&

Best Practice”
“Misconceptions
IN LABOUR
PAIN RELIEF

Dr. Roshana Mallawaarachchi

Senior Registrar in Anaesthesiology
Teaching Hospital, Kandy
 The pain of childbirth is the most severe pain most
women will endure in their lifetimes.

 Women in pain for pain relief in labor. Don’t need

an “indication”

 According to the American Society of Anesthesiology

(ASA) “in the absence of a medical contraindication,
maternal request is a sufficient medical indication for
pain relief during labor”

(Statement on pain relief during labor, Oct 17, 2007).

Etiology of pain during labor
Basic factors for pain in childbirth:

1. Physical
2. Emotional
The IASP definition of pain as;

“An unpleasant sensory and emotional experience

associated with actual or potential tissue damage,
or described in terms of such damage"
Causes of pain in labor

Uterine Anoxia
Stretching of Stretching of
the cervix the
during dilation Uterine
& effacement ligaments

Stage
One
Causes of pain in labor
Distention of the
vagina and Perineum

Stage Compression of the

nerve ganglia
Traction and Two in cervix
stretching of & lower uterus
the perineum

Pressure on urethra, bladder,

rectum during fetal descent
Factors affecting Mothers Response

Preparation -
Knowledge and
Previous
confidence
experiences Support
gained through
with pain
childbirth
classes

Cultural Maternal
influences on Fatigue, Anxiety,
expression of Sleep
pain deprivation
Goals of Pain relief

“Delivery of the infant into the arms of a

conscious and pain-free mother
is one of the most exciting and rewarding moments in medicine.”
Moir . Br J Anaesth 1979.
History

 The modern era of childbirth

analgesia began in 1847 when
Dr J Y Simpson administered
ether to a woman in childbirth.

 Queen Victoria was given

chloroform by John Snow
(1853)
Stages of Labor
Pathophysiology of Labour pain

Visceral pain
 First stage
 T10 - L1
 Distension and stretching of
lower uterine segment.

Somatic pain
 Second stage
 S2-S4
 Distension of pelvic and perineal
structures and compression of
lumbosacral plexus. Pathways of labour pain
Distribution and intensity of labour pain during each stage of
labour and delivery
Most severe pain a human can bear

McGill pain questionnaire comparing

pain scores for women in labor
Effect of labour pain on mother and foetus
 TECHNIQUES OF
LABOUR ANALGESIA
Techniques of labour analgesia
Non Pharmacological
 Mind–body interventions
 Bioelectromagnetic
 Physical methods: massage, heating pads, warm bath
 Alternative medication: Acupuncture, hypnosis

Pharmacological
 Systemic analgesia: IV, Inhalational
 Regional techniques
 General anesthesia
Mind–body interventions

 Psychoprophylactic Methods:
 Breathing exercises
 Deep abdominal breathing
 Prepared childbirth method
 Hypnosis
 Relaxation, concentration,
meditation
 Music Therapy
Water therapy(hydrotherapy )
 Standing under warm shower.
 Soaking in tube of warm water.
 Temperature of water 35-370C.

 No increase in chorioamnionitis, post partum Endometraitis,

Neonatal infection.
 No limit to the time women can stay in bath and often they
are encouraged to stay in it as long as desired.
Acupuncture

 Techniques have been

used in China
 Both for surgery as well as
for pain relief
Transcutaneous electrical nerve stimulation

 Electrical impulses are applied to

skin via electrodes.
 For 1st stage electrodes are
placed over T 10 - L1 on either
side of spinous process.
 For second stage analgesia
electrodes are placed over S2-S4.
 Diminishes the need of analgesia.
 Variable success rate.
Intradermal sterile water injections

 25G needle
 0.1 mL Intracutaneous injections
of sterile water

 Sharp burning pain 20-30 sec

 Pain relief after 2 min  45 min-3h
 No side effects
Application of Heat and Cold
Heat Application:
 Effective in relief back pain.
 Raises the pain threshold.
 To increase blood flow and relieves muscle ischemia.

Cold application:
 Increase comfort.
 Slowing transmission of pain.
Aromatherapy

When essential oil

inhaled it’s molecule
transported via olfactory
system to the brain and
the brain respond to
particular aroma with
emotional responses,
when applied externally
they absorbed to the skin
and then carried
throughout circulation .
Emotional LSB
Nursing Presence
Being with the mother rather than performing tasks
Physical, emotional, psychological, and spiritual engagement

Nursing presence includes:

 High level of nursing skills.
 Being open.
 Honest.
 Nonjudgmental with the mother.
 Listening carefully to her needs
and concerns.
SYSTEMIC ANALGESIA
Inhalational Agents

 Entonox (N2O:O2 50:50):

 Isoflurane
 Desflurane
 Sevoflurane
 NITROUS OXIDE

Entonox (50% nitrous oxide in

oxygen)
Acts Within 20-30 seconds
Maximum effect after about 45 Secs.
Mother is taught to inhale the
mixture, so that peak brain nitrous
oxide concentration coincides with
peak contraction pain.
Does not affect the course of the 1st &
2nd stages of labor and rates of
cesarean delivery.
 NITROUS OXIDE
Disadvantages

Increase the rate of maternal O2 desaturation

Direct respiratory depressant effect
Maternal drowsiness in 0-24% of mothers
Environmental pollution
Sevoflurane
• Used as 0.8% with O2.
• An effective labor analgesic.
• When compared with Entonox, provided superior
pain relief.

• Needs specialized equipment.

