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!
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