TOG 2015
Introduction
- Pain first stage → T10-L 1, 2nd stage→ S2-S3
- Most important factor during labour→ continuous support
- Gold standard analgesia in labour → EPIDURAL
- Acupuncture → 11% relief , Birthing Ball → 30-40%
- TEN→ 60% will want it again
Non Pharmacological methods
- continuous one to one care
- Prenatal information
- Music
- Aromatherapy
- Acupuncture and Acupressure
- Birthing Balls & Postures
- Transcutaneous electrical nerve stimulation
- Sterile water injection
- Water immersion
- Hypnosis — meta analyses disagree over the effectiveness
- Biofeedback — failed to reach conclusion regarding the effectiveness in labour
- Breathing /relaxation techniques and massage
Pharmacological methods
Nitrous Oxide
- Suitable for ALL
- MOA→ suppress activity in reticuloendothelial system & increases dopamine, endorphin & corticotrophins
- 1/2 life→ 2-3 min
Opioids
- Most commonly used→ Pethidine
- Opioid receptors present in → peri-aquedactal grey brain + spinal cord with sparse other locations
- these receptor activation leads to a reduction in neuronal cell excitability and transmission of nociceptive impulses
- Neonates → may take 6 days to clear
- Diamorphine → Better analgesia but increase delivery time 82 min so not used
Remifantanil
- Rapidly acting
- Cleared by tissue esterases
- 1/2 life→ 3 min
- Must monitor→ O2 saturation
- Respiratory depression → 30%
- Decreased PO2 <90%→ 5%
- Tolerance → in 60 min
- Failure to work → 10%
- Relative contraindications→ Primigravida, Morbid obesity, Chest Infection
Epidural
- Local analgesic→ blocks Na channels in nerve cell membranes (L4-S1)
- Mobile analgesia
- Risks
- 1:54000 permanent injury
- 1:140000 paraplegia/death
- Prolonged 2nd stage
- Increased instrumental delivery
- No effect on → duration of 1st stage, C/S, long-term back problems
- Improved neonatal acid-base balance
- If patient request regional→ Anaesthesist must attend within 30 min
- Early epidural advised in obese
- Maternal request is sufficient indication for epidural (even near fully/ fully dilated)
- Adverse effects:
- Failure to work → 10%
- Signs of hypotension → 2%
- Severe headache→ 1%
- Temporary Nerve damage → 1: 13000
- Permanent Nerve damage → 1:10000
- Infection/Meningitis/Blood Clots→ <1:50000
- Contraindications to regional analgesia
- Maternal refusal
- Local + untreated systemic infection
- Platelets <80
- INR >1.4
- Significant haemorrhage expected
- Spinal cord injury/surgery
- Non availability of trained staff
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