Indian J. Anaesth.

SUNANDA, ANAND,2006; 50 (5) : 363

HEMESH - 369 PAIN – LABOUR ANALGESIA
: ACUTE 363

ACUTE PAIN – LABOUR ANALGESIA

Dr. Sunanda Gupta1 Dr. GS Anand Kumar2 Dr. Hemesh Singhal3

Keywords : Labour analgesia.

Labor is characterized by regular, painful uterine and C primary afferent fibres which pass sequentially
contractions that increase in frequency and intensity and through the inferior, middle and superior hypogastric
are associated with progressive cervical effacement and plexus, the lumbar and lower thoracic sympathetic
dilatation. Labour has been divided into three stages. The chain and end in rami communicantes associated with
first stage occurs from onset of cervical change to T10-L1 spinal nerves. (fig. 1)1 It is predominantly carried
10 cms dilatation. It can be divided into latent and by the C fibres.
accelerative phases. The latent phase can last up to 8 hrs,
without the need of intervention, while the active phase is Table - 1 : Labour pain: Pathways and mechanisms.3
associated with a faster rate of cervical dilatation and
Site of Mechanism Pathway Site of
usually begins at 2-4cms dilatation and the duration varies origin action
from 2 to 6hrs. The second stage occurs from full cervical
dilatation (10 cm) to delivery of the baby. Normally the Uterus,
Cervix
Distortion,
Stretching,
Afferents which accompany
sympathetic pathway to
Upper
abdomen &
second stage lasts for 2 hrs (3 hrs with regional anaesthesia) Tearing of T10-L1Dorsal rami T10-L1 groinmid-back
Fibres refer to cutaneous branches
in a primipara and 1 hr (2 hrs with regional anaesthesia) of posterior divisions
in a multipara. The third stage occurs from delivery of the Periuterine Pressure often Lumbosacral plexus L5-S1 Low back, thigh
baby to separation and expulsion of placenta and the tissues
Lumbosacral
in association
with fetal
(?pelvic splanchnic nerves)

membranes. region malposition or

platypelloid pelvis

Pain pathways Bladder, Pressure by S2-S4 Referred to

urethra, presenting part perineum and
rectum sacral area
Mechanism of labour pain (table 1)
Vagina Distension, Somatic S2-4 Not referred
Perception of pain during the first stage of labour tearing
begins with nociceptive stimuli arising in the mechanical Perineum Distension, Pudendal (S2-4); Not referred
and chemoreceptors in the uterus and cervix.1 High threshold tearing Genitofemoral (L1-2);
Ilioinguinal (L1)
mechanoreceptors get stimulated due to intense pressure Posterior cutaneous
nerve of thigh (S2-3)
generated during contractions of the uterus.2 Myocellular
Bladder Overdistension Afferents which
injury due to repeated contractions in later stages, release accompany sympathetic Suprapubic
bradykinin, histamine, serotonin, acetylcholine and potassium pathway to T11-L1

ions which activate chemical nociceptors.3

a. Peripheral pathways
I stage of labour: Pain of the first stage of labour is
due to uterine contractions and stretching of the
cervix. It is cramping and visceral in nature, diffuse
and poorly localized. Sensations are carried through Ad

1. M.D., Ph.D., MNAMS, Prof.

2. M.B.B.S., Sr. Registrar
3. M.B.B.S., Sr. Registrar
Dept. of Anaesthesiology and Pain Management,
RNT Medical College, Udaipur, Rajasthan
Fig. 1. : Peripheral neural pathways associated with labour pain. 1
Correspond to :
Sunanda Gupta The uterus. including the cervix and lower uterine segment. is supplied by afferents
Dilshad Bhawan, 69 Chetak Circle that pass from the uterus to the spinal cord by accompanying sympathetic nerves
through the inferior hypogastric plexus (1HP). the hypogastric nerve, the superior
Udaipur - 313001, Rajasthan-India hypogastric plexus (SHP). the lumbar and lower thoracic sympathetic chain. and the
E-mail : sunandagupta@hotmail.com nerves at T10. T11. T12. and L1.
364 PG ISSUE : PAIN INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2006

