Obstetric Pain

O Objective Factors Obstetric Pain JOHN S. MCDONALD Definition Department of Anesthesiology, Obstetrics and Objective factors are those that contribute to disability, Gynecology, Torrance, CA, USA and can be assessed objectively by an examiner. They [email protected] include laboratory findings, imaging findings, and some physical examination findings. Synonym Impairment, Pain-Related Labor Pain Definition Objective Judgment Obstetric pain is an acute pain that is limited to the few hours a mother spends in labor and delivery of her baby. Definition The pain is of a severe nature i.e. pain scores on the 7–10 Objective judgment is the process of observing and scaleduring thelater phasesof thefirststageof labor and transmitting impersonal knowledge that is free from then continuing during the actual delivery of the baby in bias in judgment and that is readily quantifiable. culminationofthesecondstage.Thepainemanatesfrom Pain Assessment in Neonates the T10-L-2 cord levels for the first stage and the S2-S4 cord levels for the second stage. Characteristics Objective Medical Evidence Introduction Definition The surge of interest in obstetric pain relief by anesthesiologists, obstetricians, pediatricians, neonatologists, Medical signs and laboratory findings. and labor nurses continues to penetrate the early years Disability Evaluation in the Social Security Admin- of the 21st century. Mothers today receive significant istration instruction from natural childbirth advocates, and are often educated by lectures where anesthesiologists are included early on to outline the benefits of analgesia for Observation of Pain Behavior labor and discuss the now built in safety. The clinical practice of obstetric anesthesia in the early years of the 2000s is healthy and resilient, with more ap- Assessment of Pain Behaviors preciation now recognized by colleagues; namely, the obstetricians, and neonatologists in regard to our con- tribution to the health and wellbeing of the mother and Observational Learning baby, by the fact that anesthesiologists now offer a safe harbor for both maternal and newborn care. It is impor- Modeling, Social Learning in Pain tant to remember that today’s modern mother wants to have pain relief, but she also demands, above all, safety for her unborn baby. Obstetric Brachial Palsy Pain of the First Stage of Labor Firststageof labor pain isduetouterinecontractionsand Plexus Injuries and Deafferentation Pain stretching of the cervix. This is based on early works of 1496 Obstetric and Gynecological Pain promising the safety of her or of her unborn child. The Obstetric and Gynecological Pain most popular method for analgesia during labor and URSULA WESSELMANN delivery is epidural analgesia using a combination Departments of Neurology, Neurological Surgery of local anesthetics and opioids. Drugs can be applied and Biomedical Engineering, The Johns Hopkins as continuous epidural infusions or as patient con- University School of Medicine, Baltimore, MD, trolledepiduralanalgesia. Combinedspinalepidural USA techniques offer the advantage of a very rapid onset of [email protected] analgesiawithminimalmotorblock.Oldertechniques, which are rarely used today and are mainly reserved for obstetric pain not managed by regional anesthe- Introduction sia methods, include inhalation anesthesia and opioid Over the last 25 years there has been a growing recog- analgesia via the intramuscular or intravenous route. nition in the field of gynecology that pain is not only Psychologicalmethodsto reduceobstetricpainandthe a symptom of pelvic disease, but that women are suf- concept of natural childbirth were initially introduced fering from a chronic pelvic pain syndrome(Wessel- by Dick-Read sixty years ago (Dick-Read 1953) and mann 1999a; Wesselmann 1999b), where “pain” is the play an important role either in conjunction with anes- prominent symptom of the chronic visceral pain syn- thetic methods or as a primary approach. drome(CerveroandLaird1999).Recognizingtheexis- There is increasing awareness that obstetric pain is tence of the chronic gynecological pain syndromes has not only related to the process of labor and deliv- resulted in the development of novel animal models to ery. Women report significant pains in many sites study the pathophysiological mechanisms of chronic of the body after delivery, a phenomenon defined gynecological pain syndromes (Giamberardino and as postpartum pain. Postpartum pains may include Vecchiet 1994) and in clinical studies to assess pain urogenital, pelvic, back and breast pains as well as treatment options. While previously most clinical ef- headaches (Audit Commission 1997) persisting for fortshadfocusedonfindingaspecificetiologyandspe- months to years after labor and delivery. Anesthetic cific