History

Fact Explanation
Labor pain Labor pain is due to forceful uterine contractions, causing ischemia to the uterine muscles. Cervical dilatation is another cause for labor pain during the first stage of labor. Proper pain management is necessary in every labor.
Presence of co-morbidities Females who have congenital heart diseases, epilepsy and heart failure may need meticulous pain management and labor should progress with minimal pain and discomfort to the patient, as the medical conditions can get worsen with undue pain. [1,2]
Fetal macrosomia Maternal diabetes, gestational diabetes, history of fetal macrosomia, maternal obesity and multiparity are known risk factors for fetal macrosomia. Mode of delivery in fetal macrosomia should be decided wisely. [3]
Twin pregnancy Multiple pregnancies can be delivered either vaginally or with an elective Cesarean section. The final decision should be made considering the fetal lie, past obstetric history and maternal comorbidities. [4,6]
Breech presentation Fetuses in breech presentation can be delivered by an elective Cesarean section which has high complication rate than the vaginal delivery. However timing and mode of delivery should be decided by an experienced person. [5]
References
  1. HARRIS IS. Management of Pregnancy in Patients with Congenital Heart Disease Prog Cardiovasc Dis [online] 2011, 53(4):305-311 [viewed 21 August 2014] Available from: doi:10.1016/j.pcad.2010.08.001
  2. LAM WW. Heart Disease and Pregnancy Tex Heart Inst J [online] 2012, 39(2):237-239 [viewed 21 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384045
  3. ZAMORSKI MA, BIGGS WS. Management of suspected fetal macrosomia. Am Fam Physician [online] 2001 Jan 15, 63(2):302-6 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11201695
  4. STACH SL, LIAO AW, DE LOURDES BRIZOT M, FRANCISCO RP, ZUGAIB M. Maternal postpartum complications according to delivery mode in twin pregnancies Clinics (Sao Paulo) [online] 2014 Jul, 69(7):447-451 [viewed 22 August 2014] Available from: doi:10.6061/clinics/2014(07)01
  5. MUKUKU O, KIMBALA J, KIZONDE J. Accouchement du si?ge par voie basse: ?tude de la morbi-mortalit? maternelle et n?onatale Pan Afr Med J [online] :27 [viewed 22 August 2014] Available from: doi:10.11604/pamj.2014.17.27.2037
  6. NWANKWO TO, ANIEBUE UU, EZENKWELE E, NWAFOR MI. Pregnancy outcome and factors affecting vaginal delivery of twins at University of Nigeria Teaching Hospital, Enugu. Niger J Clin Pract [online] 2013 Oct-Dec, 16(4):490-5 [viewed 22 August 2014] Available from: doi:10.4103/1119-3077.116895

Examination

Fact Explanation
Multiple pregnancy Symphysio-fundal height is more than the dates and multiple fetal poles can be palpable. In twin pregnancies two fetal heads can be palpable. The liquor volume can be increased. Fetal heart sounds can be auscultated from two sides of the abdomen in different rates.
Breech presentation The lower pole of the uterus consists of the breech which is felt as a soft boggy mass. The head lies over the upper pole of the uterus.
Signs of fetal macrosomia Symphysio-fundal height of more than dates, increased estimated weight of the fetus and excessive weight gain of the mother are indicative of fetal macrosomia. [1]
References
  1. ZAMORSKI MA, BIGGS WS. Management of suspected fetal macrosomia. Am Fam Physician [online] 2001 Jan 15, 63(2):302-6 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11201695

Investigations - Fitness for Management

Fact Explanation
Fetal ultrasound scan Fetal ultrasound scan is important in estimating the fetal weight. If the estimated fetal weight is 4,500 g or more an elective Cesarean section is preferred over vaginal delivery. [1]
References
  1. ZAMORSKI MA, BIGGS WS. Management of suspected fetal macrosomia. Am Fam Physician [online] 2001 Jan 15, 63(2):302-6 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11201695

