Mc Gill pain scale, history , pathophysiology of labour pain , ideal labour analgesia, non pharmacological methods , birth philosophies , pharmacological methods ,systemic and inhalational agents , regional analgesia

1. LABOUR ANALGESIA
– Dr G.Abirami

2. • The pain of childbirth is the most severe pain that
women will endure in their lifetimes

3. • Women in pain don’t need an “indication” for
pain relief in labor
• According to the American Society of
Anesthesiology (ASA) “in the absence of a
medical contraindication, maternal request is a
sufficient medical indication for pain relief during
labor”

4. McGill’s Pain Scale

5. HISTORY
• The modern era of childbirth analgesia began in 1847
when Dr James Young Simpson administered ether to a
woman with rickets and severely deformed pelvis in
childbirth, and was strongly condemned by the clergy.

6. Queen Victoria was given chloroform by John Snow (1853) for
the birth of her eight child Prince Leopold and this did
much to popularize the use of pain relief in labour

7. CARL KOLLER AUGUST BIER

8. • 1880: Nitrous oxide Stanislav Klikovick
• 1961: Turnstall –50:50 N2O:O2 in a single cylinder
• 1965: Approval of Entonox by Central Midwives Board
• 1934: Divinyl Ether
• 1975: Isoflurane
 0.75% with O2
 0.2% withEntonox (Isonox)
• 1984: 1%Enflurane in air
• 1995: Desflurane- 1-4.5% in O2
INHALATIONAL AGENTS

9. FRIEDMAN’S CURVE

10. Pathophysiology of Labour pain
Visceral pain
◦ First stage
◦ T10 -L1
◦ Distension and
stretching of LUS
Somatic pain
◦ Second stage
◦ S2-S4
◦ Distension of pelvic
and perinial structures
and compression of LS
plexus

11. PAIN PATHWAY OF LABOUR

12. Distribution andintensityof labourpain
duringeach stageof labouranddelivery

13. Why do we need Obstetric Analgesia?
• Humanitarian reasons
• Medical reasons

14. EFFECT OF LABOUR PAIN

15. THE GOALS OF LABOUR
ANALGESIA
“Delivery of the infant into the armsof aconscious and pain-
free mother is one of the most exciting and rewarding
moments in medicine.”

16. IDEAL LABOUR ANALGESIA

17. • 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

18. • 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 anesthesia avoiding GA

19. • No motor effect:
Ambulation
Maternal Expulsive Efforts
Progress of Labour
• LAs
 Effective analgesia with
Min LA volume (MLAV):
Min LA Dose (MLAD): ED50 given as a 8 – 12 ml loading
dose, achieves labour analgesia in 1st stage of labour
• Should maintain Uterine blood flow.

20. METHODS OF LABOUR ANALGESIA
• Non Pharmacological
• Pharmacological

21. NON PHARMACOLOGICAL METHODS:
COMPLEMENTARY OR ALTERNATIVE TREATMENT
• Mind body interventions
• Bioelectromagnetics
• Physical methods- massage, heating pads, warm bath
• Alternative treatment- acupuncture, hypnosis

22. MIND BODY INTERVENTIONS
•PSYCHOPROPHYLACTIC METHODS:
✓Breathing exercise
✓Deep abdominal breathing
✓Prepared childbirth method

23. •HYPNOSIS

24. •Biofeedback
•Energy yoga
✓relaxation
✓concentration
✓yoga
• Haptonomy- science of affectivity

25. • MUSIC THERAPY
• ACUPUNCTURE
• TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION
• INTRADERMAL STERILE WATER INJECTION

26. Psychoprophylaxis
• Lamez philosophy
 Most recognised in the united
states
 Teaches that birth is “normal,
natural and healthy”
 Do not recommend against
pharmacological pain relief,
many of their techniques work
in conjunction with intravenous
and neuraxial analgesia

27. • Bradley philosophy
 Husband coached childbirth
 Goal is to achieve a “ a natural childbirth”- a birth
without surgery, medication or medical intervention
 Does not support use of IV or neuraxial analgesia for
labouring parturients

28. Other birth philosophies….
• Dick Read-1933
 Pain was thought to be due to “fear”
 So teach about facts of childbirth and relaxation
techniques
• Frederic Leboyer
 Inspired by indian yoga
 “environment of tranquility”

