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Management of Labor Pain

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Title: Management of Labor Pain Author: oneill_s Last modified by: oneill_s Created Date: 11/23/2005 4:46:35 PM Document presentation format: On-screen Show – PowerPoint PPT presentation

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Title: 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 physicians 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

4
Cultural Values Learned Behaviors
  • Expectations are often confirmed
  • Anxiety and fear
  • higher experience of pain
  • Confidence in her ability to cope
  • Safe and positive birth environment

5
Nature of Labor Pain 1st Stage
  • Visceral pain
  • Diffuse abdominal cramping
  • Uterine contractions

6
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

7
Trends
  • Nulliparous
  • More sensory pain during early labor
  • Multiparous
  • More intense pain during late 1st stage and the
    2nd stage
  • Rapid fetal descent

8
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

9
Nonpharmacological Pain Relief
  • Used by virtually all women
  • (different degrees)

10
Continuous Labor Support
  • Continuous labor support provided by a doula
    decreases the use of obstetric interventions.
  • Doula lay woman trained in labor support

11
Continuous Labor Support
  • Decreased
  • Operative vaginal deliveries
  • Cesarean deliveries
  • Request for pain medication
  • Fewer women have unsatisfactory births

12
Warm Water Baths
  • Increasingly available
  • Hospitals birth centers
  • Recent survey (2002 - USA)
  • 6 of women used warm water baths
  • 49 found them very helpful

13
Warm Water Baths
  • No effect on the usage of epidural analgesia
  • Short duration of pain relief
  • Only effective while shes in the bath

14
Warm Water Baths Risks?
  • No evidence of increased maternal or neonatal
    infection
  • Labor may slow if used in early labor
  • Less than 5cm dilation

15
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

16
Sterile-Water Injections
  • Intradermal injections of sterile water in the
    sacral area
  • Causes a burning sensation
  • counterirritation
  • Decreases back pain for 45-90 mins.

17
Sterile-Water Injections
  • No decrease in request for pain medications
  • Short duration
  • No effect on abdominal labor pain

18
Positions, Touch, Massage
  • Limited evidence
  • One study showed a decrease in the use of
    analgesia
  • NO side-effects!

19
Why are we looking to decrease the use of
medication?
20
The Theory of Natural Birth
  • Unmedicated

21
  • Body produces endorphins to cope with pain
  • Babys endorphins raise when moms endorphins
    raise
  • Medications decrease natural endorphins for both
  • Stimulates the babys adrenal glands
  • Fight or flight helps to adapt to life
    outside of the uterus
  • Helps baby breathe
  • Increases blood flow to baby
  • Baby is more alert facilitates bonding
  • Oxytocin peaks just after an unmedicated birth
  • Stimulates maternal behaviors

22
Pharmacological Pain Relief
23
Parenteral Opioids
  • Used in 39-56 of labors in US hospitals
  • Despite common use and decades of research
  • Insufficient data regarding safety and efficacy

24
Parenteral Opioids
  • Subsequent use of epidural analgesia
  • Adverse symptoms
  • Nausea
  • Drowsiness
  • Inability to urinate
  • Inability to participate in labor
  • Cesarian
  • Instrument-assisted vaginal delivery

25
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

26
Parenteral Opioids - Infant
  • Neonatal respiratory depression
  • Decreased alertness
  • Inhibition of sucking
  • Lower neurobeharioral scores
  • Delay in effective feeding
  • Long-term effects cannot be excluded

27
Further Research Needed
  • Compare opioids with other methods
  • Continuous support (doula)
  • Hydrotherapy
  • Pain experience
  • Maternal satisfaction
  • Adverse effects
  • Labor neonatal

28
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

29
Epidural Analgesia
  • Balance between pain relief and other goals
  • Walking (1st stage)
  • Pushing effectively (2nd stage)
  • Minimizing side effects
  • maternal and neonatal

30
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

31
Walking Epidural
  • Advantages
  • Rapid onset of pain relief
  • Potential for the intrathecal medication to
    suffice
  • Likely to deliver in 2-3 hours

32
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

33
Concern
  • Epidural-induced maternal fever
  • Unnecessarily increases work-ups for neonatal
    sepsis
  • Increased neonatal antibiotics

34
Epidural Side Effects
  • Common
  • Hypotension
  • Impaired motor function (inability to walk)
  • Need for catheterization
  • Uncommon (lt10)
  • Pruritis
  • Nausea vomiting
  • Sedation

35
Nitrous Oxide
  • Widely used in most developing countries
  • gt60 Finland and United kingdom
  • Exception - USA

36
Nitrous Oxide
  • 50/50 blend nitrous oxide and oxygen
  • Full effect 50 seconds after inhalation
  • Usually self-administered as needed

37
Nitrous Oxide Side Effects
  • Nausea
  • Vomiting
  • Poor recall of labor

38
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

39
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
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