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Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

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Susilo Chandra, MD, FRCA Department of Anesthesiology & Intensive Care Cipto Mangunkusumo General Hospital University of Indonesia, Medical Faculty Labor analgesia Is It Attainable
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Page 1: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

Susilo Chandra, MD, FRCADepartment of Anesthesiology & Intensive Care

Cipto Mangunkusumo General HospitalUniversity of Indonesia, Medical Faculty

Labor analgesia Is It Attainable

Page 2: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

ASA & ACOG STATEMENTASA & ACOG STATEMENT

The American Society of Anesthesiologists and the American College of Obstetricians and Gynecologists agree that “of the various pharmacologic methods used for pain relief during labor and delivery, regional analgesia techniques are the most flexible, effective, and least depressing to the central nervous system, allowing for an alert, participating mother and alert neonate.”

Page 3: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

Many systemic techniquesMany systemic techniques

“alternatives” to labor neuraxial analgesiapoorly effective and some are associated with significant maternal and neonatal side effects

Intravenous PCA remifentanil is the most effective technique, but safe administration?

Page 4: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

N2ON2O

Nitrous oxide 50% provides little pain relief

Page 5: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

In the context of pain relief In the context of pain relief in labor:in labor:

Individual anaesthetists’ impressions, Patient satisfaction surveys, The midwives’ ability to work with a

specific analgesic technique, The adequacy of pain relief or, even, on

the flexibility offered by the analgesia technique to the obstetrician?

Or a ‘good patient outcome’

Page 6: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

Good patient outcomeGood patient outcome

Superior quality of pain relief achieved with: – be safe (technique and drugs) for

mother and baby, – have only minimal effects on the

process of labor process,– be able to provide long lasting and

consistent pain relief – be customized to patients’ needs– be affordable to most

Page 7: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

Myles PS: Improving quality of recovery: what anaesthetic Myles PS: Improving quality of recovery: what anaesthetic techniques make a difference? in Best Practice & Research techniques make a difference? in Best Practice & Research

Clinical Anaesthesiology. Vol 15, No 4, pp. 621-631, 2001.Clinical Anaesthesiology. Vol 15, No 4, pp. 621-631, 2001.

Practising evidence-based medicine in anaesthesia can be difficult

Even more in OB anaesthesia because other – mainly, obstetrical and pregnancy - factors are often much more important determinants of outcome

Page 8: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

Which evidence is relevant to pain Which evidence is relevant to pain relief in labour:relief in labour:

Shorter time to onset of pain relief improved maternal satisfaction with the

neuraxial block Lower overall pain score Longer duration of pain relief Shorter duration of labour Reduced intensity of motor block.

Page 9: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

Reynolds F, Sharma S, Seed P: A Meta-Analysis Reynolds F, Sharma S, Seed P: A Meta-Analysis Comparing Epidural with Systemic Opioid Comparing Epidural with Systemic Opioid

Analgesia. Br J Ob Gyn 109:1344-1353, 2002Analgesia. Br J Ob Gyn 109:1344-1353, 2002

Concluded that a low concentration Concluded that a low concentration epidural is better than ‘natural childbirth’ epidural is better than ‘natural childbirth’ and that a ‘modern’ epidural’ is better and that a ‘modern’ epidural’ is better than ‘systemic opioids’ in terms of than ‘systemic opioids’ in terms of umbilical artery base deficit.umbilical artery base deficit.

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Gambling D, Sharma S, Ramin S, et al: A Randomised Study of CSE analgesia vs IV meperidine. Anesthesiol 89, 1336-1344, 1998

In their randomized study of CSE analgesia vs IV meperidine In their randomized study of CSE analgesia vs IV meperidine (pethidine), showed that fetal bradycardia can follow CSE.(pethidine), showed that fetal bradycardia can follow CSE.

Holdcroft A, Dob D: Regional Analgesia for Labour and Fetal Distress: Culprit or Innocent Bystander. IJOA 12:153-155, 2003.