• More intense sedation
IV Opioids

Most commonly used class of drugs.

Intermittent doses or via Patient controlled analgesia.
Inexpensive.
Significantly higher VAS compared with regional
anesthesia.
Side effects of opioids

 Nausea, vomiting
 Dysphoria
 Respiratory depression

 All opioids cross the placenta.

 In utero opioid exposure results in:
 Foetal bradycardia.
 Decreased beat-to-beat variability.
 Neonatal respiratory depression.
Parenteral opioids
 Pethidine
 Fentanyl
 Remifentanyl
 Tramadol
 Diamorphine

Administration can be by
IV, IM & patient controlled methods
Pethidine
 Most commnly used opioid.
 Cheap
 IM: 50-100 mg
 IV: 25 - 50 mg
 Analgesic effect: 3-4 hours
 Fetal exposure: Maximum 2-3 h

 Effects on fetus:
 Loss of beat to beat variability of FHR
 Respiratory depressant effects > pronounced in neonate
 Active metabolite- norpethidine > prolonged sedation and
respiratory depression

 Should not be administered in parturients with Cx dystocia

REGIONAL ANALGESIA

Techniques

 Epidural analgesia
 Subarachnoid block
 Combined spinal-epidural blocks.

Less frequently performed

 Lumbar sympathetic
 Paracervical block
 Pudendal block
Lumbar epidural analgesia
 Gold standard technique.
 Low doses of local anesthetic or
opioid combinations are
administered to provide a
continuous T10-L1 sensory
block during the first stage of
labor.

Advantages
 Safe and effective
 without appreciable motor
blockade
 Extended to provide surgical
anaesthesia
Technological advances

Patient-controlled epidural
analgesia (PCEA)

New continuous infusion

pumps have been
developed with the
capability to receive patient
input and deliver medication
on demand.
PCEA

Advantages

Excellent patient satisfaction.

Reduces the total amount of local anesthetic.
Less unwanted effects - motor block, hypotension.
Reduces the demands on staff.
Dosage of Epidural Catheter
DRUG INITIAL CONTINUOUS INFUSION
INJECTION

Bupivacaine 10-15 mL of a 0.1% 0.1% solution at

solution 8-15 mL/hr

Ropivacaine 10-15 mL of a 0.1%- 0.5%-0.2% solution at 8-15

0.2% solution mL/hr

Fentanyl 50-100 µg 1-4 µg/mL

Sufentanyl 10-25 µg in a 10-mL 0.03-0.05 µg/mL

volume
Complications of Epidurals

 1 in 10 - Pull catheter back

 1 in 20 - Catheter re-siting
 1 in 100 Dural puncture
 1 in 24,000 temporary
nerve damage (less than 6
months)
 1 in 80,000 permanent
nerve damage
Rare Complications

 Bleeding, including epidural haematoma

 Infection, including epidural abscess
 Pruritus
 Hypotension
 Increased risk of assisted vaginal delivery
Single shot Spinal

 Reliable
 Rapid onset
 Fast insertion

Disadvantages
 Duration limited (1-2 hours)
 Greater risk of Hypotension
 Motor block - prolongs 2nd stage of labor
 Limited duration with single shot
Combined spinal epidural anesthesia
Advantages of CSE

 Rapid onset of analgesia

 Continuous analgesia
 Reliable, less patchy blocks
 Effective sacral analgesia in advanced labor
 Better patient satisfaction
 Side effects are acceptably low
Bupivacaine

 An amide local anesthetic.

 Onset of action with
bupivacaine is rapid.
 Longer action.
 Relative motor sparing.
 Cardiotoxic.
ADJUVANTS - OPIOIDS
 Allows the use of lower doses. Synergistic effect.

Fentanyl
 Rapid onset of anlgesia
 Minimum respiratory depression

Advantages
Decreased motor blockade
Decreased hemodynamic instability

Side effects
Pruritis, nausea, vomiting, urinary retention
 Myths
&
Controversies
Myth: There’s a limited window of time
when you can get an epidural.

 Mother can get an epidural any time

during your labor:
 Inthe beginning, the middle or even
toward the end.
Myth: Epidurals can harm the baby.

 The amount of medication that reaches the baby

from the epidural is so small it doesn’t cause harm.
Do epidurals cause back pain?

 Epidural
analgesia has not been
associated with an increase in the
prevalence or incidence of backache.
Myth: Epidurals can cause permanent back
pain or paralysis in the mother.

 Serious complications from an epidural, including

paralysis, are extremely rare.
 Some women have discomfort in the lower back (where
the catheter was inserted) for a few hours or days after
the epidural, but it doesn’t last.
Myth: Epidurals can slow down labor or
increase the risk of having a cesarean section
(C-section).

 There is no credible evidence that an epidural

slows down labor or increases your risk of
having a C-section.
 Infact, there is evidence that epidurals can
speed the first stage of labor for some women.
Myth: An epidural can interfere with the
birth experience.

 Theepidural medications will not cause to

be weak or tired.
 Mother will be able to feel contractions –
they just won’t hurt – and they will be able
to push effectively.
Does epidural cause maternal fever?

 Minimal increase in body temperature

 little clinical significance
 Not associated with neonatal infection
Myth: Do epidurals interfere with
breastfeeding?
 Low-dose local anaesthetic ⁄ low-dose fentanyl
epidural labour analgesia regimens do not clinically
affect breastfeeding and should be still offered to
mothers wishing to breastfeed their babies.
THANK YOU!