Pain relief in labour in low resource setting

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Pain relief in labour in low resource setting

• DR. MANISH R PANDYA
• MD FICOG FICMCH
• PROFESSOR AND HOD
• SURENDRANAGAR
• www.drmanishpandya.com

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FROM THE HOLY QURAN

• IN THE NAME OF ALLAH THE MOST BENEFICIENT THE
  MOST MERCIFUL
• AND THE PAINS OF CHILDBIRTH DROVE HER TO THE
  TRUNK OF A DATE PALM. SHE SAID WOULD THAT I HAD
  DIED BEFORE THIS, AND HAD BEEN FORGOTTEN AND OUT
  OF SIGHT.
• SURAH 19 23 (SURAH MARYAM)

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Goals Of Labor Analgesia

• Dramatically reduce pain of labor
• Should allow parturient to participate in
  birthing experience
• Minimal motor block to allow ambulation
• Minimal effects on fetus
• Minimal effects on progress of labor

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The Debate

• Labor results in severe pain for many women.
  There is no other circumstance where it is
  considered acceptable for a person to experience
  untreated severe pain, amenable to safe
  intervention, while under a physicians care
  Maternal request is a sufficient medical
  indication for pain relief during labor.
• ACOG ASA

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Nature of Labor Pain

• Pain is subjective
• Complex interaction of influences
• Physiologic
• Psychosocial
• Cultural
• Environmental
• Expectations are often confirmed
• Anxiety and fear higher experience of pain
• Confidence in her ability to cope
• Safe and positive birth environment

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Nature of Labor Pain 1st Stage

• Visceral pain
• Diffuse abdominal cramping
• Uterine contractions

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Nature of Labor Pain 2nd Stage

• Somatic pain
• Perineum
• Sharper and more continuous
• Pressure or nerve entrapment (caused by the
  fetus head)
• May cause severe back or leg pain

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Pain pathways during labor

• Pain is sensation of discomfort resulting from
  stimulation of specialized nerve endings
• During labor, pain sensation is relayed to the
  spinal cord from T10, L1, S1-S4. These sensory
  fibers make synaptic connections in dorsal horn
  of spinal cord with cells that provide axons that
  make up the spinothalamic tract.

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• Early 1st stage before fetal head reaches zero
  station, pain impulses arise primarily from
  uterus ? via visceral afferents enter spinal cord
  at T10-L1.
• Late 1st stage 2nd stage pain impulses arise
  from uterus, pelvic structures, vagina,
  perineum.
• 3rd stage of labor is usually well tolerated with
  spontaneous placental delivery.

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Stages of Labour
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Pain pathways during labor

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Trends

• Nulliparous
• More sensory pain during early labor
• Multiparous
• More intense pain during late 1st stage and the
  2nd stage
• Rapid fetal descent

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What determines maternal satisfaction?

• Pain relief
• Quality of relationship with caregiver
• Participation in decision making
• Home-like birth environment
• Caregivers with whom they are acquainted
  personally

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Purpose

• To help obstetrician-gynecologists understand the
  available methods of pain relief to facilitate
  communication with their colleagues in the field
  of anesthesia
• To optimizing patient comfort while minimizing
  the potential for maternal and neonatal morbidity
  and mortality.

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Labor Pain

• Uterine contractions and cervical dilatation
  result in visceral pain (T10 to L1). As labor
  progresses, the descent of fetal head and
  subsequent pressure on the pelvic floor, vagina
  and perineum generate somatic pain transmitted by
  pudendal nerve (S2 to S4)

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Objectives

• Identify data for assessment of a client
  receiving pharmacologic methods of pain relief
• Formulate nursing diagnosis and select
  interventions appropriate for the client
  receiving pharmacologic pain relief

• Discuss categories of pain relief methods
• Discuss types and pros and cons
• Discuss commonly used meds during labor and
  childbirth
• Discuss regional analgesia and anesthesia

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Methods of Pain Relief

• Nursing measures
• Relaxation techniques
• Breathing techniques
• Systemic analgesia
• Regional nerve blocks
• Local anesthetics
• General anesthesia

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Assessment of the Client

• Three major factors influence the administration
  of pharmacologic pain relief 1) effect on the
  client , 2) effect on the fetus, and effect on
  the contraction pattern
• The use of electronic fetal monitoring may
  influence administration of medication
• All systemic drugs used for pain relief during
  labor cross the placental barrier by simple
  diffusion
  

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Systemic Analgesics

• 1) Stadol
• 2) Nubain
• 3) Demerol
• 4) Seconal
• 5) Nembutal
• 6) Phenergan
• 7) Vistaril
• 8) Narcan

