TBILISI STATE MEDICAL UNIVERSITY

UNICEF GEORGIA

MANUAL IN PERINATOLOGY

METHODS OF PAIN CONTROL

DURING LABOR AND DELIVERY

MODULE 7 PART 2

STUDENT’S HANDOUTS
 Birth

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bi bl i a,d abad eba,T avi 111,16

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

COMMENT OF GG

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 What is pain?
The way pain is experienced is a reflection of
the individuals emotional, cognitive, social and
cultural circumstances

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

The experience of labor pain is a highly individual reflection of variable stimuli

that are uniquely received and interpreted by each womanindividually. These stimuli
are modified by emotional, motivational, cognitive, social, and cultural
circumstances. The complexity and individuality of the experience suggest that a
woman and her caregivers may have a limited ability to anticipate her pain
experience prior to labor. Thus, choice among a variety of methods and
individualization of pain relief is desirable.

WILLIAMS OBSTETRICS<22EDITION,2005
 Pain during delivery

• Most severe pain for women

• A side effect of a normal process of labor
• Varies among the parturients
• Originates from diferent sites

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

The pain of childbirth is likely to be the most severe pain that a woman experiences
during her lifetime . Many women, especially nulliparas, rate the pain of labor as
very severe or intolerable . The pain of labor and delivery varies among women,
and each labor of an individual woman may be quite different. As an example, an
abnormal fetal presentation (eg, occiput posterior) is associated with more severe
pain and may be present in one pregnancy, but not the next. Pain originates from
different sites as the process of labor and delivery progresses
 The pain during the first stage of delivery P

• Pain occurs during contractions

• Pain is visceral or cramp-like.
• Pain originates in the uterus and cervix
• Pain is produced by dis tention of uterine and cervic al mechanoreceptors
• Pain is produced by is chemia of uterine and cervical tissue
• The pain signal enters the spinal cord.

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Pain at this time occurs during contractions, is visceral or cramp-like in nature, originates in the
uterus and cervix, and is produced by distention of uterine and cervical mechanoreceptors and by
ischemia of uterine and cervical tissues. The pain signal enters the spinal cord after traversing the
T10, T11, T12, and L1 white rami communicantes. In addition to the uterus, labor pain can be
referred to the abdominal wall, lumbosacral region, iliac crests, gluteal areas, and thighs .Transition
refers to the shift from the late first stage (7 to 10 cm cervical dilation) to the second stage of labor.
Transition is associated with greater nociceptive input as the parturient begins to experience somatic pain
from vaginal distention.u

Uterine Innervation. Pain during the first stage of labor is generated largely from the uterus.
Visceral sensory fibers from the uterus, cervix, and upper vagina traverse through the Frankenhauser
ganglion, which lies just lateral to the cervix, into the pelvic plexus, and then to the middle and
superior internal iliac plexuses . From there, the fibers travel in the lumbar and lower thoracic
sympathetic chains to enter the spinal cord through the white rami communicantes associated with
the T10 through T12 and L1 nerves. Early in labor, the pain of uterine contractions is transmitted
predominantly through the T11 and T12 nerves.The motor pathways to the uterus leave the spinal
cord at the level of the T7 and T8 vertebrae. Theoretically, any method ofsensory block that does not
also block the motor pathways to the uterus can be used for analgesia during labor.
 The pain during the second stage of
delivery

• Pain is somatic
• Pain occurs from distention:
Vagina
Perineum
Pelvic floor
Pelvic ligaments
• The pain signal is transmitted to the spinal cord
• Pain is more severe and combinated.

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Somatic pain from distention of the vagina, perineum, and pelvic floor and
stretching of the pelvic ligaments is the hallmark of the second stage of labor. The
pain signal is transmitted to the spinal cord via three sacral nerves (S2, S3, and
S4), which comprise the pudendal nerve. Second stage pain is more severe than
first stage pain and is characterized by a combination of visceral pain from uterine
contractions and cervical stretching and somatic pain from distention of vaginal and
perineal tissues. In addition, the parturient experiences rectal pressure and an urge
to "bear down" and expel the fetus as the presenting part descends into the pelvic
outlet.
Lower Genital Tract Innervation. Pain with vaginal delivery arises from stimuli from the lower
genital tract. These are transmitted primarily through the pudendal nerve, the peripheral branches of
which provide sensory innervation to the perineum, anus, and the more medial and inferior parts of
the vulva and clitoris. The pudendal nerve passes beneath the posterior surface of the sacrospinous
ligament just as the ligament attaches to the ischial spine. The sensory nerve fibers of the pudendal
nerve are derived from the ventral branches of the S2 through S4 nerves
 Adverse consequences of labor
pain
• Hyperventilation

