This document discusses pain management options for labor and delivery. It describes: 1. Labor pain is intense and often described as worse than other severe pains. Regional analgesia like epidurals are now considered the standard of care due to their safety and efficacy. 2. Non-pharmacologic methods for pain relief include childbirth education, hydrotherapy, positioning changes, and acupuncture, but they have limited effectiveness for severe labor pain. 3. Systemic opioids, inhaled gases, and some sedatives provide some analgesia but also cross the placenta and have potential neonatal effects. 4. Epidural and spinal analgesia/anesthesia allow effective pain relief with minimal fetal exposure but

1. OBSTETRIC ANALGESIA
Dr. Souvik Maitra, MD

2. • labor pain is one of the most intense pains that a
woman can experience, and it is typically worse
than a pain associated with a deep laceration.
• 60% of primiparous women described the pain
of uterine contractions as being “unbearable,
intolerable, extremely severe, or excruciating.”

3. Comparison of pain scores using the
McGill Pain Questionnaire

4. Mechanism of Labor Pain
First Stage of Labor
Pain Pathway in first stage
Parturients describe this pain as dull in nature and often poorly localized.

5. Mechanism of Labor Pain: Second Stage
• Activation of the same afferents activated
during the first stage of labor plus afferents that
innervate the vaginal surface of the cervix, the
vagina, and the perineum.
• Afferents course through the pudendal nerve
with DRG at S2-S4, and they are somatic in
nature.

6. Pain Pathways during Labor

7. Pain in labor – location and neural pathways
Site of Origin Cause Pathway Site of Pain
Uterus and cervix Contraction and distension
of uterus and dilatation of
cervix
Afférent T10 – L1
Post. Rami T10 – L1
Upper abdomen to
groin, mid back and
inner upper thighs
(referred pain)
Peri-uterine
tissue (mainly
posterior)
Pressure often associated
with occipito posterior
position and flat sacrum
Lumbo sacral plexus
L5- S1
Mid and lower back
and back of thighs
(referred pain)
Lower birth canal Distension of vagina and
perineum in second stage
Somatic roots S2- S4 Vulva, Vagina and
Perineum
Bladder Over distension Sympathetic T11-L2
Parasympathetic S2-S4
Usually suprapubic
Myometrium and
uterine visceral
peritonium
Abruption
Scar dehiscence
T10-L1 Referred Pain to site
of pathology

8. Effects of labor pain on mother
• Obstetric Course
• Neural stimulation through pain pathways results in
the release of substances that either drive (oxytocin)
or brake (epinephrine) uterine activity and cervical
dilation;
• effect of analgesia on the course of labor can vary
between individuals.

9. • Cardiac and Respiratory Effects
• The intermittent pain of uterine contractions also
stimulates respiration and results in periods of
intermittent hyperventilation. In the absence of
supplemental oxygen administration, compensatory
periods of hypoventilation between contractions result
in transient periods of maternal hypoxemia and, in
some cases, fetal hypoxemia.

10. • Psychological Effects
• Small proportion of women can be psychologically
harmed by either providing or withholding
analgesia
• Both individual and environmental influences upon
this meaning.

11. Effects of labor pain on fetus
• Labor pain affects multiple systems that
determine utero-placental perfusion:
• (1) uterine contraction frequency and intensity, by
the effect of pain on the release of oxytocin and
epinephrine;
• (2) uterine artery vasoconstriction, by the effect of
pain on the release of norepinephrine and
epinephrine; and
• (3) maternal oxyhemoglobin desaturation, which may
result from intermittent hyperventilation followed by
hypoventilation

12. Non Pharmacologic Methods of Labor Analgesia

13. Child birth preparation:
Psychoprophylaxis
• “Natural childbirth” stems from a phrase coined by
Grantley Dick-Read in 1933.
• This method focuses on teaching the mother
conditioned reflexes to overcome the pain and fear
of childbirth.
• It uses an education program, human support during
labor, breathing techniques, relaxation techniques of
voluntary muscles, a strong focus of attention, and
specific activities to concentrate on during
contractions to block pain.
• Presence of another woman during labor to support
the expectant mother has a positive effect on
outcomes, including the duration of labor.

