Pain Management in Labor

 

Am Fam Physician. 2021 Mar 15;103(6):355-364.

  Patient information: See related handout on managing pain in labor, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

A patient's sense of empowerment and control is most predictive of maternal satisfaction with childbirth. Analgesia during labor greatly affects this experience. Individual patient priorities for labor pain management should be explored as part of routine prenatal care. Continuous labor support, water immersion, and upright positioning in the first stage of labor are associated with decreased use of pharmacologic analgesia. Despite the increased risk of adverse effects, self-administered inhaled nitrous oxide appears to be safe and effective for pain relief; however, its negative environmental impact as a greenhouse gas is a drawback. Evidence is lacking that any one opioid is superior in maximizing pain relief while minimizing adverse effects. Neuraxial anesthesia provides the most effective pharmacologic analgesia and is used in nearly three-fourths of labors in the United States. Neuraxial regional anesthesia is not associated with increased rates of cesarean delivery or assisted vaginal delivery, and it has only a small effect on the length of the second stage of labor. Epidural, spinal, combined spinal-epidural, and dural puncture epidural anesthesia are commonly used neuraxial techniques. Paracervical and pudendal blocks are safe and effective pain management options in specific circumstances. Both transversus abdominis plane block and subcutaneous wound infiltration with local anesthetic can decrease the use of postoperative analgesia. Patients with opioid use disorder require individualized pain management plans throughout perinatal care, and judicious opioid prescribing practices are encouraged for all patients.

Most patients will use some form of pharmacologic analgesia for pain management during labor. Although timeliness and adequacy of pain relief are important, they are not as predictive of maternal satisfaction with childbirth as the patient's sense of empowerment and control. Therefore, creating a supportive and nurturing environment should be a priority throughout the perinatal period.1

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Continuous labor support has been shown to increase rates of spontaneous vaginal delivery, decrease the mother's negative feelings about the childbirth experience, and decrease the use of pharmacologic anesthesia.4

B

Meta-analysis of lower-quality randomized trials focused on patient-oriented evidence

Inhaled analgesia may be beneficial for patients in labor who desire some form of noninvasive pharmacologic pain relief.22

B

Meta-analysis of randomized trials focused on patient-oriented evidence with no specific clear recommendation

Parenteral opioids provide pain relief that is superior to nitrous oxide but inferior to regional anesthesia.1215

B

Meta-analyses of lower-quality randomized trials focused on patient-oriented evidence

Neuraxial regional anesthesia provides superior pain relief compared with systemic analgesia, without increasing rates of assisted vaginal delivery or cesarean delivery, regardless of whether it is initiated in latent or active labor or continued in the second stage of labor.12,45,46

B

Meta-analyses of lower-quality randomized trials focused on patient-oriented evidence


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Continuous labor support has been shown to increase rates of spontaneous vaginal delivery, decrease the mother's negative feelings about the childbirth experience, and decrease the use of pharmacologic anesthesia.4

B

Meta-analysis of lower-quality randomized trials focused on patient-oriented evidence

Inhaled analgesia may be beneficial for patients in labor who desire some form of noninvasive pharmacologic pain relief.22

B

Meta-analysis of randomized trials focused on patient-oriented evidence with no specific clear recommendation

Parenteral opioids provide pain relief that is superior to nitrous oxide but inferior to regional anesthesia.1215

B

Meta-analyses of lower-quality randomized trials focused on patient-oriented evidence

Neuraxial regional anesthesia provides superior pain relief compared with systemic analgesia, without increasing rates of assisted vaginal delivery or cesarean delivery, regardless of whether it is initiated in latent or active labor or continued in the second stage of labor.12,45,46

B

Meta-analyses of lower-quality randomized trials focused on patient-oriented evidence


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert o

The Authors

show all author info

ANDREW SMITH, MD, is director of obstetrics at the Lawrence (Mass.) Family Medicine Residency Program and is an assistant professor at Tufts University School of Medicine, Boston, Mass....

ELISE LaFLAMME, MD, is a core faculty member at the Lawrence Family Medicine Residency Program and is an assistant professor at Tufts University School of Medicine.

CAROLINE KOMANECKY, MD, is a resident physician at the Lawrence Family Medicine Residency Program.

Address correspondence to Andrew Smith, MD, Greater Lawrence Family Health Center, 34 Haverhill St., Lawrence, MA 01841 (email: asmith@glfhc.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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