1. Tubal Ligation (Female Sterilization) Session IIID: Pain Management for Minilaparotomy
Explain:
The purpose of this session on pain management for minilaparotomy is to enable participants provide safe services by minimizing the client’s psychological, physical discomfort and pain

2. Session Objectives
Define the goal of pain management during minilaparotomy
List the guiding principles for pain management during minilaparotomy
State considerations for selecting a pain management regimen
List different pain management options
Describe why local anesthesia with moderate sedation/analgesia is the regimen recommended in this training course
Define sedation, analgesia, and local anesthesia
Demonstrate (during clinical practice) the steps for administering the recommended pain management regimen
Demonstrate (during clinical practice) proper communication with the client, to reduce anxiety and pain
Explain the critical role of the client monitor in pain management during minilaparotomy procedures
Explain:
By the end of this session, participants will be able to:
Define the goal of pain management during minilaparotomy
List the guiding principles for pain management during minilaparotomy
State considerations for selecting a pain management regimen
List different pain management options
Describe why local anesthesia with moderate sedation/analgesia is the regimen recommended in this training course
Define sedation, analgesia, and local anesthesia
Demonstrate (during clinical practice) the steps for administering the recommended pain management regimen
Demonstrate (during clinical practice) proper communication with the client, to reduce anxiety and pain
Explain the critical role of the client monitor in pain management during minilaparotomy procedures
Ask if there are any questions or issues that need clarification, and respond to these as needed.

3. Goal and Guiding Principles of Pain Management
The goal of pain management is to reduce the client’s anxiety and her perception and experience of discomfort and pain, thus allowing surgery to proceed, followed by an uneventful postoperative recovery period.
Guiding Principles
Clients should receive adequate analgesia and sedation to minimize their anxiety and pain and maximize comfort
In all settings, adequate pain management is feasible
Drugs used should be safe, affordable, readily available, and in regular supply.
A readily available and safe local anesthetic drug is used to block pain.
The lightest depth of sedation and analgesia needed to adequately control pain and anxiety is preferred.
Pain management begins before the procedure and continues after it.
Ensure as much comfort as possible for the client.
Explain: The goal of pain management is to reduce the client’s anxiety and her perception and experience of discomfort and pain, thus allowing surgery to proceed, followed by an uneventful postoperative recovery period.
The guiding principles for pain management include the following:
Clients undergoing female sterilization by minilaparotomy should receive adequate analgesia and sedation to minimize their anxiety and pain and maximize comfort.
Even in low-resource settings, adequate pain management is feasible and necessary.
Drugs chosen for sedation and analgesia should be safe, affordable, readily available, and in regular supply.
A readily available and safe local anesthetic drug is used during the procedure to block pain
The lightest depth of sedation and analgesia needed to adequately control pain and anxiety is preferred, because risks increase with the depth of sedation.
Pain management should begin before the procedure, with preoperative counseling and medication aimed at allaying anxiety, and continues after the procedure to ensure a quick and uneventful recovery.
The surgical team should ensure as much comfort as possible for the client during the procedure and into the postoperative period.
Ask if there are any questions, and respond to these as needed.

4. Factors Influencing the Selection of a Pain Management Regimen
Local policies, guidelines, and protocols
The surgical approach to be used
The level of experience of the surgeon and the team
The client’s preference and understanding of pain management options
The client’s safety and comfort
The availability of drugs, equipment, and supplies
The cost of the pain management options
The service site’s ability to manage complications
Explain:
The pain management regimen that is preferred may be influenced by restrictive policies, provider biases, or lack of knowledge or skills, leading to the use of pain management options that may not be very effective or a drug regimen that is costly.
Factors to consider in selecting a pain management regimen include the following:
Local policies, guidelines, and protocols
The surgical approach to be used
The level of experience of the surgeon and the team
The client’s preference and understanding of pain management options
The client’s safety and comfort
The availability of drugs, equipment, and supplies
The cost of the pain management options
The service site’s ability to manage complications

