- Pain during labor is generally severe, with only 2–4% of women reporting minimal pain in labor.
- Pain relief (analgesia – Figure 64.1) during normal labor is not mandatory. However, all women should be aware of the options available to them. There are no contraindications for pain relief in labor.
- Analgesia is strongly recommended for certain maternal conditions (select cardiac disorders, suspected difficult intubation) and in situations where intrapartum manipulation is likely (breech, multiple pregnancy).
- Adequate analgesia is mandatory for assisted vaginal delivery, perineal repair, manual removal of placenta, and cesarean section delivery.
Pain pathways (Figure 64.3)
- During the first stage of labor, pain results from both cervical dilation and uterine contractions (myometrial ischemia). Pain sensation travels from the uterus via visceral afferent (sympathetic) nerves that enter the spinal cord through the posterior segments of thoracic spinal nerves, T10–12.
- Pain during the second stage of labor results primarily from distension of the pelvic floor, vagina, and perineum by the presenting part of the fetus, and travels via sensory fibers of sacral nerves, S2–4 (pudendal nerve). The sensation of uterine contractions also contributes, but is probably secondary.
Non-pharmacologic techniques
- Acupuncture, hypnosis, and aromatherapy may have a place in clinical practice, but their efficacy is not yet proven.
- Transcutaneous electrical nerve stimulation (TENS) is thought to act by promoting endogenous enkephalin release within the spinal cord, where it acts to inhibit the transmission of pain. Its efficacy is unproven.
- Warm baths, massage, relaxation, antenatal classes, breathing exercises, and the presence of a supportive “doula” (midwife) have all been shown to decrease analgesic requirements in labor.
Pharmacologic techniques
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