II stage labour : During the late first and second analysis occurs, and to the hypothalamic and limbic systems,
stage of labour, somatic pain predominates, as a result of where emotional (affective) and autonomic responses
distension and traction on the pelvic structures, the pelvic originate.6
floor and the perineum and is carried via the pudendal
nerve (table 1)3 through the anterior rami of S2 through S4.
Unlike visceral pain of first stage, it is sharp and well
localised, due mainly to less arborization and the faster
conduction velocity in the sacral pathways. It is
predominantly carried by the Ad fibres.4

b. Central pathways
The pathways labor sensation travels after entry into
the central nervous system includes both the ascending and
the descending pathways.

Ascending pathways
The first synapse in the pathways occurs in the dorsal
grey matter of spinal cord (Rexed’s Laminae I
to V). Most of the primary afferent neurons synapse
initially in the more superficial laminae I and II
(substantia gelatinosa); locally projecting interneurons in
turn synapse on the more deeply located wide dynamic Fig. 3 : Cephalad extension of labour sensory pathways 5
range (WDR: lamina V) neurons. The WDR neurons Secondary neurons whose cell bodies lie in the dorsal gray matter of the
receive synaptic excitatory input from both the large spinal cord project via the spinothalamic tract to the thalamus. Another synapse
occurs in the pathway before projection to the primary sensory cortex.
myelinated Aâ and Aä mechanoreceptor afferents and C
polymodal nociceptive afferents. The fact that all of the
Descending pathways
lamina V cells which respond to visceral high threshold
afferents also respond to low threshold cutaneous afferent These pathways originate in primary sensory cortex
from an area of skin supplied by the same spinal cord and project to peri aqueductal grey matter in the midbrain
segments is important. Thus the lamina V cells provide which further project to rostral ventral nuclei in thalamus
the neural basis for the phenomenon of referred pain which . Projections from thalamus enter the spinal cord through
occurs during each uterine contraction. (fig. 2) dorsilateral funiculus and end in dorsal grey matter of the
spinal cord. (fig. 4)5

Fig. 2 : Intensity and distribution of parturition pain during

the various phases of labour and delivery.

Fig. 4 : Descending inhibitory pathway5

Projections from the dorsal grey matter cross to the
contralateral ventral white matter of the cord and then
cephalad via the spinothalamic tract to the thalamus, brain
stem, and cerebellum, (fig. 3)5 where spatial and temporal
Neurons with cell bodies in the sensory cortex project caudally,
synapsing in the periaqueductal gray matter of the midbrain.
Another synapse occurs in the medulla before the pathway terminates
in the gray matter of the dorsal lumbar spinal cord.
SUNANDA, ANAND, HEMESH : ACUTE PAIN – LABOUR ANALGESIA 365

Methods for labour analgesia Acupuncture

The experience of labor pain is different for each
woman, and the different methods chosen to relieve pain
depend upon the techniques available locally and the
personal choice of the individual. The different methods
for labor analgesia are listed in table 2.
Table - 2 : Methods of labour analgesia
The needles are inserted to a depth of 2.5-3 cm and
manipulated manually or a low voltage 2–3 Hz current is
passed through the needle to achieve analgesia. Acupuncture
analgesia is thought to be mediated through release of
endorphins or release of serotonin and metencephalin.
However; this technique provides pain relief which is
incomplete, unpredictable and inconsistent.

