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Chapter 187. Labor Analgesia

Anjali Fedson Hack, MD, PhD

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Stages of Labor
StagesDermatomesDefinition
FirstT10–L1Uterine contractions with dilation of cervix until fully dilated
SecondS2–S4Full dilation of cervix until delivery of infant
ThirdS2–S4Expulsion of placenta
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Nonpharmacologic Methods of Pain Relief
MethodTechnique
HypnosisModify perception of pain through self-hypnosis and posthypnotic suggestion
PsychoanalgesiaReduction in maternal anxiety through controlled breathing and relaxation techniques (Dick-Read method)
PsychoprophylaxisReduction in pain perceptions through controlled relaxation and breathing (Lamaze)
Leboyer technique“Birth without violence” or avoidance of birth trauma for neonate through decreasing environmental stimuli
AcupunctureInsertion of fine needles at meridians to correct energy paths disrupted by labor
TENSTranscutaneous electrical nerve stimulation at T10–L1 bilaterally
Water birthingMaternal stress relief through immersion in warm bath
AromatherapyStress relief in labor through inhalation of aerosolized essential oils
Touch and massageEmotional and pain relief through therapeutic touch
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See following table.

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Systemic Medications and Inhalational Agents for Labor Pain Relief
MedicationUse and/or dosageComments
OpioidsPopular in first stage of labor
  • Maternal and fetal respiratory depression possible
  • Decrease fetal heart rate variability
Morphine
  • 5–10 mg IM (peak effect 1–2 h)
  • 2–3 mg IV (peak effect 20 min)
Often used as PCA or continuous infusion
Meperidine
  • 50–100 mg IM (peak effect 40–50 min)
  • 25–50 mg IV (peak effect 5–10 min)
Fentanyl
  • 50–100 μg IM (peak effect 7–8 min)
  • 25–50 μg IV (peak effect 3–5 min)
  • Short duration
  • Use for PCA in labor analgesia has decreased since the introduction of remifentanil
RemifentanilPCA: initial infusion 0.03 μg/kg/min; titrate to 0.1 μg/kg/min
  • Short half-life in plasma
  • Use supplemental oxygen
  • Minimizes neonatal respiratory depression
Agonist–antagonistsLimited potential for respiratory depression
Butorphanol (Stadol)1–2 mg IMTransient sinusoidal fetal heart rate pattern
Nalbuphine (Nubain)5–10 mg IVNeonatal respiratory depression
Sedatives/tranquilizers
PhenothiazinesAnxiolytic and antiemetic
Hydroxizine (Vistaril)25–50 mg IMDecreases fetal heart rate variability
Promethazine (Phenergan)25–50 mg IM
Inhalational analgesia
Entonox: 50% N2O/50% O2 (mixture not available in the United States)Patient controlled
  • May be difficult to obtain precise concentration
  • Availability of proper scavenging is often lacking
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Epidural analgesia:

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  • Analgesia provided by analgesics delivered via epidural catheter
  • Most effective form of intrapartum analgesia
  • Requires preanesthetic evaluation, presence of anesthesiologist, resuscitation equipment

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Indications:

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  • Maternal request for pain relief represents sufficient condition for epidural administration (ACOG/ASA joint guidelines)

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Contraindications:

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  • Patient refusal/inability to cooperate
  • Elevated intracranial pressure/mass effect
  • Soft tissue infection at epidural site
  • Sepsis
  • Coagulopathy
  • Hypovolemia

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Technique:

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  • Patient positioned, monitors in place
  • Epidural space accessed using epidural needle
  • Catheter passed through the needle, aspirated, and secured as usual
  • Epidural catheter tested:
    • Every dose is a test dose ...

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