Pain Management in Labor

A patient's sense of empowerment and control is most predictive of maternal satisfaction with childbirth. Analgesia during labor greatly affects this experience. Individual patient priorities for labor pain management should be explored as part of routine prenatal care. Continuous labor support, water immersion, and upright positioning in the first stage of labor are associated with decreased use of pharmacologic analgesia. Despite the increased risk of adverse effects, self-administered inhaled nitrous oxide appears to be safe and effective for pain relief; however, its negative environmental impact as a greenhouse gas is a drawback. Evidence is lacking that any one opioid is superior in maximizing pain relief while minimizing adverse effects. Neuraxial anesthesia provides the most effective pharmacologic analgesia and is used in nearly three-fourths of labors in the United States. Neuraxial regional anesthesia is not associated with increased rates of cesarean delivery or assisted vaginal delivery, and it has only a small effect on the length of the second stage of labor. Epidural, spinal, combined spinal-epidural, and dural puncture epidural anesthesia are commonly used neuraxial techniques. Paracervical and pudendal blocks are safe and effective pain management options in specific circumstances. Both transversus abdominis plane block and subcutaneous wound infiltration with local anesthetic can decrease the use of postoperative analgesia. Patients with opioid use disorder require individualized pain management plans throughout perinatal care, and judicious opioid prescribing practices are encouraged for all patients.