Dr. Ramilaben Chaudhary 2nd year resident Labour Analgesia Dr. Ramilaben Chaudhary 2nd year resident

History Pain during pregnancy is a physiological phenomenon but one must know that once it exceeds a certain intensity and duration does produce harmful effects both on mother and fetus and thence some form of analgesia must be offered to all parturient.

Cont…. In1853, Dr John gave first obstetric analgesia to Queen Victoria who delivered Prince Leopold under the effect of chloroform.

Nerve Supply Uterus and cervix -Sensory pathway ran by way : Uterus and cervical ganglia (Frankenhauser) ,inferior and superior hypogastric plexus.  Posterior roots of 11th and 12th thoracic nerves (T11 & T12) and sometimes T10 and L1.

Motor pathway run by Starts in 10,11 and 12th thoracic vertebra  Aortic,hypogestric & uterine plexuses Terminate in uterus

Vulva, Vagina and perineum Afferent fibers carrying sensations from birth canal,perineum and vulva. Afferent fibers of posterior roots of S2, S3 and S4. Main motor supply via Pudendal nerve

Cause of pain -thinning of lower uterine segment First stage: Due to - uterine contractions -thinning of lower uterine segment - dilatation of cervix

Second stage - Stretching of vulva, vagina and perineum. Due to -Uterine contractions - Stretching of vulva, vagina and perineum.

Third stage - Uterine contraction Due to -Passage of placenta through cervix - Uterine contraction

Causes of pain Myometrial hypoxia Stretching of cervix Pressure on nerve ganglia adjacent to cervix Pressure on bladder, urethra and rectum Traction on tubes, ovaries and peritoneum Traction on supporting ligament Distension of muscles of pelvic floor

Ideal prerequisites For the mother: - Relief of pain - Freedom from fear of vaginal delivery - Safe and painless delivery -Efficiency of contractions not decreased -Pt cooperation is maintained - Health of mother is not in danger

For the infant: -Should not cause neonatal depression -Should not cause fetal bradycardia For the obstetrician: -Deliberal management of labour -Optimum condition at delivery

Methods of pain relief Non pharmacological Pharmacological

Non pharmacological Natural child birth -Emotional support -Hot and cold compresses -Vertical position

Conti…. Acupuncture -Transcutaneous electrical nerve stimulation -Psycho prophylaxis

TENS Intermittently pulsed electrical current to the back over the lower thoracic and upper spine.  sensory fibres are stimulated & synapse with interneurons in substantia gelatinosa. So inhibit the release of neurotransmitter it shortens the overall duration of labour & give great satisfaction to mother.

Cont... Touch and massage -Hydrotherapy -Biofeedback -Hypnosis

Pharmacological methods Systemic drugs: -Opiates -Benzodiazepines -Barbiturates -Ketamine -Phenothiazines -NSAIDS

Cont…... Peripheral nerve blockade -Paracervical -Local infiltration -Pudendal

Cont…. Central nervous blockade -Spinal -Lumber epidural -caudal epidural -combined spinal and epidural

Inhalational agents Nitrous oxide Halothane Isoflurane

During first stage of labour Objectives: -Pain relief -Maintaining mother’s cooperation -No or with interference in progress of labour

Systemic medications Paracervical block Epidural block

Systemic medications They cross the placenta They may be -Narcotic medications -Amnesics -Sedative tranquilizers

Narcotic medications Used to alleviate pain Pethidine can be used. Dose:50-100mg IM 25-50MG IV Peak analgesia:IM 40-50 mins IV 5-10 mins Duration: 3-4 hrs

Side effects Dose dependant neonatal depression Decreased beat to beat variability in FHS Decreased Apgar score Poor neonatal neurobehavioral score

Narcotics effects in fetus can be antagonized with Naloxane 5-10 mg/kg

Amnesics Hyoscine is used 0.2 to 0.6mg intramuscularly with analgesia Effect on maternal behavior is unpredictable e.g. Excitement to Delirium S/E include dry mouth,fetal Tachycardia

Sedative Tranquilizers Barbiturates:Phenobarbital & secobarbital have been tried but causes fetal respiratory depression with repeated doses. Phenothiazines:Chlorpromazine,prochlorperazine and promethazine.Desirable effects are Sedation,antiemesis & lack of fetal resp depression.

Benzodiazepam Used as sedatives. Reduce anxiety,promote sleep in early labour & decreased narcotic requirements without prolonging labour. Diazepam:Crosses placenta immediately Dose:<30mg S/E Hypotonia,hypothermia,lethargy and resp.depression in baby

Paracervical block Effective method Easily performed Can be given by Obstetrician

Technique Transvaginaly During active phase 20 gauge needle 13-18 cm long Into posterolateral Fornices at 3& 9 o’clock position Effectiveness for 1 hour.

Complications Maternal: -Paraesthesia in limbs - IV injection -Hypotension -Hematoma Fetal: -24% bradycardia -4%Tachycardia -2% mixed pattern

Pain relief during 2nd stage Inhalational analgesia Inhalational anesthesia Intravenous anesthesia Regional anesthesia: -epidural - spinal -caudal -Pudendal

Inhalational analgesia & anesthesia Generally reserved for situations where rapid deliveries are required like fetal distress, intrauterine manipulations

Nitrous oxide Relatively insoluble in blood Induction & recovery is fast effective analgesia during contractions generally nontoxic given as Entonox :50:50 mixture in oxygen so decreased chances of maternal hypoxemia

Halothane & Isoflurane Initial analgesia Anesthesia follows with higher dosage BP decreased in a dose dependent fashion decreased intensity of uterine contraction

Intravenous anesthesia For rapid induction of GA Agents are Thiopentone, Ketamine & Propofol used as inducing agents followed by Inhalational anesthesia for maintenance.

