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Pain relief in labour in low resource setting
DR. MANISH R PANDYAMD FICOG FICMCH
PROFESSOR AND HODSURENDRANAGAR
www.drmanishpandya.com
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)
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
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
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
Nature of Labor Pain –1st Stage
• Visceral pain–Diffuse abdominal cramping–Uterine contractions
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
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.
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• 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.
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Stages of Labour
Pain pathways during labor
Trends…• Nulliparous
–More sensory pain during early labor
• Multiparous–More intense pain during late 1st
stage and the 2nd stage• Rapid fetal descent
What determines maternal satisfaction?
Pain reliefQuality of relationship with
caregiverParticipation in decision makingHome-like birth environmentCaregivers with whom they are
acquainted personally
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.
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)
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
Methods of Pain Relief• Nursing measures• Relaxation techniques• Breathing techniques• Systemic analgesia• Regional nerve blocks• Local anesthetics• General anesthesia
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
Systemic Analgesics
1) Stadol 2) Nubain 3) Demerol 4) Seconal 5) Nembutal 6) Phenergan 7) Vistaril 8) Narcan
Differentiation of regional
blocks (usually done by anaesthetist) and
field blocks (commonly performed by obstetrician)
BMJ. 1999 April 3; 318(7188): 927–930.
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)
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
Non-pharmacological methods
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)
• 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
• 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
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
Lamaze technique• Prepared child birth, including
relaxation techniques, breathing exercises etc
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
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)
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
• 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
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
“SLOW PACED” Breathing
“MODIFIED-PACE” Breathing:
Combination of slow and modified paced breathing: “Patterned – paced” Breathing: (Pant – blow)
Breath holding while pushing:
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.
• 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
Acupuncture• Traditional Chinese therapy• Releases endorphins and
enkephalins
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.)
Physical therapy• Massage• Counter pressure• Hot and Cold Compresses• Light stroking or “Effleurage”
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
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!
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
Distraction • Using music• Listening to jokes• Playing cards
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.
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"
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)
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
Labour Analgesia
Stress
INtervention Fetal Stress & Acidosis
Alleviates pain
PAIN
FEARTENSION
PROGRAMMED LABOUR - Methodology
• Proper selection , Counseling & Consent
• Labour induction / Acceleration
• All medication in Active phase of Labour
• Commence PARTOGRAPHIC monitoring
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
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
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
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
Post delivary evaluation
• Pain relief score• Amnesia score• Patient attitude record
– Satisfied with analgesia protocol– Dissatisfied with analgesia protocol
STUDY REPORT
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
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
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
Age distribution
Age 20 20-25 25-30
Primi 150 100 70
Multi 20 50 110
Total 170 150 180
Duration of labour
TIME 2-4 HRS
4-6 HRS
6-8 HRS
PRIMI 80 100 140MULTI 60 20 100TOTAL 140 120 240
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
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
Mode of delivary
Mode of delivary Normal Operative
vaginal Lscs
Primi 263 23 34
Multi 147 33 -
Total 410 56 34
DR.MANISH PANDYA
Neonatal outcome
Apgar score < 7 Nicu care Perinatal
morbidity
Primi 320 - -
Multi 180 - -
Total 500 - -
DR.MANISH PANDYA
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
Drugs used in third stage
Methyl ergometrine
Prostagalndine Oxytocine
Primi 160 160 -
Multi 90 90 -Total 250 250 -
DR.MANISH PANDYA
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
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
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
All is well!• Patient – No Pain• Dr – Easy Schedule!• Baby – Safe
Presentation designed & developed By
Dr Darshna ThakkerMB, MD, DHA, MBAConsultant Gynecologist &
Obstetricianwww.sarjanhealthcare.com
+91 98240 69989