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8/18/2019 Labour Anaelgesia...Rohitash
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LABOUR ANAELGESIA
Moderators:-
Dr.Bimla Sharma
Dr.Anjeleena Kmar G!ta
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What Is the Intensity of Pain in Labour ?
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Adverse Efects o Labour on the Foetus
•
S y m p a t h e t i c S t i m u l a t i o n
• PA
IN• Suffering• Loss of Morale
• Anxiety
• O2 Consumption
• Hyperventilation
• Hypocaria
• Catecholamine
release
• Impaire! uterine• contractions
• ↓ "teroplacental
• loo! flo#
• Car!iac Output
• Peripheral
$esistance
•
%loo! Pressure
• &elaye! gastric emptying
• A!renocortical
Output
• Lactic Aci!
• 'ree fatty aci!
• Maternal
metaolic
aci!osis
• ↓'etal pH
• ↓ 'etal O2
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Methods o" #ain Relie" Drin$ La%or
• Non-pharmacological
• Pharmacological
- Systemic drugs
- Inhalational agents
- Regional analgesia
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Non-pharmacological
Methods of Pain Relief
• ypnosis
• !iofeed bac"
• #cupuncture
• $%NS
• !reathing & rela'ation
• ydrotherapy
• #romatherapy
• $ouch & massage
• Music
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• Grantl& Di'( ) Read*s - +orre't !res'ri!tion "or
method !artrition
- Rela,ation
•#alos e'hni/e - Ed'ation o" mother
- +oo!eration drin$
%earin$ do0n
• Dola - +onstant hman s!!ort -
'om!anion• Le%o&er*s heor& - Semi dar( tran/il enironment
- 1arm %oth
#re!ared 'hild %irth
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Modern Approach (Psychoprophylaxis) by:-
FE!"#A#! LAMA$E
%each nor&al anato&y' physioloy o prenancy and
labour
%rainin in relaxation techniues
*reathin techniues by +rantly !ic, ead.s techniue
/orrect ðods durin parturition
Modern Approach (Psychoprophylaxis) by:-
FE!"#A#! LAMA$E
%each nor&al anato&y' physioloy o prenancy and
labour
%rainin in relaxation techniues
*reathin techniues by +rantly !ic, ead.s techniue
/orrect ðods durin parturition
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•#rin'i!leGate 'ontrol and en'e!haline release
• Sim!le2 sa"e2 non inasie
de'reases need "or nar'oti's
Ine3e'tie drin$ 4nd sta$e
• e'hni/es
• Dal ot!t dei'e: am!litde 5-445 olts2 rate 65-745 89
0o sili'on ele'trodes !la'ed !araerte%rall& 75-L7; S4-6<
• U!!er ) adjsted to "eel tin$lin$2 'ontinos drin$ la%or
Lo0er hi$her stimls drin$ and =5 se' a"ter t 'ontra'tion
rans'taneos Ele'tri'al Nere
Stimlation ENS<
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Adanta$es
• #atient*s air0a& re>e,es maintained
• No h&!erentilation; h&!otension or de'reased tero!la'ental
!er"sion
• No nasea or omitin$
• ?oetal ha9ards o" nar'oti's aoided
• Shortened @rst sta$e o" la%or and no "oetal meta%oli' a'idosis
Disadanta$es
• ime 'onsmin$
• Onl& 4 o" !atients res!onded
• n0illin$ !s&'hoti'2 h&steri'al !atients not sita%le
8&!nosis
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• Inje'tion o" sterile 0ater
• 5.7 ml2 intradermal C s%'taneos
• 6-!oint2 sa'ral %orders
• ↓ #ain "or !to 6-5 mins
#ain s'ore =<
• Re!eat inje'tions
Inje'tion 1aterS'andinaian +ontries
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• Gate +ontrol F en'e!haline !rod'tion theor&
Blo'(in$ !ain transmission thro* A-β @%res2
o!ens the a'tiit& in A-δ and +-@%res<
• Sterile2 ase!ti' te'hni/e
• Sele'tion o" 'oo!eratie and intelli$ent !artrient
• 8i$h motiation needed
• Sele'tion o" !oints is di'lt s!e'iall& sta$e II<
A'!n'tre
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Other Methods
• Ele'troanal$esia
• 8ome delier& : +on$enial and "amiliar srrondin$s
de'reases "ear and a!!rehension. #roide O4 s!!l&2 s'tion
F ress'itation e/i!ments
• 1ater %irth
Disadanta$es :
( Ris( o" 'ontamination o" 0ater
( o,&$en de!riation to %a%&
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#harma'olo$i'al
• o) Pharmacological Methods of Pain Relief
Related to *er+ical ,ilatation ?
