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Pain Management During Labor and Delivery

• Editor's Note
• List of Articles

List of Articles

• 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.
  
  

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