Labour Analgesia Presentation 2

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Labour Analgesia Presentation 2

  1. 2. ADVANCES IN LABOUR ANALGESIA. “ WALKING EPIDURAL” BY DR ZAHID AKHTAR RAO MBBS;MCPS;FCPS MILITARY HOSPITAL RAWALPINDI
  2. 3. <ul><li>THE DELIVERY OF THE INFANT INTO THE ARMS OF A CONSCIOUS AND PAIN FREE MOTHER IS ONE OF THE MOST EXCITING AND REWARDING MOMENTS IN MEDICINE. </li></ul>
  3. 4. <ul><ul><ul><li>THE LABOUR IS REPORTED TO BE ONE OF THE MOST PAINFULL EXPERIENCES IN A WOMAN’S LIFE. </li></ul></ul></ul>
  4. 5. <ul><li>IT IS NOW WELL RECOGNIZED THAT THE ONLY CONSISTENTLY EFFECTIVE METHOD OF PAIN RELIEF DURING LABOUR IS LUMBER EPIURAL ANALGESIA. </li></ul>
  5. 6. <ul><li>“ EPIDURAL BLOCK IS THE MOST EFFECTIVE AND LEAST DEPRESSANT (pharmacologic Option) ALLOWING FOR AN ALERT,PARTICIPATING MOTHER.” </li></ul><ul><li>(guidelines American College of Obs & gynae) </li></ul>
  6. 7. <ul><ul><ul><ul><li>“ MATERNAL REQUEST IS SUFFICIENT JUSTIFICATION FOR PAIN RELIEF DURING LABOUR.” </li></ul></ul></ul></ul>
  7. 8. <ul><li>OVER THE LAST 40-50 YEARS,LABOUR EPIDURAL ANALGESIA HAS UNDERGONE SUBSTANTIAL CHANGES. </li></ul><ul><li>CURRENTLY,”STATE-OF THE-ART” TECHNIQUES HAVE BEEN DEVELOPED AND ARE NOW USED IN ROUTINE CLINICAL PRACTICE. </li></ul>
  8. 9. <ul><li>THE IDEAL LABOUR ANALGESIC SHOULD ALSO GIVE A RESTED PARTURIENT THE ENERGY,STRENGTH AND SENSATION TO PERFORM EXPULSIVE EFFORTS AT THE TIME OF DELIVERY. </li></ul><ul><li>TO ACHIEVE THESE GOALS, RECENT DEVELOPMENTS HAVE FACILITATED MATERNAL AMBULATION WHILE RECEIVING EFFECTIVE REGIONAL ANALGESIA. </li></ul>
  9. 10. <ul><li>Why to walk? </li></ul><ul><li>The upright posture helps shorten the duration of labour by walking </li></ul><ul><li>Weight of fetus would dilate the cervix </li></ul>
  10. 11. <ul><li>Mothers who walk during labour had reduced duration and operative delivery rate. </li></ul>
  11. 12. ADVANCES IN LABOUR ANALGESIA INCLUDES: <ul><li>TRADITIONAL EPIDURALS. </li></ul><ul><li>LOW DOSE EPIDURALS. </li></ul><ul><li>WALKING EPIDURALS. </li></ul><ul><li>PATIENT CONTROLLED EPIDURAL ANALGESIA. </li></ul><ul><li>COMBINE SPINAL EPIDURAL. </li></ul><ul><li>CONTINEOUS EPIDURAL INFUSION. </li></ul>
  12. 13. TRADITIONAL EPIDURALS: <ul><li>USING 0.25% Bup. </li></ul><ul><li>HIGH INCIDENCE OF MOTOR BLOCK. </li></ul>
  13. 14. EFFECT OF LOW DOSE MOBILE VS. TRADITIONAL EPIDURAL TECHNIQUES ON MODE OF DELIVERY. <ul><li>INCREASED RATE OF NORMAL VAGINAL DELIVERY WITH LOW DOSE MOBILE. </li></ul><ul><li>DECREASED RATE OF INSTRUMENTAL VAGINAL DELIVERY WITH LOW DOSE MOBILE. </li></ul><ul><li>INCREASED RATE OF CS WITH TRADITIONAL EPIDURAL. </li></ul><ul><li>(COMET STUDY, LANCET 2001.(1054 PTS). </li></ul>
  14. 15. LOW DOSE EPIDURALS : <ul><li>USING 0.125% Bup. </li></ul><ul><li>HIGH DEGREE OF PATIENT SATISFACTION. </li></ul><ul><li>MAY HAVE SOME DEGREE OF MOTOR WEAKNESS. </li></ul><ul><li>MAY NEED ADDITION OF NORCOTICS. </li></ul>
