PAIN AND PAIN RELIEF IN LABOUR

DR CHAITRA.C.RAO

Anesthesia la Reine

John Snow (1853) on Queen Victorias Anesthetic for the birth of Prince Leopold
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.

Pain during labor and delivery

The way pain is experienced is a reflection of the individuals emotional, motivational, cognitive, social, and cultural circumstances Pain of childbirth is likely to be the most severe pain that a woman experiences during her lifetime. Pain varies among women, and each labor of an individual may be different

Pain pathway in Labour

The afferent nerve of the uterus and cervix is via A delta and C fibers, that accompany the thoraco lumbar and sacral dorsal sympathetic chains. - Pain in first stage mediated through (T10 - L1 ) - In the second stage mediated through (S2 S4 )

PATHOPHYSIOLOGY OF PAIN

Pain Pathways 1st stage

Visceral/cramping pain during contractions
Originates in the uterus and cervix Produced by distention of uterine/cervical

mechanoreceptors and by ischemia of the uterine/cervical tissues

Pain Pathways 1st stage

Signal enters spinal cord from T10-L1 Labor pain is referred to areas of skin supplied by those nerve roots, affecting: the abdominal wall, lumbosacral region, iliac crests, gluteal areas, and thighs

nd Pain Pathways 2 stage

Somatic pain from distention of the vagina, perineum and pelvic floor Stretching of the pelvic ligaments S2-S4 (pudendal nerve) More severe than first stage Combination of

Visceral pain from contractions Cervical stretching Somatic pain from distention Rectal pressure

Adverse Consequences of Labor Pain

Hyperventilation

Respiratory alkalosis could

decrease ventilatory drive between contractions impair oxygen transfer to fetus (left shift of oxyhemoglobin dissociation curve) Uteroplacental vasoconstriction

Neurohumoral Effects

Increase in catecholamines and decrease in blood flow to the uterus, lowering fetal oxygenation, increasing bradycardia and acidosis Unrelieved pain may cause postpartum psychological trauma, that could result in PTSD (prevalence of postpartum PTSD found to be 5.6%)

Psychological Effects

Potential effects of maternal hyperventilation and subsequent hypocarbia on oxygen delivery to the fetus

The Ideal Analgesic for Labour

Should provide excellent rapid onset pain relief in both first and second stages .
Without side effects to the mother or fetus. Should not effect the ability of mothers power and movement during labour.

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

Approaches to management of labor pain

Women should be involved in the decisionmaking process
Can be accomplished by educating women about pain relief techniques Providing education BEFORE labor commences (rational decision-making is compromised at times of emotional and physical stress)

Approaches to management of labor pain

Pharmacologic eliminate physical sensation of labor pain

Non-pharmacologic prevent sense of suffering

Pharmacologic management of pain

Introduced in the mid-nineteenth century
Controversial-many believe that labor pain is a natural and necessary accompaniment of childbirth

Medically unusual scenario: no other circumstance in which it is considered acceptable to experience severe, pharmacologically relievable pain, while under direct medical care
Therefore, ACOG supports the concept that MATERNAL REQUEST alone is a sufficient medical indication for labor analgesia

Pharmacologic options
Systemic analgesics
Opioids, Opioids with mixed agonist-antagonist properties, PCA, Nonopioid agents, Inhalation agents

Local injection techniques

Pudendal, Paracervical block

Neuraxial analgesia
Epidural and spinal techniques

TECHNIQUES OF LABOR ANALGESIA

Entonox (50% Nitrous oxide + 50% Oxygen) Isonox (50% Nitrous oxide + 50% O2 + 0.2% Isoflurane). Sevonox (0.8%) IV PCA Remifentanil

TECHNIQUES OF LABOR ANALGESIA

Continuous epidural analgesia Patient-controlled epidural analgesia (PCEA) Combination of the above two techniques Combined spinal-epidural analgesia (CSE) Spinal opiates Intermittent epidural bolus injections Continuous spinal analgesia

Adverse Effects of Parenteral Opioids

Nitrous oxide
Nitrous oxide has been used in obstetric practice for over a century and a survey in 1990 demonstrated its availability in 99% of UK obstetric units and use by 60 % of parturients. Entonox (50 % nitrous oxide in oxygen) provides analgesia within 20-30 seconds of inhalation with a maximum effect after about 45 seconds.

