1. Labour analgesia Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu), Dip. Diab. DCA,
Dip. Software statistics, PhD(physiology)
Mahatma Gandhi Medical College and Research Institute, Puducherry, India

2. But what is history ??
The era of obstetric anaesthesia began with James Young Simpson, when he administered ether to a woman with a deformed pelvis during childbirth.
His concept of “etherization of labour” was strongly condemned by critics
Religion condemned !!

3. 1853, when John Snow administered chloroform to Britain’s Queen Victoria during the birth of her eighth child, Prince Leopold
In 1950 s – neuraxial techniques came into existence

4. The International Association for the Study of Pain (IASP) declared 2007–2008 as the
’’Global Year against Pain in Women - Real Women, Real Pain.”
Still only 60 % accept or opt for epidurals in UK !!

5. What about India ??

6. Awareness of labour analgesia
Not a single participant knew that the delivery is possible without suffering from labour pains; (1.5%) were of the opinion that it was impossible;
196 (98%) did not know whether it is possible or not.
An equal number had no idea about labour analgesia
200 rural pregnant women
Anaesthesia, Pain & Intensive Care

7. Do we need it ??
Is there a necessity??

8. PRI

10. We need some form of labour analgesia
So we need it !!

11. PAIN TRANSMISSION IN PARTURITION

12. Visceral afferent pain fibers from the uterus, cervix, and upper vagina form the cervical plexus and enter the spinal cord at the T10–L1 levels. The visceral afferent fibers also enter the sympathetic chain at L2 and L3 levels.
lower vagina, vulva, and perineum. signals are conveyed via the S2–S4 spinal nerve roots that form the pudendal nerve

13. Hence a contradiction First stage ---- T10 – L3
Second stage --- S2, S3, S4

14. Now how to proceed Give drugs – route ?? Something other than drugs
Pharmacological
Non pharmacological

15. Nonpharmacological

16. Non pharmacological Lamaze in 1958 The training starts from six weeks
During labour
Deep breath during contraction
Relax
Physician talks – electromyographic biofeedback with lamaze √ √
Davidson hypnosis better than preparation alone

17. TENS
Four electrodes
Augustinson
44% good relief 44 % acceptable 12 % nil

18. Acupuncture

20. Acupuncture Effective relief Contractions become more regularized
Reduced oxytocin doses
But
wires
Time
Machinery
Interference with fetal monitoring ??

21. Position Vertical position Squatting – no proper studies Ambulating ??
Ambulating patients have shorter and less painful labour or vice versa ??

22. Intradermal Water Injections
The analgesic effect appears to last for 45 to 120minutes
reduce the rate of use of other analgesic techniques
Simple
No side effects

23. Some one may criticize ??
But no one stops a patient who is on intrathecal opioids to have hydrotherpay and intradermal water injection also
Isnt it ??

24. Pharmacological Narcotics
IM, SC or ( IV – more predictable, faster onset)
Pethidine – 1947
The usual dose is 50 to 100 mg intramuscularly,
which can be repeated every 4 hours.
onset of analgesia occurs in 10 to 15 minutes,
45 minutes - reach peak effect.
The duration -- 2 to 3 hours.

25. Other opioids Morphine Diamorphine Meptazinol
Fentanyl , alfentanil, remifentanyl
Tramadol
Nalbuphine
Butorphanol
Pentazocine

26. Randomized studies Significant relief Easy to administer
Staff can manage
But studies reveal more percentage needed neonatal resuscitation ( morphine ?? )
PCA - √ - better in less dosage , more analgesia and less side effects ( especially fentanyl)

28. A lot of studies
epidural analgesia is superior to remifentanil PCA, they also postulated that high maternal satisfaction with intravenous PCA may be the result of factors other than the degree of analgesia produced
What ? Is it so ??
IV paracetomol
IV ketamine ( 0.2 mg/Kg) – 25 mg IV during crowning !!

29. Benzodiazepines ????
Analgesia ??
Amnesia !!

30. INHALATIONAL ANALGESIA
Nitrous oxide as premixed entonox 50 %
Separates at 7 degress c
Safety demand valve
Inhales at each contraction
Drowsy patient Stops
Effective . Crosses but safe to neonate
Equipment ??
Resurgence of entonox !!

31. INHALATIONAL ANALGESIA-
Inhaled methoxy flurane with the help of a cardiff inhaler was practiced with conc. of 0.2 %
Enflurane
Isoflurane _ ? Less uterine atony
Sevoflurane – 0.7 MAC – good
Desflurane – cost and irritablity remains with efficiency less than nitrous oxide
Equipment, monitoring, aspiration risk , amnesia, timing ??
0.5%MAC

32. Evidence based medicine
Systemic pethidine
Remifentanyl PCA
All agents in carefully monitored doses

33. Neuraxial analgesia Spinal LA ? Opioids Continuous epidural CSEA
Caudal
Double catheter
Continuous spinal
Lumbar sympathetic ,paracervical
Pudendal ( nerve blocks )

35. Indications for epidural
Pre eclampsia/hypertensive disease
Prolonged labour
Two or more babies in utero
Anticipated instrumental delivery
Diabetes Mellitus
Breech presentation for vaginal delivery
Significant respiratory disease

36. Contraindications
No CTG tracing or inadequate CTG tracing e.g. loss of contact
Declined by the woman
Inadequate midwifery staffing levels.
&
Otherwise similar as for other epidurals

37. Epidural technique Prepare , position ,hydrate 500 ml of RL
Insert catheter – initiate dosage dilute local anaesthetics in 5 ml increments with lipid soluble opioid
TEST dose
Assess levels , monitor vitals
When ??
Effective contractions 4 cm dilation in primi