P#IN
L#!.R
/ 0 1
*%R2I*#L ,IL#$#$IN3S$ S$#4%
5N, S$#4%
#N#L4%SI#
NN 2L#$IL%2L#$IL%
&4#S%.S
%PI,.R#L !L*6#,%
3S$ P%RI, 5N, P%RI, 7R, P%RI,
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• +on'erns:- ( In'reased instrmental delieries
( 8&!otensie e!isodes
( ?or'ed %ed rest in one !la'e
( Neonatal se!sis re/irin$ anti%ioti'
( Maternal intra!artm "eer
Systemic #nalgesia for Labour Pains
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Alternative techni(ues for laour
analgesiaSystemic analgesia
Intravenous
Intramuscular
Inhalational
)ntonox *N2O+ O2 ,-+,-.
Isoflurane *-/20-/2,1.
&esflurane *03/,1 in O2 or )ntonox.
Sevoflurane *-/,041.
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Non0opioi!s
• Paracetamol
• Sedati+e tran;uili
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0edative %ranuili1ers
• Reduce an'iety
• Promote sleep
• ,o not pro+ide analgesia
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!issociative Anaesthetic
6etamine
• NM,# antagonist
• .seful ad>unct to patchy neura'ial bloc"ade
• Rapid onset 8 7@ sec9: rapid offset 8A min9
• !olus dose - @B5C mgD"g: infusion ( @B5CmgD"gDhr
• Reduced pain score 7
&isa!vantages
• Rise of maternal blood pressure
• Psychomimetic effects: unpleasant dreaming
• #naesthetic doses may compromise air)ay
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• *ommonly used ( %utorphanol5 Naluphine5 7rama!ol
A!vantages
• E*eiling effectF
• Less respiratory depression• Less nausea: +omiting than agonists
&isa!vantages
• Rapidly crosses placenta
• mnious sinusoidal =R pattern
• #cute )ithdra)al syndrome in mother and neonate
• Increase mean P#P: P*WP: mean aortic pressure: P2R: myocardial
)or"
Aonist Antaonist 2pioids
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Adanta$es
• Good anal$esi'
• Minimal !s&'homimeti' e3e't
• In'reasin$ doses !rod'e $reater
res!irator& de!ression
• +eilin$ e3e't on res!irator&
de!ression and anal$esia
Btor!henol F Nal%!hine
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Disadanta$es
• Ra!idl& 'rosses !la'ental %arrier
• 8i$h nero%ehaioral s'oresthan O#IOIDS
• Immense sedation
• Limited anal$esia 'eilin$ e3e't<
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Inhalational
• %ntono'
• Se+oflurane
• Isoflurane
• ,esflurane
• $rilene
•Metho'yflurane
• *hloroform
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Opioi!s Administration Should be Timed
• %arly labor
( ,ecreases uterine acti+ity
( Slo)s cer+ical dilatation
( Retards progress of labor
• %stablished labor
( !etter coordinated uterine contraction dDt pain relief
( Shortens acti+e phase of labor
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#ethidine
• Synthetic phenylpiperidine deri+ati+e
• #cti+e metabolite - Norpethidine - *on+ulsant properties
• Wea" base ioni
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+ontdH
• Suggested regime
• Loading dose C@ mg J 85C mg
prometha
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?entan&l
• Lipi! solule phenylpiperi!ine !erivative
• $api! onset of action *204 min.5 Short !uration of action
• No active metaolite
• $api!ly crosses placenta• Appears in foetal loo! in min an! levels pea8 at , min
• A!verse !ose !epen!ent impact on capacity to reast fee! soon after
irth
• No a!verse effect on uterine tone or loo! flo#
• No !ifference in neonatal neuroehaviour at 2 hr an! 23 hr postpartum
• Only a rief !ecrease in 'H$ variaility
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Suitale for PCIA
• Loading dose C@-3@@Kg
• !olus dose 5@-5CKg
• Loc" out inter+al C min
• Ma'imum total hourly dose 5A@ Kg
• 5C@ mcgDhr: neonatal depression is high
