Obstetric analgesia

A comprehensive review of labor analgesia

1. OBSTETRIC ANALGESIA Dr . Souvik Maitra , MD

2. labor pain is one of the most intense pains that a woman can experience, and it is typically worse than a pain associated with a deep laceration . 60% of primiparous women described the pain of uterine contractions as being “ unbearable, intolerable, extremely severe, or excruciating .”

3. Comparison of pain scores using the McGill Pain Questionnaire

4. Mechanism of Labor Pain First Stage of Labor Pain Pathway in first stage Parturients describe this pain as dull in nature and often poorly localized.

5. Mechanism of Labor Pain: Second Stage Activation of the same afferents activated during the first stage of labor plus afferents that innervate the vaginal surface of the cervix, the vagina, and the perineum . Afferents course through the pudendal nerve with DRG at S2-S4, and they are somatic in nature.

6. Pain Pathways during Labor

7. Pain in labor – location and neural pathways Site of Origin Cause Pathway Site of Pain Uterus and cervix Contraction and distension of uterus and dilatation of cervix Afférent T10 – L1 Post. Rami T10 – L1 Upper abdomen to groin, mid back and inner upper thighs (referred pain) Peri-uterine tissue (mainly posterior) Pressure often associated with occipito posterior position and flat sacrum Lumbo sacral plexus L5- S1 Mid and lower back and back of thighs (referred pain) Lower birth canal Distension of vagina and perineum in second stage Somatic roots S2- S4 Vulva, Vagina and Perineum Bladder Over distension Sympathetic T11-L2 Parasympathetic S2-S4 Usually suprapubic  Myometrium and uterine visceral peritonium Abruption Scar dehiscence T10-L1 Referred Pain to site of pathology

8. Effects of labor pain on mother Obstetric Course Neural stimulation through pain pathways results in the release of substances that either drive (oxytocin) or brake (epinephrine) uterine activity and cervical dilation; effect of analgesia on the course of labor can vary between individuals .

9. Cardiac and Respiratory Effects The intermittent pain of uterine contractions also stimulates respiration and results in periods of intermittent hyperventilation. In the absence of supplemental oxygen administration, compensatory periods of hypoventilation between contractions result in transient periods of maternal hypoxemia and, in some cases, fetal hypoxemia.

10. Psychological Effects Small proportion of women can be psychologically harmed by either providing or withholding analgesia Both individual and environmental influences upon this meaning.

11. Effects of labor pain on fetus Labor pain affects multiple systems that determine utero -placental perfusion: (1) uterine contraction frequency and intensity, by the effect of pain on the release of oxytocin and epinephrine; (2) uterine artery vasoconstriction, by the effect of pain on the release of norepinephrine and epinephrine; and (3) maternal oxyhemoglobin desaturation, which may result from intermittent hyperventilation followed by hypoventilation

12. Non Pharmacologic Methods of Labor Analgesia

13. Child birth preparation: Psychoprophylaxis “ Natural childbirth ” stems from a phrase coined by Grantley Dick-Read in 1933. This method focuses on teaching the mother conditioned reflexes to overcome the pain and fear of childbirth. It uses an education program, human support during labor, breathing techniques, relaxation techniques of voluntary muscles, a strong focus of attention, and specific activities to concentrate on during contractions to block pain. Presence of another woman during labor to support the expectant mother has a positive effect on outcomes, including the duration of labor.

14. Transcutaneous Electrical Nerve Stimulation TENS is thought to reduce pain by nociceptive inhibition at a presynaptic level in the dorsal horn by limiting central transmission. Electrical stimulation preferentially activates low-threshold myelinated nerves. Afferent inhibition effects inhibit propagation of nociception along unmyelinated small c fibers by blocking impulses to target cells in the substantia gelatinosa of the dorsal horn. TENS enhances release of endorphins and dynorphins centrally. Placement of electrode pads over the lower back region in the distribution of T10-L1 may provide some analgesia for parturients in early labor.

15. Therapeutic Use of Heat and Cold Temperature (hot or cold) applied to various regions of the body in this method. Warm compresses may be placed on localized areas, or a warm blanket may cover the entire body. Icepacks may be placed on the low back or perineum to decrease pain perception. The therapeutic use of heat and cold during labor has not been studied in a rigorous scientific manner.