  15. 16. WALKING EPIDURALS: <ul><li>USING 0.0625% Bup.+FENT 02ųg/ml. </li></ul><ul><li>HIGH DEGREE OF MATERNAL SATISFACTION. </li></ul><ul><li>NO MOTOR WEAKNESS. </li></ul><ul><li>LOW INCIDENCE OF CS. </li></ul>
  16. 17. PCEA <ul><li>LOADING DOSE REQUIRED. </li></ul><ul><li>PATIENT/NURSE EDUCATION REQUIRED. </li></ul><ul><li>LOWER DRUG DOSE. </li></ul><ul><li>LESS ANAES VISIT. </li></ul><ul><li>MORE PATIENT SATISFACTION. </li></ul><ul><li>EQUIPMENT COST VERY HIGH. </li></ul>
  17. 18. CSE <ul><ul><li>RAPID ONSET OF ANALGESIA. </li></ul></ul><ul><li>RELIABLE, FEWER FAILED,OR PATCHY BLOCKS. </li></ul><ul><li>EFFECTIVE SACRAL ANALG IN ADVANCED LABOUR. </li></ul><ul><li>LESS MOTOR BLOCK. </li></ul><ul><li>BETTER PATIENT SATISFACTION. </li></ul><ul><li>FASTER CERVICAL DILATATION. </li></ul>
  18. 19. SIDE EFFECTS OF CSE <ul><li>PDPH. </li></ul><ul><li>PRURITIS. </li></ul><ul><li>INFECTION. </li></ul><ul><li>NEUROTRAUMA. </li></ul><ul><li>HYPOTENTION. </li></ul><ul><li>RESPIRATORY DEPRESSION. </li></ul>
  19. 20. ON THE OTHER HAND…….. HOW FAST DO WE NEED A BLOCK TO BE ? <ul><li>Nickells et al: </li></ul><ul><li>Time to first painless contraction with CSE was at 10 vs 12.1 min with epid. </li></ul><ul><li>Hepner: </li></ul><ul><li>Mentioned at 5min the VAS was<3 in 26/26 with a CSE vs. 17/24 with an epid. </li></ul>
  20. 21. CONTINUOUS EPIDURAL INFUSION <ul><li>DOSE USED IS HIGH. </li></ul><ul><li>DURATION OF LABOUR IS LONGER. </li></ul><ul><li>MAY NEED RESCUE DOSE. </li></ul>
  21. 22. PCEA VS.CEI FOR LABOUR ANALGESIA. <ul><li>(80 Parturient) </li></ul><ul><li>PCEA group used less drug(5.2 v 6.9 ml/hr) </li></ul><ul><li>Had shorter duration of labour(296min v 357min) </li></ul><ul><li>(ERIKSON,GNTELE AND OLLFSSON ACTA ANAESTHESIOLOGICA SCANDINVICA 2003.) </li></ul>
  22. 23. STUDY CARRIED OUT BY DR. C.HARMS AND HIS COLLEGUES. <ul><li>COMPARISON OF THREE DIFFERENT BUPIVACAINE CONC. </li></ul><ul><li>0.25% WAS ASSOCIATED WITH INCREASE INCIDENT OF MOTOR BLOCK. </li></ul><ul><li>0.125% WAS MOST SUITABLE CONC. FOR LABOUR ANAGESIA. </li></ul><ul><li>WITH 0.0625% CONC. ANALGESIA WAS INADEQUATE. </li></ul><ul><li>(Fetal Diagnosis and Therapy 1999;14:368-74) </li></ul>
  23. 24. DR GUPTA AND HIS COLLEGUES COMPARED THE CSE & LOW DOSE EPID.; IN RELATION TO AMBULATORY LABOUR ANALGESIA: <ul><li>Ambulation achieved in 100% of parturient in both groups. </li></ul><ul><li>Rapid analgesia was achieved in CSE gp.(80% v 0%<5 min.) </li></ul><ul><li>Duration of analgesia was significantly increased in epid gp.(102.8 v 79.1 min) </li></ul><ul><li>In epid gp. 84% parturient were painless b/w 5-15 min. </li></ul><ul><li>(Drug used:bup 0.15% +fen 2ųg/ml in epid & in CSE-1.25mg bup.+20ųg fen.) </li></ul><ul><li>(Indian J. Anaesth.2002; 46(1):44-48) </li></ul>
  24. 25. With 15ml bolus of 0.1%(15mg) bup. +05ug/ml (75ug) fent. Ambulation achieved in 65% of parturient with epidural analgesia . (Anaesthesia 1998;53: 951-5)
  25. 26. Epidural analgesia with 20ml of 0.08%(16mg) bup.+2ug/ml (40ug) fent. Pain free ambulation achieved in 65% of parturient. (Canadian Journal of Anesthesia 50:R8(2003))
