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Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
Labour analgesia - ajay
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Labour analgesia - ajay

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An overview of Labour Analgesia.

An overview of Labour Analgesia.

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  • 1. Dr Ajay Dr NishthaDr Pooja Sikka
  • 2. THE LABOUR IS REPORTED TO BE ONE OFTHE MOST PAINFUL EXPERIENCES IN AWOMAN’S LIFE.
  • 3. Pain Pathways- First stage of labour- uterine contraction + cervical dilatation. Afferent- visceral afferent from uterus (symathetic) T 10, 11, 12, L 1 posterior segments. Second stage- distension of pelvic floor, vagina and perineum by descending head Afferent- sensory fibres of S 2, 3, 4 (pudendal nerve)
  • 4. EFFECTS OF PAIN AND STRESS release of adrenocorticotropic hormone, cortisol, catecholamines, and b-endorphins. b-adrenergic agents have uterine relaxant effects and higher epinephrine levels are associated with anxiety and prolonged labour. animal studies indicate that both epinephrine and nor-epinephrine can decrease uterine blood flow in the absence of maternal heart rate and blood pressure changes, contributing to occult fetal asphyxia.
  • 5.  Maternal psychological stress (induced by bright lights or toe clamp) can detrimentally affect uterine blood flow and fetal acid-base status (animal studies) Postpartum women suffer objective deficits in cognitive and memory function when compared with nonpregnant women.
  • 6. 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
  • 7. Analgesia for Vaginal Delivery Psychoanalgesic techniques Acupuncture TENS (transcutaneous electric nerve stimulation) Systemic narcotics Tranquilizers / hypnotics Inhalation analgesia
  • 8. ANALGESIA FOR LABOURPsychoprophylaxis- nonpharmacologic method Relaxation, concentration on breathing, acupuncture, gentle massage, and partner participation. may be used alone, or in conjunction with parenteral or regional techniques. efficacy of these techniques is largely unproven because of a lack of randomized clinical trials. there are no serious safety concerns with any of these techniques.
  • 9. Acupuncture Acupuncture alleviates labour pain and reduces use of both epidural analgesia and parenteral opioids. Arranging to have a qualified provider available at the time of delivery may be challenging.
  • 10. Under Water Delivery No advantage in labour outcome or in reducing the need for analgesia. The request for epidural analgesia was delayed by about 30 minutes. Lack of trials demonstrating safety and the rare but reported unusual complications such as fetal infection or asphyxia.
  • 11. Others- Intracutaneous sterile water injections- similar gating mechanism as acupuncture. transcutaneous electrical nerve stimulation during labour- made the pain less disturbing, doesn’t decrease it.
  • 12. Placental Transfer of Drugs:Maternal, Drug, Placental and Fetal Factors Lipid solubility Molecular size Total dose of drug Concentration gradient Maternal metabolism and excretion Degree of ionization pKa of drug, maternal and fetal pH Protein binding - mother and fetus Uterine blood flow
  • 13. Sedatives Do not possess analgesic qualities. Used early in labour to relieve anxiety or to aid in sleep. Cross the placenta freely. Barbiturates, Phenothiazines, and Benzodiazepines. Barbiturate and benzodiazepines are not used routinely in obstetrics.
  • 14. Phenothiazines Promethazine (Phenargan) Dose- 25 mg Antagonists are not available. Weak antiemetic. Routine use of promethazine is unnecessary.
  • 15. Systemic Opioid Analgesia Morphine-like pharmacological activity. Natural- morphine and codeine Semisynthetic- hydromorphone and heroine Synthetic- meperidine and fentanyl Provide sedation and a sense of euphoria. Analgesic effect in labour is limited. Primary mechanism of action is sedation.
  • 16. Advantages- Easy administration. Inexpensive. Avoids complications of regional block. Does not require skilled personnel. Few serious maternal complications.
  • 17. Disadvantages- All drugs easily cross placenta. Pain relief inadequate in most cases Maternal sedation Nausea, vomiting, gastric stasis Fetal heart rate effects: Loss of beat-to-beat variability Sinusoidal rhythm Dose-related maternal / neonatal depression Newborn neurobehavioral depression
  • 18. Treatment of respiratory depression- ventilation, oxygenation, gentle stimulation, naloxone.