• Neurohumoral effects

• Psychological effects

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

The pain of labor produces physiological changes in addition to emotional distress and suffering. These
changes have an impact on many maternal systems, and also affect the
fetus.Hyperventilation — Hyperventilation consistently accompanies labor pain. Arterial CO2 partial pressures
less than 20 mmHg are not uncommon, and profound hypocarbia may inhibit ventilatory drive between
contractions and result in maternal hypoxemia, lightheadedness, and loss of consciousness . Respiratory
alkalosis, which impairs oxygen transfer from the maternal to fetal circulation, may occur. Alkalosis shifts the
oxyhemoglobin dissociation curve to the left, increasing the affinity of oxygen for maternal hemoglobin, thereby
decreasing off-loading of oxygen to the fetus. Maternal alkalosis also can impair oxygen transfer to the fetus via
utero-placental vasoconstriction . These changes are usually well-tolerated in healthy parturients with normal
pregnancies.Maternal transcutaneous PO2 as low as 44 mmHg has been observed during contractions . Epidural
analgesia reverses the adverse ventilatory effects of pain and results in an increase in oxygen tension in both
mother and fetus , which may be beneficial when additional conditions contributing to fetal or maternal
hypoxemia are also present.Neurohumoral effects — Neurohumoral responses to stress and pain may
adversely affect placental perfusion and fetal oxygenation. Studies in sheep demonstrated that pain increased
circulating catecholamines and significantly decreased blood flow to the uterus . In pregnant primates, stress
and pain was shown to lower fetal oxygenation, cause fetal acidosis, and slow fetal heart rate. These changes
may be of clinical concern when other conditions contributing to fetal hypoxemia are also present.Removal of
the stressful stimulus and sedation reversed these changes . Epidural analgesia results in decreased
concentrations of circulating maternal epinephrine, probably by reducing maternal pain and anxiety . Epidural
analgesia also results in a reduction of plasma beta-endorphin and cortisol levels .Psychological effects — In
addition to untoward physiological effects, unrelieved pain may also be a factor that contributes to the
development of postpartum psychological trauma. This may negatively influence the mother's postpartum
adjustment, and in its most severe form, result in post-traumatic stress disorder (PTSD) . The prevalence of
developing postpartum PTSD was as high as 5.6 percent in one study of 499 postpartum women . The
profoundly harmful effects of postpartum PTSD on new mothers should not be underestimated .
 Defending mechanisms

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t ki vi l i s z Ru r bl i s amaRl ebas

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

stresuli zemoqmedebis Sedegad sisxlSi enogenuri opioidebi gamonTavisufldebian, romlebic ainhibireben tkivilis impulses
gadacemas Tavisa da zurgis tvinSi. Endogenuri opioidebi opioidur receptorebze zemoqmedebiT ainhibireben tkivilis specifiuri
hormonis gamoyofas e.w. substancia “P”,rac ganapirobebs endogenuri opioidebis universaluri analgetikis
bunebs.gardazemoTaRwerili periferiuli meqanizmebisa ,opioidebs axasiaTebs tkivilis gamaanalizirebel umaRles centrebze
damTrgunveli zemoqmedeba.amis wyalobiT,opioidebis koncentraciis zrdisas izrdeba tkivilis zRurblovanebac.cnobilia,rom
tkivilis,iseve rogorc nebismieri gamaRizianeblis zemoqmedeba organizmze xorcieldebagarkveuli donis zemoT misi
moqmedebisas,anu zezRurblovani zemoqmedebisas.sworad am zRurblis amaRlebas uzrunvelyofen opioidebi.amis TvalsaCino
magaliTia stresuli anesTeziis fenomeni mSobiarobis procesSi.cnobilia,rom araorsuli qalisatvis igive xarisxis tkivilis
miyeneba,rasac ganicdis mSobiare,masSi stresul Soks gamoiwvevda.
 The management of labor pain
Two general approaches

1. Pharmacological

2. nonpharmacological

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

The management of labor pain is a major goal of intrapartum care. There are two general approaches:
pharmacologic and nonpharmacologic. Pharmacologic approaches are directed at elimination of the physical
sensation of labor pain, whereas nonpharmacologic approaches are largely directed toward prevention of
suffering. Suffering may be defined in terms of any of the following psychological elements: a perceived threat
to the body and/or psyche; helplessness and loss of control; distress; insufficient resources for coping with the
distressing situation; even fear of death of the mother or baby . Although pain and suffering often occur
together, one may suffer without pain or have pain without suffering.
 The primary goal of
nonpharmacological approaches
• Not to make the pain disappear

• Help the woman to cope with labor pain

• Prevent suffering

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

The nonpharmacologic approach to pain management includes a wide variety of techniques that
address not only the physical sensations of pain, but also attempt to prevent suffering by enhancing
the psychoemotional and spiritual components of care. In this approach, pain is perceived as a side
effect of a normal process (labor). In contrast to neuraxial anesthesia, the primary goal is not to
make the pain disappear. Instead, caregivers help the woman build her self-confidence and maintain
a sense of mastery and well-being, factors which play a major role in her ability to cope with labor .
Reassurance, guidance, encouragement, and unconditional acceptance of her coping style are used.
The woman and her support person are guided and supported in using self-comforting techniques
and nonpharmacologic methods to relieve pain and enhance labor progress. With this type of care,
women perceive that they coped successfully with the pain and stress of labor and state that they
were "able to transcend their pain and experience a sense of strength and profound psychologic and
spiritual comfort during labor"Healthcare professionals should consider how their own values and beliefs inform their
attitude to coping with pain in labour and ensure their care supports the woman’s choice.
Fear and the unknown potentiate pain. A woman who is free from fear, and who has confidence in the
obstetrical staff that cares for her, usually requires smaller amounts of analgesia. Read (1944) emphasized that
the intensity of pain during labor is related in large measure to emotional tension. He urged that women be well
informed about the physiology of parturition and the various hospital procedures to which they will be subjected
during labor and delivery. Lamaze (1970) subsequently described his psychoprophylactic method, which
emphasized childbirth as a natural physiological process. Pain often can be lessened by teaching pregnant
women relaxed breathing and their labor partners psychological support techniques. These concepts have
considerably reduced the use of potent analgesic, sedative, and amnestic drugs during labor and delivery.When
motivated women have been prepared for childbirth, pain and anxiety during labor have been found to be
diminished significantly and labors are even shorter (Melzack, 1984; Saisto and associates, 2001). In addition,
the presence of a supportive spouse or other family member, of conscientious labor attendants, and of a
considerate obstetrician who instills confidence, have all been found to be of considerable benefit. In one study,
Kennell and associates (1991) randomly assigned 412 nulliparous women in labor to either continuous
emotional support from an experienced companion or to monitoring by an inconspicuous observer who did not
interact with the laboring woman. The cesarean delivery rate was significantly lower in the continuous support
group compared with that of the hands-off monitored group (8 versus 13 percent), as was the frequency of
epidural analgesia for vaginal delivery (8 versus 23 percent).