Reflected that CSE is probably no worse than epidural in Reflected that CSE is probably no worse than epidural in producing fetal bradycardia and that it occurs with both producing fetal bradycardia and that it occurs with both intrathecal opioids and intrathecal local anaesthetics.intrathecal opioids and intrathecal local anaesthetics.

Page 14: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

Summary:Summary: RA: epidural, spinal, or combination, is

an integral part of pain relief in labor Although childbirth has become much

safer for mother and neonate, there is still room for improvement

Labor analgesia is it attainable, the answer is yes

Page 15: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

Epidural analgesia Epidural analgesia

the most effective method of providing pain relief during labor.

However, there’s a big challenge in providing epidural analgesia in remote areas, particularly in developing countries and also in small birthing centres where there is lack of expertise, resources and logistical support to provide safe epidural analgesia

Intrathecal Labor Analgesia (ILA) may have a role to play in these situations.

Page 16: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

ILA ILA

single shot spinal technique to provide labor analgesia;

it has the advantage of being a low cost technique that could be easily and safely executed.

If appropriately monitored and managed, ILA may result in reasonably prolonged analgesia and good maternal satisfaction

Page 17: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

General Considerations in ILAGeneral Considerations in ILA

The timing for the institution of ILA is vital.

However, the effects of cervical dilation and stage of labor on the duration of effective intrathecal analgesia have not been well characterized

Page 18: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

Comparison of ILA with other Comparison of ILA with other neuraxial techniques: neuraxial techniques:

Onset of action: ILA produces a more rapid onset of action than epidural analgesia. The rpaidity of onset is comparable with combined spinal epidural analgesia (CSE) but CSE, being inherently a ‘2 procedure’ technique, ie. spinal AND epidural, often takes a longer to complete.

Duration of action: As ILA is not ‘extendable’ it suffers from a soreter duration of action of analgesia wehn compared with CSE and epidural analgesia. The use of a multi-modal combination of intrathecal drugs, i,e local anaesthetics, opioids and other adjuvants may potentially prolong the duration of analgesia and reduce the need for a repeat ILA.

Page 19: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

Comparison of ILA with other Comparison of ILA with other neuraxial techniques: neuraxial techniques:

Affordability: this is the greatest advantage of ILA when compared with epidural or CSE. ILA dose not involve the insertion of catheters and does not require sophisticated pumps and infusion systems to maintain labour analgesia.

Simplicity of technique: most anaesthesiologists are familiar with the isntitution of spinal anaesthesia and ILA is just a modification of the technique of providing spinal anaesthesia but for the labouring women.

Reliability: With the use the correct technique and drugs, ILA provides reasonably relaible analgesia with preservation of motor power.

Page 20: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

Practical Considerations in ILAPractical Considerations in ILA

Analgesic drug regimen: A combination of local anaesthetics, opioids and clonidine is recommended

Page 21: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

Labor Analgesia• Hyperbaric upivacaine• Plain bupivacaine• Levobupivacaine• Ropivacaine • LidocaineHypotension • Ephedrine

RECIPE

• Adjuvant Adrenalin ClonidineOpioid Morphine Fentanyl

Page 22: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

•OUR RECIPE250 µg of morphine + 2.5 mg bupivacaine + 30-45 µg clonidine/25 µg fentanyl Breakthrough pain --> repeat spinal

RECIPE

Page 23: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

•OUR RECIPE for BREAKTHROUGH PAINIf < or = 4 hours fentanyl + bupi + clonidine If > 4 hours to Mo + fentanyl/clonidine + bupi

RECIPE

Page 24: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

Conclusion Conclusion

In attempting to provide optimal labor analgesia, it is important to weigh the risks against benefits of any particular technique.

This must take in to consideration factors such as the timing of intervention and the place of practice.

Cost, accessibility, and human resources are other considerations.

Page 25: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

Conclusion Conclusion

It inadvisable to use an expensive or complicated technique in rural areas where there is limited medical access.

A properly performed ILA is a very cost effective technique for a pain relief in labour that can be recommneded as an alternative to CSE or epidural analgesia in areas where access to medical care is limited

Page 26: Labor analgesia Is It Attainable - Susilo Chandra, MD, FRCA

THANK YOUTHANK YOU


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