Pain relief in labour

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Pain relief in labour

• Dr. L. Almaghur

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objectives

• To list the different types of pain relief used
  in labour.
• To understand the advantages, disadvantages and
  contraindications to each methods.

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Why is labour painful?

• Ischemia of uterine muscles.
• Dilatation and strengthening of the cervix.
• Stretching of the perineum in the second stage of
  labour.

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Who needs pain relief?

• respect the womans wish

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• Panadol NSAID

X

• Simple analgesia is usually ineffective in
  controlling labour pain

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The ideal analgesic in labour

• Good analgesia.
• Easy to administer.
• Safe to the mother and baby.
• Easily reversible if necessary.
• Does NOT interfere with uterine contractions.
• Does NOT effect mobility.

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Types of pain relief in labour

• Non-pharmacological
• Relaxation.
• TENS.
• Hypnosis.
• Acupuncture
• Hydrotherapy.

• Pharmacological
• Opiates.
• Inhalational.
• Epidural.

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Relaxation psycoprophylaxis

• Essential in all cases.
• Antenatal classes to educate the mothers on what
  to expect.
• Helps mothers to cope with pain and satisfaction
  with pain relief.
• Carries no risk to the mother and fetus.

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Transcutaneous nerve stimulation(TENS)
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• Low grade electronic waves to nerves supplying
  the uterus via skin electrode.
• Provides good pain relief to 25 of patients.
• Not available in our hospital.
• Carries no risk to the mother and fetus.

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Hypnosis and acupuncture

• Reported to be successful.
• Needs special skill and preparation.
• Carries no risk to the mother or fetus.
• ??? Placebo effect
• Does this matter????

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opiates

• Pethidine and diamorphine are the commonly used
  drugs.
• Given inter-muscular or intravenous
• repeated when necessary.

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Advantages

• Offers good pain relief for most patients.
• Short duration of action.

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Disadvantage

• Nausea and vomiting. (antiemetic)
• Can cross BPB respiratory
  depression in the new born.
• (Nalaxone)

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Inhalational anesthesia

• The commonest is nitrous oxide.
• Self administered to the patient via face mask.
• Given in a 50-50 mixture with oxygen (Entanox).

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Advantages

• Provides analgesia varying from good to
  ineffective.
• Under control of the patient.
• Minimal adverse effects to mother and fetus.

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Disadvantage

• not adequate for second stage, instrumental
  delivery, suturing of perineum or manual removal
  of placenta.
• Light headedness and nausea.
• Not suitable for prolonged use.

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Epidural anesthesia

• ??????? ???? ???

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• Plastic catheter introduced into the epidural
  space.
• Catheter is left in and the analgesia is given
  continuously.
• Bupivican and Fentanyl

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Advantages

• The most effective pain relief.
• The absence of pain allows enjoyment and control
  of labour.
• Reduces maternal fatigue and anxiety.
• Ideal in high risk pregnancies e.g. breech, MP,
  and PET.

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Disadvantage

• Restriction of movement during labour.
• Requires CTG.
• Requires resident anesthesia, cardio-respiratory
  facilities and one to one care.
• ?increase rate of instrumental delivery.
• Beware of urine retention.

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Complications

• Failure 3.
• Hypotension.
• Epidural tap (headache)
• ? Back pain.
• Paralysis !!!!!!!!!.

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Analgesia used in second stage and third stage.

• Nerve blocks.
• Spinal anesthesia.
• General anesthesia.

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Pudendal block

• Performed by the obstetrician.
• Used for outlet forceps and vacuum delivery.

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Spinal anesthesia

• Can be used for
• Instrumental delivery.
• Manual removal of placenta.
• Repair of third degree tear.

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Difference between epidural and spinal

• Site.
• Onset.
• Duration.

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Contraindications to spinal or epidural anesthesia

• Maternal refusal.
• Hypovolemia.
• Sever back deformities,
• Local infection.
• Coagulation disorders.

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General anesthesia

• Manual removal of placenta.
• Third degree tear

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summary

• Labour is a painful experience.
• Pharmacological and non-pharmacological method
  are used for pain relief.
• Each method had its advantage and disadvantage
  and the choice of method depends on the stage of
  labour and maternal preference.