Cont….. Thiopentone: <4mg/kg Ketamine: 0.25mg/kg and infusion rate of 0.5 to 1 microgram/kg/min -lower doses it is safe and effective -Higher doses:-maternal apnea -Laryngospasm -hypertension &  ut tone.

Cont…. Contraindications of Katamine -Pre eclampsia -Eclampsia -Hypertension -Psychiatric disease -Epilepsy

Regional Anesthesia Epidural block Spinal block Caudal block Pudendal block Local infiltration

Advantages of regional anesthesia Complete relief of pain is possible so decreased degree of hyperventilation and improve Utero placental perfusion. Nearly eliminate psychological and emotional reaction to severe pain.

Effective pain relief changes incoordinate uterine contraction to co ordinate one and improve the placental circulation. Allow parturient to be awake and participate in in labor.

Disadvantages Increased incidence of Occiput posterior or Occiput transverse position if premature perineal relaxation is produced. Complications like maternal Hypotension,total spinal & local anesthetic toxicity is possible. Urge to bear down is decreased.

Epidural Anesthesia Technique: During active phase of labour -pt on side or sits up -Needle in 2nd & 3rd lumbar interspace -Catheter is inserted -Drug is injected -Relief of pain in 5-10mins & max. effect in 15-20 mins.

Contraindications Allergy to the drug Coagulopathy Skin infection at site Significant hemorrhage Supine Hypotension syndrome Significant cardiopulmonary ds. Ds of CNS or PNS

Limitations Autonomic blockade Hypotension Post dural puncture headache. Missed segment High or total spinal blockade.

Commonly used drugs Bupivacaine:Most commonly used. -Concentration ranging from0.05% to 0.5% . -Maximum dose:2mg/kg every 4hrly -Duration of action:2-3 hrs -S/E: cardiotoxicity if given IV.

Cont... Lignocaine:Used as 1-2% solutions -Toxic dose is 3mg/kg without adrenaline & 6-7mg/kg with adrenaline -Effective concentration are 0.75-1% for labour and vaginal delivery S/E: At higher conce. Compromised neonatal neurobehavioral function

Caudal block Performed by injecting into caudal space through sacral hiatus . Only after active phase. For block below T10 Damage may occur to fetal head. May paralyse perineal muscles

Spinal block Advantages: -Excellent anesthesia -Easier to administer than epidural -Useful for difficult deliveries

Disadvantages Post spinal dural headache Bladder dysfunction Parasthesia in lower limb Can not be used in early labour Increased incidence of operative deliveries

Double catheter One catheter in lumbar epidural space and another in caudal space. Combine epidural & extradural analgesia is more popular Now a days very popular

Pudendal Block Time of administration; Primi: Full dilatation Multi: 7-8cm dilatation Gives perineal analgesia & relaxation

Indications Spontaneous vaginal delivery Low forceps Breech deliveries Episiotomies Repair of lacerations

Types Percutaneous Trans perineal Trans vaginal

Advantages: -Simple -No systemic or fetal effects -Mother awake -No effects on ut contraction Disadvantages:-Does not relieve pain but gives perineal analgesia & relaxation -Perineal & Vulval infiltration needed. -Needle breaks & inj. Into vessel

Local Anesthesia For incision and repairs of episiotomy Agent used is Xylocaine 1% S/E:Trauma and inj of LA into fetal scalp .

Anesthesia for LSCS Local General Spinal

Depends on Indication of CS Prevalence of maternal condition Presence of complicating obstetric factors Fetal status Wishes of patients

Multiple pregnancy Epidural for labour ,vaginal delivery and CS GA may preferred Anteparterm hemorrhage General Anesthesia

Preeclampsia & eclampsia Epidural analgesia if no contraindications of that. GA may be used Diabetes malitus Epidural blockage for labour and delivery GA or regional for CS

Cardiac disease For Acynotic with mild MS epidural is preferred . For pts on anticoagulant:sedatives + Paracervical block.

PROGRAMMED LABOUR inclusion criteria. age-18-35yrs. maturity-37-41wks PROGRAMMED LABOUR inclusion criteria *age-18-35yrs *maturity-37-41wks *clinically no CPD *no medical or obstetric risk factors *no fetal distress With experience , high risk cases can be included

Entry criteria. Cx dilatation->3cm $ >50% effaced Entry criteria *Cx dilatation->3cm $ >50% effaced *fetal head should be engaged *show or amniotomy *Ut. Contraction ->3/10 min.& last for 35-45 sec.

Protocol *Amniotomy *FHS monitoring *Optimizing pains by prostaglandins or oxytocins *Optimizing pain relief facilitated by – 6.0 mg pentazocin & 2,0 mg diazepam diluted in 10 ml DW & give IV *Tramadol -1.0mg/kg wt IM *Inj. Drotin 1amp. Or Inj.Epidocin 1amp. *at 7-8 cm , if required , inj. Ketamine 0.5mg/kg wt. & then SOS ½ of the initial dose at ½ hrly till delievary

Thank you