14. Transcutaneous Electrical Nerve
Stimulation
• TENS is thought to reduce pain by nociceptive
inhibition at a presynaptic level in the dorsal horn by
limiting central transmission.
• Electrical stimulation preferentially activates low-
threshold myelinated nerves.
• Afferent inhibition effects inhibit propagation of
nociception along unmyelinated small c fibers by
blocking impulses to target cells in the substantia
gelatinosa of the dorsal horn.
• TENS enhances release of endorphins and
dynorphins centrally.
• Placement of electrode pads over the lower back
region in the distribution of T10-L1 may provide
some analgesia for parturients in early labor.

15. Therapeutic Use of Heat and Cold
• Temperature (hot or cold) applied to various
regions of the body in this method.
• Warm compresses may be placed on localized
areas, or a warm blanket may cover the entire
body.
• Icepacks may be placed on the low back or
perineum to decrease pain perception.
• The therapeutic use of heat and cold during
labor has not been studied in a rigorous
scientific manner.

16. Hydrotherapy
• Hydrotherapy involve a simple shower or tub
bath, or it include the use of a whirlpool or
large tub specially equipped for pregnant
patients.
• Benefits of hydrotherapy includes reduced pain
& anxiety, decreased BP & increased efficiency
of uterine relaxation.

17. Vertical Position
• The vertical position is associated with
decreased pain, especially in early labor.
• Length of labor is either unaffected or
decreased
• No difference in the incidence of instrumental
delivery.

18. Acupuncture/Acupressure
• Derived from traditional Chinese medicine.
• Effects on pain relieving is extremely variable
between different ethnic groups.
• It has not gained wide spread popularity and
hence not studied rigorously.

19. Systemic Medication for Labor Analgesia

20. Meperidine
• Meperidine is the most commonly used parenteral
opioid analgesic during labor.
• im dose ranges from 50 to 100 mg with a peak onset
of effect at 40 to 50 minutes
• iv doses of 25 to 50 mg start to act within 5 to 10
minutes.
• Analgesic effect lasts up to 3 to 4 hours.
• Fetal exposure to meperidine is highest between 2
and 3 hours after maternal administration.
• Meperidine is cause less respiratory depression in
the neonate than morphine does.
• It cause loss of beat-to-beat variability of FHR
tracings.

21. Fentanyl
• Short half-life makes fentanyl suitable for prolonged
use in labor, either as an intravenous bolus or as an
analgesic administered by means of a PCA delivery
system.
• It provides reasonable levels of analgesia with minimal
neonatal depression.
• The usual dose of fentanyl for labor analgesia is 25 to
50 µg intravenously.
• The peak effect occurs within 3 to 5 minutes and has a
duration of 30 to 60 minutes.

22. Remifentanil
• Potent, short-acting µ-opioid receptor agonist that has
a t1/2 of 1.3 min & prolonged administration does not
cause accumulation of this drug.
• PCA with intravenous remifentanil suggest that a
median effective bolus dose of 0.4 µg/kg with a
lockout time of 1 minute or a continuous infusion at
0.05 µg/kg/min with a bolus of 25 µg and a lockout
time of 5 minutes provides satisfactory labor analgesia.
• Fetal exposure to the drug is minimized because of its
rapid metabolism or redistribution, or both.
• It is an attractive alternative systemic analgesic in
parturients in whom regional anesthesia is
contraindicated.

23. Sedative-Tranquilizers
• Sedative-tranquilizers, e.g. barbiturates,
phenothiazines, hydroxyzine, and BZD, have
been used for sedation, anxiolysis, or both
during early labor and before cesarean delivery.
• Promethazine is the most commonly
administered phenothiazine in obstetrics. Used
with meperidine, given in doses of 25 to 50 mg
to prevent emesis. Its ability to potentiate the
analgesic effects of opioids, however, is in
doubt.

24. Ketamine
• Ketamine has been used in subanesthetic doses
(0.5 to 1 mg/kg or 10 mg every 2 to 5 minutes to a
total of 1 mg/kg in 30 minutes) during labor.
• ketamine in a dose of 25 to 50 mg can be used to
supplement an incomplete neuraxial blockade for
cesarean section.
• Its cause hypertension, tachycardia & emergence
reactions.
• High doses (>2 mg/kg) can produce psychomimetic
effects and increased uterine tone, which may
cause low Apgar scores and abnormalities in
neonatal muscle tone.

