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Women's Health and Education Center (WHEC)

Pain Management During Labor and Delivery

List of Articles

  • Obstetric Anesthesia: Complications and Management
    During pregnancy, there are major alterations in nearly every maternal organ system. These changes are initiated by hormones secreted by the corpus luteum and placenta. The mechanical effects of the enlarging uterus and compression of surrounding structures play an increasing role in the second and third trimesters. This altered physiologic state had relevant implications for the anesthesiologist caring for the pregnant patient. Any drug that reaches the fetus undergoes metabolism and excretion. Well-conducted obstetric analgesia and anesthesia, in addition to relieving pain and anxiety, may benefit the mother. Placental drug uptake is limited, and there is no evidence to suggest that this organ metabolizes any of the agents commonly used in obstetric anesthesia. The idea that surgical anesthesia, although deemed necessary for the patient, might have detrimental effects on the growth and development of the human fetus has led to a great deal of investigation, both in-vitro and in experimental animals. Because a single exposure to anesthetic agents seems unlikely to result in fetal abnormalities, the selection of agent should be based on specific surgical requirements.

  • Obesity and Anesthesia
    The worldwide prevalence of obesity has increased substantially over the past few decades. Economic, technologic, and life style changes have created an abundance of cheap, high-calorie food coupled with decreased required physical activity. The purpose of this document is to review pathophysiology of obesity and challenges it poses for obstetrical anesthesia. The incidence of maternal obesity and its attendant comorbid conditions (diabetes, cardiovascular disease) continues to increase at an alarming rate, with major public health implications. Obese patients should be counseled before labor, advising them what intrapartum complications to anticipate. This also includes an anesthesia consult, especially to evaluate the airway.

  • Overview of Obstetric Anesthesia Professional Liability
    Nearly in two decades, a review of liability associated with obstetric anesthesia using the American Society of Anesthesiologists (ASA) Closed Claim database found that, although awards to plaintiffs were higher in obstetric claims from the 1970s and 1980s, there were more claims for minor complications in obstetric compared to non-obstetric claims. The most common complications in obstetric claims were newborn death or brain damage (29%) and maternal death (22%). Over the past three decades, there have been numerous changes in the practice of anesthesiology in general and in the practice of obstetric anesthesia specifically. Specifically explored are the contribution of newborn death and brain damage compared to maternal death and brain damage to obstetric anesthesia liability in 1990 or later claims. This review should spur us to examine and change our practices to minimize both patient harm and our liability when we are not at fault. Only closed claim analyses can help us understand the conditions under which fatal and non-fatal injuries lead to litigation.

  • Effects of Regional Analgesia on Labor
    Most women experience significant pain during their first labor that is why obstetricians spend a considerable amount of time counseling women about their pain control options. Epidural analgesia is attractive to both patients and clinicians because it is the most effective pain control method available, are relatively safe, and have only moderate effects on the course of labor. Despite its popularity and safety, epidural analgesia is not without side effects. The most common of which are maternal fever, effects on uterine basal tone and fetal heart rate (FHR) abnormalities. Of the various pharmacologic methods of pain relief during labor and delivery, regional analgesia techniques -- spinal, epidural, and combined spinal epidural -- are the most flexible, effective, and least depressing to the central nervous system, allowing an alert, participating woman and an alert neonate.

  • Epidural Analgesia Failures: The Technique Review
    The goal of epidural analgesia is to provide satisfactory pain control for labor with the lowest dose of analgesic drugs needed to minimize motor blockage and simultaneously reduce the potential side effects of epidural analgesia during the course of labor. Epidural analgesia offers the most effective form of pain relief and is used by most women in the United States. Uterine contractions and cervical dilatation result in visceral pain (T-10 through L-1). As labor progresses, the descent of the fetal head and subsequent pressure on the pelvic floor, vagina, and perineum generate somatic pain transmitted by the pudendal nerve (S2-S4). Ideally, methods of obstetric pain relief will ameliorate both sources of pain in the patient in labor. Patients with a history of back surgery, especially those who have had spinal instrumentation and fusion to correct scoliosis, have increased rates of epidural failure. Fortunately, in patients with a history of back surgery, epidural analgesia is often successful.

