PAIN RELIEF IN LABOUR

Methods Of Pain Relief

Pharmacological Non pharmacological

Pharmacological Method
1. Analgesic 2. Inhalation 3. Epidural-regional anesthesia 4. Local anesthesia

Analgesic
This type of drugs will affects the gray area of the brain. Activation of the neuron that descend the spinal cord and inhibit the transmission of pain impulses in the substancia gelatinosa ( close the gate). Administered either by intravenously or intramuscularly.

 Administered when mother c/o pain.

(1st stage of labor until OS dilate 6cm) Not to be given if OS dilate > 6cm.

Analgesia given too early may prolong labor and depress the fetus. If given too late, it may effect the fetus and may cause neonatal respiratory distress.

Systemic Analgesics
Systemic analgesics are often given as injections into the muscle or vein. They are called systemic because they affect the whole nervous system. Systemic analgesics reduce pain, but do not cause loss of consciousness.

Common Drug Used

Opiate
Pethidine Morphine Diazepam

Non-opiate
Nubain (Nalbuphine)

Opiate Group
PETHIDINE
Dose : 50mg 75mg 6hly(as ordered) Routes : intravenous or intramuscular Mode of action : analgesia, sedative, antispasmodic, relaxes pain muscles S/E : Mother : nausea, vomiting, dizziness, bradycardia, palpitation, hypotension Fetus : depression of respiratory centre

MORPHINE
Dose : 5mg-20mg Routes : IM, IV, S/C S/E : mother : headache, dizziness, tremors, flushing, tachycardia, nausea, vomiting, constipation, urinary retention, respiratory depression.

fetus : depression of respiratory centre

DIAZEPAM (VALIUM)
Dosage : 2mg-10mg Routes : PO, IV, IM S/E : Mother : headache, blurred vision, drowsiness, bradycardia, hypotension, constipation Fetus : depression of respiratory centre

Antidote for opiate group drugs :

Narcan (naloxone) is an opioid antagonist and is used for the complete or partial reversal of opioid depression, including respiratory depression. It is available as a generic termed naloxone.

 Narcan is available as a sterile solution for intravenous, intramuscular, and subcutaneous administration in three strengths: 0.02, 0.4 and 1 mg of naloxone hydrochloride per mL in sterile solution; the 0.4 and 1 mg doses are also available in multidose vials. Use in neonates and other pediatric patients is based on weight (usually 0.01 mg per Kg) and may be adjusted; a pediatric consultant may help manages such patients. Opioid withdrawal syndrome may occur in some patients given large doses of Narcan.

Non-opiate group
NUBAIN (NALBUPHINE HYDROCHLORIDE)
Dose : 10-20mg Routes : IM , IV(titrated),S/C Action : relief moderate to severe pain in1st stage of labour. S/E : mother : addiction fetus : respiratory distress

INHALATION ANALGESIC : ENTONOX

Other Names : Entonox, Nitronox Entonox is a homogeneous gas containing a mix of 50% oxygen and 50% nitrous oxide compressed into a cylinder. Entonox is a potent analgesic with properties comparable to that of strong opioids. It can provide short term pain relief, sedation and reduced anxiety during a wide range of painful situations.

 It is most often administered via a demand valve for self administration. A safety feature is that the mother controls administration.

HOW IT WORKS?
Entonox takes 30 seconds to act and continues for approximately 60 sec after inhalation has ceased. For optimum effect inhalation should start when the contraction tightens to co-ordinate the maximal effect with the central painful part of the contraction.

 N20 is a strong analgesic. 20% N20 is equivalent to 15 mg of subcutaneous morphine. The optimal analgesic concentration was found to be 70% but some mothers became unconscious. 50% N20 in oxygen is safer and has become standard. Entonox is the BOC trade name for this gas mixture.

 Indications Moderate to severe pain Contraindications Hypersensitivity to the medication Head injuries with impaired consciousness. Maxillofacial injuries. Artificial, traumatic or spontaneous pneumothorax.

Air embolism. Middle ear occlusion, ear infection Decompression sickness. Abdominal distension / intestinal obstruction

Dosages Allow patient to titrate dosage to effect by controlling their own inhalation.

The advantages of Entonox

You decide when to use Entonox, so you feel more in control. It works in 30-40 seconds but has no lasting effect. It apparently has no unpleasant side effects on your baby. It doesn't stop you wanting to push You can use it right up to the moment of giving birth.

The disadvantages of Entonox

You may need a bit of practice with the mouthpiece and timing with your contractions, before you feel the full effects. It can make you feel sick, dizzy or light-headed It may limit how much you can walk about.

Regional Analgesia
Regional analgesia tends to be the most effective form of pain relief during labor. It causes few side effects. Examples are epidural blocks, spinal blocks, and combined spinal-epidural blocks. With these pain-management methods, the woman gets an injection in the lower back to numb the lower body.

EPIDURAL
epidural anesthesia is regional anesthesia that blocks pain in a particular region of the body. Epidurals block the nerve impulses from the lower spinal segments resulting in decreased sensation in the lower half of the body.

TYPES OF EPIDURAL
Regular Epidural: After the catheter is in place, a combination of narcotic and anesthesia is administered through either a pump or periodic injections into the epidural space. The narcotic, such as fentanyl or morphine, is given to replace some of the higher doses of anesthetic, such as bupivacaine, chloroprocaine, or lidocaine, which helps reduce some of the adverse effects of anesthesia.

