1) Labour analgesia aims to relieve maternal pain during childbirth while preserving the progress of labour and safety of both mother and baby. 2) Regional techniques like epidural analgesia are commonly used as they provide effective pain relief and allow movement. 3) Epidural analgesia involves injecting local anaesthetics near the spinal cord in the epidural space, providing pain relief. Combined spinal-epidural is also used. 4) General anaesthesia is rarely used and has risks like aspiration so regional techniques are preferred when possible for labour analgesia.

1. Mrs.Jagadeeswari.J
M.ScNursing

2. Labour analgesia
“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.”

3. DEFINITION
According to the American
Society of Anaesthesiology (ASA)
“in the absence of a medical
contraindication, maternal request
is a sufficient medical indication for
pain relief during labor”

4. Idealgoal of obstetric analgesic
 Attenuate maternal anxiety, fatigue and deliver healthy baby
 Drugs should not cross placental barrier
 Minimal effects on mother, foetus or neonate
 Could be administered late in labour
 Easy to administer with minimal monitoring: IV, bolus,
intermittent or continuous infusion, PCA
 Rapid, Profound, Consistent Analgesia (Stage I & II) & preserve
Uterine contractility
 Onset, offset should match time-course of Uterine contractions
 Easily reversible if necessary
 Facilitate Surgical Anaesthesia avoiding GA

5. cont…
 • No motor effect:
Ambulation
 Maternal Expulsive Efforts
 Progress of Labour
 Achieves labour analgesia in 1st stage of labour
 Should maintain Uterine blood flow.

6. Normal labour
Series of events that
take place in the genital
organs in an effort to expel
the fetus out of the uterus
through the vagina

7. Criteria of normal labour
 Spontaneous in onset
 At term
 Vertex presentation
 Natural termination

8. Onset of labour
 Regular painful uterine
 Contractions accompanied by
 Ruptured membranes
 Bloody show
 Complete cervical effacement
 Painful rhythmic contractions with cervical
dilatation of 3-4 cm

9. Patho-physiology of labour pain
 Visceral pain
 First stage
 T10 - L1
 Distension and stretching of LUS
 Somatic pain
 Second stage
 S2-S4
 Distension of pelvic and perineal structures and
compression of LS plexus

10. Pain pathway in I stageand II stageof labour
 First stage :
 Uterine contraction + cervical dilatation
 Afferent –visceral afferent from uterus
 T10,11,12,L1 Posterior segments
 Second stage:
 Distension of pelvic floor ,vagina,perineum
by descending head
 Afferent –sensory fibers of S2,3,4 (Pudendal
nerve)

11. Effect of pain and stress
 Release of adreno-cortisol ,catecholamine’s ,
and beta endorphins
 Beta –adnergic agents have uterine relaxant
effects and higher epinephrine level are
associated with anxiety and prolonged
labour
 Maternal psychological stress can
determentally affect uterine blood flood and
fetal acid base status.

12. Effect of labour pain onmother and fetus
 Labour pain causes-
 Marked stimulation of respiration
and circulation in mother.
 Activation of sympathetic nervous
system
 Mental disturbance- postpartum
depression and post traumatic stress
disorder

13. Techniques of labour analgesia
 Complementary or Alternative treatment
 Mind–body interventions
 Bio electromagnetic
 Physical methods : massage, heating pads, warm
bath
 Alternative medication : Acupuncture, hypnosis
 Conventional Treatments
 Systemic analgesia: IV , inhalational
 Regional techniques
 General anaesthesia

14. Regional anaesthesiatechniques
 Most commonly performed regional techniques
for labor are-
 Epidural analgesia
 Spinal block/analgesic
 Combined spinal-epidural blocks.
 Less frequently performed-
 Paravertebral block
 Paracervical block
 Pudendal block

15. 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
After local infiltration one should wait 3 minutes
before proceeding.

16. Para cervical nerve block
INDICATIONS:
Relieve the pain of uterine contractions
and the perineal discomfort is removed
by Pudendal nerve block
TECHNIQUES:
Place the patient in dorsal lithotomy

17. cont…
 Place speculum to obtain good visualization of the
entire cervix
 Place 2 to 3 ml of lidocaine at the 6 or 12 clock position
 Grasp the anesthetized portion of the cervix with a
tentaculum or a traumatic vulsellum forceps
 Inject 10cc of lidocaine at or just above each utero
sacral ligament 1cm under the mucosa where vagina
reflects off the cervix
 Inspect the injections sites for bleeding
 Wait 10 minutes before proceeding with the procedure

18. Pudendalnerve block
INDICATIONS:
 Pudendal nerve block is mostly used for
forceps and assisted breech delivery. It does
not relive the pain of labour but affords
perineal analgesia and relaxation
TECNIQUES:
 It may be either blocked by transvaginal or
transperineal route.

