Pain Relief in Labor

  • Ajay Sood
  • Nishi Sood


Birth of a child is one of the most dangerous moments in the life of a woman. It is most of the time surrounded by misconceptions. Severe pain as a result of labor and delivery is the most feared event in pregnant women. However, the perception of pain is highly variable and unpredictable. Most women report intense pain from their first contraction, while some may not experience pain till the second stage of labor. Labor pain caused by uterine contractions and cervical dilatation in the first stage is transmitted through visceral afferent sympathetic nerves from T10 to L1. In the second stage, painful stimuli due to perineal stretching are carried by pudendal nerve and sacral nerves S2 to S4 (Fig. 26.1). The exact mechanism of this difference in pain perception is not completely understood but may be genetically related. A study by Debiec J et al. found that Asian women experienced greater pain in labor than women of other races [1]. The association of pain has also been found with a single nucleotide polymorphism in the β2-adrenergic gene [2]. Other factors affecting pain include shape and size of the pelvis, presentation of fetus, and augmentation of contractions.


  1. 1.
    Debiec J, Conell-Price J, Evansmith J, et al. Mathematical modelling of the pain and progress of the first stage of nulliparous labor. Anesthesiology. 2009;111:1093–110.PubMedCrossRefGoogle Scholar
  2. 2.
    Reitman E, Conell-Price J, Evansmith J, et al. Beta2-adrenergic receptor genotype and other variables that contribute to labor pain and progress. Anesthesiology. 2011;114:927–39.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Wong CA. Advances in labor analgesia. Int J Women’s Health. 2009;1:139–54.CrossRefGoogle Scholar
  4. 4.
    Eappen S, Robbins D. Nonpharmacological means of pain relief for labor and delivery. Int Anesthesiol Clin. 2002;40(4):103–14.PubMedCrossRefGoogle Scholar
  5. 5.
    Lamaze F: Painless childbirth. Celestin LR (trans.) London: Burke, 1958.Google Scholar
  6. 6.
    Wu HC, Liu YC, Ou KL, et al. Effects of acupuncture on post cesarean section pain. Chin Med J. 2009;122:1743–8.PubMedGoogle Scholar
  7. 7.
    Cho SH, Lee H, Ernst E. Acupuncture for pain relief in labour: a systematic review and meta-analysis. BJOG. 2010;117:907–20.PubMedCrossRefGoogle Scholar
  8. 8.
    Smith CA, Levett KM, Collins CT, et al. Massage, reflexology and other manual methods for pain management in labour. Cochrane Database Syst Rev. 2012;(2):CD009290.Google Scholar
  9. 9.
    Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecol. 1946;52:191–205.PubMedCrossRefGoogle Scholar
  10. 10.
    Moya F. Use of a chloroform inhaler in obstetrics. N Y State J Med. 1961;61:421–9.PubMedGoogle Scholar
  11. 11.
    Klomp T, Van Poppel M, Jones L, et al. Inhaled analgesia for pain management in labour. Cochrane Database Syst Rev. 2012;9:CD009351.Google Scholar
  12. 12.
    Westling F, Milsom I, Zetterström H, et al. Effects of nitrous oxide/oxygen inhalation on the maternal circulation during vaginal delivery. Acta Anaesthesiol Scand. 1992;36:175–81.PubMedCrossRefGoogle Scholar
  13. 13.
    Carstoniu J, Lewtam S, Norman P, et al. Nitrous oxide in early labor: safety and analgesic efficacy assessed by a double-blind, placebo-controlled study. Anesthesiology. 1994;80:30–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Yentis MY, Cohen SE. Inhalational analgesia and anesthesia for labor and vaginal delivery. In: Shnider and Levinson’s anesthesia for obstetrics. Philadelphia: Lippincott Williams & Wilkins; 2002. p. 189–97.Google Scholar
  15. 15.
    Abboud TK, Shnider SM, Wright RG, et al. Enflurane analgesia in obstetrics. Anesth Analg. 1981;60:133–7.PubMedGoogle Scholar
  16. 16.
    Abboud TK, Gangolly J, Mosaad P, Crowell D. Isoflurane in obstetrics. Anesth Analg. 1989;68:388–91.PubMedCrossRefGoogle Scholar
  17. 17.
    Swart F, Abboud T, Zhu J. Desflurane analgesia in obstetrics: maternal and neonatal effects. Anesthesiology. 1991;75:A844.CrossRefGoogle Scholar
  18. 18.
    Yeo ST, Holdcroft A, Yentis SM, Stewart A, Bassett P. Analgesia with sevoflurane in labour. II. Sevoflurane compared with Entonox for labour analgesia. Br J Anaesth. 2007;98:110–5.PubMedCrossRefGoogle Scholar
  19. 19.
    Olofsson C, Irestedt L. Traditional analgesic agents: are parenteral narcotics passe and do inhalational agents still have a place in labour? Baillieres Clin Obstet Gynaecol. 1998;12:409–21.PubMedCrossRefGoogle Scholar
