LABOUR PAIN

&
RELIEF

Co-ordinator: Dr Veena Asthana

Presented by: Dr Aslam Aziz
Rizvi
02/12/08
 DEFINITION OF LABOUR

 LABOUR can be defined as spontaneous

painful uterine contractions associated with
the effacement and dilatation of the cervix
and the descent of the presenting part
 DEFINITION OF PAIN

 IASP defined PAIN as:

“An unpleasant sensory and
emotional experience associated with actual
or potential tissue damage or described in
terms of such damage.”
Copyright © 2003 American Society of Anesthesiologists. All rights reserved.
 STAGES OF LABOUR
I. From onset of regular uterine contractions
to full dilatation of cervix.

II. From full cervical dilatation to delivery of

the fetus.

III. From delivery of the fetus to delivery of

the placenta.
 Nerve supply of uterus

 Sympathetic:
1. Motor ( T5-T6)
2. Sensory (T10-T11)

 Parasympathetic
Pelvic n. (S 2,3,4) end in ganglion of frankenhauser
WHY PAIN OCCURS DURING
LABOUR?
FIRST STAGE PAIN

Visceral pain resulting from:

a) Uterine contractions
b) Dilatation of the cervix.

Initially confined to T11-T12 during latent phase.

Eventually involves T10-L1 in active phase.
 Perception begins with the nociceptive stimuli
arising in the mechanical & chemo receptors in uterus
& cervix→ High threshold mechanoreceptors d/t
intense pr. generated during contraction of uterus.

 As the labour progresses→ intensity of labour pain

↑ d/t lowering of stimulation threshold with repeated
stimuli.

 Myocellular injury d/t repeated contractions

releases bradykinin, histamine, serotonin, Ach, K+
ions → chemical nociceptors activated.
 Sensations are then carried by the Aδ & C fibres
that pass through the inferior, middle & superior
hypogastric plexus, the lumbar & lower
sympathetic chain and end in rami communicants
assoc. with T10-L1 spinal nerves.

 Dominantly carried by C fibres.

 Pain is transmitted slowly, poorly localized and

primarily in the lower abdomen.
 Referred to the lumbosacral area, gluteal region &
thighs as labour progresses.
 Pain intensity increases with progressive
cervical dilatation & increasing intensity &
frequency of uterine contractions.

 Nulliparous & those with h/o

dysmenorrhoea experience greater pain
during 1st stage.
SECOND STAGE PAIN:

 Onset of perineal pain at the end of 1st stage signals

beginning of fetal descent and the 2nd stage of labour.

 Caused by distension of pelvic structures and

perineum following descent of the presenting part.
This is somatic pain.

 Sensory innervation of the perineum is provided by

the pudendal nerve (S2-S4), so pain during this stage
involves T10-S4 dermatomes.
 It is sharp, well localized and not referred.
 More rapid descent in multiparous women is
associated with more intense pain.
 Dominantly carried by Aδ fibres.

 Pressure on intrapelvic structures usually involves

fibres as high as L2 nerves & as low as S3. This is the
reason parturients feel the urge to push and come to
know that the baby is coming.

 Pain of 1st stage does not end with the start of 2nd stage
but is superseded by the pain of the 2nd stage.
Copyright © 2003 American Society of Anesthesiologists. All rights reserved.
 PHYSIOLOGY OF PAIN IN
LABOUR
 Pain during labour provides a noxious and
unpleasant stimulus which may prove deleterious
to the mother and fetus.

 Various physiological effects on different organ

systems may vary. They are:
 A. EFFECTS ON VENTILATION:

Labour pain serves as a powerful respiratory

stimulant. This results in :

1. ↑ in TV(40%), MV(50%), RR(15%), PaCO2 ↓by 16-

20mmHg with rise in pH to 7.5-7.6.
Thus respiratory alkalosis occurs→ ↓ Cerebral and
Uterine BF & shifts the maternal ODC to the left.
Thus ↓in fetal PaCO2 by 23%.
2. With the onset of relaxation phase, pain no longer
stimulates respiration. So, the hypocapnia causes a
transient period of hypoventilation that ↓ maternal PaCO2
by 10-50% .
Thus inc the gradient favouring transfer of CO2.
Opioids may further enhance this depression.

