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ANALGESICS AND ANAESTHESIA IN OBSTETRICS

INTRODUCTION

Pain is a highly subjective experience. Pain is whatever the client says it is. The amount and type
of pain experienced during labour vary widely from person to person. During labour different
types of pain arise from different sources. As the uterus contracts and the cervix dilate, the client
feels visceral pain as described persistent, aching, or spreading. The pain may be localized to the
abdominal region or felt in the lower back, hips or thighs. Some women describe generalized
aching throughout the body. This type of pain is intensified by fatigue. Another type of pain
sensation is caused by pressure of the descending fetus as it stretches the birth canal. This type of
generalized body pain is called somatic pain described as intense pressure or need to bear down,
is typically most intense during the transition phase of the first stage of labour and during the
second stage of labour. Analgesia is the use of medication to reduce the sensation of pain.

DEFINITION

The terms analgesia and anesthesia are sometimes confused in common usage.

Analgesia denotes those states in which only modulation of pain perception is involved.
Anesthesia denotes those states in which mental awareness and perception of other sensations are
lost. Analgesia is the loss or modulation of pain perception. Anesthesia is the total loss of
sensory perception and may include loss of consciousness. It is induced by various agents and
techniques. In obstetrics, regional anesthesia is accomplished with local anesthetic techniques
(epidural, spinal) and general anesthesia with systemic medication and endotracheal intubation.

Analgesia can be

 local: affect only a small area of the body,

 Regional : affect a larger portion of the body, or
 Systemic Analgesia: is achieved by the use of hypnosis (suggestion), systemic
medication, regional agents, or inhalational agents.
.

PARENTERAL AND INHALATIONAL ANALGESIA

PARENTERAL NARCOTICS:
Pethidine is the most frequently used narcotic given intramuscularly. It is administered in a
dosage of 50mg to 100mg intramuscularly with 2 to 4 hours interval. Alternatively it can titrate
intravenously to effect in the presence of severe pain for a rapid response. Morphine can also be
administered but it is not frequently used as the neonatal respiratory depression and maternal
nausea and vomiting associated with morphine are more severe.
Morphine is not used in active laboring patients because of the excessive respiratory depression
seen in the neonate compared with equipotent doses of other narcotics. Fetuses that are of young
gestational age, are small for dates, or have undergone trauma or long labor are more susceptible
to narcosis.
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Fentanyl is a popular synthetic narcotic that has been used in obstetrics in both the systemic and
epidural compartments. Its use in the epidural compartment has met with good success when
combined with small quantities and low concentrations of bupivacaine.

Sufentanil is a derivative of fentanyl with increased potency and lipophilicity. It is widely used

for intrathecal and epidural analgesia during labor. Potential adverse effects of sufentanil include
possible placental deposition and neonatal respiratory depression. Adding intrathecal or
epidural sufentanil to bupivacaine improves labor analgesia with faster onset and longer duration
compared with bupivacaine alone. The usual dose is 3–5μg intrathecally and 10–15μg epidural.

Remifentanil is a newer ultra short-acting synthetic opioid with rapid onset (approximately 1
minute) after intravenous administration. It is rapidly metabolized by nonspecific blood and
tissue esterases, not depending on renal or hepatic function, and hence it does not accumulate in
the fetus. This rapid onset and elimination facilitate its effective and safe use during labor. 

Butorphanol (stadol) is a synthetic parenteral analgesic that has agonist and antagonist of

opioid properties. It is 5 times as potent as morphine and 40 times as potent as meperidine. The
typical doses are 1–2 mg intravenously or intramuscularly every 3–4 hours. Onset of analgesia is
within a few minutes after intravenous injection.

Nalbuphine (nubain) is a mixed agonist/antagonist opioid similar to butorphanol commonly

used for parenteral labor analgesia. Its potency is equivalent to that of morphine on a milligram
basis. The onset of action after intravenous injection is 2–3 minutes with duration of 5–6 hours.
The usual dose is 10–20 mg intravenously every 4–6 hours. it is metabolized predominantly by
the liver and excreted by the kidney.

