Vaginal delivery

Associated with and lower maternal and neonatal morbidity than cesarean section.

After a cesarean section results in uterine rupture in just over 1% and more than a third of the fetuses in those cases die.

After a cesarean section is accomplished in 60% to 80% of selected women given a trial of labor.

Sphincter damage from a third or fourth degree tear occurs in approximately 0.6% to 3% of women undergoing vaginal delivery.

Pudendal nerve conduction impairment occurs in 42% of women following vaginal delivery.

Approximately 14% of deliveries are assisted vaginal deliveries.

Vast majority of assisted deliveries use either a vacuum extractor or forceps.

A benefit to vaginal births are that the pressure of the birth canal helps squeeze out fluid from the babies lungs, which helps prevent transient tachypnea.

Pain during vaginal childbirth progresses with labor and the pain depends on factors including the size and position of the fetus, the rate of labor progression, and the maternal pain tolerance.

There are both pharmacologic and nonpharmacologic options to treat pain during vaginal delivery. 

The decision to use pain medication is generally a personal one.

Nonpharmacological pain management is intended to ease pain, improve the ability to cope with the pain, improve the overall experience of childbirth. 

Nonpharmacological pain management is not for the purpose of making pain disappear.

Strategies for non-pharmacological pain management include: breathing/relaxation techniques, movement/yoga, using a birthing ball, application of heat or cold, warm shower or water immersion, touching massage, acupressure or acupuncture, music therapy, and aromatherapy.

Pharmacologic Pain management can completely block pain, and is divided into regional/local and systemic treatments.

Regional/local analgesia includes neuraxial analgesic and pudendal nerve block.

Neuraxial analgesia, known as an epidural, is the choice of patients who request pharmacologic pain control and uses an anesthetic drug, such as an opioid, like fentanyl directly into the lower back, ministered into the epidural space where the nerves coming out of the spinal cord are located.

Pain relief is rapid once medication is infused, and the patient can stay fully alert during childbirth.

With this technique the patient is able to push effectively and it is generally safe, but some experience itching, and patients should not try to walk.

Less common side effects with neuraxial analgesia are nausea, vomiting, low blood pressure. 

Rarely serious neurologic side effects can occur.

A pudendal nerve block consists of an injection of local anesthetic through the vaginal canal providing pain relief to the vaginal and  perineal areas.

Systemic analgesia includes opioids and inhaled nitrous oxide.

Opioids, usually given intravenously can reduce awareness of pain, promote calmness but pain relief is less reliable than with an epidural.

Opioids can cross the placenta and may have temporary side effects on the fetus or newborn, such as changes in fetal heart rate or respiratory depression or drowsiness.

Inhaled nitrous oxide involves self administration of the gas through a handheld facemask and can provide safe and effective temporary pain relief.

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