This document discusses pain management techniques for labor and delivery. It begins by noting recommendations from professional organizations that pain relief should be provided during labor when possible. It then describes the physiology of labor pain and the ideal characteristics of labor analgesic techniques. Both non-pharmacological and pharmacological techniques are outlined, including systemic opioids, inhalational analgesia, and various regional nerve blocks like epidural analgesia. Specific drugs, doses, and considerations for safe administration are provided. Complications are also discussed.

1. Prepared by/ Dr. Islam EzzEldin Osman
Assistant lecturer of Anesthesia
Ain shams University
2017

2. As noted by the ASA and the ACOG
“There is no other circumstance where it is
considered acceptable for a person to
experience severe pain, amenable to safe
intervention, while under a physician’s care.”
“ In the absence of a medical contraindication,
maternal request is a sufficient medical
indication for pain relief during labor.”

3. Physiology of labor Pain
• Dilation of the cervix and
distention of the lower
uterine segment.
• Dull, aching and poorly
localized
• Slow conducting, visceral
C fibers, enter spinal cord
at T10 to L1
1st stage
of labor
Mostly
visceral
• Distention of the pelvic
floor, vagina and
perineum
• Sharp, severe and well
localized
• Rapidly conducting A-
delta fibers, enter spinal
cord at S2 to S4
2nd stage
of labor
Mostly
somatic

4. The ideal labor analgesic technique
is safe for both the mother and the infant
does not interfere with the progress of labor and delivery
provides flexibility in response to changing conditions
provides consistent pain relief
has a long enough duration of action
minimizes undesirable side effects (e.g., motor block)
minimizes ongoing demands on the anesthesia provider’s time

5. Techniques for Labor Analgesia
Non
pharmacological
Psycho prophylaxis as
is Lamaze, Doula
Transcutaneous
electrical nerve
stimulation TENS
Acupuncture
Pharmacological
Systemic
Inhalational
Regional

6. Non pharmacological techniques
Psycho prophylaxis
• These methods focus on teaching the mother conditional reflexes to
overcome pain and fear of childbirth.
• Includes human support, breathing techniques, relaxation techniques
and others…
Acupuncture
• Generally two local points and two distal points on the arms or on the legs are
selected.
• Best when started 4 weeks before the expected time of delivery.
• Needles are placed once a week using the specific points
TENS
• Very popular in Europe, easy to apply and frequently effective.
• 4 electrodes are placed one on either side of the spine in the lower thoracic
region (T 10) and one on either side of the spine in the sacral area.
• The patient may control level of intensity of stimuli, and can switch it off.

7. Pharmacological Techniques
Systemic opioids
Inhalational
Regional

8. Systemic Opioids
Advantages
• Easy administration
• Inexpensive
• No needles
• Avoids complications of
regional block
• Does not require skilled
personnel
• Few serious maternal
complications
• Perceived as “natural”
Disadvantages
• Placental transfer
• Inadequate pain relief
• Maternal sedation
• Nausea, vomiting, gastric stasis
• Fetal heart rate effects:Loss of
beat-to-beat variability,
Sinusoidal rhythm
• Dose-related maternal /
neonatal depression
• Newborn neurobehavioral
depression

9. Potential Fetal/Neonatal Effects
Low 1 and 5
min Apgar
scores
Respiratory
acidosis
Naloxone/
ventilatory
assistance may
be needed
Neurobehavioral
depression - dose
dependent
Occasionally,
prolonged
observation in
NICU needed

10. Modalities for systemic opioids
• Dose : 50-100 mg IM or 25-50 mg IV
• onset: 45mins for IM , 5mins for IV
• optimal time: Given early (>4hrs from expected
labor) for IM and within 1 hour from labor for IV
Meperidine
• 50-100µg/hr, peaks @ 3-5minsFentanyl
• ½life 6mins, 0.5mirogms/kgRemifentanil
• may also be usedNalbuphine
• Loading dose of 50 – 100 ug
• No background infusion
• Carefully controlled bolus dose (around 10ug) and lockout
periods (10mins) with a 4 hour limit of 300mg
Some centers advocate the use of IV-PCA fentanyl pumps or accufusers
during labor with special considerations including :

11. Dexmedetomidine
Recently , intravenous infusion of
Dexmedetomidine is being used in combination
with remifentanil infusion for labor analgesia.
• Opioid sparing effect
• Adequate level of sedation
• Minimal haemodynamic side effects.
• Very low incidence of nausea and vomiting
Advantages

12. Inhalational Analgesia
Entonox
(50% N20/50% O2)
Advantages:
• Easy to administer (no
needles or PDPH)
• “Satisfactory”
analgesia variable
• Minimal neonatal
depression
Disadvantages:
• Decreased uterine
contractility (except N2O)
• Rapid induction of
anesthesia in pregnancy
• Risk of unconsciousness and
aspiration
• Difficulties with scavenging
in labor rooms

13. Regional blocks

14. Local TechniquesParacervicalblock
• Local bilateral
injection near the
cervix
• Given during 1st
stage of labor
• Disadvantage
• fetal bradycardia
• Lidocaine toxicity
PudendalBlock
• Causes perineal
anesthesia
• Useful in 2nd stage
of labor

15. Neuraxial Blocks
Techniques
• Spinal
• Epidural
• Combined
Drugs
•Opioids
•Local anesthetics
•Both
Mode
• Single shot
• Continuous
infusion

16. Neuraxial BlocksAdvantages
Most effective & Least
depressant
Great versatility in strength
& Duration
Reduces maternal
Catecholamines
Improved Uteroplacental
perfusion
Low dose LA – NO Effect on Uterine
activity
Low dose opioids – NO neonatal
depression

