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Induction of LaborInduction of Labor
Dr Manal BeheryDr Manal Behery
20142014
InductionInduction
Induction of labor is the artificial initiation ofInduction of labor is the artificial initiation of
labor prior to its spontaneous onsetlabor prior to its spontaneous onset
AugmentationAugmentation
The artificial stimulation of labor thatThe artificial stimulation of labor that
has been started spontaneouslyhas been started spontaneously toto
increase the rate of progress of laborincrease the rate of progress of labor
TTime, place & preparationime, place & preparation
Time of inductionTime of induction:: Preferably early morningPreferably early morning
Place of inductionPlace of induction: where facility for: where facility for
intervention and fetal monitoring is availableintervention and fetal monitoring is available
Preparation of PatientPreparation of Patient :: Enema may be givenEnema may be given
to patients prior to inductionto patients prior to induction
Indication for InductionIndication for Induction
MaternalMaternal
FetalFetal
General conceptsGeneral concepts
Elective inductionElective induction
induction, in the absence of maternal or fetal indication,induction, in the absence of maternal or fetal indication,
should not be undertakenshould not be undertaken
-increase CS (especially, nulliparas)-increase CS (especially, nulliparas)
Emergent indicationEmergent indication
-ruptured membranes with chorioamnionitis-ruptured membranes with chorioamnionitis
severe preeclampsiasevere preeclampsia
MaternalMaternal
FetalFetal
 Abpruptio placentaAbpruptio placenta
 IUGRIUGR
 Rh isoimmunizationRh isoimmunization
 Unexplained IUFD in prior pregnancyUnexplained IUFD in prior pregnancy
 ChorioamnionitisChorioamnionitis
 MalformationMalformation
Factors to assess prior to inductionFactors to assess prior to induction
ContraindicationsContraindications
--Contracted pelvisContracted pelvis
 Pregnancy following classical C.sectionPregnancy following classical C.section
 Pregnancy following repair of a vesico-vaginalPregnancy following repair of a vesico-vaginal
fistulafistula
 -Acute fetal distress-Acute fetal distress
 -Abnormal presentation-Abnormal presentation
 --Presence of active herpetic genital lesionsPresence of active herpetic genital lesions
Cervical RipeningCervical Ripening
Cervical RipeningCervical Ripening
promotion of cervical change bypromotion of cervical change by
pharmacological or other meanspharmacological or other means
not primarily intended to induce labor but tonot primarily intended to induce labor but to
increase the success of subsequent inductionincrease the success of subsequent induction
Modified Bishop’s ScoreModified Bishop’s Score
Favourable score->6 Best score->8
 hygroscopic dilators, osmotic dilators (Laminaria japonicum), Foley
catheters, double balloon devices, and extraamniotic saline infusion. 
Stripping of membraneStripping of membrane
performed by inserting the index finger throughperformed by inserting the index finger through
the internal os as as far possible and rotatingthe internal os as as far possible and rotating
twice through 360 degrees to separate thetwice through 360 degrees to separate the
membranes from the lower segmentmembranes from the lower segment
Intracervical foly catherIntracervical foly cather
Amniotomy (ARMAmniotomy (ARM((
WidelyWidely used methodologyused methodology
EasyEasy
No anaesthesia or analgesiaNo anaesthesia or analgesia
SafeSafe
Cord prolapseCord prolapse
ChorioamnionitisChorioamnionitis
OxytocinOxytocin
OctapeptideOctapeptide
Synthetic Oxytocin preparations, SyntocinonSynthetic Oxytocin preparations, Syntocinon
and Pitocin are commonly usedand Pitocin are commonly used
Syntocinon is avaiable in injectionsSyntocinon is avaiable in injections
EQUIPMENT REQUIREDEQUIPMENT REQUIRED::
Complications of SyntocinonComplications of Syntocinon
Incoordinate uterine action;Incoordinate uterine action;hyperstimulationhyperstimulation
FetalFetal hypoxiahypoxia
UterineUterine rupturerupture
WaterWater intoxicationintoxication
UterineUterine fatiguefatigue;PPH;PPH
Routes of administrationRoutes of administration
OralOral
Vaginal-Gel orVaginal-Gel or