  20. 20.
    Nissen E, Widstrom AM, Lilja G. Effects of routinely given pethidine during labour on infants’ developing breastfeeding behaviour: effects of dose-delivery time interval and various concentrations of pethidine/norpethidine in cord plasma. Acta Paediatr. 1997;86:201–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Rayburn W, Rathke A, Leushcen P, et al. Fentanyl citrate analgesia during labor. Am J Obstet Gynecol. 1989;161:202–6.PubMedCrossRefGoogle Scholar
  22. 22.
    Kan RE, Hughes SC, Rosen MA, et al. Intravenous remifentanil: placental transfer, maternal and neonatal effects. Anesthesiology. 1998;88:1467–74.PubMedCrossRefGoogle Scholar
  23. 23.
    Hawkins JL. Epidural analgesia for labour and delivery. N Engl J Med. 2010;362:1503–10.PubMedCrossRefGoogle Scholar
  24. 24.
    Robinson JO, Rosen M, Evans JM, et al. Maternal opinion about analgesia for labour. A controlled trial between epidural block and intramuscular pethidine combined with inhalation. Anaesthesia. 1980;35:1173–81.PubMedCrossRefGoogle Scholar
  25. 25.
    Hollmen AI, Jouppila R, Jouppila P, et al. Effect of extradural analgesia using bupivacaine and 2-chloroprocaine on intervillous blood flow during normal labour. Br J Anaesth. 1982;54:837–42.PubMedCrossRefGoogle Scholar
  26. 26.
    Jouppila P, Jouppila R Hollmen A, Koivula A. Lumbar epidural analgesia to improve intervillous blood flow during labor in severe preeclampsia. Obstet Gynecol. 1982;59:158–61.PubMedGoogle Scholar
  27. 27.
    American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: an updated report. Anesthesiology. 2007;106:843–63.CrossRefGoogle Scholar
  28. 28.
    Leighton BL, Halpern SH. The effect of epidural analgesia on labor, maternal and neonatal outcomes: a systematic review. Am J Obstet Gynecol. 2002;186:S69–77.PubMedGoogle Scholar
  29. 29.
    Comparative Obstetric Mobile Epidural Trial (COMET) Study Group UK. Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial. Lancet. 2001;19–23(2001):358.Google Scholar
  30. 30.
    American College of Obstetricians and Gynaecologists. Obstetric analgesia and anaesthesia. Practice bulletin 36, July 2002, Reaffirmed 2013b.Google Scholar
  31. 31.
    Gaiser RR. The epidural test dose in obstetric anesthesia: it is not obsolete. J Clin Anesth. 2003;15:474–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Gambling DR, Yu P, Cole C, et al. A comparative study of patient controlled epidural analgesia (PCEA) and continuous infusion epidural analgesia (CIEA) during labour. Can J Anaesth. 1988;35(3 Pt 1):249–54.PubMedCrossRefGoogle Scholar
  33. 33.
    Scott DB, Hibbard BM. Serious non-fatal complications associated with extradural block in obstetric practice. Br J Anaesth. 1990;64:537–41.PubMedCrossRefGoogle Scholar
  34. 34.
    Crawford JS. The epidural sieve and MBC (minimal blocking concentration): a hypothesis. Anaesthesia. 1976;31:1277–80.PubMedCrossRefGoogle Scholar
  35. 35.
    Lussos S, Datta S. Anesthesia for cesarean delivery. Int J Obstet Anesth. 1992;1:208–21.CrossRefGoogle Scholar
  36. 36.
    MacArthur AJ, Macarthur C, Weeks SK. Is epidural anesthesia in labor associated with chronic low back pain? A prospective cohort study. Anesth Analg. 1997;85:1066–70.PubMedCrossRefGoogle Scholar
  37. 37.
    McKenzie AG, Darragh K. A national survey of prevention of infection in obstetric central neuraxial blockade in the UK. Anaesthesia. 2011;66:497–502.PubMedCrossRefGoogle Scholar
  38. 38.
    Green LK, Paech MJ. Obstetric epidural catheter-related infections at a major teaching hospital: a retrospective case series. Int J Obstet Anesth. 2010;19:38–43.PubMedCrossRefGoogle Scholar
  39. 39.
    Bateman BT, Myhre JM, Leffert J, et al. The risk and outcomes of epidural hematomas after perioperative and obstetric epidural catheterization: a report from the multicenter perioperative outcomes group research consortium. Anesth Analg. 2013;116:1380–5.PubMedCrossRefGoogle Scholar
  40. 40.
    Reynolds F. Neurological infections after neuraxial anesthesia. Anesthesiol Clin. 2008;26:23–52.PubMedCrossRefGoogle Scholar
  41. 41.
    Cook TM, Counsell D, Wildsmith JA. Major complications of central neuraxial block: report on the third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth. 2009;102:179–90.PubMedCrossRefGoogle Scholar
  42. 42.
    Arkoosh VA, Palmer CM, Yun EM, Sharma SK, Bates JN, Wissler RN, et al. A randomized, double-masked, multicenter comparison of the safety of continuous intrathecal labor analgesia using a 28-gauge catheter versus continuous epidural labor analgesia. Anesthesiology. 2008;108:286–98.PubMedCrossRefGoogle Scholar
