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Labor is characterized by regular, painful uterine and C primary afferent fibres which pass sequentially
contractions that increase in frequency and intensity and through the inferior, middle and superior hypogastric
are associated with progressive cervical effacement and plexus, the lumbar and lower thoracic sympathetic
dilatation. Labour has been divided into three stages. The chain and end in rami communicantes associated with
first stage occurs from onset of cervical change to T10-L1 spinal nerves. (fig. 1)1 It is predominantly carried
10 cms dilatation. It can be divided into latent and by the C fibres.
accelerative phases. The latent phase can last up to 8 hrs,
without the need of intervention, while the active phase is Table - 1 : Labour pain: Pathways and mechanisms.3
associated with a faster rate of cervical dilatation and
Site of Mechanism Pathway Site of
usually begins at 2-4cms dilatation and the duration varies origin action
from 2 to 6hrs. The second stage occurs from full cervical
dilatation (10 cm) to delivery of the baby. Normally the Uterus,
Cervix
Distortion,
Stretching,
Afferents which accompany
sympathetic pathway to
Upper
abdomen &
second stage lasts for 2 hrs (3 hrs with regional anaesthesia) Tearing of T10-L1Dorsal rami T10-L1 groinmid-back
Fibres refer to cutaneous branches
in a primipara and 1 hr (2 hrs with regional anaesthesia) of posterior divisions
in a multipara. The third stage occurs from delivery of the Periuterine Pressure often Lumbosacral plexus L5-S1 Low back, thigh
baby to separation and expulsion of placenta and the tissues
Lumbosacral
in association
with fetal
(?pelvic splanchnic nerves)
a. Peripheral pathways
I stage of labour: Pain of the first stage of labour is
due to uterine contractions and stretching of the
cervix. It is cramping and visceral in nature, diffuse
and poorly localized. Sensations are carried through Ad
II stage labour : During the late first and second analysis occurs, and to the hypothalamic and limbic systems,
stage of labour, somatic pain predominates, as a result of where emotional (affective) and autonomic responses
distension and traction on the pelvic structures, the pelvic originate.6
floor and the perineum and is carried via the pudendal
nerve (table 1)3 through the anterior rami of S2 through S4.
Unlike visceral pain of first stage, it is sharp and well
localised, due mainly to less arborization and the faster
conduction velocity in the sacral pathways. It is
predominantly carried by the Ad fibres.4
b. Central pathways
The pathways labor sensation travels after entry into
the central nervous system includes both the ascending and
the descending pathways.
Ascending pathways
The first synapse in the pathways occurs in the dorsal
grey matter of spinal cord (Rexed’s Laminae I
to V). Most of the primary afferent neurons synapse
initially in the more superficial laminae I and II
(substantia gelatinosa); locally projecting interneurons in
turn synapse on the more deeply located wide dynamic Fig. 3 : Cephalad extension of labour sensory pathways 5
range (WDR: lamina V) neurons. The WDR neurons Secondary neurons whose cell bodies lie in the dorsal gray matter of the
receive synaptic excitatory input from both the large spinal cord project via the spinothalamic tract to the thalamus. Another synapse
occurs in the pathway before projection to the primary sensory cortex.
myelinated Aâ and Aä mechanoreceptor afferents and C
polymodal nociceptive afferents. The fact that all of the
Descending pathways
lamina V cells which respond to visceral high threshold
afferents also respond to low threshold cutaneous afferent These pathways originate in primary sensory cortex
from an area of skin supplied by the same spinal cord and project to peri aqueductal grey matter in the midbrain
segments is important. Thus the lamina V cells provide which further project to rostral ventral nuclei in thalamus
the neural basis for the phenomenon of referred pain which . Projections from thalamus enter the spinal cord through
occurs during each uterine contraction. (fig. 2) dorsilateral funiculus and end in dorsal grey matter of the
spinal cord. (fig. 4)5
Table - 3 : Doses of systemic analgesics.7 Table - 4 : Technique for lumbar epidural analgesia.7
S.N. Drug Dose IV/IM Onset IV/IM Duration IV/IM • Sitting position / left lateral position
1. Meperidine 25/100 mg 5/20-30 min 20-40/90-120 • Aseptic precautions; ideal space L3-4/L4-5
10-15 mg PCA bolus min • LOR with saline for identification of epidural space
2. Morphine 5/10-15 mg 5/20-30 min 30-60/120-80 • Bevel direction cephalad; midline approach
min
• Insert 5cms multiport epidural catheter
3. Fentanyl 25-50/100 µg 2/10 min 20-40/30-60 min
10-25 mg PCA bolus • Aspirate, test for intrathecal or IV placement
4. Nalbuphine 10-25 mg/1-3 mg 2/15 min 120-240 min • Test dose: 1.5% lidocaine 45mg + Epinephrine 15ug;
PCA bolus 0.25% Bupivacaine 7.5mg + Epinephrine 15ug
5. Butorphanol 1-2 mg 5-10/10-30 min 120-240 min • Initiate catheter dosing with divided (5ml) doses of:
6. Remifentanil 0.1-0.5 mg/kg 0.5-1 min 2-3 min t 0.9%-2.0% lidocaine (10-12ml)
PCA bolus
t 0.0625%-0.25% bupivacaine (10-12 ml)
7. Tramadol 100 mg IM 10-30 min 180 min
t 0.1%-0.2% ropivacaine (10-12 ml)
Epinephrine (1:200,000-400,000)