25. Inhaled Analgesia
• Inhaled analgesia can be defined as the administration
of subanesthetic concentrations of inhaled anesthetics
to relieve pain during labor.
• It has limited efficacy, not solely effective for most of the
mothers.
• Have a place as an adjunct to neuraxial techniques or in
parturients in whom regional anesthesia is not possible.
• Inhaled analgesics can be administered either
intermittently (during contractions) or continuously.
• They can be self-administered, but the patient should
have a health care provider present to ensure an
adequate level of consciousness and proper use of the
equipment.

26. Inhaled Analgesia
• Entonox (50 : 50 N2O/O2 mixture) can be used as sole
analgesic and an adjuvant to systemic and regional
techniques for labor.
• Side effects include dizziness, nausea, dysphoria, and lack
of cooperation.
• The maximum analgesic effect occurs after 45 to 60
seconds, and it is therefore important that the parturient
use Entonox at the early onset of her contractions and
discontinue its use after the peak of the contraction.
• Desflurane (0.2%), enflurane, and isoflurane (0.2% to
0.25%) have also been used to provide labor analgesia by
means of hypnosis.
• The major risk when using volatile analgesics is accidental
overdose resulting in unconsciousness and loss of
protective airway reflexes.

27. Regional Analgesia in Obstetrics

28. Central Neuraxial Blockade
• Epidural Analgesia
• Spinal Analgesia/ Anesthesia
• CESA

29. Epidural Analgesia/ Anaesthesia
• “in the absence of a medical
contraindication, maternal request is a
sufficient medical indication for pain
relief during labor”- ASA & ACOG join
declaration

30. Timing of Epidural Analgesia
• Controversy exists regarding when it is appropriate to
begin epidural analgesia during labor in an individual
patient.
• “Early” epidural analgesia (e.g., before 5 cm cervical
dilation) may interfere with uterine contractions and
slow the progress of labor.
• If a patient in early labor requests epidural analgesia,
first administer either a spinal or epidural opioid alone
or an epidural opioid combined with a very dilute
solution of LA

31. Contraindications
• Patient refusal or inability to cooperate
• Increased intracranial pressure secondary to a mass
lesion
• Skin or soft tissue infection at the site of needle
placement
• Frank coagulopathy
• Uncorrected maternal hypovolemia (e.g.,
hemorrhage)
• Inadequate training in or experience with the
technique

32. Preparation for Epidural/ Spinal
Analgesia
• The patient requests epidural analgesia for pain relief (or for
relief of anticipated pain ,planned induction of labor).
• Preanesthetic evaluation, which includes an assessment of the
patient's medical and anesthetic history.
• The risks of epidural analgesia are discussed with the patient,
and informed consent is obtained.
• The obstetrician is consulted to confirm the following:
 That the patient is in labor and the obstetrician is committed
to delivering the infant.
 That all relevant obstetric issues are understood (e.g.,
gestational age, intrauterine growth restriction, fetal
presentation, risk of obstetric hemorrhage, previous cesarean
delivery).
• An assessment of fetal well-being is performed in consultation
with the obstetrician.

33. Resuscitation Equipments
• DRUGS
• Thiopental
• Succinylcholine
• Ephedrine
• Atropine
• Epinephrine
• Phenylephrine
• Calcium chloride
• Sodium bicarbonate
• Naloxone
• EQUIPMENT
• Oxygen supply
• Self-inflating bag and mask for
positive-pressure ventilation
• Masks
• Oral and nasal airways
• Laryngoscopes
• Endotracheal tubes
• Suction (including the necessary
supplies)
• Intravenous catheters and
fluids
• Syringes and needles

34. Recommended Technique
• Informed consent is obtained, and the obstetrician is
consulted.
• Monitoring includes the following:
 Blood pressure every 1 to 2 minutes for 15 minutes after
giving a bolus of local anesthetic;
 Continuous maternal heart rate monitoring during
induction of anesthesia;
 Continuous fetal heart rate monitoring; and
 Continual verbal communication.
• Pre-hydration with 500 mL of Ringer's lactate solution.
• Lateral decubitus or sitting position.
• The epidural space is identified with a loss-of-resistance
technique.
• The epidural catheter is threaded 3 to 5 cm into the
epidural space.