PessaryPessary
Local via catheterLocal via catheter
Mechanism of actionMechanism of action
Change the myometrial cellChange the myometrial cell
memb permeablity andmemb permeablity and
alteration in the membranealteration in the membrane
bound calciumbound calcium
sensitises the mometrium tosensitises the mometrium to
the oxytocinthe oxytocin
PGE2 has its collagenolyticPGE2 has its collagenolytic
activityactivityalter the groundalter the ground
substance of cervixsubstance of cervixcxcx
ripeningripening
ContraindicationsContraindications
Bronchial asthmaBronchial asthma
EpilepsyEpilepsy
HypersensitivityHypersensitivity
Renal diseaseRenal disease
HypertensionHypertension
Peptic ulcerPeptic ulcer
Risk of InductionRisk of Induction
 FailureFailure
 PrematurityPrematurity
 Abnormal uterine actionAbnormal uterine action
 InfectionInfection
 Maternal exhaustionMaternal exhaustion
 Fetal hypoxiaFetal hypoxia
 Amniotic fluid embolismAmniotic fluid embolism
ConclusionConclusion
reasons for induction must be convincing and
documented
risk and benefits must be discussed with patient
patient preference must be considered
ripen the cervix as much as possible
do not use oxytocin if cervix unfavourable
don't overestimate your ability to succeed
Pain relief in labourPain relief in labour
DOES LABOR PAIN NEEDDOES LABOR PAIN NEED
ANALGESIAANALGESIA??
Potential effects of maternal hyperventilation and subsequentPotential effects of maternal hyperventilation and subsequent
hypocarbia on oxygen delivery to the fetushypocarbia on oxygen delivery to the fetus
Why is labour painfulWhy is labour painful??
Ischemia of uterine muscles.Ischemia of uterine muscles.
Dilatation and stretching of the cervix.Dilatation and stretching of the cervix.
Stretching of the perineum in the secondStretching of the perineum in the second
stage of labour.stage of labour.
Pain Pathways of LaborPain Pathways of Labor
Panadol + NSAIDPanadol + NSAID
Simple analgesia is usually ineffective in controllingSimple analgesia is usually ineffective in controlling
labour painlabour pain
X
The ideal analgesic in labourThe ideal analgesic in labour
Easy to administer.Easy to administer.
Safe to the mother and baby.Safe to the mother and baby.
Easily reversible if necessary.Easily reversible if necessary.
Does NOT interfere with uterine contractions.Does NOT interfere with uterine contractions.
Does NOT effect mobilityDoes NOT effect mobility..
Types of pain relief in labourTypes of pain relief in labour
Non-pharmacological:Non-pharmacological:
Relaxation.Relaxation.
TENS.TENS.
Hypnosis.Hypnosis.
AcupunctureAcupuncture
Hydrotherapy.Hydrotherapy.
Phar macologicalPhar macological
Opiates.Opiates.
Inhalational.Inhalational.
Epidural.Epidural.
::
Relaxation“psycoprophylaxisRelaxation“psycoprophylaxis””
Essential in all cases.Essential in all cases.
Antenatal classes to educate the mothers onAntenatal classes to educate the mothers on
what to expect.what to expect.
Helps mothers to cope with pain andHelps mothers to cope with pain and
satisfaction with pain relief.satisfaction with pain relief.
Transcutaneous nerve stimulation(TENSTranscutaneous nerve stimulation(TENS((
Low grade electronic waves to nerves supplyingLow grade electronic waves to nerves supplying
the uterus via skin electrode.the uterus via skin electrode.
Provides good pain relief to 25% of patients.Provides good pain relief to 25% of patients.
Woman controls intensity and sensation patternsWoman controls intensity and sensation patterns
Drawback – interfers with FHRDrawback – interfers with FHR
monitoringmonitoring
Contraindication – cardiac pacemakersContraindication – cardiac pacemakers
TENS
Transcutaneous electrical nerve stimulation equipment
general Birthday Trust's latest survey, only about 5.5% of women use TENS
Intradermal Water InjectionIntradermal Water Injection
HydrotherapyHydrotherapy
Hypnosis and acupunctureHypnosis and acupuncture
Reported to be successfulReported to be successful..
Needs special skill and preparationNeeds special skill and preparation..
Carries no risk to the mother or fetusCarries no risk to the mother or fetus..
??????Placebo effectPlacebo effect
Does this matterDoes this matter????????
