INTRAPARTUM PAIN

MANAGEMENT
Overview of Pain
• Intrapartum pain is a subjective experience of physical sensation
associated with uterine contractions, cervical dilation and
effacement, and fetal descent during labor and birth.
• Physiologic responses to pain may include increased blood pressure,
pulse, respiration, pupil diameter, muscle tension (such as facial
tension or fisted hands) or muscle activity ( such as pacing, turning
or twisting).
• Nonverbal expressions of pain may include withdrawal, hostility,
fear or depression.
• Verbal expressions of pain may include statements of pain, moaning
and groaning.
Sources of intrapartum pain
Uterine contractions
Dilation
Distention
Pressure on adjacent organs
Tension
• The two goals of intrapartum pain management are:
1. Provide maximum relief of pain with maximal safety for mother and fetus.
2. To facilitate labor and delivery as a positive family experience.
• Pain relief may be achieved by using prepared childbirth methods (such as
Lamaze, analgesics or regional anesthetics).
• Intervention for pain relief during labor depends on the following factors:
a. Gestational age of the fetus
b. Frequency, duration and intensity of the contractions
c. Labor progress
d. Maternal response to pain and labor
e. Allergies and sensitivities to analgesics and anesthetics
Nonpharmacologic Pain Management
Relaxation techniques
Positioning
Focusing and imagery
Therapeutic touch and massage
Music therapy
Birthing partner or coach
Breathing techniques
Heat and cold application
Counterpressure
TENS
Hypnosis
Acupuncture and acupressure
Yoga
Pharmacologic Pain Relief
1. Narcotic analgesics
2. Barbiturates
3. Tranquilizers
4. Regional anesthesia
5. General anesthesia
Narcotic analgesics
a. Narcotic analgesic are systemic drugs that readily cross the placental barrier, with
depressive effects on the neonate occurring 2 to 3 hours after intramuscular
injection.
b. Maternal side effects include nausea, vomiting, mild respiratory depression, and
transient mental impairment.
c. Fetal effects are reduced fetal heart rate and decreased variability; neonatal
effects are lowered APGAR score and respiratory depression.
d. Opioid antagonists such as naloxone(Narcan) must be readily available in case of
respiratory depression in the mother or newborn.
e. The decision to administer a narcotic analgesic is based on the results of a vaginal
examination; if birth is anticipated within 2 to 3 hours, the risk of neonatal
narcosis my preclude the use of analgesics.
f. The dosage is kept to the smallest effective dose.
Opioid analgesics
• Meperidine (Demerol)
• Morphine
• Fentanyl
These drugs do not eliminate pain. They decrease the perception of pain and allow for rest and
relaxation between contractions.
Category of frugs most commonly administered parenterally during labor. It should be given
only after a labor pattern Is established.
Opioids may be administered every 2- 3 hours by the IV or IM routes. Give IV slowly during a
contraction to decrease the transfer of the medication to the fetus.
These drugs may decrease the frequency and duration of uterine contractions and may result in
decreased fetal heart rate variability.
In the newborn, respiratory depression and decreased muscle tone amy occur and last for
several days.
Barbiturates
a. These drugs cause maternal sedation and relaxation.
b. Maternal side effects of barbiturates include nausea, vomiting,
hypotension, restlessness and vertigo.
c. Neonatal side effects include CNS depression, prolonged
drowsiness, and delayed establishment of feeding(poor sucking
reflex)
d. The rapid transfer of barbiturates across the placental barrier and
the lack of an antagonist to counteract their effects make them
generally inappropriate during active labor.
Barbiturates
• Secobarbital sodium(Seconal)
• Pentobarbital(Nembutal)
These drugs do not relieve pain. They are used to induce sleep,
decrease anxiety, allow for rest and inhibit uterine contractions.
Sedatives should be given in early labor, when the birth is unlikely
to occur within 12- to 24 hours.
Sedatives may be given orally or by IM.
These drugs may have an effect on neonatal CNS, causing decreased
responsiveness and ability to suck.
Tranquilizers
a. These drugs decrease the anxiety and apprehension associated
with pain and sometimes relieve the nausea associated with
narcotic analgesics.
b. Tranquilizers potentiate active sedative and analgesic effects,
decreasing the dosage of analgesic and sedative drugs needed to
produce the desired effects.
c. Maternal side effects: hypotension, drowsiness and dizziness.
d. Fetal effects: tachycardia and the loss of normal beat-to beat
variability on electronic fetal heart monitoring.
e. Newborn effects: hypotonia, hypothermia, generalized drowsiness
and a reluctance to feed for the 1st few days.
Regional anesthesia
Types of regional anesthesia spinal, epidural, paracervical and
pudendal blocks, and local infiltration.
These blocks provide pain relief with injected anesthetic agents at
sensory nerve pathways.
Adverse reactions may include maternal hypotension, allergic or toxic
reaction, respiratory paralysis, and partial or total anesthetic failure.
Nursing responsibilities during administration of regional anesthesia
include: assisting the anesthesiologist as requested, establishing a
reliable intravenous line, being prepared with medications and
equipment for emergency situations if they arise.
General anesthesia
• General anesthesia, inhalant such as nitrous oxide and halothane
and intravenous such as Pentothal is used during childbirth only if
an emergency cesarean birth becomes necessary.
Anesthetics used in labor and birth
• Type: Lumbar epidural block
• Drug : Local anesthetic –Bupivacaine and Ropivacaine
• Usual dose and route: administer for 1st stage of labor; with continuous block,
anesthesia will last through delivery, injected at L3-4, fentanyl or morphine
possibly added
• Effect on the mother: rapid onset(in minutes); lasting 60-90 minutes; loss of pain
perception for labor contractions and delivery; possible maternal hypotension
• Effect on labor progress: slowing of labor if given early; pushing feeling
obliterated, resulting in possible prolonged 2nd stage
• Effect on fetus or newborn: may be some differences in response in 1st few days
of life
• Type: Pudendal block
• Drug: Local anesthetic- Lidocaine(Xylocaine)
• Usual dose and route: administer just before delivery for perineal
anesthesia; injected through the vagina
• Effect on the mother: rapid anesthesia of perineum
• Effect on labor progress: none apparent
• Effect on fetus or newborn: none apparent
• Type: Local infiltration of perineum
• Drug: Local anesthetic- Lidocaine(Xylocaine)
• Usual dose and route: injected just before the episiotomy incision
• Effect on mother: anesthesia of perineum almost immediate
• Effect on labor progress and fetus: none apparent
• Type: General intravenous anesthetic
• Drug: Thiopental
• Usual dose and route: administered IV by anesthesiologist or nurse-
anesthetist
• Effect on mother: rapid anesthesia; also rapid recovery
• Effect on labor progress: forceps required because abdominal
pushing is no longer possible
• Effect on fetus or newborn: results in infant being born with CNS
depression