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Differentiation of regional blocks (usually done
by anaesthetist) and field blocks (commonly
performed by obstetrician) BMJ. 1999 April 3
318(7188) 927930.
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Other than techniques

• These four factors make the greatest contribution
  to women's satisfaction in childbirth
• having good support from caregivers
• having a high-quality relationship with
  caregivers
• being involved in decision-making about care
• having better-than-expected experiences, or
  having high expectations.
• Pain relief only becomes important for
  satisfaction in childbirth when expectations are
  not met
• (Hodnett 2002, a systematic review)

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Pain relief techniques

• Water birthing
• Music
• Heat and cold
• Imagery
• Rhythmical movements
• Massage
• Relaxation
• Breathing
• Perineal massage
• Intra dermal injections of sterile water

• Narcotics
• Twilight sleep
• Entonox
• Lamaze technique
• Hypnotism
• Acupressure / Shiatsu
• Acupuncture
• Electro-acupuncture
• TENS
• Intrathecal narcotics
• Epidurals

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Non-pharmacological methods
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Water birth

• Soviet researcher Igor Charkovsky and French
  obstetrician Frederick Leboyer developed in 1960s
• Practices in United States, Canada, Australia,
  and New Zealand, as well as many European
  countries, including the United Kingdom and
  Germany
• By 2005, over 9000 hospitals in the US and more
  than three-quarters of all NHS hospitals (UK)
  provided this option
• (Dianne Garland. Waterbirth An Attitude to Care)

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• Provides pain relief and a less traumatic birth
  experience for the baby
• Redistribution of blood volume, which stimulates
  the release of oxytocin and vasopressin (Katz
  1990)
• Exerts gravitational pull
• Aid stretching of the perineum, slows crowning of
  the infant's head, reduces the use of episiotomy

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• A decrease in perinatal mortality (1.2 per 1,000
  for waterbirth vs. 4 per 1,000 for conventional
  birth) during 1994-1996 in the UK
• Risks to the infant such as infection and water
  inhalation?
• "there are no valid reports of infants deaths due
  to water aspiration or inhalation" (Harper 2000)
• Slowed labor? A decrease in the intensity of
  contractions - a "5 centimeter" rule
• Maternal blood loss? - Difficult to assess
• The amount of blood loss reduced due to lowering
  BP and heart rate

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Music

• Ancient Greeks played soothing instrumental music
  to women in labour
• Alters mood, reduces stress and promotes positive
  thoughts
• A trigger for a breathing response or as a cue
  for relaxation
• Used as a distraction

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Lamaze technique

• Prepared child birth, including relaxation
  techniques, breathing exercises etc

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TENS

• TENS (transcutaneous electrical nerve
  stimulation)
• Stimulates the release of endorphins
• Most useful in labour before the pain becomes too
  intense
• Drug dose requirements may be less

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Hypnotherapy

• Mongan method (also known as HypnoBirthing),
  Hypnobabies, the Lamaze method, Natal
  Hypnotherapy and the GentleBirth program
• Useful for heartburn, high blood pressure and
  postnatal depression
• can significantly shorten labor, reduce pain and
  reduce the need for intervention, produced higher
  apgar scores, reduce the incidence of postpartum
  depression and increase the incidence of
  spontaneous deliveries
• (British Journal of Obstetrics and Gynaecology,
  100(3), 221-226, 1993)

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Relaxation techniques

• Providing a stress-free period during the
  antenatal period helping in preparing the woman
  and also in growth of the foetus
• Decreasing the tension, fatigue, discomfort and
  pain of labour. It also increases the oxygen
  going to the baby
• Helps in providing a stress-free period during
  pueperium (i.e. after delivery). Thus helping in
  lactation and bonding between the couple and
  little one

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• Start by doing slow breathing.
• Body awareness / tension recognition
• Contract relax method
• Toes feet ankles knees thighs buttocks
  back abdomen chest shoulders fists head
  Clench teeth face eyebrows
• Touch Relaxation - a conditioned reflex

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Breathing techniques

• In some women, relaxation alone may not be
  sufficient to counter the discomfort of labour In
  such cases breathing techniques can be used to
  augment the efficacy of relaxation techniques
  used only during contraction

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• SLOW PACED Breathing
• MODIFIED-PACE Breathing
• Combination of slow and modified
• paced breathing
• Patterned paced Breathing
• (Pant blow)
• Breath holding while pushing

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Acupressure

• For relieving head / neck and upper backache
  apply circular pressure on the muscles at the top
  of the shoulder in vertical line with the nipples
  near the back.
• Massaging the center of the sole, below the ball
  of the feet will relax the lower body.
• To relieve low backache, pelvic discomfort or
  pain, press firmly in an inward direction on
  either side of the vertebral column, below the
  waist level. Circular pressure is applied during
  contraction and intermittent pressure between
  contractions.