3. Extreme hypocapnia PaCO2 <20mmHg, can reduce UBF &

cause fetal hypoxemia & acidosis.
Double Bohr effect
 refers to the situation in the placenta where the Bohr effect is
operative in both the maternal and foetal circulations.
 The inc in pCO2 in the maternal intervillous sinuses assists
oxygen unloading.
 The decrease in pCO2 on foetal side, assists O2 loading.
 The Bohr effect facilitates the reciprocal exchange of oxygen for
carbon dioxide.
 The double Bohr effect means that the oxygen dissociation
curves for maternal HbA and foetal HbF move apart (ie in
opposite directions).
 B. NEUROENDOCRINE EFFECTS:

1. Catecholamine levels ↑ 20-40% d/t noxious

stimulation.
2. NorAd levels ↑→↓in Ut BF( 35-70%)
3. > 200% ↑in levels of Adr/ Nor Ad/ Cortisol
4. Dopamine, cAMP, ACTH, Lactate &
Pyruvate also ↑
 C. CARDIOVASCULAR EFFECTS:
1. CO ↑ d/t
- extrusion of 250-300ml of blood from the uterus
- ↑ed VR from the pelvis & LL.
2. Also ↑ in sympathetic activity provoked by pain,
apprehension, anxiety and the physical effort of
labour.
Early 1st stage: 15% ↑ in CO
Late 1st stage: 30%
2nd stage : 45%
Immediately after delivery: 65-80%
During contractions: further 15-20%
 D. METABOLIC EFFECTS:

1. BMR ↑ 20%
2. FFA & Lactate ↑ (d/t ↑ CA & lipolytic metabolism)
3. O2 consumption ↑
4. Progressive maternal metabolic acidosis occurs (d/t
loss of HCO3 from the kidney to compensate pain
induced respiratory alkalosis)
 E. EFFECTS ON GASTROINTESTINAL &
URINARY SYS:

1. ↑ed gastric acid secretion

2. Stimulation of release of gastrin
3. Delay in gastric & urinary bladder emptying (d/t reflex
inhibition of gastrointestinal & urinary motility
following anxiety)
 F. EFFECT ON UTERINE ACTIVITY:

CA levels ↑ (d/t pain & emotional stress)

Nor Ad: causes ↑ in Uterine activity
Adr & Cortisol: ↓/ in-coordinate uterine contractions.

 G. PSYCHOLOGICAL EFFECTS:
Fear, apprehension, anxiety can further enhance
pain perception.
Severe pain may also produce significant post
partum emotional reactions.
 GOALS FOR PROVIDING
PAIN RELIEF
 Safe
 Satisfactory pain relief for the mother
 No depressant effects on the maternal RS / CVS
 No depressant effects on the baby
 No unpleasant maternal side effects
 No depressant effects on the progress of labour
 High technical success rate
 METHODS OF LABOUR
ANALGESIA

A. REGIONAL
B. NON-REGIONAL TECHNIQUES

1. NON-PHARMACOLOGICAL
2. PHARMACOLOGICAL
 NON REGIONAL
 NON- PHARMACOLOGICAL

1. Psychoprophylaxis
2. Hypnosis
3. Massage
4. Transcutaneous electrical nerve stimulation (TENS)
5. Relaxation/ Breathing techniques
6. Temperature modulation: hot/cold packs, water
immersion
7. Acupuncture
8. Aroma therapy 9. Biofeedback
 Psychoprophylaxis/Prepared childbirth:

1. Grantley Dick-Read method

2. Lamaze’s psychoprophylaxis
focuses on teaching the parturient conditioned reflexes
to overcome the pain & fear of childbirth.

It also uses an education program, human support

during labour, breathing techniques, relaxation techniques
of voluntary muscles, a strong focus on attention and
specific activities to concentrate on, during contractions.
Disadvantage:

Since it relies on heavy breathing exercise→ may

lead to hyperventilation & subsequent alkalosis→
impairment of uterine BF & CBF.
 Hypnosis:
Claimed to
a) Reduce pain & requirement for pharmacological
analgesia.
b) Shorten labour.
Patient is in a trance, in a state of deep concentration &
very receptive to suggestion.

Disadvantage:
1. May lead to post partum psychosis
2. May deprive the patient of the sense of active
participation during labour
 TENS
 Reduces pain by nociceptive inhibition along
unmyelinated small “c” fibres by blocking impulses to
target cells at a presynaptic level in the substantia
gelatinosa of the dorsal horn. Thus limiting central
transmission.
 Enhances release of endorphins & dynorphins centrally.
 Electrodes are placed about 2cm over the T10-L1
dermatomes in 1st stage & S2-S4 in the 2nd stage.
 Conventional TENS has high stimulation frequency (40-
150 Hz) and low intensity. Current set b/w 10-30 mA.

 The pulse duration is short (up to 50 μs).

