NURS 409: MCH II

The Labour Pain

Introduction
Labour is an emotional experience and involves both physiological and psychological mechanisms.
Virtually all women in labor experience lower abdominal pain, approximately 74% experience
contraction-related back pain, and approximately 33% experience continuous low back pain.
The general observation is that labor pain increases as cervical dilation increases, labor pain can
be independent of cervical dilation for both nulliparous and multiparous women, and there is
interindividual variability in the location, intensity, and progression of pain during labor.
Physiology of labor Pain (1 hour)
Labour pain has two components: visceral pain which occurs during the early first stage and the
second stage of childbirth, and somatic pain which occurs during the late first stage and the second
stage. The pain of labour in the first stage is mediated by T10 to L1 spinal segments, whereas that in
the second stage is carried by T12 to L1, and S2 to S4 spinal segments. All resulting nerve impulses
(visceral and somatic) pass to dorsal horn cells where they are processed and transmitted to the brain
via the spino-thalamic tract. Transmission to the hypothalamic and limbic systems accounts for the
emotional and autonomic responses associated with pain.
Visceral pain
Visceral labour pain occurs during the early first stage and the second stage of childbirth. With each
uterine contraction, pressure is transmitted to the cervix causing stretching and distension and
activating excitatory nocioceptive afferents. These afferents innervate the endocervix and lower
segment from T10 – L1.
Visceral pain is transmitted by small unmyelinated ‘C’ fibres which travel with sympathetic fibres and
pass through the uterine, cervical and hypogastric nerve plexuses into the main sympathetic chain.
The pain fibres from the sympathetic chain enter the white rami communicantes associated with T10
to L1 spinal nerves and pass via their posterior nerve roots to synapse in the dorsal horn of the spinal
cord. Some fibres cross over at the level of the dorsal horn with extensive rostral and caudal extension
resulting in poorly localised pain. Chemical mediators involved include bradykinin, leukotrienes,
prostaglandins, serotonin, substance P and lactic acid.
The pain of early labour is referred to T10-T12 dermatomes such that pain is felt in the lower
abdomen, sacrum and back. This pain is dull in character and is not always sensitive to opioid drugs;
the response to opioids depends on the route of administration.
Somatic pain
This occurs in addition to the visceral pain described above, in the late first stage of labour and also in
the second stage. It arises due to afferents that innervate the vaginal surface of the cervix, perineum
and vagina and occurs as a result of stretching, distension, ischaemia and injury (tearing or iatrogenic)
of the pelvic floor, perineum and vagina. It manifests during descent of the foetus and during this
active stage, the uterus contracts more intensely in a rhythmic and regular manner.
Somatic pain is transmitted by fine, myelinated rapidly transmitting ‘A delta’ fibres. Transmission
occurs via the pudendal nerves and perineal branches of the posterior cutaneous nerve of the thigh to
S2 - S4 nerve roots. Somatic fibres from the cutaneous branches of the ilioinguinal and genitofemoral
nerves also carry afferent fibres to L1 and L2.

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Somatic pain occurs closer to delivery, is sharp in character and easily localised to the vagina, rectum
and perineum. It radiates to the adjacent dermatomes T10 and L1 and compared to visceral pain, is
more resistant to opioid drugs.
Excitation and inhibition of labour pain
Naturally, substance P is a neurotransmitter that is released at some of the synapses when there is a
pain impulses. It facilitate information about pain, which is transmitted to the higher centre. In
contrast, endorphins and enckephalins helps to modulate the transmission of pain perception. They are
opiate like peptides/neuropeptides produced in the neural synapse at various points in the CNS
pathways. Endophins are found in the limbic system, hypothalamus, and reticular formation. They
binds to presynaptic membrane and inhibits the release of substance P.
The gate-control theory also shows that neural or spinal gating mechanism occurs in the substantia
gelatinosa of the dorsal of the dorsal horns of the spinal cord. If the gate is closed nerve impulses from
the noci receptors are blocked from reaching the medulla, the thalamus, and sensory cortex.

