Pain releif in labour - Nurses Diploma.ppt

Nursing

1. PAIN RELIEF
IN
LABOR

2. OBJECTIVES
•Different types of pain relief used in labour
•Advantages, disadvantages and
contraindications of each methods
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3. The Debate…
•“Labor results in severe pain for many women.
•There is no other circumstance where it is
considered acceptable for a person to
experience untreated severe pain, amenable to
safe intervention, while under a physician’s care
•Maternal request is a sufficient medical
indication for pain relief during labor.”
ACOG & ASA
3

4. History
•1840’s
 the first use of anaesthetics for labor

•1900’s
 the first case of regional anaesthesia in
labor
4

5. John Snow (1853) on Queen Victoria’s
Anaesthetic for the birth of Prince Leopold:
“The inhalation lasted fifty-three minutes.
The chloroform was given on a handkerchief
in fifteen minimum doses; the Queen
expressed herself as greatly relieved by the
administration.”
5

6. Pain during labour and delivery
•Pain is a subjective phenomenon
–Complex interaction of influences
•Physiologic
•Psycho-social
•Cultural-Social
•Environmental
•Pain of childbirth is likely to be the most severe pain
that a woman experiences during her lifetime.
BUT
•Pain varies among women, and each labour of an
individual may be different
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7. The Intensity of Pain in Labor
http://www.manbit.com/oa/oaindex.htm
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8. Adverse Consequences of Labour Pain
•Hyperventilation - Respiratory alkalosis
•reduces respiratory drive between contractions
•impairs oxygen transfer to fetus (left shift of oxy-hemoglobin
dissociation curve)
•Utero-placental vasoconstriction
•Neuro-humoral Effects
Increase in catecholamine and decrease in blood flow to the uterus,
lowering fetal oxygenation, increasing fetal bradycardia and acidosis
•Psychological Effects
Unrelieved pain may cause postpartum psychological trauma, that
could result in Post Traumatic Stress Disorder (prevalence of
postpartum PTSD found to be 5.6%)
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9. Potential effects of maternal hyperventilation and
subsequent hypocarbia on oxygen delivery to the fetus
9

10. Why is labour painful?
•Ischemia of uterine muscles
•Dilatation and strengthening of the cervix
•Stretching of the perineum in the second
stage of labour
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11. Nature of Labor Pain –
1
st
Stage
•Visceral pain
–Diffuse abdominal
cramping
–Uterine contractions
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12. Nature of Labor Pain –
2
nd
Stage
•Somatic pain
–Perineum
•Sharper and more continuous
•Pressure or nerve
entrapment (caused by
the head of the fetus)
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13. Approaches to management of labour
pain
•Pharmacologic –
eliminate physical sensation of labour pain
•Non-pharmacologic –
prevent sense of suffering
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14. Types of pain relief in labour
Non-pharmacological:
•Relaxation.
•TENS.
•Hypnosis.
•Acupuncture
•Hydrotherapy.
Pharmacological:
•Opiates.
•Inhalational.
•Epidural.
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15. Pharmacological Pain Relief

16. Pharmacologic options
•Systemic analgesics
–Opioids,
– Nonopioid agents
– Inhalation agents
•Local injection techniques
–Pudendal, Paracervical block
•Neuraxial analgesia
–Epidural and spinal techniques
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17. Inhalational anesthesia
•The commonest is nitrous oxide (N
2O).
•Self administered to the patient via a face
mask.
•Given in a 50/50 mixture with oxygen
(Entanox).
17

18. Inhalation Analgesia for Vaginal
Delivery
Advantages:
Easy to administer
Analgesia varying from good to ineffective
Depends on respiratory effort of the patient
Minimal neonatal depression
(N
2
O 30-50%; very low concentration volatile agents)
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19. Inhalation Analgesia for Vaginal
Delivery
Disadvantages:
– inadequate pain relief for the 2
nd
stage and for
instrumental deliveries
–Rapid induction of anesthesia in pregnancy
–Risk of drowsiness, unconsciousness and aspiration
–Difficult to remove (N
2O) nitrous oxide from labor rooms
(N
2
O 30-50%; very low concentration volatile agents)
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20. 20