Non Pharmacological 2. Pharmacological methods

pharmacological
Systemic Regional a. Inhalational methods
• Transcutaneous 1. Inhalational methods 1. Lumbar Epidural
Entonox (50% nitrous oxide in oxygen) provides
electrical nerve 2.Systemic analgesics analgesia analgesia within 20-30 seconds of inhalation, with a
stimulation (TENS); Opioid analgesics 2. CSEA maximum effect after about 45 seconds. Current clinical
• Relaxation/breathing (Meperidine, Morphine, 3. CSA
techniques Fentanyl, Sufentanil, 4. Alternative regional
data suggest that it relieves labour pain to a significant
• Bio feedback and Alfentanil, Remifentanil) anaesthetic degree in most women, however it does not provide
physical therapies Non opioid analgesics techniques complete and predictable analgesia and atmospheric
• Temperature • Agonist-antagonist Lumbar sympathetic
modulation: hot or analgesics(Nalbuphine blockPudendal block
pollution is a cause for concern.
cold packs, Butarphanol, Tramadol) Paracervical block
water immersion • Sedatives Tranquillizers
Several volatile anaesthetic agents have been
• Hypnosis (Barbiturates, Phenothiazine inhaled intermittently for labour analgesia like
• Massage derivatives, Benzodiazepines) trichloroethylene, methoxyflurane, isoflurane, enflurane,
• Acupuncture • Dissociative or
• Aromatherapy amnesic drugs
sevoflurane and desflurane. Their use is limited by
• Water block (Ketamine, Scopolamine) technical difficulties in their safe administration,
scavenging, requirement of specific vaporizers and issues
A. Non-regional techniques for labour analgesia of theatre pollution.
Non-regional methods available for analgesia in b. Systemic analgesics
labour may be divided into non-pharmacological and
Opioid analgesics : Some of the commonly used
pharmacological methods.
parentral opioids for labor analgesia are Morphine,
1. Non-pharmacological methods Pethidine, Fentanyl, Sufentanil, Alfentanil, and
The advantages of non-pharmacological techniques Remifentanil. If regional analgesia is unavailable or
include their relative ease of administration, easy contraindicated, then Patient controlled intravenous
availability and minimal side-effects; however, there is analgesia (PCA) is a useful method for painless labour
little evidence to support the efficacy of many of these (table 3).7 Remifentanil, an ultra-short-acting opioid, is
techniques, and some may be costly and time consuming. rapidly hydrolysed by blood and tissue esterases and
Some of the more commonly used non does not accumulate, even after prolonged infusions.
pharmacological methods are: There are increasing reports of its use in PCA, although,
like fentanyl, the ideal regimen remains unclear. A
Transcutaneous electrical nerve stimulation bolus dose of 0.25-0.5 gkg-1 with a 2 minute lockout has
(TENS) been used successfully.8 However, close monitoring is
Electrodes are placed about 2 cm over the essential and supplementary oxygen with ready access to
T10–L1 dermatomes on either side of the spinous processes naloxone is mandatory.
to provide analgesia for the first stage of labour. A second Non-opioid analgesics
set of electrodes is placed over the S2–S4 dermatomes for
second stage pain relief. Women can alter the amount of Agonist-Antagonist analgesics
current supplied to the electrodes providing some degree Nalbuphine (2-4 mg IV), butorphanol (2 mg)
of control throughout their labour. Blockade of pain buprenorphine (0.3 mg) have all been used as systemic
transmission to the brain through stimulation of A-fibre analgesics for providing relief from labour pain
transmission and local release of ß-endorphins are suggested (table 2). Drowsiness, dizziness, and nausea, vomiting have
theories for TENS analgesia; however, there is no evidence limited the wide spread use of these analgesics in obstetrical
that TENS provides more analgesia than placebo. pain relief.
366 PG ISSUE : PAIN INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2006

Ketamine analgesia at <4 cms cervical dilatation has been refuted

In sub-anaesthetic doses, ketamine has been used in
late labour or at delivery, as given in table 3. 9
Psychomimetic effects have been a major disadvantage
though, in labour, delirium and unpleasant dreaming is
infrequent.
by several studies which claim that it does not affect the
overall progress of labour or incidence of surgical
interventions.13 However, there is still a concern that
early initiation of labor may result in higher incidence of
operative delivery.

