Presentation on theme: "Pain relief in labour in low resource setting"— Presentation transcript:
1Pain relief in labour in low resource setting DR. MANISH R PANDYAMD FICOG FICMCHPROFESSOR AND HODSURENDRANAGAR
2IN THE NAME OF ALLAH THE MOST BENEFICIENT THE MOST MERCIFUL FROM THE HOLY QURANIN 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)
3Goals Of Labor Analgesia Dramatically reduce pain of laborShould allow parturient to participate in birthing experienceMinimal motor block to allow ambulationMinimal effects on fetusMinimal effects on progress of labor
4The 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 physician’s care… Maternal request is a sufficient medical indication for pain relief during labor.” ACOG & ASA
5*Safe and positive birth environment Nature of Labor PainPain is subjectiveComplex interaction of influencesPhysiologicPsychosocialCulturalEnvironmentalExpectations are often confirmed…Anxiety and fear = higher experience of painConfidence in her ability to cope*Safe and positive birth environment
7Nature of Labor Pain – 2nd Stage Somatic painPerineumSharper and more continuousPressure or nerve entrapment (caused by the fetus’ head)May cause severe back or leg pain
8Pain pathways during labor Pain is sensation of discomfort resulting from stimulation of specialized nerve endingsDuring 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.
9Early 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.
12Trends… Nulliparous Multiparous More sensory pain during early labor More intense pain during late 1st stage and the 2nd stageRapid fetal descent
13What determines maternal satisfaction? Pain reliefQuality of relationship with caregiverParticipation in decision makingHome-like birth environmentCaregivers with whom they are acquainted personally
14PurposeTo help obstetrician-gynecologists understand the available methods of pain relief to facilitate communication with their colleagues in the field of anesthesiaTo optimizing patient comfort while minimizing the potential for maternal and neonatal morbidity and mortality.
15Labor PainUterine 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)
16ObjectivesDiscuss categories of pain relief methodsDiscuss types and pro’s and con’sDiscuss commonly used meds during labor and childbirthDiscuss regional analgesia and anesthesiaIdentify data for assessment of a client receiving pharmacologic methods of pain reliefFormulate nursing diagnosis and select interventions appropriate for the client receiving pharmacologic pain relief
18Assessment 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 patternThe use of electronic fetal monitoring may influence administration of medicationAll systemic drugs used for pain relief during labor cross the placental barrier by simple diffusion
20Differentiation of regional blocks (usually done by anaesthetist) and field blocks (commonlyperformed byobstetrician)BMJ April 3; 318(7188):927–930.
21(Hodnett 2002, a systematic review) Other than techniquesThese four factors make the greatest contribution to women's satisfaction in childbirth:having good support from caregivershaving a high-quality relationship with caregiversbeing involved in decision-making about carehaving 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)
22Pain relief techniques Water birthingMusicHeat and coldImageryRhythmical movementsMassageRelaxationBreathingPerineal massageIntra dermal injections of sterile waterNarcoticsTwilight sleepEntonoxLamaze techniqueHypnotismAcupressure / ShiatsuAcupunctureElectro-acupunctureTENSIntrathecal narcoticsEpidurals
24(Dianne Garland. Waterbirth: An Attitude to Care) Soviet researcher Igor Charkovsky and French obstetrician Frederick Leboyer developed in 1960sPractices in United States, Canada, Australia, and New Zealand, as well as many European countries, including the United Kingdom and GermanyBy 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)
25Provides 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 pullAid stretching of the perineum, slows crowning of the infant's head, reduces the use of episiotomy
26A decrease in perinatal mortality (1. 2 per 1,000 for waterbirth vs A decrease in perinatal mortality (1.2 per 1,000 for waterbirth vs. 4 per 1,000 for conventional birth) during in the UKRisks 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" ruleMaternal blood loss? - Difficult to assessThe amount of blood loss reduced due to lowering BP and heart rate
