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Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD...

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Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR www.drmanishpandya.co m
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Page 1: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Pain relief in labour in low resource setting

DR. MANISH R PANDYAMD FICOG FICMCH

PROFESSOR AND HODSURENDRANAGAR

www.drmanishpandya.com

Page 2: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

FROM THE HOLY QURAN

IN THE NAME OF ALLAH THE MOST BENEFICIENT THE MOST MERCIFUL

“AND THE PAINS OF CHILDBIRTH DROVE HER TO THE TRUNK OF A DATE PALM. SHE SAID “ WOULD THAT I HAD DIED BEFORE THIS, AND HAD BEEN

FORGOTTEN AND OUT OF SIGHT”.

SURAH 19: 23 (SURAH MARYAM)

Page 3: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Goals Of Labor Analgesia

• Dramatically reduce pain of labor• Should allow parturient to

participate in birthing experience• Minimal motor block to allow

ambulation• Minimal effects on fetus• Minimal effects on progress of

labor

Page 4: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

The Debate…“Labor results in severe pain for many

women. There is no other circumstance where it is considered acceptable for a person to experience untreated severe

pain, amenable to safe intervention, while under a physician’s care…

Maternal request is a sufficient medical indication for pain relief during labor.”

ACOG & ASA

Page 5: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Nature of Labor Pain• Pain is subjective

– Complex interaction of influences• Physiologic• Psychosocial• Cultural• Environmental

Expectations are often confirmed…• Anxiety and fear = higher experience

of pain• Confidence in her ability to cope

*Safe and positive birth environment

Page 6: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Nature of Labor Pain –1st Stage

• Visceral pain–Diffuse abdominal cramping–Uterine contractions

Page 7: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Nature of Labor Pain – 2nd Stage

• Somatic pain–Perineum

• Sharper and more continuous

• Pressure or nerve entrapment (caused by the fetus’ head)–May cause severe back or leg

pain

Page 8: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Pain pathways during labor • Pain is sensation of discomfort

resulting from stimulation of specialized nerve endings

• During labor, pain sensation is relayed to the spinal cord from T10, L1, S1-S4. These sensory fibers make synaptic connections in dorsal horn of spinal cord with cells that provide axons that make up the spinothalamic tract.

8

Page 9: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

• 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.

9

Page 10: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Stages of Labour

Page 11: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Pain pathways during labor

Page 12: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Trends…• Nulliparous

–More sensory pain during early labor

• Multiparous–More intense pain during late 1st

stage and the 2nd stage• Rapid fetal descent

Page 13: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

What determines maternal satisfaction?

Pain reliefQuality of relationship with

caregiverParticipation in decision makingHome-like birth environmentCaregivers with whom they are

acquainted personally

Page 14: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Purpose• To help obstetrician-gynecologists

understand the available methods of pain relief to facilitate communication with their colleagues in the field of anesthesia

• To optimizing patient comfort while minimizing the potential for maternal and neonatal morbidity and mortality.

Page 15: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Labor Pain• Uterine contractions and cervical

dilatation result in visceral pain (T10 to L1). As labor progresses, the descent of fetal head and subsequent pressure on the pelvic floor, vagina and perineum generate somatic pain transmitted by pudendal nerve (S2 to S4)

Page 16: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Objectives• Discuss categories

of pain relief methods

• Discuss types and pro’s and con’s

• Discuss commonly used meds during labor and childbirth

• Discuss regional analgesia and anesthesia

• Identify data for assessment of a client receiving pharmacologic methods of pain relief

• Formulate nursing diagnosis and select interventions appropriate for the client receiving pharmacologic pain relief

Page 17: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Methods of Pain Relief• Nursing measures• Relaxation techniques• Breathing techniques• Systemic analgesia• Regional nerve blocks• Local anesthetics• General anesthesia

Page 18: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Assessment of the Client• Three major factors influence the

administration of pharmacologic pain relief: 1) effect on the client , 2) effect on the fetus, and effect on the contraction pattern

• The use of electronic fetal monitoring may influence administration of medication

• All systemic drugs used for pain relief during labor cross the placental barrier by simple diffusion

Page 19: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Systemic Analgesics

1) Stadol 2) Nubain 3) Demerol 4) Seconal 5) Nembutal 6) Phenergan 7) Vistaril 8) Narcan

Page 20: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Differentiation of regional

blocks (usually done by anaesthetist) and

field blocks (commonly performed by obstetrician)

BMJ. 1999 April 3; 318(7188): 927–930.

