Labor analgesia

Introduction to principles of labor analgesia and management

1. Saneesh P J
Specialist (A) -Anesthesiology

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Childbirth -most painful experiences women
will experience in their lifetime
Childbirth pain was “divine retribution for Eve’s
disobedience in the Garden of Eden”
Many believed it was wrong to treat the pain
and escape God’s punishment

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Several non-pharmacologic techniques have
been used to relieve the pain of childbirth
throughout history
acupuncture
massage
hypnosis
Drugs were not used in Western medicine to
relieve pain in childbirth until the mid-1800s

5. English Queen Victoria chose to inhale
chloroformfor analgesia during the birth of
Prince Leopold
John Snow Queen Victoria

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Alwayscontroversial!
“Birth is a natural process”
Women should suffer!!
Concerns for mother’s safety
Concerns for baby
Concerns for effects on labor

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<10% of laboring women in US in 2001
underwent childbirth without analgesia
Neuraxialanalgesia is by far the most common
form of pain management
Development of increasingly safe techniques for
neuraxialanalgesia

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Acupuncture
Massage
Hypnosis
Others
Lamaze method
LeBoyertechnique
Transcutaneous nerve stimulation
Hydrotherapy
Presence of a support person
Intradermal water injections
Biofeedback

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Good pain relief
No autonomic block (no hypotension)
No adverse maternal or neonatal effects
No motor block

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No effect on labor and delivery:
No increase in C/S rate
No increase in forceps/vacuum delivery
Patient can ambulate
Economical: cost and personnel

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Prenatal education classes
Anesthesiologists must become effective
educators as well as health care providers
Patients should have realistic expectations
regarding the pain of labor and the variability of
individual labor patterns

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Well-informed patients are more likely to accept
the interventions that may become necessary
during labor

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Anesthesiologists should encourage and
facilitate the honest discussion of the risks and
benefits of the analgesic/anesthetic techniques
available

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All parenteral opiates cross placenta
Degree of depression depends on
specific agent
Dose
time between administration and delivery
prematurity

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Morphine
Pethidine
Fentanyl
Ketamine

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Inhaled anesthetics were the first treatments
for labor analgesia used in modern times.
However, as volatile anesthetics became more
commonly used in childbirth, side effects were
more commonly encountered.
Neonatal depression
Maternal gastric aspiration

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Delivery was complicated by aspiration of
gastric contents in 66 women from 44,016
deliveries (0.15%) between 1932 and 1945.
The preventive fasting measures -
recommended by Mendelson
restricting intake
provision of non-particulate antacids
improvement of anesthetic-induction technique

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Volatile anesthetics are no longer used for labor
analgesia.
Nitrous oxide, however, is still commonly used
worldwide and is welcomed by many
parturientsas a less invasive approach to pain
relief in labor.

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Typically NITROUS OXIDE is blended with O2 in a
50:50 ratio or slightly greater for patient-inhaled
self-administration.
ENTONOX

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The most reliable and effective method of
reducing pain during labor.
However, it is encumbered by small but real and
predictable risks.

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Assessment of all laboring women for risk
factors for neuraxialanalgesia and general
anesthesia is recommended
Sufficient time should be available for adequate,
safe evaluation and discussion with the patient.
In otherwise healthy women, routine laboratory
testing is not required.

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Although any laboring woman has the potential
to require cesarean section, labor takes many
hours and requires adequate nutrition and
hydration.
ASA has recommended that moderate amounts
of clear liquids be allowed during the
administration of neuraxialanalgesia and
throughout labor
Aperiod of abstention from solids before the
placement of neuraxialanalgesia is not
required.

28. Timing of placement
Current ASA guidelines note that maternal request
for labor pain relief is sufficient justification for
intervention and the decision should not depend
on an arbitrary cervical dilation.

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Epidural analgesia is most commonly initiated
after placement of a catheter into the epidural
space between L2-3 and L4-5

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IV fluids
Monitoring
CTG
Positioning

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The “test dose” tests for inadvertent
intravascular or intrathecalplacement of the
catheter.
Choice of local anesthetic drugs
Bupivacaine
Ropivacaine
Adjuvants –opioids

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Very dilute local anesthetic mixtures (0.0625%)
generally do not produce motor blockade and
may allow some patients to ambulate
(“walking” or “mobile” epidural)

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The long duration of action of bupivacaine
makes it a popular agent for labor.
Ropivacainemay be preferable because of its
reduced potential for cardiotoxicity

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Patient-controlled epidural
analgesia (PCEA)
Total drug requirements may be less
Patient satisfaction is greater with
PCEA compared with other epidural
techniques.
PCEA settings are typically a 5-mL
bolus dose with a 5–10 min lockout
and 0–12 mL/h basal rate; a 1-h
limit of 15–25 mL may used.

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Hypotension
Unintentional intravascular injection
Unintentional intrathecalinjection
Post-duralpuncture headache (PDPH)
Epidural abscess/hematoma
Neurological deficits (rare)

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Combined Spinal & Epidural (CSE) Analgesia
Spinal anesthesia
Saddle block

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Paracervicalblock
LA is injected lateral to the cervix at 4 o’clock and
10 o’clock, taking care to avoid vascular structures.

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Paracervicalblock
The paracervicalblock is effective to relieve pain of
cervical dilation but does not affect cramping pain
from contraction of the uterine corpus.
However, paracervicalblock does reduce pain in
the second stage of labor.

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Pudendalnerve block
The pudendalnerve is derived from sacral nerve
roots and can be blocked with local anesthetic
using a transvaginalor transperinealapproach to
treat pain during the second stage of labor and for
episiotomy repair.

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Low-dose epidural analgesia can be inadequate
for assisted vaginal delivery with forceps or
vacuum.
A higher concentration local anesthetic can be
administered through an indwelling epidural
catheter or a “second-stage spinal” can provide
excellent perinealanalgesia.

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Supplementation of an indwelling epidural
catheter with 5 to 10 mL of 1% to 2% lidocaine
or 2% to 3% 2-chloroprocaine is usually
adequate, depending on whether vacuum or
forceps are being used.
Pudendalnerve block also can be considered for
operative delivery.

43. Individualize technique to patient’s goals
and stage of labor
Optimize management for spontaneous
delivery
Provide safe, cost-effective analgesia

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