27MusicAncient Greeks played soothing instrumental music to women in labourAlters mood, reduces stress and promotes positive thoughtsA trigger for a breathing response or as a cue for relaxationUsed as a distraction
28Lamaze techniquePrepared child birth, including relaxation techniques, breathing exercises etc
29TENS TENS (transcutaneous electrical nerve stimulation) Stimulates the release of endorphinsMost useful in labour before the pain becomes too intenseDrug dose requirements may be less
30(British Journal of Obstetrics and Gynaecology, 100(3), 221-226, 1993) HypnotherapyMongan method (also known as HypnoBirthing), Hypnobabies, the Lamaze method, Natal Hypnotherapy and the GentleBirth programUseful for heartburn, high blood pressure and postnatal depressioncan 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), , 1993)
31Relaxation techniques Providing a stress-free period during the antenatal period helping in preparing the woman and also in growth of the foetusDecreasing the tension, fatigue, discomfort and pain of labour. It also increases the oxygen going to the babyHelps in providing a stress-free period during pueperium (i.e. after delivery). Thus helping in lactation and bonding between the couple and little one
33Breathing techniquesIn 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
34Breath holding while pushing: “SLOW PACED” Breathing“MODIFIED-PACE” Breathing:Combination of slow and modifiedpaced breathing:“Patterned – paced” Breathing:(Pant – blow)Breath holding while pushing:
35AcupressureFor 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.
36The ball of the thumbs is the part that is used to put the pressure 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 thumbapply the pressure in a circular motionto release the pressure point when the pregnant women exhales and then one must transfer to another acupressure pointLarge areas of the body include the shoulder point, the buttock point and the thighs
37Acupuncture Traditional Chinese therapy Releases endorphins and enkephalins
38Electro-acupuncturea significant difference in the concentration of β-endorphin (β-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 β-EP and 5-HT into the peripheral blood.(Fan Qu, Jue Zhou. Electro-Acupuncture in Relieving Labor Pain. Evid Based Complement Alternat Med March; 4(1): 125–130.)Fan Qu, Jue Zhou studied the effects of electro-acupuncture in primiparas were randomly divided into an electro-acupuncture group and a control group. Assessments of pain intensity and degree of relaxation during labor were analyzed. The differences between the electro-acupuncture group and the control group on the concentration of β-endorphin (β-EP) and 5-hydroxytryptamine (5-HT) in the peripheral blood were compared. The electro-acupuncture group was found to exhibit a lower pain intensity and a better degree of relaxation than the control group (p = 0.018; p = 0.031). There existed a significant difference in the concentration of β-EP and 5-HT in the peripheral blood between the two groups at the end of the first stage (p = 0.037; p = 0.030). Electro-acupuncture was found to be an effective alternative or complementary therapy in the relief of pain during labor. The benefit of electro-acupuncture for relieving labor pain may be based on the mechanism of producing a synergism of the central nervous system (CNS) with a direct impact on the uterus through increasing the release of β-EP and 5-HT into the peripheral blood.
39Physical therapy Massage Counter pressure Hot and Cold Compresses Light stroking or “Effleurage”
40MassageTouch has been associated with the power of healing since the beginning of civilisationa source of counter-stimulationExamples; Therapeutic massage (eg: shiatsu), perineal massage
41Methods of touch and massage Lightly stroking the abdomenVigorously firm stroking where it hurts mostFirm circular massage using the palm of the hand over the centre of the back or sacrum.Rhythmical squeezing and letting go of the shoulder musclesA long stroke down the length of the back, buttocks and down the back of the legsStroking across the forehead, down the neck and down the arms simply holding hands!