29. ACUPUNCTURE
• Techniques have
been used in China
• Both for surgery as
well as for pain relief

30. TRANSCUTANEOUS ELECTRICAL NERVE
STIMULATION
 Electrical impulses are applied to skin via electrodes
 For 1st stage electrodes are placed over T 10 - 11 on either side of
spinous process
 For second stage analgesia electrodes are placed over s2-s4
 Diminishes the need of analgesia
 Variable success rate

32. INTRADERMAL STERILE WATER
INJECTIONS
• 25G needle
• 0.1-0.15 mL Intracutaneous
injections of sterile water
• Point 1: PSIS
• Point 2: 1cm medial, & 1-2 cm inf
• Sharp burning pain 20-30 sec
• pain relief after 2 min
• Lasts for 45 min-3 h
• No side effects

34. HYDROTHERAPY

35. PHARMACOLOGICAL METHODS:
Systemic medication
-Intravenous
-Inhalational agents
Regional analgesic techniques
-central neuraxial
-nerve blocks

36. SYSTEMIC MEDICATION:
• Opioids
• Tranquilizers
• Dissociative or amnesic drugs
• Alpha 2 agonists

37. OPIOIDS
• Pethidine
• Tramadol
• Fentanyl
• Remifentanyl
• Dexmedetomidine
• ketamine

38. PETHIDINE
• Shortens first stage of labour
• Equilibrates with fetus rapidly
• IM:50- 100 mg IV:25- 50 mg
• Metabolized to norpethidine 2 to 4 hours in mother
and > 24 hours in fetus

39. • Maximum neonatal depression : 2 to 4 hours
• Antidote: Naloxone (100 mcg/kg)
• Should not be administered in parturients with Cervical
dystocia

40. TRAMADOL
• Popular among obstetricians
• Weak mu agonist + effect on Noradrenaline +
serotonin
• Acts on descending cortico spinal tract
• Not helpful in active phase of labour

41. FENTANYL
• Shorter duration of action
• Infusion and bolus dose
- Bolus : 1 to 2 mcg/kg
- Infusion: 1 to 2 mcg/kg/hr
• Nor fentanyl produces prolonged neonatal depression
• Hence not popular

42. REMIFENTANYL
• ultra short acing mu-1 opioid receptor agonist
• Context sensitive half time is 3.5 mins and is
independent of duration of infusion.
• The analgesic half life is 6 min, thus allowing effective
analgesia for several consecutive painful uterine
contractions.

43. Administration -
• intermittent patient administered bolus with a
lockout interval and with or without background
infusion
• Usual dose is 0.5mcg/kg with a 2 min lockout interval.
• It can also be given as a PCIA bolus dose of
0.25mcg/kg (2 min lockout) with a background
infusion of 0.025 to 0.1mcg/kg/minute.

44. Eligibilty Informed consent
No opioid use in the previous 4 hrs
Dedicated IV cannula for Remifentanyl infusion
PCIA protocol PCIA bolus – 0.25 mcg/kg
Lockout interval : 2 min
Continuous observations SaO2 (pulse oximetry)
Nursing supervision : one to one
Respiratory rate
30 min observations Sedation score
Pain score
Excessive Sedation score( not arousable to voice)
Indications for contacting the
anaesthesia personnel
Respiratory rate < 8 breaths/min
SaO2<90% while breathing room air.

45. DEXMEDETOMIDINE
• Alpha 2 agonist
• Adjuvant to PCIA
• Sedation more, but arousable to verbal stimuli
• No episodes of maternal hypotension, bradycardia ,
fetal heart abnormalities.

46. KETAMINE
• NMDA receptor antagonist
• Good analgesic in first stage of labour
• Bolus : 0.5mg/kg
• Infusion : 0.5mg/kg/hr
• Not be used in preeclampsia ( emergence
phenomenon)
• Catatonia in newborn

47. SIDE EFFECTS OF OPIOIDS
• Nausea, vomiting
• Dysphoria
• Respiratory depression
• All opioids cross the placenta. In utero opioid
exposure results in -
-Fetal bradycardia
-decreased beat-to-beat variability.
-neonatal respiratory depression

48. INHALATIONAL AGENTS

49. • ENTONOX :
- 50% oxygen + 50% nitrous oxide
- Critical temperature of N2O is 36.5 deg C
- If it is combined with O2 (critical temperature –
118deg C)
- Critical temperature of mixture is –6 deg C
- Pseudocritical temperature
- POYNTING EFFECT