35. Recommended Technique
• A test dose of 3 ml of 1.5% lidocaine with 1:200,000
epinephrine is injected after careful aspiration and after a
uterine contraction.
• If the test dose is negative, one or two 5-mL doses of 0.25%
bupivacaine are injected to achieve a cephalad sensory level of
approximately T10.
• After 15 to 20 minutes, the block is assessed by means of loss of
sensation to cold or pinprick.
• If no block is evident, the catheter is replaced.
• If the block is asymmetric, the epidural catheter is withdrawn 0.5
to 1.0 cm, and an additional 5 to 10 ml of the same bupivacaine
solution is injected.
• If the block remains inadequate, the catheter is replaced.

36. Recommended Technique
• The patient is cared for in the lateral or semilateral
position to avoid aortocaval compression.
• Subsequently, maternal blood pressure is measured
every 5 to 15 minutes.
• The fetal heart rate is monitored continuously.
• The level of analgesia and the intensity of motor block
are assessed every 1 to 2 hours.

37. Maintenance of Epidural Analgesia
INTERMITTENT BOLUS INJECTION
• Single epidural injection of LA
does not provide adequate
analgesia for the duration of
labor.
• Exclude migration of the
epidural catheter into a blood
vessel or the subarachnoid
space.
• After several injections,
blockade of the sacral segments,
intense motor block, or both
may develop.
• Sensory level and the intensity
of motor block should be
assessed and recorded before
and after each bolus injection of
local anesthetic.
CONTINUOUS EPIDURAL INFUSION
• Benefits include:(1) the
maintenance of a stable level
of analgesia;
• stable maternal heart rate and
blood pressure, & decreased
risk of hypotension;
• less frequent need to give
bolus doses of LA, which
reduce the risk of LAST.
• continuous epidural infusion
technique does not obviate the
need for frequent assessment
of the patient.

38. Recommended Regimen for Epidural
Drug Intermittent injection Continuous infusion
Bupivacaine 5-10 mL of a 0.125%-
0.375% solution every
60-120 min
0.0625%-0.25%
solution given at a
rate of 8-15 mL/hr
Ropivacaine 5-10 mL of a 0.125%-
0.25% solution every
60-120 min
0.125%-0.25%
solution given at a
rate of 6-12 mL/hr
Lidocaine 5-10 mL of a 0.75%-
1.5% solution every
60-90 min
0.5%-1.0% solution
given at a rate of 8-
15 mL/hr

39. Patient Controlled Epidural Analgesia
• With this technique, each patient can adjust her level
of analgesia.
• PCEA has been associated with greater maternal
satisfaction as compared with both intermittent bolus
injectionand continuous epidural infusion.
• PCEA results in a lower average hourly dose of
bupivacaine than does a continuous epidural infusion
of bupivacaine.
• Reserved for patients who are willing and able to
understand that they are in control of their analgesia.

40. Regimens of PCEA
Anesthetic solution Basal infusion
rate
(mL/hour)
Bolus dose (mL) Lockout interval
(minutes)
Maximum
hourly dose (mL)
Bupivacaine, 0.125% 4 4 20 16
Bupivacaine,
0.125%, plus
fentanyl, 2 μg/mL
6 3 10 24
Bupivacaine, 0.25% 0 3 5–20 12
Bupivacaine, 0.11%,
plus fentanyl, 2
μg/mL
10 5 10 30
Bupivacaine,
0.0625%, plus
fentanyl, 2 μg/mL,
plus clonidine, 4.5
μg/mL
0 4 15 16
Ropivacaine, 0.125% 6 4 10 30

41. Analgesia for Second stage of labor
• Require a more concentrated solution and/or a greater
volume of LA than is required during the first stage of
labor.
• The continuous epidural infusion of bupivacaine often
results in the gradual development of sacral analgesia.
• Additional bolus doses of LA can be required to augment
perineal analgesia.
• Administration of a larger volume of LA solution
facilitates the onset of sacral analgesia. This also results
in a higher (i.e., more cephalad) sensory level of
analgesia, and the patient should be observed for
evidence of hemodynamic or respiratory compromise.

