Anjani Reddy, PGY-11/12/09

Case Presentation37 y/o G1P0 @ 38wks and 1day EGA, presents

complaining of ctx q5 min for 6 hoursPNI: AMA: neg. quad screen, declined amnioPMH: nonePSH: nonePObH: nonePGynHx: no STIs/abnl PAPs/ovarian

cysts/uterine fibroidsMeds: PNVAll: NKDA

Case PresentationVS: stableExam:

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 – 1st stageVisceral/cramping pain during

contractionsOriginates in the uterus and cervixProduced 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 – 2nd stageSomatic pain from

distention of the vagina, perineum and pelvic floor

Stretching of the pelvic ligaments

S2-S4 (pudendal nerve)More severe than first

stageCombination of

Visceral pain from contractions

Cervical stretchingSomatic pain from

distentionRectal pressure

Adverse Consequences of Labor PainHyperventilation

Respiratory alkalosis could decrease ventilatory drive between contractions impair oxygen transfer to fetus (left shift of

oxyhemoglobin dissociation curve) Uteroplacental vasoconstriction

Neurohumoral EffectsIncrease in catecholamines and decrease in blood

flow to the uterus, lowering fetal oxygenation, increasing bradycardia and acidosis

Psychological EffectsUnrelieved 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“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 deliveryPain relief was NOT the most important

factor influencing satisfaction with childbirthStudy 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 painWomen should be involved in the decision-

making processCan be accomplished by educating women

about pain relief techniquesProviding education BEFORE labor commences

(rational decision-making is compromised at times of emotional and physical stress)

Approaches to management of labor painPharmacologic – eliminate physical sensation

of labor painNon-pharmacologic –prevent sense of

suffering

Pharmacologic management of painIntroduced 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 careTherefore, ACOG supports the concept that

maternal request alone is a sufficient medical indication for labor analgesia

Pharmacologic optionsSystemic analgesics

Opioids, Opioids with mixed agonist-antagonist properties, PCA, Nonopioid agents, Inhalation agents

Local injection techniquesPudendal, Paracervical block

Neuraxial analgesiaEpidural and spinal techniques

Systemic analgesicsOpioids

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)Dose: 25-50mg IV, 50-100mg IMOnset: 5min IV, 40min IMDuration: 2-3hrsSide effect profile: respiratory depression,

serotonergic crisis, seizures, and metabolite activity in the neonate for up to 2.5 days

MorphineDose: 2-5mg IV, 40min IMOnset: 3-5min IV, 20-40min IMDuration 3-4hrSide effects: Greater respiratory depression

in mother/infant than Demerol

FentanylDose: 25-50mcg IV, 100mcg IMOnset: 1-3min IV, 7-10min IMDuration: 1-2hrs IMSide effects: respiratory depressionRemifentanil is in the same subclass – same

onset, but metabolized quickly, thus, should not cause respiratory depression

Mixed Agonist-AntagonistsButorphenol, Nalbuphine, Pentazocine, and

buprenorphineDose 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 analgesicsPCA pumpAntiemetics: Hydroxyzine and promethazineNitrous 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 TechniquesUsed by more than 70% of women who give

birth in hospitals with greater than 1500 deliveries per year

Spinal vs. Epidural techniquesImmediate onset vs lower side effect profile

Side effects include hypotension, fever, HA, numbness, and infection

Epidural Continuous infusion

of:Local anesthetic

(Bupivacaine or Ropivacaine)

Opioid (usually lipid soluble Fentanyl or Sufentanyl

+/-Epinephrine (works on alpha 2 receptors)

Pudendal Nerve BlockAlleviates pain arising from vaginal and

perineal distentionUsed as a supplement for epidural analgesia

if the sacral nerves are not sufficiently anesthetized

Provide analgesia for low forceps delivery

Systemic vs. Regional analgesiaSystematic 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 pain1,330 ptsIncreased rate of c-section delivery

secondary to dystocia in the epidural anesthesia group (OR = 1.98, 9% vs 5%)

Epidural associated withIncreased 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 painPharmacologic – eliminate physical sensation

of labor painNon-pharmacologic –prevent sense of

suffering

Non-pharmacologic approachGoal is to eliminate her sense of:Perceived threat to body and/or psychHelplessness, loss of controlDistressInsufficient resources for coping with the

situationFear of death of the mother or baby

Non-pharmacologic approachPain is a side effect of a normal processGoal is NOT to make the pain disappear

