Case Study on the Effect of Epidural Analgesia on Pain Management During Labour

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Med & Health 2013; 8(1): 33-36

CASE REPORT

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Address for correspondence and reprint requests: Assoc. Prof. Ho Siew Eng, Department of Nursing,

Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Jalan Yaacob Latif, Bandar Tun Razak,56000 Cheras, Kuala Lumpur, Malaysia. Tel: 603-91456262 Fax: 603-91456683 Email: [email protected]/[email protected]

Case Study on the Effect of Epidural Analgesia onPain Management During Labour

HO SE1, SUMATHI U1, ISMAIL MS2, CHOY YC3, AHMAD ZAILANIH4, LIU CY3

Department of 1Nursing, 2 Emergency Medicine, 3 Anaesthesiology, and 4 Obstetrics &Gynecology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Jalan

Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia.

ABSTRAK

Rasa sakit merupakan suatu perasaan yang sangat kurang enak dan tidak

menyenangkan. Wanita hamil akan merasakan kesakitan yang amat sangat semasamelahirkan anak. Walaupun rasa sakit yang amat kuat tidak membawa kemudaratanyang mengancam nyawa, namun ianya boleh meninggalkan kesan neuropsikologiyang ketara. Misalnya kemurungan lepas bersalin adalah lebih kerap dilaporkanbagi mereka yang tidak menerima ubat analgesia dan kesakitan kuat yang dialamisemasa bersalin adalah berkait rapat dengan kejadian gangguan-tekanan-pasca- trauma. Pemberian bius epidural semasa bersalin melibatkan pemberian ubat biussetempat di kawasan tulang belakang. Ianya dianggap sebagai rawatan piawai bagimelegakan kesakitan semasa proses bersalin. Kami ingin berkongsi satu kajian kes

yang melibatkan seorang pesakit berusia 37 tahun gravida 1 para 0 yang dirawatdengan bius epidural bagi mengawal kesakitan semasa melahirkan anak.

Kata kunci: kesakitan, pengurusan, analgesik, epidural, bersalin

ABSTRACT

Child birth is associated with severely painful experience for the parturient, andoften exceeds one’s expectations. Even though, severe pain is non life-threateningcondition in healthy parturient women, it may lead to undesired neuropsychological

consequences. When no analgesia was used, postnatal depression may be morecommon, and this labour pain leads to the development of post-traumatic stressdisorder. Epidural analgesia is now considered gold standard for effective painrelief during labour. We here report a case of a 37-year-old G1 P0 patient at termgestation who successfully used epidural analgesia for labour pain management.

Keywords: pain, management, analgesia, epidural, labour



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management in labour (SOGC 2004).Epidural analgesia during labour anddelivery encompass the injectionof local anesthetic agents such aslignocaine, bupivacaine or ropivacaineand an opioid analgesic agent suchas morphine or fentanyl injected intothe lumbar epidural space (Catterall& Mackie 2006). The injected agentsgradually diffuse across the dura intothe subarachnoid space, where they actprimarily on the spinal nerve roots andto some extend on the spinal cord and

paravertebral nerves. Oftenly combinedwith epidural analgesia, spinal analgesiainvolves the injection of analgesicagents directly into the subarachnoidspace, resulting in rapid onset ofanalgesia (Catterall & Mackie 2006).The drug concentration and volume oflocal anaesthetics, and opioids used forepidural analgesia are tailored to the

stages of labour and the parturient’spreference or need for analgesia.Commonly during early labour, 12-14ml of 0.1% bupivacaine with 2 mcg/mlof fentanyl may suffice. These epiduralmedications are administered into theepidural space to avoid complicationsrelated to inadvertent procedures.

