This document discusses the history and physiology of labor analgesia. It provides an overview of the controversy around pain relief during labor and outlines both non-pharmacological and pharmacological options. Regional techniques like epidural analgesia are highlighted as the most effective methods with minimal effects on the fetus when used properly. The goals of labor analgesia and factors to consider when selecting drugs and techniques are also summarized.
Advances in the field of labour analgesia have tread a long journey from the days of ether and chloroform in 1847 to the present day practice of comprehensive programme of labour pain management using evidence-based medicine. Newer advances include introduction of newer techniques like combined spinal epidurals, low-dose epidurals facilitating ambulation, pharmacological advances like introduction of remifentanil for patient-controlled intravenous analgesia, introduction of newer local anaesthetics and adjuvants like ropivacaine, levobupivacaine, sufentanil, clonidine and neostigmine, use of inhalational agents like sevoflourane for patient-controlled inhalational analgesia using special vaporizers, all have revolutionized the practice of pain management in labouring parturients.
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
Advances in the field of labour analgesia have tread a long journey from the days of ether and chloroform in 1847 to the present day practice of comprehensive programme of labour pain management using evidence-based medicine. Newer advances include introduction of newer techniques like combined spinal epidurals, low-dose epidurals facilitating ambulation, pharmacological advances like introduction of remifentanil for patient-controlled intravenous analgesia, introduction of newer local anaesthetics and adjuvants like ropivacaine, levobupivacaine, sufentanil, clonidine and neostigmine, use of inhalational agents like sevoflourane for patient-controlled inhalational analgesia using special vaporizers, all have revolutionized the practice of pain management in labouring parturients.
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
General anesthesia & obstetrics- c-section part ISandro Zorzi
→ Discuss indications of general anesthesia for operative delivery
→ Explain aspiration risk for general anesthesia in pregnancy and prevention strategy
Outline anaesthesia plan of care for induction, maintenance and emergency
Describe effect of volatile anaesthetics on uterine blood flow and tone
Discuss intraoperative strategies to prevent postoperative nausea and vomiting
Discuss other complications of general anaesthesia and clinical management
History, Myths, Indications & Contraindications, and Methods of painless labor as a means of natural way of childbirth with a lot of benefits for mothers & babies.
Summary:
- Preeclampsia is a syndrome of unknown etiology with multiorgan involvement
- It presents with a wide spectrum of symptoms
- It is sometimes difficult to distinguish from other systemic diseases
- Severe cases may progress to MOF and death
- Delivery of the child and placenta is the only specific treatment – other lines of teatment are only supportive
There are several issues regarding diagnostic techniques and treatment options that need further evaluation
General anesthesia & obstetrics- c-section part ISandro Zorzi
→ Discuss indications of general anesthesia for operative delivery
→ Explain aspiration risk for general anesthesia in pregnancy and prevention strategy
Outline anaesthesia plan of care for induction, maintenance and emergency
Describe effect of volatile anaesthetics on uterine blood flow and tone
Discuss intraoperative strategies to prevent postoperative nausea and vomiting
Discuss other complications of general anaesthesia and clinical management
History, Myths, Indications & Contraindications, and Methods of painless labor as a means of natural way of childbirth with a lot of benefits for mothers & babies.
Summary:
- Preeclampsia is a syndrome of unknown etiology with multiorgan involvement
- It presents with a wide spectrum of symptoms
- It is sometimes difficult to distinguish from other systemic diseases
- Severe cases may progress to MOF and death
- Delivery of the child and placenta is the only specific treatment – other lines of teatment are only supportive
There are several issues regarding diagnostic techniques and treatment options that need further evaluation
This topic includes Introduction for analgesia and anesthesia used in obstetrics, maternal risk factors for anesthesia, anatomical and physiological considerations, analgesia during labour and delivery, sedatives and analgesia, opioid analgesics, combination of narcotics and antiemetics, inhalation methods, commonly used local anesthesia in obstetrics, spinal anesthesia, infiltration anesthesia, patient controlled anesthesia, psychoprophylaxis, general anesthesia for cesarean section, complication of general anesthesia and its management.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Evaluation of antidepressant activity of clitoris ternatea in animals
Labour analgesia
1.