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• The ball of the thumbs is the part that is used
  to put the pressure. Do not use your nails or the
  tip of the thumb
• apply the pressure in a circular motion
• to release the pressure point when the pregnant
  women exhales and then one must transfer to
  another acupressure point
• Large areas of the body include the shoulder
  point, the buttock point and the thighs

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Acupuncture

• Traditional Chinese therapy
• Releases endorphins and enkephalins

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Electro-acupuncture

• a significant difference in the concentration of
  ß-endorphin (ß-EP) and 5-hydroxytryptamine (5-HT)
  in the peripheral blood between the two groups at
  the end of the first stage (p 0.037 p 0.030)
• producing a synergism of the central nervous
  system (CNS) with a direct impact on the uterus
  through increasing the release of ß-EP and 5-HT
  into the peripheral blood.
• (Fan Qu, Jue Zhou. Electro-Acupuncture in
  Relieving Labor Pain. Evid Based Complement
  Alternat Med. 2007 March 4(1) 125130.)

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Physical therapy

• Massage
• Counter pressure
• Hot and Cold Compresses
• Light stroking or Effleurage

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Massage

• Touch has been associated with the power of
  healing since the beginning of civilisation
• a source of counter-stimulation
• Examples Therapeutic massage (eg shiatsu),
  perineal massage

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Methods of touch and massage

• Lightly stroking the abdomen
• Vigorously firm stroking where it hurts most
• Firm circular massage using the palm of the hand
  over the centre of the back or sacrum.
• Rhythmical squeezing and letting go of the
  shoulder muscles
• A long stroke down the length of the back,
  buttocks and down the back of the legs
• Stroking across the forehead, down the neck and
  down the arms simply holding hands!

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Shiatsu

• Japanese form of therapeutic massage. Shiatsu
  means finger pressure.
• Similar to acupuncture.
• Pain-relieving pressure points (tsubo) are
  stimulated without the use of needles

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 Distraction

• Using music
• Listening to jokes
• Playing cards

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Intra dermal injections of sterile water

• Intense stinging followed by relief of backache
  for 60 90 minutes
• May be due to release of endorphins or by
  counter-irritation

0.1 ml of sterile water is injected into four locations on the lower back, two over each posterior superior iliac spine (PSIS) and two 3 cm below and 1 cm medial to the PSIS. The injections should raise a bleb below the skin.
Simkin PP, O'Hara M. Nonpharmacologic relief of
pain during labor systematic eviews of five
methods. Am J Obstet Gynecol 2002186(Suppl 5)
S131-59.
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Twilight sleep

• Known and more or less used since 1903
• "Freiburg Method,"
• "Dammerschlaf" of Gauss
• "scopolamine-morphine" method of obstetric
  anesthesia
• Monitoring pupils, pulse, respiration, character
  of the uterine contractions and the character of
  the fetal heart action "memory tests"

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Cochrane review

• We found evidence that acupuncture and hypnosis
  may help relieve labour pain
• There is insufficient evidence about the benefits
  of music, massage, relaxation, white noise,
  acupressure, aromatherapy
• No evidence about the effectiveness of massage or
  other complementary therapies
• (Smith CA, Collins CT, Cyna AM, Crowther CA.
  Complementary and alternative therapies for pain
  management in labour. Cochrane Database of
  Systematic Reviews 2006, Issue 2. Art. No.
  CD003521. DOI 10.1002/14651858.CD003521.pub2)

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Use of drugs for pain relief

• Immediate short term relief
  Pentazocine HCl 6.0 mg Diazepam 2.0 mg
• Long term Pain Relief
  Tramadol 50 100 mg IM
• Supplementation in Advance Labour SOS
  KETAMINE Continuous infusion
  Intermitted IV boluses Loading Dose 0.5 mg
  /kg wt Maintenance doses 0.25 mg /kg wt every
  30 min

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Labour Analgesia
Alleviates pain
PAIN
FEAR
TENSION
Fetal Stress Acidosis
?INtervention
Stress
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PROGRAMMED LABOUR - Methodology

• Proper selection , Counseling Consent
• Labour induction / Acceleration
• All medication in Active phase of Labour
• Commence PARTOGRAPHIC monitoring

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Procedure medication

• Active phase of Labour
• Amnioinfusion /oxytocin drip /P.G.
• Infusion 5 glucose /Ringer Lactate
• I.V. bolus Pentazocine HCl 6.0 mg Diazepam 2.0
  mg
• I.M Drotaverine / Camylofin/ Valethamate Bromide/
  Buscopan
• Commence partogram