42. Analgesia in advanced labor
• Advanced labor does not preclude the placement of a
lumbar epidural catheter, especially in a nulliparous
woman.
• Another option is to administer combined spinal-
epidural (CSE) analgesia.
• A caudal epidural catheter, which facilitates the onset of
sacral analgesia, is an option for analgesia late in labor.
Disadvantages are(1) increased technical difficulty; (2)
increased LA dose requirement during the first stage;
and (3) the risk of injecting the LA into the fetus.
• Sacral analgesia adequate for labor and delivery can be
achieved with an injection of 12 to 15 mL of 0.25%
bupivacaine, 1.0% to 1.5% lidocaine.

43. Spinal Analgesia/ Anesthesia
• Not very effective in laboring women.
• A single-shot injection has a finite duration, and multiple
injections result in an increased risk of PDPH.
• Single subarachnoid injection of an opioid may be
appropriate.
• A “saddle block” can be administered to achieve
blockade of the sacral spinal segments; a small dose of a
hyperbaric local anesthetic solution is adequate for this
purpose.
• Placement of a catheter in the subarachnoid space is not
recommended by US FDA

44. Complications
• Hypotension (Incidence 17-20%)
• Inadequate Analgesia (0.5-1.5%)
• Intravascular Injection of Local Anesthetic
• Unintentional Dural Puncture (1-7.6%)
• Unexpected High Block
• Subdural injection of a local anesthetic (0.82%)
• Extensive Motor Block
• Urinary Retention
• Back Pain: prospective studies have consistently shown
that no causal relationship exists between the use of
epidural analgesia and the development of long-term
postpartum backache.
• Pelvic Floor Injury

45. Neonatal Outcome
• Newborns whose mothers received epidural analgesia
had higher pH measurements and less metabolic
acidosis in the first hour of life as compared with
newborns whose mothers received systemic opioid
analgesia.
• No difference in neonatal outcome (as assessed by
Apgar scores and umbilical cord blood pH
measurements).
• No difference in long term neonatal outcome.

46. “Expectant mothers can be reassured that, although
epidural analgesia may be associated with some
short term maternal side effects, it does not
exacerbate fetal acidosis, and if anything, may
partially protect the fetus from fetal hypoxia. It is
important to dispel the notion that epidural
analgesia is in some way harmful to babies.”- Reynolds
F, Sharma SK, Seed PT: Analgesia in labor and fetal acid-base balance: A meta-
analysis comparing epidural with systemic opioid analgesia. BJOG 2002; 109:1344-
1353.

47. Neuraxial Opioid
• Opioids block the transmission of pain-related
information by binding at presynaptic and
postsynaptic receptor sites in the dorsal horn of the
spinal cord (i.e., Rexed laminae I, II, and V), and in the
brainstem nuclei, periventricular gray matter, medial
thalamus.
• They are associated less adverse effects than systemic
use

48. Epidural Opioid
• Opioid and a LA are given epidurally, they interact
synergistically to provide effective pain relief.
• Epidural administration of an opioid alone provides
moderate analgesia during early labor, but the dose
needed to maintain analgesia is accompanied by
significant side effects.
• Epidural opioid alone provides inadequate analgesia
during the advanced phase of the first stage of labor &
during the second stage.

49. OPIOIDS USED TO PROVIDE EPIDURAL
ANALGESIA DURING LABOR
Drugs Dose Onset (Minutes) Duration (hours)
Morphine 3–5 mg 30–60 4–12
Pethidine 25–50 mg 5–10 2–4
Butarophanol 2–4 mg 10–15 6–12
Fentanyl 50–100 μg 5–10 1–2
Sufentanil 5–10 μg 5–10 1–3