Nitrous oxide
Advantages Ease of use No requirement for physician supervision Minimal accumulation with intermittent use Self-administration provides some control.

Nitrous oxide
Disadvantages
Drowsiness, disorientation and nausea may occur including brief episodes of loss of consciousness (observed in 0.4% of cases after prolonged use) Does not provide complete analgesia.

Nitrous oxide
Efficacy of inhaled nitrous oxide for labour pain much debated Does not provide complete analgesia for many Nitrous oxide remains a useful analgesic modality for labour pain and is especially beneficial in units where other analgesic options are limited.

REMIFENTANIL IV PCA
Remifentanil is a novel , ultra short acting synthetic opioid. Selective mu opioid agonist. Rapid onset; peak effect of blood/brain equilibration time (1.2 1.4 min) . It has ester linkage rendering it susceptible to rapid metabolism by non specific blood and tissue esterases. A short duration of action independent of duration of infusion ( context sensitive half time 3.7 minutes).

LOCAL ANAESTHETICS

CHOICE OF LOCAL ANESTHETIC

IDEAL 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

LOCAL ANESTHETICS
BUPIVACAINE Onset 8-10 min Duration 2 hrs, dilute solution-no motor block, Tachyphylaxis-rare Umbilical vein/maternal vein ratio 0.3 ROPIVACAINE Less cardio-depressant and arrythmogenic than bupivacaine Rapid Clearance 40% less potent, equipotent doses (0.0625% bupivacaine0.1% ropivacaine), probably no advantage in terms of toxicity Longer duration of action, ? Less motor block

LOCAL ANESTHETICS

Levobupivacaine: Levorotatory enantiomer of racemic bupivacaine

Lidocaine May not provide analgesia comparable to bupivacaine umbilical vein/ maternal vein ratio: twice than bupivacaine

Others 2 Chloroprocaine chloroprocaine

UV/MV Fetal-Maternal Drug Ratios

Bupivacaine: Mepivacaine: Lidocaine: 0.25-0.3 0.7 0.5

Correlates with degree of protein binding, but may not reflect total amount of drug in fetus because of high lipid solubility leading to significant tissue uptake

LOCAL ANESTHETICS
CONTINUOUS INFUSION Bupivacaine 0.0625%-0.25%-8 -15 ml/hr Ropivacaine: 0.125%-0.25%- 6 -12 ml/hr Lidocaine: 0.5%-1% -8-15 ml/hr

2-chloroprocaine 0.75% -27 ml/hr

INTERMITTENT BOLUS

Bupivacaine: 0.125%-0.375%, 5-10 ml, Duration:1-2 hr

Ropivacaine: 0.125%-0.25%, 5-10 ml, Duration: 1-2 hr Lidocaine: 0.75%-1.5%, 5-10 ml, Duration: 1-1.5 hr 2 chloroprocaine 1-2%, 5-10 ml, Duration: 0.75-1 hr

Epinephrine Use in Labor

May transiently slow labor

Increases motor block

Improves analgesia ( 1:600K works) 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.

Systemic analgesics

Opioids
Morphine Fentanyl Meperidine

Mixed opioid agonists-antagonists

Nalbuphine Butorphanol

NEURAXIAL ANALGESIA

The anesthesiologist should conduct a focused history and physical examination The anesthesiologists decision to order or require a platelet count should be individualized Patients in early labor (i.e., 5 cmdilation) should be given the option of neuraxial analgesia when this service is available should not be withheld on the basis of achieving an arbitrary cervical dilation, and should be offered on an individualized basis.