Page 21: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Other than techniques• These four factors make the greatest

contribution to women's satisfaction in childbirth: – having good support from caregivers – having a high-quality relationship with caregivers – being involved in decision-making about care – having better-than-expected experiences, or

having high expectations.

• Pain relief only becomes important for satisfaction in childbirth when expectations are not met

(Hodnett 2002, a systematic review)

Page 22: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Pain relief techniques• Water birthing• Music• Heat and cold• Imagery • Rhythmical

movements• Massage• Relaxation• Breathing• Perineal massage• Intra dermal

injections of sterile water

• Narcotics• Twilight sleep• Entonox• Lamaze technique• Hypnotism• Acupressure /

Shiatsu• Acupuncture• Electro-acupuncture• TENS• Intrathecal narcotics• Epidurals

Page 23: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Non-pharmacological methods

Page 24: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Water birth

• Soviet researcher Igor Charkovsky and French obstetrician Frederick Leboyer developed in 1960s

• Practices in United States, Canada, Australia, and New Zealand, as well as many European countries, including the United Kingdom and Germany

• By 2005, over 9000 hospitals in the US and more than three-quarters of all NHS hospitals (UK) provided this option

(Dianne Garland. Waterbirth: An Attitude to Care)

Page 25: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

• Provides pain relief and a less traumatic birth experience for the baby

• Redistribution of blood volume, which stimulates the release of oxytocin and vasopressin (Katz 1990)

• Exerts gravitational pull • Aid stretching of the perineum, slows

crowning of the infant's head, reduces the use of episiotomy

Page 26: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

• A decrease in perinatal mortality (1.2 per 1,000 for waterbirth vs. 4 per 1,000 for conventional birth) during 1994-1996 in the UK

• Risks to the infant such as infection and water inhalation?

• "there are no valid reports of infants deaths due to water aspiration or inhalation" (Harper 2000)

• Slowed labor? A decrease in the intensity of contractions - a "5 centimeter" rule

• Maternal blood loss? - Difficult to assess• The amount of blood loss reduced due to

lowering BP and heart rate

Page 27: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Music• Ancient Greeks played

soothing instrumental music to women in labour

• Alters mood, reduces stress and promotes positive thoughts

• A trigger for a breathing response or as a cue for relaxation

• Used as a distraction

Page 28: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Lamaze technique• Prepared child birth, including

relaxation techniques, breathing exercises etc

Page 29: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

TENS• TENS (transcutaneous electrical

nerve stimulation)• Stimulates the release of

endorphins• Most useful in labour before the

pain becomes too intense• Drug dose requirements may be

less

Page 30: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Hypnotherapy • Mongan method (also known as HypnoBirthing),

Hypnobabies, the Lamaze method, Natal Hypnotherapy and the GentleBirth program

• Useful for heartburn, high blood pressure and postnatal depression

• can significantly shorten labor, reduce pain and reduce the need for intervention, produced higher apgar scores, reduce the incidence of postpartum depression and increase the incidence of spontaneous deliveries

(British Journal of Obstetrics and Gynaecology, 100(3), 221-226, 1993)

Page 31: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Relaxation techniques • Providing a stress-free period during

the antenatal period helping in preparing the woman and also in growth of the foetus

• Decreasing the tension, fatigue, discomfort and pain of labour. It also increases the oxygen going to the baby

• Helps in providing a stress-free period during pueperium (i.e. after delivery). Thus helping in lactation and bonding between the couple and little one

Page 32: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

• Start by doing slow breathing. • Body awareness / tension recognition• Contract relax method • Toes; feet; ankles; knees; thighs;

buttocks; back; abdomen; chest; shoulders; fists; head; Clench teeth; face; eyebrows

• Touch Relaxation - a conditioned reflex

Page 33: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Breathing techniques• In some women, relaxation alone

may not be sufficient to counter the discomfort of labour In such cases breathing techniques can be used to augment the efficacy of relaxation techniques used only during contraction

Page 34: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

“SLOW PACED” Breathing

“MODIFIED-PACE” Breathing:

Combination of slow and modified paced breathing: “Patterned – paced” Breathing: (Pant – blow)

Breath holding while pushing:

Page 35: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Acupressure• For relieving head / neck and upper backache

apply circular pressure on the muscles at the top of the shoulder in vertical line with the nipples near the back.

• Massaging the center of the sole, below the ball of the feet will relax the lower body.

• To relieve low backache, pelvic discomfort or pain, press firmly in an inward direction on either side of the vertebral column, below the waist level. Circular pressure is applied during contraction and intermittent pressure between contractions.