OpiatesOpiates
Pethidine and diamorphine are thePethidine and diamorphine are the
commonly used drugs.commonly used drugs.
Given inter-muscular or intravenousGiven inter-muscular or intravenous
repeated when necessary.repeated when necessary.
AdvantagesAdvantages::
Offers good pain relief for most patients.Offers good pain relief for most patients.
Short duration of action.Short duration of action.
DisadvantageDisadvantage::
Nausea and vomiting. (antiemetic(Nausea and vomiting. (antiemetic(
Can cross BPB respiratoryCan cross BPB respiratory
depression in the new born.depression in the new born.
(Nalaxone((Nalaxone(
Inhalational anesthesiaInhalational anesthesia
The commonest is nitrous oxide.The commonest is nitrous oxide.
Self administered to the patient via face mask.Self administered to the patient via face mask.
Given in a 50-50 mixture with oxygen (EntanoxGiven in a 50-50 mixture with oxygen (Entanox).).
AdvantagesAdvantages
Provides analgesia varying from good toProvides analgesia varying from good to
ineffective.ineffective.
Under control of the patient.Under control of the patient.
Minimal adverse effects to mother andMinimal adverse effects to mother and
fetus.fetus.
DisadvantageDisadvantage::
not adequate for second stage, instrumental delivery,not adequate for second stage, instrumental delivery,
suturing of perineum or manual removal of placenta.suturing of perineum or manual removal of placenta.
Light headedness and nausea.Light headedness and nausea.
Not suitable for prolonged useNot suitable for prolonged use..
Epidural anesthesiaEpidural anesthesia
‫ألم‬ ‫بدون‬ ‫الولةدة‬‫ألم‬ ‫بدون‬ ‫الولةدة‬
Alternative Regional AnaestheticAlternative Regional Anaesthetic
TechniquesTechniques
Epidural blockEpidural block
Plastic catheter introduced into the epidural space.Plastic catheter introduced into the epidural space.
Catheter is left in and the analgesia is givenCatheter is left in and the analgesia is given
continuously.continuously.
Bupivican andBupivican and FentanylFentanyl
AdvantagesAdvantages::
The most effective pain relief.The most effective pain relief.
The absence of pain allows enjoyment andThe absence of pain allows enjoyment and
control of labour.control of labour.
Reduces maternal fatigue and anxiety.Reduces maternal fatigue and anxiety.
Ideal in high risk pregnancies e.g. breech, MP,Ideal in high risk pregnancies e.g. breech, MP,
and PET.and PET.
DisadvantageDisadvantage::
Restriction of movement during labour.Restriction of movement during labour.
Requires CTG.Requires CTG.
Requires resident anesthesia, cardio-Requires resident anesthesia, cardio-
respiratory facilities and one to one care.respiratory facilities and one to one care.
?increase rate of instrumental delivery.?increase rate of instrumental delivery.
ComplicationsComplications::
Failure 3%.Failure 3%.
Hypotension.Hypotension.
Epidural tap (headache)Epidural tap (headache)
? Back pain.? Back pain.
Paralysis !!!!!!!!!.Paralysis !!!!!!!!!.
Analgesia used in second stage andAnalgesia used in second stage and
third stagethird stage..
Nerve blocks.Nerve blocks.
Spinal anesthesia.Spinal anesthesia.
General anesthesia.General anesthesia.
Paracervical blockParacervical block
Pudendal blockPudendal block
Performed by the obstetricianPerformed by the obstetrician..
Used for outlet forceps and vacuumUsed for outlet forceps and vacuum
deliverydelivery..
Spinal anesthesiaSpinal anesthesia
Can be used for …Can be used for …
Instrumental delivery.Instrumental delivery.
Manual removal of placenta.Manual removal of placenta.
Repair of third degree tear.Repair of third degree tear.
Contraindications to spinal or epiduralContraindications to spinal or epidural
anesthesiaanesthesia
Maternal refusal.Maternal refusal.
Hypovolemia.Hypovolemia.
Sever back deformities,Sever back deformities,
Local infection.Local infection.
Coagulation disorders.Coagulation disorders.
