Labour Analgesia

Dr Jyotsna Paranjpe,
Prof & head, Dept of Anesthesia
 History
• James Yong Simpson –Ether to mother with
deformed pelvis at childbirth. Condemned by
all.
• Yr 1847 – John Snow gave Chloroform to
Queen Victoria for 8 th delivery. Royal
patronage
 Nonpharmacological techniques
• Transcutaneous electrical nerve
stimulation(TENS),Touch & massage, water
immersion in first stage of loabour,
Intradermal sterile water inj, acupuncture,
hypnosis

• No proven data analysis regarding quality of

pain relief
 Pharmacological techniques
• Pethidine (Meperidine) – Opioid agonist.
Most widely used by obstreticians. Not to be used in
cervical dystocia (inertia)
• Ketamine, Midazolam – risk of neonatal respiratory
depression, adverse outcome
• Buterphenol – agonist –antagonist resembling
pentazocaine. 5 times potent than morphine, 40
times that of pethidine. With analgesia causes
respiratory depression, sedation. Dose 2-4 mg IM. –
not frequently used.
 Use of Opioids
• Tramadol – Pethidinelike synthetic opiod. Low affinity
for µ receptors. Potency 1/10 th of Morphine. Low
respiratory depression. Dose 1-2 mg/kg IM.onset -10
min, duration -2-3 hrs. Crosses placenta but
metabolised.
• Fentanyl – Highly lipid soluble synthetic. 100 times
potent than Morphine, 800 times that of Pethidine.
Dose 100 mcg (2ml) equivalent to 10 mg Morphine.
After IV administration onset 2-3 min, short (30-60 min)
duration, no active metabolites. Can be used in PCA.
 Use of Opioids
• Remifentanyl – ultrashort acting synthetic,
potent, opioid. Readily metabolised by plasma
& tissue esterases of mother & foetus to
inactive metabolites. Effective analgesic half
life is 6 min. Crosses placenta.
• Dose IV bolus 20 mcg with lock out interval of
3 min. on PCA pump. IV infusion
rate .025mcg/kg/min, increase stepwise
upto .15 mcg/kg/min.
 Monitoring & treatment of overdose
• Monitoring – maternal pain, maternal & foetal heart rate,
maternal B.P., maternal O2 saturation by pulse ox, side
effects (pruritus, nausea-vomitting,, respiratory depression,
uterine atony/overstimulation), maternal satisfaction score
• Naloxone – (10mg/ml) For respiratory depression in
newborn dose .01mg/kg IV/IM/SC. (Not as primary
treatment.)
• Maternal depression dose 2mg IV , repeat every 3 min(also
reverses analgesic action)
• Then .01mg/kg/hr infusion as its action is shorter than
most opioids.
 Inhalational
• Entonox – 50% O2 & 50% N2O. In a cylinder.
Poor analgesic efficacy, environmental
pollution. PCA mode ( mask tied to hand of
patient)
• Sevoflurane - .8% concentration with O2. PCA.
Needs specialised vaporiser.
Environmental pollution, maternal amnesia,
loss of respiratory reflexes
 Central neuraxial
Most versatile – currently gold standard as per recent
RCTs & Cocrane studies, EA is preferred by 60%
parturients.
Availability of RA for labour is included in std. obstretic
care by American soc of obstretics & Anesthesiologist.
• CSE
• Continuous SA with microcatheter
• Low/ ultra low dose EA (Ambulatoty EA)
• PCEA
 Stages of labour & timing of EA
• First stage - dilation of the cervix
• Second stage - birth of the baby
• Third stage - delivery of the placenta.
• EA catheter to be placed in early first stage (2
finger dialatation of Cx), On maternal request of
pain relief. Not to stop EA during second stage.
• Withhold dose if pain/parasthesia after top up
dose
 Favorable recent advances
• CSEA kit (needle through needle pencil point)
• Use of ultrasound in obese, difficult block
• Use of CT/MRI (with dye) – to locate tip, torn,
knotted catheter
• PCEA pumps, infusion pumps
• Newer drugs – Ropivacaine, L- Bupivacaine,
Remifentanyl
 Counseling & postpartum monitoring
• Myths – backache, fever, increased incidence
of LSCS,PDPH, intracranial complications
• Monitoring – Fetomaternal outcome,
breakthrough pain, motor blockage, PDPH,
fever, breast feeding, signs of LA toxicity,
hypersensitivity
 Dosage
• Give Bupivacaine bolus -
• Minimum LA volume & dose - 13.6 ml of
0.125% Bupi or 9.2 ml of 0.25% Bupi
• Then give continuous infusion of 0.0625% Bupi
with 2mcg/ml (0.25mcg/kg/hr) fentanyl. Rate
10-12 ml/hr
• Give Ropivacaine bolus 5ml of 0.1% with
fentanyl, 10 min lockout . Infusion rate 5-10
ml/hr.
 Analgesia at 2 stagend

• Spinal anesthesia with –

• O.125% L Bupivacaine 2 cc (1/2 cc of .5% diluted
to 2 cc with 0.9% N Saline)
• With 10 µg buprenorphine or 5 µg Fentanyl
diluted with N Saline 1cc
• To maintain baricity
• Useful for episiotomy too
• Analgesia remains 4-6 hrs post op ( pain of
uterine involution is not felt)
 Treatment of complications
• Hypoxia – O2 by mask
• Hypotension – vsopressor like ephedrine
• Bradycardia – Atropine
• Hypersensitivity – diphenhydramine and
corticosteroids
• Seizure – Benzodiazepines
• Avoid vasopressin, calcium channel blockers,
beta-blockers, or other local anesthetics.
 Symptoms of LAST
• CNS (excitement) – an early manifestation of LAST that often begins
with confusion or slurred speech ,subjective symptoms like metallic
taste in the mouth, tinnitus, oral numbness, dizziness,
lightheadedness, or visual or auditory disturbances. If not treated
promptly, these symptoms often progress to seizures, syncope,
coma, respiratory depression, or cardiovascular collapse.
• Cardiovascular – often preceded by CNS symptoms but not always.
May include hypertension, tachycardia or bradycardia, arrhythmias,
and asystole. Depressed contractility of the heart then leads to
progressive hypotension and ultimately cardiac arrest.
• Hematologic – methemoglobinemia, cyanosis
• Allergic – urticaria, rash, and rarely anaphylaxis
• Local tissue response – numbness, paresthesia
 Lipid rescue for overdose
• if local anesthetic is inadvertently administered directly into a vessel.
Onset of LAST is within 1-5 min
• Intralipid, a soya-based lipid emulsion that contains long-chain
triglycerides, is the most commonly used intralipid. It acts as a “sink” by
creating a lipid compartment within the plasma that attracts lipophilic
compounds like LAs.
• An initial dose of 20% lipid emulsion at 1.5 ml/kg or a 100 ml bolus given
over a few minutes. Can be repeated after 5 min for 2-3 times for
persistent hemodynamic instability. The bolus(es) should immediately be
followed by a continuous infusion at 0.25-0.5 ml/kg/min. The infusion
should run for a minimum of 10 min after return of hemodynamic
stability.
• Safe in pregnant, neonates.
• Adverse effect – hypersensitivity to egg/soya. Treated with steroids, evil.