SECOND EDITION OF THE ALARM INTERNATIONAL PROGRAM SYLLABUS

CHAPTER 12
ANALGESIA FOR LABOR

12.0.1 Support Measures in Labor
Physiological discomforts will accentuate labor pain and need to be relieved. Maintenance of mobility and
frequent position changes are helpful. Fear and anxiety are major contributors to pain and should be dealt with
taking into account unique personality and cultural factors. Some comfort measures include
!ncourage and facilitate position changes and mobility
"educe fear and anxiety
Facilitate appropriate rest
Provide a labor companion
Companion Support in Labor
#he presence of a labor companion to provide physical contact and encouragement to the mother$ has been shown
to reduce the length of labor and decrease the use of analgesia and the need for labor interventions. %ther studies
have addressed the effect of the continuous presence of a professional care provider.
Non-Pharmacological Pain Relief
&t must be recogni'ed that non(pharmacological pain relief varies from country to country. #he wishes of the
patient must be determined to ensure the most comfortable birthing experience.
Pharmacologic Methods - Sstemic
Sedatives and tranquili'ers were used regularly in the past but now are used primarily in small doses in early labor
only.
Narcotics
)arcotics are used routinely in many centres. #he agent used is dependent primarily on the caregiver*s preference.
)arcotics may be given intramuscularly or by repetitive intravenous boluses. #he intravenous route has the
advantage of a rapid effect when needed. )arcotics may be usefully combined with an antiemetic.

)arcotics may cause decreased fetal heart rate variability and neonatal respiratory depression. "espiratory
depression in the newborn may be easily treated with repeated doses of naloxone.
12.0.2 Peripheral Ner!e "loc#s
Pudendal Ner!e "loc#
#hese are used for analgesia of the perineum in the second stage of labor. #his form of analgesia can be very
useful and should be considered when other regional analgesia is not available. +ocal anesthesia with epinephrine
allows administration of larger volumes with greater effectiveness and limits systemic levels in the mother and
transfer to the fetus.
ALARM INTERNATIONAL , Chapter 12 - Analgesia for Labor ,
Learning Objectives:
"ecogni'e the role of non pharmacological pain relief in labor
+ist available pharmacological methods of pain relief
-escribe the proper techniques used in pain relief labor
130
SECOND EDITION OF THE ALARM INTERNATIONAL PROGRAM SYLLABUS
Perineal $nfiltration
.enerous and widespread infiltration should be used. /se of an agent with epinephrine is helpful. 0are should be
taken not to inject intravascularly and the toxic dose of the agent being used must be known.
Regional %naesthesia
12.0.& Summar'
#he type of pain relief should always be individuali'ed after a complete discussion with the pregnant woman.
1omen should enter the labor process fully appraised of all available pain relief options.
ALARM INTERNATIONAL , Chapter 12 - Analgesia for Labor , 131
(pidural "loc#
!pidural block can provide effective pain relief throughout all stages of labor and delivery.
!pidural anaesthesia has been reported in some studies to have a negative effect on the progress of labor and to increase
operative delivery rates. 0o(founders such as a large number of nulliparous women who experienced prolonged labors or
malposition of the fetal head bias these studies.
#he hormonal response to pain includes a rise in endogenous catecholamines. #he effective relief of pain lowers epinephrine
concentrations resulting in improved uterine contractions and possibly improved placental perfusion.
2 particular benefit of epidural analgesia exists for women with dystocia of labor due to hypotonic contractions whose labor
will require augmentation. Provision at this point of more effective pain relief is truly humane and permits augmentation and
subsequent vaginal delivery.
3igh dose motor block epidurals may lead to prolongation of second stage. #his may be due to the blockage of the natural
increase in oxytocin that occurs in the second stage of labor. %xytocin augmentation may be necessary if contractions are too
infrequent or ineffective. Paralysis of the pelvic floor musculature may result in persistent fetal head malposition. 41alking5
and low dose epidurals lead to less motor blockade and therefore less head malposition and a shorter second stage.
-iscontinuing an epidural in the second stage to allow effective pushing is disadvantageous. #he sudden return of pain is
often worse than if there hadn*t been relief provided at all. #he woman may be so distracted and distressed by pain that she
cannot push effectively.
)acts about (pidurals
!pidurals effectively relieve pain
First stage progress is unaltered or enhanced
3igh motor block epidurals prolong the second stage progress
Second stage management may be altered to ameliorate epidural effect
delayed pushing
extending time limits for second stage
placental blood flow and fetal well(being are preserved or enhanced
(pidurals and the Second Stage
Management %ptions
-on*t stop the epidural
2void early intervention with operative delivery
0ontinue the epidural and allow more time
0ontinue the epidural and use oxytocin
SECOND EDITION OF THE ALARM INTERNATIONAL PROGRAM SYLLABUS
ALARM INTERNATIONAL , Chapter 12 - Analgesia for Labor , 132