-their-stomachs/&h=fAQGMc9JV

http://www.facebook.com/l.php?u=http://www.kaliyogainc.com/community/shanti-uganda-society/&h=9AQGJUlo5

http://www.facebook.com/l.php?u=http://www.kaliyogainc.com/community/shanti-uganda-society/&h=9AQGJUlo5

pain management during labor & second stage of labor

Health & Medicine