CASE REPORT

We here report a case of a 37-year-old primigravida, married for threeyears, who had a history of uterinefibroid and sub-fertility. She wasnot on any treatment for her uterinefibroid. For this pregnancy, she hadhistory of premature contractionwith administration of intra-musculardexamethasone during her secondtrimester. At term, she was admitted to

INTRODUCTION

Pain is a common symptom in medicalpractice, usually associated with

advanced illness or other acute orchronic conditions. It is the symptomthat most patients and their familiesfear most. Child birth is associatedwith severe pain for most women,(Hiltunen et al. 2004). To few, it can betheir greatest pain during their lifetimes(Catterall & Mackie 2006). Labourpain is caused by uterine contractionsand cervical dilatation. Pain sensationis conveyed through visceral afferent(sympathetic) nerves entering the spinalcord from T10-L1 through L1 levels.In the later phase of labour, perinealstretching causes painful stimulitransmitted through the pudendal nerveand sacral nerves from S2,3,4 levels.This pain increases maternal stressresponse and may lead to increase in

the release of corticotrophin, cortisol,noradrenaline, B-endorphins, andadrenaline. Adrenaline may haverelaxant effects on the uterus andmay prolong labour. Catecholaminerelease may also increase maternalcardiac output, systemic vascularresistance, and oxygen consumption.In few cases with preexisting cardiac

or respiratory insufficiencies, thisexcessive catecholamine release maybe life-threatening. Epidural, spinal (intrathecal), andcombined techniques are the mosteffective means of pain relief duringlabour. These are known as regionaltechniques because pain relief islimited to a specific region in thebody. Epidural analgesia is consideredas the gold standard for effective pain



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Epidural Analgesia on Pain Management Med & Health 2013; 8(1): 33-36

our hospital in latent phase of labourwith mild uterine contractions. Vaginalexamination revealed her cervical was2 cm dilated. She was observed andtransferred to labour room when her oswas 4 cm dilated. Artificial rupture ofmembrane was performed and she wasoffered epidural analgesia to reduce herlabour pain. Patient agreed for epidural analgesiaafter the attending obstetrician hadexplained the benefits and possibleadverse effects of epidural analgesia to

her and her husband. An anaesthetistfurther counselled the patient andproceeded with epidural catheterinsertion after taking written consent. Atest dose of 4 ml ropivacaine 0.2% wasadministered slowly whilst observingfor any adverse reactions. Epiduralinfusion of ropivacaine 0.2%. and 2mcg/ml of fentanyl was subsequently

started at 7 ml/hr. The patient’s vitalsigns were stable with sedation scoreof 1/10 and pain score of 1/10. Foetalheart rate was between 122-140 beatsper minute.

Following three hours of activelabour, the patient’s cervix was fullydilated. She was encouraged to beardown in order to shorten the secondstage of labour. She could still feel

the tightening and urge to bear downwithout any pain. Episiotomy wasperfomed on crowning of baby’s headwithout any local anaesthesia. After 25minutes, a vigorous baby boy, crying atbirth, with APGAR score 9 in 1 minuteand 10 in 5 minutes was delivered. Thebaby was born healthy with a weight of2.93 kg. The epidural analgesia infusion

was tapered down until episiotomyrepair was completed and removed

after one hour. Patient and baby werelater discharged to General Ward,eventually.

DISCUSSION

Epidural analgesia during labouris common. Nurses attending topatients on epidural analgesia mustpossess adequate knowledge about itsindications and contra-indications, andhave skills in monitoring its effectivenessand potential complications (Dickinson

et al. 2003). The nurses should be aptin assessing the sensory level of theepidural analgesia, usually by using anice cube in a rubber glove in order todetermine the epidural block height. Ifthe patient is unable to detect a coldsensation at/or above the nipple line (atT4 thoracic level), the epidural infusionshould be stopped immediately, as theepidural block is too high. They mustalso prepare, check and update theresuscitation equipment and drugs thatmay be used during labour.