2. Analgesia for Labor and Delivery
ALWAYS controversial !
“Birth is a natural process”
Women should suffer!!
Concerns for mother’s safety
Concerns for baby
Concerns for effects on labor
3. Garden of Eden
History
Original Sin
God punished Eve: “In sorrow thou shalt bring forth children.”
Genesis 3:16
Formed the basis of 1800 years of opposition to pain relief in
labor.
1591
Lady Euframe MacAlyane of Edinburgh, Scotland: was Burned
at the Stake because asking for labor analgesia.
4. HISTORY
1847 – James Young Simpson; ETHER
1853 – John Snow ; CHLOROFORM
- Queen Victoria, 8th child
5. Chloroform a’ la reine
“The inhalation lasted fifty-three minutes.
The chloroform was given on a
handkerchief in fifteen minim doses; the
Queen expressed herself as greatly
relieved by the administration.”
6. Chloroform a’ la reine
“Dr Snow gave me the blessed
chloroform and the effect was soothing,
quieting and delightful beyond measure”
7. History contd..
1855
Religious acceptance
Archbishop of Canterbury's (leader of
the Anglican/Episcopal Church) daughter received
chloroform for labor pains. He refused to criticize.
1860-1940 : Dark ages of obstetric anesthesia
8. History
August Bier ,……………..,
Virginia Apgar ,…
1900 :
Oskar Kreis , used spinal anesthesia for
childbirth for the first time
10. DEFINITION OF PAIN
ISAP - AS AN UNPLEASANT SENSORY
AND EMOTINAL EXPERIENCE
ASSOCIATED WITH ACTUAL
POTENTIAL TISSUE DAMAGE (OR)
DESCRIBED IN TERMS OF SUCH
DAMAGE.
17. CENTRAL MECHANISMS
NOCICEPTIVE AFFERENTS
DORSAL ROOT
GANGLION
DORSALHORN
C&SOME A-DELTA SUPERFICIAL LAMINA(1&2)
SOME A-FIBERS —LAMINA - 5
30% -C-FIBERS
—DOUBLE BACK THROUGH
VENTRAL ROOT
1&5 -------THALAMUS
LAMINA 2—SUBSTANTIA GELATINOSA (INHIBITORY)
“THE GATE CONTROL THEORY OF PAIN”
22. PAIN PATHWAYS
1st stage of labor – mostly visceral
Dilation of the cervix and distention of the
lower uterine segment
Dull, aching and poorly localized
Slow conducting, C fibers, T10 to L1
2nd stage of labor – mostly somatic
Distention of the pelvic floor, vagina and
perineum
Sharp, severe and well localized
Rapidly conducting, A-delta fibers,S2 to S4
33. ACUPUNTURE
Generally two local points and two distal points on the
arms or on the legs are selected.
Begin Acupuncture 4 weeks before the expected time of
delivery.
Needles are placed once a week using the specific points.
Points
LI.4 Hegu, SP.6 Saninjiao, Extra Neima
PC 6 (Neiguan), Du.20,Du.2,Du6, GB.21,
He.7(shenmen)
34. TENS
Beneficial in patients with moderate to severe
contraction pains in an otherwise reasonably
normal labor.
Very popular in Europe.
Easy to apply, non-toxic and frequently
effective.
4 electrodes are placed one on either side of
the
spine in the lower thoracic region (T 10) and
one
on either side of the spine in the sacral area.
The patient may control up to 3 levels of
intensity
of stimuli, and she can switch it off if she
wishes.
36. Factors Determining Fetal Drug Levels
Lipid solubility
Molecular size
Total dose of drug
Concentration gradient
Maternal metabolism and excretion
Degree of ionization
pKa of drug, maternal and fetal pH
Protein binding - mother and fetus
Uterine blood flow
Time for equilibrium to occur
37. Systemic Opioids in Labor
Advantages:
Easy administration
Inexpensive
No needles
Avoids complications of regional block
Does not require skilled personnel
Few serious maternal complications
Perceived as “natural”
45. Inhalation Analgesia
Disadvantages:
Decreased uterine contractility (except N2O)
Rapid induction of anesthesia in pregnancy
Risk of unconsciousness and aspiration
Difficulties with scavenging in labor rooms
47. Paracervical Block
Local bilateral injection near the cervix
Given during 1st stage of labor
Lasts about 2 hours
Disadvantage
fetal bradycardia
Lidocaine toxicity
51. Indications
PAIN EXPERIENCED BY A WOMAN IN LABOR
ACOG and ASA stated
“ in the absence of a medical contraindication,
maternal request is a sufficient medical
indication for pain relief…”
Points of controversy
When?