  • 19. Tramadol Centrally acting opioid analgesic used in treating severe pain. Route- IV or IM Dose- 50 mg Emetic. Should be given with antiemetic. Maximum respiratory depression and low apgar score occur in newborns that are delivered within- 3 hours after an IM administration 2 hours after an IV administration.
  • 20. Meperidine Meperidine 100 mg is roughly equi-analgesic to morphine 10 mg. Side effects- tachycardia, nausea and vomiting, and a delay in gastric emptying. Normeperidine - active metabolite of meperidine, potentiating meperidines depressant effects in the newborn. Concentrations increase slowly, therefore, exerts its effect on the newborn during the second hour after administration. Multiple doses of meperidine = greater accumulation of both meperidine and normeperidine in fetal tissues.
  • 21. Fentanyl Fast-onset, short-acting synthetic opioid. Requires frequent redosing or the use of a patient- controlled intravenous infusion pump. Fewer neonatal effects and less maternal sedation and nausea. Other opioids are nalbuphine, pentazocine, buprenorphine and butorphanol
  • 22. Inhalational analgesia Easy to administer (no needles) Nitrous oxide is administered in subanaesthetic concentrations. (N2O 30-50%) Analgesia without loss of consciousness. Crosses the placenta but is eliminated efficiently, no untoward neonatal effects. No effects on uterine contractions. Most effective for short term (1-2 hrs) pain relief Most beneficial in late first stage of labour.
  • 23. Local and regional techniques Local infiltration Pudendal block Paracervical block Paravertebral (lumbar sympathetic block) Epidural - lumbar (caudal) Spinal Combined spinal-epidural (CSE)
  • 24. Perineal Infiltration Direct infiltration of 1% lignocaine is used for perineal and lower vaginal lacerations. Advance the needle and inject and aspirate to avoid intravascular injection. Dose of lignocaine is 3-4 mg/kg plain solution, and 7-8 mg/kg with added epinephrine. 1% solution = 10 mg/ml For 6O kg woman total dose should not exceed 200 mg or 20 ml. After local infiltration one should wait 3 minutes before proceeding.
  • 25. Paracervical block 5 to 6 ml of a dilute solution of local anesthetic without epinephrine (e.g., 1 percent lidocaine or 1 or 2 percent 2-chloroprocaine) is injected into the mucosa of the cervix at the 3- and 9-oclock positions fetal bradycardia that follows in 2 to 70 percent of applications fetal acidosis and death have been reported Paracervical block should be used cautiously at all times and should not be used at all in mothers with fetuses in either acute or chronic distress.
  • 26.  mechanism of postparacervical block bradycardia- local anesthetic injected close to the uterine artery passed to the fetus uterine artery vasoconstriction secondary to a direct effect of the local anesthetic on the uterine artery local anesthetic injected directly into the uterine musculature increases uterine tone
  • 27. Pudendal nerve block minor regional block, effective and very safe. Using a 20-gauge needle, inject 5 to 10 ml of local anesthetic just below the ischial spine. Because the hemorrhoidal nerve may be aberrant in 50 percent of patients, some prefer to inject a portion of the local anesthetic somewhat posterior to the spine. Although a transperineal approach to the ischial spine is possible, most prefer the transvaginal approach. One-percent lidocaine or 2-percent 2-chloroprocaine can be used
  • 28.  satisfactory for all spontaneous vaginal deliveries and episiotomies, and for some outlet or low operative vaginal deliveries. The potential for local anesthetic toxicity is higher with pudendal block compared with perineal infiltration because of large vessels proximal to the injection site. Aspiration before injection is particularly important.
  • 29. Regional Analgesia for Labor Epidural (LA or opioids) Spinal (LA ± opioids) CSE- combined spinal epidural (opioids ± LA)
  • 30. Fetal / Neonatal Effects of RegionalAnalgesia in Labor Uterine perfusion maintained. Profound hypotension & possible fetal compromise. LA toxicity - extremely rare. FHR changes:  baseline variability  periodic decelerations (due to maternal catecholamine) Neurobehavioral effects absent with current agents.