50. INFUSION REGIMENS FOR CONTINUOUS
EPIDURAL ANALGESIA DURING LABOR
Drug Bupivacaine-fentanyl Bupivacaine-
butorphanol
Bupivacaine-
sufentanil
Loading dose
Bupivacaine 0.125%–0.25% 0.125%–0.25% 0.125%–0.25%
Opioid 2µg/ml 2.5–5 μg/mL 0.2 mg/mL
Volume 10–15 mL 10–15 mL 10–15 mL
Infusion
Bupivacaine 0.125%–0.25% 0.0625%–0.125% 0.0625%–0.125%
Opioid 1µg/ml 1–2 μg/mL 0.1 mg/mL
Rate 10–15 mL/hr 10–15 mL/hr 8–12 mL/hr

51. Intrathecal Opioids
• rapid onset of pain relief
• have a predictable duration of action
• minimize undesirable side effects (e.g., motor block,
hypotension)
• preserve proprioception
• have no effect on the fetus
• Intrathecal opioids alone provide effective analgesia
during early labor but they do not provide effective
analgesia during advanced labor.

52. Intrathecal Opioid: Regimen
Drug Dose
Morphine 0.25–0.3 mg
Fentanyl 15–30 μg
Sufentanil 5–10 μg
Meperidine 10 mg

53. Complications of Neuraxial Opioid
• Pruritus
• Neurotoxicity
• Sensory Changes
• Hypotension
• Nausea and Vomiting
• Respiratory Depression
• Delayed Gastric Emptying
• Recrudescence of Herpes Simplex Viral
Infection
• Postdural Puncture Headache

54. Fetal Effects of Opioid
• Direct fetal effects may include intrapartum
effects on the FHR as well as possible
respiratory depression after delivery.
• Indirect fetal effects include fetal bradycardia.
• Fetal bradycardia after labor analgesia does
not appear to have a detrimental effect on the
outcome of labor.

55. Effects of analgesia on labor
• Epidural analgesia to reduce uterine activity in some
patients, but it results in enhanced uterine activity in
others.
• Duration alone is of little significance if labor pain is
adequately controlled and fetal/neonatal well-being is
preserved.
• Maintenance of total anesthesia prolongs the second
stage of labor.
• Use of epidural analgesia results in a small increase in
the cesarean section rate.

56. Effects of analgesia on labor
• Administration of a dilute solution of LA results
in fewer cases of malposition of the vertex and
fewer instrumental vaginal deliveries than
administration of a more concentrated
solution.
• Epidural analgesia was not associated with a
prolonged third stage of labor.

57. Peripheral Nerve Blocks
• In first stage of labor:
1. Paracervical block
2. Lumbar sympathetic block
• In second stage of labor:
1. Pudendal nerve block

58. Paracervical Block
• This nerve plexus lies lateral & posterior to the junction
of uterus & cervix, at the base of broad ligament.
• Patient position: Lithotomy with left uterine
displacement.
• Timing: First stage of labor, before the cervix is dilated 8
cm.
• Equipments: 12-14cm 22G needle/ Kobak needle with
Iowa trumpet.
• Technique: Index & middle finger of right hand introduce
the needle into the lateral fornix for the right side & vice-
versa in the left, with lateral diversion, the after
aspiration deposit 10ml LA just beneath the epithelium.

59. Paracervical Block
• Site of drug deposition:
• Two 10ml at 3 & 9 o’clock cervical position
• 3-5ml LA at four sites ( 4,5,7,8 o’clock position)
• Six different injections, 3ml each
• Contralateral injection should be given after 5 min or two
uterine contraction.
• Onset usually within 5 minute, failure rate between 5-13%
• Lignocaine without adrenalin is the most preferred drug.
Bupivacaine is NOT recommended for this block.
• Complications include broad ligament hematoma, sciatic
nerve block, parametritis, subgluteal & retropsoal
abscess, neuropathy and LAST

60. Lumbar Sympathetic Block
• Paravertebral lumbar sympathetic block interrupts
the transmission of pain impulses from the cervix and
lower uterine segment to the spinal cord.
• Lumbar sympathetic block provides analgesia during
the first stage of labor but does not relieve pain
during the second stage.
• It provides analgesia comparable to that provided by
paracervical block but with less risk of fetal
bradycardia.

