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Study of Labor Pain and Pain Remedies: An
Overview
Dr. NirajP 1*
P
, Nehika SwarupP 2
P
, PinkiP 2
P
, Gaurav KumarP 2
P
, Harish KumarP 2
P
, Dr. Rashmi TripathiP 2
College of Pharmacy, AgraP 1, 2
P
1
P
10/172/12 Ghi Ai Mandi Taj Ganj, Agra, U.P. 282001 E.mail - 31TUnirajg261@gmail.com, U31TMob. - 9012395301
U
ABSTRACT
Delivery of the infant into the arms of a conscious and pain-free mother is one of the most
exciting and rewarding moments in medicine. Both physical and emotional factors play a part in
the feelings of labor pain. Women body goes through a great physical change as it prepares for
the birth of your baby and these changes cause pain. Pain during the first stage of labor is due to
distention of the lower uterine segment, mechanical dilatation of the cervix and lastly due to
stretching of excitatory nociceptive afferents resulting from the contraction of the uterine
muscles and In the second stage additional factors, such as contraction and pressure on the
parietal peritoneum, uterine ligaments, urethra, bladder, rectum, lumbosacral plexus, fascia and
muscles of the pelvic floor increase the intensity of pain. In general there are two opposite views
about labor pain. One is that the labor pain is part of a natural process and although it is painful it
does not mean that there is anything wrong. Thus, labor pain should not necessarily be treated
with medications. The other view is that the pain of labor is unacceptable, and there are no other
circumstances in life when it is reasonable to experience such pain. Consequently, all women
must be offered pain relief. The purpose of this study was to explore the methods of pain
management during labor and birth outcomes.
Keywords: Labor pain; Pain relief method; Treatment
INTRODUCTION:
The International Association for the Study of Pain (IASP) defined pain as a subjective and
unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Historically, the era of obstetric anesthesia began with James Young Simpson, when he
administered ether to a woman with a deformed pelvis during childbirth. His concept of
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appropriateness of anesthesia for labor continued till 1853, when John Snow administered
chloroform to Britain’s Queen Victoria during the birth of her eighth child, Prince Leopold. The
International Association for the Study of Pain (IASP) declared 2007–2008 as the ‘‘Global Year
against Pain in Women - Real Women, Real Pain.” With labor pain outside her control, a mother
also faces increased risk of feeling fear, anxiety, helplessness, and loss of control of the overall
birthing.
LABOR PAIN AND ITS EFFECT:
The first stage of labor is associated with diffuse pain which originates from the dilatation and
stretching of lower uterine segment and the cervix. The second, third and the fourth sacral spinal
segment carry pain impulses of 2nd stage of labor through pudendal nerve. The visceral pain
during the two stages of labour is typified by the involvement of the respective dermatomes. The
chemical mediators involved are bradykinin, leukotrienes, prostaglandins, serotonin, substance P
and lactic acid. First stage labour pain can be blocked by paracervical plexus blockade whereas
2nd stage pain can be abolished by blocking pudendal nerve.
BODY SYSTEM EFFECT CAUSE
Cardio-vascular Labor pain causes a progressive
increase in maternal cardiac output
primarily due to increase in stroke
volume and to a lesser extent
maternal heart rate.
Special precautions have to be
taken in pregnant patients with
heart disease, pulmonary
hypertension and pre-eclampsia
before resorting to any clinical
intervention.
Nervous system The sympathetic nervous system
gets activated as a result of labor
stress and this increases the plasma
catecholamine levels. Excessive
sympathetic activity may result in
in-coordinate uterine action,
prolonged labour and abnormal fetal
This effect acquires clinically a
very significant aspect in case the
parturient has to be taken up for
operative delivery under general
anesthesia as there will be a
Potentially increased risk of
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heart rate pattern. Activation of
autonomic nervous system also
delays gastric emptying and reduces
intestinal peristalsis.
Respiratory Pain initiates hyperventilation,
increase minute ventilation and
increased oxygen consumption
Pain initiates hyperventilation,
increase minute ventilation and
increased oxygen consumption.
Levels of care and associated functions in the prevention and management of pain:
PAIN RELIEF METHODS:
1. Non-pharmacological methods:
It includes Emotional support, childbirth education, massage, aroma therapy, hydrotherapy,
intradermal water injection, biofeedback, TENS (transcutaneous electrical nerve stimulation),
acupuncture, acupressure and hypnosis have been promulgated as non-pharmacological methods
to relieve pain associated with childbirth.
LEVEL PREVENTION TREATMENT
Primary Interventions to prevent
pain occurring.
Mainly passive modalities directed toward pain
relief to promote early healing of tissues.
Secondary Interventions intended to
avoid chronic disability/
pain.