50. • Provides analgesia within 20-30 seconds of inhalation
with a maximum effect after about 45 seconds
• Mother is taught to inhale the mixture , so that peak
brain nitrous oxide concentration coincides with peak
contraction pain.
• Does not affect the course of the 1st & 2nd stages of
labour and rates of caesarean delivery

51. • ADVANTAGES:
– Very effective for first stage (not so good for second
stage)
– Can be used when delivery is occurring (if no other
analgesic given and mother is already delivering)

52. • DISADVANTAGES
Increase the rate of maternal O2 desaturation
 Direct respiratory depressant effect
Maternal drowsiness in 0 – 24% of labouring women
Environmental pollution
Requires special apparatus (demand flow machine)

53. SEVONOX
• Entonox + 0.8% sevoflurane
• Better analgesia
• DISADVANTAGE:
- Pollution of labour suit
- Mother may loose protective airway reflexes, nausea
and vomiting.

54. OTHERS
• METHOXY FLURANE :
- very popular in older days for labour
-Even now used in Australia and New Zealand
• TRICHLOROETHYLENE
• ISOFLURANE (0.2-0.25%)
• DESFLURANE (1-4.5% in O2 or Entonox)

55. REGIONAL ANALGESIA
 Most commonly performed regional techniques for
labor are-
• Epidural analgesia
• Subarachnoid block
• Combined spinal-epidural blocks.
 Less frequently performed-
• Lumbar sympathetic
• Paracervical block
• Pudendal block

56. INDICATIONS
• Maternal request
• Hypertensive disorders of pregnancy
• Pre existing medical disease
• Multiple pregnancy
• Previous caesarean section with trial labour
• Prolonged labour
• Deterioration in foetal well-being

57. CONTRAINDICATIONS
• Maternal refusal
• Coagulopathy & thrombocytopenia
• Local or systemic infection
• Inadequate staffing or facilities

58. LUMBAR EPIDURAL ANALGESIA
• Gold standard technique for
pain control in obstetrics
• Low doses of local anesthetic or
opioid combinations are
administered to provide a
continuous T10-L1 sensory block
during the first stage of labor.

59. TIMING OF EPIDURAL
• No need to wait for a cervical dilatation of at least 4 cm.
• The Cesarean section rate was not influenced by early CSE or
epidural analgesia.

60. TECHNIQUE OF EPIDURAL
LOSS OF RESISTANCE TO SALINE OR AIR?
LOR to air technique is associated with various
Complications -
• Incomplete analgesia,
• Inadvertent intravascular position of the catheter
• Pneumocephalus
• headache
• Accidental dural taps
• Venous air embolism

61. ADVANTAGES OF SALINE :
• Is rigid and incompressible.
- Hence a better appreciation of loss of resistance
• Expands the epidural space.
• Removed within 3-5 minutes.
• Decreased incidence of ADP.

62. Fluid preloading
• May be beneficial prior to labour epidurals in situations
where fetus is at increased risk.
• However, routine use of preload in current epidural
practice is questionable and may lead to prolonged
labour due to decreased uterine activity.

63. TEST DOSE FOR EPIDURAL CATHETER
POSITION
Highly Controversial
• Lidocaine 1.5% +adrenaline1:200,000 3ml
• Lidocaine 1.5% can produce motor blockade
• Hypobaric lidocaine - if intrathecal in sitting
position can produce total spinal

64. • Adrenaline –
• If coincides with uterine contraction rise in heart rate may be
confusing
• Decrease in utero placental blood flow
• Decrease uterine contractions
• Present practice is that test dose is not given for labour epidural
analgesia
• It is necessary for epidural injection for operative delivery, where
higher concentration and larger volumes of local anaesthetics are
used.

65. SAFE PRACTICE
• Aspirating before each injection
• Maintaining verbal contact with the patient
• Not injecting more than 5 ml of local anaesthetic as a
single bolus.
• Every bolus dose of the LA given should be
considered as a test dose

66. DRUG REGIMEN
• Epidural catheter is positioned & placement
verified
Initial block –
• Bupivaciane 0.1% (10 – 15 ml) with fentanyl 2
mcg/ml of Bupivacaine.
• Ropivacaine – 0.125% to 0.2% with fentanyl (10 –
15 ml)

67. MAINTAINENCE ANALGESIA
• Intermittent bolus technique
• Continuous infusion technique
• Continuous infusion with intermittent bolus
technique
• Patient controlled epidural analgesia