Table - 3 : Doses of systemic analgesics.7 Table - 4 : Technique for lumbar epidural analgesia.7

S.N. Drug Dose IV/IM Onset IV/IM Duration IV/IM • Sitting position / left lateral position

1. Meperidine 25/100 mg 5/20-30 min 20-40/90-120 • Aseptic precautions; ideal space L3-4/L4-5
10-15 mg PCA bolus min • LOR with saline for identification of epidural space
2. Morphine 5/10-15 mg 5/20-30 min 30-60/120-80 • Bevel direction cephalad; midline approach
min
• Insert 5cms multiport epidural catheter
3. Fentanyl 25-50/100 µg 2/10 min 20-40/30-60 min
10-25 mg PCA bolus • Aspirate, test for intrathecal or IV placement

4. Nalbuphine 10-25 mg/1-3 mg 2/15 min 120-240 min • Test dose: 1.5% lidocaine 45mg + Epinephrine 15ug;
PCA bolus 0.25% Bupivacaine 7.5mg + Epinephrine 15ug

5. Butorphanol 1-2 mg 5-10/10-30 min 120-240 min • Initiate catheter dosing with divided (5ml) doses of:

6. Remifentanil 0.1-0.5 mg/kg 0.5-1 min 2-3 min t 0.9%-2.0% lidocaine (10-12ml)
PCA bolus
t 0.0625%-0.25% bupivacaine (10-12 ml)
7. Tramadol 100 mg IM 10-30 min 180 min
t 0.1%-0.2% ropivacaine (10-12 ml)

t 0.0625%-0.25% levobupivacaine (10-12 ml)

Table - 3 : Low dose ketamine analgesia.9 t Adjuncts: Fentanyl (50 mg total)