  43. 43.
    Macarthur AJ. Gerard W. Ostheimer: “What’s new in obstetric anesthesia” lecture. Anesthesiology. 2008;108:777–85.PubMedCrossRefGoogle Scholar
  44. 44.
    Norris MC, Fogel ST, Conway-Long C. Combined spinal-epidural versus epidural labor analgesia. Anesthesiology. 2001;95:913–20.PubMedCrossRefGoogle Scholar
  45. 45.
    Simmons SW, Cyna AM, Dennis AT, Hughes D. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database Syst Rev. 2007;(3):CD003401.Google Scholar
  46. 46.
    Nageotte MP, Larson O, Rumney PJ. Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women. N Engl J Med. 1997;337:1715–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Sia AT, Chongj L, Tay DH, et al. Intrathecal sufentanil as the sole agent in combined spinal-epidural analgesia for the ambulatory parturient. Can J Anesth. 1998;45:620–5.PubMedCrossRefGoogle Scholar
  48. 48.
    Parry MG, Fernando R, Bawa GP, Poulton BB. Dorsal column function after epidural and spinal blockade: implications for the safety of walking following low-dose regional analgesia for labour. Anaesthesia. 1998;53:382–7.PubMedCrossRefGoogle Scholar
  49. 49.
    Beardsley D, Holman S, Gantt RM, et al. Transient neurologic deficit after spinal anesthesia: local anesthetic maldistribution with pencil point needles? Anesth Analg. 1995;81:314–20.PubMedGoogle Scholar
  50. 50.
    Ong B, Baker C. Temporary back and leg pain after bupivacaine and morphine spinal anaesthesia. Can J Anaesth. 1995;42:805–7.PubMedCrossRefGoogle Scholar
  51. 51.
    Chabbouh T, Lentschener C, Zuber M, et al. Persistent cauda equina syndrome with no identifiable facilitating condition after an uneventful single spinal administration of 0.5% hyperbaric bupivacaine. Anesth Analg. 2005;101:1847–8.PubMedCrossRefGoogle Scholar
  52. 52.
    Collis RE, Davies DW, Aveling W. Randomised comparison of combined spinal-epidural and standard epidural analgesia in labour. Lancet. 1995;345:1413–6.PubMedCrossRefGoogle Scholar
  53. 53.
    O’Meara ME, Gin T. Comparison of 0.125% bupivacaine with 0.125% bupivacaine and clonidine as extradural analgesia in the first stage of labour. Br J Anaesth. 1993;71:651–6.PubMedCrossRefGoogle Scholar
  54. 54.
    Sabbe MB, Penning JP, Ozaki GT, et al. Spinal and systemic action of the alpha 2 receptor agonist dexmedetomidine in dogs: antinociception and carbon dioxide response. Anesthesiology. 1994;80:1057–72.PubMedCrossRefGoogle Scholar
  55. 55.
    Van de Velde M, Berends N, Kumar A, Devroe S, Devlieger R, Vandermeersch E, et al. Effects of epidural clonidine and neostigmine following intrathecal labour analgesia: a randomised, double-blind, placebo-controlled trial. Int J Obstet Anesth. 2009;18:207–14.PubMedCrossRefGoogle Scholar
  56. 56.
    Niemi G, Breivik H. Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: a randomised, double-blind, cross-over study with and without adrenaline. Acta Anaesthesiol Scand. 1998;42:897–909.PubMedCrossRefGoogle Scholar
  57. 57.
    Meert TF, Noorduin H, Van Craenendonck H, et al. Effects of adrenaline, an alpha 2-adrenoceptor agonist, the volume of injection, and the global pain state of the animal on the activity of epidural sufentanil. Acta Anaesthesiol Belg. 1989;40:247–61.PubMedGoogle Scholar
  58. 58.
    Jensen F, Qvist I, Brocks V, et al. Submucous paracervical blockade compared with intramuscular meperidine as analgesia during labor: a double-blind study. Obstet Gynecol. 1984;64:724–7.PubMedGoogle Scholar
  59. 59.
    Nikkola EM, Jahnukainen TJ, Ekblad UU, et al. Neonatal monitoring after maternal fentanyl analgesia in labor. J Clin Monit Comput. 2000;16:597–608.PubMedCrossRefGoogle Scholar
  60. 60.
    Morishima HO, Covino BG, Yeh MN, et al. Bradycardia in the fetal baboon following paracervical block anesthesia. Am J Obstet Gynecol. 1981;140:775–80.PubMedCrossRefGoogle Scholar
  61. 61.
    Pace MC, Aurilio C, Bulletti C, et al. Subarachnoid analgesia in advanced labor: a comparison of subarachnoid analgesia and pudendal block in advanced labor: analgesic quality and obstetric outcome. Ann N Y Acad Sci. 2004;1034:356–63.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2020

Authors and Affiliations

  • Ajay Sood
    • 1
  • Nishi Sood
    • 2
  1. 1.Department of AnaesthesiaIGMCShimlaIndia
  2. 2.Department of ObgIGMCShimlaIndia

Personalised recommendations