PAIN RELIEF IN LABOUR

Pain in labourAn inevitable priceAim - Minimize Elimination

How does the pain occur?(1)1st stageUterine contractionsReduced blood supplyIschemiaAccumulation of pain causing metabolites

How does the pain occur? (2)2nd stageAdvancing presenting part of the fetusStretching of perineal tissue

Why should the pain be relieved?(1)

Unpleasant Maternal exhaustion Maternal acidosis Fetal acidosis Fatigue Low morale

Why should the pain be relieved?(2)Catecholamine release HR & BP Coronary blood flow Splanchnic blood flow Uterine blood flow Fetal hypoxia Uterine dystonia Delayed gastric emptying Paralytic ileus

Mode of pain relief(1)Depends on: Obstetric history Labour - Course Length

Modes of pain relief(2)Non pharmacological managementPharmacological management + Anaesthetic methods

Non pharmacological managementPsychoprohylaxisPsychotherapyPhysical methods

Pharmacological managementPethidineMorphineNitrous oxide gas

Anaesthetic methodsEpidural analgesiaSpinal analgesiaCombined spinal and epidural analgesiaCaudal block Pudendal block

Psychoprophylaxis

Starts in antenatal periodEducation on process of labour,available modes of pain reliefElimination of myths

PsychotherapyAn adjuvant therapyMother in labourCounsellingReassuringAdvice to requestCalm and friendly approach(TLC)

Physical methodsTrans cutaneous electrical nerve stimulation (TENS)Breathing exercisesRelaxation techniquesHomeopathyAcupunctureHypnosis

TENS

Used in early labourLess adverse effectsLess effectiveNot practiced in Sri Lanka

Breathing exercisesProlonged hyperventilation Dizziness Alkalosis

Relaxation techniquesDoes not relieve painEasy to manage

Pethidine(1)Dose: 1mg/kg body weight 50mg-small built mother 75mg- average built mother 100mg- well built motherRoute-IM

Pethidine(2)Side effectsNauseaVomitingSedation Mother NB-Bonding, breast feedingRespiratory distress to the new bornDelayed gastric emptying

Pethidine(3)Management of side effectsVomiting Metaclopromide 10mg IM Promethazine 25 mg IM (cheaper) Respiratory distress of the new born Naloxone 60mic.g/kg(200mic.g) IV

Pethidine(4)Not suitable forHT/PIH Norpethidine- convulsant propertiesDanger if have to under go GA Delayed gastric emptying Regurgitation and aspiration Skilled cricoid pressure IV Ranitidine

MorphineSubstitute for pethidinePreferred in heart disease,multi motherDose: 10mg SC/IM

Epidural analgesia(1)Most effective methodCan top up the doseGood for primi,those who have the risk of going into EM/LSCSNeed trained personIncreases operative delivery rate, length of labourIncreases the needed dose of oxytocics

Epidural analgesia(2)IndicationsProlonged labourMultiple gestationsCertain maternal medical diseasesHigh risk of going into surgeryPost LSCS analgesia

Epidural analgesia(3)ContraindicationsCoagulation disordersLocal/systemic sepsisHypovolaemia

Epidural analgesia(4)Technique(1)IV infusion of 500-1000ml crystalloid (To prevent hypotension)Interspace - L2/3,L3/4,L4/5 Insert the catheterAspirate to confirm the space (Blood, CSF)Test dose-2ml 0.5% Bupivacaine

Epidural analgesia(5)Technique(2)Observe- 5min SAS Leg weakness, hypotensionLoading dosePatient-Lateral positionMonitor BP in every 5min for 30 minSupplementation- Fentanyl

Epidural analgesia(6)Side effectsNauseaLight headednessHypotension (Therefore good in HT/PIH)HyperventilationMaternal and fetal hypocapneaDizzinessTetany

Epidural analgesia(7)Treatment of hypotensionOther lateral positionLeft uterine displacementIntravenous fluidVasopressors Ephedrine

Spinal analgesia(1)Need trained personCannot top up the dosePreferred for multi, LSCSDrugs - Morphine + FentanylCaution- Maternal respiratory depression

Spinal analgesia(2)Side effects-Post-dural puncture headacheSevere hypotensionRespiratory failureUnconsciousness (Can Be Fatal)Drug toxicityNeurological complications

Combined epidural & spinal analgesiaRapid onset of actionLow dose of local anaesthetic

Caudal blockGood for late stage

Pudendal blockGood for forceps delivery

ReferencesGuidelines for Introductory Obstetrics & Gynaecology (Professor C. Randeniya)Obstetrics By Ten Teachers(17th edition)

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