ANALGESIA AND ANAESTHESIA IN LABOR

Analgesia in normal labor

Labor pain is experienced by most women with satisfaction at the end of a successful labor. Antenatal classes, sympathetic care and encouraging environment during labor can reduce the need of analgesia. The intensity of labor pain depends on the intensity and duration of uterine contraction, degree of dilatation of cervix, distension of perineal tissue, parity and the pain threshold of the subject. The most distressing time during the whole labor is just prior to the full dilation of the cervix. The drug must be non-toxic and safe for both mother and fetus METHODS OF PAIN RELIEF Sedatives and analgesics Inhalation agents Regional analgesia Patient controlled analgesia (PCA) Transcutaneous electrical nerve stimulation (TENS) Psychoprophylaxis. General anesthesia.

Sedatives and Analgesics

The following factors are important to control the dose of sedatives and analgesics 1. The threshold of pain 2. Primigravidae or multigravidae the multiparous women need less analgesia due to added relaxation of the birth canal and rapid delivery. 3. Maturity of the fetus minimal dose of drug is indicated while the fetus is thought to be premature to avoid the risk of neonatal asphyxia. purpose of selecting a analgesic agent, labor is divided in to 2 phase.

First phase corresponds up to 8cm dilation of cervix in primi and 6cm in multi. Second phase corresponds to dilation of the cervix beyond the above limits upto delivery. The first phase is controlled by sedatives and analgesics and the second phase is controlled by inhalation agent.the idea is to avoid the risk of delivery of a depressed baby. OPIOID ANALGESICS Pethadine : it has got strong sedative but less analgesic efficacy. Pethadine is generally used in the first phase of labor and indicated when the discomfort of labor merges into regular, frequent and painful contractions. The initial dose is 100mg i.m. and repeated as the effect of the first dose begins to wane, without waiting for the re-establishment of labor pain. Side effects:For mother; nausea, vomiting, delayed gastric empting. For fetus; respiratory and suckling depression. Meptazinol has got similar similar analgesic and sedative property as that of pethadine. It causes less respiratory deoression of the newborn Pentazecin ( Fortwin ) : it is given I.M in a dose of 30-40 mg.its duration is shorter and causes some respiratory depression. It also cause drug dependence. Naloxone is an efficient and reliable antagonist. To antagonize the effect of narcotics given to mother when the labor proceeds more rapidly than anticipated, naloxone in a dose of 0.4 mg should be given i.v and may be repeated at 3 mts interval or i.v and repeated if necessary when the infant is born with narcotic depression.

 Tranquilisers : Diazepam : it is well tolerated by the patient.it does not produce vomiting and helps in the dilation of cervix. It is matabolised in the liver. The usual dose is 5-10mg. it may be used in larger doses in the management of pre-eclampsia. Midazolam is more potent and neonatal side effects are less compared to diazepam. It has good anxiolytic property. It is cleared from the tissue more rapidly. Dose of 0.05 mg/kg is given i.v. Combination of narcotics and tranquilisers: narcotics may be used in combination with promethazine, chlorpromazine, or promazine.

INHALATION METHOD 1. Nitrous Oxide and air: nitrous oxide has minimal effect on the fetus and does not interfere with uterine contraction.this agent is used in the second phase. Now a days, nitrous oxide and air are not used because this mixture produce hypoxia. 2. Premixed nitrous oxide and oxygen: cylinders contain 50 % nitrous oxide and 50% oxygen mixture. Entonox apparatus has been approved for use by midwives. It can be self administered. 3. Trichloroethylene (trilene ): this is an useful drug in labor with high analgesic effect. It gives better result in nervous and strung women than nitrous oxide. It is no longer used these days. 4. Methoxyflurane, isoflurane, enflurane: they are good analgesic agents and more effective than trichloroethylene.

REGIONAL ANAESTHESIA When complete relief of pain is needed throughout labor, epidural analgesia is the safest and simplest method for procuring it. 1. Continuous lumbar epidural block :

A lumbar puncture is made between L2 and L3 with the epidural needle (Tuohy needle). With the patient on her left side, the back of the patient is cleansed with antiseptics before injection. when the epidural space is ensured, a plastic catheter is passed through the epidural needle for continuous analgesia. Repeated dose of 4-5 ml of 0.5 percent bupivacaine or 1 % lignocaine are used to maintain analgesia. Contraindication to epidural analgesia:- Sepsis at the site of injection. - Haemorrhage disease or anticoagulant therapy. - Supine hypotension. - Hypovolaemia. - Neurological disease. - Spinal deformity or chronic low back pain. Complications of epidural analgesia:- Hypotension due to sympathetic blockade. Parturient should be well hydrated with crystalloid solution beforehand. - Pain at the insertion site. - Post spinal headache due to leakage of cerebrospinal fluid through the needle hole in the dura. - Total spinal due to inadvertent administration of the drug in the subarachnoid space. - Injury to nerves. 2. Caudal epidural analgesia: With the patient in left lateral position and after full aseptic precautions. The sacral hiatus is identified and a malleable needle is pushed through it, first piercing the skin and the sacro-coccygeal ligament at right angle and then depressing the needle towards the natal cleft so that the needle lies at an angle of 400 to the skin the needle is gently advanced in to sacral canal. The stylet is withdrawn and an aspiration test is carried out to ensure that the dura or vein is not punctured. An epidural nylon catheter is

