The document outlines pain management principles especially in maternity care, emphasizing the importance of pain assessment and the subjective nature of pain experiences. It details different types of pain (nociceptive, neuropathic, mixed) and corresponding treatment guidelines based on pain intensity using a tiered approach to analgesics. Furthermore, it discusses specific considerations such as post-spinal puncture headache and their management within the context of obstetric patients.

1. PAIN MANAGEMENT – DEC 2018
MATERNITY
DASHT-E BARCHI
Dr. Sandro Zorzi
References:
- Clinical guidelines 2016
- MSF protocols
- Review: Post spinal puncture headache, an old problem and new concepts: review of
articles about predisposing factors Caspian J Intern Med 2013; 4(1): 595-602
- OAA PDPH guideline 2014 - Stevenage

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WHAT IS PAIN?
Pain results from a variety of pathological processes and is considered as
a vital sign.
It is expressed differently by each patient depending on cultural
background, age, etc,etc.
IT IS A HIGHLY SUBJECTIVE EXPERIENCE MEANING THAT ONLY THE
INDIVIDUAL IS ABLE TO ASSESS HIS/HER LEVEL OF PAIN.
Regular assessment of the intensity of pain is indispensable in
establishing effective treatment.
The International Association for the Study of Pain defines pain as “an
unpleasant sensory and emotional experience” associated with actual or
potential tissue damage.

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PAIN ASSESSMENT:
Pain management is essential in the taking care of all patients, including in
case of emergencies.
Efficient pain management can only be accomplished with an efficient pain
evaluation BEFORE and AFTER the administration of pain killers. The
assessment consider:
- Intensity: use a simple verbal scale in children over 5 years and adults,
and NFCS or FLACC scales in children less than 5 years (see pain rating
scales on following page).
- Pattern: sudden, intermittent, chronic; at rest, at night, on movement,
during care procedures, etc.
- Character: burning, cramping, spasmodic, radiating, etc.
- Aggravating or relieving factors.

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PAIN ASSESSMENT:
- Clinical examination
Of the organ or area where the pain is located.
Specific signs of underlying disease (e.g. bone or osteoarticular pain may
be caused by a vitamin C deficiency) and review of all systems.
– Associated signs (fever, weight loss, etc.).These are the
recommended simple tools for pain evaluation:
The synthesis of information gathered during history taking and clinical
examination allows aetiological diagnosis and orients treatment. It is
important to distinguish between:
– Nociceptive pain
– Neuropathic pain
– Mixed pain

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PAIN ASSESSMENT:
– Nociceptive pain: it presents most often as acute pain and the cause-effect
relationship is usually obvious (e.g. acute post-operative pain, burns, trauma, renal
colic, etc.). The pain may be present in different forms, but neurological exam is
normal. Treatment is relatively well standardized.
– Neuropathic pain, due to a nerve lesion (section, stretching, ischaemia): most often
chronic pain. On a background of constant, more or less localized pain, such as
paraesthesia or burning, there are recurrent acute attacks such as electric shock-like
pain, frequently associated with disordered sensation (anaesthesia, hypo or
hyperaesthesia). This type of pain is linked to viral infections directly affecting the
CNS (herpes simplex, herpes zoster), neural compression by tumors, post- amputation
pain, paraplegia, etc.
– Mixed pain (cancer, HIV) for which management requires a broader approach.

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PAIN EVALUATION SCALES:

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The treatment of pain is based on a few fundamental
concepts:
– Pain can only be treated correctly if it is correctly evaluated. The only person who can
evaluate the intensity of pain is the patient himself. The use of pain assessment scales is
invaluable.
– The pain evaluation observations should be recorded in the patient chart in the same
fashion as other vital signs.
– Treatment of pain should be as prompt as possible.
– It is recommended to administer analgesics in advance when appropriate (e.g. before
painful care procedures).
– Analgesics should be prescribed and administered at fixed time intervals (not on demand).
– Oral forms should be used whenever possible.
– The combination of different analgesic drugs (multimodal analgesia) is advantageous.
– Start with an analgesic from the level presumed most effective: e.g., in the event of a
fractured femur, start with a Step 3 analgesic.
– The treatment and dose chosen are guided by the assessment of pain intensity, but also by
the patient’s response which may vary significantly from one person to another.

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TREATMENT:
Treatment depends on the type and intensity of the pain. It may be both aetiological and
symptomatic if a treatable cause is identified. Treatment is symptomatic only in other cases
(no cause found, non-curable disease).
Nociceptive pain---→ TRAUMA PATIENTS
The WHO classifies analgesics used for this type of pain on a three-step ladder:
– Step 1/MILD PAIN: non-opioid analgesics such as paracetamol and nonsteroidal anti-
inflammatory drugs (NSAIDs).
– Step 2/MODERATE PAIN: weak opioid analgesics such as codeine and tramadol. Their
combination with one or two Step 1 analgesics is recommended.
– Step 3/SEVERE PAIN: strong opioid analgesics, first and foremost morphine. Their
combination with one or two Step 1 analgesics is recommended.

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THERAPY:

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THERAPY:

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….AND PREGNANCY?

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PHARMACOLOGY OF LEVEL 1 PAINKILLERS

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PHARMACOLOGY OF LEVEL 2 PAINKILLERS

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PHARMACOLOGY OF LEVEL 3 PAINKILLERS

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PAIN ≠ NOCICEPTION
What is the difference?
- Pain is a product of higher brain center processing of signals it has
received.
- Nociception refers to the peripheral and central nervous systems
processing information generated by stimulation of nociceptors by
noxious stimuli.
- Nociception can occur in the absence of pain.