5. Factors Contributing to Successful Pain Management
Adequate counseling and provision of complete and correct information about the procedure
Proper client assessment
Administration of adequate analgesia and sedation
Skillful and adequate infiltration of the local anesthetic
Skillful and gentle surgical technique
Counseling and clear instructions on what to do and when to use analgesics after the procedure
Explain:
Factors that contribute to successful pain management during and after a minilaparotomy procedure include the following:
Adequate counseling and provision of complete and correct information about the procedure
Proper client assessment
Administration of adequate analgesia and sedation
Skillful and adequate infiltration of the local anesthetic
Skillful and gentle surgical technique
Counseling and clear instructions on what to do and when to use analgesics after the procedure
Mention that these factors will be revisited in more detail after discussion of the different pain management options.

6. Pain Management Options for Minilaparotomy
Pharmacological
Local anesthesia with sedation and analgesia
Regional anesthesia
General anesthesia
Nonpharmacological
Communication (ongoing verbal and nonverbal support, counseling)
Gentle surgical technique
Note: In most instances, a combination of pharmacological and nonpharmacological approaches is recommended.
Explain
In pain management, a combination of pharmacological and nonpharmacological approaches should be used. Options for pain management range from reliance only on pharmacological drugs to use of both pharmacological drugs and nonpharmacological approaches for managing pain during and after the surgical procedure.
Pain management options for minilaparotomy include the following:
Pharmacological options
Local anesthesia was in past decades the preferred option for pain management in minilaparotomy, but as evidence of other better and more effective multimodal options has emerged, this regimen is no longer recommended.
Local anesthesia with sedation to allay anxiety became a preferred option, but this combination also is no longer recommended, given the evidence of more effective and safer pain management through a combination with analgesia and nonpharmacological approaches.
Local anesthesia with sedation and analgesiais now the preferred option. This approach also is recommended in combination with non-pharmacological approaches. It is safer, is effective, and allows quick recovery.
Regional anesthesia includes use of spinal anesthesia. Because minilaparotomy is a short procedure, this approach is not recommended. Other, less complex options are safe, are effective, and allow quick recovery, with the client ready for discharge after a short period.
General anesthesia is not recommended for routine use. In some cases, general anesthesia may be needed, as described in the medical eligibility criteria (i.e., for clients with conditions such as obesity or previous scars, as well as for extremely anxious clients for whom other pain management options will likely be less effective).
Nonpharmacological options
Nonpharmacological options are not recommended for use as the only pain management option during the surgical procedure. These options include:
Establishment of good communication with the client (as part of counseling and ongoing verbal communication during the procedure)
Gentle surgical technique
Other nonpharmacological approaches or options that have been tried in the past includes hypnosis.
Ask the participants if they have any questions or points for clarification, and respond to these as appropriate.

7. Anesthesia
Anesthesia is the total loss of the ability to perceive pain, sometimes including the loss of consciousness.
Three common types of anesthesia are:
Local anesthesia
Regional anesthesia
General anesthesia
A combination the a local anesthesia with sedation and analgesia—administration of sedatives and analgesics to help the client to relax and relieve her from pain; accompanied by the administration of local anesthetics in the area of the incision
Explain: Anesthesia is defined as the total loss of the ability to perceive pain, sometimes including the loss of consciousness. Types of anesthesia include the following:
Local anesthesia—delivered at the surgical site by infiltration of the tissue with an anesthetic agent to cause loss of sensation
Regional anesthesia—delivered around the nerves supplying a particular area of the body (e.g., spinal and epidural), causing the loss of the sensation of pain in those specific regions of the body
General—systemic delivery of an anesthetic agent intravenously or by inhalation, producing a state of unconsciousness
A combination of local anesthesia with sedation and analgesia —administration of sedatives and analgesics to help the client to relax and relieve her from pain; accompanied by the administration of local anesthetics in the area of the incision

8. Recommended Pain Management Regimen and the Rationale for It
Minimal-to-moderate sedation and analgesia (conscious sedation) with local anesthesia
Rationale
Provides the client with adequate comfort, with minimal or no anxiety or pain.
Entails less cardiorespiratory depression, lower peak drug blood levels, and faster recovery.
Has lower risks of unexpected, life-threatening complications.
Is less complicated and expensive than general anesthesia, given the equipment and level of training required for general anesthesia.
Explain:
The recommended pain management is minimal-to-moderate sedation and analgesia (conscious sedation) with local anesthesia.
The rationale for this option is that it:
Provides the client with adequate comfort, with minimal or no anxiety or pain
Entails less cardiorespiratory depression, lower peak drug blood levels, and faster recovery
Has lower risks of unexpected, life-threatening complications
Is less complicated and less expensive than general anesthesia, given the equipment and level of training required for general anesthesia
These advantages allow minilaparotomy to be more widely available and accessible.