61. Lumbar Sympathetic Block
• Technique
• Patient in the sitting position
• 10-cm, 22-gauge needle is used to identify the
transverse process on one side of the second lumbar
vertebra. The needle is then withdrawn, redirected, and
advanced another 5 cm so that the tip of the needle is
at the anterolateral surface of the vertebral column, just
anterior to the medial attachment of the psoas muscle.
• Two increaments of 5ml LA solution on each side of
vertebral column after careful negative aspiration.
• Modest hypotension occurs in 5% to 15% of patients.

62. Pudendal Nerve Block
• The pudendal nerve(S2-4) represents the primary source of
sensory innervation for the lower vagina, vulva, and
perineum. It also provides motor innervation to the perineal
muscles and to the external anal sphincter.
• Effective in relieving second stage labor pain.
• Technique: Transvaginal (More popular)
• A needle and needle guide is introduced into the vagina
with the left hand for the left side of the pelvis and with
the right hand for the right side. The needle is
introduced through the vaginal mucosa and
sacrospinous ligament, just medial and posterior to the
ischial spine. The pudendal artery lies in close proximity
to the pudendal nerve; thus the one must aspirate
before and during the injection of LA.

63. Pudendal Nerve Block
• A 7-10 ml LA is sufficient.
• A diluted solution of any LA is safe & effective.
• Maternal complications are uncommon, but can be
Laceration of the vaginal mucosa, Vaginal and
ischiorectal hematoma, Retropsoal and subgluteal
abscess & LAST.
• Fetal complications are rare. The primary fetal
complications result from fetal trauma and/or direct
fetal injection of local anesthetic.

64. Postoperative Analgesia after LUCS
• Epidural analgesia: Epidural opioid, LA or
LA+Opioid
• Intrathecal opioid
• Systemic analgesic
• Peripheral nerve block

65. Opioids in Postoperative Analgesia
• Opioids can be given as intermittent im or iv
injection or continuous iv infusion.
• PCA can also be an attractive options for those
who are willing & educated.
• Most important concern is the neonatal
effects of opioids that secreted in breast milk.

66. Opioids & Lactation
Analgesic Category Milk: plasma ratio Newborn tolerance
Butorphanol 3 1.9 (oral) 0.7
(intramuscular)
No reports of adverse effects
Codeine 3 2.5 Possible accumulation
Fentanyl 3 > 1 Well tolerated
Heroin 3 > 1 Possible addiction
Hydromorphone — No data No data
Meperidine 3 1.4 Prolonged half-life
Methadone 3 0.83 CAUTION: Withdrawal symptoms
possible with abrupt cessation
Morphine 3 0.23–5.07 Possible accumulation
Nalbuphine — No data No data
Oxycodone — 3.4 Periodic sleeplessness; failure to
feed
Oxymorphone — No data No data
Pentazocine — Minimal excretion No data
Propoxyphene 3 0.50 Poor muscle tone reported

67. • The effects of maternal medication can be
minimized by giving attention to the following
principles:
• (1) avoiding the administration of drugs with a
long plasma half-life;
• (2) when possible, delaying drug administration
until just after an episode of breast-feeding;
• (3) observing the neonate for abnormal signs or
symptoms (e.g., change in feeding or sleep
patterns, somnolence, decreased muscle tone,
increased irritability);
• (4) when possible, choosing drugs that have the
least potential for excretion into breast milk and
accumulation in the neonate or that are known to
be tolerated by the newborn.

68. “The American Academy of Pediatrics Committee
on Drugs lists butorphanol, codeine, fentanyl,
methadone, and morphine as maternally
administered opioids that typically are
compatible with breast-feeding.”- American Academy of
Pediatrics Committee on Drugs.: The transfer of drugs and other
chemicals into human milk. Pediatrics 2001; 108:776-789

69. NSAID
• They reduce opioid consumption by the
patient.
• NSAIDs reduce the inflamatory pain.
• Acitamenophen, Ibuprofen, Aspirin,
Ketorolac & Diclofenac are designated as
Category 3 drug by AAP, so they are well
tolerated.

70. Adjunctive Peripheral Nerve Blocks
• Rectus sheath block
• Bilateral ilioinguinal & iliohypograstic nerve
block
• Bilateral transversus abdominis plane block

71. Thank you