Obstetric Analgesia

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Obstetric Analgesia & Anaesthesia

Pain Pathway during Labour Systemic Medication


Benzodiazepines
Benefits Adverse Effects
Anxiolytics Hypotonia
Adjuvant to narcotics Lethargy
Premedicant to LSCS ↓Feeding
Preeclampsia, eclampsia Hypothermia
↓ Beat to beat variability of fetal heart
Maternal sedation (minimal fetal respiratory depression)
Crosses placenta
No adverse effects on acid-base, clinical status
Opioids (Pethidine, Morphine, Fentanyl, Remifentanil)
Adverse Effects
Pain Maternal Fetal
1st Stage of Labour 2nd Stage of Labour Drowsy, sleepy Respiratory depression
Uterine contraction Perineal stretching Nausea, vomiting Antidote – Naloxone (at birth)
Cervical dilatation Somatic nerves Suppress cough reflex
Pathways Pudendal nerve NSAIDs
Sympathetic pathway T10-L1 Posterior cutaneous nerve of thigh Paracetamol
Referred pain to cutaneous T10-L1 Ilioinguinal nerve S2,3,4 Mefenamic acids
Lumbosacral plexus L5S1 Cox 2 Inhibitors – Celecoxib, Valdecoxib
Sites of pain Sites of pain Indications
Early 1st stage T11-T12 Perineal region  Perineal pain after delivery
Late 1st stage T10-L1 Sacral region  Post-caeserean section
Backache  Contraction pain post delivery
Some amount secreted via breast milk (not significant level in baby)
Stress Response to Pain in Labour Inhalation Agents (Nitrous oxide, ENTONOX – NO:O = 50:50)
CVS Pain relief in 1st, 2nd stages of labour
↑ Maternal CO (↑ stroke volume, ↑ heart rate) Not Associated With Benefits
Greatest increase in CO immediately after delivery ↓ Uterine tone Self administered
 ↑ Venous return Strength of contractions Rapid onset, offset
 Relief of venocaval compression Responsiveness to oxytocins No accumulation in mother
 Autotransfusion (resulting from uterine involution) Neonatal acid-base status No effects on uterine contraction
Respiratory Respiration No effect on oxytocics responsiveness
Hyperventilation (due to pain in labour) Oxygenation No change in
Maternal hypocarbia Apgar scores  Neonatal acid-base status
Respiratory alkalosis Neurobehaviour score  Respiration
Compensatory metabolic acidosis  Oxygenation
O2-dissociation curve shift to left - ↓ O2 transfer to tissue  Apgar scores
(compromised by ↑ O2 consumption associated with labour)  Neurobehaviour score
Hormonal
Release of β-endorphine, ACTH from anterior pituitary (due to pain, anxiety) Alleviation of Labour Pain
↑ Adrenaline, Noradrenaline (from adrenal medulla) 1st Stage 2nd Stage
(lead to progressive rise in peripheral resistance, cardiac output) Lumbar epidural Low epidural
Activation Intrathecal block Caudal
Sympathetic Activity Autonomic Nervous System Bilateral paracervical blocks Spinal saddle block
Incoordinate uterine action Delays gastric emptying Bilateral lumbar sympathetic blocks at L2 Bilateral pudendal nerve blocks
Prolonged labour ↓ Intestinal peristalsis Bilateral paravertebral blocks (T10-L1)
Abnormal fetal heart-rate patterns
Metabolic Labour Epidural
Maternal Fetal Indications Contraindications
↑ Glucagon, GH, Renin, ADH Maternal catecholamines secreted Maternal request, distress Absolute
↓ Insulin, testosterone (cause fetal acidosis) Induction of labour Sepsis
Breech presentation Bacterimia
Ideal Labour Analgesia Twins, multiple pregnancy Skin infection at injection site
Maternal, fetal safety Occipito-posterior position Severe hypovolaemia
Ease of administration PIH+/- proteinuria Coagulopathy
Consistent, predictable, rapid onset Prematurity Therapeutic anticoagulation
Maternal composure, control during 1st, 2nd stages of labour IUGR, fetus small for gestational age Patient refusal
Analgesia through all stages of labour Previous caesarean section Relative
Devoid of motor blockade, enable ambulation, various birthing positions Induction of labour Peripheral neuropathy
Preserve stimulus for expulsive efforts during 2nd stage of labour Forcep delivery Mini dose heparin
Retain maternal expulsive efforts Psychoses
Facilitate delivery of supplemental analgesia (without additional invasiveness) Aspirin, antiplatelet drugs
Facilitate delivery of analgesia for surgery (avoid need for general anaesthesia) Demylinating CNS disease
Idiopathic hypertrophic subaortic
stenosis
Aortic stenosis
Psychological, emotional instability
Uncooperative patient
Continuous Epidural Infusion
Advantages Complications
↓ Fluctuations in pain relief level Overdose, high blockade
↓ Amount of motor blockade Segmental blockade
↓ Hypotensive episodes Subarachnoid catheter migration
Not required to repeat test dosing Intravascular migration
(frequent monitoring)
Complications
Hypotension
Inadequate analgesia
Intravascular Injection
Unintentional dural puncture
High block
Catheter misplaced into subarachnoid space
Urinary retention
Back pain
Maternal fever
Progress of labour

Regional Anaesthesia
Advantages Disadvantages
Awake patient Sympathetic blockade
 Improved maternal-child bond (with hypotension)
 Husband friendly Incomplete, patchy block
Avoid problems of GA Limited duration in spinal epidural
 Airway, aspiration risk Complications
 Multiple drug administration Inadvertent intravascular injection
Provide effective post OP analgesia Dural puncture
(↓ Thromboembolic phenomena)

Spinal Anaesthesia
Advantages Complications
Simplicity with definite end-point Hypotension
Minimal drug usage Excessive spread, high spinal anaest.
Rapid onset Post-dural puncture headache
Reability Incomplete anaesthesia
Dense motor, sensory block Nerve injury (rare with spinal below L2)
Infection

General Anaesthesia
Advantages Disadvantages
Shorter induction time Difficult airway management
Lower failure rate Risk of regurgitation
Better CVS control (pulmonary aspiration)
Full control of respiratory functions Awareness
Rapid control of convulsion GA related problems
No patient cooperation required  PONV
 Hangover effect
 Lack post OP analgesia
Stress response during induction
(emergence)

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