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Pain relief in labour in low resource setting

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1 Pain relief in labour in low resource setting


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 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 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 Multiparous More sensory pain during early labor
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 Discuss categories of pain relief methods Discuss types and pro’s and con’s Discuss commonly used meds during labor and childbirth Discuss regional analgesia and anesthesia 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

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 April 3; 318(7188): 927–930.

21 (Hodnett 2002, a systematic review)
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 (Dianne Garland. Waterbirth: An Attitude to Care)
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
A decrease in perinatal mortality (1.2 per 1,000 for waterbirth vs. 4 per 1,000 for conventional birth) during 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 (British Journal of Obstetrics and Gynaecology, 100(3), 221-226, 1993)
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), , 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 Breath holding while pushing:
“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
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 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.

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 2002;186(Suppl 5): S

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.: CD DOI: / CD 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 Fetal Stress INtervention & Acidosis Stress
Alleviates pain PAIN TENSION FEAR 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 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 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 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


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 50 110
Total 170 180

61 Duration of labour TIME 2-4 HRS 4-6 HRS 6-8 HRS PRIMI 80 100 140 MULTI
60 20 TOTAL 120 240

62 Pt. Doesn’t desire relief
Pain score Pain score 3 pain unbearable 2 pain is severe 1 pain bearable Pt. Demand relief Pt. Seek relief Pt. Doesn’t desire relief Primi 280 40 - Multi 100 60 20 Total 380

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 40 120 Total 80 360

64 Mode of delivary Mode of delivary Normal Operative vaginal Lscs Primi
263 23 34 Multi 147 33 - Total 410 56 DR.MANISH PANDYA

65 Neonatal outcome Apgar score < 7 Nicu care Perinatal morbidity
Primi 320 - Multi 180 Total 500 DR.MANISH PANDYA

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 330 130 DR.MANISH PANDYA

67 Drugs used in third stage
Methyl ergometrine Prostagalndine Oxytocine Primi 160 - Multi 90 Total 250 DR.MANISH PANDYA

68 Duration of third stage
Drugs < 3 min 3 -6 min Amount of blood loss Methylergomertine 48 112 Routine Prostaglandine 89 01 Markedly less Oxytocine - Not used DR.MANISH PANDYA

69 Conclusion In this study >> 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 DR.MANISH PANDYA

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 DR.MANISH PANDYA

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

72 Thank YOU all. . . Dr Darshna Thakker MB, MD, DHA, MBA +91 98240 69989
Presentation designed & developed By Dr Darshna Thakker MB, MD, DHA, MBA Consultant Gynecologist & Obstetrician

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