WILLIAMS OBSTETRICS,22ED.2005
 Nonpharmacologic techniques

• Birth environment
• Water immersion
• Intradermal water blocks
• Maternal movement and positioning
• Touch and massage
• Acupuncture and acupressure
• Hypnosis
• Relaxation and breathing
• Aromatherapy
• Music and audioanalgesia

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

The most common options for nonpharmacologic techniques for management of

labor pain will be discussed here. Most birthing facilities offer at least some of these
techniques; however, some procedures, such as acupuncture, usually require
credentialling and may not be available in all birth settings.
 Birth environment

• Comfort aids and places to walk, bath and rest

• The ideal environment for a nonpharmacologic

approach fosters a sense of comfort and privacy

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

The ideal environment for a nonpharmacologic approach fosters a sense of

comfort and privacy. It contains comfort aids and places to walk, bathe, and rest. A
systematic review of randomized trials of home-like versus conventional institutional
settings for birth found that home-like settings increased the likelihood of the
woman not using intrapartum analgesia/anesthesia (RR 1.19, 95% CI 1.01- 1.40) .
Women in home-like settings were more likely to request the same setting the next
time (RR 1.81, 95% CI 1.65-1.98) and express satisfaction with intrapartum care
(RR 1.14, 95% CI 1.07-1.21) than those who gave birth in conventional institutional
settings. However, women willing to participate in such trials may not represent
"typical" patients.
 Water immersion
• Immersion in warm water deep enough to
cover the woman’s abdomen

• Enhance relaxation and reduce labor pain

• Didn’t increase the risk of maternal or

neonatal infection

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Immersion in warm water deep enough to cover the woman's abdomen is thought to enhance
relaxation and reduce labor pain. The water should be at or slightly above body temperature so as
not to increase the woman's core temperature, and her temperature should be monitored. Women
usually remain in the bath for a few minutes to hours during the first stage of labor. Showers during
labor, although commonly used, have not been studied.

Eight randomized trials on use of water immersion during labor have been published . Meta-
analysis was not possible because the trials varied so widely in study design and quality. As an
example, there were large differences in labor status at time of entry into the water, water
temperature, duration of immersion, characteristics of usual care in the control group, and number
of crossover patients. Overall, four of the eight trials noted a significant reduction in pain, which was
determined by a decreased pain score on a pain scale or decreased narcotic use. However, none of
the trials demonstrated a statistically significant reduction in use of epidural anesthesia. Bathing did
not increase the risk of maternal or neonatal infection, even in women with ruptured membranes .

Women generally like the feelings associated with taking a warm bath, and it appears to be a
safe intervention. There are inadequate data to allow clear conclusions on the effect of water
immersion on labor progress and need for interventions, or for making recommendations on the
timing or duration of water immersion.
 Intradermal water blocks
• intracutaneous sterile water injections may
reduce the perception of severe low back
pain in laboring women without side-effects
on the fetus or mother.

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Intradermal water blocks, also called intracutaneous sterile water injections, decrease back pain during
labor, and, to a certain extent, the abdominal pain of labor . Estimates of the incidence of low back pain in labor
range between 15 and 74 percent of all labors . Possible etiologies include a fetal occiput posterior position,
persistent asynclitism, the woman's lumbopelvic characteristics, and referred pain from the uterus. There is
anatomical support that low back pain in labor is actually referred pain since the corpus uteri and cervix are
supplied by afferent neurons ending in the dorsal horn of spinal segments T10-L1 and cutaneous afferents from
the low back converge in the same segments Intradermal water blocks consist of four intradermal injections of
0.05-0.1 mL sterile water (using a 1 mL syringe with a 25-gauge needle) to form four small blebs or papules,
one over each posterior superior iliac spine and two others placed 3 cm below and 1 cm medial to each of the
first sites. The exact locations of the injections does not appear to be critical to its success . The injections can
be quite painful; to offset the discomfort of administration, some providers give injections during a contraction
and have two providers give injections simultaneously to speed the process. The water blocks can be repeated
as desired.While the exact mechanism of action is not known, it is presumed that "closing the gate" in gate
theory and/or the release of local endorphins are responsible. The use of "unphysiological" sterile water is
required. Physiological saline does not burn and does not work.

Five randomized trials compared the effect of intradermal water blocks or a "placebo" blank (using saline),
or an alternative nonpharmacological method (Transcutaneous Electrical Nerve Stimulation [TENS], movement,
massage, baths) for low back pain in labor. All five studies found that intradermal water blocks significantly
decreased severe low back pain in laboring women. Pain relief lasted 45 to 120 minutes and most women stated
they would want to use intradermal water blocks again during a subsequent birth In summary, intradermal
water blocks may reduce the perception of severe low back pain in laboring women without side-effects on the
fetus or mother, but the injections are transiently painful. Further research is needed on the effects of repeated
injections, ways to decrease the stinging of the injections without losing benefits, mode of action, and the
effects of varying dosages, locations, and number of sites injected.
 Maternal movement and
positioning
• The use of upright positions is associated
with less painful labor
Standing
Walking
Kneeling