Who?
How?
54. Contraindications
ABSOLUTE
Patients refusal
Inability to cooperate
Increased intracranial
pressure
Infection at the site
Frank coagulopathy
Hypovolemic shock
RELATIVE
Systemic maternal infection
Preexisting neurological
deficiency
Mild coagulation
abnormalities
Relative hypovolemia
Poor communication
55. GOALS OF LABOR ANALGESIA
Dramatically reduce pain of labor
Should allow parturients to participate in birthing
experience
Minimal motor block to allow ambulation
Minimal effects on fetus
Minimal effects on progress of labor
56. How to Achieve Goals:
What you put in:
Drugs, concentrations, combinations
How you deliver it:
Intermittent boluses, Continuous, PCEA
How much you give:
Low Vs. High infusion rates
58. Neuraxial Blocks
Spinal opioids alone: very high risk pts
Epidural opioids alone: High doses
Spinal LA alone: Saddle block, 6mg bupivacaine
Epidural LA alone
Epidural LA + Opioid ± Adjuvants
Combined Spinal & epidural – LA+Opioid
± Adjuvants
Continuous spinal – LA ± Opioids
59. Choice Of Local Anesthetic
Rapid onset with minimal motor block
Minimal risk of maternal toxicity
Negligible effects on uterine activity and
uteroplacental perfusion
Limited uteroplacental transfer
Long duration of action
60. Choice of Epidural LA
Lignocaine: Rapid onset, Dense motor block, Risk of
cummulative toxicity, UV/MV ratio – 0.6
Chlorprocaine:Rapid onset, Low toxicity, Dense block,
Antagonises bupivacaine &poioids
Bupivacaine( 0.0625%): Good sensory, Minimal motor
block, 2hrs, No adverse effects on labor, UV/MV – 0.3
Ropivacaine: Lower toxicity, ?Less motor block, Less
potent
Levobupivacaine: Lower toxicity
61. Epinephrine Use in Labor
May transiently slow labor
Increases motor block, Improves analgesia
Epinephrine test dose often avoided in labor
Low specificity - maternal heart rate very variable
Low sensitivity - ↓ response to sympathomimetics
Increases motor block - prevents ambulation
Potential for ↓ UBF with repeated doses
Very dilute agents - “whole first dose is test dose.”
62. Epidural Opioids in Labor
Inadequate analgesics if used alone
Synergize with local anesthetics
Speed onset of analgesia
Improve quality of analgesia
Permit use of very dilute LA solutions
Help relieve persistent perineal pain and
unblocked segments
63. Effect of low conc LA + opioid
(Comet Study UK , Lancet 2001;358:19)
50
%
Patients
40
*
*
*
30
20
10
0
"Traditional"
Bupivacaine
0.25%
Low-dose
Infusion
Bupiv 2.5 mg
+ Fent 25 mcg
Bupivacaine
0.1% + fentanyl
Spontaneous
Instrumental
C/Section
64. Which Epidural Opioid ?
Fentanyl and Sufentanil
Rapid onset, few side effects
Sufentanil slightly more effective
No significant fetal drug accumulation
No serious adverse neonatal effects
68. Continuous epidural infusion
“A larger volume of a more dilute agent is more
effective for labor analgesia than a smaller
volume of higher concentration”
Good pain releif
Less motor block
Increased maternal hamodynamic stability
Safe drug concentrations
No change in neonatal outcome
69. PCEA
Good analgesia
Patient autonomy
Less anaesthetist interventions
Cost effective
Lower total dose
Bupivacaine 0.125% + Fentanyl 2µg/ml – 6ml basal
infusion, 3ml bolus, 10min lockout interval, max
24ml/hr
70. From Gambling DR et al. Comparison of patient-controlled epidural
analgesia and conventional intermittent top up injections during labor.