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Remi"entan&l
• A - #nilido piperidine deri+ati+e
• .ltrashort acting u-3 opioid receptor agonist
• Rapid onset of action 87@-@sec9 Pea" action 85BC min9
• *onte't sensiti+e half life 7BC min 8independent of duration of infusion9• Rapid placental transfer 8.2 to maternal artery ratio @B9
• Rapid plasma and tissue esterase metabolism and foetal redistribution 8.#D
.2 ratio @B59 short neonatal elimination half life
• Inacti+e metabolite
• #nalgesic half life min
( %ffecti+e analgesia for se+eral painful uterine contractions
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7iming of !rug !elivery is crucial
• Remifentanil bolus dose begins to )or" after @-35@ sec
• #+erage duration of contraction @-@ sec
• I2 bolus dose deli+ered at beginning of contraction does not ease pain of
that contraction
• !etter results )ith constant I2 infusion along )ith rescue P*# bolus dose
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• Suggested regime for P*I# ( !olus dose ( @B5C µgD"g Loc" out inter+al 5 min ( !ac"ground infusion @B@5C-@B3 µgD"gDmin
• %nsure
( No opioid use for pre+ious A hrs ( ,edicated I2 cannula: continuous one to one monitoring
( 7@ min obser+ation ( RR: sedation and pain score
( Inform anaesthetist
• %'cessi+e sedation 8unarousable to +oice9
• RR breaths D min: Sp5 @H on room air
( Supplemental o'ygen and nalo'one: readily a+ailable
• Side effects 8dose @BC µgD"g9 ( Maternal dro)siness: apnoea bet)een contractions
( Profound respiratory depression: chest )all rigidity
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2 agonist
• #d>unct to opioid analgesia
• Significant analgesic and sympatholytic properties
• Limited effects on uteroplacental blood flo)
• Negligible placental transfer
• #dditional analgesia )ith impro+ed ;uality )ithout respiratory depression
• Loading dose ( @BCµgD"g o+er 3@ min
• Infusion ( @B5 ( @B µgD"gDhr
• Immediate reduction in pain score
• %nsure continuous pulse o'imetry
&exme!etomi!ine
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• Nitros o,ide ) sed sin'e 77• Adanta$es : eas&2 'hea!2 minimal a''mlation 0ith #+IIA
• Disad: in'om!lete2 in'onsistent anal$esia2 atmos!heri' !olltion
• Entono, 5 N4O in o,&$en
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• ,esflurane: enflurane & isoflurane effecti+eness is comparable to
that of N5
• Re'ent studies suggest se+oflurane in inspired concentration of
@BH to be acceptable & effecti+e• Pro+ide superior pain relief but )ith more intense sedation )ithout
ad+erse effects )ith compared )ith entono'
• Isoflurane @B5 - @B5CH )ith N5 8ISNO9
• ,esflurane 3 - ABCH )ith N5
• .se limited by dro)siness: unpleasant smell & high cost
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Re$ional e'hni/es
• Lm%ar s&m!atheti' %lo'(
• Lm%ar e!idral anal$esia
• Intermittent doses2 'ontinos in"sion2 #+EA
• Se$mental e!idral anal$esia2 sele'tie e!idral• Do%le 'atheter - e!idral anal$esia
• +ontinos s!inal anal$esia
• +om%ined s!inal - e!idralC0al(in$ e!idral anal$esia
• Sa'ral e!idral anal$esia C do%le 'atheter %lo'(
• #ara'eri'al %lo'(
• #dendal nere %lo'(
i l i
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Nera,ial Anatom& in#re$nan'&
• Lm%ar lordosis
• 1idenin$ and rotation o" the !elis
• ers line 'rosses s!ine at a hi$her leel ie L=-6 s!a'e
• En$or$ement o" e!idral eins
• Di'lt identi@'ation o" li$amentm >am
• In'reased sensitiit& to lo'al anestheti's
↑ !ro$esterone e3e't
↑ as'larit& o" menin$es2↑ di3sion o" LAs a'ross nere sheaths
↑ sensitint& to LAs
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+ontdH.
• Red'tion in intererte%ral $a!
