Labor analgesia
-
Upload
saneesh-p-j -
Category
Education
-
view
172 -
download
2
Transcript of Labor analgesia
LABOR ANALGESIA
Saneesh P JSpecialist (A) - Anesthesiology
Sultan Qaboos University Hospital
https://www.facebook.com/AnesthesiaTOOLS
Introduction
Childbirth - most painful experiences women will experience in their lifetimeChildbirth pain was “divine retribution for Eve’s disobedience in the Garden of Eden”Many believed it was wrong to treat the pain and escape God’s punishment
Introduction
https://www.facebook.com/AnesthesiaTOOLS
Introduction
Several non-pharmacologic techniques have been used to relieve the pain of childbirth throughout history
acupuncturemassagehypnosis
Drugs were not used in Western medicine to relieve pain in childbirth until the mid-1800s
Introduction
English Queen Victoria chose to inhale chloroform for analgesia during the birth of Prince Leopold
John Snow Queen Victoria
https://www.facebook.com/AnesthesiaTOOLS
Analgesia for Labor and Delivery
Always controversial!
“Birth is a natural process”
Women should suffer!!
Concerns for mother’s safety
Concerns for baby
Concerns for effects on labor
https://www.facebook.com/AnesthesiaTOOLS
<10% of laboring women in US in 2001 underwent childbirth without analgesiaNeuraxial analgesia is by far the most common form of pain managementDevelopment of increasingly safe techniques for neuraxial analgesia
https://www.facebook.com/AnesthesiaTOOLS
Pain Pathways in Labor and Delivery
https://www.facebook.com/AnesthesiaTOOLS
Labor Pain at different Stages of Labor
https://www.facebook.com/AnesthesiaTOOLS
Labor Pain at different Stages of Labor
Labor Pain at different Stages of Labor
https://www.facebook.com/AnesthesiaTOOLS
Non-pharmacological Methods
AcupunctureMassageHypnosisOthers
Lamaze methodLeBoyer techniqueTranscutaneous nerve stimulationHydrotherapyPresence of a support personIntradermal water injectionsBiofeedback
https://www.facebook.com/AnesthesiaTOOLS
The Ideal Labor Analgesic
Good pain relief
No autonomic block (no hypotension)
No adverse maternal or neonatal effects
No motor block
https://www.facebook.com/AnesthesiaTOOLS
The Ideal Labor Analgesic
No effect on labor and delivery:No increase in C/S rateNo increase in forceps/vacuum delivery
Patient can ambulate
Economical: cost and personnel
https://www.facebook.com/AnesthesiaTOOLS
How to Achieve Goals:
Prenatal education classes
Anesthesiologists must become effective educators as well as health care providers
Patients should have realistic expectations regarding the pain of labor and the variability of individual labor patterns
https://www.facebook.com/AnesthesiaTOOLS
How to Achieve Goals:
Well-informed patients are more likely to accept the interventions that may become necessary during labor
https://www.facebook.com/AnesthesiaTOOLS
How to Achieve Goals:
Anesthesiologists should encourage and facilitate the honest discussion of the risks and benefits of the analgesic/anesthetic techniques available
https://www.facebook.com/AnesthesiaTOOLS
Parenteral agents
All parenteral opiates cross placentaDegree of depression depends on
specific agentDosetime between administration and deliveryprematurity
https://www.facebook.com/AnesthesiaTOOLS
Parenteral Agents
MorphinePethidineFentanylKetamine
https://www.facebook.com/AnesthesiaTOOLS
Inhaled Analgesia
Inhaled anesthetics were the first treatments for labor analgesia used in modern times. However, as volatile anesthetics became more commonly used in childbirth, side effects were more commonly encountered.
Neonatal depressionMaternal gastric aspiration
https://www.facebook.com/AnesthesiaTOOLS
Inhaled Analgesia
Delivery was complicated by aspiration of gastric contents in 66 women from 44,016 deliveries (0.15%) between 1932 and 1945. The preventive fasting measures - recommended by Mendelson
restricting intakeprovision of non-particulate antacidsimprovement of anesthetic-induction technique
https://www.facebook.com/AnesthesiaTOOLS
Inhaled Analgesia
Volatile anesthetics are no longer used for labor analgesia. Nitrous oxide, however, is still commonly used worldwide and is welcomed by many parturients as a less invasive approach to pain relief in labor.
https://www.facebook.com/AnesthesiaTOOLS
Inhaled Analgesia
Typically NITROUS OXIDE is blended with O2 in a 50:50 ratio or slightly greater for patient-inhaled self-administration. ENTONOX
NEURAXIAL ANALGESIA
https://www.facebook.com/AnesthesiaTOOLS
Neuraxial Analgesia
The most reliable and effective method of reducing pain during labor. However, it is encumbered by small but real and predictable risks.