Therapy driven programs intended to promote
rehabilitation within a limited time frame
Tertiary Interventions to minimize
the impact of chronic
conditions
Individualized and intensive treatment for the
small fraction of patients whose biomechanical
dysfunction, physical deconditioning and
psychosocial stressors have led to chronic,
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2. Pharmacological methods:
METHOD EXAMPLES AND THEIR EFFECTS
Inhalational analgesia
1. The earlier agents used were ether, chloroform and
cyclopropane, followed by trichloroethylene and
methoxyflurane. Ether has several side effects including
potent emetic effect with a pungent odor. It is also an irritant
to the respiratory tract and is explosive so cannot be used in
modern times where extensive use of electric cautery is
mandatory.
2. Chloroform has dose related side effects namely
arrhythmias and liver damage.
3. Only agent that has survived the test of times is nitrous
oxide and is administered as 'Entonox' which is an
equal-proportional mixture of (50:50) oxygen and nitrous oxide.
4. Isoflurane, enflurane, desflurane and sevoflurane are the
most recent additions in the armamentarium of an
anesthesiologist.
Systemic narcotics/analgesics:
1. Pethidine (meperidine): commonly used opioid derivatives
for a long time now for the relief of pain.
2. Morphine: possible respiratory depression in the newborn,
addiction and nausea and vomiting.
3. Ketamine: For relief of labour pain it has to be administered
in higher doses (anaesthetic doses) which can compromise
the airway because of diminution of airway reflexes.
4. Fentanyl: The peak analgesic effect occurs within 3-5
minutes and the duration of the effect lasts for
approximately 30 minutes. It can be administered in boluses
of 25-50 mcg every hour or as a continuous infusion of 0.25
mcg / kg / hr.
222 50-100 mg 4 hourly. It has no clinically significant
respiratory depression but incidence of nausea is more
common with tramadol than with pethidine or morphine.
6. Nalbuphine: administered in doses of 10-20 mg
intramuscularly for the relief of labor pain. Sedation and
dysphoria are the main disadvantages of this drug.
7. Butorphanol: The dose of butorphanol is 1-2 mg
intramuscularly.
8. Remifentanil: rapid onset of action and a half-life of 6
minutes. It can readily cross placenta but is extensively
metabolized by the fetus. The recommended infusion dose is
0.025 mcg/kg/min which can be increased in incremental
manner up to a maximum dose of 0.15 mcg/kg/min.
Possible adverse side effects of herbal preparations when used in labor pain:
Herbal agent
Aloe vera Nausea, vomiting, diarrhea.
Astragalus Autoimmune disease..
Belladonna
Atropine side effects of atropine sulfate include dryness of the
mouth, blurred vision, sensitivity to light, lack of sweating,
dizziness, nausea, loss of balance, and rapid heartbeat
Chaparral Hepatitis
Ephedrine – banned in the
US due to serious side
effects including death
High blood pressure, irregular heartbeat, nervousness, headaches,
trouble falling asleep, heart attack or strokes
Ginkgobiloba Excess bleeding
St. John's wort Upset stomach, a tired feeling, dizziness, confusion or dry mouth.
Sunburn occurs more easily.
Kava products Sleepiness, a rash, or strange movements of the mouth and tongue
223 Medicine used safely in pregnancy for others effect or category:
D1SEASE DRUG USED FOR TREATMENT
ACNE Benzoyl Peroxide, Topical Erythromycin, Salicylic Acid
CONSTIPATION Colace, Dulcolax
ANTIBIOTICS Ceclor, Cephalosporins, E-mycins, Keflex Macrobid/Macrodantin,
Penicillin Zithromax
COUGH Cough Drops Phenergan, Codeine if Rx’d Robitussin (Plain & DM
formulas)
DIARRHEA Kao-Pectate, Imodium AD
FEVER Tylenol (Regular or Extra Strength) Extra Strength-Do not exceed
8tabs/24H Regular-Do not exceed 12tabs/24H Tylenol Sinus Tylenol
PM
COLDS/HAYFEVER Benadryl Claritin **Claritin-D Chlor-Trimeton Dimetapp
Drixoral-Non-Drowsy Mucinex (guaifenasin) Sudafed/Sudafed-12 Hour
**Sudafed PE Pseudoephedrine Tylenol Cold & Sinus Vicks Vapor
Rub Zyrtec
**AVOID If Problems With Blood Pressure
GAS Mylicon, Phazyme
HEADACHES ASA-Free Excedrin Cold, Compress Tylenol (Regular or Extra
Strength)
NAUSEA Vitamin B6 25mg TID, Dramamine, Emetrol, Ginger Root 250mg
QID High Complex Carbs @ Bedtime Sea Bands – Accupressure
Unisom ½ tab TID
VACCINES Flu Shot *Gardasil Hepatitis A Hepatitis B Pneumovax Polio Booster
Tetanus Tuberculosis test or ppd AVOID: *Gardasil Live Poliovirus
MMR (measles, mumps & rubella) Varicella (chickenpox) *No known
complications if received before known Pregnancy; resume series after
delivery
224 CONCLUSION:
Pharmacy pain management team can be connective link to guiding the appropriate prescribing
practices of inpatient opioids and ensure best practices with quantity and quality of opioid
prescriptions written on discharge. Current days Due to the availability of safer and more
effective new drugs and techniques, the incidence of caesarean or instrumentally assisted vaginal
delivery have decreased significantly.