21. Panadol + NSAID
Simple analgesia is usually ineffective in
controlling labour pain
X
21

22. Systemic Opioids in Labour
•Easy administration
•Inexpensive
•Avoids complications of regional or motor
block
•Does not require skilled personnel
•Few serious maternal complications
•Perceived as “natural”
Advantages:
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23. Systemic Opioids in Labor
•All drugs easily cross placenta
•Pain relief inadequate in most cases
•Maternal sedation / an uncooperative mother in labor
•Nausea, vomiting, gastric stasis
•Fetal heart rate effects:
•Dose-related maternal / neonatal depression
•Newborn neuro-behavioral depression
Disadvantages:
23

24. Which Systemic Opioid?
•Morphine:
– long half-life, neonatal depression
•Pethidine:
– neonatal depression (norpethidine effect)
– nausea, vomiting
•Fentanyl:
– short duration, minimal newborn effects
? Alfentanil
? Remifentanil
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25. •Pethidine
–The most commonly used opioid for pain relief
in labor
–Typical dose: 50 to 100 mg IM, 25 to 50 mg IV
Peak effect : 10 min IV, 50 min IM
Duration : 4 hr
–Neonate effects
•respiratory depression (less than morphine)
•The neonate is less likely to be affected if delivered
less than 1 hour after dosing or more than 4 hour
after dosing
•Metabolites have long half-life
26

26. Parenteral Opioids
•Adverse symptoms
–Nausea
–Drowsiness
•Inability to urinate
•Inability to participate in labor
•LSCS is not possible
•Instrument-assisted vaginal delivery
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27. Parenteral Opioids - Infant
•Neonatal respiratory depression
•Decreased alertness
•Inhibition of sucking
•Lower neuro-behavioral scores
•Delay in effective feeding
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28. Local and regional techniquesLocal and regional techniques
•Local injection techniques – not practical at
this situation
–Pudendal block
–Paracervical block
–Paravertebral (lumbar sympathetic block)
•Regional neuraxial analgesia
–Epidural - lumbar (caudal)
–Spinal
–Combined spinal-epidural (CSE)
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29. Regional anesthesia
•Epidural anesthesia
•Spinal anesthesia
•Combined Spinal and epidural technique (CSE)
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30. Regional Analgesia : Epidural
•Epidural analgesia offers the most effective form of
pain relief.
•Indications
–Maternal request for pain relief - primary indication
–Medical indications
•anticipated difficulty in intubation
• history of malignant hyperthermia
•selected cardiac or respiratory disease
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31. Regional Analgesia : Epidural
•Continuous epidural infusion of local anesthetics
+/- opioids.
•Medication dose and rate can be titrated.
•Can be used for LSCS or postpartum tubal
ligation after the delivery
•Combination of a low dose local anesthetic, such
as bupivacaine, with an opioid are preferred
because they decrease motor blockade and
result in an increased rate of NVD.
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32. Epidural Analgesia
•Balance between pain relief and other
goals…
–Walking (1
st
stage)
–Pushing effectively (2
nd
stage)
–Minimizing side effects
•maternal and neonatal
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33. 35
Con’t Anesthesia
Epidural anesthesia:
•Most commonly
used technique for
both labor &
delivery.
•19 gauge
indwelling catheter
inserted into
lumbar epidural
space @ L3-4.

34. 36
Con’t Anesthesia
•Does not prolong 1
st

stage, but may
reduce maternal
expulsive efforts,
therefore usually
used in earlier
stages of labor (<4
cm).

35. Epidural anesthesia
•Need prior IV hydration
•Continuous monitoring of the FHR and
contractions
•20 min of close BP monitoring after 1
st

dose and after top up doses for 10min
•Placed at L2-3 or L3-4
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36. Epidural
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37. Equipment needed
•Anaesthetic machine with a good source of O
2
•Multi monitor
•Suction apparatus
•Theater table or a trolley with tilt-able facility
•Good Light source
•Epidural set ( 16G or 18G)
•Drugs – (Emergency) Atropine, ephedrine & adrenaline
•Sterile procedure trolley
•IV cannula, IV fluids & plaster
•Trained MOA, Nurse, helping staff
•Papers for documentation
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38. •A sterile trolley with epidural set
•Aseptic technique – mask, cap, gown & glows
•IV cannula with running saline drip
•Monitoring Pulse and BP
•Sitting position or lateral position
•Clean the back
•Sterile towels
•Local anaesthetic to skin
•18G/16G Tuohy needle
•Loss of resistance with air or saline
•Catheter placement 3-4 cm inside the epidural space
•Sterile dressing
•Test dose 3ml 0.5% plain bupivacaine
•Infusion started 0.1% plain bupivacaine in 50ml syringe +/- fentanyl 6-8ml per hour ( rate
can be adjusted according to pain)
•Continue monitoring
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Procedure