Investigations - Followup

Fact Explanation
Fetal cardiotocogram Monitoring of the fetal cardiac activity enables diagnosis of side effects of opoids on fetus. Decreased beat-to-beat variations is seen with opioids. [1]
References
  1. SHOORAB NJ, ZAGAMI SE, MIRZAKHANI K, MAZLOM SR. The Effect of Intravenous Fentanyl on Pain and Duration of the Active Phase of First Stage Labor Oman Med J [online] 2013 Sep, 28(5):306-310 [viewed 20 August 2014] Available from: doi:10.5001/omj.2013.92

Management - General Measures

Fact Explanation
Patient education Patient education should be provided to all pregnant females. They should be well educated about the natural progress of the labor, available options of pain relief and the justification for the current recommendation of the mode of delivery (holistic approach). Pros and cons of each method should be discussed and the final choice should be made on patients' request. [1]
Psychological support Every patient should be provided with enough psychological support to face labor and later on change in their lives.
Relaxation techniques This is a non-pharmacological method of pain management. Patterned breathing exercises are helpful for the patient to relax and also to reduce her anxiety. Music can be combined for this on patients' preference. [1,2]
Positioning Patients generally experience less pain while they maintain a vertical posture or doing some rhythmic movements. Vertical positioning has some added beneficial effects due to the effects of gravity. [1,3]
Trans cutaneous electrical nerve stimulation (TENS) TENS is a non-pharmacological mode of pain relief. An electrical stimulation is delivered through the skin, which inhibits the transmission of painful impulses through the spinal cord. Also it stimulates the release of endogenous opioids by the brain. [4]
References
  1. BROWN ST, DOUGLAS C, FLOOD LP. Women's Evaluation of Intrapartum Nonpharmacological Pain Relief Methods Used during Labor J Perinat Educ [online] 2001, 10(3):1-8 [viewed 20 August 2014] Available from: doi:10.1624/105812401X88273
  2. SHOORAB NJ, ZAGAMI SE, MIRZAKHANI K, MAZLOM SR. The Effect of Intravenous Fentanyl on Pain and Duration of the Active Phase of First Stage Labor Oman Med J [online] 2013 Sep, 28(5):306-310 [viewed 20 August 2014] Available from: doi:10.5001/omj.2013.92
  3. GIZZO S, DI GANGI S, NOVENTA M, BACILE V, ZAMBON A, NARDELLI GB. Women's Choice of Positions during Labour: Return to the Past or a Modern Way to Give Birth? A Cohort Study in Italy Biomed Res Int [online] 2014:638093 [viewed 21 August 2014] Available from: doi:10.1155/2014/638093
  4. MELLO LARISSA F. D., NóBREGA LUCIANA F., LEMOS ANDREA. Estimulação elétrica transcutânea no alívio da dor do trabalho de parto: revisão sistemática e meta-análise. Rev. bras. fisioter. [online] 2011 June, 15(3):175-184 [viewed 22 August 2014] Available from: doi:10.1590/S1413-35552011000300002