1. Antacid prophylaxis
• Adequate analgesia: Begin infusion of bupivacaine
2. Pre-anaesthetic evaluation
(0.04%-0.125%)+fentanyl(1.5-2 mgml-1) at 12-16 mlhr-1
3. I stage labour : Bolus 10-15 mg then infusion 0.5-1 mgkg-1min-1
• If pain persists 15 min after injection, repeat bolus dose,
4. Monitor sensorium in sitting position or after withdrawing 1cm catheter.
Replace catheter if pain persists after 5min.
5. At crowning, 0.2-0.4 mgkg-1 (total dose 12.5 mg-25 mg) don’t exceed
100 mg
Techniques for maintenance of epidural analgesia
B. Regional techniques for labour analgesia (Table 5) 7
Regional techniques represent the “gold standard” There are advantages and disadvantages to the
for labour analgesia. different techniques available for delivery of epidural
analgesia. Some of the popular methods are:
1. Lumbar epidural analgesia (Table 4) 7
Effective analgesia during the first stage of a. Intermittent top-ups
labour can be achieved by blocking the T10 to L1 Ideally a low dose mixture of local anaesthetic and
dermatomes with low concentrations of opioids or local opioid is used. It is a relatively safe and simple method of
anaesthetics. The block has to be extended up to S2-4 delivery and does not require complex infusion devices.
dermatomes in the second stage of labour to ameliorate However, it may prove to be labour intensive for the labor
the pain due to vaginal distension and pressure on the room staff.
perineum of the descending fetal part. Recent evidence b. Continuous epidural infusion (CEI)
suggests that there is minimum to no alterations in duration A typical low dose infusion of bupivacaine and opioid
and outcome of labour with regional analgesia,10 there is no is titrated to achieve the desired block height with an
increase in the need for labour augmentation with oxytocics11 infusion device. It provides adequate analgesia and
neither is there any difference in the rates of normal haemodynamic stability. Compared to low dose intermittent
vaginal delivery12 but there was a significant increase in top-ups and PCEA, increased total dose of local anaesthetic
maternal satisfaction in parturients administered epidural and opioid is required. It may also increase the chances of
analgesia. Concern about early initiation of epidural anaesthetic intervention when analgesia fails.
SUNANDA, ANAND, HEMESH : ACUTE PAIN – LABOUR ANALGESIA 367
19. Asik I, Goktug A, Gulay I et al. Comparison of bupivacaine 23. Polley LS, Columb MO, Naughton NN et al. Effect of epidural
0.2% and ropivacaine 0.2% combined with fentanyl for epinephrine on the minimum local anaesthetic concentrations
epidural analgesia during labour. Eur J Anaesth 2002; 19(4): of epidural bupivacaine in labor. Anaesthesiology 2002; 96:
263-70. 1123-28.
20. Lee BB, WD Ngan Kee, FF NG et al. Epidural infusions of 24. Roelants F, Lavan d’homme, PM, Mercier-fuzier V. Epidural
ropivacaine and bupivacaine for labor analgesia: a randomized, administration of neostigmine and clonidine to induce labor
double-blind study of obstetric outcome. Anesth Analg 2004; analgesia: evaluation of efficacy and local anaesthetic sparing
98(4): 1145-52. effect. Anesthesiology 2005; 102(6): 1205-1210.
21. Supandji Mia, Alex TH, Sia MMED and Ocampo CE. 0.2% 25. Vloka JD, Hadzic A, Drobnik L. Nerve blocks in the pregnant
ropivacaine and levobupivacaine provide equally effective patient. In Drs David J Birbach, Stephen Gatt and Sanjay
epidural labour analgesia. Canadian Journal of Anesthesia 2004; Datta (Eds) Textbook of Obstetric Anesthesia. Churchill
51: 918-922. Livingstone, Philadelphia 2000; 693-707.
22. Morrison SG, Dominguez JJ, Frascarolo P, Reiz S: A 26. Wong C. Neurologic deficits and labor analgesia. Reg Anesth
comparison of the electrocardiographic cardiotoxic effects of Pain Med 2004; 29(4): 1-16.
racemic bupivacaine, levobupivacaine, and ropivacaine in
anesthetized swine. Anesth Analg 2000; 90: 1308-14.
ISACON 2006
54th Annual National Conference of Indian Society Of Anaesthesiologists
Mysore, 26 – 29th Dec, 2006 (Organised by ISA Karnataka State Chapter and Mysore City Branch)
th