1. Antacid prophylaxis
2. Pre-anaesthetic evaluation
3. I stage labour : Bolus 10-15 mg then infusion 0.5-1 mgkg-1min-1
4. Monitor sensorium
5. At crowning, 0.2-0.4 mgkg-1 (total dose 12.5 mg-25 mg) don’t exceed
100 mg
B. Regional techniques for labour analgesia
Regional techniques represent the “gold standard”
for labour analgesia.
1. Lumbar epidural analgesia (Table 4) 7
Effective analgesia during the first stage of
labour can be achieved by blocking the T10 to L1
dermatomes with low concentrations of opioids or local
anaesthetics. The block has to be extended up to S2-4
dermatomes in the second stage of labour to ameliorate
the pain due to vaginal distension and pressure on the
perineum of the descending fetal part. Recent evidence
suggests that there is minimum to no alterations in duration
and outcome of labour with regional analgesia,10 there is no
increase in the need for labour augmentation with oxytocics11
neither is there any difference in the rates of normal
vaginal delivery12 but there was a significant increase in
maternal satisfaction in parturients administered epidural
analgesia. Concern about early initiation of epidural
Epinephrine (1:200,000-400,000)
• Adequate analgesia: Begin infusion of bupivacaine
(0.04%-0.125%)+fentanyl(1.5-2 mgml-1) at 12-16 mlhr-1
• If pain persists 15 min after injection, repeat bolus dose,
in sitting position or after withdrawing 1cm catheter.
Replace catheter if pain persists after 5min.
Techniques for maintenance of epidural analgesia
(Table 5) 7
There are advantages and disadvantages to the
different techniques available for delivery of epidural
analgesia. Some of the popular methods are:
a. Intermittent top-ups
Ideally a low dose mixture of local anaesthetic and
opioid is used. It is a relatively safe and simple method of
delivery and does not require complex infusion devices.
However, it may prove to be labour intensive for the labor
room staff.
b. Continuous epidural infusion (CEI)
A typical low dose infusion of bupivacaine and opioid
is titrated to achieve the desired block height with an
infusion device. It provides adequate analgesia and
haemodynamic stability. Compared to low dose intermittent
top-ups and PCEA, increased total dose of local anaesthetic
and opioid is required. It may also increase the chances of
anaesthetic intervention when analgesia fails.
SUNANDA, ANAND, HEMESH : ACUTE PAIN – LABOUR ANALGESIA
Table - 5 : Drug doses for various epidural analgesia
maintenance techniques.7
Technique Concentration and dosing schedule
Intermittent bolus 0.1%-0.25%, Bup+fentanyl 3 mgml-1+ Epinephrine
1:200,000: (5+5 ml)
Boluses as needed
Continuous infusion 0.044%-0.125% Bup+fentanyl 1.5-2 mgml-1
at 8-14 mlh -1
PCEA with basal 0.625%-0.125%Bup+fentanyl 2 mgml -1 at the
infusion following settings: basal rate 8-12 mlh -1 Bolus
dose 5 ml lockout 10minhourly limit 30 ml.
PCEA without a 0.125%Bup+fentanyl 2 mgml -1 at the
basal infusion following settings: 8 ml Bolus dose;
lockout 15 min; no hourly limit.
c. Patient-controlled epidural analgesia (PCEA)
It allows the patient to match dose of analgesia to
amount of pain as labour progresses with individual
variability. It instills a degree of control to the woman
and may improve maternal satisfaction. Other advantages
include a reduction in the need for clinician top-ups,
amount of local anaesthetic and opioid requirement, and
incidence of motor block along with more extensive
spread with the mechanical pump.14 However, infusion
pumps required may be costly and the women require
instructions on utilization of PCEA. There is no difference
in obstetric or neonatal outcomes when compared to CEI.
2. Combined spinal epidural analgesia (CSEA)
The CSE technique15 has gained increasing popularity
in recent years.16 It is one technique wherein, selected
advantages of both spinal and epidural techniques are
combined without an increase in complications. It provides
rapid onset of analgesia with minimal local anaesthetic
doses and has the flexibility and unlimited duration of an
epidural technique. Because CSE allows for ambulation of
the parturient it has been called the “Walking epidural”17
(also refers to any epidural or spinal technique which allows
for ambulation). There are certain situations where CSE
may be the preferred technique. These include the
multiparous parturient who had an ineffective epidural on
a previous occasion or the patient having a rapid painful
labour. The technique and doses for CSE labour epidural
analgesia are given in table 6.9
3. Continuous spinal analgesia
Spinal analgesia given as a single shot technique
provides only 1 to 3 hrs of pain relief which may not be
adequate to cover the whole duration of labor, though it
may be a useful option in the absence of other methods of
pain relief, in a mother in the very advanced first stage of
367
labor and in need of an instrumental delivery. Continuous
spinal analgesia (CSA) with microcatheters (size 28G)
offers some advantages over the single shot spinal or the
continuous epidural techniques, however it increases the
likelihood of complications, like cauda equina syndrome