16. Hydrotherapy Hydrotherapy involve a simple shower or tub bath, or it include the use of a whirlpool or large tub specially equipped for pregnant patients. Benefits of hydrotherapy includes reduced pain & anxiety, decreased BP & increased efficiency of uterine relaxation.

17. Vertical Position The vertical position is associated with decreased pain, especially in early labor. Length of labor is either unaffected or decreased No difference in the incidence of instrumental delivery.

18. Acupuncture/Acupressure Derived from traditional Chinese medicine. Effects on pain relieving is extremely variable between different ethnic groups. It has not gained wide spread popularity and hence not studied rigorously.

19. Systemic Medication for Labor Analgesia

20. Meperidine Meperidine is the most commonly used parenteral opioid analgesic during labor. im dose ranges from 50 to 100 mg with a peak onset of effect at 40 to 50 minutes iv doses of 25 to 50 mg start to act within 5 to 10 minutes. Analgesic effect lasts up to 3 to 4 hours. Fetal exposure to meperidine is highest between 2 and 3 hours after maternal administration. Meperidine is cause less respiratory depression in the neonate than morphine does. It cause loss of beat-to-beat variability of FHR tracings.

21. Fentanyl Short half-life makes fentanyl suitable for prolonged use in labor, either as an intravenous bolus or as an analgesic administered by means of a PCA delivery system. It provides reasonable levels of analgesia with minimal neonatal depression. The usual dose of fentanyl for labor analgesia is 25 to 50 µg intravenously. The peak effect occurs within 3 to 5 minutes and has a duration of 30 to 60 minutes.

22. Remifentanil Potent, short-acting µ- opioid receptor agonist that has a t1/2 of 1.3 min & prolonged administration does not cause accumulation of this drug. PCA with intravenous remifentanil suggest that a median effective bolus dose of 0.4 µg/kg with a lockout time of 1 minute or a continuous infusion at 0.05 µg/kg/min with a bolus of 25 µg and a lockout time of 5 minutes provides satisfactory labor analgesia. Fetal exposure to the drug is minimized because of its rapid metabolism or redistribution, or both. It is an attractive alternative systemic analgesic in parturients in whom regional anesthesia is contraindicated.

23. Sedative-Tranquilizers Sedative-tranquilizers, e.g. barbiturates, phenothiazines , hydroxyzine , and BZD, have been used for sedation, anxiolysis , or both during early labor and before cesarean delivery. Promethazine is the most commonly administered phenothiazine in obstetrics. Used with meperidine , given in doses of 25 to 50 mg to prevent emesis. Its ability to potentiate the analgesic effects of opioids, however, is in doubt.

24. Ketamine Ketamine has been used in subanesthetic doses (0.5 to 1 mg/kg or 10 mg every 2 to 5 minutes to a total of 1 mg/kg in 30 minutes) during labor. ketamine in a dose of 25 to 50 mg can be used to supplement an incomplete neuraxial blockade for cesarean section. Its cause hypertension, tachycardia & emergence reactions. High doses (>2 mg/kg) can produce psychomimetic effects and increased uterine tone, which may cause low Apgar scores and abnormalities in neonatal muscle tone.

25. Inhaled Analgesia Inhaled analgesia can be defined as the administration of subanesthetic concentrations of inhaled anesthetics to relieve pain during labor. It has limited efficacy, not solely effective for most of the mothers. Have a place as an adjunct to neuraxial techniques or in parturients in whom regional anesthesia is not possible. Inhaled analgesics can be administered either intermittently (during contractions) or continuously. They can be self-administered, but the patient should have a health care provider present to ensure an adequate level of consciousness and proper use of the equipment.

26. Inhaled Analgesia Entonox (50 : 50 N 2 O/O 2 mixture) can be used as sole analgesic and an adjuvant to systemic and regional techniques for labor. Side effects include dizziness, nausea, dysphoria , and lack of cooperation. The maximum analgesic effect occurs after 45 to 60 seconds, and it is therefore important that the parturient use Entonox at the early onset of her contractions and discontinue its use after the peak of the contraction. Desflurane (0.2%), enflurane , and isoflurane (0.2% to 0.25%) have also been used to provide labor analgesia by means of hypnosis. The major risk when using volatile analgesics is accidental overdose resulting in unconsciousness and loss of protective airway reflexes.