68. a. Intermittent bolus technique
• Bupivacaine 0.1% with fentanyl 2 mcg/ml, 10
ml injected once in 60 to 90 minutes
• Ropivacaine 10 ml of 0.125% to 0.2% with
fentanyl 2mcg/ml once in 60 - 90 minutes

69. • Advantage
- better spread of the local anaesthetic in the
epidural space with better analgesia.
• Disadvantage - is the breakthrough pain

70. b. Continuous infusion technique
0.0625% Bupivacaine 8-15ml/hr with fentanyl
2mcg/ml

71. Advantages
• Maintenance of a stable level of analgesia
• A more stable maternal heart rate and blood pressure
with decreased risk of hypotension.
• A less frequent need to give bolus doses of local
anaesthetic which may reduce the risk of systemic local
anaesthetic toxicity.
• Satisfactory perineal analgesia

72. • Disadvantages – because of continuous
infusion the spread of the drug may be limited
to a small number of segments and hence may
produce inadequate analgesia

73. c.Continuous infusion with intermittent
bolus technique
• 0.0625% Bupivacaine 8-15 ml/hr with fentanyl
2 mcg/ml + intermittent bolus dose of 5 to 10
ml of 0.1% bupivacaine with fentanyl 2mcg/ml
whenever there is breakthrough pain.

74. • The advantages of both intermittent bolus and
continuous infusion techniques will be there
without any disadvantage.

75. d. Patient controlled epidural analgesia (PCEA)
• Initial bolus dose same
• Basal infusion – 6 ml/hr of Bupivacaine 0.0625%
with fentanyl 2 mcg/ml

76. • Demand bolus dose – 3 to 5 ml – Bupivacaine 0.0625%
to 0.1% with fentanyl 2 mcg/ml.
• Lock out interval – 10 minutes
• Ropivacaine 0.125% with fentanyl 2 mcg/ml can also
be used instead of Bupivacaine in the same dose

77. Advantages
• Effective labour analgesia
• Excellent patient satisfaction
• Decreases the total amount of LA used
• Lessens unwanted effects like hypotension & motor
block
• Reduces the demands on staff
• Gives many parturient with a feeling of empowerment

78. Technological advances
• Ultrasound imaging of the spine has recently been proposed to
facilitate identification of the epidural space and predict difficult
spine score
• Identification of landmarks & estimation of depth of epidural
space
• especially in obese woman and with abnormal lumbosacral
anatomy

79. COMPLICATIONS
 Dislodgement of catheters
 Haemodynamic instability
Hypotension & bradycardia
 Respiratory consequences
 Total spinal anesthesia
 Transient paraesthesias (5-25%)
 Intra-vascular injection of the local
anaesthetic drug
 Foetal bradycardia

80. Neurological complications-
- Accidental dural punctures with PDPH
-Direct trauma to the spinal cord
- Cauda equina syndrome
-Adhesive arachnoiditis
- Thrombosis of the anterior spinal artery

81. COMBINED SPINAL EPIDURAL
ANALGESIA
• The CSE technique is widely used in obstetric practice.
• Rapid- onset analgesia with minimal risk of toxicity or
impaired motor block.
• If operative delivery is required the same catheter can be
used for providing anaesthesia

82. • Many methods may be used to perform a CSE block
• Epidural catheter insertion followed by spinal needle
placement at a lower interspace
• An epidural needle beside the spinal needle at the
same interspace with specially designed needles.

83. • The most commonly used “needle- through- needle technique
involves identification of epidural space & insertion of a long fine-
bore pencil point spinal needle through the epidural needle until
the tip of spinal needle pierces the dura.
• Free flow of CSF confirms correct placement & the opioid alone (
25mcg of fentanyl) or in combination with LA ( Bupivacaine 0.5%
Heavy 0.5 ml + fentanyl 25 mcg ) is injected.
• After spinal injection, the spinal needle is withdrawn & the
epidural catheter is placed 3 to 5 cms into the epidural space via
the epidural needle.

84. • Advantages
- Advantages of a spinal anaesthetic with a fast onset of
analgesic action, reliable anaesthesia of sacral root
- a high quality of analgesia especially during the
second stage of labour
- high maternal satisfaction and
- low maternal and cord blood drug concentrations.