 The onset of analgesia is immediate. Pain relief lasts
while the stimulus is turned on, but abates when the
stimulation stops.
 Women can alter the amount of current supplied to the
electrodes, thus providing some degree of control.
 However, no evidence that TENS provides more
analgesia than placebo.
 Acupuncture

1. Mediated through release of endorphins or

serotonin
2. Significantly reduces length of birth
3. Reduced requirement of epidural analgesia
4. Incomplete, unpredictable & inconsistent
 PHARMACOLOGICAL METHODS

 INHALATIONAL ANALGESIA
Adm of subanesthetic conc. of inhaled anesthetics to
relieve pain

 ENTONOX (50% Nitrous Oxide in Oxygen)

1. Used as a sole analgesic & adjuvant to systemic &

regional tech
2. Provides analgesia within 20-30sec of inhalation, max
effect: 45sec
1. Thus important that it is used at the early onset of
contractions & discontinued after peak of
contractions.
2. No effect on hepatic, renal, cardiac or pulmonary
functions.
3. Safe & economic but does not provide complete &
predictable analgesia
4. Lack of co-operation of patient
5. Atmospheric pollution
S/E: Dizziness, Nausea, Dysphoria.
 OTHER VOLATILE ANESTHETICS
Trichloroethylene, Methoxyflurane, Isoflurane(0.2%),
Enflurane(1%), Sevoflurane(2-3%), Desflurane(0.2%)
Isonox(0.2% isoflurane + Entonox)

Advantage of subanesthetic conc:

a) Lack of irritation to respiratory tract
b) Pleasant odour
Disadvantages:
a) Technical diff in safe administration & scavenging
b) Requirement of specific vapourisers (c) drowsiness
d) unpleasant smell (e) high cost (f) accidental overdose
 SYSTEMIC ANALGESICS:

 OPIOID ANALGESICS:
a) For parturients who request analgesia other than epidural
b) Those who cannot receive neuraxial analgesia
Nearly all parenteral opioid analgesics & sedatives readily cross
the placenta and can affect the fetus.

Other S/E:
1. CNS depression
2. Loss of beat to beat variability in FHR 3.↓ed Fetal movt.
4. Maternal respiratory depression, nausea, vomiting, delayed
gastric emptying
 MEPIRIDINE:

M/C used
I/V, 25-50mg, acts within 5-10min
I/M, 50-100mg, peak effect in 40-50min
Max fetal depression seen in 10-20min in I/V & 1-3hrs in
I/M
Analgesia lasts for 3-4hrs, so c/b given when delivery
not expected for around 4hrs
Causes less respiratory depression than morphine in
neonate
S/E: loss of beat to beat variability of FHR
 FENTANYL:

25-100µg I/V, OA: 3-10min, DOA: 60min (1hr)

However maternal respiratory depression outlasts
analgesia.
Lower doses m/b assoc with little or no neonatal resp
depression and has no effect on Apgar scores.
Used in labour as an I/V bolus or as an analgesic
administered by means of PCA system.
Advantage: s/c, orally, as patch.
Disadv: Use limited in labour by side effects & short DOA.
 REMIFENTANIL:

1. Short acting, µ opioid receptor agonist

2. Biperidine derivative with a normal opioid
configuration but contains an ester linkage that allows
metabolism by non specific esterases.
3. Thus it has an extremely rapid plasma clearance &
offset of action→ Fetal exposure minimized
4. Risk of accumulation of drug in the mother & fetus in
PCA regime, thus close monitoring is essential with
supplementary oxygen and ready access to naloxone.
 BUTARPHANOL:
κ agonist & µ antagonist
1-2mg i/m, i/v; DOA: 4hrs

 NALBUPHINE:
Partial κ agonist & potent µ antagonist
10mg, i/v; OA: 2-3min; i/m; OA: 10-15min; DOA: 6hrs

Both demonstrate a ‘ceiling effect’ i.e. increasing doses

does not produce further respiratory depression.
S/E: Rapidly crosses placenta, dizziness, drowsiness,
nausea, vomiting
 SEDATIVE-TRANQUILIZERS:

Barbiturates
1. Prolonged depressant effect on fetus
2. Antanalgesic effect
3. Used in latent phase of labour when delivery not
anticipated for 12-24hrs

Phenothiazines,
1. Relieve anxiety
2. Dec opioid requirement
3. Control emesis during labour
 BDZ