  • Pain Relief During Childbirth: A Comprehensive Review
    The methods of pain relief offered to expectant mothers have increased significantly since the first half of the 20th century. It is fortunate that in this era, pain relief during labor and delivery is an accepted part of the birthing process. The first pain-free childbirth using regional anesthesia was reported in July of 1900. Since then, a firm and dedicated commitment of anesthesiologists and professional societies such as the Society of Obstetric Anesthesia and Perinatology (SOAP) in the last century have led to tremendous advances in regional anesthesia. This has led to the availability of safe pain-free delivery to requesting expectant mothers. More than 2 million mothers used epidural analgesia to deliver their babies in the year 2000. Over 70% of pregnant women at Brigham & Women's Hospital, Boston choose epidural analgesia for childbirth. In the United States, national average use of epidural analgesia in the year 1992 was about 51%. The American College of Obstetricians and Gynecologists (ACOG) also believes that "of the various pharmacological methods used for pain relief during labor and delivery, the lumbar epidural block is the most effective and least depressant, allowing for an alert, participating mother."

  • Epidural & Spinal Anesthesia: Understanding the Facts
    Epidural & spinal anesthesia (regional anesthesia) has become more popular recently, because they are well suited to pain management during labor. It offers the most effective form of pain relief and is used by most women in the United States. In obstetric patients, regional analgesia refers to a partial to complete loss of pain sensation below the T8 to T10 level. In addition, a varying degree of motor blockade may be present, depending on the agents used. The spine consists of 33 vertebrae (7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4 fused coccygeal). The vertebral bodies are stabilized by five ligaments that increase in size between the cervical and lumbar vertebrae. In most obstetric patients, the primary indication for epidural analgesia is the patient's desire for pain relief. The American Society of Anesthesiologists (ASA) and the American College of Obstetricians and Gynecologists (ACOG) recommend that third-party payers should not deny reimbursement for regional analgesia and anesthesia because of an absence of other medical indications.

  • Obstetric Anesthesia in High-Risk Situations
    Pregnancy and delivery are considered "high-risk" when accompanied by conditions unfavorable to the well-being of the mother or unborn baby or both. Analgesia management in acute and chronic fetal distress and in maternal complications such as preeclampsia, eclampsia, hypertension, heart disease, renal disease, neurologic disorder, obesity, substance abuse and diabetes are affected by it. The analgesic management of obstetric complications such as placenta previa, cord prolapse, abruptio placentae, prematurity, multiple gestation, and breech presentation may increase the risk to the mother or the fetus. There is less room for error because many of these functions may be compromised before the induction of anesthesia. Significant acidosis is prone to develop in fetuses of diabetic mothers when delivered by cesarean section with spinal anesthesia complicated by even brief maternal hypotension. Because the high-risk pregnant patients may have received a variety of drugs, anesthesiologists must be familiar with potential interactions between these drugs and the anesthetic drugs they plan to administer.

  • Analgesia & Anesthesia
    The terms analgesia and anesthesia are sometimes confused in common usage. Obstetric analgesia is the loss or regulation of pain perception during labor. It may be local and affect only a small area of the body; regional and affect a larger portion; or systemic. Analgesia is achieved by the use of hypnosis (suggestion), systemic medication, regional agents, or inhalation agents. Anesthesia is the total loss of sensory perception, and may include loss of consciousness. It is induced by various agents and techniques. In obstetrics, regional anesthesia is accomplished with local anesthetic techniques (epidural, spinal) and general anesthesia with systemic medication and endotracheal intubation. It is helpful in decreasing maternal and neonatal mortality and morbidity. Labor results in severe pain for many women. Pain management should be provided whenever it is medically indicated. The use of techniques and medications to provide pain relief in obstetrics requires and expert understanding of their effects to ensure the safety of both mother and fetus.

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