19. Transvaginal route of Pudendal block

20. cont…
 20 ml syringe -1
 15cm 17-20 gauge spinal needle
 20ml of 1% lignocaine hydrochloride are required
The index and middle finger of one hand are
introduced into the vagina ,finger tips are placed
on the tip of the ischial spine of one side. The
needle is passed along the groove of the fingers and
guided to pierce the vaginal wall on the apex of
ischial spine and thereafter to push a little to pierce
the Sacro- Spinous ligament just above the ischial
spine tip. After aspirating to exclude blood about
10ml of the solution is injected .The similar
procedure is adopted to block the nerve of the
other side by changing the hands.

21. cont…..
COMPLICATIONS:
 Lacerations of vaginal mucosa
 Prolonged II stage of labour due to loss of bearing
down reflex
 Systemic anesthetic complications like
drowsiness ,loss consciousness ,hypotension and
bradycardia
 Hematomas
 Infections
 Needle stick injury

22. Lumbar epidural analgesia
INDICATIONS:
Painless labour
TYPES OF EPIDURAL ANALGESIA:
Lumbar epidural analgesia
Caudal epidural analgesia

23. Pre requisites for epidural analgesia
 Maternal consent
 Maternal /fetal status
 Progress of labour
 Iv cannula
 Maternal hydration
 Monitor vital status
 Continuous fetal monitor
 safety

24. Lumbar epidural analgesia

25. Caudalepidural analgesia

26. Benefits of epidural analgesia
Pregnancy induced hypertension
Breech presentation
Twin pregnancy
Preterm labour
Previous cs

27. Complications ofepidural analgesia
Hypotension
Pain at insertion site
Post spinal headache
Injury to nerves

28. Contraindications of epidural analgesia
 Sepsis at injection site
 Hemorrhagic disease or anti coagulant
therapy
 Supine hypotension
 Hypovolemic
 Neurological disease
 Spinal deformity or chronic low back pain

29. Drugs usedin epidural anaesthesia
Lidocaine:
Rapid onset, dense motor block, risk of
cumulative toxicity with repeated doses
Bupivacaine:
Good sensory block with minimal
motor effect

30. Epidural opiods in labour
 Inadequate analgesics used alone
 Synergistic with local anaesthetics
 Speedy onset of analgesia
 Improves quality of analgesia
 Permits use of very dilute LA solutions
 Help relieve persistent perineal pain and unblocked
segments

31. cont…
Fentanyl and Sufentanil
 Rapid onset, few side effects
 Sufentanil slightly more effective
No significant fetal drug
accumulation
No serious adverse neonatal effects
with either

32. Role of midwife in epidural analgesia
 Support for the laboring woman
 Continuous monitoring of vital signs and
fetal status
 Pain assessment
 Continues fetal heart rate monitoring
 Continuous epidural infusion monitoring

33. Spinalanaesthesia
 INDICATIONS:
 To alleviate pain during delivery and III stage
of labour
 Forceps or ventose delivery
 LSCS
 ADVANTAGES OF SPINAL ANAESTHESIA:
 Less fetal hypoxia

34. Side effects of spinal analgesia
 Hypotension due to blocking of sympathetic
fibers leading to vasodilatation and low
cardiac output
 Respiratory depression
 Post spinal headache
 Transient or permanent paralysis
 Urinary retention

35. Techniques

37. Combined spinal epidural anaesthesia

38. prerequisites
 Complete blood count
 Coagulation profile
 Back examination
 Informed consent
 Detailed history
 Continuous fetal monitoring

39. Benefits of CSE analgesia
CSE provides more effective
analgesia
CSE is faster in onset
CSE has lower failure rate 10%
comparing to 14% in epidural only

40. Disadvantages of CSE
Risk of threading epidural catheter
intrathecally
Excessive high block
Increase the risk of fetal
bradycardia from spinal block
Increase equipment cost

41. Contra indications
 Patient refused
 Sepsis
 Hypovolemic
 Coagulapathy
 Elevated ICD
 Back injury
 Chronic back pain
 Localized infection in injection site

42. complications
 Headache
 Back pain
 Injury to nerves
 Epidural hematomas
 Hypotension
 Shivering
 Bladder distension
 Supine hypotension
 Leg numbness and weakness

43. General anaesthesia

44. Complicationsof GA
Aspiration of gastric content
Tachycardia
Hypotension
Dyspnea
Cyanosis
bronchospasm

45. Prevention of complications
 NPO during labour
 H2 blocker should be given night before and
to be repeated one hour before the
administration of GA to raise gastric PH
 Intubation with adequate cricoids pressure
 Awake extubation should be routine

46. Management
 Immediate suctioning of oropharynx and
nasopharynx is done to remove the inhaled
fluid
 CPAP is given to maintain the oxygen
saturation of 95%
 Pulseoximeter is useful guide
 Antibiotics are administered when infection
is evident

47. Role of midwife during postoperative LSCS
 Pain killers to prevent pneumothorax or
thrombhophelebitis
 Pain assessment
 Comfort measures
 Early ambulation
 Assisting in breast feeding
 Stool softeners
 High fiber diet
 Assessing vital signs and wound healing