Prima

Pain Management in Labour and Delivery

!! REMEMBER: HER PAIN IS REAL!!

Under-treatment of pain for those with dependence is more of a trigger than giving opiates.
Ask and assess level of pain. Honour her choices.

Pain Management Options

> Support by caregivers, family, friends, doulas (professional labour support)
> Comfort measures in labour (e.g., dim lights, back massage, change of position, walking, music, ice chips, showers, etc.)
> Opioid analgesia (fentanyl, meperidine, morphine) - variety of routes can be used
> Epidural anaesthesia usually works well for substance-dependent women and may be preferred

!! Mixed agonists-antagonists are CONTRAINDICATED for acute pain management of opiate-dependent patients eg. nalbuphine (Nubain), pentazocine (Taiwin), butorphanol (Stadol)

In Labour

> If on methadone, maintain patient on regular dose
> If in withdrawal from opiates, treat appropriately (see opiates section)
> If analgesia required, use any option above and recognize that cross-tolerance to opiates may require increased dosing
> Many substance-using women have a lower pain threshold
> Fetal heart tones may have minimal variability with opiate, alcohol or sedative use; assess further for fetal compromise
> Consider consulting anaesthesia and paediatrics

Postpartum

> Treat pain with ibuprofen and/or narcotics (e.g., acetaminophen & codeine, oxycodone, or hydromorphone - give a 3-5 day quantity); re-evaluate long-term use of analgesics
> Consider patient-controlled analgesia (PCA) or patient-controlled epidural anaesthesia (PCEA), if available, after caesarean section

Factors That May Affect a Woman's Perception of Pain

Personal	Hospital
> Past negative experience e.g., history of sexual abuse > Occiput posterior (OP) labour > Cultural perspective > Fear > Anxieties and apprehension > Tolerance > Partner issues	> Lack of support > Unwanted support > Loss of control > Hypervigilence > Heightened vulnerability > Lack of privacy