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

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

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Pain relief in labour in low resource setting DR. MANISH R PANDYA MD FICOG FICMCH PROFESSOR AND HOD SURENDRANAGAR Slide 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) Slide 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 Slide 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 Slide 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 Slide 6 Nature of Labor Pain 1 st Stage Visceral pain Diffuse abdominal cramping Uterine contractions Slide 7 Nature of Labor Pain 2 nd Stage Somatic pain Perineum Sharper and more continuous Pressure or nerve entrapment (caused by the fetus head) May cause severe back or leg pain Slide 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 T 10, L 1, S 1 -S 4. These sensory fibers make synaptic connections in dorsal horn of spinal cord with cells that provide axons that make up the spinothalamic tract. 8 Slide 9 Early 1 st stage: before fetal head reaches zero station, pain impulses arise primarily from uterus via visceral afferents enter spinal cord at T 10 -L 1. Late 1 st stage & 2 nd stage: pain impulses arise from uterus, pelvic structures, vagina, & perineum. 3 rd stage of labor is usually well tolerated with spontaneous placental delivery. 9 Slide 10 Stages of Labour Slide 11 Pain pathways during labor Slide 12 Trends Nulliparous More sensory pain during early labor Multiparous More intense pain during late 1 st stage and the 2 nd stage Rapid fetal descent Slide 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 Slide 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. Slide 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) Slide 16 Objectives 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 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 Slide 17 Methods of Pain Relief Nursing measures Relaxation techniques Breathing techniques Systemic analgesia Regional nerve blocks Local anesthetics General anesthesia Slide 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 Slide 19 Systemic Analgesics 1) Stadol 2) Nubain 3) Demerol 4) Seconal 5) Nembutal 6) Phenergan 7) Vistaril 8) Narcan Slide 20 Differentiation of regional blocks (usually done by anaesthetist) and field blocks (commonly performed by obstetrician) BMJ. 1999 April 3; 318(7188): 927930. Slide 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) Slide 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 Slide 23 Non-pharmacological methods Slide 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) Slide 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 Slide 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 Slide 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 Slide 28 Lamaze technique Prepared child birth, including relaxation techniques, breathing exercises etc Slide 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 Slide 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 apgar (British Journal of Obstetrics and Gynaecology, 100(3), 221-226, 1993) Slide 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 Slide 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 Slide 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 Slide 34 SLOW PACED Breathing MODIFIED-PACE Breathing: Combination of slow and modified paced breathing: Patterned paced Breathing: (Pant blow) Breath holding while pushing: Slide 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. Slide 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 Slide 37 Acupuncture Traditional Chinese therapy Releases endorphins and enkephalins Slide 38 Electro-acupuncture a significant difference in the concentration of -endorphin ( -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 impa