9. Drug Regimen Proposed
The recommended regimen includes drug administration before, during, and after the procedure.
A: Immediately before and during the procedure:
For sedation, diazepam, midazolam, or promethazine
For analgesia:
Nonnarcotics, such as a nonsteroidal antiinflammatory drugs (NSAIDs) diclofenac or ibuprofen
Narcotics such as meperidine, nalbuphine, pentazocine, or fentanyl
Local anesthesia
1% lignocaine (without epinephrine)
B: After the procedure:
Diclofenac or ibuprofen
NB: Atropine premedication may be a requirement in some settings
Explain:
The recommended regimen for minilaparotomy includes drug administration before, during, and after the procedure.
Before and during the procedure
The recommended drugs include:
For sedation, diazepam, midazolam, or promethazine
For analgesia, nonnarcotic analgesics, including nonsteroidal antiinflammatory drugs such as diclofenac or ibuprofen, and narcotic analgesics such as meperidine, nalbuphine, pentazocine, and fentanyl
For local anesthesia, 1% lignocaine without epinephrine
After the procedure
Nonnarcotic drugs such as diclofenac or ibuprofen
Different combinations of these drugs may be administered to attain moderate sedation. Exactly which drug is used varies by country and setting and is influenced by local national or institutional policies and other health system–related factors. In some settings, for example, atropine is routinely used to premedicate all clients or patients undergoing any intraabdominal surgical procedure such as minilaparotomy.

10. Why Add a Sedative and an Analgesic?
The purposes of sedation and analgesia are to:
Reduce anxiety and fear
Induce amnesia
Provide analgesia
Reduce or prevent nausea and vomiting
Blocking pain (with the local anesthestic)
Explain:
Sedation is an adjunct to analgesia and anesthesia.
Sedatives produce drowsiness, reduce anxiety, and induce tranquility and amnesia and a sense of well-being. With these characteristics, sedatives complement local and regional anesthesia.
Analgesia, on the other hand, is the loss or alteration of the perception of pain, locally or systemically.
Analgesics enhance the pain-relieving effect of local anesthesia, but they do not block pain. Combining a sedative and an analgesic drug with local anesthesia has the result of:
Reducing anxiety and fear
Inducing amnesia
Providing analgesia
Reducing or preventing nausea and vomiting
Blocking pain (with the local anesthesia)
It is common practice for health workers to use a combination of the two drugs (a sedative and an analgesic) to relieve pain when performing minor procedures on clients.
By varying the dosage of the sedative or using more potent analgesics, the provider can vary the client’s level of consciousness during the minilaparotomy procedure.
The sedative and analgesic should be administered early enough for timely onset of action by the time surgery begins.