Thiobarbiturate intravenous anesthetics such as thiopental and thiamylal are widely used in
general surgery. However, less than 4 minutes after a thiobarbiturate is injected into the mother's
vein, the concentrations of the drug in the fetal and maternal blood will be equal. The mother
will lose consciousness and airway protective reflexes with a thiopental dose of 1.5–2 mg/kg;
therefore, it should be used only in association with general endotracheal anesthesia. Thiopental
doses of 3–4 mg/kg are used for induction of general anesthesia.
Propofol is a newer induction agent that was introduced into practice in the United States in the
early 1990s. As an induction agent, it is similar to the barbiturates in mild cardiac depression and
loss of peripheral vasomotor tone. It offers the advantages of rapid clearance, short duration of
action, antiemetic properties, and reduced risk of airway reactivity. It is an ideal agent for
induction of general anesthesia at a dose of 2 mg/kg in parturients. It also can be used in 10- to
20-mg increments during surgery under regional block to treat nausea and vomiting. Neonatal
apgar scores and umbilical gases are similar after induction with propofol or barbiturates.

Etomidate is an intravenous induction agent that has been used in obstetric anesthesia since
1979. It produces a rapid onset of anesthesia with minimal cardiorespiratory effects. This
property makes it ideal for parturients who are hemodynamically unstable or who would not
tolerate hemodynamic aberrations well. With an induction dose of 0.2–0.3
mg/kg, etomidate undergoes a rapid hydrolysis that leads to quick recovery. 
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Ketamine the phencyclidine derivative ketamine produces anesthesia by a dissociative

interruption of afferent pathways from cortical perception. it has become a useful and widely
used adjunctive agent in obstetrics because maternal cardiovascular status and uterine blood flow
are well maintained.
Inhalational analgesia: nitrous oxide is the main inhalational anesthetic that is used for obstetric
analgesia. It is used mainly in a 50:50 combination with oxygen. It is delivered with a demand
valve and there will not be any flow from the system unless an inspiratory effort is made with the
mask properly sealed on the face. It may produce light headedness and nausea. It is suitable for
use when the mother is in severe pain especially during late whilst waiting for the effects of other
methods to take their effects.

REGIONAL ANALGESIA

Regional analgesia is the most effective method of providing labour analgesia for the mother
currently available and is more costly and need the services of an anaesthetist in their
administration and maintenance.

Epidural analgesia: This involves the administration of a diluted amount of local anaesthetic
either in the form bupivacaine combined with a low concentration of short acting narcotic like
fantasy, through a catheter placed in the epidural space and administered either in the form of
bolus doses by a doctor or nurse,

Combined spinal epidural (CSE) analgesia: This technique is fairly similar to an epidural
except that after the epidural needle is an in the epidural space, a long spinal needle is placed
through this needle to the intrathecal space. The CSE set is more expensive compared to an
epidural set.

Spinal analgesia: This method which involves the administration of a small amount a local
anaesthetics and narcotic into the intrathecal space as a bolus dose is not frequently used for
labour analgesia. The local anesthetic provides only 1 to 3 hours of pain relief which may not be
adequate to cover pain toward the end of the first stage or second stage.

COMPLICATIONS

Complication can arise from these methods in the form of hypotension, spinal headaches, and
convulsions, peripheral or central neurological damage.
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ANAESTHESIA

Anaesthesia is the use of medication to partially or totally block all sensation to an area of body.
It may loss of normal sensation, and sometimes in loss of consciousness.

Local infiltration: It is the least extensive form of anaesthesia and presents the lowest risk to the
mother and fetus. It is administered by direct injection of the anaesthetic agent, such as lidocaine,
into the perineal tissue surrounding the area where the episiotomy will be made. Local
anaesthesia is performed immediately before the delivery and blocks sensation long enough for
the delivery and for repair of the episiotomy. The most side effects are hypotension, dizziness,
palpitations and headache, tachycardia or tremors.

REGIONAL ANAESTHESIA

Regional anaesthetics block a nerve or group of nerves without causing loss of consciousness.
This form of anaesthesia allows the women to remain alert and be able to participate in the
delivery. Regional forms of anaesthesia are most commonly recommended by health care
providers and chosen by expectant. it includes paracervical, pudendal, epidural and spinal blocks.