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Laboring women have always walked, moved, and changed positions spontaneously to make themselves more
comfortable . Pelvic dimensions vary with differences in maternal positions, thus these changes may help to
ameliorate labor pain . Besides these self-initiated comfort-seeking movements, caregivers often suggest specific
positions to accelerate labor progress or correct a fetal or maternal problem (eg, fetal heart rate decelerations or
malposition, maternal hypotension).First stage of labor — Most trials of movement and positioning during labor
have compared various upright positions with horizontal positions for their effects on pain and labor progress. There
have been at least 16 controlled trials of positioning during the first stage of labor in healthy women at term] . Eight
of these trials used each woman as her own control by having her take one specified position for 15 to 30 minutes,
and then having her alternate to another position for the same length of time. In seven of these eight trials, women
were asked to alternate positions several times or until complete dilation; in one, they took each position only
once] . Positions evaluated included sitting, standing, or walking compared to supine or lying on the side; resting on
hands and knees compared to supine or lying on the side; as well as some other combinations. The women's pain
and progress were assessed in each position. None of the women in these eight trials found the supine position more
comfortable than other positions. Second stage of labor — A randomized trial assigned primiparous subjects to a
kneeling or a sitting position during the second stage of labor] . A sitting position during the second stage of
labor was associated with a significantly higher level of delivery pain, more frequent perception of the second
stage as being long, less comfort for giving birth and more frequent feelings of vulnerability and exposure than
the kneeling position. A systematic review of nine randomized trials and one cohort study evaluated the routine
use of the supine position during the second stage of labor to other positions and found that women experienced
more severe pain in the supine position and had a preference for other birthing positions

In summary, these trials suggest that early in labor the use of upright positions, interspersed with other
positions, is associated with less painful labor
 Touch and massage
• Touching can communicate such possitive
messages as:
Caring
Concern
Reassurance
Love
• Massage enhanced relaxation and reduce pain

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Touching another human being can communicate such positive messages as

caring, concern, reassurance, and love. Massage, "the intentional and systematic
manipulation of the soft tissues of the body to enhance health and healing" , is used
during labor to enhance relaxation and reduce pain.

In summary, there are no harmful effects to the use of touch or massage.

Women appreciate these interventions, which appear to reduce pain and enhance
feelings of well-being.
 Acupuncture and acupressure
• Acupuncture-placement of needles at
specific points on the body.

• Acupressure-pressure with fingers or small

beads at acupuncture points.

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Acupuncture, an important and ancient component of Traditional Chinese Medicine, involves placement of
needles at specific points on the body (termed acupuncture points). For labor pain, placement of needles
depends on the degree and location of pain, stage of labor, level of maternal fatigue, tension, anxiety, and a
variety of other factors .

Acupressure, or Shiatsu, a simpler alternative to acupuncture, is pressure with fingers or small beads at
acupuncture points. Acupressure can be done with minimal instruction, in contrast to acupuncture, which
requires significant training and, in many areas, some type of certification. Two randomized trials showed that
acupressure decreased labor pain (measured by visual analog scale scores) compared to light skin stroking or
no treatment/conversation only. In one of the trials, analgesics were used by 5 of 36 women in the acupressure
group versus 10 of 39 patients in the control group; the number of patients may have been too small to show a
statistically significant change .

A systematic review of acupuncture for pain relief in labor reported that acupuncture was associated with a
trend toward less use of pharmacological analgesia (RR 0.70, 95% CI 0.49-1.00) . Compared to controls who
had no or sham acupuncture, women who underwent acupuncture were more relaxed and used less
pharmacological pain relief, but did not have lower pain intensity scores. Maternal satisfaction was high among
all the women in both the acupuncture and control groups.

There are no known risks to acupuncture, when practiced by trained practitioners using disposable needles.
It may provide relief of labor pain and women appear to be very satisfied with the intervention . More, larger
studies are warranted to establish its cost-effectiveness, implementation in maternity care settings, and
acceptance by childbearing women. Use of sham acupuncture in control groups is important, given that
acupuncture is associated with a powerful placebo effect .
 Hypnosis

• Hypnosis used for childbirth is almost always

self-hypnosis.
• Common hypnotic pain relief techniques are:
“Glove anesthesia”
“Time distortion”
“Imaginative transformation”

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Hypnosis is "a state of deep physical relaxation with an alert mind producing alpha waves, and it is in this
state that critical faculties are suspended and the subconscious mind can be more readily accessed" and
respond to suggestions . Hypnosis used for childbirth is almost always self-hypnosis: the hypnotherapist teaches
the woman to induce the hypnotic state in herself during labor. Sometimes her partner is taught to signal her
into the hypnotic state.

Common hypnotic pain relief techniques are "glove anesthesia," in which the woman imagines that her
hand is numb and that it can spread numbness to other areas by placing her hand on painful areas; "time
distortion," which enables the woman to perceive the time between painful contractions as longer and the
painful period as shorter than it really is; and "imaginative transformation," in which the pain is interpreted as
benign and acceptable, and contractions are seen as surges of energy that cause only a light pressure sensation
.

Five small randomized trials on hypnosis for childbirth have been performed. A systematic review found
that use of hypnosis was associated with a significant reduction in use of pharmacological analgesia (RR 0.53,
95% CI 0.36-0.79) . One trial also reported a significant decrease in use of epidural anesthesia. There were no
differences in adverse obstetric or neonatal outcomes between hypnosis and control groups.

