LABOR PAIN

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LABOR PAIN

• Yes, it hurts!!!!

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PAIN

• The pain of uterine contractions is conducted
  through small sensory nerve fibers of the
  paracervical and inferior hypogastric plexuses to
  join the sympathetic nerve chain at L2-L3
• pain of uterine contractions is often referred to
  the area over the upper sacrum and the lower
  lumbar spine.

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PAIN

• Pregnancy appears to reduce anesthetic
  requirements.
• It has been postulated that high progesterone
  levels lead to increased quantities of endogenous
  endorphins, which may increase the maternal
  threshold to pain.

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• Augmentation of labor with oxytocin increases the
  strength of uterine contractions and increases
  the pain.
• The primiparous woman may perceive greater pain
  than the multipara who enters labor with more
  advanced cervical dilatation.

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• Exhaustion, psychologic factors, and protracted
  nausea and vomiting may also increase the
  parturient's perception of labor pain.

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GIVE me a Shot!!

• Narcotics
• newborn side effect is respiratory depression
• maternal side effects
• respiratory depression
• nausea
• vomiting
• hypotension
• obtundation of protective reflexes
• decreased gastrointestinal motility

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Systemic Narcotics

• Demerol(meperidine)
• Morphine (10xs as strong as demerol)
  rarely used!!
• Fentanyl (100xs as strong as morphine)
  short acting, rapid onset
• Nubain
• Stadol -great for first stage

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benzodiazepine

• Valium
• Versed
• Both cross placenta - if used have narcan
  ready!!!

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• Hydroxyzine (Vistaril)phenothiazine Maternal
  sedation is achieved without significant maternal
  or newborn side effects. Hydroxyzine is
  considered an effective tranquilizer that may
  potentiate the effects of narcotics.

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Neonatal Effects

• The neonatal effects of these agents include
• CNS depression
• respiratory depression
• impaired early breast-feeding
• altered neuroadaptive behavior
• decreased ability to regulate body temperature

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Local analgesia

• May get to fetus!!
• Lidocaine
• chloroprocaine

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Too much lidocaine

• a relaxed feeling
• drowsiness
• lightheadedness
• tinnitus
• circumoral paresthesias
• metallic taste

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Cond

• slurred speech
• blurred vision
• unconsciousness
• convulsions
• cardiac dysrhythmias
• arrest

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pudendal block

• Provides analgesia of the vaginal introitus and
  perineum.
• Because the elapsed time between administration
  and delivery is short, there is relatively little
  systemic absorption and therefore little
  opportunity for the drug to directly affect the
  fetus

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Paracervical block

• Rarely used
• associated with fetal acidosis bradycardia

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Lumbar Epidural Analgesia

• L4-L5, L3-L4, or L2-L3 interspace.
• 17 or 18 gauge needle
• catheter is thread cephalad for 2-3cms
• fentanyl bupivacaine

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Epidural Labor

• ?Prolonged 2nd stage
• Not suppose to affect uterine contractions if
  used after 5cm of dilation

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Epidural Advantages

• The parturient remains awake and cooperative
• The incidence of complications is very low when
  the technique is used correctly
• The epidural technique can be used to provide
  analgesia or anesthesia for a vaginal delivery or
  a cesarean section delivery.

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Epidural Disadvantages

• possibility of poor perineal analgesia
• the presence of "hot spots" where analgesia is
  insufficient
• delayed onset of action
• technical difficulty
• intravascular injection
• accidental dural puncture
• hypotension

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Spinal Headache

• From decrease in CSF or blood loss from delivery
  normal postpartum diuresis
• Bed rest
• Blood patch!!

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• Hypnosis
• Acupuncture
• TENS unit