Guidelines
Neuraxial Analgesia and Trial of Labor after Previous Caesarean Delivery
It is appropriate to consider early placement of a neuraxial catheter that can be used later for labor analgesia or for anesthesia in the event of operative delivery

Guidelines
Early Insertion of a Spinal or Epidural Catheter for Complicated Parturients
obstetric (e.g., twin gestation or preeclampsia) or anesthetic indications (e.g., anticipated difficult airway or obesity) should be considered to reduce the need for GA if an emergent procedure becomes necessary

Guidelines
Single-injection Spinal Opioids with or without Local Anesthetics
Single-injection spinal opioids with or without local anesthetics may be used to provide effective although time-limited, analgesia for labor when spontaneous vaginal delivery is anticipated Pencil-point spinal needles should be used

Combined SpinalEpidural Analgesia

Rapid and Effective analgesia

Guidelines
Combined SpinalEpidural (CSE)Anesthetics
CSE techniques may be used to provide effective and rapid analgesia for labor

Patient-controlled Epidural Analgesia (PCEA).

PCEA may be used to provide an effective and flexible approach for the maintenance of labor analgesia PCEA may be preferable to CIE for providing fewer anesthetic interventions,reduced dosages of local anesthetics, and less motor blockade than fixed-rate continuous epidural infusions PCEA may be used with or without a background infusion

NEURAXIAL OPIOIDS
SIDE EFFECTS
Pruritus, Nausea and vomiting, Hypotension, Respiratory depression (first two hrs-fentanyl, sufentanil; up to 16

hrs with morphine)

Urinary retention, Delayed gastric emptying, Reactivation of herpes simplex virus Fetal bradycardia from uterine hyperstimulation (no increased incidence of cesarean section)

EPIDURAL ANALGESIA
ADVANTAGES Provides excellent pain relief reducing maternal catecholamines Decreases maternal hyperventilation Ability to extend the duration of block to match the duration of labor

Facilitates delivery of twins, delivery of preterm infants and vaginal breech delivery
Blunts hemodynamic effects of uterine contractions: beneficial for patients with preeclampsia, mitral stenosis, spinal cord injury, intracranial neuro-vascular lesions.

Influence of epidural analgesia on maternal plasma concentrations of catecholamines during labor. Modified from Shnider SM et al. Maternal catecholamines decrease during labor after lumbar epidural analgesia. Am J Obstet Gynecol 1983;147:13-5.

EPIDURAL ANALGESIA

EPIDURAL ANALGESIA
DISADVANTAGES Not instant in onset May be associated with motor block Postdural puncture headache (50-85% with 16 or 18-G Tuohys needle)

EPIDURAL ANALGESIA
CONTINUOUS EPIDURAL INFUSION Maintenance of stable level of analgesia More stable maternal heart rate and blood pressure with decreased risk of hypotension Studies suggest administration of greater dose of local anesthetic with continuous infusion technique PATIENT CONTROLLED EPIDURAL ANALGESIA (PCEA) Greater maternal satisfaction due to autonomy Lower dose requirement than continuous infusion COMBINATION OF CONTINUOUS INFUSION+PCEA

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.

LEVEL OF BLOCK
High Level: Can result from high dose or subdural/subarachnoid migration of catheter Low level: Can result from intravenous migration of catheter, catheter outside the epidural space or administration of inadequate dose of local anesthetic

COMBINED SPINAL-EPIDURAL
Faster onset due to intrathecal injection Lack of motor block if only opioid used for spinal Additional flexibility of renewal/top ups with epidural Not recommended for morbidly obese, difficult airway or nonreassuring fetal heart rate Early labor Consider using opioid alone or opioid+0.125 mg bupivacaine; Advanced labor opioid+2-2.5 mg bupivacaine Doses of IT opioids: Fentanyl 5-25 g, sufentanil 5-10 g

CONTINUOUS EPIDURAL INFUSION

Used routinely at many centers Good pain relief Less motor block Maternal and neonatal drug concentrations safe if used cautiously We routinely use 0.1% bupivacaine+fentanyl 2g/ ml at 6 to 8 ml/hr

Other concentrations used are 0.0625% bupivacaine+fentanyl 2.5 g/ ml at 12 ml/hr (early labor)+demand dose: 4 ml q 15 min 0.125% bupivacaine+fentanyl 2 g/ml at 8 ml/hr (advanced labor)+ demand dose : 3 ml q 15 min

Effect of epidural fentanyl on minimal local anesthetic concentration. Data from Lyons G et al. Extradural pain relief in labor: Bupivacaine sparing by extradural fentanyl is dose dependent. Br J Anaesth 1997;493-6.