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NOCICEPTION AND DRUGS...?
- Transduction: noxious stimulus is translated into electrical activity at
sensory nerve endings.
Medications that alter transduction: COX-2 inhibitors, local anesthetics,
NSAIDs
- Transmission: propagation of action potential along spinothalamic
pathway.
Medications that alter transmission: local anesthetics
- Modulation: dampening or amplifying of pain signal along the pathway.
Medications that alter modulation: clonidine, dexmedetomidine, opioids
- Perception: subjective sensation of pain.
Medications that alter perception: acetaminophen, alpha-2
agonists,ketamine, pregabalin

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WHERE WE TREAT THE PAIN?

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POSTOPERATIVE C-SECTION...
Compulsory use of auto evaluation scale. → only the patient knows his/her pain!!
Systematic prescription of analgesics (at fixed time).
Oral route as much as possible.
Avoid NSAID in case of risk of renal function disturbance and impaired coagulation
(sepsis, pre eclampsia).
■ D0 – D5 : Paracetamol: 1 g / 6 h
■ D0 – D3 : NSAID Ibuprofen: 400 mg / 8
■ D0 – D1 : Tramadol: 50 mg / 8 h
Adapt according to a systematic and regular auto evaluation of the pain.
If necessary, Morphine 10 mg every 4 hours could be added.
Finally, infiltration of the scar by the surgeon at the end of the procedure with Levobupivacaine 0,5%
(max. dose 2 mg / kg; max. 150 mg or max. 30 ml), can provide analgesia in the initial 4 to 8 hours.
○

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FOR C-SECTION....WHAT’S PSPH?
Postspinalpuncture headache (PSPH) is one of the most common complications of spinal
anesthesia. Advances in needle design and gauge, as well as a better understanding of the
physiologic mechanism of PSPH, have dramatically reduced the incidence of PDPH
associated with spinal anesthesia, even in the obstetric population. However, the
incidence of PDPH after epidural anesthesia in obstetric patients remains unchanged, with
incidence of headaches ranging from 0% to 36% of cases.
The typical feature of PSPH is the postural character of the dull pain in a frontal-occipital
distribution, which is when the individual assumes an upright position. Any movements
that increase intracranial pressure (such as coughing, sneezing, straining, or ocular
compression) may exacerbate symptoms.
The onset of PSPH may be immediate or delayed for several days, presumably depending
on the rate of cerebrospinal fluid (CSF) leakage. The symptoms of PSPH start within 5 days
of dural puncture in 90% of cases. The duration of PSPH is usually self-limiting to
approximately 5-7 days.The onset of PSPH may be immediate or delayed for several days,
presumably depending on the rate of cerebrospinal fluid (CSF) leakage. The symptoms of
PSPH start within 5 days of dural puncture in 90% of cases. The duration of PSPH is
usually self-limiting to approximately 5-7 days.

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DIFFERENTIAL DIAGNOSIS OF PSPH
Exacerbation of symptoms with the upright position does not occur with other forms of
postpartum headache except pneumoencephalus.
Other conditions that may cause postpartum headache are:
1. Non-specific postnatal headache.
2. Migraine (history of migraine,unilateral pulsatile headache, associated with vasomotor
signs).
3. Pre-eclampsia (recent labour complicated with condition up to 10 days postpartum).
4. Septic and aseptic meningitis (increasing headache,nausea, vomiting &neck stiffness).
5. Intracranial haemorrhage/mass lesion (signs of intracranial hypertension).
6. Cerebral vein thrombosis (a headache of increasing intensity,convulsions,Intracranial
hypertension, deteriorating consciousness and fever. MRI and MRA are diagnostic).
7. Postnatal depression headache.
8. Pneumoencephalus (sudden headache, due to injection of air in the subdural or
subarachnoid space, associated with epidural using loss of resistance to air technique.
Headache is worse in sitting position and relieved by lying down. It disappears after few
hours).

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PSPH MANAGEMENT
PREVENTION IS POSSIBLE?
Prevention of PDPH relies on the education of anesthesia providers regarding the factors
influencing its incidence. There is a strong link between onset of headache and:
● needle gauge: small is better
● age: young patients are at greatest risk of PSPH, as their greater dural elasticity
maintains a patent defect compared with the less elastic dura of the elderly
● sex: female more affected
● pregnancy: more affected, up to 40%!!!
● bevel design: pencil point is better
● bevel orientation: vertically oriented is better
● experience of the operator
● number of attempts
● obesity: lower Body mass index (BMI) has been shown to be associated with higher
risk of PSPH
● hydratation: dehydration makes symptoms worse
● level of puncture: different studies showed that PSPH was more frequent when L4-L5
was chosen than L3-L4 and explained by pressure of CSF

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PSPH TREATMENT:
1. All cases of suspected PDPH should be discussed with a consultant anaesthetist as
soon as possible.
2. Patients with recognised accidental dural puncture should be reviewed daily by an
obstetric anaesthetist.
3. Assess severity, onset and duration of PDPH once a diagnosis is reached.
4. Discuss with the patient the available treatment modalities and its success rates.
Conservative measures, including bed rest and oral hydration, remain popular therapies
for PDPH like somministration of NSAIDS ATC, caffeine. Obstetric patients should be
encouraged to mobilize soon after delivery for early diagnosis and treatment while the
patients are yet in the hospital. 72% of PDPH will resolve spontaneously within seven
days.
→ CAFFEINE: Since PDPH results in part from dilation of the intracranial veins, caffeine, a
cerebral vasoconstrictor, has been found in some studies to be an effective therapy in
some cases. The dose recommended for PDPH is 300-500mg oral or IV once or twice daily.
A 200 ml cup of brewed coffee : 160mg. A 200ml cup of instant coffee: 120mg. A shot of
espresso: 100mg. A cup of tea: 40mg. A can of red bull: 80mg. A can of coke: 35mg.

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QUESTIONS?