 Combined Spinal-Epidural (CSE) or Walking Epidural: An initial dose of narcotic, anesthetic or a combination of the two, is injected beneath the outermost membrane covering the spinal cord, and inward of the epidural space. This is the intrathecal area.. With the use of these drugs, muscle strength, balance and reaction is reduced. CSE should provide pain relief for 4-8 hours.

Benefits Of Epidural Anesthesia

Allows you to rest if your labor is prolonged Relieving the discomfort of childbirth can help some woman have a more positive birth experience Most of the time an epidural will allow you to remain alert and be an active participant in your birth

Disadvantages of epidural anesthesia

Epidurals may cause your blood pressure to suddenly drop. For this reason your blood pressure will be routinely checked to make sure there is adequate blood flow to your baby.

 You may experience a severe headache caused by leakage of spinal fluid. Less than 1% of women experience this side effect from epidural use. If symptoms persist, a special procedure called a blood patch, an injection of your blood into the epidural space, can be done to relieve the headache

 After your epidural is placed, you will need to alternate from lying on one side to the other in bed and have continuous monitoring for changes in fetal heart rate. Lying in one position can sometimes cause labor to slow down or stop.

 You may experience the following side effects: shivering, ringing of the ears, backache, soreness where the needle is inserted, nausea, or difficulty urinating. You may find that your epidural makes pushing more difficult and additional interventions such as Pitocin, forceps, vacuum extraction or cesarean may become necessary.

 For a few hours after birth the lower half of your body may feel numb which will require you to walk with assistance. Though research is somewhat ambiguous, most studies suggest some babies will have trouble "latching on" which can lead to breastfeeding difficulties. Other studies suggest that the baby may experience respiratory depression, fetal malpositioning; and an increase in fetal heart rate variability, which may increase the need for forceps, vacuum, cesarean deliveries and episiotomies.

LOCAL ANAESTHESIA
Local anesthesia is a type of pain prevention used during minor procedures to numb a small site where pain is likely to occur without changing the patient's awareness. A numbing medication is either applied to or injected into the area, sometimes with several small injections, and after a few minutes the area should be completely numb. If the area still has sensation, additional injections or applications may be given to insure total numbness.

 Three types of local anesthesia may be used for childbirth: the paracervical block, the pudendal block, and local infiltration of the perineum.

The Paracervical Block

The paracervical block is given during the late first stage. Two injections of local anesthetic drugs are made into the cervix and bring pain relief during contractions.

The Pudendal Block

The pudendal block causes anesthesia in the birth canal and is given in the second stage. Local anesthetic agents are injected into each side of the vaginal wall. A pudendal block can be used for forceps delivery or pain in the second stage. Most doctors also give a pudendal block before an episiotomy is performed.

Perineal Infiltration
Local infiltration of the perineum consists of several injections to numb the area of skin and muscle between the vagina and the anus. It is most commonly used after natural childbirth if stitches are needed. It can also be given in the second stage before an episiotomy is performed. Side effects of a local block appear to be slight.

Non-pharmacological Method
The nonpharmacological approach to pain management includes a wide variety of techniques that address not only the physical sensations of pain, but also attempt to prevent suffering by enhancing the psychoemotional and spiritual components of care.

Explanation To Mother
Inform mother her labour progress ; eg. os dilatation ? cm.. Mother know her labour progress thus reducing her anxiety and fear and ready to push when require. Inform mother complication arise if she push before os fully dilate : 10cm
Can causing cervical tear

Psychological support
By practicing husband friendly hospital, supporting from husband can reduce motherto-be discomfort, anxiety and fear toward labour and childbirth. With husband/closed relative beside her, she can ease her mind thus reducing level of pain and concentrate on birthing her child.

REST IN BED
Once mothers admitted into labour room, shes not allowed to move around. She will be placed in her station and advice for CRIB. All her needs will be attended by staff in labour room. Once shes rest , all her energy can be use for birthing her child.

Deep Breathing Exercise

DBE is essential for reducing pain during contraction. When contraction occur, advice mother to inhale for a count of 4, then exhale to a count of 8. This technique can be repeated every time contraction occur. Contractions come in waves, so carefully controlled rhythmic breathing can help relieve pain during labor and promote relaxation. Mother will felt more relax and less pain although pain will not diminished until her child is born.

Positioning
The best position for mom during in contraction pain is according to her own comfortable. Suggestion given to mother for lie in left lateral position. This position reduce pressure on her back and spine, mom felt more comfortable. Promotes blood circulation and oxygen to the fetus.

Back Rub
By touching skin to skin you are best able to stimulate the nerves that let the brain know you are being touched. In labor you will need to help mom use all five of her senses to stay relaxed, by touching her skin you help her relax. But the more she relaxes now, both in between contractions and even, as much as possible, during them, the more strength she will have when it comes time to actually push.

Divertional Therapy
Says prayer when in contraction pain can help mother find her inner strength and get through labour pain. With prayers(depends on mother religion), she can remove her thought from contraction pain and the pain will become more bearable for her to cope. Aromatherapy also can help mother more relax and she can concentrate on birthing her child.

Hot Water Bag

Can be use to reduce contraction pain. Advice husband to apply hot water bag on his wife back with caution and gently. This method rarely used in our country.

TENS (Transcutaneous Electrical Nerve Stimulation)

How it works ???

Little pads stuck on your back deliver small electric shocks on to your skin. You can control the strength of these by twiddling a dial (or pressing a button if you've got a fancy one) - just make sure your partner knows which way to twiddle or you could get a bit of a surprise. The shocks confuse your nerve pathways, distracting them from the sensations of labour. They also speed up your body's natural production of endorphins - your very own morphine!