REFERENCES:
1. A.Rudra;pain relief in labor; A review culture National memorial hospital, India PP:6-10
2. Amy semple et.al; Research review: self-hypnosis for labor and birth, Freelance researcher,
PP 15-19; dec2011
3. American society of anesthesiologist ; labor and delivery pain research, 2014
4. American pregnancy association; Gonorrhea during pregnancy;2017
5. Curalolo et.al; central hypersensitivity in chronic pain after whiplash injury; PP1-7; clin J
pain vol17[4]; dec2001
6. Department of anesthesia et.al; Pain management labor and delivery; Health sciences center;
dec 2008
7. Deepak et.al; Effect of acupressure on intensity of labor pains duration of first stage of labor
among primigravida mothers; nursing and midwifery research journal vol9; oct 2013
8. Department of health; treatment of TB in pregnant women; PP1-4
9. Dipti Agarwal et.al; Impact of epidural Analgesia on labor pain: A review; Swami Dayanand
hospital, Delhi, India; PP: R2-R7 vol1 issue1; 2015
10.Era vermani et.al; Pelvic girdle pain and low back pain in pregnancy: A review, A
department of Anesthesiology; PP60-68
11.Edward Mills et.al, Herbal medicines in pregnancy and labor; Taylor and francis medical an
impact of the Taylor and francis gp; pp:1-349, 2006
12.Ekaterina Mishanina et.al; use of labor induction and risk of cesarean delivery:A systematic
review of meta-analysis, Canadian medical association or its licensors; pp665-669; June 10
225
13.Elsevier Ireland lmt, management of the second stage of labor, international journal of
gynecology and obstetrics; pp:111-116, 2016
14.Jasmine N. Tucker Jones, Pharmacist role in pain management; kennestone hospital, pp1-47;
nov 2008
15.J.Edmond Charlton,pain & pregnancy & labor; IASP press, Seattle, pp 1-4;2015
16.Jiya Milal,A.A Manzoor; An empirical study of role homeopathy in pregnancy; IDSR journal
of dental & medical sciences,vol-9; pp14-16; sept-oct 2013
17.Jones L et.al;pain management for women in labor: A overview of systematic reviews, the
Cochrane lib issue3; pp1-10; 2012( copyright2013)
18.Joyce Douglas et.al;safe homoeopathic remedies for you and your baby; university of
Maryland center for medicine
19.Joanne Douglas,et.al; pain management option during labor; British Colombia prenatal health
programmed ; pp2-27; oct2007
20.K.Gladwell et.al; managing the pain of labor; NHS Trust; pp1-10: 2010
21.Linda B White; Wise uses of herbs and vitamins during pregnancy; interweave press
22.Lone Holst et.al; the use and the user of herbal remedies during pregnancy; Journal of
alternative and complementary medicines, vol-15; pp787-79
23.Moir Br J Anaesth; labor analgesia and recent advances
24.Mid-Michigan medical center midland; Managing pain during labor and labor delivery
25.Nancy corol walker; the relationship between method of pain management; university of
Alberta; pp1-47,1997
26.Natsuki Kubotera, Jeffrey Fudin; pain management for pharmacist; Albany college of
pharmacy; pp36-43,April 2013
27.Neda Rwashdeh; drug in pregnancy; pp1-16,2012
28.Royal college of obstetricians and gynaecologists; the diagnosis and treatment of malaria in
pregnancy; pp2-29,april2010
29.Simona labor, simon Maguire; the pain of labor; Shawe hospital Manchester; pp15-18 vol-2,
dec20
30.Sunil T. Pandya; labor analgesia: Recent advances; Fernandaz hospital; pp 400-407, sept-
226
31.Sukhwinder kaur bajwa et.al; painless labor: How far have have we travelled? ; Shri lanka
journal of obstetrics and gyne-cology; pp 93-98, 2010
32.Sheena Byrom et.al;The pregnancy book ;department of health;pp4-174
33.Shu ling et.al ;efficiency of women shower on labor pain and birth experiences during the
first labor stage the association of women health; obstetric and neonatal nurses, pp 18-27,
vol42, issue1,2013
34.Sevi Burcak cengiz et.al; the pregnant patient: considerations for dental management and
drug use; research department of pediastric and drug use; research department of pediastric
dentistry; pp 133-142,2007
35.Tekoa L.king et.al; approaches to lmt ibntervention during labor and birth; the americian
college of obspetrichians and gynecologists;pp1-6 feb2017
36.Tridip sarkar;Heomeopathic management gynecological disorder; medical officier NIH;
pp1-34 march 2004
37.US department of health and human services; managing asthama during pregnancy
recommendation for pharmacologic
38.Z.Ozturk, A Tatliparmak; leprosy treatment during pregnancy and breast feeding: A case
report and brief review lit. ; department of clinical pharmacology and toxicology
