Labour Anaelgesia...Rohitash

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 &ethods 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 &ethods 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


36/50

• 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.


47/50

#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

Documents

Labour Anaelgesia...Rohitash