85. • An increased frequency of non reassuring FHR tracings
& fetal bradycardia occurs with CSE.
• The aetiology of fetal bradycardia may be related to an
acute reduction in circulating maternal catecholamine
levels leading to uterine hypertonicity. The typical fetal
bradycardia resolves within 5 to 8 minutes.

86. CONTINUOUS SPINAL ANALGESIA
• Indications
• Previous spinal surgery
• Significant cardiac disease
• Morbid obesity
• Difficult epidural catheter placement
• Difficult airway

87. • Reliable and rapid onset of neural blockade
• Disadvantages
 Repeated IT injections may be required for a long
labour, thus increasing the risk of PDPH
 Pencil point needle -(1–2%)
 Unacceptably high rate historically associated with
sharp-ended, cutting spinal needle
 Motor block prolongs 2nd stage of labour
 Limited duration with single shot

88. INTRATHECAL DRUGS
INTRATHECAL
DRUGS
DOSE EFFECT
OPIOIDS ALONE Profound analgesia with
Fentanyl 15-25 mcg absence of motor block
Sufentanil 5-10 mcg No maternal hypotension
Morphine 0.1-0.2 mcg Foetal bradycardia
LA ALONE Excellent analgesia but
Bupivacaine 0.25% 2.5 –5 mg significant motor block
Ropivacaine 0.2% 2 – 4 mg
Lignocaine 1.5% 20 – 40 mg
ALPHA 2AGONIST Moderate analgesia of short
Clonidine 30 – 50 mcg duration
Significant sedation and
Hypotension

89. DURAL PUNCTURE EPIDURAL TECHNIQUE
• The dural puncture creates a conduit for translocation
of medications from the epidural to subarachnoid
spaces, a process that is believed to be responsible for
the unique characteristics that are observed with the
DPE technique.
• improve sacral block onset and spread of anaesthesia
and analgesia.

91. COMPUTER INTEGRATED PCEA

92. CS Intrathecal fentanyl 15μg +Ropivacaine 2 mg
↓
No infusion
↓
Demand dose: 5ml*, lockout 10 minutes
↓
Change infusion to 5 ml/hr
↓
2nd Demand within 1 hr
↓
Change infusion to 10 ml/hr
↓
3rd Demand within 1 hr
↓
Change infusion to 15 ml/hr
↓
4th Demand within 1 hr→ Stop infusion and activate
Alarm.
(* 0.1% Ropivacaine + fentanyl 2 μg/ml)

93. PROGRAMMED INTERMITTENT BOLUS
TECHNIQUE
• Thehourly total amount of local anaesthetic solution
normally used in a continuous epidural infusion
administered as intermittent boluses.

94. ADVANTAGE:
• higher maternal satisfaction
• less need for unscheduled rescue boluses and
• a reduced consumption of Bupivacaine

95. WALKING EPIDURAL
• CSEA performed with subarachnoid opioids (with or without
local anesthetic) causes minimal or no motor block and has
been referred as the "walking epidural".
• This approach with the application of low-dose local
anaesthetic and/or opioid can provide a very selective sensory
block with minimal motor blockade, allowing parturients to
ambulate.

96. • The initial subarachnoid dose of bupivacaine, 2.5 mg, and
fentanyl, 5-10 µg is extremely efficacious, abolishing most
severe labor pain in 2-3 minutes.
• Although the initial dose is usually a low-dose mixture of local
anesthetic and opioid, fentanyl or sufentanil alone may also be
used.
• Before making the woman ambulate she should be assessed
for motor blockade, sensory blockade, postural hypotension
and must be accompanied by the attendant or the nurse .

97. • Motor assessment to determine ability to ambulate unassisted
• Task
• Leg strength (supine) - Straight leg raise (both legs)
• Postural hypotension - sit at bedside
• Leg strength & postural hypotension - stand at bedside
•
• Leg strength (standing) -partial deep knee bend
• Ambulation -six unassisted steps

98. • Purported advantages of ambulation in labour include
 parturient's enjoyment of mobility
 autonomy and self-control in labour
 increased uterine activity and increased intensity of
contractions
 decreased duration of the first stage of labour
 decreased incidence of foetal heart rate
abnormalities
 decreased incidence of operative and/or assisted
deliveries.

