Transcript 2 - pain relief in labour in low resource setting Sarjan

Pain relief in labour
in low resource setting
DR. MANISH R PANDYA
MD FICOG FICMCH
PROFESSOR AND HOD
SURENDRANAGAR
www.drmanishpandya.com
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)
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
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
Nature of Labor Pain
• Pain is subjective
– Complex interaction of influences
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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
Nature of Labor Pain –1st Stage
• Visceral pain
– Diffuse abdominal cramping
– Uterine contractions
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
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
Pain pathways during labor
Trends…
• Nulliparous
– More sensory pain during early labor
• Multiparous
– More intense pain during late 1st stage and
the 2nd stage
• Rapid fetal descent
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
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.
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)
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
Methods of Pain Relief
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Nursing measures
Relaxation techniques
Breathing techniques
Systemic analgesia
Regional nerve blocks
Local anesthetics
General anesthesia
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
Systemic Analgesics
1) Stadol
2) Nubain
3) Demerol
4) Seconal
5) Nembutal
6) Phenergan
7) Vistaril
8) Narcan
Differentiation of
regional
blocks (usually done
by anaesthetist) and
field blocks
(commonly
performed by
obstetrician)
BMJ. 1999 April 3; 318(7188):
927–930.
Other than techniques
• These four factors make the greatest contribution to
women's satisfaction in childbirth:
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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)
Pain relief techniques
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Water birthing
Music
Heat and cold
Imagery
Rhythmical movements
Massage
Relaxation
Breathing
Perineal massage
Intra dermal injections
of sterile water
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Narcotics
Twilight sleep
Entonox
Lamaze technique
Hypnotism
Acupressure / Shiatsu
Acupuncture
Electro-acupuncture
TENS
Intrathecal narcotics
Epidurals
Non-pharmacological
methods
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)
• 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
• 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
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
Lamaze technique
• Prepared child birth, including relaxation
techniques, breathing exercises etc
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
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)
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
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
“SLOW PACED” Breathing
“MODIFIED-PACE” Breathing:
Combination of slow and modified
paced breathing:
“Patterned – paced” Breathing:
(Pant – blow)
Breath holding while pushing:
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.
• 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
Acupuncture
• Traditional Chinese therapy
• Releases endorphins and enkephalins
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. 2007 March; 4(1): 125–130.)
Physical therapy
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Massage
Counter pressure
Hot and Cold Compresses
Light stroking or “Effleurage”
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
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!
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
Distraction
• Using music
• Listening to jokes
• Playing cards
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 counterirritation
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): S131-59.
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)
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
Labour Analgesia
Alleviates pain
PAIN
TENSION
FEAR
Fetal Stress
& Acidosis
INtervention
Stress
PROGRAMMED LABOUR - Methodology
• Proper selection , Counseling &
Consent
• Labour induction / Acceleration
• All medication in Active phase of
Labour
• Commence PARTOGRAPHIC
monitoring
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
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
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
Post delivary evaluation
• Pain relief score
• Amnesia score
• Patient attitude record
– Satisfied with analgesia protocol
– Dissatisfied with analgesia protocol
STUDY REPORT
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
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
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
Age distribution
Age
Primi
Multi
Total
20 20-25 25-30
150 100
70
20
50
110
170 150
180
Duration of labour
TIME
PRIMI
MULTI
TOTAL
2-4
HRS
80
60
140
4-6
HRS
100
20
120
6-8
HRS
140
100
240
Pain score
3 pain
2 pain is
Pain score unbearable
severe
Pt. Demand Pt. Seek
relief
relief
1 pain
bearable
Pt. Doesn’t
desire relief
Primi
280
40
-
Multi
100
60
20
Total
380
100
20
Relief of pain
Pain relief 1 .Not to
2.
3.
score
the desire substantial Complete
extent
relief of
relief of
pain
pain
Primi
20
60
240
Multi
40
20
120
Total
60
80
360
Mode of delivary
Mode of
delivary
Normal
Operative
vaginal
Lscs
Primi
263
23
34
Multi
147
33
-
Total
410
56
34
DR.MANISH PANDYA
Neonatal outcome
Nicu care
Primi
Apgar score
<7
320
-
Perinatal
morbidity
-
Multi
180
-
-
Total
500
-
-
DR.MANISH PANDYA
Weight of babies
Weight
2.5 kg
Primi
40
230
50
Multi
-
100
80
Total
40
330
130
DR.MANISH PANDYA
2.5-3.0kg 3.0-3.5 kg
Drugs used in third stage
Primi
Multi
Total
DR.MANISH PANDYA
Methyl
Prostagal Oxytocine
ergometrine
ndine
160
160
90
250
90
250
-
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
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
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
All is well!
• Patient – No Pain
• Dr – Easy Schedule!
• Baby – Safe
Presentation designed & developed By
Dr Darshna Thakker
MB, MD, DHA, MBA
Consultant Gynecologist & Obstetrician
www.sarjanhealthcare.com
+91 98240 69989