Analgesia in labour

SARVESSWARA
BMS15091423
 Stages of Labor
• Divided into 3 stages
I. onset of labor until the cervix is fully dilated.
a. Latent -can persist for many hours and days
b. Active -occurs between 5 to 6 cm dilation
Transmitted via visceral afferent fibers entering the spinal cord from
T10-L1

II. cervix is fully dilated and ends when the neonate is born.
stretching of vaginal and perineal tissues and is transmitted via sacral
somatic fibers

III. Begins once the neonate is delivered and is completed

when the placenta is delivered.
transmitted via sacral somatic fibers
 Methods of labor analgesia
1. Non pharmacological technique
2. Systemic medications
3. Neuraxial (Regional) Analgesia
1. Non pharmacological technique
• Various technique but data is limited.
• lack of rigorous scientific methodology for
useful comparison with other techniques

Acupuncture
Acupression

Relaxation
Massage
 2. Systemic medications
• Systemic analgesics are used but normally limited by
bolus dose,
dosing interval, and
24-hour cumulative dose.

• The use of systemic opioid analgesics is quite

common
• But the use of sedatives, anxiolytics, and dissociative
drugs is rare
 a) Opioids
• Maternal side effects including
• nausea • pruritus
• vomiting • decreased stomach emptying

• Neonatal side effect

• decreased FHR variability
• dose-related neonatal respiratory depression
II. Morphine
• more frequently in the past, but rarely use now
• T½ is longer in neonates compared to adults
and it produces significant maternal sedation.
• This produces analgesia for approximately 2.5 to
6 hours
• with an onset of 10 to 20 minutes and
• does not appear to affect maternal or neonatal
morbidity.
III. Fentanyl
• commonly used for labor analgesia.
• It has a short duration and no active
metabolites
• When given in small IV doses of 50 to 100 μg
in an hour, there are no significant change in
neonatal Apgar scores and respiratory effort
compared
IV. Remifentanil patient-controlled analgesia
(PCA)
• women who have contraindications to
neuraxial blockade.
• has potential for significant maternal
respiratory depression, its use should remain
under close supervision of an anesthesiologist.
b) Nitrous Oxide
 3. Neuraxial (Regional) Analgesia
• cause blockade of sympathetic, sensory, and
motor input and, depending on the dose, can
provide analgesia or complete anesthesia
 Local Anesthetics
• Bupivacaine and ropivacaine are the most
commonly used
• extremely safe when appropriately dosed for
epidural administration
• Accidental large dose can result in loss of
consciousness, severe arrhythmias, and
cardiovascular collapse
 Neuraxial Opioids
• fentanyl and sufentanil are frequently used to
augment the local anesthetics.
• prolongs and improves the quality of analgesia
and has local anesthetic-sparing effects.
• Provide moderate analgesia when use alone
but less effective than LA
ANESTHESIA FOR CAESEREAN
DELIVERY
HAZIRAH HAMZAH
BMS 15091533
Regional Anesthesia
• Spinal Anesthesia
• Epidural Anesthesia
General Anesthesia
 Pre medication
• Pharmacological aspiration prophylaxis helps to
reduce gastric acidity and volume in patients
undergoing caesarean section or tubal ligation.
• Sodium citrate (30 ml of 0.3 M orally)- antacids
given 15-30 minutes prior to surgery are nearly
100% effective at raising gastric pH to > 2.5
• Ranitidine (50 mg IV), famotidine (20 mg IV).
• Metoclopramide (10 mg IV)
• Oral omeprazole,40mg
SPINAL ANESTHESIA
• Bupivacaine (10 to 15mg) + preservative-free
morphine (50 to 200 μg) (to decrease postoperative pain)
• Hyperbaric solution of local anesthetic is often
used to facilitate anatomic and gravitational
control of the block distribution.
EPIDURAL ANESTHESIA
 15 to 20 mL of 2% lidocaine or 3% 2-chloroprocaine in divided doses
3% 2-chloroprocaine ( use in urgent csec - most rapid onset of any epidural local
anesthetic)
2-chloroprocaine diminishes both the efficacy and duration of epidural morphine
administered for postoperative analgesia.
Epinephrine (1:200,000) or fentanyl (50 to 100 μg) can enhance the intensity and
duration of the block.
Epidural morphine (1.5 to 3 mg) is typically administered near the end of the procedure
to decrease postoperative pain for up to 24 hours.
General anesthesia
• Opioids and benzodiazepines are administered after
the baby is delivered to avoid placental transfer of
these drugs to the neonate.
• The primary anesthetic for the incision and delivery is
the induction agent, as there is little time for uptake
and distribution of the inhaled anesthetic into either
the mother or fetus.
• Halogenated anesthetics are often partially replaced
with other anesthetics following delivery to decrease
uterine atony.
• Entirely replaced with maintenance anesthetics that do
not affect uterine tone (e.g., total intravenous
anesthesia [TIVA] with propofol and opioids) to further
reduce the risk of uterine atony.
 Post operative medications
• Epidural anesthesia:
– 3 mg Epidural morphine and pitocin, with
ketorolac at end of surgery.
• Spinal anesthesia:
– Pitocin 20–30 U in 1 L IV bag.
• General anesthesia:
– Pitocin and opioids (fentanyl), with ketorolac at
end of surgery.
 Refernces
• Miller's Basics of Anesthesia by Manuel C.
Pardo et al (7 Ed, 2018)
• Clinical Anesthesia Fundamentals by Paul G.
Barash et al (2015)