Pain Relief In Labour1

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nursing symposium
may 10,2010

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  • 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

    1. 1. Pain Relief in Labour<br />DR HUSSAIN KARIM, DEAA, MRCA<br />Consultant Anesthetist, Lead Pain Team<br />Security Forces Hospital, Riyadh<br />
    2. 2. Aim<br />Is how we can achieve better management of labour pain.<br />
    3. 3. Objectives<br />Why do we give analgesia for child birth? <br />Humanitarian reason.<br />Economic benefit.<br />Medical reasons.<br />
    4. 4. Medical Effects of Labour Pain <br />
    5. 5. 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 />
    6. 6. 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 />
    7. 7. Entonox (50% Nitrous oxide + 50% Oxygen), Isonox (50% Nitrous oxide + 50% O2 + 0.2% Isoflurane).<br />IV PCA Remifentanil.<br />Parenteral opioids, Morphine, Pethedine, Fentanyl.<br />
    8. 8. Adverse Effects of Parenteral Opioids<br />
    9. 9. The Ideal Analgesic for Labour<br />
    10. 10. 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 />
    11. 11. PATHOPHYSIOLOGY OF PAIN<br />
    12. 12. Pharmacological Treatments of Pain<br />
    13. 13. 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 />
    14. 14. 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 />
    15. 15. 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 />
    16. 16. 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 />
    17. 17. The Failing epidural<br />
    18. 18. Complication of Epidural<br />Hypotension.<br />Tachycardia <br />Bradycardia.<br />Nausea and vomiting.<br />
    19. 19. Loss of motor power<br />Dural tap.<br /> (post dural puncture headache)<br />
    20. 20.
    21. 21. Combined Spinal Epidural (CSE) Analgesia <br /><ul><li>In 1993, anaesthetists in Queen Charlotte’s Hospital in London described the CSE technique.
    22. 22. Touhy Needle is advanced in the lumber region.
    23. 23. Then 25 –27 gauge, 120 mm-long pencil point spinal needle.
    24. 24. 1 ml of 0.25% Bupivacaine + 25 Micgr Fentanyl injected intrathecally.
    25. 25. Epidural bolus 15 mls 0.1% Bupivacaine + 2 Micgr/ml Fentanyl without test dose.</li></li></ul><li>Is CSE Better Than Epidural Analgesia?<br /><ul><li> Support:
    26. 26. CSE provides more effective analgesia.
    27. 27. CSE is faster in onset
    28. 28. CSE has lower failure rate 10% , comparing to 14% in Epidural only.</li></ul> Miller’s Anaesthesia <br />
    29. 29. 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 />
    30. 30. 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 />
    31. 31.
    32. 32. 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 />
    33. 33. 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 />
    34. 34. 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 />
    35. 35. 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 />
    36. 36. 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.
    37. 37. 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 />
    38. 38. References<br />Journals<br /><ul><li>British Journal of Anaesthesia (V: 95/no. 4, V: 88/no.4 ).
    39. 39. Anaesthesia Analgesia (2005;101:1242-1243, 100: 233-238).
    40. 40. Anaesthesia Journal of GB and Ireland (V:60 Issue 1, P: 22-27).
    41. 41. Acta Anaesthesiologica Scandinavia (V:49,Issue 4, P: 453-458).
    42. 42. Current Opinion Anaesthesiology (2008 Jun; Issue 21, P:270- 274)
    43. 43. Canadian Journal of Anaesthesia (V 48, N 2, Feb 2001).</li></ul>Text Books <br /><ul><li>Current Therapy in pain ( Howard Smith, 2009).
    44. 44. Miller’s Anaesthesia ( Ronald Millers 2009).
    45. 45. Clinical Anaesthesia ( Paul Barash 2009).
    46. 46. Complication in Anaesthesiology ( Emilio Lobato, 2008).
    47. 47. 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 />
    48. 48. THANK YOU<br />THANK YOU<br />

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