and may be inherently more dangerous than the other two
techniques. CSA is typically provided by either intermittent
bolus or continuous infusion techniques18 and may be preferred
in cases of accidental dural puncture.
Table - 6 : Suggested Drug doses and mixtures for CSE
Labour analgesia.9
Administration LocalAnaesthetic Opioid
1 Intrathecal Bupivacaine 1.0-2.5 mg Fentanyl 20-25 mg
injection (Isobaric 0.1%-0.25%) or Sufentanil
3 - 5 mg
2 Epidural Bupivacaine (0.1%-0.125%) Fentanyl 20-25 mg
top-ups 10-15 mg for I stage of labour, or Sufentanil
for II stage labour or assisted 5-10 g
delivery this dose is sufficient
Choice of neuraxial drugs for labour and delivery
Local anesthetics
Epidural bupivacaine provides excellent sensory block
and has been used for labour analgesia for many years.
However, concerns about its cardiac toxicity and the intensity
of its motor block have led to the investigation of other
agents.
Ropivacaine has been associated with reduced
incidence of operative vaginal delivery and less motor
block when compared with bupivacaine.19 Recently it
has also been shown that both Ropivacaine20 and
Levobupivacaine21 appear equipotent to bupivacaine.
However, both the newer local anesthetics, are considered
significantly less cardiotoxic22 and neurotoxic and seem
to be a more suitable agent for pain relief in laboring
women.
Chlorprocaine, an ester local anaesthetic with a
rapid onset of action, is used in the United States to top
up epidurals for an operative delivery, but due to its short
duration of action it is not a suitable agent for labour
analgesia. Similarly, lidocaine which is used in the
same circumstances may cause tachyphylaxis with
repeated use and is therefore not a suitable agent for labour
analgesia.
Opioids
The addition of epidural opioids to local anaesthetic
solutions has gained popularity over the years. Opioids have
a synergistic effect by acting directly on opioid receptors
368 PG ISSUE : PAIN
in the spinal cord and help reduce local anaesthetic
requirements. Various opioids have been used; however those
with low lipid solubility (e.g. morphine) are associated
with delayed respiratory depression and should be used with
caution. Fentanyl, Sufentanil, and Alfentanil are all being
currently used for labour analgesia.
Non-opioid adjuncts
The a-adrenergic receptor agonist epinephrine23
(1:200,000–1:600,000),2-adrenergic receptor agonist
clonidine and anti-cholinesterase neostigmine,24 have been
used as epidural and spinal adjuncts. These drugs have
however, not yet gained wide acceptance for labour
analgesia.
4. Alternative regional anaesthetic techniques
These include Lumbar sympathetic block (LSB),
Paracervical block(PCB)25 and Pudendal nerve block
(PNB).25 Paracervical block using low-dose bupivacaine
provides up to 2 hours of first stage analgesia, the drawback
being the high incidence of fetal bradycardia. Pudendal
nerve (S2,3,4) block is safe and effective for only the
second stage, while Paravertebral lumbar sympathetic block
provides only first-stage labour analgesia and though it
requires expertise to perform this block, it may speed cervical
dilatation in nulliparous women.
These alternative techniques do not have the
flexibility of epidural or CSE analgesia, they are
technically difficult to perform and produce more frequent
complications. However, they can be used in special
circumstances such as: i) Failed or inadequate neuraxial
analgesia. ii) Contraindications to neuraxial techniques
(e.g.– spinal deformity, previous spine surgery, abnormal
coagulation). iii) Absence of qualified anaesthesia personnel.
Complications of regional analgesia in labour
Some immediate serious complications of obstetric
epidural analgesia26 include: i) Massive misplaced injection:
intravascular, intrathecal or subdural. ii) High or total
spinal block.* iii) Hypotension. iii) Local anaesthetic induced
convulsions.* iv) Local anaesthetic induced cardiac arrest.*
v) Delayed complications. vi) Postdural puncture headache.
vii) Transient backache. viii) Urinary retention. ix) Epidural
haematoma, abscess or meningitis.* x) Permanent neurologic
deficit.* (*are fortunately rare complications).
Most obstetric neurologic injuries are not directly
related to neuraxial analgesia but rather are intrinsic to
labor and delivery. However, strict attention to technique
may further limit the rare injury directly related to
anaesthesia.
INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2006
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Dr. Sheela S. Rao
0821-2518991
Non-ISA Members Dr. N. V. Nagalaxmi
Conference Rs. 3200 Rs. 3900 0821-2598912
C.M.E Rs. 800 Rs. 900
Conf + C.M.E Rs. 3900 Rs. 4700
Organising Secretary
Contact : Dr. P. N. Vishwanathan
Accompanying person
(Children above 5 yrs) Rs. 1000 Rs. 1000
ISACON - 2006, Dept. of Anaesthesiology,
K.R. Hospital, Mysore - 570 001. Karnataka. India
Overseas Delegates US$ 160 US$ 180 Ph. : 0821 - 2463999, 2566794,
Mobile : 09448054699
Overseas Delegates US$ 110 US$ 130 E-mail : poolaviswanathan@yahoo.com
Accompanying Person Website : www.isacon2006.net