Hypnosis is contraindicated in persons with any history of psychosis . Any phobias or distressing situations
need to be ascertained and avoided when suggesting a visualization intended to be relaxing . There are no
apparent risks to the use of hypnosis for childbirth, except that it requires prenatal training by a trained
hypnotherapist, which involves financial costs. Hypnosis may be an effective technique to manage labor pain
and enhance maternal satisfaction during childbirth . More large trials are necessary to establish its true value.
 Relaxation and breathing

• Relaxation and breathing

may contribute more to a
woman's ability to cope with
labor pain than to actually
reduce the pain

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Most childbirth education classes and most books on childbirth present relaxation techniques, along with a
variety of rhythmic breathing patterns intended to complement and promote relaxation or to provide distraction
from labor pain. They are also used to enhance a woman's sense of control. The thoroughness of the teaching
along with the amount of time devoted to rehearsing these techniques vary widely, from a quick mention or
demonstration to repeated practice and adaptation to the individuals' preferences, with the goals of mastery and
confidence. Relaxation and breathing techniques have not been studied as independent variables in randomized
trials.

A survey of women in the United States who gave birth in 2005 found that 49 percent of the respondents
used breathing techniques, and of those, 77 percent rated them as "very" or "somewhat" helpful, while 22
percent rated them as "not very helpful" or "not helpful at all" . This finding may reflect differences in the
quality of the teaching received by the women, or indicate that breathing techniques are not helpful for
everyone. A survey of British women found that 88 percent of women who reported using relaxation techniques
found them to be "good" or "very good" .

There are no known drawbacks to the use of properly performed relaxation and breathing techniques,
except that women sometimes expect more pain relief than they actually get from them during labor, and
express disappointment. Relaxation and breathing may contribute more to a woman's ability to cope with labor
pain than to actually reduce that pain. The high satisfaction expressed by large majorities of surveyed women
justifies their continued inclusion in childbirth classes and encouragement of their use by maternity staff.
 Aromatherapy
• The science of using highly
concentrated essential oils or
essences distilled from plants in
order to utilize their therapeutic
properties

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Aromatherapy is "the science of using highly concentrated essential oils or essences distilled from plants in
order to utilize their therapeutic properties" . Use of aromatherapy during labor is increasing, although some
experts have stated that, "Essential oils are as potent as pharmacological drugs and are equally open to misuse
or abuse, whether intentional or not," and, "...until more clinical research trials have been undertaken, it would
be prudent for midwives to work cautiously with essential oils, using the lowest possible dose and on the least
number of occasions" .

There are no data from published randomized trials. One large, uncontrolled prospective study reported on
the use and effectiveness of aromatherapy in a large referral maternity unit . During this time, 8058 women
received aromatherapy during labor under the supervision of midwives trained in aromatherapy (lavender, rose,
or frankincense). It was used for a variety of purposes: to reduce fear, anxiety, and pain; to reduce nausea or
vomiting; to enhance women's sense of well-being; and to improve contractions. About one-half of the women
found it helpful, 1 percent reported undesired effects, such as nausea and headache. It is not clear whether
these side effects were caused by the essential oils or other factors.
 Music and audio analgesia
• Audio analgesia –the use of auditory
stimulation ,such as music, white noise or
environmental sounds to decrease pain
perception
• Listening to music reduced pain intensity
levels and opioid requirements

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Audioanalgesia is the use of auditory stimulation, such as music, white noise, or environmental
sounds to decrease pain perception. Its use is popular for the relief of pain during dental work, after
surgery, and for other painful situations. A Cochrane review that evaluated the effect of music on
acute, chronic or cancer pain intensity, pain relief, and analgesic requirements concluded that
listening to music reduced pain intensity levels and opioid requirements, but the magnitude of these
benefits was small . Music is also used during labor and is often provided by the labor and delivery
unit.

Some women prefer to use headphones to listen to music, because this provides more compelling
distraction and the woman is in constant control of the volume. Before labor the woman selects music
(sometimes with the help of a music therapist) or environmental sounds that have a positive effect on her.
She may use these to rehearse relaxation or self-hypnosis, and to take her into a relaxed or hypnotic state
during labor. During labor, she chooses selections to help her relax and lift her spirits . Her selections
personalize the birth event and may give her a greater sense of control.Most studies of audioanalgesia
during labor have reported that it can increase pain tolerance, reinforce or elevate moods, or cue the
woman to move or breathe rhythmically, especially if she has conditioned herself to do so before the onset
of labor

In the meantime, as there are no known adverse effects of audioanalgesia and it appears to be a
popular option for laboring women, its use should be encouraged.
 recommendation

• offering women nonpharmacological methods to help them cope

with pain (grade1B)
• all nonpharmacologic al methods have few, if any serious side
effects and require few safety precautions
• nonpharmac ological methods help women to maintain or restore
a sense of personal control over the birth process
• nonpharmac ological techniques can be combined or used
sequentially to increase the total effect
• nonpharmac ological methods are generally inexpensive

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

We recommend offering women nonpharmacological methods to help them cope

with labor (Grade 1B). All of the nonpharmacologic methods for management of
labor pain discussed above have few, if any, serious side effects and require few
safety precautions. They can be combined or used sequentially to enhance their
total effect, and are generally inexpensive. Surveys suggest that women like
nonpharmacologic interventions, as they help women to maintain or restore a
sense of personal control over the birth process. Women tend to rate
nonpharmacologic interventions highly in terms of satisfaction and a desire to
repeat them in a future labor, even though their pain-relieving capability is
modest or short-lived.
 pharmacological methods
• pharmacological approaches are directed at
elimination of the physical sensation of labor
pain
Inhalation analgesia
Parenteral opioids
Regional analgesia

