 Pain during the first stage of labor is visceral or cramping.

It originates in the uterus and cervix, and is produced by

distention of uterine and cervical mechanoreceptors and
by ischemia of uterine and cervical tissues.
 Transition (7 to 10 cm cervical dilation) refers to the
shift from the late first stage to the second stage of
labor.
 Second stage pain includes a combination of visceral pain from uterine
contractions and cervical stretching, and somatic pain from distention of
vaginal and perineal tissues


 Severe maternal alkalosis can cause utero-placental
vasoconstriction(RESPIRTORIO)
 Neurohumoral responses to stress and pain may adversely
affect placental perfusion and fetal oxygenation, and may
be reversed by analgesia. Elevated plasma catecholamines
increase maternal peripheral vascular resistance and
decrease uteroplacental perfusion. (NEUROHORMONAL)
 Women who experience unrelieved pain during childbirth
may be more likely to develop postpartum
depression(pSICOLOGICO)
 Systemic analgesics may be associated with sedation and
respiratory depression, and are transferred across the
placenta to the fetus
 Neuraxial analgesia may be medically indicated for
patients with anticipated difficulty with intubation, a
history of malignant hyperthermia or some cardiovascular
and respiratory disorders, and for prevention of autonomic
hyperreflexia in women with a high spinal cord lesion [31].
Neuraxial anesthesia is also preferred for women with
preeclampsia
 Pharmacologic approaches to manage childbirth pain can
be broadly classified as either systemic or locoregional.
Systemic administration includes parenteral and
inhalation routes. Locoregional analgesic techniques
consist of neuraxial techniques (ie, epidural, spinal,
combined spinal-epidural, or dural puncture epidural [32])
and pudendal and paracervical nerve blocks
TIPOS DE ANALGESIA
Regional
 The risks and benefits of initiation of neuraxial blockade in
laboring women must be considered on a case-by-case
basis. Although there are few contraindications to
neuraxial labor analgesia, in certain settings such as
coagulopathy, increased intracranial pressure, or skin
infection of the lower back, the advantages of neuraxial
analgesia must be weighed against its risks.
 Bilateral pudendal nerve blocks are useful for alleviating
pain arising from vaginal and perineal distention during
the second stage of labor [33]. They may be used as a
supplement for epidural analgesia if the sacral nerves are
not sufficiently anesthetized. Pudendal nerve blocks may
also be performed to provide analgesia for low forceps
delivery, but they are inadequate for mid-forceps delivery
(rarely performed).
Sistemicos
 Opioid analgesia — Patients desiring pain relief during
labor are likely to be offered opioids when neuraxial
analgesia is not an option. Opioids have the advantages of
ease of administration, wide availability, lower cost, and
are less invasive than neuraxial techniques, though
substantial relief of labor pain is generally not achieved. In
one study of women who received meperidine or morphine
for labor analgesia, the opioid resulted in somnolence with
little change in pain scores [36]. Opioids cross the
placenta, which may be manifested in utero by decreased
fetal heart rate variability and in the neonate by
respiratory depression and neurobehavioral changes
[37,38].
 Patient controlled analgesia (PCA) — Use of a PCA pump
allows the patient to self-administer a programmed dose of
IV medication with lockout intervals between doses. This
method of opioid administration is the most effective
option for the parturient in whom neuraxial analgesia is
contraindicated, not desired, or not available
o Remifentanil PCA is less effective than neuraxial
analgesia, but more effective than long-acting opioid
analgesia or nitrous oxide [43,45,46]. However,
remifentanil is a potent respiratory depressant;
oxygenation and respiratory rate should be
continuously monitored when remifentanil PCA is
used [47-49], and one to one nursing care is
indicated. (20 to 60 mcg demand dose, lockout
interval one to two minutes)
o Fentanyl PCA — Fentanyl PCA is an alternative to
remifentanil; it provides effective pain relief and low
risk of side effects, although data are limited to a few
small studies. Fentanyl has rapid onset, relatively
short duration of action (though longer than
remifentanil), and lacks active metabolites. Typical
regimens for fentanyl PCA include a 50 to 100 mcg
initial loading dose, demand doses of 10 to 25 mcg,
 and lockout intervals of 5 to 10 minutes, without a
background infusion
o Choice of opioid — For patients in whom neuraxial
analgesia and PCA are not options, we prefer to use
IV doses of mixed agonist-antagonists (eg,
nalbuphine 2.5 to 10 mg IV) every 2 to 4 hours,
depending on the level of analgesia and maternal
sedation [4]. There is a dose ceiling effect with regard
to respiratory depression in contrast to longer-acting
opioids such as morphine [64]. Similar to other
opioids, nalbuphine is associated with opioid side
effects in the mother and fetus; maternal dysphoria
may be particularly disconcerting.
 Fentanyl has been used to provide labor pain
relief
 Morphine may be used to provide labor
analgesia
 Meperidine is commonly administered for labor
analgesia in the United Kingdom [39], while it
has fallen out of favor in the United States. We
avoid meperidine because of potential side
effects in both the parturient and the neonate,
although it is the most commonly prescribed
opioid for labor pain relief worldwide
 Acetaminophen and nonsteroidal anti-inflammatory drugs
— The literature regarding the efficacy of nonopioid
analgesics (ie, acetaminophen and nonsteroidal anti-
inflammatory drugs [NSAIDs]) is limited. NSAIDs are
avoided during labor because of their potential for
precipitating premature closure of the ductus arteriosus
[71]. We do not offer acetaminophen for labor analgesia
because of its limited efficacy.
 Sedatives and analgesic adjuncts — Various agents have
been used to minimize opioid side effects or provide
sedation, relief from anxiety, or analgesia during labor
 o Scopolamine is a muscarinic anticholinergic drug
that induces a dissociative state.(raramente usado
hoy en dia)
o Ketamine is a phencyclidine derivative that produces
a dissociative state and analgesia. It is a potent
amnestic
o Benzodiazepines (eg, midazolam and diazepam) are
anxiolytics that may be used for sedation during
vaginal delivery. Midazolam is preferred because it is
nonirritating to veins, and has a short duration of
action.
 Nitrous oxide — Nitrous oxide inhalation analgesia
(usually a blend of 50 percent nitrous oxide and 50
percent oxygen gas) for labor pain has been used for
decades in Great Britain, Scandinavia, Australia, New
Zealand, Canada, and other countries
 Due to the time lag for nitrous oxide to
take effect, inhalation should begin
approximately 30 seconds before the
contraction is expected to begin and
should cease as the contraction begins to
recede. This makes use of nitrous oxide
particularly challenging during the second
stage, as the parturient needs to be alert to
push during the contraction.
Approach to the episiotomy
 Mediolateral episiotomy is associated with a lower risk of
third- and fourth-degree laceration than a median
episiotomy.