Pharmacological and non-pharmacological Pain management during labor (3 hours)

The level of pain experienced by women in labour varies considerably and is influenced by previous
experience, socio-demography, and genetic differences, antenatal preparation, length of labour and
strength of contractions. Emotions such as fear and anxiety often occur with labour pain, thereby
affecting the mother’s perception of labour pain. Because the experience of pain is related to the
mental state of the patient, a lot of time is invested in antenatal classes to ensure adequate knowledge
of the process of labour, thereby decreasing the stress of the unknown. There are various methods of
pain management in labour.
Non-pharmacological approaches.
There are many accepted nonpharmacological methods of relieving labour pain, some deriving from
long usage and others from more recent understanding of pain and its perception.
Massage - including aromatherapy
Massage, especially to the lower back, may work by the same principle as TENS (transcutaneous
electrical nerve stimulation) with incoming nerve impulses modifying transmission along pain fibres.
Massage may also relieve 'stress'. The 'stress' hormones (adrenaline (epinephrine) and noradrenaline
(norepinephrine)) are thought to interfere with the coordination of uterine contractions and so
relaxation techniques may enhance the progress of labour. Aromatherapy may work in a similar way
and the use of lavender oil has found favour with some mothers.
Acupuncture and acupressure
Acupuncture may also have a role, with use of specific points to provide pain relief and possible
additional electrical current to augment these analgesic effects. Acupressure, where the fingers are
used to press over the acupuncture point, may be easier to apply in labour and does not restrict
mobility.
Mobilization
Labouring women, if left unrestricted, adopt a wide variety of positions. Sitting, standing and walking
may all be used during labour. Patients with low back pain often adopt a forward leaning position that
may relieve pressure on the sacroiliac joint. Control of breathing patterns is widely taught in antenatal

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classes - this may work by diverting the mind away from the pain but is also a technique used to
relieve stress.
Hydrotherapy
Many women already know the soothing effect of warm water on the uterine cramping pain
experienced during menstruation. In the past, obstetric care tended to confine labouring women to bed
but with greater freedom many select a warm bath or shower during the first stage of labour. The
mode of action of any analgesic effect is unclear but over the centuries hydrotherapy has been used
for many painful conditions so the expectation of a soothing effect may be its main method of action.
In the mid1950s abdominal decompression found a role in labouring women and immersion in water
may be found to act similarly by relieving external pressures on the uterus and allowing it to assume a
more rounded position.
Transcutaneous electrical nerve stimulation (TENS)
TENS uses the gate theory of pain control and, by application of an electrical current to the nerves
carrying the painful stimuli, transmission of pain is partially blocked. Skin surface electrodes are used
to apply a low voltage electrical current, which is modified by the patient. These are usually applied
across the lower back covering the T10-L1 nerve roots (the innervation of the uterus) early in the first
stage for optimum effect. Although concern has been expressed about the use of TENS applied over
the lower abdomen as the electrical activity may theoretically have an effect on the fetal heart, no
adverse effect has been documented.
'Audioanalgesia'
Music can reduce stress and enhance other pain-relieving measures. White sound has been used
during contractions and may block external stimuli. Studies of the use of so-called 'audioanalgesia'
have suggested a trend towards decreased use of analgesic medication.
Pharmacological approaches
Inhalational analgesia
This has the benefits of long usage and thus familiarity whilst also being controlled by the patient in
both timing and dose. Entonox is most commonly used and contains a 50: 50 mix of oxygen and
nitrous oxide. This would be expected to have a powerful analgesic effect as a 20% mixture is
equipotent to 15 mg subcutaneous morphine, but in reality it is a poor analgesic. Despite its
widespread use it is the most widely used agent in labouring mothers in the UK - no major side effects
have been noted. An excess may theoretically lead to demyelination and megaloblastic anaemia but
these effects have not been observed. Many women experience light-headedness and nausea, and
hyperventilation may lead to hypocapnia and eventually tetany.
Narcotic analgesia
Pethidine was introduced in 1939 by the Germans who found it to be useful in treatment of war
wounds. By 1950 it was generally accepted and in use by midwives for pain relief in labour.
Unfortunately it is a rather poor analgesic, being associated with a 20% reduction in pain score, but it
has powerful sedative effects on the mother at the expense of nausea and vomiting. In as many as half
of all mothers there is no analgesic effect and, as it acts to delay gastric emptying, it should probably
be used in labour in conjunction with ranitidine.
All opiates have a depressant effect on the neonate. This has led to attempts to develop other opioid
analgesics with better pain-relieving properties and less respiratory depression in the neonate. Though
neonatal respiratory depression is noted it need not limit the use of pethidine, as naloxone will rapidly
reverse the respiratory effects, after delivery.