Paracervical block: Paracervical block prevents impulse transmission from the lower segment
of the uterus surrounding the cervix. It is accomplished by injecting a local anaesthetic
transvaginally, adjacent to the outer rim of the cervix. It may be administered during the active
phase of labour, achieving rapid and complete relief of uterine pain during cervical dilation. It
does not block pain impulses from the vagina or perineum and does not interfere with the bearing
down reflux. It is used infrequently.

Pudendal block: Pudenda block prevents impulse transmission through the pudendal nerves,
which transmit impulses from the perineum. The pudendal nerve is located near the lower
margin of the Ischial spines. Injection of the pudendal nerves is accomplished by the transvaginal
route. A long needle, with or without a protective guide (sometimes called a trumpet), is used to
instill medication around the nerves on each side of the body. The pudendal block is given within
a few minutes of delivery and results in relaxation of the muscles of the perineum thus hastening
delivery. It also blocks pain transmission when episiotomy is performed and repaired.

Epidural block: Epidural anesthesia results in loss of sensation from the lumbosacral region of
the spinal cord by blocking impulse transmission from major nerve roots located outside the
Dura mater. While the pain impulses are blocked by epidural anesthesia, sensation of
manipulation or pressure can still be detected by the women. It administered by the epidural
route affects the lower trunk and legs; therefore it can be used during labour and during either
vaginal or caesarean delivery. Epidural anesthesia is accomplished by insertion of a needle or
catheter into the epidural space and medication is inserted through the needle or catheter so that
it can flow around the Dura mater and may be administered as a single dose shortly before
delivery. The site of insertion will vary based on the type of epidural selected. In the lumbar
epidural the needle or catheter is inserted into the space between vertebrae l4 and l5 using
surgical aseptic technique.
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Spinal block: spinal anaesthesia causes loss of sensation to the lower trunk and lower
extremities by blocking transmission of nerve impulses from major nerve roots located within
the subarachnoid space of the spinal column. It is not typically used for vaginal delivery but is
reserved for caesarean delivery. It is administered using a procedure similar to that used in a
spinal tap.

GENERAL ANAESTHESIA

General anaesthesia is administered intravenously or by inhalation. Medications used for general

anaesthesia given by inhalation include the gases nitrous oxide, halothane, enflurane, and
isoflurane intravenous medications used for include ketamine and thiopental sodium, general
anaesthesia is not common because of the risks it presents to both the mother and fetus. It may be
used for routine caesarean sections but is less desirable than spiral anaesthesia. It may be
required in emergency situations when rapid administration of anaesthesia is essential or in cases
where a regional anaesthesia is contraindicated because of other medical conditions such as
infection, malformation of the spinal column.
When general anaesthesia is anticipated, the woman is given supplemental oxygen before
surgery in order to increase the oxygen saturation level. An intravenous line is established so that
there is direct access to the vasculature. The intravenous line is used to administer anaesthetics
for induction and to provide immediate access for any other medications that may be needed.

All patient for caesarean section, more so those who have undergone a period a labour and given
narcotic parenterally are considered to have "full stomach" as they have delays in gastric
emptying. These when aspirated whilst they are rendered unconscious during the administration
of a general anaesthesia can give rise to consequences that can threaten the mother's life. Hence,
general anaesthesia for caesarean section whether in an elective or emergency situation involves
a "crash induction" which is the administration of an induction agent together with a very rapid-
acting muscle relaxant whilst cricoids pressure is applied before the endotracheal tube is inserted
and its cluff inflated.

TYPES OF GENERAL ANAESTHESIA

Nitrous oxide: The anaesthetic, which is 40 percent

nitrous oxide and 60 percent oxygen, is administered by facemask or inhaler. its induction is fast
and pleasant and it is non-irritating, on-explosive and less disruptive of physiological functions
than any other general anaesthetic. Its main use is in the second stage of labour, as an induction
agent or as a supplement to more potent general anaesthesia.