Thank youThank you

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THORACOTOMY . SURGICAL PERSPECTIVES VOL 1
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Induction of labor& pain reief inlabor for undergraduate

  • 1. Induction of LaborInduction of Labor Dr Manal BeheryDr Manal Behery 20142014
  • 2. InductionInduction Induction of labor is the artificial initiation ofInduction of labor is the artificial initiation of labor prior to its spontaneous onsetlabor prior to its spontaneous onset
  • 3. AugmentationAugmentation The artificial stimulation of labor thatThe artificial stimulation of labor that has been started spontaneouslyhas been started spontaneously toto increase the rate of progress of laborincrease the rate of progress of labor
  • 4. TTime, place & preparationime, place & preparation Time of inductionTime of induction:: Preferably early morningPreferably early morning Place of inductionPlace of induction: where facility for: where facility for intervention and fetal monitoring is availableintervention and fetal monitoring is available Preparation of PatientPreparation of Patient :: Enema may be givenEnema may be given to patients prior to inductionto patients prior to induction
  • 5. Indication for InductionIndication for Induction MaternalMaternal FetalFetal
  • 6. General conceptsGeneral concepts Elective inductionElective induction induction, in the absence of maternal or fetal indication,induction, in the absence of maternal or fetal indication, should not be undertakenshould not be undertaken -increase CS (especially, nulliparas)-increase CS (especially, nulliparas) Emergent indicationEmergent indication -ruptured membranes with chorioamnionitis-ruptured membranes with chorioamnionitis severe preeclampsiasevere preeclampsia
  • 8. FetalFetal  Abpruptio placentaAbpruptio placenta  IUGRIUGR  Rh isoimmunizationRh isoimmunization  Unexplained IUFD in prior pregnancyUnexplained IUFD in prior pregnancy  ChorioamnionitisChorioamnionitis  MalformationMalformation
  • 9. Factors to assess prior to inductionFactors to assess prior to induction
  • 10. ContraindicationsContraindications --Contracted pelvisContracted pelvis  Pregnancy following classical C.sectionPregnancy following classical C.section  Pregnancy following repair of a vesico-vaginalPregnancy following repair of a vesico-vaginal fistulafistula  -Acute fetal distress-Acute fetal distress  -Abnormal presentation-Abnormal presentation  --Presence of active herpetic genital lesionsPresence of active herpetic genital lesions
  • 11.
  • 12.
  • 13.
  • 14.
  • 16. Cervical RipeningCervical Ripening promotion of cervical change bypromotion of cervical change by pharmacological or other meanspharmacological or other means not primarily intended to induce labor but tonot primarily intended to induce labor but to increase the success of subsequent inductionincrease the success of subsequent induction
  • 17. Modified Bishop’s ScoreModified Bishop’s Score Favourable score->6 Best score->8
  • 18.  hygroscopic dilators, osmotic dilators (Laminaria japonicum), Foley catheters, double balloon devices, and extraamniotic saline infusion. 
  • 19. Stripping of membraneStripping of membrane performed by inserting the index finger throughperformed by inserting the index finger through the internal os as as far possible and rotatingthe internal os as as far possible and rotating twice through 360 degrees to separate thetwice through 360 degrees to separate the membranes from the lower segmentmembranes from the lower segment
  • 21. Amniotomy (ARMAmniotomy (ARM(( WidelyWidely used methodologyused methodology EasyEasy No anaesthesia or analgesiaNo anaesthesia or analgesia SafeSafe Cord prolapseCord prolapse ChorioamnionitisChorioamnionitis
  • 22. OxytocinOxytocin OctapeptideOctapeptide Synthetic Oxytocin preparations, SyntocinonSynthetic Oxytocin preparations, Syntocinon and Pitocin are commonly usedand Pitocin are commonly used Syntocinon is avaiable in injectionsSyntocinon is avaiable in injections
  • 23.
  • 25. Complications of SyntocinonComplications of Syntocinon Incoordinate uterine action;Incoordinate uterine action;hyperstimulationhyperstimulation FetalFetal hypoxiahypoxia UterineUterine rupturerupture WaterWater intoxicationintoxication UterineUterine fatiguefatigue;PPH;PPH
  • 26.
