This document discusses labour analgesia, or pain relief during childbirth, in India. It notes that while childbirth should be a joyous experience, it is also associated with pain, fear, and anxiety for many women. The document summarizes studies finding high levels of pain during childbirth in India and low awareness of pain relief options. It then reviews current practices of labour analgesia amongst healthcare providers in India. The document identifies gaps in knowledge amongst providers and awareness amongst women and families. It outlines various pharmacological and non-pharmacological methods for pain relief during labour. Finally, it proposes ways to address these issues such as educating providers and women, integrating midwifery care, and increasing access to pain relief in

1. Labour Analgesia: An unmet
right of labouring women in
India
Manju Puri
Director Professor & Ex HOD
Department of Obstetrics & Gynaecology
Lady Hardinge Medical College
New Delhi

2. Introduction
• The experience of childbirth is a subjective and multidimensional issue, and each
woman passes through it in a different way.
• It is one of the most beautiful episodes in a mother’s life, associated with joy,
happiness, and celebration.
• However, a childbirth is also related to negative emotions: fear, anxiety, low sense
of security, and the expectation of pain which is defined as ‘an unpleasant
sensory and emotional experience associated with actual or potential tissue
damage’ 1, 2
• Because of their anxiety women prefer a caesarean section rather than a natural
birth 3
Karksdottir SI etal Sex Reprod. Healthc. 2015,
Niven C et al Soc. Sci. Med. 1984
Sercekus P et al Midwifery 2009

5. • Women in this study described having pain of varying intensities in
waist area, vagina and back
• They express pain by shouting , crying and screaming
• Some prayed to God to help reduce severe pain
• Others cried inwardly
• Some felt lonely and some talked about bad behaviour of health
professionals

6. • Of the 256 women included in the study 89.8% had no idea 10.25%
had some idea of pain relief measures in labour
• 38.9% had severe pain, 58.9% had moderate pain and 2.7% mild pain
in their pervious delivery

7. Practice of labour analgesia amongst
anaesthesiologists across India
Survey was carried out using SurveyMonkey, an online internet website
Questionnaires were sent by mail to 11,986 anesthesiologists.
There were 1351 responses to the survey.
Labor analgesia was practiced mainly by anesthesiologists (71.34%, n = 945)
followed by both (27.27% n=368) and least by obstetricians only (1.39% n=18)
Obstetricians mainly used tramadol 45%, fentanyl 20%, pentazocine 19% whereas
anesthesiologists used epidural analgesia
Most respondents were from corporate hospitals 31.16%, private nursing homes
32.24%, private medical colleges 21.10% and least from Govt medical colleges
12.44% and Govt hospitals 2.96%
Narayanappa A et al Anesth Essays Res 2018

8. Reasons
• Mothers and their families: Lack of awareness of availability, myths
related to use of labour analgesia, social pressure
• Service providers: Lack of resources, skewed HCP to birthing woman
ratio, lack of knowledge of the neurophysiology of labour and
evidence based non pharmacological interventions for reducing pain

9. Adverse consequences of labour pains
• Produce emotional distress and physiological changes
• Hyperventilation with resultant alkalosis and impaired oxygen transfer
to foetus
• Uteroplacental vaso constriction affecting placental perfusion
• Psychological effects in the form of anxiety and dysfunctional labor
• Fear and anxiety resulting in higher CS rates

12. Gap in
knowledge
of Healthcare
providers of
physiology of
labour pain and
effectiveness of
non
pharmacological
methods
Gap in
awareness of
women and
their families
of the
available
methods

13. The Circular Pain Model: Multidimensional
Real and potential injury
First stage Referred pain in
lower abdomen and back
Stretching of cervix , ligaments
muscles etc
Second stage stretching of
pelvic floor and perineum,
pressure on sacral nerve roots Physical
Modulated by pleasant sensation, painful
stimulus at other site or pharmacological
methods
Psychological and Emotional
Call on higher centres,
emotional support, ambience,
relation ship with staff
Woman’s expression of pain
Influenced by cultural,
motivational, social and
cognitive factors
Marchand S IASP 2015

14. Non pharmacological Pharmacological
Gate control theory techniques (nonpainful stimulus of painful site)
Water immersion/shower
Warm/cold pack
Gentle massage
Mobility and positions
Opiates
DNIC techniques (painful stimulation during a painful contraction)
Acupuncture/acupressure
Sterile water injections
Ice packs
Painful TENS
Inhalational
Central nervous system control (CNSC) techniques
Yoga
Relaxation and visualization
Breathing
Hypnosis, self hypnosis, Hypnotherapy
Aroma therapy
Music
Prenatal education
Regional
Pharmacological and Nonpharmacological methods of
Labour Analgesia

17. • Ensure that Health care providers are
familiar with the neurophysiological and
hormonal mechanisms and related
methods in physiological labour and
birth (III-A)
• Help women cope with normal labour
by use of non pharmacological
approaches as a safe first line method
of pain relief and continued whether or
not pharmacologic method is used (I-A)
HCP should promote and support
physiological progress of labour, delivery
and Postpartum period (III-A)

18. • Address the emotional component of pain
with support and nonpharmacological
approach to prevent suffering (I-A)
• HCP should reduce a woman’s stress level by
encouraging her and having a positive
attitude and creating a calm, stress free
environment (I-A)
Continuous labour support as part of
nonpharmacological approaches to pain
management during child birth for women
should be promoted and provided for all
women in labour (I-A)

19. Antenatal preparedness
HCP should encourage parents and the people
assisting them to prepare for the birth by
learning about birth physiology and gaining
skills in working with pain (III-A)

20. In labour
• Provide continuous support
to mother during child birth
and allow a birth companion
• Allow her to move around
and adopt any posture that
provides her relief from pain

21. Advantages of nonpharmacological methods
For women who birth without medical interventions, there may be many
benefits, including:
• Less pain after birth
• Faster recovery from birth
• Less chance of Caesarean birth
• Increase in self-esteem as a result of the birth
• More bonding with the baby
• A calmer, more settled baby
• Less likelihood of postnatal depression and blues
• Potential for easier breastfeeding

22. Way forward
Integrated Maternal and child health and
Midwifery led units
Integrate with Anaesthesiologists to Build capacity for
provision of pharmacological labour analgesia
Antenatal birth
preparedness classes
Ensure a birth companion and
provide respectful care to
mother in labour

23. To conclude
• There is a huge unmet need for pain relief during labour
• There are gaps in both the supply and demand
• We need to re-educate obstetricians on the importance of non
medicalization of childbirth and effectiveness of nonpharmacological
methods of pain relief
• Introduce midwives to take forward the concept of natural birth
• Have provision for epidural in government set ups
• Sensitize the public on the importance of normal birth and availability of
pain relief measures in labour
• Empower our mothers to birth vaginally and enjoy their motherhood with
a positive birth experience