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Diamorphine is used for its enhanced pain-relieving effect though some mothers experience
considerable nausea and vomiting with it.
Epidural analgesia
This developed from the need for analgesia without neonatal respiratory depression and acts by
affecting the spinal opioid receptors directly. Epidural analgesia has indications besides simple pain
relief during labour:

 pregnancy-induced hypertension to control hypertension which may worsen during labour

(exclude coagulopathy)
 trial of scar - the epidural has not been found to mask the pain of a scar dehiscence but will
give adequate analgesia.
 preterm labour - there may be positive advantages in these cases as epidural analgesia has
been shown to be associated with a reduced neonatal mortality rate among low birthweight
babies
 breech presentation - to ensure a controlled delivery, by preventing the urge to push prior to
full cervical dilatation - a problem in the preterm breech « multiple pregnancy - delivery may
be complicated and the presence of an epidural allows intervention as necessary
 incoordinate uterine activity - pain relief in this situation is associated with improved uterine
action.
Correct placement of the catheter in the epidural space is confirmed by loss of resistance as the
catheter finds the space and the absence of cerebrospinal fluid running from the catheter end.
Confirmation of correct placement is vital before giving the full dose of local anaesthetic down the
catheter or a 'total spinal' (i.e. a high block) may result, with rapidly rising numbness and dyspnoea
which may require ventilation until the effect wears off.
Alternatively, the catheter may be located intravascularly and during the test dose the patient will note
light-headedness and tingling in the lips and fingers. If further anaesthetic is given, convulsions and
cardiac dysrhythmias may ensue, necessitating resuscitation.
Methods of administration
Intermittent doses: These are given as the mother requires, which may be at an approximate hourly
rate. This may mean that pain relief is not complete and the midwife has to check with each dose
whether the mother experiences any side effects. Patients are in bed and immobile.
Continuous infusion: This allows for more smooth pain relief and, if problems arise, a lower dose of
the anaesthetic has been administered. Better analgesia, however, may be at the expense of an
increased instrumental delivery rate or caesarean section and immobilization.
Spinal opioids: By acting on the spinal opioid receptors these enhance the analgesic effect of the
epidural. They are short acting (2-4 hours) with a better analgesic effect in a more even distribution.
They may be associated with pruritus.
Mobile epidural: These developed from the wish to overcome the immobility associated with
standard epidural techniques. The pain-carrying nerve fibres are smaller than the motor nerve fibres
and by giving appropriate anaesthetic mixes it may be possible to achieve blockage of only the
smaller fibres.
Pudendal nerve block
This technique is used in the second stage of labour to obtain analgesia for an instrumental delivery.
It blocks the pudendal nerve (S2, 3, 4) and is usually combined with perineal infiltration to allow

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episiotomy. The pudendal needle is guarded so that it can be advanced into the vagina in the region of
the ischial spine. The needle is then advanced in turn and lidocaine (lignocaine) is introduced around
the nerve. Once both sides are blocked the analgesia achieved should allow outlet forceps but would
not give complete pain relief for a mid-cavity instrumental delivery.
Transition to extra uterine life (2hrs)
The first few moments and hours of extrauterine life are among the most dynamic of any
that occur during the entire life cycle. At birth, the newborn moves from complete dependence
to physiologic independence. Some organs, such as the lungs, make rapid changes that are
fully accomplished within days of birth. Other organ systems, such as the hepatic system, take
longer to convert to extrauterine function. Overall, the transition to extrauterine life is an ongoing
process and part of a continuum that starts with conception and extends through infancy.
The most dramatic and rapid extrauterine transitions that happen immediately after birth occur in
four areas:
The respiratory system,
The circulatory system,
Thermoregulation, and
Glucose metabolism.
These four areas of transition are interdependent—failure of one can lead to impairment of
others, and all must occur successfully for neonatal transition to proceed smoothly. Prenatal and
intapartum events may affect neonatal coping with extrauterine life.
Respiratory Changes
Before birth, the fetus receives oxygen from the maternal circulation via the placenta and
umbilical vein. Lung development progresses through distinct stages during gestation. Type II
epithelial alveolar are sparse cuboidal cells that produceand store surfactant. Surfactant is the
complex phospholipid that lines the alveoli and keeps them partially open during exhalation via
its surface-acting properties.
The primary events that occur in the lung after birth are (1) clearance of alveolar fluid, (2) lung
expansion, and (3) circulatory changes that increase pulmonary perfusion. Prior to labour, the lungs
are full of fluid,which is secreted in Type II alveolar cells into the alveolar space as a secondary
effect of chloride ion secretion. The term fetus begins to experience a decrease in lung fluid in the
days before labor, which in turn reduces the amount of fluid that needs to be cleared during
the neonate’s initial respirations. Clearance of alveolar fluid is facilitated by increased production
and activity of epithelial sodium channels (ENaCs). This facilitate clearance of alveoli fluid. In
addition, fetal plasma levels of catecholamines and cortisol increase and further cause the
reabsorption of lung fluid during labour.
The squeezing of the thorax that occurs in the last minutes of second-stage labor when the fetus is
in the birth canal helps extrude some upper airway fluid, although this effect is small. When the head
is born, mucus drains from the nares and mouth. Many newborns gasp and even cry at this
time. With the first few breaths, room air starts to fill the large airways of the neonate’s trachea
and bronchi.
All of the alveoli expand with air over time. The maximum function of the alveoli occurs in the
presence of adequate surfactant and adequate blood flow through the pulmonary microcirculation.