passed through the needle and the needle is then withdrawn 16ml to 20 ml of 1% lignocaine is passed and relief of pain becomes established within 1020 mts. Bupivacaine (0.5%) can be used for prolonged analgesia. Caudal analgesia is rapidly falling into discus because the approach to the epidural space through sacral hiatus is dirtier, harder and fails more often. 3. Paracervical nerve block: It is useful for pain relief during the first stage of labor. Following the usual antiseptic safe guards, a long needle(15cm or more) is passed in to the lateral fornix, at the three and nine o clock position. 5-10 ml of 1% lignocaine with adrenaline are injected at the site of the cervix and the procedure is repeated on the other side.bupivacane is avoided due to its cardiotoxicity. Paracervical block should not be used where placental insufficiency is present.fetal bradycardia is a known complication. 4. Pudental nerve block: It is a safe and simple method of analgesia during delivery. Pudental nerve block does not relieve the pain of labor but affords perineal analgesia and relaxation. Pudental nerve block is mostly used for forceps and vaginal breech delivery. The pudental nerve may be blocked by either the transvaginal or the transperineal route. 5. Transvaginal route: Transvaginal route is commonly preffered. A 20ml syringe/ one 15cm 17-20G spinal needl;e and about 20ml of 1% lignocaine hydrochloride are required. The index and middle fingers of one hand are introduced into the vagina, the finger tip are placed on the tip of the ischial spine of one side. The needle is passed along the groove of the finger and guided to pierce the vaginal wall on the apex of spine and thereafter to push a little to pierce the sacrospinous ligament just above the ischial spine tip. After aspirating to exclude blood, about 10ml of the solution is injected. The similar procedure is adopted to block the nerve of the other side by changing the hands.

6. Spinal anesthesia: Spinal anesthesia can be employed to alleviate the pain of delivery and during the third stage of labor. For normal delivery or for outlet forceps with episiotomy, block should extend to S1. Procedure: Spinal anesthesia can be obtained by injecting 1ml of hyperbaric lignocaine (5%) into the subarachanoid space of the third or fourth lumbar interspace. Advantages: -less fetal hypoxia -easy technique -no inhalation anesthesia is require. Disadvantages: -hypotension due to block of sympathetic fibres leading to vasodilation and low cardiac output. -respiratory depression may occur. -postspinal headache-due to low or high CSF pressure and leakage of CSF. -meningitis due to faulty asepsis. -transient or permanent paralysis. -toxic reaction of local anesthetic drug. -nausea and vomiting are not uncommon. -urinary retention. PATIENT CONTROLLED ANALGESIA (PCA) Narcotics are administered by the mother herself from a pump at continuous or intermittent demand rate through I.V route. This offers better pain control than high doses given at a long interval by the midwife. Maternal satisfaction is high with this method. Drug commonly used are pethidine, meperidine or fentanyl. PSYCHOPROPHYLAXIS It is psychological method of antenatal preparation designed to prevent or at least to minimize pain and difficulty during labor. Relaxation and motivation can reduce the fear and apprehension to a great extent.

Patient is taught about the physiology of pregnancy and labor in antenatal classes. Relaxation exercises are practiced. Husband or the partner is also involved in the management. His presence in labor would encourage the bearing down efforts. Need of analgesia would be less. TRANSCUTANEOUS ELECTRIC NERVE STIMULATION (TENS) It is a noninvasive procedure and is preferred by many women during labor, electrodes are placed over the level of T 10-L1 and S2-4. Current strength can be adjusted according to pain. It works by transmitter release through inter neurone level. However , no change in pain score was observed when TENS was switched on. GENERAL ANESTHESIA FOR CAESARIAN SECTION The following are the important considerations of general anesthesia for caesarian section: - Caesarian section may have to be done either as an elective or emergency procedure. - The mother may have a full stomach raising the probability of aspiration - A large number of drugs pass through the placental barrier and may depress the baby. - Uterine contractility may be diminished by volatile anesthesia agents like ether, halothane. - Hypoxia and hypercapnia may occur. - Time interval from uterine incision to delivery is related directly to fetal acidosis and hypoxia. - Long the exposure to general anesthetic before delivery the more depressed is the apgar score. Procedure: 100% oxygen is administered by mask. Induction of anesthesia is done with the inj thiopentone sodium 200 to 250mg (4mg /kg) as as a 2.5 % solution I.V followed by refrigerated suxamethonium 100mg.

the patient is intubated with a cuffed endotracheal tube. Anesthesia is maintained with 50% nitrous oxide, 50% oxygen and a trace (0.5%) of halothane. Relaxation is maintained with nondepolarising muscle relaxant. After delivery of the baby, the nitrous oxide concentration should be increased to 70% and narcotics are injected I.V to supplement anesthesia. Complication of General Anesthesia: Aspiration of gastric contents (Mendelsons syndrome) is a serious and life threatening one. The complication is due to aspiration of gastric acid contents with the development of chemicals pneumonitis and bronchopneumonia. Other complication: - Failure in intubation and ventilation. - Nausea, vomiting and sore throat Prevention: The following safety measures should be taken to prevent this complication:- Patient should be NBM. - H2 blocker (Tab Ranitidine 150mg) should be given night before (elective procedure) and to be repeated (50mg) one hour before the administration of GA, to rise the gastric ph - Metoclopramide (10mg I.V) is given after minimum 3minute of pre-oxygenation to decrease gastric volume and to increase the tone of lower esophageal sphincter. - Non-particulate antacid(0.3 molar sodium citrate) is given orally before transferring the patient to theatre to neutralizing the existing gastric juice. - Intubation with adequate cricoid pressure following induction should be done. - Awake extubation should be a routine.