Management - Specific Treatments

Fact Explanation
Paracetamol (acetaminophen) Paracetamol is a safe and effective mode of analgesia which can be used in labor, especially during the latent phase. Both oral and intravenous paracetamol can be used. [4]
Inhaled nitrous oxide This contains a mixture of 50 % oxygen and 50 % N2O (nitrous oxide). Nitrous oxide has slight sedative effects and moderately powerful analgesic effects. Action of nitrous oxide begins quickly but it is short lasting. Patient controlled analgesia is possible with use of nitrous oxide. Dizziness, nausea, vomiting and sleepiness are common side effects. In addition nitrous oxide is considered safe to use during the postpartum period for birth related injuries. [3]
Opioids Morphine, meperidine (pethidine), fentanyl, and remifentanil are commonly used opioids for pain relief during labor. However opioids can cause maternal nausea, vomiting, sedation, euphoria and respiratory depression as side effects. Transplacental transmission of opioids to the fetal circulation can cause neonatal respiratory depression. Fentanyl is a short acting synthetic opioid. Opoids can be used in both first and second degree of pregnancy. [1,2]
Paracervical block Paracervical block is helpful, simple, safe and effective mode of pain relief during the first stage of labor. Pain during the first stage of labor is due to cervical dilatation which is transmitted through the uterine, hypogastric and pelvic plexus (at the level of eleventh and twelfth thoracic segments). This should be done by experienced persons once the cervix is dilated up to 5cm. Anesthetic effects last for about one hour and twenty minutes. [5]
Pudendal nerve block Pudendal nerve block the pain arising from the vaginal introitus and the perineum, but not the pain due to uterine contractions. So it is usually given in combination with other mode of pain relief. It is usually given during the end of the second stage. [6,7]
Caudal analgesia This is a mode of regional anesthesia. A local anesthetic agent is injected in to the extradural space of the sacral canal. Maternal hypotension, seizures and accidental injection in to the spinal canal, or to a blood vessel are possible complications of the procedure. [8]
Epidural analgesia Epidural analgesia is the commonly used (around 44 %) method of pain relief during labor. [1,3]
Spinal analgesia Spinal anesthesia is indicated for Caesarean sections. Combined spinal and epidural analgesia are often used if facilities are available. This should be done by an experienced person. Maternal hypotension, accidental injection in to a vessel and systemic toxicity are possible side effects of the procedure. [6]
General anesthesia General anesthesia is less commonly used in labor. It is useful in emergencies (maternal or fetal distress) where quick induction of anesthesia is necessary. [9]
References
  1. BROWN ST, DOUGLAS C, FLOOD LP. Women's Evaluation of Intrapartum Nonpharmacological Pain Relief Methods Used during Labor J Perinat Educ [online] 2001, 10(3):1-8 [viewed 20 August 2014] Available from: doi:10.1624/105812401X88273
  2. SHOORAB NJ, ZAGAMI SE, MIRZAKHANI K, MAZLOM SR. The Effect of Intravenous Fentanyl on Pain and Duration of the Active Phase of First Stage Labor Oman Med J [online] 2013 Sep, 28(5):306-310 [viewed 20 August 2014] Available from: doi:10.5001/omj.2013.92
  3. DAMMER U, WEISS C, RAABE E, HEIMRICH J, KOCH MC, WINKLER M, FASCHINGBAUER F, BECKMANN MW, KEHL S. Introduction of Inhaled Nitrous Oxide and Oxygen for Pain Management during Labour - Evaluation of Patients' and Midwives' Satisfaction Geburtshilfe Frauenheilkd [online] 2014 Jul, 74(7):656-660 [viewed 21 August 2014] Available from: doi:10.1055/s-0034-1368606
  4. ABDOLLAHI MH, MOJIBIAN M, PISHGAHI A, MALLAH F, DARESHIRI S, MOHAMMADI S, NAGHAVI-BEHZAD M. Intravenous paracetamol versus intramuscular pethidine in relief of labour pain in primigravid women Niger Med J [online] 2014, 55(1):54-57 [viewed 21 August 2014] Available from: doi:10.4103/0300-1652.128167
  5. VAN PRAAGH IG, POVEY WG. Paracervical Block Anesthesia in Labour Can Med Assoc J [online] 1966 Feb 5, 94(6):262-267 [viewed 21 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1935290
  6. SCHROCK SD, HARRAWAY-SMITH C. Labor analgesia. Am Fam Physician [online] 2012 Mar 1, 85(5):447-54 [viewed 21 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22534222
  7. SAHAY PA. Pudendal Nerve Block Br Med J [online] 1959 Mar 21, 1(5124):759-761 [viewed 21 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1992979
  8. MEEHAN FP. Continuous caudal analgesia in obstetrics. Proc R Soc Med [online] 1969 Feb, 62(2):185-6 [viewed 21 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/5775242
  9. MCCLELLAND RM, LAWSON JG. Sedation and Analgesia in Labour Br Med J [online] 1964 Jun 13, 1(5397):1555-1557 [viewed 21 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1814625