Painless Labor

dr. Pangkuwidjaja, Sp. An

The Pain of Childbirth

there is no other circumstance where it is considered
acceptable for a person to experience severe pain, amenable
to safe intervention, while under a physicians care

(ASA & ACOG)

The pain of childbirth

Varies
Type
Location
Stage of Labor
More Severe
Abnormal position
A history of severe dysmenorrhea
Young maternal age
Increased maternal / fetal weight
The presence of the infants father during labor

The pain of childbirth

Mechanisms
Visceral component
Lower uterine segment
cervix
during uterine contraction
distention, stretching by fetal presenting part

ischemia
Afferent pathway
accompany sympathetic nerves
paracervical
inferior hypogastric plexus
lumbar sympathetic chain
T10 L1
Occurs in the first stage of labor

The pain of childbirth

Mechanisms
Somatic component
pelvic floor
vagina
perineum
Afferent pathway
pudendal nerve
sacral nerves S2, S3, and S4
uncontrollable reflux to have valsava maneuver
to bear down and push
Occurs late in the first stage (6 8 cm)
persist throughout the second stage

Effect of Labor Pain on Maternal

Physiology
Respiratory system

Hyperventilation
as pain becomes severe
minute ventilation
first stage 75 150%
second stage
150 300%
Oxygen consumption
increases above pre-labor value
first stage 40%
second stage 75%

Effect of Labor Pain on Maternal

Physiology
Respiratory system

Hyperventilation
fetal hypoxemia during maternal hyperventilation
uteroplacental & fetoplacental vasoconstriction
left-shift of the maternal oxyhemoglobin dissociation curve

maternal hypocarbia & alkalemia

hypoventilation between contraction
maternal & fetal hypoxemia

Effect of Labor Pain on Maternal

Physiology
Adrenergic response

Pain
Stress maternal plasma concentration of
catecholamines
Anxiety
uterine activity
prolonged labor
incidence of abnormal FHR patterns

Analgesia/Anesthesia methods
Non-pharmacologic analgesia
Simple techniques of pharmacologic analgesia
Inhalational analgesia and anesthesia
Regional analgesia and anesthesia

Non-pharmacologic analgesia
Natural childbirth

Physiotherapeutic and

psychophysiologic

Psycho-prophylactic method

fear-tension-pain syndrome

(Dick-Read)
Conditional reflex labor pain (velvovsky)
anxiety
+ anatomy, physiology (Lamaze)

Hypnosis
Acupuncture
TENS
gate-control theory of pain

Simple techniques of pharmacologic

analgesia
Mild pain during the early first stage
suggestion
sedatives
tranquilizer
Moderate-severe pain during the active phase of labor
opioids
not complete relief (70-80%)
neonatal depression

Inhalational Analgesia and

Anesthesia

Produce moderately effective pain relief, without causing:

loss of consciousness
significant maternal or neonatal depression
N2O 40 50% in O2
Entonox
intermittently during uterine contractions
should begin 10 -15 seconds before the painful period of each
contraction

Inhalational anesthesia
Analgesic concentration
maximum control of depth and duration of action
rapidly eliminated at the end of the procedure

Regional Analgesia and Anesthesia

Produce complete relief of pain
Obviates the pain-induced deleterious reflex responses

Produce block of nociceptive fibers (A- and C)

Use of dilute local anesthetic solutions
minimal or no effect on the larger somatomotor and tactile
fibers

The risk of pulmonary aspiration of gastric contents

Permits the mother remains awake and alert
experience
participating

No maternal or neonatal depression

No clinical significant effect on the progress of labor
Can be modified for SC

Regional Analgesia and Anesthesia

Requires greater knowledge of anatomy
Requires greater technical skill
technical failures

Vasomotor block
Premature perineal muscle relaxation
interfere with the mechanism of internal rotation
incidence of occipitoposterior or occipitotransverse
positions

Produce perineal analgesia

Loss of afferent limb of the reflex urge to bear down
prolong labor or require the use of outlet forceps

Relatively contraindicated in coagulopathy patient

Only in hospital

 the delivery of the infant into the arms of a conscious and

pain free mother is one of the most exciting and rewarding
moment in medicine