11. Local Anesthesia General considerations for local anesthesia
Lidocaine is the preferred local anesthestic.
The recommended dosage is 4.5–5.0 mg/kg of 1% lidocaine without epinephrine, not to exceed 300 mg or 30 ml (depending on the weight of the client).
The drug should be infiltrated into all layers of the abdominal wall.
It may take 2–3 minutes to achieve adequate anesthesia.
Anesthesia may be augmented, if necessary.
Explain:
Several local anesthetic agents may be used; however, lidocaine is preferred, as it is easy to use, has fewer side effects, is less expensive, and is short-acting.
Note: Other local anesthetic drugs can be used, but they may be more costly and have a longer duration of action.
The recommended dosage is 4.5–5.0 mg/kg of 1% lidocaine without epinephrine. This translates to 300 mg in total; if it is in a 1% solution, the volume of the solution will be 30 ml for the average person weighing 60 kg. Exceeding this total dosage of 300 mg is likely to lead to side effects of lidocaine. (Note that for a 50 kg client, the recommended dosage should not exceed 250 mg.) Using the two infiltration techniques recommended, in most instances far less than 20 ml of 1% lidocaine will be adequate to achieve good local anesthetic effect.
The drug should be infiltrated into the layers of the abdominal wall (that is, from the skin to the peritoneal layer), while ensuring that the needle is not in a vessel.
Once the surgeon has entered the peritoneal cavity, irrigating the uterine cornuae and the isthmic segment of tube with a few ml of 1% lidocaine solution blocks pain associated with manipulation and occlusion of the fallopian tubes.
Lidocaine’s onset of action depends on several factors, including the drug concentration and volume. In general, it will take 2–3 minutes to achieve adequate anesthesia.
If needed, the anesthesia may be augmented to ensure that the anesthetic effect is maintained. However, the maximum allowable dosage must not be exceeded.

12. Infiltration techniques
Diamond-shape technique
Fan-shape technique
Explain:
The two recommended techniques for infiltration of the local anesthesia are:
The diamond-shape technique
The fan-shape technique
Both techniques are effective, and with minimal adjustments, either can be used for suprapubic and subumbilical minilaparotomy procedures.

13. Field Block Using the Diamond-Shape Technique
(a) Entry of the needle at the incision site
(b) Skin infiltration
(c) Infiltration of the different layers
Explain: For the diamond-shape field block, the steps are as follows:
After establishing a sterile field, withdraw 20 ml of 1% lidocaine.
Inform the client that you will inject the medication to block pain and that she will feel a needle prick on her abdomen.
At the center of the incision site, insert the needle into the intradermal layer and infiltrate 0.5–1.0 ml to make a wheal. Then advance the needle horizontally along the incision site to the left or right.
Once the needle is inserted to its full length, aspirate to confirm that you have not punctured a blood vessel, then slowly infiltrate about 1.5 ml of lidocaine slowly as the needle is withdrawn.
Repeat the same steps in the opposite direction, without withdrawing the needle from the skin or from the wheal. Advance the needle in the cephalic direction in the intradermal layer to its full length and again aspirate to confirm that you are not in a blood vessel, then slowly infiltrate the lidocaine while withdrawing the needle toward the incision site.
Once at the center of the incision, now advance the needle fully in the intradermal layer caudally, aspirating to confirm that it is not in a blood vessel, then again slowly infiltrating the lidocaine solution while withdrawing the needle toward the incision site. A total of about 6 ml of lidocaine will have been infiltrated into the skin.
The next step is to anesthetize the fascial layer in all four directions, as was done with the skin. This time, instead of advancing the needle as in the above, it just needs to be inserted at an angle of 45 degrees in each direction. In each direction, aspirate first to ensure that the needle is not in a blood vessel, then infiltrate with about 1 ml while withdrawing the needle toward the center of the incision.
The peritoneum will be the next layer to be anesthetized. This is done by advancing the needle at a 90-degree angle, just beyond the rectus sheath.
Once all the layers have been infiltrated with lidocaine solution, wait for at least two minutes before making the skin incision. Verify that the anesthesia has taken effect by using the toothed forceps to grasp the skin.
Source: EngenderHealth 2014