1. Provide sedation & anxiolysis

2. Used in very early labour
3. Diazepam: maternal & fetal plasma levels are equal
within minutes
4. Floppy baby syn.
5. Midazolam: rapid i/v amnesia, deep sedation
 FLOPPY BABY SYNDROME

Diazepam & Chlordiazepoxide

1. Late third trimester use and exposure during

labour.
2. Symptoms vary from mild sedation, hypotonia, and
reluctance to suck, to apnoeic spells, cyanosis, and
impaired metabolic responses to cold stress.
3. Symptoms persist from hours to months after birth.
 ANTAGONISTS:

NALOXONE: 0.1mg/kg iv

Can be administered in 3 ways:

a) To the mother with each dose of opioid
b) To the mother 10-15min before delivery
c) To the neonate immediately after delivery

The rationale for administering opioid & opioid

antagonist simultaneously is to provide max
analgesia with min respiratory depression
 REGIONAL TECHNIQUES
 Most effective means of providing analgesia for
labour & delivery

 Most commonly used are:

1. Lumbar Epidural Analgesia

2. Combined Spinal Epidural analgesia
3. Continuous Spinal Analgesia
4. Alternative regional anesthetic techniques
 Benefits:

1. Pt awake & able to participate.

2. Effective pain relief without appreciable motor
block
3. Reduction in maternal catecholamines
4. Drug induced fetal depression unlikely
5. Means to rapidly achieve surgical anesthesia
 Indications  Contraindications

1. Pt. request 1. Local infection

2. Diff. ETI anticipated 2. Coagulopathy
3. Prolonged labour 3. Thrombocytopenia
4. Fetal prematurity 4. Allergy to LA
5. Breech extraction 5. Pt. refusal
6. Multiple gestation
6. Preexisting neuro dis
7. Spine disorders
8. Some Cardiac dis
 LUMBAR EPIDURAL ANALGESIA

 Provides effective analgesia during both stages of

labour.
 Traditionally given when labour is well established.
 However, recent studies suggest:

1. There is min. to no alterations in duration &

outcome of labour.
2. No increase in need for labour augmentation with
oxytocics.
3. No diff. in the rates of vaginal delivery.
4. Significant ↑ in maternal satisfaction .
 Thus, it s/b generally initiated when the parturient
wants it & the obstetrician approves it.

 Commonly accepted criteria for placement:

1. No fetal distress
2. Good regular contractions 3-4 min apart & lasting
abt. 1 min
3. Adequate cervical dilatation i.e. 3-4cm
4. Engagement of the fetal head.
 REGIONAL TECHNIQUES

 Patient Evaluation & Preparation:

1. Informed consent must be obtained.

2. Procedure & potential complications to be explained
3. Full check of emergency equipments to be done
4. Intravenous infusion to be started
5. Appropriate maternal & fetal monitoring to be in
place before starting the procedure
 TECHNIQUE
1. Sitting/ lateral position
2. 500-1000ml IVF
3. Place catheter as usual
4. Test dose→ to check accidental I/V or SA placement
2-3ml lignocaine, bupivacaine
sensory block in 2-3min; motor in 3-5min
For IV placement:
a) LA + 15-20µg epinephrine→ HR↑ 20-30bpm in 30-60s
b) 3ml lignocaine→ tinnitus/ peri-oral numbness
c) 1-2ml air into epidural catheter→ monitoring precordial
doppler
 Safe practice:

1. Catheter aspiration
2. Test dose for possible I/v; SA placement
3. Injecting total dose in small increments (<5ml) &
observe pt for signs of LA toxicity
 Epidural space in Pregnancy

1. Volume ↓
thus, Segmental dose req↓
Catheter should not be placed during contraction→ iv
placement
2. Pressure ↑: Non pregnant: -1cmH2O
End of 1st stage: 4-10cm H2O

So, test used is LOR & not –ve pr. technique

 If signs of IV/SA inj. absent ,
 Initial block options:
1. Bupivacaine 0.0625-0.125%, 10-15ml
2. Ropivacaine 0.1-0.2%
3. Fentanyl 50-100µg or Sufentanil 10-20µg in a 10ml vol

 Subsequent analgesia options

1. Intermittent (as above)
2. Continuous infusion @ 10-15ml/hr
Bupivacaine 0.0625-0.125% without opioids
Bupivacaine 0.04-.125% / Ropivacaine 0.05-0.2%+ fentanyl 1-5µg/ml or
Sufentanil 0.03-0.05µg/ml
3. PCEA:
Bupivacaine 0.04-.125% + fentanyl 2µg/ml
5ml bolus, 5-10min lockout @ 5-10ml/hr, hourly limit
30ml

