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Pain Management for Labor and Delivery

Introduction

A wide range of pain can be experienced during childbirth. Because of the wide variation in the perception of discomfort, pain control is individualized for each patient. Patients will be provided with prenatal and intrapartum care that makes the patient aware of the benefits and risks of all methods of pain relief for labor and delivery so that they can discuss the options.

No Analgesics

A small percentage of women do not receive analgesics (pain medication) for labor and delivery. They may have mild pain or rapid labor.

Often times if a woman is prepared on what to expect for labor and delivery, she will have less pain due to being less tense during the labor process. Childbirth classes, prenatal birthing books, the internet (reputable sources) and your physician are all wonderful sources to help you to become prepared. The purpose of childbirth training is to lessen anxiety and decrease pain, regardless of whether additional pain control techniques are employed. Various coping techniques are taught in childbirth classes. Practicing the techniques is essential for their effectiveness. Some of the newer cognitive techniques, such as systematic desensitization and sensory transformation, may be more effective than traditional Lamaze techniques that use breathing exercises and relaxation. Emotional support for patients in labor is beneficial. Although this support is often provided by the patient’s husband or other family members, there is evidence that other birth attendants, whether it is professional nurses or lay attendants (doulas), can reduce a patient’s anxiety and sense of isolation. Such emotional support has been shown to reduce the need for pain medication.

Non-Pharmacological Analgesic Techniques

The following are non-invasive and non-pharmacological techniques that have been used to provide pain relief during labor:

  • touch and massage, pressure and counter pressure
  • heat and cold
  • hydrotherapy, tub bath or shower
  • ambulation and change of position
  • biofeedback
  • transcutaneous electrical nerve stimulation (TENS)
  • acupuncture/acupressure

Parenteral Narcotics

IV or IM (given as a shot) pain medication that can be used to manage pain during labor and delivery.

Disadvantages

  • There is evidence that the analgesic effect of parenteral agents used in labor is limited. Their primary effect is sedation. Furthermore, there are dose-related side effects, including nausea, vomiting, sedation, hypotension, and respiratory depression.
  • Neonatal respiratory depression can occur if doses of narcotics are administered, particularly close to time of delivery.

Epidural Anesthesia

Epidural analgesia is the most effective methods of pain relief and are used by the majority of patients in the United States. The aim is to segmentally block the lower thoracic and upper lumbar areas for the 1st stage of labor, and in the 2nd and 3rd stages to extend the analgesia to the sacral area.

Advantages

Advantages of epidural analgesia include excellent pain relief without maternal and fetal respiratory or cardiac depression. Fetal heart rate and variability are not significantly altered. Pain relief may begin as long as 20 minutes after the start of the procedure. The patient still feels the pressure of contractions and delivery and can be an active participant in the birth process. If a cesarean delivery is required, the epidural block can be extended and used for surgery.
This anesthetic technique is particularly advantageous for women with respiratory or cardiac disease, those with an increased likelihood of cesarean delivery (twins), those who require a controlled vaginal delivery (breech), those who have an unstable fetus and those with pre-eclampsia.

There is no significant increase of chronic back pain caused by the procedure.

Disadvantages

  • Failed or inadequate analgesia occurs in 10% of patients.
  • Hypotension (low blood pressure) is produced in about 10% of patients, but is usually restored quickly with intravenous fluids and ephedrine without untoward effect on the fetus.
  • Post lumbar puncture headache occurs in about 1% of patients.
  • Prolonged 2nd stage of labor and increase in the use of vacuum or forceps delivery, but there is no increase in the risk of cesarean delivery.

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