pain relief in labour.ppt

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  • 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)

  • Thank You!