99. DRUGS FOR NEURAXIAL ANALGESIA
The ideal analgesic drug for neuraxial labour
analgesia would-
 provide rapid onset of effective analgesia
 minimal motor blockade
 minimal risk of maternal toxicity
 negligible effect on uterine activity and
uteroplacental perfusion.
 limited placental transfer
 long duration of action
 minimal effects on progress or outcome of labour

100. DRUGS
• Local anaesthetics
- Bupivacaine
- Ropivacaine
- Levobupivacaine
• Adjuvants
- Opiods
- Clonidine
- Neostigmine

101. BUPIVACAINE
 Bupivacaine is an amide local anesthetic
 onset of action with bupivacaine is rapid
 duration of anesthesia is significantly longer
with bupivacaine than with any other
commonly used local anesthetic.
 It has a high protein binding capacity (95%)has
a low fetal/maternal ratio (0.2 to 0.4)
 Relative motor sparing
 Cardiotoxic

102. ROPIVACAINE
• Ropivacaine is a homologue of
bupivacaine, formulated as a single
levorotary enantiomer.
• Its latency and duration of action are similar
to bupivacaine
• it has less potential for cardiac toxicity.
• studies suggest that ropivacaine is
approximately 40% less potent than
bupivacaine

103. LEVOBUPIVACAINE
• S(-) enantiomer of bupivacaine
• No difference in onset, spread and
duration of analgesia
• Less potency
• Advantage- less motor blockade
- less cardiotoxic .

104. ADJUVANTS- OPIOIDS
The combination of a local anesthetic with a lipid-
soluble opioid allows the use of lower doses of each
agent, thus minimizing undesirable side effects
• Synergistic effect by acting directly on opioid receptors
in the spinal cord
• “ultralight epidurals”.

105. FENTANYL -
• rapid onset of anlgesia
• minimum respiratory depression
• 10 -25µ.
• Advantages-
• decreased motor blockade
decreased hemodynamic
instability
• Side effects –
• pruritis, nausea, vomiting, urinary retention

106. Sufentanil-
10 times more potent than fentanyl
• Dose -2.5-7.5µg

107. NEWER ADJUVANTS
• CLONIDINE-
 α2 adrenergic agonist
 Prolongs sensory block
 15 µg an optimal dose
 Side effects
-hypotension
- bradycardia
- sedation

108. • NEOSTIGMINE :
an acetylcholinesterase inhibitor, that indirectly stimulates both
muscarinic & nicotinic receptors in the spinal cord,
DOSE: 500mcg
Can be given in epidural along with clonidine.

109. Newer Insights into the Mythsand
Controversies

110. Prolonged 2nd stage of labour
• Early epidural did not affect lengths of labour or
caesarean rates
• It is actually associated with shorter labour compared with
late epidural placement
• Women managed actively in labour, regardless of timing
of epidural placement, had shorter duration than controls

111. Increased rate of operative and
instrumental delivery: Is epidural
the cause?
 In nulliparous women of a very low-risk population, use
of epidural analgesia for labor pain was associated with
higher risks of emergency cesarean section and vacuum
extraction.
The Cochrane Database Systemic trials 2012 have emphasized
that epidural analgesia had no statistically significant impact on
the risk of caesarean section

112. Timing of epidural during labour:
Epidural taken early vs. late?
In RCT of 750 primigravid women in early labour,
concluded that there was no difference in caesarean
rates when neuraxial analgesia was administered early
in labour (2 cm) vs. a group where epidural analgesia
was administered late in labour (4–5 cm).
The ACOG and the American Society of
Anesthesiologists (ASA) have also jointly emphasized
“ Maternal request is a sufficient indication for pain relief
in labour.

113. Maternal Fever?
• Minimal increase in body temperature
after induction :
– little clinical significance
– Not associated with neonatal
infection

114. Backache and epidural?
• Epidural analgesia has not been associated with an
increase in the prevalence or incidence of
backache.

115. FETALBRADYCARDIA
• Incidence of 11-30%
• Management of fetal bradycardia associated with uterine
hyperactivity:
• fluids, oxygen, interrupting oxytocin administration, raising
maternal BP, IV or SL NTG
• CSE with subarachnoid injection of local anaesthetic without
opioids f/b early initiation of epidural analgesia provides
satisfactory painrelief
• minimises the risks of opioid-induced transient fetal
bradycardia.

116. BREAST FEEDING
• Low-dose local anaesthetic ⁄ low-dose fentanyl
epidural labour analgesia regimens (as is the current
practice in many obstetric anaesthesia centres) do
not clinically affect breastfeeding and should be still
offered to mothers wishing to breastfeed their
babies.

117. THANK YOU