14. Field Block Using the Fan-Shape Technique
(a) Skin infiltration
(b) Infiltration of the different layers
Explain:
For the fan-shape field block, the steps are as follows:
After establishing a sterile field, withdraw 20 ml of 1% lidocaine.
Inform the client that you will inject the medication for blocking pain and that she will feel a needle prick in her abdomen.
From one end of the planned incision site, advance the needle into the intradermal layer and raise a wheal.
Advance the needle horizontally in the intradermal plane to the full length of the incision.
Aspirate the needle to verify that it has not punctured a blood vessel.
If not, slowly infiltrate about 3–4 ml of lidocaine solution as you slowly withdraw the needle. Once the tip of the needle is at the wheal, again advance the needle to its full length and at a 30-degree angle along the length of the incision to infiltrate the fascial layer. Again, aspirate to confirm that a blood vessel has not been punctured and infiltrate about 3–4 ml of the lidocaine as the needle is withdrawn toward the wheal.
Next, advance the needle at a 60-degree angle along the incision length, and finally repeat the process at a 90-degree angle, to anesthetize the peritoneum. Aspirating each time to avoid infiltrating the anesthetic into a blood vessel, inject in each layer 3–4 ml of lidocaine solution.
Withdraw the needle from the incision site and wait for at least 2 minutes for the anesthetic to take effect. Verify that the anesthesia has taken effect by using the toothed forceps to grasp the skin.
With both the fan-shape and diamond-shape techniques, the remaining few ml of local anesthetic agent should be reserved for use in anesthetizing the fallopian tubes once the peritoneum is opened.
Ask if all participants are clear about the differences between the two techniques, and respond to any questions as needed.
Source: EngenderHealth 2014

15. Anesthetizing the Fallopian Tubes
(a) Viewing the uterine fundus through the incision
Explain:
The fallopian tubes, located on either side of the uterus, can be anesthetized by dripping about 2–3 ml of lidocaine solution over them and over the cornua of the uterus.
The onset of action is rapid.
Source: EngenderHealth 2014

16. Use of Gentle Surgical Techniques
Both the surgeon the and assistant surgeon must be gentle when manipulating or grasping tissues.
The surgeon should follow the recommended steps in the correct sequence.
The surgeon must not be in a rush and should avoid harsh movements.
When holding and retracting the skin, the assistant must hold the retractors in the correct horizontal plane.
The assistant should avoid excessive traction of tissues.
The surgeon should complete the procedure within 20–25, minutes before the anesthetic effect begins to wear off.
Explain: Like any other surgical procedure, applying gentle surgical techniques is also important for effective pain management.
Be gentle when manipulating or grasping tissues, and avoid rushed and harsh movements when manipulating tissues.
The surgeon should follow the recommended steps in the correct sequence. You will learn what the procedural steps are and practice how to perform them later.
The surgeon and the assistant should apply the retractors correctly, and traction should be done correctly, in the horizontal plane.
The surgeon should aim to complete the procedure within 20–30 minutes, before the anesthetic effect begins to wear off.

17. Communication with the Client
Communication before the procedure
Make sure that the client knows the pain management option that will be used.
Always inform the client what to expect.
Reassure the client and answer any question she may have about pain management.
Lessen the client’s anxiety.
Communication during the procedure
Staff should engage the client by speaking to her throughout the procedure—to distract her, etc.
Staff must monitor the client’s condition throughout, to recognize evidence of her feeling pain or any early sign of complications.
The client should be informed of the progress of the surgery/procedure.
Explain:
When preparing the client for the procedure, she should be informed of what the surgical team will be doing and what to expect.
The provider should also discuss with the client the pain management option that is recommended for her case.
Allow the client to ask questions, and respond to her questions about the procedure and pain management.
The client should be reassured that all will be well. If she is overly anxious, consider using a different pain management option.
During the procedure, the provider should be with the client at all times and should continuously engage her; and the provider should explain what is happening, unless the client specifically asks not to be informed of the progress of the surgery. When observing the client for pain, avoid asking her if she is feeling pain or if the procedure hurts, as such questions tend to raise anxiety. The provider should also be observant to detect any signs of pain or distress, such as groaning, biting of teeth, or tightly clenching fists, etc.
Ask:
Can anyone of you share with us your observation of some of the non verbal reactions to pain or discomfort by women, how did you recognize that she was in pain and what was your response or the response of your team members.
Allow a few participants to share their experiences and some follow on discussions.