39. Procedure
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40. 42

41. Variations..
•CSE - Combined Spinal Epidural
•Intrathecal opioid injection before
continuous epidural infusion
*Often are unable to walk…
–Substantial motor blockade
–Need continuous fetal monitoring
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42. Advantages:
•Rapid onset of complete pain relief
•Can convert quickly into “epidural
anaesthesia” if an emergency LSCS is
needed
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43. First steps to painless
Motherhood!
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Walking Epidural

44. Epidural Analgesia - Effects
•Slows labor (1st and 2nd stages)
•Increases use of oxytocin
–oxytocin augmentation
•Increased instrument-assisted delivery
–forceps/vacuum extraction
•Increased cesarean (?)
•Maternal fever in (15% - 25%) – cause not
known
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45. Concern
•Epidural-induced maternal fever
–Unnecessarily increases work-ups for
neonatal sepsis
–Increased neonatal antibiotics
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46. Epidural – Side Effects
Common:
•Hypotension
•Impaired motor function depends on dose of the
epidural
•Need for catheterization
Uncommon (<10%):
•Pruritis – if an opioid is added
•Nausea & vomiting
•Sedation
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47. Epidurals- Complications
•incomplete block, Unilateral block
• Maternal hypotension
•accidental dural puncture – PDPH
–50% get headache because of large bore needle
–incidence 0.5-1%
•intravascular injection
•Accidental Sub arachnoid injection
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48. EPIDURAL ANALGESIA
Disadvantages:
•Onset – takes time
•May be associated with motor block
•Risk of post dural puncture headache (50-85%
with 16 or 18-G Tuohy’s needle)
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49. •Regional anesthesia
–Side effect
•Pruritus
•inability to pass urine
•Hypotension
–The effects of regional anesthesia
•Not increase the rate of primary cesarean section
•increase the rate of oxytocin administration,
operative vaginal delivery, episiotomy, and
antibiotic use
•increase the length of both the first and second
stages of labor
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50. Fetal / Neonatal Effects of Regional
Analgesia in Labor
•Uterine perfusion maintained
•Profound hypotension & possible fetal
compromise
•LA toxicity - extremely rare
•FHR changes:
•Apgar scores, acid-base status, unaffected
•Neurobehavioral effects absent with current
agents
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51. Systemic vs. Regional analgesia
•Systematic Review found:
–Opioids provided limited pain relief, only
slightly better than placebo
–Epidural analgesia provided better pain relief
than parenteral opioids
–Epidural analgesia assoc with longer duration
of labor, increased oxytocin augmentation,
more instrumental deliveries
–Effect on LSCS rate varied by study
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52. FAQs of epidurals
•How is the epidural catheter placed?
•Is placement of an epidural painful?
•What kind of pain relief can I expect from my epidural?
•Will an epidural slow my labor?
•How am I positioned during the placement of my
epidural?
•Will an epidural increase my risk for a C-section?
•What are the most common side effects of an epidural?
•What drugs are used in an epidural?
•Is everyone a candidate for an epidural?
•I am going to have a C-section. What can I expect?
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53. Conclusions
•Individualize technique to patient’s
goals and stage of labor
•Optimize management for spontaneous
delivery
•Provide safe, cost-effective analgesia
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54. Ideal labour analgesia ?
•Mother
•Fast, effective, continuous analgesia;
mobility & 2
nd
stage pushing.
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55. Ideal labour analgesia ?
•Obstetrician
•No effect on labour outcome.
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56. Ideal labour analgesia ?
•Neonatologist
•No effect on neonatal outcome.
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57. Ideal labour analgesia ?
•Anaesthetist
•All the above + no side effects, complications,
risks.
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58. The Ideal Labor Analgesic
•Good pain relief
•No autonomic block (no hypotension)
•No adverse maternal or neonatal effects
•No motor block
•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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