  • 31. Epidural Analgesia Epidural block is the most effective and least depressant (pharmacologic option) allowing for an alert, participating mother. (guidelines American College of Obs & gynae) Primary indication is the patients desire for pain relief. Medical indications during labor- selected forms of cardiovascular and respiratory disease, and prevention or treatment of autonomic hyperreflexia in parturients with a high spinal cord lesion.
  • 32.  Epidural analgesia prevents increases in both cortisol and 11-hydroxycorticosteroid levels during labor, but systemically administered opioids do not. Epidural analgesia also attenuates elevations of epinephrine, norepinephrine, and endorphin levels.
  • 33. Contraindications- Coagulopathy Sepsis Patient’s refusal Fixed cardiac output disease History of allergy to local anaesthetics Thrombocytopenia Hypovolemia
  • 34. Types- Lumbar- routinely done Caudal- not favoured
  • 35. Lumbar- Low concentrations of local anesthetic are injected at L2-L5. Affecting the small easily blocked sympathetic nerves that mediate early labour pain. Sparing the sensation of pressure and motor function of the perineum and lower extremities. Dose can be adjusted according to patient’s response.
  • 36. Choice of epidural local anaestheticLignocaine- rapid onset, dense motor block, risk of cumulative toxicity with repeated doses.Bupivacaine- good sensory block with minimal motor effect. No adverse effect on labour with 0.0625% concentration Highly protein bound, fetal blood concentrations are lower than with other local anaesthetics.
  • 37. Epidural Opioids in Labour Inadequate analgesics used alone Synergistic with local anesthetics Speedy onset of analgesia Improves quality of analgesia Permits use of very dilute LA solutions Help relieve persistent perineal pain and unblocked segments
  • 38. Fentanyl and Sufentanil Rapid onset, few side effects Sufentanil slightly more effective No significant fetal drug accumulation No serious adverse neonatal effects with either
  • 39. Side effects of epidural- hypotension local anesthetic toxicity allergic reaction high or total spinal anesthesia neurologic injury spinal headache. Fetal bradycardia
  • 40.  The effect of epidural analgesia on labour progression, fetal position, and risk of cesarean delivery is controversial. Randomized studies support the conclusion that epidural analgesia results in a modest prolongation of both the first and second stages of labour. Significant increase in the use of oxytocin for labour augmentation.
  • 41.  Increased rate of instrumental delivery. Several well-designed randomized studies suggest that, in settings with baseline low rates of caesarean delivery, epidural analgesia does not increase the risk of caesarean delivery.
  • 42.  Epidural analgesia during labor is associated with an increase in maternal temperature. Dependent on the duration of exposure. Possible mechanisms- noninfectious inflammatory activation, changes in thermoregulation, and acquired intrapartum infection.
  • 43. Combined spinal epidural Opioids ± LA Rapid onset of intense analgesia. Ideal in late or rapidly progressing labour. Very low failure rate. Less need for supplemental boluses. Minimal motor block (“walking epidural”) Walking epidural- Use of opioid only to allow parturients to ambulate during labour because there is little or no interference with motor function.
  • 44.  Early intrathecal opioids followed by continuous epidural infusion in active labour may be a good option for women desiring regional analgesia, offering superior pain control until active labour has been achieved.
  • 45.  One randomized study found that use of intrathecal opioids increased speed of cervical dilatation and decreased length of labour when compared with conventional epidural. The use of intrathecal opioids improved pain control in early labor without increasing the risk of caesarean delivery. avoids maternal sedation , decreases nausea and vomiting. comparisons of intrathecal opioid analgesia versus epidural or parenteral opioids in labour found the use of intrathecal opioids significantly increases the risk of fetal bradycardia .
  • 46.  Fetal heart rate should be monitored during and after the administration of either epidural or intrathecal medications to allow for timely intrauterine resuscitation. No increase in emergency caesarean delivery.
  • 47. Conclusions Individualize technique to patient’s goals and stage of labour. Optimize management for spontaneous delivery. Provide safe, cost-effective analgesia.
  • 48. Thank you

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