  26. 27. With 20ml of either 0.08% ropivacaine+2ug/ml fentanyl or 0.08% bupivacaine+2ug/ml fentanyl given in epidural space. <ul><li>Ambulation in 100% parturients receiving ropivacaine. </li></ul><ul><li>Ambulation in 75% parturients receiving bupivacaine. </li></ul><ul><li>(Anesth Analg 2000; 90:1384-9) </li></ul>
  27. 28. DR MAHARJAN SK AND HIS COLLEGUE MATERNITY HOSPITAL, THAPATHALI KHATMANDU, NEPAL. <ul><li>USING 10ml of Bup.0.1%+25mg Pethidine. </li></ul><ul><li>75% Spontaneous vaginal deliveries. </li></ul><ul><li>20% Instrumental deliveries. </li></ul><ul><li>5% Caesarean section. </li></ul>
  28. 29. A POPULATION BASED STUDY OF 94,217 PRIMIPARAE. EPID ANALG & ITS RELATION TO CS & INSTRUMENTAL DELIVERIES. (Eur J Obstet Gynecol Report Biol. 2005 Dec 09.) <ul><li>Normal deliveries-70.6%. </li></ul><ul><li>Instrumental deliveries-18.8% </li></ul><ul><li>C.S. 10.6% </li></ul>
  29. 30. STUDY BEING CARRIED OUT AT MILITARY HOSPITAL RAWALPINDI. <ul><li>LABOUR ANALGESIA </li></ul><ul><li>COMPARISION OF BUPIVACAINE 0.25%+5mg/ml TRAMADOL VS. BUPIVACAINE 0.1%+5mg/ml TRAMADOL. </li></ul>
  30. 31. GROUP-A: 25 PARTURIENTS GIVEN 10 ml OF BUP.0.25%+5mg/ml TRAMADOL. <ul><li>100% of parturients were pain free in 10-20 min. </li></ul><ul><li>None of them were able to ambulate. </li></ul><ul><li>All were able to move in bed. </li></ul>
  31. 32. GROUP-B: 50 PARTURIENTS GIVEN 10ml OF BUP.0.1%+5mg/ml TRAMADOL. <ul><li>45 parturients were pain free within 10-20 min. </li></ul><ul><li>05 needed initial rescue dose </li></ul><ul><li>46 of them were able to ambulate independently. </li></ul><ul><li>04 of them were able to ambulate with support. </li></ul>
  32. 33. MODE OF DELIVERIES EPID. 0.25% Bup. (GP-A) <ul><li>40% spontaneous deliveries. </li></ul><ul><li>40% instrumental deliveries. </li></ul><ul><li>20% c-section. </li></ul>
  33. 34. MODE OF DELIVERIES EPID. 0.1% Bup.(GP-B) <ul><li>37 spontaneous deliveries. </li></ul><ul><li>06 instrumental deliveries. </li></ul><ul><li>03 c-sections. </li></ul><ul><li>(expected) </li></ul><ul><li>04 patients ( planned for C-section; were delivered vaginally (instrumental) </li></ul>
  34. 35. “ DURING THE FIRST STAGE OF LABOUR THE PATIENT USUALLY PREFERS TO MOVE ABOUT HER ROOM…… THEREFORE, SHE SHOULD NOT BE COMPELLED TO TAKE TO HER BED UNLESS SHE FEELS SO INCLINED.” RECOMMENDATIONS
  35. 36. <ul><li>The CSE technique should ideally be reserved for only those parturients who require rapid onset of analgesia as in later stages of labour. </li></ul><ul><li>Routine use of the epidural technique in early active labour. </li></ul>
  36. 37. CONCLUSION MODERN LABOUR EPIDURAL ANALGESIC TECHNIQUES AND MEDICATIONS HAVE RESULTED IN MORE CONSISTENT, PRIDICTABLE AND EFFECTIVE ANALGESIA. OUR GOAL IS TO IMPROVE PATIENT CARE AND SAFETY; WHILE INCREASING THE SATISFACTION AND PARTICIPATION OF WOMEN IN THEIR LABOUR AND DELIVERY EXPERIENCE.
  37. 38. Thank You

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