WHEN TO CONSIDER EPISIOTOMY p

 Expedite delivery of the fetus – Episiotomy can be helpful
in situations where expedited delivery of the fetus is
desired during the second stage of labor, such as with a
category III fetal heart rate tracing that does not respond
to resuscitative measures
 Facilitate placement of forceps--As median episiotomy
during an operative vaginal delivery triples the risk of an
anal sphincter injury compared with operative vaginal
delivery alone, median episiotomy is not advised [33,34].
Forceps-assisted deliveries have a higher rate of anal
sphincter injury compared with spontaneous vaginal or
vacuum-assisted deliveries, and the protective benefit from
a mediolateral or lateral episiotomy seems to also be
higher in observational data
 Shoulder dystocia{ que ocurre cuando uno o ambos hombros
del bebé quedan atascados adentro de la pelvis de la
madre durante el trabajo de parto y nacimiento } – In some
cases of shoulder dystocia, performing an episiotomy can
increase space for the operator's fingers and thus facilitate
delivery of the posterior shoulder and other internal
procedures, but does not appear to prevent shoulder
dystocia or release the impacted anterior shoulder
 History of female genital cutting (circumcision) – For
women with a history of female genital cutting, there may
be an increased need for, or at least consideration of,
 episiotomy during delivery, especially with type III
infibulation{ estrechamiento de la abertura vaginal, }. The
degree or type of female circumcision may result in a
significantly narrowed introitus or effectively a tissue
bridge overlying the vaginal opening.
PROCEDURES AND SELECTION h
 Patient education and consent
 Anesthesia options
o A neuraxial anesthetic (ie, spinal or epidural),
pudendal block, or local anesthetic
 Timing
o A reasonable approach is to perform the procedure
when the delivery of the fetus is anticipated within
the next three to four contractions
 Procedure
o Median episiotomy – For a median (midline) incision, the perineum is
incised vertically within 3 mm of the midline, or at the 6 o'clock
position, starting at the introitus (figure 1). The goal is to release any
restriction imposed by the perineal body, which can sometimes be felt
as a band of tissue cephalad and inferior to the vaginal orifice. The
incision is directed internally to minimize the amount of perineal skin
incised. The length of the incision is determined by patient anatomy
and perceived need. As the general goal of episiotomy is to facilitate
delivery of the fetal head, the incision is made long enough to expedite
that process but avoid the rectum
o Mediolateral episiotomy: The incision is initiated at the fourchette and
cut at an angle (usually to the maternal right for right handed
clinicians) that may be almost perpendicular to the midline (80 to 90
degrees as the fetal head is crowning); however, after delivery of the
infant, this angle becomes smaller, approaching 45 degrees, since the
perineum is no longer stretched and distorted by the fetal presenting
part. The final angle of the incision is ideally 60 degrees from the
midline to minimize the occurrence of sphincter injury [52-54]. This
angle is considered most protective as <30 to 40 degrees does not
optimally reduce the risk of OASIS while a 90-degree angle does not
relieve perineal pressure and OASIS[Las lesiones obstétricas
del esfínter anal] risk [53]. The incision is usually between 3 and 5
cm in length.