What is the role of pain management during labor and delivery?

Updated: Jan 24, 2019
  • Author: Sarah Hagood Milton, MD; Chief Editor: Christine Isaacs, MD  more...
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Answer

Answer

Laboring women often experience intense pain. Uterine contractions result in visceral pain, which is innervated by T10-L1. While in descent, the fetus' head exerts pressure on the mother's pelvic floor, vagina, and perineum, causing somatic pain transmitted by the pudendal nerve (innervated by S2-4). [4] Therefore, optimal pain control during labor should relieve both sources of pain.

A number of opioid agonists and opioid agonist-antagonists can be given in intermittent doses for systemic pain control. These include meperidine 25-50 mg IV every 1-2 hours or 50-100 mg IM every 2-4 hours, fentanyl 50-100 mcg IV every hour, nalbuphine 10 mg IV or IM every 3 hours, butorphanol 1-2 mg IV or IM every 4 hours, and morphine 2-5 mg IV or 10 mg IM every 4 hours. [4] As an alternative, regional anesthesia may be given. Options are epidural, spinal, or combined spinal epidural anesthesia. These provide partial to complete blockage of pain sensation below T8-10, with various degree of motor blockade. These blocks can be used duringlabor and for surgical deliveries.

Studies performed to compare the analgesic effect of regional anesthesia and parenteral agents showed that regional anesthesia provides superior pain relief. [69, 44, 70] Although some researchers reported that epidural anesthesia is associated with a slight increase in the duration of labor and in the rate of operative vaginal delivery, [71, 72] large randomized controlled studies did not reveal a difference in frequency of cesarean delivery between women who received parenteral analgesics compared with women who received epidural anesthesia [69, 70, 72] given during early-stage or later in labor. [73] Although regional anesthesia is effective as a method of pain control, common adverse effects include maternal hypotension, maternal temperature >100.4°F, postdural puncture headache, transient fetal heart deceleration, and pruritus (with added opioids). [4]

Despite the many methods available for analgesia and anesthesia to manage labor pain, some women may not wish to use conventional pain medications during labor, opting instead for a natural childbirth. Although these women may use breathing and mental exercises to help alleviate labor pain, they should be assured that pain relief can be administered at any time during labor.

A Cochrane review update concluded that relaxation techniques and yoga may offer some relief and improve management of pain. Studies in the review noted increased satisfaction with pain relief and lower assisted vaginal delivery rates with relaxation techniques. One trial involving yoga noted reduced pain, increased satisfaction with pain relief, increased satisfaction with the childbirth experience, and reduced length of labor. [74]

Of note, use of nonsteroidal anti-inflammatory drugs (NSAIDs) are relatively contraindicated in the third trimester of pregnancy. The repeated use of NSAIDs has been associated with early closure of the fetal ductus arteriosus in utero and with decreasing fetal renal function leading to oligohydramnios.


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