1. Pain Relief During Labor
Lecture 7 1

2. Principles of Pain Relief
Treatments for pain relief during labor depends on:
1. client’s tolerance for pain
2. ability to focus on labor
3. ability to remain motivated.
Some of labor process home:
aromatherapy, warm bath, music, visualization, breathing exercises,
massage. hypnosis, acupuncture. ~ 70% clients ask for epidural
Method of Pain Relief Should Exhibit:
Simplicity
Safety
Preservation of fetal homeostasis
Monitor client closely: B/P, Pulse, RR, FHR, anesthetic levels,
maternal oxygenation. 2

3. Analgesia and Sedation During Labor
Analgesia: loss of sensitivity to pain.
Pain meds can be sufficient to get through labor along with: aromatherapy, music, visualization, etc.
Systemic drugs - 3 factors to consider
effects on mother
effects on fetus - all systemic drugs cross placenta by simple diffusion.
Fetal liver & kidney function immature, drugs metabolized slowly & effects last longer
Affect progress of labor; can slow labor. 3

4. Assessment Maternal assessment Fetal assessment Labor assessment
informed consent ; VS stable
Fetal assessment
FHR /min with no late/variable decels.
Variability average.
Normal fetal movement and accelerations present.
Term Fetus
No Meconium
Labor assessment
Contraction pattern well established.
Cervix 4-5 cm dilated in primips and 3-4 in multips
Progressive descent of presenting part
no complications
Delivery at least 2-3 hours away. 4

5. Meperidine (Demerol) and Promethazine (Phenergan)
Narcotic Pain Relief:
Meperidine (Demerol) and Promethazine (Phenergan)
Demerol mg with Phenergan 25 mg IM or IVP q 2-4 hours
crosses placenta
Half-life is 2.5 hrs. (mother) & 13 hrs. (newborn)
Right > administration, FHR variability may decrease
Narcan (naloxone) antagonist
Butorphanol (Stadol) 1-2 mg IVP/IM x2.
Stronger than Morphine & Demerol. Starts working in < 5 min. Has minimal fetal effects; may cause hallucinations in mom.
Nalbuphine (Nubain) – mg IVP/IM
does not cause neonatal depression.
Fentanyl –short-acting potent synthetic opioid.
mcg IV q 1hr. Used in spinal/epidural. 5

6. Anesthesia
Anesthesia: reversible loss of sensation & movement in region of body.
Types of Anesthesia
Local anesthesia: local anesthetic directly into perineum. Used for minor procedures. No effects on newborn.
Lidocaine 1% typically used for NSVD
Relieves pain from episiotomies or when suturing episiotomy and/or lacerations from vaginal deliveries.
Rapid onset
Client awake 6

7. Pudendal Block
Relieves pain associated with 2nd (pushing) stage of labor. Lidocaine 1% used.
through vaginal wall and into pudendal nerve in pelvis, numbs area between vagina & anus
22 gauge needle [bilateral]
Does not relieve pain of contractions.
Works quickly; does not affect baby.
Given shortly before delivery, but cannot be used if baby's head is too far down in birth canal.
Can prolong 2nd stage labor d/t loss of bearing-down reflex.
Provides satisfactory perineal anesthesia for normal delivery, low forceps manipulation, episiotomy.  7

8. Regional anesthesia - injection of local anesthetic around
nerves of spinal cord to block pain from larger but still
limited part of body.
Types:
1. Epidural Anesthesia
Usually uses Marcaine (bupivicaine) - into epidural space
at 3rd - 4th lumbar interspace.
single dose to be repeated or as continuous infusion; common in USA
administered > active labor established
Good analgesia without CNS depression in mom or fetus; Relieves pain from uterine contractions, vaginal delivery, C/S
Analgesia block from T-10 to S-5
Epidurals slow labor and may require Pitocin (oxytocin) augmentation. 8

9. Most common complications:
Maternal hypotension > can lead to> fetal bradycardia and late decelerations.
Preloading 1000ml of RL IVF
Tx hypotension with ephedrine.
Less w. continuous infusion than single dose
Other complications: total spinal block & respiratory paralysis (improper placement of catheter)
Does not prolong 1st stage labor if established
Can interfere with woman's ability to push. May ^ C/S
Can elevate maternal temp.
Bladder sensation lost – insert foley catheter
Interfere with descent and rotation of fetus
Long-term problems
Backache; headaches; Migraine headache
Neckache; Tingling in hands or fingers 9

10. Technique for Epidural Analgesia
Get informed consent
Monitor BP, P, FHR, q 1-2 min. for 15 min. > bolus of local anesthetic.
Maintain verbal communication with patient.
Hydrate w. RL cc. to maintain BP.
Patient maintains lateral or sitting position
Epidural space identified - catheter threaded 3cm
Test dose given - observe for s/s of toxicity (metalic taste, ringing in ears, palpitations)
Place in lateral or semifowler to prevent aortocaval compression.
Maternal BP monitored q 5-15 min.
Analgesia level assessed. 10

11. 2. Spinal Anesthesia
Subarachnoid space [lumbar region] - provides spinal block. Passes through dura & CSF reached. Meds inserted, needle removed.
Spinal cord above this site.
Used in C/S. Block level from 8th thoracic dermatome [ xiphoid process/breast. Longer anesthetic effects.
Anesthetics used: bupivacaine, lidocaine, fentanyl. Duramorph {morphine} side effects include urinary retention (foley), pruritis, nausea, hypotension. Preload with RL (1000cc). Maintain IVF. 11

12. L side, hydrate with 500-1000 cc of RL/NS, ephedrine 5-10 mg IV
Complications:
Hypotension [20% decrease from baseline]; may occur > administration of local anesthetic
Vasodilatation & obstructed venous return from uterine compression of vena cava and large veins
Manage:
L side, hydrate with cc of RL/NS, ephedrine 5-10 mg IV
Spinal Headache (low volume/low pressure in spinal column)
CSF leaks from site of dura mater.
Treatment:
lie flat for few hours.
Vigorous IV hydration.
Blood patch – very effective
5 mL of blood without anticoagulunt - injected into epidural space - forms clot & stops leakage
VS observed for ~ 2 hrs. 12

13. Vital signs monitored closely
Post-op Pain Management: administered either by IVP, IM or PCA (Patient control anesthesia) Medications such as:
Fentanyl ; Morphine ; Demerol
Duramorph/astromorph- systemic effects ~ 24 hours without PCA/IM medication.
Vital signs monitored closely
Monitor q 15 minutes for first hour:
BP, P, RR, HR
Pain, Motor Sensory, Alertness, Epidural access
PCA bolus/infusion amount and VTBI
Then, 30 minutes x2 , q hour X 4 hours, q 4 hrs. X 24 hrs.
Patient education - Inform patient – PCA is continuous programmed infusion pump. Patient may self-administer medication
Reassure patient - overdose can’t occur; Infusion programmed – delivers additional med q minutes; lock out system. 13

14. General Anesthesia (total induced unconsciousness)
C-sec → fetal distress, failed epidural/spinal/allergy
Prophylactic antacid – 30 cc Bicitra
Pre-O2; wedge under R hip - prevents venacaval compression.
Induced unconsciousness [inhalation or IV therapy]
Halothane, ketamine, nitrous oxide, thiopental
Endotracheal intubation
Cricoid pressure on trachea - occludes esophagus & prevents aspiration.
After intubation, additional meds given via IV & ET tube - maintains anesthesia for rest of surgery.
Used for emergency delivery
Complications: Pulmonary aspiration of gastric contents, failed intubation, aspiration pneumonia, neonatal depression. NPO for about 8 hours. 14