Pain Relief in Labor: A Long and Winding Road

Pain
Intensity
Pain and Labor Outcome
Spontaneous Forceps Cesarean
Discomforting 70.4% 29.6% 0.0%
Distressing 53.6% 39.3% 7.1%
Horrible
Excruciating
31.6% 42.1% 26.3%
Had epidurals been available…
• The “horrible/excruciating” group
was heading for a long labor and
high chance of Cesarean delivery.
• The Horrible/excruciating group
would very likely have requested
epidurals in great numbers in early
labor.
• If this had happened, then epidurals
would have been blamed for long
labors, C/S.
Narcotics Vs. Epidural
JAMA, 1998, Meta-analysis
• All RCTs of epidural vs. narcotics in labor
• Better pain relief with epidural
• Higher patient satisfaction with epidural
• No change in Cesarean delivery rate.
• 4x higher newborn resuscitation with
narcotic
• 1 hour longer total labor in 1 st pregnancy
• More maternal fevers with epidural.
• More “assisted” deliveries with epidural.
When is “too early” to get an
epidural?
• What we know:
• 3 RCTs
• Women contracting
regularly, cervix
dilating, > 2 cm
• No advantage found in
waiting until later in
labor for the epidural.
• That is, if you are sure
you want an epidural.
When is too late?
• No evidence-based response.
• My experience with patients almost
or completely dilated: 50%-50%
• Can a person cooperate with the
procedure?
• Often a single spinal injection is
chosen.
• Be well educated.
• Listen to your
body.
• Be flexible in your
plans.
• Only get as much
as you need.
Parting words
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