17. Neuraxial Blocks
• Uterine
perfusion
maintained
• Doesn’t affect
Apgar scores,
acid-base status
• Neurobehavioral
effects absent
• LA toxicity -
extremely rare
Specific
Fetal
Advantages
• Blunts Haemodynamic
response in :
• Hypertensive
disorders
• Cardiac disease
• Asthma
• Diabetics
• Avoids depressant
effects of opioids in :
• Prolonged labor
• Prematurity
• Multiple gestation
• Breach delivery
Specific
Maternal
Advantages

18. Contraindications to neuroaxial blocks
ABSOLUTE
• Patients refusal
• Inability to cooperate
• Increased
intracranial pressure
• Infection at the site
• Frank coagulopathy
• Hypovolemic shock
RELATIVE
• Systemic infection
• Preexisting
neurological
deficiency
• Mild coagulation
abnormalities
• Relative hypovolemia
• Poor communication

19. Spinal Anelgesia
Involves intrathecal injection of opiods, Local anesthetics
or more commonly a mixture of both.
Has the benefit of having the most rapid onset of
analgesia.
The most commonly used modality for labor, the “saddle
block” provides profound perineal analgesia with minimal
hemodynamic side effects.

20. Choice Of Local Anesthetic
Rapid onset with
minimal motor
block
Minimal risk of
maternal
toxicity
Negligible effects
on uterine activity
and uteroplacental
perfusion
Limited
uteroplacental
transfer
Long duration of
action

21. Local Anesthetic agents
• Rapid onset
• Dense motor block
• Risk for cumulative toxicity
Lignocaine
• Good sensory block
• Minimal motor block
• No adverse effects on labor
Bupivacaine
(0.0625%)
• Lower toxicity
• Less motor block
• Less potent
Ropivacaine
• Lower toxicity than BupivacaineLevobupivacaine

22. Intrathecal opioids
Inadequate analgesics if used alone
Synergize with local anesthetics
Speed onset of analgesia
Improve quality of analgesia
Permit use of very dilute LA solutions
Help relieve persistent perineal pain and unblocked segments

23. Side effects of Intrathecal opioids
Nausea, Vomiting
Pruritis
Sedation
At very high doses can cause respiratory depression
and fetal bradycardia
• Using the least effective doses
• Mixing opioids with local anesthetics
These side effects can be controlled via

24. Choice of Intrathecal opioids
• Both have rapid onset and few side effects.
• Sufentanil is slightly more effective
• No significant fetal drug accumulation
• No serious adverse neonatal effects
Fentanyl &
Sufentanyl

25. Continuous Spinal Analgesia
Used by some centers in Europe,
however it is restricted by FDA
regulations in the US.
Uses 28 or 32-G catheters for 22
or 26-G spinal needles.
Risks include development of
cauda Equina Syndrome,
hypotension and nerve injury.

26. Epidural AnalgesiaIntermittentBolus
•Analgesia is
reestablished with
bolus injection of 8
to 12 ml of LA/Opioid
solution.
•Pain relief is
constantly
interrupted by
regression of
analgesia.
•The spread and
quality of analgesia
may change with
repeated lumbar
epidural injections.
Continuousinfusion
•Prolonged infusion
might lead to
Significant motor
blockade. Therefore
dose requires
titration.
•Strict monitoring is
required as migration
of catheter into
subarachnoid,
subdural or
intravenous space
are likely to go
unnoticed.
PatientcontrolledEpidural
Analgesia
•May be utilized with or
without an ongoing
background infusion rate.
•A meta-analysis of five studies
reported in the ASA Practice
Guidelines for Obstetric
Anesthesia concluded that a
background infusion provides
better analgesia than pure
PCEA without a background
infusion.
•There is no evidence that the
higher local anesthetic dose
associated with a background
infusion increases motor
blockade or has adverse
effects on obstetric outcome
when low-concentration
infusion solutions are used.
Common Applications

27. Suggested infusion rates for Epidural analgesia
Intermittent bolus injections
• 5 to 10 ml of Bupivacaine (0.125%-0.375%) every 1 to two
hours
Continuous infusion
• Bupivacaine 0.0625%-0.25%,8 -15 ml/hr
• Ropivacaine: 0.125%-0.25%, 6 -12 ml/hr
• Fentanyl 1-2 µg/ml
• Sufentanyl 0.2-0.5µg/ml
Epidural opioids

28. Ambulatory Neuraxial
Analgesia “Walking epidural”
Applied to any
neuraxial analgesic
technique that allows
safe ambulation. It
was first coined to
describe low-dose
CSE opioid analgesia
because motor
function was
maintained and the
ability to walk was
not impaired.

29. •Faster onset with intense analgesia.
•Additional flexibility due to presence
of epidural.
•Very low failure rate.
•Minimal motor block if only opioid
used for spinal.
•Less need for supplemental boluses.
Combined spinal Epidural
Needle through needle Back eye

30. Causes of inadequate epidural analgesia
Catheter
migration
Inadequate
dose
Blocked
catheter
Subdural
placement
Uterine
Rupture
Second stage
of labor

31. Complications of Epidural analgesia
Hypotension
Inadequate analgesia
Extensive motor blockade
Respiratory depression
Faulty placement
Back pain

32. How to avoid epidural disasters
• Maintain constant verbal contact.
• Nurse in lateral position as much as possible.
• Assure continuous maternal and fetal monitoring throughout
placing and handling epidural infusions.
• Always aspirate before each injection.
• Treat every injection as a test dose.
• Always observe for passive return through the catheter.
• Do not inject more than 4 ml of LA at a time.
• If in doubts, repeat test dose. Still in doubts? Replace it
• After all, be mentally prepare to treat :
1. Convulsions
2. Total spinal
3. Cardiovascular collapse and arrest