In attempting to provide optimal labor analgesia, it is important to weigh the risks against benefits of any particular technique. This must take in to consideration factors such as the timing of intervention and the place of practice. Cost, accessibility, and human resources are other considerations. It inadvisable to use an expensive or complicated technique in rural areas where there is limited medical access. A properly performed ILA is a very cost effective technique for a pain relief in labour that can be recommneded as an alternative to CSE or epidural analgesia in areas where access to medical care is limited

1. Susilo Chandra, MD, FRCA
Department of Anesthesiology & Intensive Care
Cipto Mangunkusumo General Hospital
University of Indonesia, Medical Faculty
Labor analgesia
Is It Attainable

2. ASA & ACOG STATEMENTASA & ACOG STATEMENT
The American Society of Anesthesiologists
and the American College of Obstetricians
and Gynecologists agree that “of the
various pharmacologic methods used for
pain relief during labor and delivery,
regional analgesia techniques are the most
flexible, effective, and least depressing to
the central nervous system, allowing for an
alert, participating mother and alert
neonate.”

3. Many systemic techniquesMany systemic techniques
“alternatives” to labor neuraxial
analgesiapoorly effective and some
are associated with significant maternal
and neonatal side effects
Intravenous PCA remifentanil is the
most effective technique, but safe
administration?

4. N2ON2O
Nitrous oxide 50% provides little pain
relief

5. In the context of pain reliefIn the context of pain relief
in labor:in labor:
Individual anaesthetists’ impressions,
Patient satisfaction surveys,
The midwives’ ability to work with a
specific analgesic technique,
The adequacy of pain relief or, even, on
the flexibility offered by the analgesia
technique to the obstetrician?
Or a ‘good patient outcome’

6. Good patient outcomeGood patient outcome
Superior quality of pain relief achieved with:
– be safe (technique and drugs) for
mother and baby,
– have only minimal effects on the
process of labor process,
– be able to provide long lasting and
consistent pain relief
– be customized to patients’ needs
– be affordable to most

7. Myles PS: Improving quality of recovery: what anaestheticMyles PS: Improving quality of recovery: what anaesthetic
techniques make a difference? in Best Practice & Researchtechniques make a difference? in Best Practice & Research
Clinical Anaesthesiology. Vol 15, No 4, pp. 621-631, 2001.Clinical Anaesthesiology. Vol 15, No 4, pp. 621-631, 2001.
Practising evidence-based medicine
in anaesthesia can be difficult
Even more in OB anaesthesia
because other – mainly, obstetrical
and pregnancy - factors are often
much more important determinants of
outcome

8. Which evidence is relevant to painWhich evidence is relevant to pain
relief in labour:relief in labour:
Shorter time to onset of pain relief
improved maternal satisfaction with the
neuraxial block
Lower overall pain score
Longer duration of pain relief
Shorter duration of labour
Reduced intensity of motor block.

9. Reynolds F, Sharma S, Seed P: A Meta-AnalysisReynolds F, Sharma S, Seed P: A Meta-Analysis
Comparing Epidural with Systemic OpioidComparing Epidural with Systemic Opioid
Analgesia. Br J Ob Gyn 109:1344-1353, 2002Analgesia. Br J Ob Gyn 109:1344-1353, 2002
Concluded that a low concentrationConcluded that a low concentration
epidural is better than ‘naturalepidural is better than ‘natural
childbirth’ and that a ‘modern’ epidural’childbirth’ and that a ‘modern’ epidural’
is better than ‘systemic opioids’ inis better than ‘systemic opioids’ in
terms of umbilical artery base deficit.terms of umbilical artery base deficit.

13. Gambling D, Sharma S, Ramin S, et al: A Randomised Study of
CSE analgesia vs IV meperidine. Anesthesiol 89, 1336-1344,
1998
In their randomized study of CSE analgesia vs IV meperidineIn their randomized study of CSE analgesia vs IV meperidine
(pethidine), showed that fetal bradycardia can follow CSE.(pethidine), showed that fetal bradycardia can follow CSE.
Holdcroft A, Dob D: Regional Analgesia for Labour and Fetal
Distress: Culprit or Innocent Bystander. IJOA 12:153-155,
2003.
Reflected that CSE is probably no worse than epidural inReflected that CSE is probably no worse than epidural in
producing fetal bradycardia and that it occurs with bothproducing fetal bradycardia and that it occurs with both
intrathecal opioids and intrathecal local anaesthetics.intrathecal opioids and intrathecal local anaesthetics.

