LAUSR

Most women experience intense pain during labor. Labor pain induces a neuroendocrine stress response with associated physiological effects including increased oxygen consumption, hyperventilation, respiratory alkalosis, increased cardiac output, increased systemic vascular resistance, and blood pressure with resultant impacts on the parturient and fetus. There is evidence to suggest that poor pain control may be associated with increased risk of postpartum depression or posttraumatic stress disorder. However, effective pain control is not always associated with maternal satisfaction. Positive maternal experience with labor and childbirth appears to improve in the context of feeling in control of one’s care options and providing choices, informed consent, and a relaxing environment. Epidural analgesia is the gold standard for pain relief in labor compared with available alternatives, but it is not always available and/or desired. Epidural utilization across the United States varies based on institutional practices and patient population from 36.6% in Maine to 80.1% in Nevada. The multifactorial disparity likely involves racial and ethnic impacts, patients’ understanding of risk, access to health care, and cultural preferences. Neuraxial anesthesia requires sterile equipment, trained anesthesia professionals, and skilled nursing staff to be delivered safely and effectively, including the ability to manage any complications. The absence of one, or all of these, may preclude the safe administration of epidural analgesia. There are several relative and absolute contraindications to neuraxial analgesia. These may include medical conditions (eg, coagulation abnormalities, elevated intracranial pressure, or infection at the site of injection), thromboprophylaxis, and anatomic limitations such as severe spinal deformity. Clinicians are increasingly interested in learning about alternative options to offer patients and the evidence to support their efficacy and safety. Limitations of available evidence include very low to moderate quality of evidence and challenges with ability to blind patients or treatment providers to epidural versus no epidural options. In addition, pain associated with labor is complex and multifactorial and impacted by cultural, social, and individual factors. For these reasons, labor pain is difficult to quantify and measure. Alternatives to neuraxial analgesia for labor can be divided into nonpharmacological treatments, regional nerve blocks, and pharmacological interventions. Nonpharmacological interventions include transcutaneous electrical nerve stimulation (TENS) unit, massage and relaxation techniques, acupuncture, hypnosis, intradermal sterile water injection, and virtual augmented reality (VAR). Regional options include peripheral nerve blocks such as pudendal or paracervical injections. Pharmacological treatment of pain includes opioid therapy, inhaled nitrous oxide, and nonopioid medications.