https://www.facebook.com/AnesthesiaTOOLS
Neuraxial Analgesia
Assessment of all laboring women for risk factors for neuraxial analgesia and general anesthesia is recommended Sufficient time should be available for adequate, safe evaluation and discussion with the patient.In otherwise healthy women, routine laboratory testing is not required.
https://www.facebook.com/AnesthesiaTOOLS
Neuraxial Analgesia
Although any laboring woman has the potential to require cesarean section, labor takes many hours and requires adequate nutrition and hydration. ASA has recommended that moderate amounts of clear liquids be allowed during the administration of neuraxial analgesia and throughout labor A period of abstention from solids before the placement of neuraxial analgesia is not required.
Neuraxial Analgesia
Timing of placementCurrent ASA guidelines note that maternal request for labor pain relief is sufficient justification for intervention and the decision should not depend on an arbitrary cervical dilation.
https://www.facebook.com/AnesthesiaTOOLS
Epidural Analgesia
Epidural analgesia is most commonly initiated after placement of a catheter into the epidural space between L2-3 and L4-5
https://www.facebook.com/AnesthesiaTOOLS
Epidural Analgesia
https://www.facebook.com/AnesthesiaTOOLS
Epidural Analgesia
IV fluidsMonitoringCTGPositioning
https://www.facebook.com/AnesthesiaTOOLS
Epidural Analgesia
The “test dose” tests for inadvertent intravascular or intrathecal placement of the catheter. Choice of local anesthetic drugs
BupivacaineRopivacaineAdjuvants – opioids
https://www.facebook.com/AnesthesiaTOOLS
Epidural Analgesia
Very dilute local anesthetic mixtures (0.0625%) generally do not produce motor blockade and may allow some patients to ambulate (“walking” or “mobile” epidural)
https://www.facebook.com/AnesthesiaTOOLS
Epidural Analgesia
The long duration of action of bupivacaine makes it a popular agent for labor. Ropivacaine may be preferable because of its reduced potential for cardiotoxicity
https://www.facebook.com/AnesthesiaTOOLS
Epidural Analgesia
Patient-controlled epidural analgesia (PCEA)
Total drug requirements may be less Patient satisfaction is greater with PCEA compared with other epidural techniques.
PCEA settings are typically a 5-mL bolus dose with a 5–10 min lockout and 0–12 mL/h basal rate; a 1-h limit of 15–25 mL may used.
https://www.facebook.com/AnesthesiaTOOLS
Complications
HypotensionUnintentional intravascular injection Unintentional intrathecal injection Post-dural puncture headache (PDPH) Epidural abscess/hematomaNeurological deficits (rare)
https://www.facebook.com/AnesthesiaTOOLS
Other techniques
Combined Spinal & Epidural (CSE) Analgesia Spinal anesthesia
Saddle block
https://www.facebook.com/AnesthesiaTOOLS
OTHER REGIONAL NERVE BLOCKS
Paracervical blockLA is injected lateral to the cervix at 4 o’clock and 10 o’clock, taking care to avoid vascular structures.
https://www.facebook.com/AnesthesiaTOOLS
OTHER REGIONAL NERVE BLOCKS
Paracervical blockThe paracervical block is effective to relieve pain of cervical dilation but does not affect cramping pain from contraction of the uterine corpus. However, paracervical block does reduce pain in the second stage of labor.
https://www.facebook.com/AnesthesiaTOOLS
OTHER REGIONAL NERVE BLOCKS
Pudendal nerve blockThe pudendal nerve is derived from sacral nerve roots and can be blocked with local anesthetic using a transvaginal or transperineal approach to treat pain during the second stage of labor and for episiotomy repair.
https://www.facebook.com/AnesthesiaTOOLS
Anesthesia for Operative Delivery
Low-dose epidural analgesia can be inadequate for assisted vaginal delivery with forceps or vacuum.
A higher concentration local anesthetic can be administered through an indwelling epidural catheter or a “second-stage spinal” can provide excellent perineal analgesia.
https://www.facebook.com/AnesthesiaTOOLS
Anesthesia for Operative Delivery
Supplementation of an indwelling epidural catheter with 5 to 10 mL of 1% to 2% lidocaine or 2% to 3% 2-chloroprocaine is usually adequate, depending on whether vacuum or forceps are being used. Pudendal nerve block also can be considered for operative delivery.
Conclusions
Individualize technique to patient’s goals and stage of labor
Optimize management for spontaneous delivery
Provide safe, cost-effective analgesia
discussion
Thank youhttps://www.facebook.com/AnesthesiaTOOLS