18. Communication with the Client (cont.)
Communication after the procedure
Make sure that the client is comfortable.
Ask the client if she has any problems.
Continue observation of vital signs and of the surgical wound for bleeding and general condition for at least 2–4 hours.
Before giving instructions, confirm that the client is fully awake and lucid.
Review postoperative care instructions with the client.
Communication at discharge
Provide information to the client about what to expect at discharge and follow-up.
Discuss how she should take her medication after discharge.
Explain:
At the end of the procedure, the provider should explain to the client what to expect next, now that the procedure has been completed.
The provider should also find out if she is experiencing any pain or other problems.
The provider should continue observing the client’s vital signs, her general condition, and the condition of her surgical wound.
The client should be informed that her recovery has been uneventful and that she is now ready to go home.
The provider should also review the postoperative instructions with the client; these will include, among other things, the follow-up return dates, danger signs to look for, and what to do if she notices any such signs.
The client should also receive medication (analgesic) for use upon discharge, with directions on how to take the medication and what it is for.
The client may also be given mobile phone numbers of specific nearby health facility and care providers to contact as soon as she experiences any problems following discharge.

19. Roles of Team Members in Pain Management
Surgeon
Assesses the client's level of anxiety or degree of relaxation
Administers the local anesthesia
Communicates with the client and the client monitor regarding the client’s comfort
Communicates with the client about what is being done and what she can expect to feel
Administers more local anesthetic, as needed
Performs the minilaparotomy procedure efficiently and gently.
Manages anesthesia-related complications
Assistant Surgeon
Withdraws local anesthetic from the vial held by the circulating nurse
Assists the surgeon with the procedure, using gentle technique to minimize tissue trauma and pain
Assists the surgeon in the management of anesthesia-related complications
Explain: Each member of the surgical team has a role to play in the management of a client during the minilaparoromy procedure.
For the pain management, the following are the recommended roles and responsibilities of each team member.
The surgeon's role is to:
Assess the client's level of anxiety or degree of relaxation
Administer the local anesthetic
Communicate with the client and the client monitor regarding the client’s comfort
Communicate with the client about what is being done and what she can expect to feel
Perform the minilaparotomy procedure efficiently and gently
Manage anesthesia-related or surgical complications
The surgeon also assumes the overall responsibility for the client’s condition during the surgery.
The assistant surgeon’s role is to:
Withdraw local anesthetic from the vial held by the circulating nurse
Assist the surgeon with the procedure, using gentle technique to minimize tissue trauma and pain
Assist the surgeon in the management of anesthesia-related complications

20. Roles of Team Members in Pain Management (cont.)
Client Monitor
Obtains and records baseline vital signs
Communicates with the client; maintains eye and touch contact with the client; watches for signs of distress
Reports any increased discomfort of the client to the surgical team
Ensures that the client’s record form has been completed, and accompanies the client to the recovery area
Ensures that the client is not left unattended in the recovery room
Circulating Nurse
Assesses and verifies that the client has not eaten in the last six hrs or taken liquids within the last two hours
Administers sedation and analgesics 45–60 minutes prior to the procedure
Ensures that the client has emptied her bladder
Ensures that resuscitation equipment and supplies are immediately available in the operating area
Assists the surgeon in managing any anesthesia-related complications
Explain:
For pain management, the client monitor performs the following roles:
Obtains and records baseline vital signs of the client before and shortly after medication is given, and monitors the client’s vital signs once the peritoneum is opened, when the tubes are being occluded, and when the incision is being closed. The client monitor may have to perform these tasks every 10–15 minutes if the procedure is slow.
Communicates with the client; maintains eye contact and touch contact with the client; and watches for signs of distress.
Reports any increased discomfort of the client to the surgical team.
Ensures that the client's record form has been completed, and accompanies the client to the recovery area.
Ensures that the client is not left unattended in the recovery room.
The circulating nurse performs the following functions:
Assesses and verifies that the client has not eaten in the last six hours or taken liquids within the last two hours
Administers sedation and analgesics 45–60 minutes prior to procedure
Ensures that the client has emptied her bladder
Ensures that resuscitation equipment and supplies are immediately available in the operating area
Assists the surgeon in managing any anesthesia-related complications
These roles are applicable when the surgical team uses the recommended pain regimen; however, if general anesthesia is used, then the team expands to include the anesthetist, who performs the roles of administering anesthesia, monitoring the client’s condition while she is under general anesthesia, and helping the client recover from the anesthesia.
Note: If the team is made up of three providers only, the client monitor also performs all of the tasks assigned to the circulating nurse.