Halothane (fluothane): not used as frequently as nitrous oxide, halothane nevertheless bears
mention for obstetrical anaesthesia. Its induction is rapid, predictable and safe, since it causes
little or no nausea or vomiting. It provides moderate to good uterine relaxation, although it may
cause respiratory depression as well as irritability of cardiac tissue, which can result in
arrhythmia. It may also cause increased uterine contraction along with the risk of postpartum
haemorrhage.
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Methoxyflurane (penthrane): Administered by inhaler for analgesia, or in combination with

other agents for anaesthesia, methoxyflurane induction is pleasant but slower than with gas
agents. Uterine contraction may result from its use, and administration is restricted to low doses
for short periods because of the risk of postpartum bleeding.

Thiopental sodium (pentothal): This ultra short- acting barbiturate is given intravenously and it
produces narcosis within 30 seconds. Induction and emergence are smooth and pleasant, with
little nausea or vomiting. It is most frequently used for induction or as an adjuvant to more potent
anaesthetics.

ROLES AND RESPONSIBILITIES OF NURSE

 Know and comply with the state laws and regulations regarding prescribing of
medications. Know and comply with the state nurse practice act related to medication
prescribing authority.
 Limit access to prescription pads and notify local pharmacies and the drug enforcement
agency if blank prescriptions are stolen.
 limit telephone refills to one prescription and require the patient to come in and be seen
before providing additional telephone refills,
 Avoid refilling narcotics and pain medication by telephone and outside of regular office
hours.
 Perform peer review of the prescribing practices of licensed independent practitioners
and obtain additional education and expertise as needed .
 Maintain drugs in a safe area with limited access and if appropriate or required by law,
under lock and key.
 Store drugs at manufacturer's recommended temperature.
 Store drugs in a separate location away from food or other materials or supplies.
 Avoid storing similar looking drugs near one another.
 Avoid keeping drugs with similar sounding names o the formulary, but if such
similarities do occur, provide adequate additional warnings on packaging.
 Regularly check drug expiry dates and properly discard/destroy expired drugs prescribing
medications.
 Know the appropriate indications, dosage range, and route of administration,
contraindications, side effects, and warnings related to the drugs prescribed and/or
administered.
 Maintain readily available, current drug reference materials and refer to them whenever
there are questions regarding a drug or when prescribing a drug that is not frequently
prescribed.
 Maintain access to resources that provide clinical information on drug interactions.
 Consult with physicians and pharmacists when appropriate to confirm appropriate drug
selection, prescription and ordering, and to check for potential drug interaction or
contraindication with patient's existing drug therapy.
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CONCLUSION

Labor causes severe pain for many women. There is no other circumstance in which it is
considered acceptable for an individual to experience untreated severe pain that is amenable to
safe intervention while the individual is under a physician's care. Many women desire pain
management during labor and delivery, and there are many medical indications for analgesia and
anesthesia during labor and delivery. In the absence of a medical contraindication, maternal
request is a sufficient medical indication for pain relief during labor. A woman who requests
epidural analgesia during labor should not be deprived of this service based on the status of her
health insurance. Third-party payers that provide reimbursement for obstetric services should not
deny reimbursement for labor analgesia because of an absence of “other medical indications.”
anesthesia services should be available to provide labor analgesia and surgical anesthesia in all
hospitals that offer maternal care.

JOURNAL STUDY

During the first stage of labour pain is determined mainly by the elongation of the cervix and
lower uterine segment. Subsequently, during the expulsion stage, pain is caused by the foetus
engaging in the birth canal with increasing pressure on the vaginal and perineal structures. The
pain intensity varies greatly from person to person and is higher in first pregnancies than in
subsequent pregnancies. The reason for this is that in subsequent pregnancies the cervix is
already softened before the start of the labour pains and uterus contractions are less intense at the
onset of labour. First pregnancies in older women frequently also result in greater pain than in
younger nulliparae. Other factors associated with stronger pain intensity are, for instance,
dysmenorrhoea and maternal exhaustion. 

REFERENCES

1. Midwifery and obstetrical nursing, as per INC syllabus ,third edition ,

Nima Baskar,page no.658-660,emess medical publishers

2. Melzack R. The myth of painless childbirth (the John J. Bonica

lecture) Pain. 1984;19:321–337.