Educational Materials

1. Pain Relief in Labor,
for 4th year Med. Students
Associate Clinical Prof. Dr. Aisha M. El-Bareg, MD, PhD
Senior Consultant in (Obs & Gyn)/ Reproductive Medicine
Faculty of Medicine, Misurata University, LIBYA

3. Etiology of pain during laborBasic factors for pain in childbirth
1. Physical pain in labor is caused by:
Muscle cramps/ uterine contraction.
Stretching of cervix and perineum .
Position of the baby and pressure of presenting
part on tissue like bladder, urethra, back, lower
colon.
Medical tests and procedures (pelvic exams, IVs,
catheterization, etc).

4. Basic factors for pain in childbirth
2. Emotional Factors
Many negative emotions can actually increase your
perception of pain,:
Fear of pain
Fear of the unknown, Anxiety
Self-doubt
Lack of education
Exhaustion
Dehydration, Hunger

5. Endorphins
 Inhibitory neuropeptides acts as Natural pain killer
(endogenous narcotics), produced from pituitary
gland.
Released during stressful events or in moment of
grate pain, it is responsible for euphoric feelings
known as “runner’s high” and “adrenaline rush “.
 Relieve stress and enhance pleasure & happiness.

6. • It’s secretion triggered by
• Exercise.
• Smiling, gossiping.
• Eating certain food “chocolate, chili peppers” .
• Massage therapy or acupuncture.
Endorphins

7. Unmedicated labor
• Body produces endorphins to cope with pain.
• Baby’s endorphins raise when mom’s endorphins
raise.
• Oxytocin peaks just after unmedicated birth.
• Stimulates the baby’s adrenal glands

8. Unmedicated labor
• Helps to adapt to life outside of the uterus
–Helps baby breathe
–Increases blood flow to baby
–Stimulates immune system (increased WBC’s)
–Baby is more alert – facilitates bonding.
• Medications decrease natural endorphins for
both.

9. Objectives of pain relief:
Why do we give analgesia for child birth?
1. Humanitarian reason
1. Economic benefit
1. Medical reason

10. Medical Effects of Labour Pain
Pain compromises
placental blood flow
leading to fetal
hypoxia and acidosis.
Increase catecholamine
secretion leads to
increased blood
pressure which
adversely effects fetal
circulation
Releases Adrenocortical
hormone which may
effect electrolytes,
carbohydrates and
protein metabolism.
A traumatic labour
may lead to post
traumatic stress
syndrome.

11. Background
It is only in the last 100 years
that effective methods of pain
relief have become available.
Queen Victoria was given
chloroform by John Snow for
the birth of her eight child and
this did much to popularize the
use of pain relief in labor

12. The ideal analgesic in labor
• Should provide excellent rapid onset pain relief
in both first and second stages .
• Easy to administer.
• Safe to the mother and baby.
• Easily reversible if necessary.
• Does NOT interfere with uterine contractions.
• Does NOT affect patient’s mobility.

13. Physiology of labor pain
1st stage of labor- mostly
visceral
•Dilatation of the cervix and
distension of lower uterine seg.
•Dull, aching and poorly
localized.
•Slow conducting, visceral C
fibers, enter spinal cord at level
of T10-L1.

14. Physiology of labor pain
2nd stage of labor- mostly
somatic
•Distension of the pelvic floor,
vagina and perineum
•Sharp, severe and well
localized
•Rapidly conducting A-delta
fibers, enter the spinal cord at
S2 to S4

15. How does pain occur ?
 1st Stage is due to ischemia of the
uterine muscle caused by uterine contraction
resulting in obstruction of its own blood supply.
this result in accumulation of pain metabolites.
 2nd Stage stretching of perineal tissue by
advancing presenting part of the fetus.