  • 27. Routes of administrationRoutes of administration OralOral Vaginal-Gel orVaginal-Gel or PessaryPessary Local via catheterLocal via catheter
  • 28. Mechanism of actionMechanism of action Change the myometrial cellChange the myometrial cell memb permeablity andmemb permeablity and alteration in the membranealteration in the membrane bound calciumbound calcium sensitises the mometrium tosensitises the mometrium to the oxytocinthe oxytocin PGE2 has its collagenolyticPGE2 has its collagenolytic activityactivityalter the groundalter the ground substance of cervixsubstance of cervixcxcx ripeningripening
  • 30. Risk of InductionRisk of Induction  FailureFailure  PrematurityPrematurity  Abnormal uterine actionAbnormal uterine action  InfectionInfection  Maternal exhaustionMaternal exhaustion  Fetal hypoxiaFetal hypoxia  Amniotic fluid embolismAmniotic fluid embolism
  • 31. ConclusionConclusion reasons for induction must be convincing and documented risk and benefits must be discussed with patient patient preference must be considered ripen the cervix as much as possible do not use oxytocin if cervix unfavourable don't overestimate your ability to succeed
  • 32. Pain relief in labourPain relief in labour
  • 33. DOES LABOR PAIN NEEDDOES LABOR PAIN NEED ANALGESIAANALGESIA??
  • 34. Potential effects of maternal hyperventilation and subsequentPotential effects of maternal hyperventilation and subsequent hypocarbia on oxygen delivery to the fetushypocarbia on oxygen delivery to the fetus
  • 35. Why is labour painfulWhy is labour painful?? Ischemia of uterine muscles.Ischemia of uterine muscles. Dilatation and stretching of the cervix.Dilatation and stretching of the cervix. Stretching of the perineum in the secondStretching of the perineum in the second stage of labour.stage of labour.
  • 36. Pain Pathways of LaborPain Pathways of Labor
  • 37. Panadol + NSAIDPanadol + NSAID Simple analgesia is usually ineffective in controllingSimple analgesia is usually ineffective in controlling labour painlabour pain X
  • 38. The ideal analgesic in labourThe ideal analgesic in labour Easy to administer.Easy to administer. Safe to the mother and baby.Safe to the mother and baby. Easily reversible if necessary.Easily reversible if necessary. Does NOT interfere with uterine contractions.Does NOT interfere with uterine contractions. Does NOT effect mobilityDoes NOT effect mobility..
  • 39. Types of pain relief in labourTypes of pain relief in labour Non-pharmacological:Non-pharmacological: Relaxation.Relaxation. TENS.TENS. Hypnosis.Hypnosis. AcupunctureAcupuncture Hydrotherapy.Hydrotherapy. Phar macologicalPhar macological Opiates.Opiates. Inhalational.Inhalational. Epidural.Epidural. ::
  • 40. Relaxation“psycoprophylaxisRelaxation“psycoprophylaxis”” Essential in all cases.Essential in all cases. Antenatal classes to educate the mothers onAntenatal classes to educate the mothers on what to expect.what to expect. Helps mothers to cope with pain andHelps mothers to cope with pain and satisfaction with pain relief.satisfaction with pain relief.
  • 41. Transcutaneous nerve stimulation(TENSTranscutaneous nerve stimulation(TENS(( Low grade electronic waves to nerves supplyingLow grade electronic waves to nerves supplying the uterus via skin electrode.the uterus via skin electrode. Provides good pain relief to 25% of patients.Provides good pain relief to 25% of patients. Woman controls intensity and sensation patternsWoman controls intensity and sensation patterns
  • 42. Drawback – interfers with FHRDrawback – interfers with FHR monitoringmonitoring Contraindication – cardiac pacemakersContraindication – cardiac pacemakers TENS Transcutaneous electrical nerve stimulation equipment general Birthday Trust's latest survey, only about 5.5% of women use TENS
  • 45. Hypnosis and acupunctureHypnosis and acupuncture Reported to be successfulReported to be successful.. Needs special skill and preparationNeeds special skill and preparation.. Carries no risk to the mother or fetusCarries no risk to the mother or fetus.. ??????Placebo effectPlacebo effect Does this matterDoes this matter????????
  • 46. OpiatesOpiates Pethidine and diamorphine are thePethidine and diamorphine are the commonly used drugs.commonly used drugs. Given inter-muscular or intravenousGiven inter-muscular or intravenous repeated when necessary.repeated when necessary.
  • 47. AdvantagesAdvantages:: Offers good pain relief for most patients.Offers good pain relief for most patients. Short duration of action.Short duration of action.