PATIENT CONTROLLED EPIDURAL ANALGESIA

Advantages Flexibility and benefit of self administration Ability to minimize drug dosage Reduced demand on professional time Disadvantages May provide uneven block Addition of a basal infusion provides More even block producing greater patient satisfaction

CONTINUOUS SPINAL ANALGESIA

Use of spinal microcatheters restricted by FDA in 1992 due to reports of Cauda Equina Syndrome 28 or 32-G catheters for 22 or 26-G spinal needles Ongoing multi-institutional study with FDA approval for evaluating the safety and efficacy of delivering sufentanil and/or bupivacaine via 28-G catheters Results still preliminary but it appears safe for labor analgesia and may offer some advantages Some routinely use spinal macrocatheters through standard epidural needles for obese parturients or parturients with kyphoscoliosis

INTRATHECAL OIPIODS
100-300 g morphine 15-30 g fentanyl 5-10 g sufentanil 10 mg meperidine 0.2-0.5 mg diamorphine (heroin)

CAUDAL ANALGESIA
First form of labor analgesia (before lumbar epidural) Caudal epidural associated with: Increased technical difficulties Increased local anesthetic dose requirement during first stage Risk of injection of local anesthetic into fetal scalp or perforation of fetal head. Double catheter technique: lumbar for first stage, caudal for second stage of labor

PUDENDAL BLOCK
Mueller published the first description of pudendal nerve block in 1908. Lower vagina & post vulva
Works well and is an extremely safe and relatively simple method of providing analgesia for spontaneous delivery For Forceps delivery

PUDENDAL BLOCK

PUDENDAL BLOCK
COMPLICATIONS
IV injection of a local anesthetic agent : serious systemic toxicity (stimulation of cerebral cortex leading to convulsions) Hematoma Severe infection at the injection site (rare)

PARACERVICAL BLOCK
Excellent pain relief during the 1st stage of labor

Additional analgesia is required for delivery

PARA CERVICAL BLOCK

PARA CERVICAL BLOCK

PARACERVICAL BLOCK
Difficulty of exposing the lateral vaginal fornix during the course of labour. The other is the seeming impossibility of inserting a needle-which of necessity is long and pliable-in the correct anatomical position without injuring the foetus or damaging the uterine vessels and ureter

PARA CERVICAL BLOCK

Six injections a depth of 3-7 mm alongside the cervix in the vaginal fornices. injections of smaller volumes at several sites (3, 5, 7,and 9 o'clock) the risk of injecting a potentially toxic dose if the needle tip should inadvertently enter a blood vessel at any one site

Two large doses at 4 o'clock and 8 o'clock minimizes

PARACERVICAL BLOCK
COMPLICAITONS
Fetal bradycarida : 10~70%
Within 10 min, last up to 30min Not a sign of fetal asphyxia usually transient and newborns are in most instances vigorous at birth Result form decreased pl perfusion (drug-induced Ut a. vasoconstriction & myometrial hypertonus)

Should not be used in situations of potential fetal compromise

Non-pharmacologic approach
Goal is to eliminate her sense of Perceived threat to body and/or psych Helplessness, loss of control Distress Insufficient resources for coping with the situation Fear of death of the mother or baby

Non-pharmacologic approach
Pain is a side effect of a normal process
Goal is NOT to make the pain disappear
Instill self-confidence, sense of mastery and well-being So that pain is neither feared, nor focused on

Women who feel that they have successfully coped with the pain and stress of labor note that they were able to transcend their pain and experience a sense of strength and profound psychologic and spiritual comfort during labor.