27. Regional Analgesia in Obstetrics

28. Central Neuraxial Blockade Epidural Analgesia Spinal Analgesia/ Anesthesia CESA

29. Epidural Analgesia/ Anaesthesia “in the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labor”- ASA & ACOG join declaration

30. Timing of Epidural Analgesia Controversy exists regarding when it is appropriate to begin epidural analgesia during labor in an individual patient. “Early” epidural analgesia (e.g., before 5 cm cervical dilation) may interfere with uterine contractions and slow the progress of labor. If a patient in early labor requests epidural analgesia, first administer either a spinal or epidural opioid alone or an epidural opioid combined with a very dilute solution of LA

31. Contraindications Patient refusal or inability to cooperate    Increased intracranial pressure secondary to a mass lesion    Skin or soft tissue infection at the site of needle placement    Frank coagulopathy     Uncorrected maternal hypovolemia (e.g., hemorrhage)     Inadequate training in or experience with the technique

32. Preparation for Epidural/ Spinal Analgesia The patient requests epidural analgesia for pain relief (or for relief of anticipated pain ,planned induction of labor).   Preanesthetic evaluation, which includes an assessment of the patient's medical and anesthetic history.   The risks of epidural analgesia are discussed with the patient, and informed consent is obtained. The obstetrician is consulted to confirm the following:    That the patient is in labor and the obstetrician is committed to delivering the infant. That all relevant obstetric issues are understood (e.g., gestational age, intrauterine growth restriction, fetal presentation, risk of obstetric hemorrhage, previous cesarean delivery).   An assessment of fetal well-being is performed in consultation with the obstetrician.

33. Resuscitation Equipments DRUGS Thiopental Succinylcholine Ephedrine Atropine Epinephrine Phenylephrine Calcium chloride Sodium bicarbonate Naloxone EQUIPMENT Oxygen supply Self-inflating bag and mask for positive-pressure ventilation Masks Oral and nasal airways Laryngoscopes Endotracheal tubes Suction (including the necessary supplies) Intravenous catheters and fluids   Syringes and needles

34. Recommended Technique Informed consent is obtained, and the obstetrician is consulted.    Monitoring includes the following:    Blood pressure every 1 to 2 minutes for 15 minutes after giving a bolus of local anesthetic;   Continuous maternal heart rate monitoring during induction of anesthesia; Continuous fetal heart rate monitoring; and Continual verbal communication . Pre-hydration with 500 mL of Ringer's lactate solution. Lateral decubitus or sitting position. The epidural space is identified with a loss-of-resistance technique. The epidural catheter is threaded 3 to 5 cm into the epidural space.

35. Recommended Technique A test dose of 3 ml of 1.5% lidocaine with 1:200,000 epinephrine is injected after careful aspiration and after a uterine contraction. If the test dose is negative, one or two 5-mL doses of 0.25% bupivacaine are injected to achieve a cephalad sensory level of approximately T10. After 15 to 20 minutes, the block is assessed by means of loss of sensation to cold or pinprick. If no block is evident, the catheter is replaced. If the block is asymmetric, the epidural catheter is withdrawn 0.5 to 1.0 cm, and an additional 5 to 10 ml of the same bupivacaine solution is injected. If the block remains inadequate, the catheter is replaced.

36. Recommended Technique The patient is cared for in the lateral or semilateral position to avoid aortocaval compression. Subsequently, maternal blood pressure is measured every 5 to 15 minutes. The fetal heart rate is monitored continuously. The level of analgesia and the intensity of motor block are assessed every 1 to 2 hours .

37. Maintenance of Epidural Analgesia INTERMITTENT BOLUS INJECTION Single epidural injection of LA does not provide adequate analgesia for the duration of labor. Exclude migration of the epidural catheter into a blood vessel or the subarachnoid space. After several injections, blockade of the sacral segments, intense motor block, or both may develop. Sensory level and the intensity of motor block should be assessed and recorded before and after each bolus injection of local anesthetic. CONTINUOUS EPIDURAL INFUSION Benefits include:(1) the maintenance of a stable level of analgesia; stable maternal heart rate and blood pressure, & decreased risk of hypotension; less frequent need to give bolus doses of LA, which reduce the risk of LAST. continuous epidural infusion technique does not obviate the need for frequent assessment of the patient.

