Obstetric Pain Management

Labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor can be extremely painful, and adequate pain management during labor and delivery is an important part of obstetric care. Appropriate therapy should be administered based on patient preference and medical need. Both pharmacological and non-pharmacological pain control options are available. Maternal request alone is sufficient indication for pharmacologic pain management. Options include systemic analgesics, including inhaled nitrous oxide and opioids Opioids Opiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics, as well as local and regional techniques, including pudendal nerve blocks, epidural, and spinal anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts. In truly emergent situations requiring urgent cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery, general anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts can also be used.

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Overview

Definition

Obstetric pain management refers to the pharmacological and non-pharmacological options available to help manage discomfort during labor and delivery. Such options include spontaneous vaginal deliveries and cesarean deliveries.

Maternal perceptions of labor pain

  • Labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor pain is influenced by a woman’s emotional, motivational, cognitive, social, and cultural circumstances.
  • Perception can vary significantly between women.
  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain may be affected by:
    • Fetal position
    • Shape and size of the maternal pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis
    • Maternal parity (i.e., nulliparous vs. multiparous women)
    • Status of the fetal membranes (i.e., ruptured vs. intact)
    • Medical comorbidities (e.g., fibromyalgia Fibromyalgia Fibromyalgia is a chronic pain syndrome characterized by widespread body pain, chronic fatigue, mood disturbance, and cognitive disturbance. It also presents with other comorbid symptoms such as migraine headaches, depression, sleep disturbance, and irritable bowel syndrome. Fibromyalgia)
    • Obstetric complications (e.g., intraamniotic infection)

Non-pharmacological pain management techniques

  • Ambulation
  • Position changes
  • Massage
  • Warm water (e.g., shower, bath)
  • Meditation/self-hypnosis

Indications for pharmacological pain management

According to the American College of Obstetrics and Gynecology (ACOG), “There is no other circumstance in which it is considered acceptable for an individual to experience untreated severe pain that is amenable to safe intervention while the individual is under a physician’s care.”

  • For patients in labor, maternal request alone is sufficient indication for pain control.
  • Appropriate pain management options should be offered to all patients.
  • Therapy should be administered based on patient preference:
    • A sense of personal control over decision-making is more important than absolute levels of pain. 
    • Postpartum depression (PPD) and PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD) are associated with uncontrolled pain.
  • Absent medical contraindications, patients may choose:
    • When to start labor analgesia
    • What type of analgesia they prefer
    • Whether or not they want labor analgesia at all 

Options for pharmacologic pain management

  • Systemic analgesics
  • Local and regional analgesics
  • General anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts

Physiology

Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in the 1st stage of labor

The 1st stage of labor begins with the onset of regular uterine contractions causing cervical change and ends when the patient’s cervix is fully dilated at 10 cm.

Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in the 1st stage of labor is:

  • Visceral cramping pain
  • Originates from:
    • Ischemia of the uterus during contractions
    • Distension of the cervix
    • Referred pain to the abdominal wall, lumbosacral region, and upper legs
  • Perceived by nerves T10–L1

Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in the 2nd stage of labor

The 2nd stage of labor begins when the cervix is fully dilated at 10 cm and ends with expulsion of the fetus.

  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain typically described as more severe
  • Often perceived as intense rectal pressure
  • Due to a combination of:
    • Visceral pain from the uterus and cervix
    • Somatic pain from distension of the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor and perineum
  • Somatic pain is transmitted through the pudendal nerve (S2–S4).

Systemic Analgesics

Systemic analgesics can be used during labor but are not adequate for cesarean deliveries. They are commonly chosen by women for management of earlier labor, prior to getting an epidural.

Inhaled analgesia: nitrous oxide (“laughing gas”)

  • Inhaled intermittently, during contractions only
  • Self-administered by patient
  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain relief: minimal and short lasting
  • Side effects: lightheadedness, dizziness, and nausea
  • Provides some pain relief early in labor
  • For patients who prefer to avoid other options 

IV analgesia: opioids Opioids Opiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics

  • May be given as:
    • Intermittent IV bolus of standard-dose opioids Opioids Opiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics
    • Patient-controlled analgesia:
      • May or may not include a low-dose continuous infusion (basal rate)
      • Patients can self-administer small boluses.
  • Intermittent IV bolus options (usually administered every 2–4 hours):
    • Nalbuphine 
    • Meperidine
  • Patient-controlled analgesia options:
    • Remifentanil
    • Fentanyl
  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain relief: 
    • Minimal to moderate 
    • Short lasting 
    • Provides more relief than nitrous oxide but significantly less than an epidural
  • Side effects: nausea, vomiting, and drowsiness
  • Can affect the fetus because opioids Opioids Opiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics cross placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity, leading to:
    • Decrease in fetal heart rate (FHR) variability
    • Fetal respiratory depression if drugs remain in the fetal system after delivery → avoid giving opioids Opioids Opiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics within 4 hours of delivery