 Pt supine (Lt ut. Displacement)

 Oxygen
 BP monitoring every 1-2min for 1st 15min, then every
5min thereafter until block wears off.
 If pt in lateral position, turn side-side to prevent one
sided
 Check sensory, motor analgesia level regularly
 Adjust infusion rate acc to dermatome level
 If ↓ analgesia→ repeat test dose before giving drug
(IV/SA migration)
 If dev of motor block (SAB migration) → locate
catheter position by aspiration, repeat test dose
 Epidural Opioids:

1. Morphine
Dose: upto 7.5mg; OA : 30-60min
>5mg → resp depression
Only effective in early 1st stage of labour
2. Meperidine
Dose 50-100mg; DOA: 1-3hr
3. Fentanyl
Dose: 50-150µg; OA: 5-10min; DOA: 1-2hr
4. Sufentanil
Dose 5-15µg → 1hr; 40-50µg → 2hr
 Epidural LA
1. Bupivacaine
Adv:
Blocks Na channels→ stops cond.
Disad: Cardiotoxicity

↑lipid solubility→ enters CM easily

2. Lignocaine
Dose: 0.75-1%
3. 2 Chloroprocaine
Rapid onset, brief DOA (hydrolysis by plasma ChE)
Disad: a) Apparent antagonism of subsequent opioid
b) Additive for low pH– Arachnoiditis
4. Ropivacaine: less cardiotoxic than Bupivacaine
 Epidural Opioid + LA
1. Action on 2 diff sites→ Synergy
2. More chances of spont vaginal delivery
3. Neonatal Adverse effects ↓
4. Less LA reqd→↓ motor block, so can push

 Choice of Catheter
1. Multi holed
2. Single holed
 Spinal Opioid Analgesia

1. Single SA shot of LA/Opioid

2. Early labour/ distressed parturient
3. When catheter placement is diff d/t obesity, anatomical
distortion, multiparous
4. Effective analgesia without systemic effect of opioid
5. Early ambulation
6. In cardiac pts to prevent inc in HR & CO d/t pain
7. Very advanced 1st stage & requiring instrumental
delivery .
8. Disadv:
1. Morphine: 0.25-0.5mg, OA: 40-60min; DOA 4-6hr
2. Sufentanil: 10µg, OA: rapid; DOA: 60-180min
Disadv: a) pruritis , nausea, vomiting b) ↓SBP
c) resp depression d) variations in FHR

3. Fentanyl: 10-25µg, OA: rapid; DOA: 30-120min

4. Meperidine: 10-20mg, effective in advanced labour

 Continuous spinal analgesia

1. In c/o dura puncture, pass 28G microcatheter
2. But , inc chances of complications
 Combined Spinal Epidural

1. Rapid onset with sacral coverage

2. Min risk of toxicity
3. Dec risk of impaired motor block
4. Early ambulation possible
5. Ability to prolong duration of analgesia
6. Can be useful if operative delivery needed
7. Greater satisfaction as greater degree of control
8. Reduces incidence of problems with epidural
 Methods:
1. Epidural catheter with spinal needle in lower space
2. Epidural needle beside spinal needle, same space
3. Needle through needle technique

 S/E:
1. Fetal bradycardia ( sudden dec in CA)
2. Dec UBF (epi-norepi imbalance → unopposed α
adrenoceptor effect)
 Complications

Immediate Delayed
1. Misplaced injection 1. PDPH
2. High/ Total Spinal 2. Transient backache
3. Hypotension 3. Urinary retention
4. LA induced Convulsion 4. Epidural
5. Cardiac Arrest hematoma/abcess
5. Meningitis
6. Neurological deficit
 Paracervical Block

1. Simple
2. LA injected into submucosa of fornix just lateral to Cx to
block n. transmission through paracervical ganglion
3. Frankenhauser Ganglion: Contains all visceral, sensory n.
fibres from uterus, Cx, upper vagina
4. Somatosensory fibres from perineum are not blocked
5. So, 1st stage analgesia
6. Disad: Fetal bradycardia→ →neonatal depression
7. LA toxicity, postpartum neuropathy, infection
8. OA: 2-10min; DOA: upto 2hrs
 Pudendal block

1. Pudendal n. S 2,3,4
2. Supplies lower p/o vagina, vulva, perineum
3. Transvaginal approach→ LA deposited behind each
sacrospinous ligament
4. Forceps/Vaginal delivery
5. Effective for 2nd stage
6. Complications: IV inj, Retroperitoneal hematoma,
Subgluteal abscess
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