38. Recommended Regimen for Epidural Drug Intermittent injection Continuous infusion Bupivacaine 5-10 mL of a 0.125%-0.375% solution every 60-120 min 0.0625%-0.25% solution given at a rate of 8-15 mL /hr Ropivacaine 5-10 mL of a 0.125%-0.25% solution every 60-120 min 0.125%-0.25% solution given at a rate of 6-12 mL /hr Lidocaine 5-10 mL of a 0.75%-1.5% solution every 60-90 min 0.5%-1.0% solution given at a rate of 8-15 mL /hr

39. Patient Controlled Epidural Analgesia With this technique, each patient can adjust her level of analgesia. PCEA has been associated with greater maternal satisfaction as compared with both intermittent bolus injection and continuous epidural infusion. PCEA results in a lower average hourly dose of bupivacaine than does a continuous epidural infusion of bupivacaine . Reserved for patients who are willing and able to understand that they are in control of their analgesia.

40. Regimens of PCEA Anesthetic solution Basal infusion rate (mL/hour) Bolus dose (mL) Lockout interval (minutes) Maximum hourly dose (mL) Bupivacaine, 0.125% 4 4 20 16 Bupivacaine, 0.125%, plus fentanyl, 2 μg/mL 6 3 10 24 Bupivacaine, 0.25% 3 5–20 12 Bupivacaine, 0.11%, plus fentanyl, 2 μg/mL 10 5 10 30 Bupivacaine, 0.0625%, plus fentanyl, 2 μg/mL, plus clonidine, 4.5 μg/mL 4 15 16 Ropivacaine, 0.125% 6 4 10 30

41. Analgesia for Second stage of labor Require a more concentrated solution and/or a greater volume of LA than is required during the first stage of labor. The continuous epidural infusion of bupivacaine often results in the gradual development of sacral analgesia. Additional bolus doses of LA can be required to augment perineal analgesia. Administration of a larger volume of LA solution facilitates the onset of sacral analgesia. This also results in a higher (i.e., more cephalad ) sensory level of analgesia, and the patient should be observed for evidence of hemodynamic or respiratory compromise.

42. Analgesia in advanced labor Advanced labor does not preclude the placement of a lumbar epidural catheter, especially in a nulliparous woman. Another option is to administer combined spinal-epidural (CSE) analgesia. A caudal epidural catheter, which facilitates the onset of sacral analgesia, is an option for analgesia late in labor. Disadvantages are(1) increased technical difficulty ; (2) increased LA dose requirement during the first stage; and (3) the risk of injecting the LA into the fetus. Sacral analgesia adequate for labor and delivery can be achieved with an injection of 12 to 15 mL of 0.25% bupivacaine , 1.0% to 1.5% lidocaine .

43. Spinal Analgesia/ Anesthesia Not very effective in laboring women. A single-shot injection has a finite duration, and multiple injections result in an increased risk of PDPH. Single subarachnoid injection of an opioid may be appropriate. A “saddle block” can be administered to achieve blockade of the sacral spinal segments; a small dose of a hyperbaric local anesthetic solution is adequate for this purpose. Placement of a catheter in the subarachnoid space is not recommended by US FDA

44. Complications Hypotension (Incidence 17-20%) Inadequate Analgesia (0.5-1.5%) Intravascular Injection of Local Anesthetic Unintentional Dural Puncture (1-7.6%) Unexpected High Block Subdural injection of a local anesthetic (0.82%) Extensive Motor Block Urinary Retention Back Pain: prospective studies have consistently shown that no causal relationship exists between the use of epidural analgesia and the development of long-term postpartum backache. Pelvic Floor Injury

45. Neonatal Outcome Newborns whose mothers received epidural analgesia had higher pH measurements and less metabolic acidosis in the first hour of life as compared with newborns whose mothers received systemic opioid analgesia. No difference in neonatal outcome (as assessed by Apgar scores and umbilical cord blood pH measurements). No difference in long term neonatal outcome.

46. “Expectant mothers can be reassured that, although epidural analgesia may be associated with some short term maternal side effects, it does not exacerbate fetal acidosis, and if anything, may partially protect the fetus from fetal hypoxia. It is important to dispel the notion that epidural analgesia is in some way harmful to babies.” - Reynolds F, Sharma SK, Seed PT: Analgesia in labor and fetal acid-base balance: A meta-analysis comparing epidural with systemic opioid analgesia.   BJOG   2002; 109:1344-1353.

