Labor analgesia

Saneesh P J
Specialist (A) - Anesthesiology

https://www.facebook.com/AnesthesiaTOOLS
Childbirth - most painful experiences women
will experience in their lifetime
Childbirth pain was “divine retribution for Eve’s
disobedience in the Garden of Eden”
Many believed it was wrong to treat the pain
and escape God’s punishment

Several non-pharmacologic techniques have
been used to relieve the pain of childbirth
throughout history
acupuncture
massage
hypnosis
Drugs were not used in Western medicine to
relieve pain in childbirth until the mid-1800s

English Queen Victoria chose to inhale
chloroform for analgesia during the birth of
Prince Leopold
John Snow Queen Victoria

Always controversial!
“Birth is a natural process”
Women should suffer!!
Concerns for mother’s safety
Concerns for baby
Concerns for effects on labor

<10% of laboring women in US in 2001
underwent childbirth without analgesia
Neuraxial analgesia is by far the most common
form of pain management
Development of increasingly safe techniques for
neuraxial analgesia

Acupuncture
Massage
Hypnosis
Others
Lamaze method
LeBoyer technique
Transcutaneous nerve stimulation
Hydrotherapy
Presence of a support person
Intradermal water injections
Biofeedback

Good pain relief
No autonomic block (no hypotension)
No adverse maternal or neonatal effects
No motor block

No effect on labor and delivery:
No increase in C/S rate
No increase in forceps/vacuum delivery
Patient can ambulate
Economical: cost and personnel

Prenatal education classes
Anesthesiologists must become effective
educators as well as health care providers
Patients should have realistic expectations
regarding the pain of labor and the variability of
individual labor patterns

Well-informed patients are more likely to accept
the interventions that may become necessary
during labor

Anesthesiologists should encourage and
facilitate the honest discussion of the risks and
benefits of the analgesic/anesthetic techniques
available

All parenteral opiates cross placenta
Degree of depression depends on
specific agent
Dose
time between administration and delivery
prematurity

Morphine
Pethidine
Fentanyl
Ketamine

Inhaled anesthetics were the first treatments
for labor analgesia used in modern times.
However, as volatile anesthetics became more
commonly used in childbirth, side effects were
more commonly encountered.
Neonatal depression
Maternal gastric aspiration

Delivery was complicated by aspiration of
gastric contents in 66 women from 44,016
deliveries (0.15%) between 1932 and 1945.
The preventive fasting measures -
recommended by Mendelson
restricting intake
provision of non-particulate antacids
improvement of anesthetic-induction technique

Volatile anesthetics are no longer used for labor
analgesia.
Nitrous oxide, however, is still commonly used
worldwide and is welcomed by many
parturients as a less invasive approach to pain
relief in labor.

Typically NITROUS OXIDE is blended with O2 in a
50:50 ratio or slightly greater for patient-inhaled
self-administration.
ENTONOX

The most reliable and effective method of
reducing pain during labor.
However, it is encumbered by small but real and
predictable risks.

Assessment of all laboring women for risk
factors for neuraxial analgesia and general
anesthesia is recommended
Sufficient time should be available for adequate,
safe evaluation and discussion with the patient.
In otherwise healthy women, routine laboratory
testing is not required.

Although any laboring woman has the potential
to require cesarean section, labor takes many
hours and requires adequate nutrition and
hydration.
ASA has recommended that moderate amounts
of clear liquids be allowed during the
administration of neuraxial analgesia and
throughout labor
A period of abstention from solids before the
placement of neuraxial analgesia is not
required.

Timing of placement
Current ASA guidelines note that maternal request
for labor pain relief is sufficient justification for
intervention and the decision should not depend
on an arbitrary cervical dilation.

Epidural analgesia is most commonly initiated
after placement of a catheter into the epidural
space between L2-3 and L4-5

IV fluids
Monitoring
CTG
Positioning

The “test dose” tests for inadvertent
intravascular or intrathecal placement of the
catheter.
Choice of local anesthetic drugs
Bupivacaine
Ropivacaine
Adjuvants – opioids

Very dilute local anesthetic mixtures (0.0625%)
generally do not produce motor blockade and
may allow some patients to ambulate
(“walking” or “mobile” epidural)

The long duration of action of bupivacaine
makes it a popular agent for labor.
Ropivacaine may be preferable because of its
reduced potential for cardiotoxicity

Patient-controlled epidural
analgesia (PCEA)
Total drug requirements may be less
Patient satisfaction is greater with
PCEA compared with other epidural
techniques.
PCEA settings are typically a 5-mL
bolus dose with a 5–10 min lockout
and 0–12 mL/h basal rate; a 1-h
limit of 15–25 mL may used.

Hypotension
Unintentional intravascular injection
Unintentional intrathecal injection
Post-dural puncture headache (PDPH)
Epidural abscess/hematoma
Neurological deficits (rare)

Combined Spinal & Epidural (CSE) Analgesia
Spinal anesthesia
Saddle block

Paracervical block
LA is injected lateral to the cervix at 4 o’clock and
10 o’clock, taking care to avoid vascular structures.

Paracervical block
The paracervical block is effective to relieve pain of
cervical dilation but does not affect cramping pain
from contraction of the uterine corpus.
However, paracervical block does reduce pain in
the second stage of labor.

Pudendal nerve block
The pudendal nerve is derived from sacral nerve
roots and can be blocked with local anesthetic
using a transvaginal or transperineal approach to
treat pain during the second stage of labor and for
episiotomy repair.

Low-dose epidural analgesia can be inadequate
for assisted vaginal delivery with forceps or
vacuum.
A higher concentration local anesthetic can be
administered through an indwelling epidural
catheter or a “second-stage spinal” can provide
excellent perineal analgesia.

Supplementation of an indwelling epidural
catheter with 5 to 10 mL of 1% to 2% lidocaine
or 2% to 3% 2-chloroprocaine is usually
adequate, depending on whether vacuum or
forceps are being used.
Pudendal nerve block also can be considered for
operative delivery.

Individualize technique to patient’s goals
and stage of labor
Optimize management for spontaneous
delivery
Provide safe, cost-effective analgesia

Labor analgesia

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