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Continuation of breathing occurs secondary to central brain stem activity and the actions of
specialized cellswithin the carotid body. In the term newborn, the chemoreceptors in the carotid
body initiate increases in ventilator effort in response to acidosis and hypercapnia, and decreases
in ventilator effort in response to hypocapnia.
Circulatory Changes
The blood flow from the placenta stops with the clamping of the umbilical cord. This action
eliminates the maternal supply of oxygen to the newborn and triggers a subsequent series of
reactions. These reactions are complemented by those occurring in the lungs in response to the
first breath.
Fetal circulation is characterized by three shunts: (1) the foramen ovale, (2) the ductus arteriosus and
(3) the ductus venosus. Because the lungs are a closed, fluidfilled organ, they need minimal blood
flow; therefore, the pulmonary circulation has a high vascular resistance. Oxygenated blood bypasses
the lungs by flowing through the opening between the right and left atria—that is, the foramen ovale
—and then into the descending aorta. In the second shunt, blood in the right ventricle does not
preferentially flow very far into the pulmonary arteries because of the high-pressure pulmonary
vasculature, but rather flows through the ductus arteriosus directly into the descending aorta.
Placental prostaglandin, prostacyclin, and low oxygen tension keep the ductus arteriosus open. The
third fetal shunt, the ductus venosus, connects the umbilical vein to the inferior vena cava, which
allows a portion of fetal blood to bypass the circulation through the liver.
At birth, oxygen tension rises, and placental prostaglandins and prostacyclin no longer enter the
system via the umbilical vein. This causes constriction of the ductus arteriosus. Blood from the
right ventricle is then able to enter the pulmonary circulation, and the oxygenated blood now
routinely passing by the ductus arteriosus also facilitates closure of this shunt. Within 48 hours, the
ductusarteriosus functionally closes.
Clamping the umbilical cord shuts down the low-pressure system that characterizes the fetal–
placental circulatory unit, so that the newborn circulatory system becomes a freestanding, closed
system. The immediate effect of cord-clamping is a rise in systemic vascular resistance (SVR). Most
importantly, this rise occurs at the same time the newborn takes the initial breaths. The oxygen in
those breaths causes the pulmonary vasculature to relax and open.

The pulmonary vasculature resistance (PVR) decreases just as the SVR increases, and this shift in
pressure, in combination with closure of the ductus arteriosus, encourages blood flow into the
pulmonary system. As blood flow increases in the left side of the heart, the foramen ovale closes.
Deoxygenated blood enters the neonatal heart, becomes fully oxygenated in the lungs, and is
distributed to all other body tissues.
The changes in circulation is manifested as increasingly pink color, normal heart rate, and strong
pulses. Although these changes are not anatomically complete for weeks, the functional closureof
the foramen ovale and the ductus arteriosus occurs soon after birth. The change from fetal to
newborn circulation is intimately related to adequate respiratory function and oxygenation.
The Thermoregulatory System
The fetus is surrounded in amniotic fluid that maintains a fairly constant environmental temperature
based on the maternal body temperature. Once the neonate enters the extrauterine world, he must
adapt to changes in the environmental temperatures. The fetal temperature is typically 0.6°C
higher than the maternal temperature. The neonate’s responses to extra uterine temperature
changes during the first few weeks are delayed and place the neonate at risk for cold stress. The

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neonate responds to cold by an increase in metabolic rate, an increase of muscle activity, peripheral
vascular constriction, and metabolism of brown fat. A neutral thermal environment (NTE) decreases
possible complications related to the delayed response to environmental temperature changes.
a) Aneutral thermal environment (NTE) is an environment that maintains body temperature with
minimal metabolic changes and/or oxygen consumption.
b). Brown fat, also referred to as brown adipose tissue or nonshivering thermogenesis, is a highly
dense and vascular adipose tissue that is unique to neonates.