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

The proportion of maternal deaths caused by anesthesia-related complications also has declined from 2.5 percent
between 1979 and 1990 to 1.6 percent between 1991 and 1999 (Koonin and associates, 1997). Several factors likely have
contributed to improved safety of obstetrical anesthesia. Eltzschig and associates (2003) and Hawkins and colleagues (1997b)
have suggested that the recent trend toward increased use of regional analgesia, rather than general anesthesia, may be the
most significant factor. The increased availability of in-house anesthesia coverage almost certainly is another important reason
(Hawkins and associates, 1997a). Indeed, inadequate anesthesia services have been identified as a leading and potentially
preventable cause of maternal deaths in Japan (Nagaya and associates, 2000). a request for pain relief by the woman is
sufficient medical indication for its use. The American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists (2002) have specified that it is the responsibility of the obstetrician or certified nursemidwife, in consultation
with an anesthesiologist, if appropriate, to develop the most suitable response to accomplish th request for pain relief This
plan should include strategies to minimize the need for emergency anesthesia in women for whom such anesthesia would be
especially hazardous.Goals for optimizing obstetrical anesthesia services have been jointly established by the American
College of Obstetricians andGynecologists and the American Society of Anesthesiologists (2001). These goals should be sought
by any hospital providing obstetrical care:1. Availability of a licensed practitioner who is credentialed to administer an
appropriate anesthetic whenever necessary and tomaintain support of vital functions in an obstetrical emergency.2.
Availability of anesthesia personnel to permit the start of a cesarean delivery within 30 minutes of the decision to performthe
procedure.3. Anesthesia personnel immediately available to perform an emergency cesarean delivery during the active labor
of a womanattempting vaginal birth after cesarean 4. Appointment of a qualified anesthesiologist to be responsible for all
anesthetics administered.5. Availability of a qualified physician with obstetrical privileges to perform operative vaginal or
cesarean delivery during administration of anesthesia.6. Availability of equipment, facilities, and support personnel equal to
that provided in the surgical suite.7. Immediate availability of personnel, other than the surgical team, to assume
responsibility for resuscitation of the depressed
To meet these goals, 24-hour in-house anesthesia coverage is usually necessary. Providing such services in smaller
facilities ismore challenging  a problem underscored by the fact that approximately half of all hospitals providing obstetrical
care havefewer than 500 deliveries per year (American College of Obstetricians and Gynecologists, 2001).Bell and colleagues
(2000) calculated the financial burden that may be incurred when trying to provide "24/7" obstetricalanesthesia coverage.
Given the average indemnity and Medicaid reimbursement for labor epidural analgesia, they concludedthat such coverage
could not operate profitably at their tertiary referral institution. Compounding this burden, some third-partypayers have
denied reimbursement for epidural analgesia in the absence of a specific medical indication. In response, theAmerican College
of Obstetricians and Gynecologists and the American Society of Anesthesiologists (2004) issued a jointstatement that
reimbursement for regional analgesia should not be denied if given only for pain relief.

WILLIAMS OBSTETRICS,22EDITION,2005
 Inhalation analgesia
Inhalation analgesia with nitric oxide is:
• Inexpensive
• Easy to administer
• Safe for mother and fetus\neonate
• The analgesic effect is better than that
produced by opioids,but less than with
epidural analgesia

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Nitrous oxide inhalation analgesia for labor is used in Great Britain, although it is
rarely used in the United States. The parturient self-administers the anesthetic gas
using a hand-held face mask. The safety of this technique is that the parturient will
be unable to hold the mask if she becomes too drowsy, and thus will cease to inhale
the anesthetic. Efficient scavenging is difficult with self-administered inhalation
agents, resulting in environmental pollution. A systematic review on nitric oxide for
relief of labor pain concluded it was inexpensive, easy to administer, and safe for
both mother and fetus/neonate . The analgesic effect was better than that produced
by opioids, but less than with epidural analgesia.
Entonox (a 50 : 50 mixture of oxygen and nitrous oxide) should be available in all birth settings as it
may reduce pain in labour, but women should be informed that it may make them feel nauseous and light-
headed
 Parenteral opioids
• Exert their effects in the maternal brain.
• Crosses the placenta and affects the fetus:
• Fetal heart rate changes
• Central nervous system depression
• Slowing of respiratory rate
• Changes in muscle tone
• Long-term neonatal effects

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

When uterine contractions and cervical dilatation cause discomfort, pain relief with a narcotic
such as meperidine, plus one of the tranquilizer drugs such as promethazine, is usually appropriate.
With a successful program of analgesia and sedation, the mother should rest quietly between
contractions. In this circumstance, discomfort usually is felt at the acme of an effective uterine
contraction, but the pain is generally not unbearable. The most commonly prescribed systemic opioid
for labor pain relief worldwide is meperidine, a synthetic opioid . However, its use has fallen into
disfavor in the United States and there is a movement to replace meperidine with more efficacious
and less toxic opioid analgesics because of its potential side effects (eg, serotonergic crisis, seizures
and normeperidine toxicity) and multiple drug interactions (eg, MAO inhibitors). Morphine is a less
popular choice, but is occasionally used to provide labor analgesia. However, the lack of efficacy of
these medications and their associated maternal and neonatal side effects have resulted in
decreased usage in many labor units where superior means of analgesia, such as regional
techniques, are available
Systemic analgesics may be administered by individuals who are not qualified to perform
epidural or spinal blocks, thus, they are often used in situations when an anesthesiologist is not
available. They also are useful for patients in whom regional techniques are contraindicated. The
most popular agents are opioids (eg, morphine, fentanyl, meperidine) or mixed opioid agonists-
antagonists (eg, butorphanol). They exert their effects in the maternal brain, although a portion of
the dose also crosses the placenta and affects the fetus. This is manifested in utero by changes in
fetal heart rate patterns (eg, decreased variability, pseudosinusoidal pattern with butorphanol) and
in the neonate by central nervous system depression, slowing of respiratory rate, and changes in
muscle tone. These effects are usually evanescent; however, systemically administered analgesics
may exert longer-term neonatal effects that can be detected by sensitive neurobehavioral
measurement techniques.

