1. Pain management
Dhuha F Shamsaldeen
315-316

2. Objectives
1.Explain how the pain of labor and birth differs from other types of
pain.
2.Describe sources of labor pain.
3.List factors influencing the woman’s experience of labor pain.
4.Discuss principles of labor pain management.
5.Compare nonpharmacologic interventions to manage labor pain.
6.Explain various relaxation techniques that help a woman cope with
labor.
7.Differentiate analgesia from anesthesia.
8.Describe advantages and disadvantages of opioid administration.
9.Compare methods of regional anesthesia.
10.Explain major complications associated with epidural and spinal
anesthesia.
11.Discuss reasons general anesthesia is risky for a pregnant woman
and her fetus.

3. What is labor ?
Labor is the process by which the fetus and the
placenta leave the uterus. Delivery can occur in
two ways, vaginally or by a cesarean delivery.

4. Signs of labor ?
• Some women experience very distinct signs of labor, while
others do not. No one knows what causes labor to start or
when it will start, but several hormonal and physical changes
may indicate the beginning of labor:
Lightening
Passing of the mucus plug
Contractions
Water breaking
Effacement and dilation of the cervix

5. The Pain of Labor and
Childbirth
•Unique
• Different from other types of pain (usually pain is warning sign of
injury)
• Increased intensity desired and positive (greater intensity is
associated with approaching birth)
• Occurs in predictable pattern (begins without warning, but once
established it is predictable, respite between)

6. Causes of pain in labor
Stage
One
Stretching of
the cervix
during dilation
& effacement
Uterine Anoxia
Stretching of
the
uterine
ligaments

7. Causes of pain in labor
Stage
Two
Distention of the
vagina and
Perineum
Compression of
the nerve
ganglia in cervix
& lower uterus
Pressure on
urethra, bladder,
rectum during
fetal descent
Traction on and
stretching of
the perineum

8. Factors affecting Mothers
Response to Pain in Labor
Preparation -
Knowledge and
confidence
gained through
childbirth
classes
Cultural
influences on
expression of
pain
Previous
experiences
with pain
Maternal
fatigue, anxiety
, sleep
deprivation
Support

9. The goal of pain management
pain management prior to delivery may
help ease your anxiety in the moment of
labor.

10. Pain Management Principles and
Techniques
• Principles of pain relief during labor
• Women are more satisfied when they have control
over the pain experience
• Caregivers commonly underrate the severity of pain
• Women who are prepared for labor usually report a
more satisfying experience than do women who are
not prepared

11. Pain Management Principles and
Techniques (cont.)
• Non-Pharmacologic Pain Interventions
• Continuous labor support-doula
• Acupressure and acupuncture
• Relaxation techniques-helps to facilitate labor process
• Patterned breathing
• Attention focusing (imagery)
• Movement and positioning
• Touch and massage
• Water therapy

12. Breathing pattern

13. Movement and positioning

14. Touch and massage

15. Water therapy

16. Pain Management Principles and
Techniques (cont.)
• Advantages and disadvantages of non-pharmacologic
interventions
• Advantages
• Noninvasive
• Address emotional and spiritual aspects of birth
• Promote women’s sense of control over pain
• Disadvantages
• Many of the interventions require special training and/or practice
before birth
• These methods are not effective for every woman

17. Pharmacological Interventions
• Analgesia and sedation
• The use of medication to reduce the sensation of pain
• Sedatives given to promote sedation and relaxation
• Opioids given to promote analgesia during labor
• Anesthesia
• The use of medication to partially or totally block all
sensation to an area of the body
• Local, regional, general

18. Analgesics and
anesthetics
commonly used in
labor and birth

19. Type Drug Usual
dosage
Effect on
mother
Effect on labor
progress
Effect on fetus
or newborn
Narcotic
analgesic
Meperidine
(demerol)
25 mg IV, 50-
100 mg IM q3-4
hr: also
epidurally
Effective of
analgesic:
feeling of well-
being
Relaxation, possibly
aiding progress during
cervical relaxation.
Slows labor
contractions if given
early
Should be given 3 hr
before birth to avoid
respiratory depression
and decrease heart
rate
Nalbuphine(nubai
n)
10-20 mg IM q3-
6 hr, 0.3-3
mg/kg over 10-
15 min IV
Slowing of
respiratory rate;
effective
analgesic
Mild maternal
sedation
Results in some
respiratory depression
Butorphinol
(stadol)
1-2 mg IM or IV
q3-4hr
Withdrawal
symptoms if
woman is opiate
dependent
Possible slowing of
labor if given early
Results in some
respiratory depression
Morphine sulfate Intrathecally
0.2-1mg: 5 mg
epidurally
Pruritus;
effective
analgesia
Possible slowing of
labor contractions
some respiratory
depression
Fentanyl
(subilimaze)
50-100µg IM or
25-50 µg IV ;
epidurally
Hypotension;
respiratory
depression
slowing of labor if
given early
respiratory depression