47. Neuraxial Opioid Opioids block the transmission of pain-related information by binding at presynaptic and postsynaptic receptor sites in the dorsal horn of the spinal cord (i.e., Rexed laminae I, II, and V), and in the brainstem nuclei, periventricular gray matter, medial thalamus. They are associated less adverse effects than systemic use

48. Epidural Opioid Opioid and a LA are given epidurally , they interact synergistically to provide effective pain relief. Epidural administration of an opioid alone provides moderate analgesia during early labor, but the dose needed to maintain analgesia is accompanied by significant side effects. Epidural opioid alone provides inadequate analgesia during the advanced phase of the first stage of labor & during the second stage.

49. OPIOIDS USED TO PROVIDE EPIDURAL ANALGESIA DURING LABOR Drugs Dose Onset (Minutes) Duration (hours) Morphine 3–5 mg 30–60 4–12 Pethidine 25–50 mg 5–10 2–4 Butarophanol 2–4 mg 10–15 6–12 Fentanyl 50–100 μ g 5–10 1–2 Sufentanil 5–10 μ g 5–10 1–3

50. INFUSION REGIMENS FOR CONTINUOUS EPIDURAL ANALGESIA DURING LABOR Drug Bupivacaine-fentanyl Bupivacaine-butorphanol Bupivacaine-sufentanil Loading dose Bupivacaine 0.125%–0.25% 0.125%–0.25% 0.125%–0.25% Opioid 2µg/ml 2.5–5 μ g/mL 0.2 mg/mL Volume 10–15 mL 10–15 mL 10–15 mL Infusion Bupivacaine 0.125%–0.25% 0.0625%–0.125% 0.0625%–0.125% Opioid 1µg/ml 1–2 μ g/mL 0.1 mg/mL Rate 10–15 mL/hr 10–15 mL/hr 8–12 mL /hr

51. Intrathecal Opioids rapid onset of pain relief have a predictable duration of action minimize undesirable side effects (e.g., motor block, hypotension) preserve proprioception have no effect on the fetus Intrathecal opioids alone provide effective analgesia during early labor but they do not provide effective analgesia during advanced labor.

52. Intrathecal Opioid: Regimen Drug Dose Morphine 0.25–0.3 mg Fentanyl 15–30 μ g Sufentanil 5–10 μ g Meperidine 10 mg

53. Complications of Neuraxial Opioid Pruritus Neurotoxicity Sensory Changes Hypotension Nausea and Vomiting Respiratory Depression Delayed Gastric Emptying Recrudescence of Herpes Simplex Viral Infection Postdural Puncture Headache

54. Fetal Effects of Opioid Direct fetal effects may include intrapartum effects on the FHR as well as possible respiratory depression after delivery. Indirect fetal effects include fetal bradycardia . Fetal bradycardia after labor analgesia does not appear to have a detrimental effect on the outcome of labor.

55. Effects of analgesia on labor Epidural analgesia to reduce uterine activity in some patients, but it results in enhanced uterine activity in others. Duration alone is of little significance if labor pain is adequately controlled and fetal/neonatal well-being is preserved. Maintenance of total anesthesia prolongs the second stage of labor. Use of epidural analgesia results in a small increase in the cesarean section rate.

56. Effects of analgesia on labor Administration of a dilute solution of LA results in fewer cases of malposition of the vertex and fewer instrumental vaginal deliveries than administration of a more concentrated solution. Epidural analgesia was not associated with a prolonged third stage of labor.

57. Peripheral Nerve Blocks In first stage of labor: Paracervical block Lumbar sympathetic block In second stage of labor: 1. Pudendal nerve block

58. Paracervical Block This nerve plexus lies lateral & posterior to the junction of uterus & cervix, at the base of broad ligament. Patient position: Lithotomy with left uterine displacement. Timing: First stage of labor, before the cervix is dilated 8 cm. Equipments: 12-14cm 22G needle/ Kobak needle with Iowa trumpet. Technique: Index & middle finger of right hand introduce the needle into the lateral fornix for the right side & vice-versa in the left, with lateral diversion, the after aspiration deposit 10ml LA just beneath the epithelium.

59. Paracervical Block Site of drug deposition: Two 10ml at 3 & 9 o’clock cervical position 3-5ml LA at four sites ( 4,5,7,8 o’clock position) Six different injections, 3ml each Contralateral injection should be given after 5 min or two uterine contraction. Onset usually within 5 minute, failure rate between 5-13% Lignocaine without adrenalin is the most preferred drug. Bupivacaine is NOT recommended for this block. Complications include broad ligament hematoma, sciatic nerve block, parametritis , subgluteal & retropsoal abscess, neuropathy and LAST

60. Lumbar Sympathetic Block Paravertebral lumbar sympathetic block interrupts the transmission of pain impulses from the cervix and lower uterine segment to the spinal cord. Lumbar sympathetic block provides analgesia during the first stage of labor but does not relieve pain during the second stage. It provides analgesia comparable to that provided by paracervical block but with less risk of fetal bradycardia .