In laboring women, systemic opioids produce relief by inducing somnolence rather than by producing
analgesia per se. In a study of morphine and meperidine, repeated intravenous administration
resulted in increasing sedation scores in parturients with little change in pain scores
 Systemic opioids
Compared to epidural analgesia:
• Less changes in pain score
• More sedative effects
• Shorter duration of labor,
• less oxytocin augmentation
• Fewer instrumental deliveries

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

A systematic review of randomized trials of parenteral opioids for labor pain relief noted considerable
heterogeneity among studies and many limitations to data interpretation (eg, low power, methodology issues) .
The major findings were:

 Satisfaction with pain relief provided by opioids during labor was low and only slightly better than
placebo (29 versus 17 percent, p = 0.04). There was no evidence that any opioid was significantly more
effective than meperidine, which is widely available and inexpensive. However, side effect profiles
differed.
 Epidural analgesia provided better pain relief than parenteral opioids. However, opioids were associated
with a shorter duration of labor, less oxytocin augmentation, and fewer instrumental deliveries
compared to epidural analgesia.

 Nausea, vomiting, and sedation were common maternal side effects. Respiratory depression was the
major neonatal concern; further investigation is required regarding possible long-term effects [30] .

High doses of opioids are usually needed to obtain good pain relief; however, at these dosages
maternal aspiration and maternal and neonatal respiratory depression are significant concerns.
Parenteral opioids decrease fetal heart rate variability; therefore, consideration of alternative
analgesic methods is useful when the fetus is at high risk for or demonstrates a nonreassuring fetal
heart rate
Women should be informed that these will provide limited pain relief during labour and may have significant side effects
for both the woman (drowsiness, nausea and vomiting) and her baby (short-term respiratory depression and drowsiness which
may last several days). Women should be informed that pethidine, diamorphine or other opioids may interfere with
breastfeeding. If an intravenous or intramuscular opioid is used, it should be administered with an antiemetic. Women should
not enter water (a birthing pool or bath) within 2 hours of opioid administration or if they feel drowsy.
 Epidural analgesia(1)

A central nerve block technique acheved

by injection of a local anaesthetic close to
the nerves that transmit pain

Various nerve blocks have been developed over the years to provide pain relief during labor and
delivery. They are correctly referred to as regional analgesics.
Epidural techniques — Local anesthetics, such as 0.02 to 0.125 percent bupivacaine or 0.04 to 0.2
percent ropivacaine, administered via the epidural route using continuous infusion pumps provide
safe and effective labor analgesia. For the lower concentrations of local anesthetics to be effective,
they must be combined with other analgesics, most commonly neuraxial opioids. Neuraxial opioids
alone, whether delivered by the intrathecal or epidural route, also provide excellent analgesia for the
early first stage of labor.
Women in labour who desire regional analgesia should not be denied it, including women in severe
pain in the latent first stage of labour.
The following additional observations should be undertaken for women with regional analgesia:
• During establishment of regional analgesia or after further boluses (10 ml or more of lowdose
solutions) blood pressure should be measured every 5 minutes for 15 minutes.
• If the woman is not pain free 30 minutes after each administration of local anaesthetic/opioid
solution, the anaesthetist should be recalled.
• Hourly assessment of the level of the sensory block should be undertaken.
Women with regional analgesia should be encouraged to move and adopt whatever upright positions
they find comfortable throughout labour. Once established, regional analgesia should be continued until after completion
of the third stage of labour and any necessary perineal repair. Upon confirmation of full cervical dilatation in women with
regional analgesia, unless the woman has an urge to push or the baby’s head is visible, pushing should be delayed for at least 1
hour and longer if the woman wishes, after which pushing during contractions should be actively encouraged. Following the
diagnosis of full dilatation in a woman with regional analgesia, a plan should be agreed with the woman in order to ensure that
birth will have occurred within 4 hours regardless of parity. Oxytocin should not be used as a matter of routine in the second
stage of labour for women with regional analgesia.
Continuous EFM is recommended for at least 30 minutes during establishment of regional analgesia
and after administration of each further bolus of 10 ml or more.
Intrapartum care care of healthy women and their babies dur ing childbirth-CL.GUID.2007

clinicekkgkkCVVDClinical Guideline
2007
Funded to produce guidelines for the NHS by NICE

Guideline
September 2007

• Ep.analg.technique photo

d
 Epidural analgesia(2)

• The only consistently effective means of

relieving the pain of labor and delivery.
• Provide safe and effective labor analgesia
• May reverse the untoward physiological
consequences of labor pain

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Regional analgesic techniques are the most reliable means of relieving the pain of labor and delivery.
Furthermore, by blocking the maternal stress response, epidural and spinal analgesia may reverse the untoward
physiological consequences of labor pain. Another advantage of the epidural technique is that an in situ epidural
catheter may be used to administer anesthetics to provide pain relief for instrumental or cesarean delivery, if
required. For these reasons, we recommend use of regional analgesia to manage the pain of labor and delivery
for parturients desiring pharmacologic analgesia, in the absence of a contraindication.

