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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 * * * * * * * * Fan Qu, Jue ... – PowerPoint PPT presentation

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Title: Pain relief in labour in low resource setting


1
Pain relief in labour in low resource setting
  • DR. MANISH R PANDYA
  • MD FICOG FICMCH
  • PROFESSOR AND HOD
  • SURENDRANAGAR
  • www.drmanishpandya.com

2
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)

3
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

4
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

5
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

6
Nature of Labor Pain 1st Stage
  • Visceral pain
  • Diffuse abdominal cramping
  • Uterine contractions

7
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

8
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.

9
  • 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.

10
Stages of Labour
11
Pain pathways during labor

12
Trends
  • Nulliparous
  • More sensory pain during early labor
  • Multiparous
  • More intense pain during late 1st stage and the
    2nd stage
  • Rapid fetal descent

13
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

14
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.

15
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)

16
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

17
Methods of Pain Relief
  • Nursing measures
  • Relaxation techniques
  • Breathing techniques
  • Systemic analgesia
  • Regional nerve blocks
  • Local anesthetics
  • General anesthesia

18
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

19
Systemic Analgesics
  • 1) Stadol
  • 2) Nubain
  • 3) Demerol
  • 4) Seconal
  • 5) Nembutal
  • 6) Phenergan
  • 7) Vistaril
  • 8) Narcan

20
Differentiation of regional blocks (usually done
by anaesthetist) and field blocks (commonly
performed by obstetrician) BMJ. 1999 April 3
318(7188) 927930.
21
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)

22
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

23
Non-pharmacological methods
24
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)

25
  • 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

26
  • 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

27
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

28
Lamaze technique
  • Prepared child birth, including relaxation
    techniques, breathing exercises etc

29
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

30
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)

31
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

32
  • 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

33
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

34
  • SLOW PACED Breathing
  • MODIFIED-PACE Breathing
  • Combination of slow and modified
  • paced breathing
  • Patterned paced Breathing
  • (Pant blow)
  • Breath holding while pushing

35
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.

36
  • 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

37
Acupuncture
  • Traditional Chinese therapy
  • Releases endorphins and enkephalins

38
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.)

39
Physical therapy
  • Massage
  • Counter pressure
  • Hot and Cold Compresses
  • Light stroking or Effleurage

40
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

41
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!

42
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

43
 Distraction
  • Using music
  • Listening to jokes
  • Playing cards

44
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.
45
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"

46
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)

47
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

48
Labour Analgesia
Alleviates pain
PAIN
FEAR
TENSION
Fetal Stress Acidosis
?INtervention
Stress
49
PROGRAMMED LABOUR - Methodology
  • Proper selection , Counseling Consent
  • Labour induction / Acceleration
  • All medication in Active phase of Labour
  • Commence PARTOGRAPHIC monitoring

50
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

51
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

52
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

53
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

54
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

55
Post delivary evaluation
  • Pain relief score
  • Amnesia score
  • Patient attitude record
  • Satisfied with analgesia protocol
  • Dissatisfied with analgesia protocol

56
STUDY REPORT
57
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

58
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

59
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

60
Age distribution
Age 20 20-25 25-30
Primi 150 100 70
Multi 20 50 110
Total 170 150 180
61
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
62
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
63
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
64
Mode of delivary
Mode of delivary Normal Operative vaginal Lscs
Primi 263 23 34
Multi 147 33 -
Total 410 56 34
65
Neonatal outcome
Apgar score lt 7 Nicu care Perinatal morbidity
Primi 320 - -
Multi 180 - -
Total 500 - -
66
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
67
Drugs used in third stage
Methyl ergometrine Prostagalndine Oxytocine
Primi 160 160 -
Multi 90 90 -
Total 250 250 -
68
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
69
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

70
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

71
All is well!
  • Patient No Pain
  • Dr Easy Schedule!
  • Baby Safe

72
Thank YOU all. . .
  • Presentation designed developed By
  • Dr Darshna Thakker
  • MB, MD, DHA, MBA
  • Consultant Gynecologist Obstetrician
  • www.sarjanhealthcare.com
  • 91 98240 69989
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