Birth Environment

Promotes sense of comfort and privacy Comfort aids Places to walk, bathe, and rest Study comparing hospital vs home births found hospital births were associated with higher pain ratings Systematic review of randomized trials of home-like versus conventional institutional settings for birth

Increased likelihood of not using intrapartum analgesia/anesthesia Request same setting the next time Express satisfaction with intrapartum care

Continuous Labor Support

Nonmedical care of laboring women throughout labor and delivery by a trained person Supportive companion during labor can help with pain and anxiety Multiple studies have shown to decrease:
Half the risk of unplanned c-sections Half the risk of instrumental delivery Significantly shorten labor

Water Immersion
Warm water, deep enough to cover the womans abdomen Enhances relaxation, reduces labor pain Body temperature should be monitored Few minutes to hours in the first stage of labor Randomized trials show:
Significant reduction in pain (via pain score or decreased narcotic use) No increase in infection rates (even c ROM)

Intradermal Water Blocks

Incidence of low back pain in labor is 15-74%
Etiologies include: asynclitism, fetal OP position, referred uterine pain, lumbopelvic characteristics

Endorphins release thought to be responsible for pain relief Randomized trials have found:
Significant decrease in severe LBP Relief lasts 45 -120 minutes

Intradermal Water Block

4 intradermal injections of .05-.1mL sterile water with a 25 gauge needle. Over each posterior superior iliac spine and two 3cm below and 1cm medial to the first sites.

So many positions, so little time!

Knee-Chest* Dangle Hands and Knees* Labor Dance* The Lift* The Lunge* Rocking Side Lying* Squatting Toilet Sitting Tug of War Walking and Swaying* Semi-prone*

Rhythmic ritual for handling contractions Pelvic dimensions vary with different maternal positions, ameliorating labor pain *Certain positions are specifically helpful when back pain is the primary cause for discomfort

Touch and Massage

Touch communicates caring, concern, reassurance, and love Massage enhances relaxation and reduces pain Decrease anxiety and blood pressure Improve mood, and sense of support NO harmful effects !

Application of Heat and Cold

Personal choice Place one or two layers of cloth to protect against skin damage and intact sensation is a prerequisite Heat

Applied to back, lower abdomen, groin, perineum Relieves pain, chills, stiffness, muscle spasm, and increases extensibility of connective tissue Applied to back, chest, face Relieves pain, muscle spasm, inflammation and edema

Cold

Childbirth Education
Reading, classes, office visits
Information on the process of labor and birth pain experience options for pain management

Provision of education PRIOR to labor!!

Relaxation and Breathing

Rhythmic breathing patterns that promote relaxation
distract women from labor pain

Enhance sense of control Survey of women who gave birth in the US in 2005:
49% used breathing techniques
77% found these helpful 22% did not

Study of British women using relaxation techniques 88% found techniques helpful

Music and Audioanalgesia

Few studies, with small sample sizes and inadequate controls Cochrane review on the effect of music on acute pain
Small reduction in pain intensity levels and opioid requirements

Aromatherapy
Use of concentrated oils distilled from plants Use is increasing They are potent as pharmacological drugs and should be used with caution One uncontrolled prospective study

8058 women Lavender, rose or frankincense used under supervision of midwives Used to decrease fear, anxiety, pain, nausea and vomiting Half of women found it helpful 1% reported nausea/headache as side effect

Acupuncture/Acupressure
Pressure applied with fingers or small beads at acupuncture points
Lead to lower use of pharmacologic pain relief

Acupuncture increase relaxation in laboring patients

Hypnosis
A state of deep physical relaxation with an alert mind, in this state, the subconscious mind can be more readily accessed Self hypnosis: glove anesthesia, time distortion, imaginative transformation Significant reduction in analgesic use Contraindicated in women with history of psychosis

Transcutaneous Electrical Nerve Stimulation

Low voltage impulses to the skin via surface electrodes Paravertebrally at T10-L1 and S2-4 Woman controls intensity and sensation patterns Increases endorphins