Anesth Analg 1990;70:256-61.
71. Combined spinal-epidural
Faster onset - intense analgesia
Additional flexibility - epidural
Very low failure rate
Minimal motor block if only opioid used for spinal
Less need for supplemental boluses
IT opioids: Fentanyl 5-25 μg, sufentanil 5-10 μg
Early labor : opioid ± 0.125 mg bupivacaine;
Advanced labor: opioid ± 2-2.5 mg bupivacaine
72. COMBINED SPINAL EPIDURAL
Needle” through “Needle”
“ Back “ eye”
Needle” through “Needle” technique is the best
Can be placed in lateral or sitting position
Walking Epidural possible
73. Onset of Analgesia: CSE vs.
Epidural
Collis et al. Lancet 1995;345:1413
100
CSE
Epidural
75
VAPS
(0-100)
50
25
0
Baseline
5
10
Time (minutes)
15
20
74. Combined spinal-epidural
Not recommended - morbidly obese, difficult airway
or non-reassuring fetal heart rate
Two interspace techniques
Needle through needle
-PDPH: 1% or less, small bore atraumatic needles.
-Subarchanoid migration of epidural catheter - No added
risk with CSE
75. Continuous Spinal Analgesia
28 or 32-G catheters for 22 or 26-G spinal needles
Bupivacaine 2.5mg+25µg fentanyl,
1-2ml/hr of bupivacaine 0.125% + 2µg/ml fentanyl
Cauda Equina Syndrome
Restricted by FDA in 1992
Ongoing multi-institutional study – 28-G catheters
sufentanil ± bupivacaine
Appears safe
76. Side effects of IT opioids
Nausea, Vomitting
Pruritis
Sedation
At very high doses - Resp depression
- Fetal bradycardia
Stratergy to ↓ side effect - Add LA
- Lowest dose opioid
77. We are All Ready…Now What?
Obstetrician is consulted
Pre-anesthetic evaluation
Pt’s informed consent
Fetal well-being assessed and reassured
(obstetrician?, midwife?, yourself?)
Stage of labor/ Cervical dilatation
Resuscitation equipment and drugs are
immediately available
Aspiration prophylaxis
78. Conduct of Labour analgesia
Baseline BP, HR, FHR
IV access, Preload 500 -1000ml
Perform epidural / CSE
Pregnancy – Physiologic changes
Left lateral / sitting
R/O intrathecal/ IV placement
3-5cm catheter inside space
4ml of the drug
79. Conduct of Labour analgesia
Monitoring:
BP every 1 to 2 min , 20 min
Continuous maternal HR during induction
(pulseoximetry)
Continuous FHR monitoring
Continual verbal communication
After 5mins, 4-8ml of drug » T10-L1 block
Alternatively continuous infusion /PCEA
Assess progression of labor
Treat every bolus as test dose
80. Conduct of Labor analgesia
Nursed in lateral position
Second stage of labor – S2 -4
Head end elevation, 4-8ml drug bolus
Intermittent techniques – 10-15ml drug
Prolonged for instrumental delivery /
C.section
85. Controversial areas
Maternal pyrexia:
↑0.1 C/hr, No infection, No neonatal sepsis
Progress of Labor:
?only minimally prolongs
Rate of C/S: Not increased
Epidural test dose:
? Adrenaline, ?isoprotenerol
Careful aspiration
86. Avoiding Epidural Disasters
Maintain constant verbal contact
Always aspirate before each injection
Observe for passive return through the catheter
Do not inject more than 4 ml of LA at a time
Observe the patient at least 1.5-2 min between boluses
If in doubts, repeat test dose. Still in doubts? Replace it
i
After all, be mentally prepare to treat
1. Convulsions
2. Total spinal
3. Cardiovascular collapse and arrest
87. Conclusions
Individualize technique to patient’s goals and
stage of labor
Optimize management for spontaneous delivery
Provide safe, cost-effective analgesia
88. The Ideal Labor Analgesic
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