Instill self-confidence, sense of mastery and well-being

So that pain is neither feared, nor focused onWomen 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 EnvironmentPromotes sense of comfort and privacyComfort aidsPlaces to walk, bathe, and restStudy 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 birthIncreased 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 SupportNonmedical 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-sectionsHalf the risk of instrumental deliverySignificantly shorten labor

Water ImmersionWarm water, deep enough to cover the

woman’s abdomenEnhances relaxation, reduces labor painBody temperature should be monitoredFew minutes to hours in the first stage of

laborRandomized trials show:

Significant reduction in pain (via pain score or decreased narcotic use)

No increase in infection rates (even c ROM)

Intradermal Water BlocksIncidence 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 LBPRelief lasts 45 -120 minutes

Intradermal Water Block4 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 Positioning76% of hospitalized laboring women do not

walk around. Limited movement was secondary to:Connections (IVs, tocometers, BP cuffs,

catheters)Pain medicationsInstructed not to by medical staff

So many positions, so little time!Knee-Chest*DangleHands and Knees*Labor Dance*The Lift*The Lunge*RockingSide Lying*SquattingToilet SittingTug of WarWalking 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 1st stage16 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 2nd stageSupine position found to be more painful than

other positionsKneeling position preferred to sitting position

Touch and MassageTouch communicates caring, concern,

reassurance, and loveMassage enhances relaxation and reduces

painHave been found to decrease pain, anxiety

and blood pressureShown to improve mood, and sense of

supportNO harmful effects!

Application of Heat and ColdPersonal choicePlace one or two layers of cloth to protect against

skin damage and intact sensation is a prerequisite

HeatApplied to back, lower abdomen, groin, perineumRelieves pain, chills, stiffness, muscle spasm, and

increases extensibility of connective tissueCold

Applied to back, chest, faceRelieves pain, muscle spasm, inflammation and

edema

Childbirth EducationReading, classes, office visitsInformation 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 BreathingRhythmic breathing patterns that promote

relaxation, and distract women from labor painEnhance sense of controlSurvey 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 AudioanalgesiaFew studies, with small sample sizes and

inadequate controls Cochrane review on the effect of music on

acute painSmall reduction in pain intensity levels and

opioid requirements

AromatherapyUse of concentrated oils distilled from plantsUse is increasingSome sources note that they are potent as

pharmacological drugs and should be used with caution

One uncontrolled prospective study8058 womenLavender, rose or frankincense used under supervision

of midwivesUsed to decrease fear, anxiety, pain, nausea and

vomitingHalf of women found it helpful1% reported nausea/headache as side effect

Acupuncture/AcupressureAcupressure 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“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 useContraindicated in women with history of

psychosis

Transcutaneous Electrical Nerve Stimulation

Low voltage impulses to the skin via surface electrodes

Rentals available w/o rxParavertebrally at T10-L1

and S2-4Woman controls intensity

and sensation patternsIncreases endorphinsRandomized trials showed

Decreased and later introduction of pain meds

Reduction of pain scores was shown in some studies

Case Presentation Continued…6PM: Patient admitted.

Options discussed. Patient expressed interest in systemic analgesics

Preference presented to OB staffOB 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 placed12:30PM: Unplanned C/S performed 2/2 “non-

reassuring heart tones”

Resources Ramin, S. Randomized Trial of Epidural vs. IV analgesia during labor. Obstet Gynecol 1996 Nov; 86(5): 783 Lowe, NK. The nature of labor pain. Am J Obstet Gynecol 2002; 186:So16 Goetzl, LM. ACOG Practice Bulletin. Clinical Management Guidelines for OB-Gyns Number 3, July 2oo2. Obstetric analgesia and

anesthesia. Obstet Gynecol 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. Parenteral opioids for labor pain relief: A systematic review. Am J Obstet Gynecol 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 Obstet Gynecol 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. 2 nd

Edition. Balliere Tindall, New York 2000. Cepeda MS. Music for pain relief. Chochrane Database Syst Rev 2006; CD004843 http://birthingnaturally.net/