Page 36: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

• The ball of the thumbs is the part that is used to put the pressure. Do not use your nails or the tip of the thumb

• apply the pressure in a circular motion• to release the pressure point when the

pregnant women exhales and then one must transfer to another acupressure point

• Large areas of the body include the shoulder point, the buttock point and the thighs

Page 37: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Acupuncture• Traditional Chinese therapy• Releases endorphins and

enkephalins

Page 38: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Electro-acupuncture • a significant difference in the

concentration of β-endorphin (β-EP) and 5-hydroxytryptamine (5-HT) in the peripheral blood between the two groups at the end of the first stage (p = 0.037; p = 0.030)

• producing a synergism of the central nervous system (CNS) with a direct impact on the uterus through increasing the release of β-EP and 5-HT into the peripheral blood.

(Fan Qu, Jue Zhou. Electro-Acupuncture in Relieving Labor Pain. Evid Based Complement

Alternat Med. 2007 March; 4(1): 125–130.)

Page 39: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Physical therapy• Massage• Counter pressure• Hot and Cold Compresses• Light stroking or “Effleurage”

Page 40: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Massage• Touch has been associated

with the power of healing since the beginning of civilisation

• a source of counter-stimulation • Examples; Therapeutic massage

(eg: shiatsu), perineal massage

Page 41: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Methods of touch and massage

• Lightly stroking the abdomen • Vigorously firm stroking where it hurts most • Firm circular massage using the palm of the

hand over the centre of the back or sacrum. • Rhythmical squeezing and letting go of the

shoulder muscles • A long stroke down the length of the back,

buttocks and down the back of the legs• Stroking across the forehead, down the

neck and down the arms simply holding hands!

Page 42: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Shiatsu

Japanese form of therapeutic massage. Shiatsu means ‘finger

pressure’. Similar to acupuncture.

Pain-relieving pressure points (‘tsubo’) are stimulated without

the use of needles

Page 43: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

 Distraction • Using music• Listening to jokes• Playing cards

Page 44: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Intra dermal injections of sterile water • Intense stinging followed by relief of

backache for 60 – 90 minutes• May be due to release of endorphins or by

counter-irritation

0.1 ml of sterile water is injected into four locations on the lower back, two over each posterior superior iliac spine (PSIS) and two 3 cm below and 1 cm medial to the PSIS. The injections should raise a bleb below the skin.

Simkin PP, O'Hara M. Nonpharmacologic relief of pain during labor: systematic eviews of five methods. Am J Obstet Gynecol 2002;186(Suppl 5): S131-59.

Page 45: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Twilight sleep • Known and more or less used since

1903• "Freiburg Method," • "Dammerschlaf" of Gauss• "scopolamine-morphine" method of

obstetric anesthesia• Monitoring: pupils, pulse, respiration,

character of the uterine contractions and the character of the fetal heart action "memory tests"

Page 46: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Cochrane review • We found evidence that acupuncture

and hypnosis may help relieve labour pain

• There is insufficient evidence about the benefits of music, massage, relaxation, white noise, acupressure, aromatherapy

• No evidence about the effectiveness of massage or other complementary therapies

(Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative therapies for pain management in labour. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD003521. DOI: 10.1002/14651858.CD003521.pub2)

Page 47: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Use of drugs for pain relief• Immediate short term relief :

Pentazocine HCl – 6.0 mg + Diazepam – 2.0 mg

• Long term Pain Relief : Tramadol : 50 – 100 mg IM

• Supplementation in Advance Labour –SOS KETAMINE : Continuous infusion Intermitted IV boluses ; Loading Dose – 0.5 mg /kg wt: Maintenance doses : 0.25 mg /kg wt every 30 min

Page 48: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Labour Analgesia

Stress

INtervention Fetal Stress & Acidosis

Alleviates pain

PAIN

FEARTENSION

Page 49: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

PROGRAMMED LABOUR - Methodology

• Proper selection , Counseling & Consent

• Labour induction / Acceleration

• All medication in Active phase of Labour

• Commence PARTOGRAPHIC monitoring

Page 50: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Procedure & medication• Active phase of Labour:• Amnioinfusion /oxytocin drip /P.G.• Infusion – 5% glucose /Ringer Lactate• I.V. bolus Pentazocine HCl 6.0 mg +

Diazepam 2.0 mg• I.M Drotaverine / Camylofin/

Valethamate Bromide/ Buscopan• Commence partogram

Page 51: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Procedure & medication Analgesia in advance labour

Ketamine intermittent I.V after 7.0 cm dilatation

Active management of third stage: Active management of third stage with

125.mg PGF2a /Methergine Post delivery evaluation :