61. Lumbar Sympathetic Block Technique Patient in the sitting position 10-cm, 22-gauge needle is used to identify the transverse process on one side of the second lumbar vertebra. The needle is then withdrawn, redirected, and advanced another 5 cm so that the tip of the needle is at the anterolateral surface of the vertebral column, just anterior to the medial attachment of the psoas muscle. Two increaments of 5ml LA solution on each side of vertebral column after careful negative aspiration. Modest hypotension occurs in 5% to 15% of patients.

62. Pudendal Nerve Block The pudendal nerve(S2-4) represents the primary source of sensory innervation for the lower vagina, vulva, and perineum. It also provides motor innervation to the perineal muscles and to the external anal sphincter. Effective in relieving second stage labor pain. Technique: Transvaginal (More popular) A needle and needle guide is introduced into the vagina with the left hand for the left side of the pelvis and with the right hand for the right side. The needle is introduced through the vaginal mucosa and sacrospinous ligament, just medial and posterior to the ischial spine . The pudendal artery lies in close proximity to the pudendal nerve; thus the one must aspirate before and during the injection of LA.

63. Pudendal Nerve Block A 7-10 ml LA is sufficient. A diluted solution of any LA is safe & effective. Maternal complications are uncommon, but can be Laceration of the vaginal mucosa, Vaginal and ischiorectal hematoma, Retropsoal and subgluteal abscess & LAST. Fetal complications are rare. The primary fetal complications result from fetal trauma and/or direct fetal injection of local anesthetic.

64. Postoperative Analgesia after LUCS Epidural analgesia: Epidural opioid, LA or LA+Opioid Intrathecal opioid Systemic analgesic Peripheral nerve block

65. Opioids in Postoperative Analgesia Opioids can be given as intermittent im or iv injection or continuous iv infusion. PCA can also be an attractive options for those who are willing & educated. Most important concern is the neonatal effects of opioids that secreted in breast milk.

66. Opioids & Lactation Analgesic Category Milk: plasma ratio Newborn tolerance Butorphanol 3 1.9 (oral) 0.7 (intramuscular) No reports of adverse effects Codeine 3 2.5 Possible accumulation Fentanyl 3 > 1 Well tolerated Heroin 3 > 1 Possible addiction Hydromorphone — No data No data Meperidine 3 1.4 Prolonged half-life Methadone 3 0.83 caution: Withdrawal symptoms possible with abrupt cessation Morphine 3 0.23–5.07 Possible accumulation Nalbuphine — No data No data Oxycodone — 3.4 Periodic sleeplessness; failure to feed Oxymorphone — No data No data Pentazocine — Minimal excretion No data Propoxyphene 3 0.50 Poor muscle tone reported

67. The effects of maternal medication can be minimized by giving attention to the following principles: (1) avoiding the administration of drugs with a long plasma half-life; (2) when possible, delaying drug administration until just after an episode of breast-feeding; (3) observing the neonate for abnormal signs or symptoms (e.g., change in feeding or sleep patterns, somnolence, decreased muscle tone, increased irritability); (4) when possible, choosing drugs that have the least potential for excretion into breast milk and accumulation in the neonate or that are known to be tolerated by the newborn.

68. “The American Academy of Pediatrics Committee on Drugs lists butorphanol, codeine, fentanyl, methadone , and morphine as maternally administered opioids that typically are compatible with breast-feeding.”- American Academy of Pediatrics Committee on Drugs.: The transfer of drugs and other chemicals into human milk.   Pediatrics   2001; 108:776-789

69. NSAID They reduce opioid consumption by the patient. NSAIDs reduce the inflamatory pain. Acitamenophen , Ibuprofen, Aspirin, Ketorolac & Diclofenac are designated as Category 3 drug by AAP, so they are well tolerated.

70. Adjunctive Peripheral Nerve Blocks Rectus sheath block Bilateral ilioinguinal & iliohypograstic nerve block Bilateral transversus abdominis plane block

71. Thank you