“The delivery of the infant into the arms of a conscious and pain-free mother is one of the most exciting and rewarding moments in medicine.”
Pain relief in labour, today, is attracting more clinical and scientific interest. Improved postoperative pain relief came from the medical profession, considering pain as the fifth vital sign. Increasing knowledge of the physiology and pharmacology of pain, and the development of obstetric anesthesia as a subspecialty has increased the quality of labour pain relief and the availability of effective analgesia for parturients.
History of labour analgesia
The pain of childbirth is arguably one of the most severe types of pain a woman will experience in her lifetime. Relief of the pain of childbirth has always been associated with religious and cultural taboos and myths and controversies. In the nineteenth century, the relief of obstetric pain had significant social and religious consequences, which made anesthesia during childbirth a contentious subject.
James Young Simpson, the professor of midwifery in Edinburgh, Scotland, was among the first to use ether for the relief of labor pain on 19 January 1847. The royal anaesthetic, John Snow administered the historic chloroform to Queen Victoria for labour analgesia, helping Her Royal Majesty delivering her sixth and seventh children.
Do women in labour need pain relief?
No doubt labour results in severe pain and often results in a physiologic response that may harm the mother and the fetus. Melzack in 1971 had clearly demonstrated that only the pain of causalgia or digit amputation exceeds that of labour, as shown in the McGill pain score index.
Pain during parturition varies greatly among women. The parity status, fear, anxiety, expectation, socio cultural factors, induction of labour with prostaglandin’s and degrees of changes with the progress of labour, all influence the labour pain.
Regional analgesia is currently the gold standard of practice for pain control in obstetrics and is unlikely that this will change soon. The search for improvements in the quality and safety of epidurals and spinals in obstetrics deserves therefore closest attention. Epidural analgesia has been combined with subarachnoid narcotics to ease the pain of labor. Regional analgesia has become one of the leading techniques on obstetric floors in the present-day practice.
Labour analgesia methods
Non-regional techniques for labour analgesia is divided into either into non-pharmacological and pharmacological methods.
These methods are easier to administer; however, some may be expensive, and there is not enough research/evidence supporting their efficacy.1
• Transcutaneous electrical nerve stimulation (TENS)
• Relaxation/breathing techniques
Inhalational method: Nitrous oxide
• Meperidine (Pethidine)
Regional technique for labour analgesia: Lumbar Epidural Analgesia
Myths and facts about breastfeeding, backache, and headaches
Epidural and breastfeeding
The effect of epidural analgesia on breastfeeding continues to appear in the lay press, in part due to conflicting reports in the scientific literature. Several studies and trials failed to demonstrate a significant association between epidural and lactation failure or less-successful breastfeeding attempts. Further studies are needed in this area to assess the strength and the impact of any association, if any.
Backache and epidural
In two recent randomized trials, there were no significant differences in the incidence of long-term back pain between women who received epidural pain relief and women who received other forms of pain relief.2
Postdural puncture headache
The use of small-bore atraumatic spinal needles will reduce the incidence of postdural puncture headache (PDPH) in patients receiving CSEA to approximately 1% or less. It was suggested that the incidence of unintentional dural puncture is less in CSEA patients than in patients receiving conventional epidurals as the spinal needle may be used for verification of correct placement of the epidural needle. Intrathecal placement of the conventional epidural catheter in case of inadvertent dural puncture reduced the incidence of PDPH.
Labour induced complications and maternal mortality
Maternal mortality, including during birth is a key indicator of women’s health and status (WHO). Overwhelming evidence demonstrates that skilled attendance at birth (as well as adequate prenatal and postpartum care) could dramatically reduce maternal (and infant) mortality rates.
UNICEF states that the maternal mortality ratio declined by 50% in the MENA region from 1990 to 2015. Preventable causes of pregnancy and labour-related complications accounted for almost 70% of all maternal deaths in MENA.
Many countries in the region suffer ongoing conflicts – detrimentally affecting vulnerable women and children. Pregnant women in these regions do not have access to adequate prenatal, labour, or postpartum care. Thus, labour analgesia options are lacking.
In order to deliver an infant into the arms of a conscious and pain-free mother, it is vital to provide supportive prenatal care and discuss pain relief options with the women prior to labour. By informing women and engaging them in discussions around their values, expectations, and preferences rather than expecting them to make firm decisions in advance of such an unpredictable event as labour. Furthermore, in order to reduce maternal mortality, especially for preventable labour-related problems, it is vital that resources are provided to hospitals and clinics.
Finally, the take home message is, do not deny pain relief if requested by the labouring woman.