14. Summary:Summary:
RA: epidural, spinal, or combination, is
an integral part of pain relief in labor
Although childbirth has become much
safer for mother and neonate, there is
still room for improvement
Labor analgesia is it attainable, the
answer is yes

15. Epidural analgesiaEpidural analgesia
the most effective method of providing pain
relief during labor.
However, there’s a big challenge in providing
epidural analgesia in remote areas,
particularly in developing countries and also
in small birthing centres where there is lack
of expertise, resources and logistical support
to provide safe epidural analgesia
Intrathecal Labor Analgesia (ILA) may have a
role to play in these situations.

16. ILAILA
single shot spinal technique to provide
labor analgesia;
it has the advantage of being a low cost
technique that could be easily and
safely executed.
If appropriately monitored and
managed, ILA may result in reasonably
prolonged analgesia and good
maternal satisfaction

17. General Considerations in ILAGeneral Considerations in ILA
The timing for the institution of ILA is
vital.
However, the effects of cervical dilation
and stage of labor on the duration of
effective intrathecal analgesia have not
been well characterized

18. Comparison of ILA with otherComparison of ILA with other
neuraxial techniques:neuraxial techniques:
Onset of action: ILA produces a more rapid onset of
action than epidural analgesia. The rpaidity of onset is
comparable with combined spinal epidural analgesia
(CSE) but CSE, being inherently a ‘2 procedure’
technique, ie. spinal AND epidural, often takes a longer
to complete.
Duration of action: As ILA is not ‘extendable’ it suffers
from a soreter duration of action of analgesia wehn
compared with CSE and epidural analgesia. The use of
a multi-modal combination of intrathecal drugs, i,e local
anaesthetics, opioids and other adjuvants may
potentially prolong the duration of analgesia and
reduce the need for a repeat ILA.

19. Comparison of ILA with otherComparison of ILA with other
neuraxial techniques:neuraxial techniques:
Affordability: this is the greatest advantage of ILA when
compared with epidural or CSE. ILA dose not involve the
insertion of catheters and does not require sophisticated pumps
and infusion systems to maintain labour analgesia.
Simplicity of technique: most anaesthesiologists are familiar
with the isntitution of spinal anaesthesia and ILA is just a
modification of the technique of providing spinal anaesthesia
but for the labouring women.
Reliability: With the use the correct technique and drugs, ILA
provides reasonably relaible analgesia with preservation of
motor power.

20. Practical Considerations in ILAPractical Considerations in ILA
Analgesic drug regimen: A combination
of local anaesthetics, opioids and
clonidine is recommended

21. Labor Analgesia
• Hyperbaric upivacaine
• Plain bupivacaine
• Levobupivacaine
• Ropivacaine
• Lidocaine
Hypotension
• Ephedrine
RECIPE
• Adjuvant Adrenalin
ClonidineOpioid Morphine
Fentanyl

22. •OUR RECIPE
250 µg of morphine + 2.5 mg bupivacaine + 30-45
µg clonidine/25 µg fentanyl
Breakthrough pain --> repeat spinal
RECIPE

23. •OUR RECIPE for BREAKTHROUGH PAIN
If < or = 4 hours fentanyl + bupi + clonidine
If > 4 hours to Mo + fentanyl/clonidine + bupi
RECIPE

24. ConclusionConclusion
In attempting to provide optimal labor
analgesia, it is important to weigh the
risks against benefits of any particular
technique.
This must take in to consideration
factors such as the timing of
intervention and the place of practice.
Cost, accessibility, and human
resources are other considerations.

25. ConclusionConclusion
It inadvisable to use an expensive or
complicated technique in rural areas
where there is limited medical access.
A properly performed ILA is a very cost
effective technique for a pain relief in
labour that can be recommneded as an
alternative to CSE or epidural
analgesia in areas where access to
medical care is limited

26. THANK YOUTHANK YOU