8ead do0n tilt
Enhan'ed rostral s!read
• Smaller olme a'hiees similar e3e'ts
• Onset time %e'omes "aster
Narro0 e!idral s!a'e
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Lm%ar E!idral Anal$esia
"ndicati
ons• #atient : demand2 di'lt air0a&2
res!irator&C'ardia' disease
Attenation o" h&!ertensie
res!onse 2 red'es "ati$e
• O%st: #rolon$ed la%or2
in'oordinate terine 'ontra'tions
+eri'al d&sto'ia2 "ll stoma'h
• ?oetal : #rematrit&2
mlti!le !re$nan'& or %ree'h
• MIS+ : ↑ I+2
"ailre o" 'onentional te'hni/es
/ontraindication
• Un0illin$2 n'oo!eratie !atient
• Non aaila%ilit& o" e,!ert hand or
e/i!ment
• Lo'al se!sis2 %leedin$ disorders
• S!inal de"ormit& or sr$er&2
seere 'ardia' disease
• #reo! s&m!toms o" s!ine
h&!otension
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• Adanta$es
Lm%ar E!idral Anal$esia
• A0a(e2 +oo!eratie drin$ e3e'tie olntar& e,!lsion
• ?le,i%le 0ith !ro$ress o" la%or2 minimal MC? side e3e'ts
• S&ner$isti' a'tion 0ith o!ioids2 e,tenda%le "or LS+S
• Use"l drin$ !ost!artm !eriod MR#2 e!isiotom&<
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+ontdH
• Disadanta$es
• itration 0ith 'han$in$ maternal haemod&nami's
• 8i$h doses ) to,i'it&2 ta'h&!h&la,is Lido'aine<
• ?ailed2 !at'h& %lo'(2 s%ara'hnoid !n'tre
• +ontroersiall& %lamed "or ↑ in'iden'e o" LS+S
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+om!li'ations
• ?ailed or in'om!lete anael$esia
• Maternal h&!otension
• #D#8
• otal s!inal or 8i$h s!inal• 8&!erstimlation o" ters-"oetal %rad&'ardia
• Inhi%ition o" ?er$oson*s re>e,- de'reasedo,&to'in !rod'tion
• #rolon$ation o" se'ond sta$e
• o,i' rea'tion at hi$h doses
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%3E EP"!4AL %E0% !20E
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ME%32!0 2F L2/A%"#+ %3E EP"!4AL 0PA/E
Loss o resistance• #a$e*s method:Sdden loss o"
resistan'e
• Do$liotti*s method: Sdden ease o"inje'tion o" air or >id
• M'Intosh*s e!idral s!a'e indi'ator 0ith
a small red %alloon• M'Intosh*s s!rin$-loaded needle deised
%& R.A.Salt.
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#eative pressure sins
• Gtierre9 han$in$ dro! si$n: ( 1ithdra0al o" a han$in$ dro! o" saline !la'ed on the h% o" a needle
“Sena de gota” or “sign of the drop”.
• Odom*s indi'ator: ( Odom*s indi'ator is a $lass t%e o" @ne %ore 'ontainin$ saline and an air
%%%le. On enterin$ the e!idral s!a'e there is an in0ard moement o" the>id alon$ 0ith the air %%%le.
• Loss o" resistan'e te'hni/es are easier to eli'it in lm%ar re$ion0here the li$amentm >am is the thi'(est. Ne$atie !ressresi$ns are ado'ated "or thora'i' e!idrals .
B i R i t i
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Basi' Re/irements in#re!aration
• horo$h ealation
• In"ormed 'onsent
• Anta'id !ro!h&la,is
• ?astin$
• Intraenos line
• Ress'itatie dr$s
• Load and la%el
• Atro!ine
• Me!henteramine2 E!hedrine
• E!idral C s!inal 'atheter• A%solte ase!sis2 lo0er lm%ar s!a'e !re"erred
• ?oetal F maternal monitorin$
• #reloadin$ ) de,trose "ree %alan'ed soltion
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Dose re$imes
•$raditionally
(!upi+acaine - @B5C-@BCH
•No) ML#, & ML#2
(!upi+acaine - @B@5CH - @B35CH
(Ropi+acaine @B3H -@B5H
•↓$otal dose of LB#B
•↓Side effects such as motor bloc"ade
#ddition of pioid•Lo) dose mi'ture of LB#B & opioid
L#8@B@5CH - @B35CH9 J 5µg/ml fentanyl
•Infusion - mlDhr
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Methods to Administer
• Intermittent to! !s
• -75 ml 5.4-5.74 %!ia'aine "entan&l 4 µ$Cml
•+ontinos e!idral in"sion +IEA<
• 5.54 - 5.7 %!ia'aine "entan&l 4 µ$ C ml 75-74 mlChr
•#+EA : Intermittent doses• ml %olses o" 5.54 ) 5.7 %!ia'aine "entan&l 4 µ$ C mlLo'( ot time 7-45 min
In"sion rate 75-7 mlChr