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Obstetric Analgesia & Anaesthesia Pain Pathway during Labour Systemic Medication Benzodiazepines Benefits Anxiolytics Adjuvant to narcotics

Premedicant to LSCS Preeclampsia, eclampsia

Pain 1st Stage of Labour Uterine contraction Cervical dilatation Pathways Sympathetic pathway T10 -L1 Referred pain to cutaneous T10-L1 Lumbosacral plexus L5S1 Sites of pain Early 1st stage T11-T12 Late 1st stage T10 -L1 Backache 2nd Stage of Labour Perineal stretching Somatic nerves Pudendal nerve Posterior cutaneous nerve of thigh Ilioinguinal nerve S2,3,4 Sites of pain Perineal region Sacral region

Stress Response to Pain in Labour CVS Maternal CO ( stroke volume, heart rate) Greatest increase in CO immediately after delivery y Venous return y Relief of venocaval compression y Autotransfusion (resulting from uterine involution) Respiratory Hyperventilation (due to pain in labour) Maternal hypocarbia Respiratory alkalosis Compensatory metabolic acidosis O2-dissociation curve shift to left - O2 transfer to tissue (compromised by O2 consumption associated with labour) Hormonal Release of -endorphine, ACTH from anterior pituitary (due to pain, anxiety) Adrenaline, Noradrenaline (from adrenal medulla) (lead to progressive rise in peripheral resistance, cardiac output) Activation Sympathetic Activity Autonomic Nervous System Incoordinate uterine action Delays gastric emptying Prolonged labour Intestinal peristalsis Abnormal fetal heart-rate patterns Metabolic Maternal Fetal Glucagon, GH, Renin, ADH Maternal catecholamines secreted Insulin, testosterone (cause fetal acidosis) Ideal Labour Analgesia Maternal, fetal safety Ease of administration Consistent, predictable, rapid onset Maternal composure, control during 1st, 2nd stages of labour Analgesia through all stages of labour Devoid of motor blockade, enable ambulation, various birthing positions Preserve stimulus for expulsive efforts during 2nd stage of labour Retain maternal expulsive efforts Facilitate delivery of supplemental analgesia (without additional invasiveness) Facilitate delivery of analgesia for surgery (avoid need for general anaesthesia)

Adverse Effects Hypotonia Lethargy Feeding Hypothermia Beat to beat variability of fetal heart Maternal sedation (minimal fetal respiratory depression) Crosses placenta No adverse effects on acid-base, clinical status Opioids (Pethidine, Morphine, Fentanyl, Remifentanil) Adverse Effects Maternal Fetal Drowsy, sleepy Respiratory depression Nausea, vomiting Antidote Naloxone (at birth) Suppress cough reflex NSAIDs Paracetamol Mefenamic acids Cox 2 Inhibitors Celecoxib, Valdecoxib Indications y Perineal pain after delivery y Post-caeserean section y Contraction pain post delivery Some amount secreted via breast milk (not significant level in baby) Inhalation Agents (Nitrous oxide, ENTONOX NO:O = 50:50) Pain relief in 1st, 2nd stages of labour Not Associated With Benefits Uterine tone Self administered Strength of contractions Rapid onset, offset Responsiveness to oxytocins No accumulation in mother Neonatal acid-base status No effects on uterine contraction Respiration No effect on oxytocics responsiveness Oxygenation No change in Apgar scores y Neonatal acid-base status Neurobehaviour score y Respiration y Oxygenation y Apgar scores y Neurobehaviour score Alleviation of Labour Pain 1st Stage Lumbar epidural Intrathecal block Bilateral paracervical blocks Bilateral lumbar sympathetic blocks at L2 Bilateral paravertebral blocks (T10-L1) Labour Epidural Indications Maternal request, distress Induction of labour Breech presentation Twins, multiple pregnancy Occipito-posterior position PIH+/- proteinuria Prematurity IUGR, fetus small for gestational age Previous caesarean section Induction of labour Forcep delivery

2nd Stage Low epidural Caudal Spinal saddle block Bilateral pudendal nerve blocks

Contraindications Absolute Sepsis Bacterimia Skin infection at injection site Severe hypovolaemia Coagulopathy Therapeutic anticoagulation Patient refusal Relative Peripheral neuropathy Mini dose heparin Psychoses Aspirin, antiplatelet drugs Demylinating CNS disease Idiopathic hypertrophic subaortic stenosis Aortic stenosis Psychological, emotional instability Uncooperative patient

Continuous Epidural Infusion Advantages Complications Fluctuations in pain relief level Overdose, high blockade Amount of motor blockade Segmental blockade Hypotensive episodes Subarachnoid catheter migration Not required to repeat test dosing Intravascular migration (frequent monitoring) Complications Hypotension Inadequate analgesia Intravascular Injection Unintentional dural puncture High block Catheter misplaced into subarachnoid space Urinary retention Back pain Maternal fever Progress of labour Regional Anaesthesia Advantages Awake patient y Improved maternal-child bond y Husband friendly Avoid problems of GA y Airway, aspiration risk y Multiple drug administration Provide effective post OP analgesia ( Thromboembolic phenomena) Spinal Anaesthesia Advantages Simplicity with definite end-point Minimal drug usage Rapid onset Reability Dense motor, sensory block

Disadvantages Sympathetic blockade (with hypotension) Incomplete, patchy block Limited duration in spinal epidural Complications Inadvertent intravascular injection Dural puncture

Complications Hypotension Excessive spread, high spinal anaest. Post-dural puncture headache Incomplete anaesthesia Nerve injury (rare with spinal below L2) Infection

General Anaesthesia Advantages Shorter induction time Lower failure rate Better CVS control Full control of respiratory functions Rapid control of convulsion No patient cooperation required

Disadvantages Difficult airway management Risk of regurgitation (pulmonary aspiration) Awareness GA related problems y PONV y Hangover effect y Lack post OP analgesia Stress response during induction (emergence)

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