Pain Relief in Labour

Question 1

What non-pharmacological techniques help in pain management of labour?

Answer 1

Several things can improve the symptoms without medications:

• Understanding what to expect
• Having good support
• Being in a relaxed environment
• Changing position to stay comfortable
• Controlled breathing
• Water births may help some women
• TENS machines may be useful in the early stages of labour

Question 2

What simple analgesia is offered in labour?

Answer 2

Paracetamol is frequently used in early labour. Codeine may be added for additional effect. NSAIDs are avoided.

Question 3

What is the role of gas and air in labour?

Answer 3

Gas and air contains a mixture of 50% nitrous oxide and 50% oxygen. This is used during contractions for short term pain relief. The woman takes deep breaths using a mouthpiece at the start of a contraction, then stops using it as the contraction eases. It can cause lightheadedness, nausea or sleepiness.

Question 4

What is the role of intramuscular pethidine or diamorphine in labour?

Answer 4

Pethidine and diamorphine are opioid medications, usually given by intramuscular injection. They may help with anxiety and distress. They may cause drowsiness or nausea in the mother, and can cause respiratory depression in the neonate if given too close to birth. The effect on the baby may make the first feed more difficult.

Question 5

What is the role of patient controlled analgesia in labour?

Answer 5

Patients may be offered the option of patient-controlled intravenous remifentanil. This involves the patient pressing a button at the start of a contraction to administer a bolus of this short-acting opiate medication.

Patient-controlled analgesia requires careful monitoring. There needs to be input from an anaesthetist, and facilities in place if adverse events occur. This includes access to naloxone for respiratory depression, and atropine for bradycardia.

Question 6

Briefly describe an epidural

Answer 6

An epidural involves inserting a small tube (catheter) into the epidural space in the lower back. This is outside the dura mater, separate from the spinal cord and CSF. Local anaesthetic medications are infused through the catheter into the epidural space, where they diffuse to the surrounding tissues and through to the spinal cord, where they have an analgesic effect. This offers good pain relief during labour. Anaesthetic options are levobupivacaine or bupivacaine, usually mixed with fentanyl.

Question 7

What are the adverse effects of an epidural?

Answer 7

Adverse effects:

• Headache after insertion
• Hypotension
• Motor weakness in the legs
• Nerve damage
• Prolonged second stage
• Increased probability of instrumental delivery

Question 8

What is the signifiance of motor weakness following an epidural?

Answer 8

Women need urgent anaesthetic review if they develop significant motor weakness (unable to straight leg raise). The catheter may be incorrectly sited in the subarachnoid space (within the spinal cord), rather than the epidural space.

Question 9

What is the step up management of paint relief in labour?

Answer 9

• Simple analgesia
• Gas and air
• Intramuscular pethidine or diamorphine
• Patient controlled analgesia
• Epidural