Local and Regional Analgesic Techniques

Pudendal nerve block

  • Injection of opioids Opioids Opiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics into the pudendal nerve (S2–S4) 
  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain relief: 
    • Excellent along the nerve distribution
    • Effect covers the lower vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor, labia, and perineum only.
  • Used for: 
    • Operative vaginal deliveries and laceration repairs in patients without epidurals
    • Additional pain control when epidural anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts fails to adequately anesthetize the sacral nerves
  • Does not provide analgesia for uterine pain and is not helpful for:
    • Contraction pain during labor
    • Cesarean deliveries
  • Complications: hemorrhage due to inadvertent laceration of the pudendal artery
Site of injection for a pudendal nerve block

Site of injection for a pudendal nerve block

Image by Lecturio. License: CC BY-NC-SA 4.0

Epidural anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts

  • Slow-flow continuous administration of opioid into the epidural space via a catheter
  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain relief:
    • Continuous pain relief while running
    • Excellent pain relief at T8 and below
    • May have some “hot spots” (areas of poor pain relief)
  • Used for: 
    • Labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor pain management through vaginal delivery
    • Cesarean deliveries: 
      • Typically used only after failed trials of labor when the epidural is already in place (e.g., arrested labor)
      • Spinal anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts is superior to epidurals for cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery due to a lack of “hot spots.”
  • Maternal side effects:  hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension (may cause uteroplacental insufficiency until corrected)
  • Contraindications: 
    • Certain coagulopathies
    • Increased intracranial pressure Increased Intracranial Pressure Normal intracranial pressure (ICP) is defined as < 15 mm Hg, whereas pathologically increased ICP is any pressure ≥ 20 mm Hg. Increased ICP may result from several etiologies, including trauma, intracranial hemorrhage, mass lesions, cerebral edema, increased CSF production, and decreased CSF absorption. Increased Intracranial Pressure (ICP)
    • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin infections in the lower back
Location of epidural catheter placement

Location of epidural catheter placement

Image by Lecturio. License: CC BY-NC-SA 4.0

Spinal anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts

  • Single injection of opioid into the subarachnoid space
  • Pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain relief: 
    • Lasts 2–4 hours 
    • Excellent pain relief at T10 and below
  • Used for: cesarean deliveries
  • Maternal side effects of spinal anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts:
    • Hypotension (may cause uteroplacental insufficiency until corrected)
    • Bradycardia
Spinal anesthesia location of opioid injection

Location of opioid injection during spinal anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts

Image by Lecturio. License: CC BY-NC-SA 4.0

Regional anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts

Table: Regional anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts
Epidural anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts Spinal anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts
Site of injection Epidural space Subarachnoid space
Level of injection T8 T10
Duration of pain relief Continuous while catheter remains in place 2–4 hours
Side effects Hypotension Hypotension and bradycardia

General Anesthesia

  • Reserved for emergency C-sections: Spinal anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts should always be attempted first if time allows and unless there are specific contraindications.
  • Increases risk for:
    • Maternal aspiration → aspiration pneumonitis
    • Postpartum hemorrhage Postpartum hemorrhage Postpartum hemorrhage is one of the most common and deadly obstetric complications. Since 2017, postpartum hemorrhage has been defined as blood loss greater than 1,000 mL for both cesarean and vaginal deliveries, or excessive blood loss with signs of hemodynamic instability. Postpartum Hemorrhage (general anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts causes uterine atony)
    • Fetal respiratory depression at birth
  • Fetal care:
    • Pediatric care providers should be present at delivery to provide respiratory support, as the infant will also be under the effects of general anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts.
    • Infants should be delivered as quickly as possible after induction of anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts to minimize fetal effects.

References

  1. Lowe, NK. (2002). The nature of labor pain. Am J Obstet Gynecol. 186(5 Suppl Nature), S16–24. https://pubmed.ncbi.nlm.nih.gov/12011870/ 
  2. Melzack, R, Taenzer, P, Feldman, P, & Kinch, RA. (1981). Labour is still painful after prepared childbirth training. Can Med Assoc J. 125(4), 357–63. https://pubmed.ncbi.nlm.nih.gov/7272887/ 
  3. Hodnett, ED. (2002). Pain and women’s satisfaction with the experience of childbirth: A systematic review. Am J Obstet Gynecol. 186(5 Suppl Nature), S160–72. https://pubmed.ncbi.nlm.nih.gov/12011880/ 
  4. Brownridge, P. (1995). The nature and consequences of childbirth pain. Eur J Obstet Gynecol Reprod Biol. 59 Suppl, S9–15. https://pubmed.ncbi.nlm.nih.gov/7556828/ 
  5. Goetzl, LM, ACOG Committee on Practice Bulletins-Obstetrics. (2002). ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists Number 36, July 2002. Obstetric analgesia and anesthesia. Obstet Gynecol. 100(1), 177–91. https://pubmed.ncbi.nlm.nih.gov/12100826/ 
  6. Committee on Obstetrics. (2019). American College of Obstetrics and Gynecology Practice Bulletin No. 209: Obstetric Analgesia and Anesthesia. Retrieved May 27, 2021, from https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/03/obstetric-analgesia-and-anesthesia 

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