16. Types of pain relief in labor
Non-pharmacological:
• Educate on the process of
labor & pain relief methods.
• Continuous labor support
• Relaxation.
• TENS.
• Hypnosis.
• Acupuncture
• Hydrotherapy (water birth)
Pharmacological:
• Opiates.
• Inhalational.
• Regional analgesia

17. Continuous Labor Support
Continuous labor support
provided by a doula
decreases :
• Operative vaginal deliveries
• Cesarean deliveries
• Request for pain medication

18. Relaxation
“psychoprophylaxis”
• Essential in all cases.
• Antenatal classes to educate the mothers on
what to expect.
• During labor ask the mother to relax, breathe
deeply and slowly.
• Increase the spirit of the mother and Helps to
cope with pain and satisfaction with pain relief.
• Carries no risk to the mother and fetus.

19. Transcutaneous electronic nerve stimulation
(TENS)
• Low grade electronic waves to block
afferent nerve fibers supplying the
uterus
• Via skin electrode applied on (T10-L1).
• Also facilitate release of endorphins.
• Provides good pain relief to 25% of
patients.
• The mother can control the stimulus
• Carries no risk to the mother and fetus.

20. Hypnosis and acupuncture
• Multiple theories of how it works,
including altered neuro-transmitters,
increased endorphins, suppression
of excitatory neurons.
• Reported to be successful.
• Needs special skill and preparation.
• Carries no risk to the mother or
fetus.
• ??? Placebo effect

21. Standing under warm shower or soaking in tube
of warm water, the temperature of water used
should be between 35-37◦c .
No limit to the time women can stay in bath and
often they are encouraged to stay in it as long as
desired.
No increase in chorioamnionitis , post partum
indometritis, neonatal infection or antibiotic use.
Water therapy (hydrotherapy )

22. • Labor may slow if used in early labor
–Less than 5cm dilation.
• No effect on the usage of epidural analgesia
• Short duration of pain relief.
• Only effective while she’s in the bath.
Water therapy (hydrotherapy )

23. Narcotics (Opiates)
• Pethidine and diamorphine are the commonly
used drugs.
• Very simple to give: IM or IV
• Rapid onset of effect.
• Repeated when necessary.
• Can still get an epidural later

24. Disadvantage:
• Limited pain relief.
• Maternal sedation, drowsiness.
• Nausea and vomiting. (antiemetic)
• Delayed gastric emptying
• Restricted movement, inability to urinate.
• Inability to participate in labor
• Increase rate in instrumental and cesarean del.
• Can cross BPB respiratory depression in
the new born. So give antidote (Naloxone) and
breathing assistance

25. Inhalational anesthesia
• The commonest is nitrous oxide.
• Given in a 50-50 mixture with
oxygen (Entonox).
• Self administered to the patient
via face mask.
• It does not interfere with uterine
contraction

26. • Quick onset (1-2min), short duration of effect (2-
8 min). Start inhaling at the onset of contraction.
• Entonox- side effect:
• Nausea
• Vomiting
• Poor recall of labor
Inhalational anesthesia

27. Advantages
• Provides analgesia varying from good to ineffective.
• Under control of the patient.
• Minimal adverse effects to mother and fetus.
• Not adequate for second stage, instrumental
delivery, suturing of perineum or manual
removal of placenta.
• Light headedness and nausea.
• Not suitable for prolonged use.
Disadvantages

28. • Injection of local anesthetics around sensory
nerves of spinal cord to block pain from
larger but still limited part of body.
• Does not block the motor pathway to the
uterus (T7 &T8).
• Types:
• Epidural
• Spinal
• Combined epidural spinal
• Pudendal block
Regional analgesia

29. ‫ألم‬‫بدون‬ ‫الوالدة‬
Epidural analgesia

30. History of Epidural
•First description of Ep. Analgesia dates back to J,
Leonard. corning, a neurologist who in 1885
inadvertantly injected cocaine in the epidural space.
•1921, Spanish military surgeon –technique of
‘single- shot’ lumber epidural anesthesia.
•1941, Robert Andrew Hingosn – technique
continuous caudal anesthesia with indwelling
needle
•1942- the first use of continuous caudal anesthesia
in laboring women.