  • 48. DisadvantageDisadvantage:: Nausea and vomiting. (antiemetic(Nausea and vomiting. (antiemetic( Can cross BPB respiratoryCan cross BPB respiratory depression in the new born.depression in the new born. (Nalaxone((Nalaxone(
  • 49. Inhalational anesthesiaInhalational anesthesia The commonest is nitrous oxide.The commonest is nitrous oxide. Self administered to the patient via face mask.Self administered to the patient via face mask. Given in a 50-50 mixture with oxygen (EntanoxGiven in a 50-50 mixture with oxygen (Entanox).).
  • 50. AdvantagesAdvantages Provides analgesia varying from good toProvides analgesia varying from good to ineffective.ineffective. Under control of the patient.Under control of the patient. Minimal adverse effects to mother andMinimal adverse effects to mother and fetus.fetus.
  • 51. DisadvantageDisadvantage:: not adequate for second stage, instrumental delivery,not adequate for second stage, instrumental delivery, suturing of perineum or manual removal of placenta.suturing of perineum or manual removal of placenta. Light headedness and nausea.Light headedness and nausea. Not suitable for prolonged useNot suitable for prolonged use..
  • 52. Epidural anesthesiaEpidural anesthesia ‫ألم‬ ‫بدون‬ ‫الولةدة‬‫ألم‬ ‫بدون‬ ‫الولةدة‬
  • 53.
  • 54. Alternative Regional AnaestheticAlternative Regional Anaesthetic TechniquesTechniques
  • 55. Epidural blockEpidural block Plastic catheter introduced into the epidural space.Plastic catheter introduced into the epidural space. Catheter is left in and the analgesia is givenCatheter is left in and the analgesia is given continuously.continuously. Bupivican andBupivican and FentanylFentanyl
  • 56. AdvantagesAdvantages:: The most effective pain relief.The most effective pain relief. The absence of pain allows enjoyment andThe absence of pain allows enjoyment and control of labour.control of labour. Reduces maternal fatigue and anxiety.Reduces maternal fatigue and anxiety. Ideal in high risk pregnancies e.g. breech, MP,Ideal in high risk pregnancies e.g. breech, MP, and PET.and PET.
  • 57. DisadvantageDisadvantage:: Restriction of movement during labour.Restriction of movement during labour. Requires CTG.Requires CTG. Requires resident anesthesia, cardio-Requires resident anesthesia, cardio- respiratory facilities and one to one care.respiratory facilities and one to one care. ?increase rate of instrumental delivery.?increase rate of instrumental delivery.
  • 58. ComplicationsComplications:: Failure 3%.Failure 3%. Hypotension.Hypotension. Epidural tap (headache)Epidural tap (headache) ? Back pain.? Back pain. Paralysis !!!!!!!!!.Paralysis !!!!!!!!!.
  • 59. Analgesia used in second stage andAnalgesia used in second stage and third stagethird stage.. Nerve blocks.Nerve blocks. Spinal anesthesia.Spinal anesthesia. General anesthesia.General anesthesia.
  • 61. Pudendal blockPudendal block Performed by the obstetricianPerformed by the obstetrician.. Used for outlet forceps and vacuumUsed for outlet forceps and vacuum deliverydelivery..
  • 62. Spinal anesthesiaSpinal anesthesia Can be used for …Can be used for … Instrumental delivery.Instrumental delivery. Manual removal of placenta.Manual removal of placenta. Repair of third degree tear.Repair of third degree tear.
  • 63. Contraindications to spinal or epiduralContraindications to spinal or epidural anesthesiaanesthesia Maternal refusal.Maternal refusal. Hypovolemia.Hypovolemia. Sever back deformities,Sever back deformities, Local infection.Local infection. Coagulation disorders.Coagulation disorders.

Editor's Notes

  1. It initiates hyperventilation leading to maternal hypocarbia, respiratory alkalosis and subsequent compensatory metabolic acidosis. The oxygen dissociation curve is shifted to the left and thus reduces tissue oxygen transfer, which is already compromised by the increased oxygen consumption associated with labor
  2. Electrodes are placed about 2cm over the T10-L1 dermatomes in 1st stage & S2-S4 in the 2nd stage
  3. Central neuraxial blockade is the gold standard technique for labor analgesia that is currently available