Before choosing epidural analgesia, women should be informed about the risks and benefits, and
the implications for their labour. This information about choosing epidural analgesia should include the following:
• It is only available in obstetric units.
• It provides more effective pain relief than opioids.
• It is associated with a longer second stage of labour and an increased chance of vaginal
instrumental birth.
• It is not associated with long-term backache.
• It is not associated with a longer first stage of labour or an increased chance of caesarean
birth.
• It will be accompanied by a more intensive level of monitoring and intravenous access.
• Modern epidural solutions contain opioids and, whatever the route of administration, all opioids
cross the placenta and in larger doses (greater than 100 micrograms in total) may cause short-term respiratory depression
in the baby and make the baby drowsy.
 Epidural analgesia(3)
Epidural analgesia is associated with:
• Increased risk of instrumental vaginal
delivery
• Longer second stage of labor
• Increased oxytocin requirement
• Likelihood of maternal fever
• unlikely to increase the risk of caesarean
section

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Epidural analgesia during labour is effective but has been associated with increased rates of instrumental delivery
NULLIPAROUS WOMEN WHO RECEIVE EPIDURAL ANALGESIA DURING LABOUR DO NOT SEEM TO BE AT AN INCREASED RISK OF
DELIVERY BY CAESAREAN SECTION; THE WIDE CONFIDENCE INTERVALS INTRODUCE SOME UNCERTAINTY. EPIDURAL
ANALGESIA MAY BE ASSOCIATED WITH A HIGHER RISK OF INSTRUMENTAL VAGINAL DELIVERY. ALTHOUGH EPIDURAL
ANALGESIA WAS ASSOCIATED WITH A LONGER SECOND STAGE OF LABOUR, NEONATES SEEMED UNHARMED. WE FOUND NO
WORSENING OF APGAR SCORES OR UMBILICAL ACID-BASE STATUS IN NEONATES WHOSE MOTHERS HAD RECEIVED EPIDURAL
ANALGESIA, DESPITE THE INCREASED RISK OF INSTRUMENTAL VAGINAL DELIVERY. THESE NEONATES WERE ALSO LESS
LIKELY TO NEED NALOXONE THAN NEONATES WHOSE MOTHERS RECEIVED OPIOID ANALGESIAAlthough epidural analgesia is
associated with an increased risk of instrumental vaginal delivery, operator bias cannot be excluded Epidural analgesia is
associated with a longer second stage labour and increased oxytocin requirement, but the importance of these is unclear as
maternal analgesia and neonatal outcome may be better with epidural analgesi

With epidural techniques, ultra-low concentrations of local anesthetics may not be

adequate to relieve the intense pain of the second stage, as local anesthetic
requirements increase as labor progresses
.
 Epidural analgesia(4)

• Eepi d ur al ur i anal gez i i s gamo yenebi T

mSo bi ar o ba f i z i o l o gi ur i d an gad ad i s
paTo l o gi ur Si

• Eepi d ur al ur i anal gez i a nayo f i s

r ut i nul i mo ni t o r i ngi s Cvenebaa

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Epidural analgesia may increase the risk of instrumental

delivery by several mechanisms. Reduction of serum oxytocin
levels can result in a weakening of uterine activity.28 29 This may
be due in part to intravenous fluid infusions being given before
epidural analgesia, reducing oxytocin secretion. 30 The increased
use of oxytocin after starting epidural analgesia may indicate
attempts at speeding up labour. Maternal efforts at expulsion can
also be impaired, causing fetal malposition during descent. 31 Previously,
the association of neonatal morbidity and mortality with
longer labour (second stage longer than two hours) had justified
expediting delivery, leading to increased rates of instrumental
delivery.32
Delaying maternal pushing until the fetus’s head is visible or
until one hour after reaching full cervical dilation may reduce
the incidence of instrumental delivery and its attendant morbidity.
32 Although patients receiving epidural analgesia had a longer
second stage labour, this was not associated with poorer neonatal
outcome in our analysis. With increasing use of continuous
electronic fetal monitoring, a longer but more comfortable
labour may cause little harm to the neonate.
It is doubtful whether epidural analgesia with low concentration
bupivacaine increases the risk of caesarean section or harms
neonates. Fears about an increased risk of caesarean section
should not be used to discourage epidural analgesia in
nulliparous women if requested.
 Which one?

• The battle between nonpharmacologic and

pharmacological treatment must be decided by women
• The women should be involved in the decision-making
process regarding all aspects of the childbirth, including
pain relief, to increase maternal satisfaction.
• The women must be educated and informed about all
pain relief techniques during pregnancy, prior to the
onset of labor and make her own free choice

TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA

Most scientific evaluations of nonpharmacological approaches to labor pain use either the mother's pain
ratings or her use of pain medications as outcome measures; however, these outcome measures may be
misleading. As an example, the use of pain ratings ignores the meaning of the pain for the woman, which is
really more important than the degree of pain. If a woman rates her pain very highly, one must not assume that
she cannot cope with it, or that she is overwhelmed by it. We suggest that examining the woman's ability to
cope with her pain is as important an outcome as the degree of pain that she describes. The high degree of
satisfaction expressed by most women for all the nonpharmacological methods indicates there may be other
benefits to these methods that are not fully appreciated in standard outcome studies.

The use of pharmacological analgesia as an outcome may also be misleading, and

may reflect the usual care practices of the hospital as much as it does the
effectiveness of nonpharmacological approaches. Furthermore, a more subtle, but
meaningful, way to measure this outcome is to record when in labor the woman
receives the medication. The duration of use of pharmacological analgesia is itself a
risk factor: as an example, the duration of epidural analgesia is associated with the
likelihood of maternal fever and all the clinical concerns that go with it. The
cumulative dose, which increases over time, affects the woman's mobility and
effectiveness in expulsion. Therefore, if nonpharmacological methods are used, they
may delay the use of pharmacological analgesia (as was found with TENS,
intradermal water blocks, and immersion in water), and obviate some of its
undesirable side effects. Trials should measure the woman's coping ability and the
timing of administration of pharmacological analgesia
Healthcare professionals should consider how their own values and beliefs inform their attitude
to coping with pain in labour and ensure their care supports the woman’s choice.