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Pharmacologic management of pain during labor and delivery

Gilbert J Grant, MD
Section Editor
David L Hepner, MD
Deputy Editors
Marianna Crowley, MD
Vanessa A Barss, MD, FACOG


The way pain is experienced is a reflection of the individual's emotional, motivational, cognitive, social, and cultural circumstances [1]. The pain of childbirth is likely to be the most severe pain that a woman experiences during her lifetime [2]. Many women, especially nulliparas, rate the pain of labor as very severe or intolerable [3,4]. The pain of labor and delivery varies among women, and each labor of an individual woman may be quite different. As an example, an abnormal fetal presentation (eg, occiput posterior) is associated with more severe pain and may be present in one pregnancy, but not the next.

Pharmacological treatment of labor pain was introduced in the mid-nineteenth century. These analgesic techniques were controversial, as many women and their physicians strongly believed that labor pain was a natural and necessary accompaniment of childbirth. This battle continues to the present day, with a vocal minority arguing that the use of pharmacological analgesic agents in parturients is unnecessary, unnatural, and harmful. Thus, laboring women are often treated differently than other patients suffering from pain. The American College of Obstetricians and Gynecologists (ACOG) has recognized this double-standard, noting that there is no other circumstance in which it is considered acceptable to experience severe pain, amenable to safe relief, while under a physician's care [5,6]. ACOG supports the concept that maternal request alone is a sufficient medical indication for labor analgesia.

Although lower levels of labor pain have been correlated with higher levels of childbirth satisfaction, higher levels of labor pain do not preclude an overall satisfying experience. When interviewed after delivery, mothers tend to downplay the intensity of their labor pain [7] and it is not the most important factor influencing satisfaction with the childbirth experience [8]. However, a sense of personal control over decision-making processes in labor has consistently been shown to correlate with overall maternal satisfaction with childbirth [9,10]. As an example, a study of 100 women undergoing vaginal delivery reported that satisfaction with pain relief was associated with a feeling of being in control and having input in the decision making process [10].

These findings suggest that women should be involved in the decision-making process regarding all aspects of childbirth, including pain relief, to increase maternal satisfaction. This can be accomplished by educating women about pain relief techniques during pregnancy, prior to the onset of labor, so that women can carefully contemplate their options before labor commences, as rational decision-making is difficult during times of emotional stress and physical anguish. Furthermore, patient-controlled epidural analgesia (PCEA) empowers the parturient by giving her direct control of her pain relief, and this has the potential to increase maternal satisfaction [11-13].

Issues related to labor pain and pharmacologic modalities for pain relief will be reviewed here. Specific issues regarding administration and complications of neuraxial anesthesia and nonpharmacologic approaches to manage labor pain are discussed separately. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics" and "Nonpharmacologic approaches to management of labor pain" and "Neuraxial analgesia for labor and delivery (including instrumented delivery)".)


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Literature review current through: Nov 2016. | This topic last updated: Tue Jun 07 00:00:00 GMT 2016.
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