Page 434 Acute Pain Management

Drug Cat Comments
Antiemetics, antinauseants
Phenothiazines:
prochlorperazine, promethazine, C When given in high doses during late pregnancy,
thiethylperazine phenothiazines have caused prolonged
neurological disturbances in the infant.
Others:
dimenhydrinate, diphenhydramine, A
metoclopramide
dolasetron, granisetron, ondansetron B1
domperidone, hyoscine, hyoscine B2
hydrobromide
tropisetron B3
Source: ADEC (1999). © Commonwealth of Australia. Reproduced with permission (see notes on verso page).
11.1.2 Management of pain during delivery
Pain during labour and delivery represents a complex interaction of multiple physiological and
psychological factors involved in parturition. Women’s desires for and expectations of pain
relief during labour and delivery vary widely. High quality relief does not necessarily equate
with a high level of satisfaction and no difference in satisfaction was reported following
epidural or non‐epidural analgesia (Anim‐Somuah et al, 2005 Level I). Severe pain during labour is
one of several factors associated with post‐traumatic stress symptoms following childbirth
(Slade, 2006 Level IV). Consistent with pain experience in other settings, high scores on a pain
catastrophising scale have been associated with increased report of intense labour pain (Flink
et al, 2009 Level IV).
Women should have access to safe and appropriate maternity services, including anaesthesia
and analgesia (RANZCOG et al, March 2009). Guidelines from the American Society of
Anesthesiologists (ASA) Taskforce on Obstetric Anesthesia include recommendations for
analgesia during labour and delivery (ASA, 2007).
Systemic analgesia in labour pain
Systemic opioid analgesics continue to be used in labour although practice varies, as there are
insufficient data to evaluate the comparative efficacy and safety of different opioids (Tuckey et
CHAPTER 11 labour, but pain scores remained high in both groups and side effects were more common
al, 2008 Level IV). IM tramadol provided similar pain relief to pethidine in the first stage of
following tramadol (Khooshideh & Shahriari, 2009 Level II). IV administration has greater efficacy
than equivalent IM dosing (Isenor & Penny‐MacGillivray, 1993 Level II).
In comparison with epidural analgesia, systemic opioids provided less analgesia and increased
the need for additional pain relief methods, although with no measurable difference in
maternal satisfaction (Anim‐Somuah et al, 2005 Level I). Their use also worsened fetal acid‐base
balance (Reynolds et al, 2002 Level I).
A quantitative assessment of the efficacy of nitrous oxide (N 2O) inhalational analgesia is
currently not possible. However, although it is not a potent labour analgesic, it is safe (Rosen,
2002 Level I). In cross‐over comparisons with N 2O, self‐administration of low‐concentration
sevoflurane (0.8%) (Yeo et al, 2007 Level III‐2) and IV PCA remifentanil (Volmanen et al, 2005
Level II) reduced pain to a greater degree, but also increased sedation. Although, IV PCA
remifentanil can reduce pain, particularly in early labour, it had less effect on pain scores and

386 Acute Pain Management: Scientific Evidence