Painless Labor

Painless Labordr. Pangkuwidjaja, Sp. AnThe Pain of Childbirth there is no other circumstance where it is considered acceptable for a person to experience severe pain, amenable to safe intervention, while under a physicians care

(ASA & ACOG)

The pain of childbirthVaries Type Location Stage of Labor

More Severe Abnormal position A history of severe dysmenorrhea Young maternal age Increased maternal / fetal weight The presence of the infants father during labor

The pain of childbirth Mechanisms

Visceral componentLower uterine segmentcervixduring uterine contraction distention, stretching by fetal presenting part ischemiaAfferent pathwayaccompany sympathetic nervesparacervicalinferior hypogastric plexuslumbar sympathetic chainT10 L1Occurs in the first stage of laborThe pain of childbirth Mechanisms

Somatic componentpelvic floorvaginaperineum

Afferent pathwaypudendal nervesacral nerves S2, S3, and S4 uncontrollable reflux to have valsava maneuver to bear down and push

Occurs late in the first stage (6 8 cm) persist throughout the second stage

Effect of Labor Pain on Maternal PhysiologyRespiratory system

Hyperventilationas pain becomes severe minute ventilationfirst stage75 150%second stage 150 300%

Oxygen consumptionincreases above pre-labor valuefirst stage40%second stage75%Effect of Labor Pain on Maternal PhysiologyRespiratory system

Hyperventilation fetal hypoxemia during maternal hyperventilationuteroplacental & fetoplacental vasoconstrictionleft-shift of the maternal oxyhemoglobin dissociation curve

maternal hypocarbia & alkalemiahypoventilation between contractionmaternal & fetal hypoxemia

Effect of Labor Pain on Maternal PhysiologyAdrenergic response

PainStress maternal plasma concentration of catecholaminesAnxiety

uterine activityprolonged labor incidence of abnormal FHR patternsAnalgesia/Anesthesia methodsNon-pharmacologic analgesiaSimple techniques of pharmacologic analgesiaInhalational analgesia and anesthesiaRegional analgesia and anesthesiaNon-pharmacologic analgesia Natural childbirth Physiotherapeutic and psychophysiologic Psycho-prophylactic method fear-tension-pain syndrome (Dick-Read) Conditional reflex labor pain (velvovsky) anxiety + anatomy, physiology (Lamaze)

Hypnosis Acupuncture TENS gate-control theory of painSimple techniques of pharmacologic analgesia Mild pain during the early first stagesuggestionsedativestranquilizer Moderate-severe pain during the active phase of laboropioidsnot complete relief (70-80%)neonatal depressionInhalational Analgesia and AnesthesiaProduce moderately effective pain relief, without causing:loss of consciousnesssignificant maternal or neonatal depression

N2O 40 50% in O2Entonoxintermittently during uterine contractionsshould begin 10 -15 seconds before the painful period of each contraction

Inhalational anesthesiaAnalgesic concentrationmaximum control of depth and duration of actionrapidly eliminated at the end of the procedureRegional Analgesia and AnesthesiaProduce complete relief of painObviates the pain-induced deleterious reflex responsesProduce block of nociceptive fibers (A- and C)Use of dilute local anesthetic solutionsminimal or no effect on the larger somatomotor and tactile fibersThe risk of pulmonary aspiration of gastric contentsPermits the mother remains awake and alertexperienceparticipatingNo maternal or neonatal depressionNo clinical significant effect on the progress of laborCan be modified for SCRegional Analgesia and AnesthesiaRequires greater knowledge of anatomyRequires greater technical skilltechnical failuresVasomotor blockPremature perineal muscle relaxationinterfere with the mechanism of internal rotation incidence of occipitoposterior or occipitotransverse positionsProduce perineal analgesiaLoss of afferent limb of the reflex urge to bear downprolong labor or require the use of outlet forcepsRelatively contraindicated in coagulopathy patientOnly in hospital

the delivery of the infant into the arms of a conscious and pain free mother is one of the most exciting and rewarding moment in medicine