PAIN OF PARTURITION

1st STAGE

Visceral distention originating from rhythmic uterine

contractions and progressive cervical dilatation causes much
of the pain experienced during the first stage of labor

Afferent impulses are transmitted to the spinal cord via

segments T10-L1.

2nd STAGE

Pain is usually more intense.

Somatic in nature and is transmitted through the spinal S2-
4 segments.
Scull, et. Al (1998):

The metabolic stress response to the pain of labour

(plasma beta-endorphin and cortisol concentrations)

was attenuated by epidural analgesia. In contrast, plasma

oxytocin concentration and frequency of uterine
contractions were unaffected by the attenuation of
metabolic stress response.

Scull, Timothy J., MBBS; Hemmings, Gisle T., MD; Carli, Franco, MD MPHIL; Weeks,
Sally K., MBBS; Mazza, Louise, BSc; Zingg, Hans H., PhD*: Epidural analgesia in early
labor blocks the stress response but uterine contractions remain unchanged: Report of
Investigation Can Journal of Anesth, July 1998, vol. 45, number 7
Advantages of Epidural Analgesia

Provides superior pain relief during first and

second stages of labor

Facilitates patient cooperation during labor and

delivery

Provides anesthesia for episiotomy or forceps

delivery

Allows extension of anesthesia for cesarean

delivery

Avoids opioid-induced maternal and neonatal

respiratory depression
Preliminary Considerations

The American Society of Anesthesiologists

Provided only by practitioners with appropriate privileges

Sources of oxygen and suction
Equipment to maintain an airway and perform endotracheal
intubation
A means of providing positive pressure ventilation
Drugs and equipment for cardiopulmonary resuscitation.
Regional anesthesia not be given before the patient has been
examined and the maternal and fetal status and progress of
labor have been evaluated by a physician with obstetric
privileges.
Timing Considerations
3 cm of cervical dilation
It is appropriate to induce epidural analgesia after the
diagnosis of active labor has been established and the
patient has begun to request pain relief.
Women receiving augmentation of labor with oxytocin may
request analgesia at minimal cervical dilation.

Epidural analgesia should not be instituted

until the diagnosis of labor has been
established and the patient is requesting
pain relief.
Contraindications to Epidural
Analgesia

Patient refusal

Active maternal hemorrhage

Maternal septicemia or untreated febrile illness

Infection at or near needle insertion site

Maternal coagulopathy (inherited or acquired)

Complications of Epidural Analgesia

Immediate

Hypotension (systolic blood pressure <100 mm Hg or a

decrease of 25 percent below preblock average)
Urinary retention
Local anestheticinduced convulsions*
Local anestheticinduced cardiac arrest*

Delayed

Postdural puncture headache

Transient backache
Epidural abscess or meningitis*
Permanent neurologic deficit*

*very rare
The two most common complications of
epidural analgesia are maternal hypotension
and postdural puncture headache
(inadvertent dural puncture).
The American College of Obstetricians and
Gynecologists and the American Society of
Anesthesiologists

"maternal request is sufficient justification for

pain relief during labor

"there is no other circumstance where it is

considered acceptable for a person to experience
severe pain, amenable to safe intervention, while
under a physician's care
Sharma et. al. (1997):

Labor epidural analgesia in women at full term with

uncomplicated pregnancies and in spontaneous active labor
is not associated with increased numbers of cesarean
delivery.

Sharma, Shiv K., M.D., F.R.C.A.*; Sidawi, J. Elaine, M.D.*; Ramin, Susan M., M.D.; Lucas,
Michael J., M.D.; Leveno, Kenneth J., M.D.; Cunningham, F. Gary, M.D. Cesarean Delivery: A
Randomized Trial of Epidural versus Patient-controlled Meperidine Analgesia during Labor ,
Anesthesiology, Sept 1997, vol. 87, number 3
Cochrane Review
Effects of Discontinuing Epidurals in Late Labor

Based on three good studies of 462 patients,

discontinuing epidural analgesia in the second
stage of labor does not significantly change rates
of instrumented delivery or cesarean delivery,
duration of the second stage of labor, low Apgar
scores, or fetal malposition at delivery. The only
statistically significant difference was an increased
rate of inadequate pain relief during the second
stage of labor.
Controversial Issues
Crossover between treatment groups,
Inadequate sample size
Inappropriate statistical analysis have led many
clinicians and academicians to question the results of
these trials.
Randomized and blinded trials cannot be easily
performed, because it is ethically unacceptable to assign
women to either receive or not receive labor analgesia
against their wishes
The actual dose of local anesthetic given to each patient
was not standardized

Segal, B. Scott, MD*; Birnbach, David J., MD:

Epidurals and Cesarean Deliveries: A New Look at an Old Problem EDITORIAL, Anesth and
Analg, April 2000, vol. 90, number 4.