Degree of pain relief – Extent of amnesia

Page 52: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Active phase of labour• Amniotomy /Oxytocin drip / P.G• Infusion – 5% Glucose / Ringer lactate• I.V bolus Pentazocine Hcl 6.0 mg +

Diazepam 2.0 mg • IM Tramadol 50.0.100.0 mg• IM Drotaverine /

Camylofin/Valathamide bromide / Buscopan

• Commence Partogram

Page 53: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Analgesia in advance labour

• Ketamine intermittent I.V after 7.0 cm dilatation

• Anesthetic dose – 2mg /kg body wt.• For labour Analgesia – initial dose 0.5 mg /kg wt -top up dose 0.25 mg/kg

wt.Wide margin of safety

Page 54: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Post delivary evaluation

• Pain relief score• Amnesia score• Patient attitude record

– Satisfied with analgesia protocol– Dissatisfied with analgesia protocol

Page 55: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

STUDY REPORT

Page 56: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Medication protocol• This study of 500 case for evaluation

of programme labour protocol in private set up

• 320 patient of primipara and 180 patient of multiparity are included in study

• Selection of patients are done after they enter into active labour i.e. after 3 cm cervical dilatation

Page 57: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Medication protocol• At admission of patient enema given • As they enter into active phase

-Administer 6.0 mg Pentazocine and inj. Diazepam 2.0 mg as bolus slowly through the infusion line . This provides short term pain relief.

• Injection Drotine or Tramazac is also given

Page 58: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Medication protocol • Injection velocine are given at

1 hour interval to all patients• After the dose of fortwin and

campose all patients were relived with pain and so many are in sound sleep.

• Cervical dilatation is very fast when they are in sleep and progress of labour is speedy

Page 59: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Age distribution

Age 20 20-25 25-30

Primi 150 100 70

Multi 20 50 110

Total 170 150 180

Page 60: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Duration of labour

TIME 2-4 HRS

4-6 HRS

6-8 HRS

PRIMI 80 100 140MULTI 60 20 100TOTAL 140 120 240

Page 61: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Pain score

Pain score 3 pain unbearable

2 pain is severe

1 pain bearable

Pt. Demand relief

Pt. Seek relief

Pt. Doesn’t desire relief

Primi 280 40 -

Multi 100 60 20

Total 380 100 20

Page 62: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Relief of pain

Pain relief score

1 .Not to the desire

extent

2 . substantial

relief of pain

3. Complete relief of

painPrimi 20 60 240

Multi 40 20 120

Total 60 80 360

Page 63: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Mode of delivary

Mode of delivary Normal Operative

vaginal Lscs

Primi 263 23 34

Multi 147 33 -

Total 410 56 34

DR.MANISH PANDYA

Page 64: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Neonatal outcome

Apgar score < 7 Nicu care Perinatal

morbidity

Primi 320 - -

Multi 180 - -

Total 500 - -

DR.MANISH PANDYA

Page 65: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Weight of babies

Weight 2.5 kg 2.5-3.0kg 3.0-3.5 kg

Primi 40 230 50

Multi - 100 80

Total 40 330 130

DR.MANISH PANDYA

Page 66: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Drugs used in third stage

Methyl ergometrine

Prostagalndine Oxytocine

Primi 160 160 -

Multi 90 90 -Total 250 250 -

DR.MANISH PANDYA

Page 67: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Duration of third stage

Drugs < 3 min 3 -6 min Amount of blood loss

Methylergomertine 48 112 Routine

Prostaglandine 89 01 Markedly less

Oxytocine - - Not used

DR.MANISH PANDYA

Page 68: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Conclusion• In this study >> duration and pain

during labour is shortened• Rate of LSCS has gone down• Neonates are in good Apgar score

and no entry into NICU• We can adjust our schedule with

programmed labour • Injecting the remains of Inj. Fortwin

and Inj. Anxol into Injection Dextrose 5% will give excellent relief of pain in early postpartum

DR.MANISH PANDYA

Page 69: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Conclusion

• Patient experience is fantastic as number of new delivery is increased in practice

• Patient attitude towards this protocol is appreciable by both patients as well as relatives

• It may spread rumors like we make patients sleep and arrest the progress of labour as she in not taking pain while in sleep

• Sincere thanks to Dr.Daftary for giving such wonderful protocol for safe motherhood

DR.MANISH PANDYA

Page 70: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

All is well!• Patient – No Pain• Dr – Easy Schedule!• Baby – Safe

Page 71: Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR .

Presentation designed & developed By

Dr Darshna ThakkerMB, MD, DHA, MBAConsultant Gynecologist &

Obstetricianwww.sarjanhealthcare.com

+91 98240 69989


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