1. Humanitarian reason, to reduce patient suffering.2. Economic benefits, quick recovery and rapid discharge. Less morbidity.3. Medical reasons, next slide.
Labour pain may produce sustained maternal hyperventilation and elevated oxygen demand, resulting in intermittent hypoxemia, hypocapnea and dramatically increased catecholamine production. This in turn can lead to hypo- perfusion, fetal hypoxia and acidosis. Pain relief, especially epidural analgesia avoids or attenuates many of adverse maternal and fetal responses to labour.4. Quick recovery and fast discharge with minimum complication.
There are many options available to relieve the pain of child birth.
Due to Neuro-axial failure, there are many obstetrical anaesthetist suggesting that CSE provides more effective analgesia
A pilot study of comparing the efficacy of two regimens of remifentanil PCA.
Pain Relief In Labour1
Pain Relief in Labour<br />DR HUSSAIN KARIM, DEAA, MRCA<br />Consultant Anesthetist, Lead Pain Team<br />Security Forces Hospital, Riyadh<br />
Aim<br />Is how we can achieve better management of labour pain.<br />
Objectives<br />Why do we give analgesia for child birth? <br />Humanitarian reason.<br />Economic benefit.<br />Medical reasons.<br />
Background<br />It is only in the last 100 years that effective methods of pain relief have become available.<br />Queen Victoria was given chloroform by John Snow for the birth of her eight child and this did much to popularize the use of pain relief in labour<br />
Nowadays most women who deliver in modern obstetric units request some kind of pharmaco- logical pain relief.<br />Epidural analgesia is the gold standard in obstetric analgesia.<br />If an epidural is contraindicated or a woman dose not wish to have epidural, other methods can be used.<br />
Pain pathway in LabourThe afferent nerve of the uterus and cervix is via A delta and C fibers, that accompany the thoraco lumbar and sacral dorsal sympathetic chains. - Pain in first stage mediated through (T10 - L1 ). - In the second stage mediated through (S2 – S4 ).<br />
History of Epidural (Current therapy in pain, Howard Smith, 2009)<br />First description of Ep. Analgesia dates back to Leonard J. Corning, a neurologist who in 1895 inadvertently injected cocaine in the Epidural space.<br />Since 1900, Epidural analgesia was being used to treat the pain of child birth.<br />
In 1931 a continuous technique was described by Italian surgeon, A.M. Dogliotti. He was the first to describe the loss of resistance technique.<br />Philip Bromage published the first <br /> text book on Epidural anesthesia <br /> in 1978. <br />Bromage introduced the administration of epidural opioids for post operative analgesia in 1980.<br />1988: Introduction of PCA with Epidural by many anesthetists, allover the world.<br />
Absolute Contraindications of Epidural <br />Patient refusal.<br />Blood Coagulopathy<br />Infection at the site of injection<br />Sever hypovolemia<br />Fixed cardiac out put <br /> - Sever aortic stenosis<br /> - Sever mitral stenosis<br /> - Hypertrophic obstructive cardiomyopathy<br />Contraindicated <br />In pregnancy<br />
Relative Contraindications of Epidural<br />Systemic sepsis.<br />Uncooperative patient.<br />Preexisting neurological deficits, <br /> e.g. demyelinating disease, peripheral neuropathy<br />Sever spinal deformity.<br />Avoid in pregnancy<br />
CSE has lower failure rate 10% , comparing to 14% in Epidural only.</li></ul> Miller’s Anaesthesia <br />
Disadvantages of CSE<br /><ul><li> Against</li></ul>Risk of threading epidural catheter intrathecally<br />Excessive high block.<br />Increase the risk of PDPH.<br />Increase the risk of fetal bradycardia from spinal opioid.<br />Increase equipment cost.<br />
Remifentanil IV PCA <br />Remifentanil is a novel , ultra short acting synthetic opioid.<br />It is a selective mu opioid agonist.<br />Rapid onset; peak effect of blood/brain equilibration time (1.2 – 1.4 min) .<br />It has ester linkage rendering it susceptible to rapid metabolism by non specific blood and tissue esterases.<br />A short duration of action independent of duration of infusion ( context sensitive half time 3.7 minutes).<br />
Blair et al, 2001<br />Has investigated the efficacy and safety of Remifentanil on 21 women.<br />ASA I or II. Patient in active labour, cervix dilated at minimum 3 cm.<br />Excluded preeclampsia, multiple pregnancy and allergy to any medications used, or failure to obtain informed consent.<br />Bolus dose 0.25 – 1.0 Micgr/kg, with or without background infusion(0.025- 0.05) Micgr/kg/min<br />
Blair et al, 2001 (cont.)<br />Monitors mother and fetus.<br />VAS was used to assess pain score.<br />Conclusion<br />Remifentanil PCA with bolus dose 0.25 – 0.5 Micgr/kg , and lockout time 2 min appears safe and effective to control labour pain.<br />The technique appears to be most beneficial with multiparous women ( 73%).<br />
Volikas et al, 2005<br />Studied maternal and neonatal side effects of remifentanil in labour.<br />50 women enrolled in the study ( 24 multiparous and 26 primiparous).<br />Bolus dose 0.5 Micgr/kg, lockout time 2 min.<br />VAS was used to asses pain, nausea, and itching. <br />There was no evidence of cardiovascular instability or respiratory depression.<br />Pain score decreased significantly.<br />
Conclusion<br />At the bolus dose the PCA remifentanil has an acceptable level of maternal side effects and minimal effect on the neonates.<br />Remifentanil crosses the placenta and appears to be either rapidly metabolized or redistributed in the neonate.<br />
Balki et al,2007 (Toronto)Comparing the efficacy of two regimens of Remifentanil PCA<br /><ul><li>Group A: The infusion was increased from 0.025 to 0.05 , 0.075 , and 0.1 Micgr / kg / min. Bolus was kept constant at 0.25 Micgr/ kg.
Group B: The bolus increased 0.25 to 0.5, 0.75 and 1 Micgr/kg. The infusion was kept constant at 0.025 Micgr/kg/min.</li></li></ul><li>Result and conclusion<br />Pain and patient satisfaction scores were similar in both groups.<br />The over all incidence of side effects was greater in group B with drowsiness observed in 100% of patients compared to 30% in Group A. <br />The minimum SaO2 was 94.3% Group A, and 92.2 Group B.<br />PCA remifentanil is efficacious for labour analgesia as bolus of 0.25 Micgr/kg with lockout time 2 min, and infusion background of 0.025 to 0.1 Micgr/kg/min.<br /> Potential for respiratory depression mandates close respiratory monitoring.<br />
Complication in Anaesthesiology ( Emilio Lobato, 2008).
Textbook Of Anaesthesia (Atkenhead, 2007).</li></li></ul><li>Summary<br />Pain and suffering in child birth is no longer acceptable in modern delivery suites.<br />Epidural analgesia or CSE are the best methods of analgesia available at present . <br />We have to find an alternative method for patients in whom epidural analgesia is unsuitable.<br />There is a place for PCA Remifentanil in controlling labour pain. But more research is needed. <br />