38. Beware of fentanyl pharmacogenetics

39. Lidocaine, morphine, and meperidine are not commonly used for labor analgesia because of their short duration of action (lidocaine), long latency (morphine), and high incidence of nausea and vomiting (morphine and pethidine).
Epidural block is the most effective and least depressant (pharmacologic option) allowing for an alert, participating mother

40. Opioids Inadequate analgesics used alone
Synergistic with local anesthetics
Speedy onset of analgesia
Improves quality of analgesia
Permits use of very dilute LA solutions
Help relieve persistent perineal pain and unblocked segments

41. I have initiated – maintain ??

42. ?
Intermittent boluses
Continuous infusion
PCEA

43. Intermittent Epidural catch up phenomenon Intermittent dose delayed
Severe pain
Influence the next dose

44. Infusion Bupivacaine 10 ml /hour
Bupivacaine 12 ml/ hour with 2.5 mic/ml fentanyl
Ropivacaine 10 ml of 0.25 %
Levo bupi + fentanyl
Lignocaine 0.75 %

45. Double catheter technique
Cleland
T11 catheter 6 ml of dilute solution of LA
Caudal catheter - 5 ml for stage 2

48. Any problem with epidural ??

49. 2 – 20 rule Problem with neuraxial anaesthesia
2 hour – dystocia in first stage
20 min dystocia in second stage

50. CSEA
CSEA as a routine and are indicated only in certain specific situations,
like very early stage of labour where local anaesthetics are avoided,
advanced stages of labour where rapid analgesia is desirable
difficult epidurals as CSEA reduces the failure rate of epidurals.

51. Computer integrated PCEA
Lim et al. reported another adaptation of the epidural delivery pump technology. Their centre has developed a computer-integrated PCEA (CI-PCEA) that controls background infusion rates depending on the previous hour’s demand boluses.

52. Walking epidural
THE IDEAL LABOUR ANALGESIC SHOULD GIVE A RESTED PARTURIENT THE ENERGY,STRENGTH AND SENSATION TO PERFORM EXPULSIVE EFFORTS AT THE TIME OF DELIVERY.
TO ACHIEVE THESE GOALS, RECENT DEVELOPMENTS HAVE FACILITATED MATERNAL AMBULATION WHILE RECEIVING EFFECTIVE REGIONAL ANALGESIA.

53. Why walk ??
The upright posture helps shorten the duration of labour by walking
Mothers who walk during labour had reduced duration and operative delivery rate.
Weight of fetus would dilate the cervix
Aorto caval compression ??
Vertical position !!

54. Walking epidural dilute local anaesthetics with opioids
Motor block check
No hypotension
Supervised trial walk
Then allow

55. Spinal Bupivacaine 2.5 mg with an opioid Faster onset Effective relief
Prolong ??
Motor block ??
Hypotension and fetal effects ??
Micro catheters

56. 8 cm dilation .. Comes and gives what ??

57. Some doubts about epidurals

58. Increased rate of operative and instrumental delivery: Is epidural the cause ??
The Cochrane Database Systemic trials have emphasized that epidural analgesia had no statistically significant impact on the risk of caesarean section.
In two different metaanalyses of randomized trials, comparing patients with and without epidural, caesarean delivery was clearly not associated with epidural analgesia

59. Question 2 : Epidural taken early vs. late ??
4 – 5 cm
no no 2 -3 cm
no no 6 cm !!
4 -5 – once thought
there is no need to wait arbitrarily till the cervical dilation has reached 4–5 cm, and endorsed a statement that “Maternal request is a sufficient indication for pain relief in labour.” (ACOG guidelines )

60. Question 3 : Early vs. delayed pushing
The Pushing Early or Pushing Late with Epidural (PEOPLE) Study also supported delayed pushing for a better outcome

61. Withholding the epidural top-up in the second stageNo
Instrumental deliveries are not increased
But
Inadequate pain relief remains

62. Vaginal birth after caesarean and epidural
Task force guidelines 2007 jointly issued by the ASA and the Society of Obstetric Anaesthesiologists and Perinatologists (SOAP) recommend neuraxial techniques being offered to patients attempting vaginal birth after previous caesarean delivery
Do it
Do it early
Use it for post pain if needed

63. Epidural and breastfeeding
No impact
No proper studies
Go ahead
Backache and epidural
No significant change

64. Backache and epidural ??
In two recent randomized trials, there were no significant differences in the incidence of long-term back pain between women who received epidural pain relief and women who received other forms of pain relief

65. Epidural and baby
local anesthetics administered as components of epidural analgesia were sometimes associated with minor, transient effects on neonatal behavior
Intrathecal – very less effects
Beware of hypotension

66. Lumbar sympathetic block
10 ml of 0.5 % bupi with 1 in 2 lakh adrenaline each side for first stage followed by pudendal nerve block for second stage
Effective analgesia without hypotension and motor block
But technique ??

67. Paracervical block 4 and 8 o clock

68. PCB
The goal is to block transmission through the paracervicalganglion—
(Frankenhäuser’s ganglion)—which lies immediately lateral and posterior to the cervicouterine junction.
% relief in primi first stage

69. Maternal complications

70. Fetal complications – bradycardia 110 or 120 !! // 0- 70 % !!
LA in the fetal scalp blood
Uterine art. Constriction
Stimulation of head
Uterine activity
5 – 10 minutes - betters without intervention .

71. Pudendal nerve block

72. Two approaches – common ??

73. Iowa trumpet
Pudendal nerve block does not abolish sensation to the anterior part of the perineum, as the perineum is supplied by branches of the ilioinguinal and genitofemoral nerves.

75. Summary Labour analgesia – do we need ? Awareness Pathways
Adverse effects of pain
Techniques
Lamaze
Commonest opioid –
Best technique

77. Appaa over !! – thank you all