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DEFINITION OF LABOR. ‘LABOR can be defined as spontaneous painful uterine contractions associated with the effacement and dilatation of the cervix and the descent of the presenting part’. Intensity of Pain in Labor. (Melzack and Katz, 1999). .

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definition of labor
DEFINITION OF LABOR

‘LABOR can be defined as spontaneous painful uterine contractions associated with the effacement and dilatation of the cervix and the descent of the presenting part’

intensity of pain in labor
Intensity of Pain in Labor

(Melzack and Katz, 1999).

slide3

Early 1st stage: before fetal head reaches zero station, pain impulses arise primarily from uterus  via visceral afferents enter spinal cord at T10-L1.

  • Late 1st stage & 2nd stage: pain impulses arise from uterus, pelvic structures, vagina, & perineum.
  • 3rd stage of labor is usually well tolerated with spontaneous placental delivery.
pain of childbirth
Pain of Childbirth
  • Visceral pain
    • First stage
    • T10 - L1
  • Somatic pain:
    • Second stage
    • S2-S4
slide5

Pain Management Options

  • Non-pharmacological
  • Systemic analgesia
  • Epidural analgesia
  • Combined Spinal Epidural Analgesia (CSE)
pain management options
Pain Management Options

Non-pharmacological:

  • Emotional Support
  • Touch & Massage
  • Heat & Cold
  • Hydrotherapy
  • Vertical Position
  • TENS
  • Acupuncture
  • Hypnosis
con t analgesia
Con’t Analgesia
  • Systemic medications
  • Narcotics:
  • Although narcotics provide both analgesic & sedation, their S.E are:
    • Maternal: Orthostatic hypotension, nausea, vomiting.
    • Fetal: ↓ beat-to-beat variability of FHR.
    • Neonatal: respiratory depression  Rx: Naloxone (Narcan).
con t analgesia1
Con’t Analgesia

Meperidine (Demerol or Pethidine):

  • Best use in early stages of labor, less effective once labor is well established.
  • If IV (25-50 mg)  peak effect = 7-8 min. Duration = 1.3-3 hrs.
  • If IM (50-100 mg)  peak effect = 2-4 hrs.
disadvantages of pethidine
Disadvantages of Pethidine.
  • Somnolence
  • Confusion and even hallucinations.
  • Nausea and / or vomiting.
  • Dizziness is common.
  • Desaturation episodes (SpO2 between 70 to 90%) in about 50% of women (Reed et al 1989, Minnich et al 1990).
  • Elimination of Pethidine from the bodies of both mother and child is relatively slow,
sedative tranquillizers
Sedative-Tranquillizers
  • These agents given in combination with a narcotic.
  • The phenothiazine –Promethazine (Phenergan)- 25 mg IM or 12.5 mg IV.
  • Relieves anxiety, controls nausea & vomiting, ↓ narcotic requirements during labor.
con t analgesia2
Con’t Analgesia
  • Inhalational analgesia (Entonox)
  • Provides partial pain relief during labor as well as @ delivery.
  • 50% Nitrous oxide in O2. It’s administered with a mask / mouthpiece in a manner such that the parturient remains awake, cooperative & in control of her airway  to prevent pulmonary aspiration of gastric contents.
  • Does not prolong labor or interfere with uterine contractions but administration > 20 minutes may result in neonatal depression.
  • < risk of neonatal depression when compared with narcotics.
anesthesia regional anesthesia
Anesthesia (Regional anesthesia)
  • Peripheral nerve block:
    • Local infiltration for episiotomy (Lidocaine).
    • Pudendal block.
  • Central nerve block:
    • Epidural anesthesia.
    • Spinal (subarachnoid) block.
pudendal block
Pudendal block

:

  • Administered shortly before delivery to anesthetize pudendal nerve.
  • Insert needle  aspirate with syringe to check for absence of blood  inject 1% Lidocaine on each side.
  • Analgesia produced in lower birth canal & perineum provides maternal comfort for low forceps delivery & episiotomy.
  • Advantages: easy to administer, not a/w maternal hypotension/ fetal distress.
  • Disadvantage: incomplete analgesia @ time of delivery, since pain of uterine contraction is unaffected.
epidural anesthesia
Epidural anesthesia
  • In USA approximately 60 percent of women choose epidural or combined spinal-epidural analgesia for pain relief during labor.
advantages of epidural analgesia
Advantages of Epidural Analgesia

Provides superior pain relief

90% to 95% are satisfied with epidural analgesia.

Facilitates patient cooperation during labor and delivery

Decreases maternal hyperventilation

Avoids opioid-induced maternal and neonatal respiratory depression

advantages of epidural analgesia1
Advantages of Epidural Analgesia
  • Extend the duration of block to match the duration of labor
  • Allows extension of anesthesia for cesarean delivery
epidural analgesia contraindications
Epidural Analgesia Contraindications:
  • Co-operation
  • Active neurologic disorder
  • Coagulopathy
  • Hypotension
  • Systemic / local infection
epidural complications
Epidural Complications

Early

  • IV toxicity
  • LA toxicity
  • Hypotension
  • High block/total spinal
  • Extensive motor block
  • Urinary retention
  • Labour progress

Late

  • PDPH
  • Neurological injury
  • Epidural abscess
  • Epidural hematoma
  • Back pain
controversy still remains over the effects of epidural analgesia
Controversy Still Remains Over the Effects of Epidural Analgesia
  • rate of c-section delivery
  • rate of instrument-assisted delivery (vacuum extraction and forceps)
  • prolongation of labor
  • effects on the fetus
segal 2000
Segal (2000)
  • Meta-analysis of 37,000 patients in a variety of different practice settings and time periods in several different countries showed:
  • No significant change in
    • overall c-section delivery rate
    • rate of c-section deliveries for dystocia
    • rate of forceps delivery
prospective randomized trials
Prospective, Randomized Trials
  • 11 clinical trials since 1990 have assessed the effect of epidural analgesia on c-section rates by randomizing women to opiod versus epidural analgesia
  • Epidural analgesia associated with an increase in c-section delivery rate in only one study
sharma 2004
Sharma (2004)
  • Individual meta-analysis of 2700 nulliparous women
  • No difference in overall c-section rate (10.5% vs. 10.3%) or rate for dystocia
  • Significant increase in forceps deliveries (13% vs. 7%) in epidural group
  • Epidural analgesia was associated with prolongation of 1st and 2nd stages of labor, increased need for oxytocin, and maternal fever
  • One and 5 minute apgar scores significantly worse in the intravenous meperidine group
  • Significantly lower pain scores and greater satisfaction both stages of labor in epidural group
characteristics of patients who select epidural analgesia
Characteristics of Patients Who Select Epidural Analgesia
  • earlier stage of labor at admission
  • higher fetal station at admission
  • greater use of oxytocin
  • smaller pelvic outlets and larger babies
  • more fetal malpresentation
  • more likely to be primagravid
pain in labor itself
Pain In Labor Itself
  • Pain early in labor is associated with a slower labor resulting in an increased rate of c-section and instrumental deliveries
  • More pain in labor is associated with a higher likelihood of selecting epidural analgesia
spinal subarachnoid block
Spinal (subarachnoid) block
  • Injection of local anesthetic (Tatracaine, Bupivacaine, or Lidocaine) into subarachnoid space thru a spinal needle placed in L3-4 interspace.
  • Fastest onset.
  • Least drug exposure for fetus because small dose required.
  • Be aware of rapid hypotension & preload mother with 1000 mL IV fluid.