Analgesia and anesthesia options for labor and delivery include neuraxial, locoregional, parenteral analgesia, and general anesthesia. Neuraxial methods (eg, epidural or spinal anesthesia) are typically preferred (1). Locoregional injections (eg, pudendal block, paracervical block) are less common. Parenteral opioids or other medications are generally used only if neuraxial anesthesia is not available, if the patient has contraindications to neuraxial anesthesia (eg, prior spine surgery or significant scoliosis), or if the patient strongly prefers to avoid neuraxial anesthesia (eg, due prior bad experience with this method). General anesthesia is used only if needed for emergency cesarean delivery.
General reference
1. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins: Obstetrics. ACOG Practice Bulletin No. 209: Obstetric Analgesia and Anesthesia. Obstet Gynecol 133(3):e208-e225, 2019. doi:10.1097/AOG.0000000000003132
Neuraxial Anesthesia for Labor and Delivery
Neuraxial anesthesia is the preferred approach to analgesia during labor and delivery. It provides effective pain control, allows the laboring patient to remain awake and to push, and does not result in neonatal sedation. Several neuraxial methods are available, including epidural, spinal, and combined spinal-epidural.
Epidural anesthesia
Epidural anesthesia has a gradual onset of pain control. It can be continued throughout labor and vaginal delivery, and the level of analgesia can be increased for cesarean delivery.
Use of epidural analgesia does not increase the risk of cesarean delivery (1).
Spinal anesthesia
Spinal anesthesia (a single injection into the paraspinal subarachnoid space) has a rapid onset and may be used for cesarean delivery for a patient without an epidural catheter in place. Spinal anesthesia is used less often for vaginal deliveries because it is short-lasting (approximately 2 to 3 hours), but it is sometimes used if vaginal delivery is imminent and the patient desires pain control. Spinal anesthesia has a small risk of spinal headache afterward.
When spinal injection is used, patients must be constantly attended, and vital signs must be checked every 5 minutes to detect and treat possible hypotension.
Neuraxial anesthesia reference
1. Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology*. Anesthesiology 124:270–300, 2016. doi: 10.1097/ALN.0000000000000935
Locoregional Analgesia for Labor and Delivery
Methods include pudendal block, perineal infiltration, and paracervical block.
Pudendal block involves injecting a local anesthetic through the vaginal wall so that the anesthetic bathes the pudendal nerve as it crosses the ischial spine. This block anesthetizes the lower vagina, perineum, and posterior vulva; the anterior vulva, innervated by lumbar dermatomes, is not anesthetized. Pudendal block is a safe, simple method for uncomplicated spontaneous vaginal deliveries if women do not desire epidural or spinal anesthesia or if labor is advanced and there is no time for epidural injection. Complications of pudendal block include intravascular injection of anesthetics, hematoma, and infection.
Infiltration of the perineum with an anesthetic is used in limited circumstances. For example, it may be used if a patient has perineal pain even with an epidural or pudendal block in place or for a patient without other analgesia, particularly if a large laceration or episiotomy is anticipated. This method is not as effective as a well-administered pudendal block.
Paracervical block is rarely appropriate for delivery because incidence of fetal bradycardia is > 10% (1
Locoregional analgesia reference
1. LeFevre ML: Fetal heart rate pattern and postparacervical fetal bradycardia. Obstet Gynecol 64 (3):343–6, 1984.
Parenteral Anesthesia for Labor and Delivery
Intravenous or intramuscular analgesics are typically given only if neuraxial anesthesia is not available, although some clinicians offer these analgesics as an option during the first stage of labor. The minimum amount required for maternal comfort should be given because analgesics cross the placenta and may depress the neonate’s breathing. Even with the minimum amount, neonatal toxicity can occur because after the umbilical cord is cut, the neonate, whose metabolic and excretory processes are immature, clears the transferred drug much more slowly by liver metabolism or by urinary excretion.
General Anesthesia for Labor and Delivery
General anesthesia typically consists of a hypnotic medication and a paralytic. Use is typically reserved for an emergency cesarean delivery if neuraxial anesthesia is not available or cannot be administered rapidly.
Rarely, nitrous oxide 40% with oxygen may be used for analgesia during vaginal delivery as long as verbal contact with the woman is maintained.
Postpartum Pain Management
1).
Clinicians should engage in shared decision-making with patients about pain control. They should be aware of inequities in the assessment and treatment of pain (eg, based on race or ethnicity) and avoid bias in clinical decisions regarding pain management.
2).
Postpartum pain management references
1. Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1. Obstet Gynecol. 2021;138(3):507-517. doi:10.1097/AOG.0000000000004517