 It is located in the neck,thorax,axillary area,intrascapular areas,and around the adrenal glands

and kidneys.
 Heat is produced by intense lipid metabolic metabolism ofthe brown fat.
 Brown fat reserves are rapidly depleted during periods of cold stress.
 Preterm neonates have limited brown fat.
c) Neonates are at higher risk for thermoregulatory problems related to:
 Higher body surface-area-to-body-mass ratio
 Higher metabolic rate
 Limited and immature thermoregulatory abilities
d) Factors that negatively affect thermoregulation are:
 Decreased subcutaneous fat
 Decreased brown fat in preterm neonates
 Large body surface
 Loss of body heat from convection, radiation, conduction, and/or evaporation
 Convection: Loss of heat from the neonate’s warm body surface to cooler air
currents such as air conditioners or oxygen masks
 Radiation: Transfer of heat from the neonate to cooler objects that are not in direct
contact with the neonate such as cold walls of the isolette or cold equipment near the
neonate
 Conduction: Transfer of heat to cooler surface by direct skin contact such as cold
hands of caregivers or cold equipment
 Evaporation: Loss of heat that occurs when water on the neonate’s skin is converted
to vapors such as during bathing or directly after birth
Cold stress: is a term that describes excessive heat loss that leads to hypothermia and results in the
utilization of compensatory mechanisms to maintain the neonate’s body temperature. Neonates
function at close to maximal capacity and have little reserve to respond to physiological stresses. Cold
stress occurs when there is:
A decrease in environmental temperatures  a decrease in the neonate’s body temperature - an
increase in respiratory rate, heart rate - an increase on oxygen consumption,a depletion of
glucose,and a decrease in surfactant -respiratory distress
Risk Factors: Prematurity, small for gestational age, hypoglycaemia, prolonged resuscitation efforts,
sepsis, neurological, endocrine, or cardiorespiratory problems.
The Metabolic System
Large quantities of glycogen are stored by the fetus during pregnancy in preparation for meeting
energy requirements when transitioning from intrauterine to extrauterine life. Immediately after birth,
the neonate becomes independent of his mother’s metabolism and must balance the amount of insulin
production with glucose availability.

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Hypoglycemia: (blood glucose level under 40 mg/dL in the neonate) is common during this
transitional time, especially in neonates of diabetic mothers.
During intrauterine life, neonates of diabetic mothers produce high levels of insulin in response to the
high levels of circulating maternal glucose. During the first few hours of extrauterine life the
neonate’s insulin level remains higher than normal, leading to hypoglycaemia.
The Hepatic System
The neonate’s liver is immature, but is capable of carbohydrate metabolism and blood coagulation.
Bilirubin conjugation is limited. Coagulation factors II, VII,IX,and X are synthesized in the liver.
Vitamin K influences the activation of these factors. During intrauterine life, the fetus receives
vitamin K from his mother. After birth, the neonate experiences a decrease in vitamin K and is at risk
for delayed clotting and for hemorrhage. Vitamin K is synthesized in the intestinal flora, which is
absent in the newborn. A vitamin K injection is given as a prophylaxis to decrease the risk of bleeding
related to vitamin K deficiency.
The Gastrointestinal System
The neonate’s gastrointestinal system is functionally immature, but rapidly adapts to demands for
growth and development through ingestion, digestion, and absorption of nutrients, as well as
eliminations of waste.
 Gastric capacity for the first few days is approximately 40 to 60 mL and increases to 90 mL
around day 3 or 4.
 Neonates should feed at least every 4 hours,but may need to be fed more frequently as
stomach emptying time is 2 to 4 hours.
 During the first few days,neonates may appear uninterested in feeding,which may be related
to a quiet sleep state.
 The characteristics of stools and stool pattern vary depending on the type, frequency, and
amount of feeding and the age of the neonate
The Immune System
The immune system protects the body from invasion by foreign materials such as bacteria and viruses.
Before rupture of membranes, the fetus lives in the sterile environment of the maternal uterus and
relies on the maternal immune system to protect him from pathogenic organisms. During the
transition from intrauterine to extra uterine life, the neonate begins the process of developing normal
microbial flora and must respond to colonization by potential pathogenic bacteria. The immune
system is complex.
Neonates are at risk for infection related to: Immature defence mechanism, lack of experience with
and exposure to organisms, which leads to a delayed response to antigen, and breakdown of skin and
mucus membranes.
During the transitional period,the neonate’s immune system begins to:
 Develop normal microbial flora of the skin, respiratory tract, and gastrointestinal tract
 Respond to bacterial colonization of potential pathogens
Neonates are first exposed to organisms from the maternal genital tract during the birthing process.