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

2. IN THE NAME OF ALLAH THE MOST BENEFICIENT THE MOST MERCIFUL
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 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 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 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

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 50 110
Total
170
180

61. Duration of labour TIME 2-4 HRS 4-6 HRS 6-8 HRS PRIMI 80 100 140 MULTI60 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