20. Type Drug Usual
dosage
Effect on
mother
Effect on
labor
progress
Effect on
fetus or
newborn
Lumbar epidural
block
Marcaine or
Naropin
Administered for
first stage of
labor; with
continuous
block, anesthesia
will last through
birth; injected at
L3-4;
Rapid onset, in
minutes; lasting
60-90 min; loss
of pain
perception of
labor
contractions and
birth; possible
maternal
hypotension
slowing of labor
if given early;
pushing feeling
obliterated
resulting in
possible
prolonged
second stage
May result in
respiratory
depression. May
be some
differences in
response in first
few days of life.
Pudendal block Local anesthetic
lidocaine
(Xylocaine)
Administered
just before birth
for perineal
anesthesia;
injected through
vagina
Rapid anesthesia
of perineum
None apparent None apparent
Local infiltration
of perineum
Local anesthetic
lidocaine
(Xylocaine)
Injected just
before
episiotomy
incision
anesthesia of
perineum
Almost
immediately
None apparent None apparent
General
intravenous
anesthetic
thiopental Administered IV
by
anesthesiologist
or nurse-
anesthetist
Rapid
anesthesia; also
rapid recovery
Forceps required
because
abdominal
pushing is no
longer possible
Results in infant
being born with
CNS deperssion

21. Pharmacological Interventions
(cont.)
• Advantages and Disadvantages of Opioid
Administration
• Advantages
• an increased ability for a woman to cope with labor
• The medications may be nurse-administered
• Disadvantages
• Frequent occurrence of uncomfortable side effects, such as nausea
and vomiting, pruritus, drowsiness, and neonatal depression
• Pain is not eliminated completely

22. Pharmacological Interventions
(cont.)
• Types of anesthesia
• Local anesthesia
• Used to numb the perineum just before birth to allow for episiotomy
and repair
• Regional anesthesia
• Involves blocking a group of sensory nerves that supply a particular
organ or area of the body
• General anesthesia
• Not used frequently in obstetrics because of the risks involved

23. Pharmacological Interventions
(cont.)
• Types of regional anesthesia
• Pudendal block-pain relief for the birth
• Paracervical block-pain relief during labor
• Epidural anesthesia-pain relief during labor
• Intrathecal anesthesia-provides pain relief until the
epirdural begins to work

24. Epidural Anesthesia
Injection of an anesthetic
agent into the epidural
space
Provides pain relief
during labor and delivery

25. Spinal Anesthesia
A local anesthetic is
injected directly into
the spinal fluid in the
spinal canal to provide
anesthesia for
cesarean birth and
occasionally for vaginal
birth

26. Pudendal Anesthesia
Anesthesia administered
transvaginally and
intercepts pudendal
nerve.
Provides pain relief for
episiotomy and delivery.

27. Local Anesthesia
Local injection of
anesthetic agent in
the perineum for
episiotomy and
repair

28. Pharmacological Interventions
(cont.)
• Complications Associated With Epidural and Spinal
Anesthesia
• Hypotension
• Maternal fever
• Shivering
• Pruritus
• Inadvertent injection into the blood stream
• Spinal headache
• Fetal distress

29. Pharmacological Interventions
(cont.)
• Life-Threatening Complications Occurring With
General Anesthesia
• Failed intubation-due to physiological changes: trachea and
thorax
• Aspiration-often premedicated
• Malignant hyperthermia-(rare) inherited condition that causes
sustained muscle contractions in the presence of certain
anesthetic agents

30. Refrencess
• http://www.webmd.com/baby/guide/pregnancy-pain-relief
• http://www.webmd.com/baby/labor-signs
• Pilitteri, A.(2010) Maternal and Child Health
Nursing, Philadelphia. J.B Lippincott Co. (6th edition) Pp 395-
414 ch16