1. Max Brinsmead MB BS PhD May 2015
Analgesia in Labour
Max Brinsmead MB BS PhD
May 2015

2. This Talk Pain in Labour Non – Pharmacological Options
Who gets it and how bad
Pain & satisfaction with the birth experience
The role of endorphins
Non – Pharmacological Options
Position for labour
Breathing and relaxation
Massage and Touch
Distraction and Music
Acupuncture and Hypnosis
Transcutaneous Electrical Nerve Stimulation (TENS)
Other methods e.g. Aromatherapy
Labouring in Water
The role of antenatal education
The role of a support person

3. This Talk (2) Anaesthetic Techniques (not considered)
Pharmacological Options
Nitrous oxide by inhalation
Narcotics
Advantages and Disadvantages
Choice of drug, dose and route
Sterile Water by Injected Papule
Anaesthetic Techniques (not considered)
Epidural and Caudal
Spinal
Paracervical Block
Pudendal Block
Perineal infiltration

4. Pain in Labour
80 – 90% of women describe their pain in labour as “very severe” or “intolerable”
Pain does not correlate with...
Age
Education
Social class
Satisfaction with “the birth experience” does not correlate either with the pain of labour or with satisfaction with analgesia
Only 60% of women are “moderately satisfied” with their analgesia and
20% still rate their pain as “severe”

5. Pain in Labour (2)
Patient’s rating of pain in labour and satisfaction with analgesia VARIES according to when they are studied:
In labour
Immediately postpartum
Several weeks postpartum
This is due to the amnesic effects of labour and is presumably mediated by endorphins
“Nature’s opiates”
Which are elevated by pregnancy and...
Highest in labour

6. Pain in Labour (3)
Patient’s reaction to the pain of labour will vary according to her expectations
Personal
Cultural
The continuum ranges from...
“No woman needs to suffer”
Therefore it is our role to remove it completely
To...
It is “natural” or “ordained”
And a “part of the experience”
Most women are somewhere in between
so your role is to establish rapport and find out where they are

7. Pain in Labour (4) Because a sense of control is important
In providing analgesia carers of labouring women need to...
Examine their own beliefs and values
Respect a patient’s right to choose
Because a sense of control is important
And what correlates with satisfaction with labour is the attitude and support provided by the carer

8. Position in Labour Pain is greatest when the patient lies on her back
Patients should be encouraged to adopt a position of comfort
There is evidence that remaining upright and mobile improves labour efficiency
Mobility may be encouraged by the use of Birth Balls...
But RCTs have not been done

9. Breathing & Relaxation
Limited studies show benefit
Harmless to mothers and babies
Provided that prolonged breath-holding is avoided
So patients who wish to use this should be supported

10. Massage & Therapeutic Touch
Has been studied by RCT
Shown to reduce the pain of labour
Reduces anxiety and stress
And resulted in better mood and less postnatal depression in one study

11. Distraction & Music Has been studied by one RCT
Reduces both the pain and distress from pain
Harmless to mothers and babies

12. Acupuncture and Acupressure
Has been studied in 4 RCTs
Reduces the need for pharmacological pain relief and epidural anaesthesia
Reduces the need for augmentation of contractions
But not the rate of spontaneous birth

13. Hypnosis Has been studied in 5 RCTs
Reduces the need for pharmacological pain relief
And the need for augmentation of contractions

14. Transcutaneous Electrical Nerve Stimulation (TENS)
Has been studied in 10 RCTs
None showed any reduction in pain or use of further analgesia
Some actually showed an increase in pain scores
So this method should not be offered
But I allow TENS by patients who wish to do so

15. Aromatherapy Has been studied in one RCT
Found no effect on pain or the need for other analgesia
And no effect on the rate of spontaneous birth
But I allow aromatherapy by patients who wish to do so

16. Labouring in Water
Studies consistently show that women who have access to water (bath or shower) resort to epidural anaesthesia less frequently
Please note that this does not mean “water births”
Does not affect any other outcome...
Length of labour
Rate of SVD
Infant outcomes (Apgars etc)
Maternal trauma (to the perineum)
Infant or maternal infection
But keep temperature <37.50 C
And keep it clean

17. Antenatal Education
Reported pain in labour is influenced by a patient’s expectations
So preparation for childbirth is one important component of antenatal care
However antenatal education does not influence...
The use of analgesia in labour
Length of labour
Rate of SVD, assisted birth & need for Caesarean
Infant outcomes (Apgars etc)
Any measure of maternal outcome
With the exception of satisfaction if the education is provided by the same person who provides intrapartum care

18. Role of a Support Person
Rates of spontaneous birth are possibly increased...
and length of labour is reduced by
One to one care from an empathetic person
This can be provided by a female companion or “doula”
Whether this role can be taken by a patient’s male partner has not be confirmed
But it is a shame if his only role at a birth is to protect his wife from uncaring midwives!

19. Nitrous Oxide by Inhalation (Entonox)
Is a weak analgesic agent
That “takes the edge off” the pain of labour
Rapidly effective and rapidly excreted
Can be used anywhere (including in water)
Has no effect on the progress of labour
Causes dizziness/light headedness in 5 – 36%
Success in its use is all about timing
And this requires a little practice
NICE recommends that Entonox be available to all labouring women

20. Narcotic Analgesics Intensively used and studied for >50 years
But there are only a few placebo-controlled RCTs
Is a relatively poor analgesic agent when compared to epidural anaesthesia
Causes nausea and drowsiness in women
This can interfere with her ability to cooperate in the 2nd stage of labour
Should always be administered with an anti emetic drug
Which actually enhances its analgesic effects
The main problem is its potential to cause respiratory depression in the neonate
And a reluctance to feed which can last several days

21. Neonatal Depression from Narcotics
Depends on maternal metabolism of the drug
And this varies from woman to woman
But the effect is “dose related” and...
Because the breakdown metabolites of Pethidine are also a respiratory depressant in the neonate
The greatest potential for harm comes from repeated doses
Whilst the effect can be totally reversed by Naloxone...
This drug is often misused in neonatal resuscitation & has not been shown to be effective by RCT

22. Neonatal Depression from Narcotics (2)
Because early studies suggested that the transplacental passage of narcotics is greatest in the first 2 hours after maternal administration
Most midwifery and obstetric texts counsel against their use if delivery is expected within 2 hours
However, because of the wide individual variation in metabolism...
It is my view that no woman should be denied her FIRST dose of a narcotic at any stage in labour
But beware of the mother who goes to sleep when she should be pushing!

23. Narcotic Analgesia Choice of Agent, Dose & Route of Administration
There are a large number of studies available
Some suggest small advantages for Diamorphine & Meptazinol over Pethidine
But the best outcomes are achieved by the PCA administration of an intravenously administered short-acting narcotic e.g. Remifentanil
Where such resources are not possible...
There is quite a lot to be said for the use of Pethidine 50 mg IV and 50 mg IM
Provided the IM injection is not into subcutaneous fat
Upper arm is recommended over lower limb
Why do the ED docs always use SC morphine?

24. Sterile Water by Injection
The intradermal injection of 0.1 ml of sterile water into 1 – 4 sites of lumbosacral skin has been shown by RCT to reduce back ache in labour by up to 60% for up to 2 hrs
Causes a “bee sting” like pain
Presumably works by “inhibitory gate control”
Useful for the patient with an OP
When an epidural is not possible
Not endorsed by NICE

25. Sterile Water by Injected Papules

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