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Procedure medication

• Analgesia in advance labour
• Ketamine intermittent I.V after 7.0 cm dilatation
• Active management of third stage
• Active management of third stage with 125.mg
  PGF2a /Methergine
• Post delivery evaluation
• Degree of pain relief Extent of amnesia

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Active phase of labour

• Amniotomy /Oxytocin drip / P.G
• Infusion 5 Glucose / Ringer lactate
• I.V bolus Pentazocine Hcl 6.0 mg Diazepam 2.0
  mg
• IM Tramadol 50.0.100.0 mg
• IM Drotaverine / Camylofin/Valathamide bromide /
  Buscopan
• Commence Partogram

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Analgesia in advance labour

• Ketamine intermittent I.V after 7.0 cm dilatation
• Anesthetic dose 2mg /kg body wt.
• For labour Analgesia
• initial dose 0.5 mg /kg wt
• -top up dose 0.25 mg/kg wt.
• Wide margin of safety

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Active management of third stage stage

• Inj. 125.0 mcg PGF2 a I.M
• Inj. Methergine I.M / Slow I.V
• Inj. Oxytocine I.M / Infusion / Intraumbilical

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Post delivary evaluation

• Pain relief score
• Amnesia score
• Patient attitude record
• Satisfied with analgesia protocol
• Dissatisfied with analgesia protocol

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STUDY REPORT
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Medication protocol

• This study of 500 case for evaluation of
  programme labour protocol in private set up
• 320 patient of primipara and 180 patient of
  multiparity are included in study
• Selection of patients are done after they enter
  into active labour i.e. after 3 cm cervical
  dilatation

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Medication protocol

• At admission of patient enema given
• As they enter into active phase
• -Administer 6.0 mg Pentazocine and inj.
  Diazepam 2.0 mg as bolus slowly through the
  infusion line . This provides short term pain
  relief.
• Injection Drotine or Tramazac is also given

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Medication protocol

• Injection velocine are given at 1 hour interval
  to all patients
• After the dose of fortwin and campose all
  patients were relived with pain and so many are
  in sound sleep.
• Cervical dilatation is very fast when they are in
  sleep and progress of labour is speedy

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Age distribution
Age 20 20-25 25-30
Primi 150 100 70
Multi 20 50 110
Total 170 150 180
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Duration of labour
TIME 2-4 HRS 4-6 HRS 6-8 HRS
PRIMI 80 100 140
MULTI 60 20 100
TOTAL 140 120 240
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Pain score
Pain score 3 pain unbearable 2 pain is severe 1 pain bearable
Pt. Demand relief Pt. Seek relief Pt. Doesnt desire relief
Primi 280 40 -
Multi 100 60 20
Total 380 100 20
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Relief of pain
Pain relief score 1 .Not to the desire extent 2 . substantial relief of pain 3. Complete relief of pain
Primi 20 60 240
Multi 40 20 120
Total 60 80 360
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Mode of delivary
Mode of delivary Normal Operative vaginal Lscs
Primi 263 23 34
Multi 147 33 -
Total 410 56 34
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Neonatal outcome
Apgar score lt 7 Nicu care Perinatal morbidity
Primi 320 - -
Multi 180 - -
Total 500 - -
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Weight of babies
Weight 2.5 kg 2.5-3.0kg 3.0-3.5 kg
Primi 40 230 50
Multi - 100 80
Total 40 330 130
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Drugs used in third stage
Methyl ergometrine Prostagalndine Oxytocine
Primi 160 160 -
Multi 90 90 -
Total 250 250 -
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Duration of third stage
Drugs lt 3 min 3 -6 min Amount of blood loss
Methylergomertine 48 112 Routine
Prostaglandine 89 01 Markedly less
Oxytocine - - Not used
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Conclusion

• In this study gtgt duration and pain during labour
  is shortened
• Rate of LSCS has gone down
• Neonates are in good Apgar score and no entry
  into NICU
• We can adjust our schedule with programmed labour
  
• Injecting the remains of Inj. Fortwin and Inj.
  Anxol into Injection Dextrose 5 will give
  excellent relief of pain in early postpartum

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Conclusion

• Patient experience is fantastic as number of new
  delivery is increased in practice
• Patient attitude towards this protocol is
  appreciable by both patients as well as relatives
• It may spread rumors like we make patients sleep
  and arrest the progress of labour as she in not
  taking pain while in sleep
• Sincere thanks to Dr.Daftary for giving such
  wonderful protocol for safe motherhood

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All is well!

• Patient No Pain
• Dr Easy Schedule!
• Baby Safe

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Thank YOU all. . .

• Presentation designed developed By
• Dr Darshna Thakker
• MB, MD, DHA, MBA
• Consultant Gynecologist Obstetrician
• www.sarjanhealthcare.com
• 91 98240 69989