Monitoring of the patient’s vital signsis also important to ensure their safetyin labour. Should there be any fall ofsystolic blood pressure below 100mmHg or if the patient becomes sleepyand difficult to arouse, the epidural

infusion should be stopped immediatelyand the attending doctors informed(Capogna et al. 2007). Occasionallyduring labour, there may be suddenhypotensive episodes. During suchinstances, while alerting the doctors,the nurses should turn the patient toher side; increase the intravenous fluidflow rate and supplement oxygen via aface mask. For patients with excessivedrowsiness due to opioids, naloxone



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may have to be considered (Kumar &Paes 2003).

During the second stage oflabour, constant reassurance andencouragement by the nurses to thepatient is essential to achieve successfulpain management. In addition, patients’epidural acceptance during labourmay increase the success of painmanagement (Pugliese et al. 2013).

According to Niesen and Jacob(2013), the initiation of labour analgesiahas been reported to have a higher

degree of maternal satisfaction while inlabour compared to conventional painmanagement techniques. It is knownthat instrumental delivery is commonwith the use of epidural analgesiaduring labour. The nurses should guidethe patient to push using the correcttechnique during these procedures.At all times, the nurse should closely

monitor foetal well being and mother’scondition to ensure a safe delivery

(Hansen et al. 2002).

CONCLUSION

We believe that patient’s education andreadiness to accept epidural analgesiaduring labour is very important as itenhances the success of an epidural

analgesia. Pain management shouldbe individualised to cater to everyparturient. Epidural analgesia is themost effective form of intra-partumanalgesia currently available inMalaysia. It is particularly beneficial for

parturients with medical problems suchas hypertension and cardiac disorders.

REFERENCESCapogna, G., Camorcia, M., Stirparo, S. 2007.

Expectant father’s experience during laborwith or without epidural analgesia. Int J ObstetAnesth 16(2): 110-115.

Catterall, W.A., Mackie, K. 2006. Local anesthetics.In: Brunton, L.L., Lazo, J.S., Parker, K.L. (eds).Goodman & Gilman’s the pharmacologicalbasis of therapeutics . 11th edn. New York:McGraw-Hill, Medical Publishing Division;369-386.

Dickinson, J.E., Paech, M.J., McDonald, S.J., Evans,

S.F. 2003. Maternal satisfaction with childbirthand intrapartum analgesia in nulliparous labor.Aust N Z J Obstet Gynaecol 43(6): 463-468.

Hansen, S.L., Clark, S.L., Foster, J.C. 2002. Activepushing versus passive fetal descent in thesecond stage of labor: a randomized controlledtrial. Obstet Gynecol 99(1):29-34.

Hiltunen, P., Raudaskoski, T., Ebeling, H., Moilanen, I.2004. Does pain relief during delivery decreasethe risk of postnatal depression? Acta ObstetGynecol Scand 83(3): 257-261.

Kumar, M., Paes, B. 2003. Epidural opioid analgesiaand neonatal respiratory depression. J Perinatol

23(5):425-427.Niesen, A.D., Jacob, A.K. 2013. Combined spinal-

epidural versus epidural analgesia for labor anddelivery. Clin Perinatol 40(3):373-384.

Pugliese, P.L., Cinnella, G., Raimondo, P., DeCapraris, A., Salatto, P., Sforza, D., Menga, R.,D’Ambrosio, A., Fede, R.N., D’Onofrio, C.,Consoletti, L., Malvasi, A., Brizzi, A., Dambrosio,M. 2013. Implementation of epidural analgesiafor labor: is the standard of effective analgesiareachable in all women? An audit of two years.Eur Rev Med Pharmacol Sci 17(9): 1262-1268.

Society of Obstetricians and Gynecologists (SOGC).

2004. Cesarean Section on Demand – SOGC’s position . Ottawa: Society of Obstetriciansand Gynaecologists of Canada. http://apps.fims.uwo.ca/NewMedia2007/resources/10/ reports/Elective_Caesareans_-_position_statement-2004[1].pdf. [Accsessed on 17 January 2014]

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Case Study on the Effect of Epidural Analgesia on Pain Management During Labour