42ShiatsuJapanese form of therapeutic massage. Shiatsu means ‘finger pressure’.Similar to acupuncture.Pain-relieving pressure points (‘tsubo’) are stimulated without the use of needles
43 DistractionUsing musicListening to jokesPlaying cards
44Intra dermal injections of sterile water Intense stinging followed by relief of backache for 60 – 90 minutesMay be due to release of endorphins or by counter-irritation0.1 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 2002;186(Suppl 5): S
45Twilight sleep Known and more or less used since 1903 "Freiburg Method,""Dammerschlaf" of Gauss"scopolamine-morphine" method of obstetric anesthesiaMonitoring: pupils, pulse, respiration, character of the uterine contractions and the character of the fetal heart action "memory tests"
46Cochrane reviewWe found evidence that acupuncture and hypnosis may help relieve labour painThere is insufficient evidence about the benefits of music, massage, relaxation, white noise, acupressure, aromatherapyNo 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.: CD DOI: / CD pub2)
47Use of drugs for pain relief Immediate short term relief : Pentazocine HCl – 6.0 mg + Diazepam – 2.0 mgLong term Pain Relief : Tramadol : 50 – 100 mg IMSupplementation 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
51Procedure & medication Analgesia in advance labourKetamine intermittent I.V after 7.0 cm dilatationActive management of third stage:Active management of third stage with 125.mg PGF2a /MetherginePost delivery evaluation :Degree of pain relief – Extent of amnesia
53Analgesia in advance labour Ketamine intermittent I.V after 7.0 cm dilatationAnesthetic 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
54Active management of third stage stage Inj mcg PGF2 a I.MInj. Methergine – I.M / Slow I.VInj. Oxytocine –I.M / Infusion / Intraumbilical
55Post delivary evaluation Pain relief scoreAmnesia scorePatient attitude recordSatisfied with analgesia protocolDissatisfied with analgesia protocol
57Medication protocolThis study of 500 case for evaluation of programme labour protocol in private set up320 patient of primipara and 180 patient of multiparity are included in studySelection of patients are done after they enter into active labour i.e. after 3 cm cervical dilatation
58Medication 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
59Medication protocolInjection velocine are given at 1 hour interval to all patientsAfter 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
60Age distribution Age 20 20-25 25-30 Primi 150 100 70 Multi 50 110 Total170180
61Duration of labour TIME 2-4 HRS 4-6 HRS 6-8 HRS PRIMI 80 100 140 MULTI 6020TOTAL120240
63Relief of pain Pain relief score 1 .Not to the desire extent 2 . substantial relief of pain3. Complete relief of painPrimi2060240Multi40120Total80360
64Mode of delivary Mode of delivary Normal Operative vaginal Lscs Primi 2632334Multi14733-Total41056DR.MANISH PANDYA
65Neonatal outcome Apgar score < 7 Nicu care Perinatal morbidity Primi320-Multi180Total500DR.MANISH PANDYA
66Weight of babies Weight 2.5 kg 2.5-3.0kg 3.0-3.5 kg Primi 40 230 50 Multi-10080Total330130DR.MANISH PANDYA
67Drugs used in third stage Methyl ergometrineProstagalndineOxytocinePrimi160-Multi90Total250DR.MANISH PANDYA
68Duration of third stage Drugs< 3 min3 -6 minAmount of blood lossMethylergomertine48112RoutineProstaglandine8901Markedly lessOxytocine-Not usedDR.MANISH PANDYA
69ConclusionIn this study >> duration and pain during labour is shortenedRate of LSCS has gone downNeonates are in good Apgar score and no entry into NICUWe can adjust our schedule with programmed labourInjecting the remains of Inj. Fortwin and Inj. Anxol into Injection Dextrose 5% will give excellent relief of pain in early postpartumDR.MANISH PANDYA
70ConclusionPatient experience is fantastic as number of new delivery is increased in practicePatient attitude towards this protocol is appreciable by both patients as well as relativesIt may spread rumors like we make patients sleep and arrest the progress of labour as she in not taking pain while in sleepSincere thanks to Dr.Daftary for giving such wonderful protocol for safe motherhoodDR.MANISH PANDYA
71All is well!Patient – No PainDr – Easy Schedule!Baby – Safe
72Thank YOU all. . . Dr Darshna Thakker MB, MD, DHA, MBA +91 98240 69989 Presentation designed & developed ByDr Darshna ThakkerMB, MD, DHA, MBAConsultant Gynecologist & Obstetrician