31. Spinal
cord
Pia matter
Subarachnoid space filled
with CSF
Arachnoid Dura mater
Epidural space

32. • Epidural catheter inserted to the epidural space at
the level of L3-L4 interspace.(segmental)
• Patient maintains lateral or sitting position
• Catheter is aspirated to check the position. The
catheter is left in.
•Test dose given to confirm the catheter position.
small volume of diluted local anesthetic.
•After 5mins loading dose of mixture of 0.1%
Bupivacaine with fentanyl 12mcg/ml is given.
Epidural analgesia

33. Epidural analgesia

34. Important…
• Secure IV access.
• Hydrate with 500-1000cc RL
• Establishment/after each bolus measure BP
every 5min for 15min, provide continuous
EFM for 30 min.
• Every hour; check level of sensory block.
• Continue until completion of the 3rd stage &
any perineal repair.
• Birth should take place within 4 hours.

35. Advantages:
• The most effective pain relief (T10-S5).
• The absence of pain allows enjoyment and
control of labor (alert mom).
• Reduces maternal fatigue and anxiety.
• Compared to narcotics, greatly reduced newborn
resuscitation rates.
• Ideal in high risk pregnancies e.g. breech, MP,
and PET.

36. Disadvantage:
• Prolonged labor 1 hour. (require oxytocin)
• Restriction of movement during labor.
• Requires CTG.
• Requires resident anesthesia, cardio-
respiratory facilities and one to one care.
• ?increase rate of instrumental delivery.
• Beware of urine retention.
• Risk of headache.

37. Absolute Contraindications of Epidural
1) Patient refusal.
2) Blood Coagulopathy
3) Infection at the site of injection
4) Treatment with low-molecular-weight heparin
within 12 hr.
5) Sever hypovolemia
6) Fixed cardiac out put
- Sever aortic stenosis, Sever mitral stenosis
- Hypertrophic obstructive cardiomyopathy
Contraindicated
In pregnancy

38. Relative Contraindications of Epidural
1) Systemic sepsis.
1) Uncooperative patient.
2) Preexisting neurological deficits,
e.g. demyelinating disease, peripheral neuropathy
4) Sever spinal deformity.
Avoid in pregnancy

39. Complications
• Accidental Dural puncture-leak of CSF causing
spinal headache.
• Accidental total spinal anesthesia -severe
hypotension, respiratory failure, unconsciousness
& death.
• Drug toxicity occur with accidental placement of
catheter within a blood vessel.
• Bladder dysfunction, Back pain , paralysis.
• Short term respiratory distress in baby.

40. Analgesia used in second stage and third
stage.
• Nerve blocks.
• Spinal anesthesia.
• General anesthesia.

41. Spinal anesthesia
• Not used for routine analgesia in labor.
Can be used for …
• Instrumental delivery.
• Manual removal of placenta.
• Repair of third degree tear.
• Mainly used for CS.

42. Spinal Anesthesia
• A fine gauge atraumatic spinal needle is inserted
into the subarachnoid space below level of L2.
• Small volume of local anesthetic is injected, after
which the spinal needle is withdrawn.
• Combined spinal- epidural analgesia?
• Block level from 8th thoracic dermatome (xiphoid
process/breast)
• Quick onset, Longer anesthetic effects

43. Pudendal block
•Quick pain relief to the perineum, vulva, and vag.
•Usually given in the second stage of labor, just
before delivery of the baby.
•Also just before episiotomy
•Anesthesia is produced by blocking the pudendal
nerve (S2,3,4) near to ischial spin.

44. C-sec → failed epidural/spinal/allergy.
• NPO for about 8 hours
• Prophylactic antacid, antiemetic
• Pre-O2
• Induced unconsciousness (inhalational or IV
• Endotracheal intubation- cricoid pressure on
trachea- occludes esophagus, prevent aspiration
• Maintain anesthesia for the rest of surgery using
additional medication given via IV or ET tube
General Anesthesia
(total induced unconsciousness)

45. Complications of GA
 Pulmonary aspiration of gastric contents
 Aspiration pneumonia (Mandelson’s syndrome)
 Failed intubation
 Neonatal depression.

46. summary
• Labor is a painful experience.
• Pharmacological and non-pharmacological
method are used for pain relief.
• Each method had its advantage and
disadvantage and the choice of method
depends on the stage of labor and maternal
preference.

47. THANK YOU
THANK YOU