pathologicalmarkersfor pelvic disease inpatients techniques during labor and delivery and gonadal hor- complaining of pelvic pain, many of these women are monal changes may play a role in the etiology of these now offered pain treatment similartopatientssuffering pain complaints. from other chronic pain syndromes. In addition there have been enormous advances in obstetric pain re- Chronic Gynecological Pain Syndromes lief. Women can obtain almost complete relief from Definitions of Chronic Gynecological Pain Syndromes the pain of labor and the use of analgesia during labor and delivery is now safer than ever before (Hawkins Definitions are important, if a body of reliable infor- et al. 1997). The purpose of this section review is to mation isto be built up in the scientific literature, which will eventually lead to a better understanding of the introduce this previously under recognized and under- studied novel field of obstetric and gynecological pain pathophysiology of chronic pelvic pain. One of the and to highlight advances in basic science and clinical major problems of research into chronic pelvic pain is research, recent epidemiologicalstudies and advances the lack of agreed upon definitions, which would allow in pain treatment options for this patient population. comparison between studies. However, since there is a lack of understanding of the pathophysiological etiology of pelvic pain, it is difficult to decide on criteria Obstetric Pain, Analgesia during Labor to define chronic pelvic pain conditions. and Delivery, Postpartum Pain There is no generally accepted definition of chronic Traditionallywomenhavebeenexpectedtosufferfrom pelvic pain. The International Association for the severe pain during labor and delivery, some enduring Study of Pain (IASP) defines chronic pelvic pain with- the process more stoically than others. There are three out obvious pathology as chronic or recurrent pelvic distinct stages of Labor Pain related to uterine con- pain that apparently has a gynecological origin, but for tractions,cervicalstretchinganddistensionofthevagi- which no definitive lesion or cause is found (Merskey nal canal during fetal descent. Pain of the first stage of 1994). This definition for pelvic pain has not been laborismediatedbyneuralpathwaysinvolvingtheT10 widely used in the literature (Campbell and Collett to L1 spinal cord segments, while pain of the second 1994), since it implies absence of pathology, which and third stages of labor involves spinal cord segments might not necessarily be the case and it also excludes S2toS4.Nowadayspainreliefcanbeofferedduringall cases where pathology is present although not neces- stages of labor and delivery, targeted to the individual sarily the cause of pain. Similar to other chronic pain needsandwishesofthepregnantwoman,withoutcom- syndromes (i.e. chronic back pain) the exact relation- Obstetric and Gynecological Pain 1497 ship of the pain complaint to the presence of pathol- In addition to gynecological pain syndromes charac- ogyisoftenunclearinwomenwithchronicpelvicpain. terized by pain localized to the pelvic cavity, gyneco- Given the difficulties of applying the IASP pelvic pain logicalpainsyndromeslocalizedtotheurogenitalfloor definition to clinical research, several medical soci- have been described. Specific terms have been coined eties have recently taken a lead in revising the defini- for these conditions; however, similar to the definitions tion of chronic pelvic pain. The International Conti- of chronic pelvic pain, many of these definitions are nence Society has defined “pelvic pain syndrome” as currently being revised. Chronic perineal pain is re- theoccurrenceofpersistentorrecurrentepisodicpelvic ferredtoas pudendalneuralgia,ifelectrophysiologi- pain associated with symptoms suggestive of lower cal evaluation confirms impairment of the pudendal urinary tract, sexual, bowel or gynecological dysfunc- nerve (Bensignor et al. 1993). Vulvar pain occurring tion in the absence of proven infection or other obvi- in the absence of an underlying recognizable disease ous pathology (Abrams 2002). The European Associ- has become an increasingly common clinical prob- ation of Urology has suggested to extend this defini- lem and is referred to as vulvodynia. Two sub- tion by considering two subgroups based on the pres- groups are recognized (Moyal-Barracco and Lynch ence or absence of well-defined conditions that pro- 2004), generalized vulvodyniaand localized vulvody- duce pain (Fall 2004). The American College of Ob- nia, including pain localized to the vulvar vestibule – stetricians and Gynecologists has proposed the follow- vestibulodynia ( vulvar vestibulitis) and to the cli- ing definition: chronic pelvic pain is non-cyclic pelvic toris – clitorodynia (clitoral pain) (Gordon

Load more