Susilo Chandra, MD, FRCADepartment of Anesthesiology & Intensive Care
Cipto Mangunkusumo General HospitalUniversity of Indonesia, Medical Faculty
Labor analgesia Is It Attainable
ASA & ACOG STATEMENTASA & ACOG STATEMENT
The American Society of Anesthesiologists and the American College of Obstetricians and Gynecologists agree that “of the various pharmacologic methods used for pain relief during labor and delivery, regional analgesia techniques are the most flexible, effective, and least depressing to the central nervous system, allowing for an alert, participating mother and alert neonate.”
Many systemic techniquesMany systemic techniques
“alternatives” to labor neuraxial analgesiapoorly effective and some are associated with significant maternal and neonatal side effects
Intravenous PCA remifentanil is the most effective technique, but safe administration?
N2ON2O
Nitrous oxide 50% provides little pain relief
In the context of pain relief In the context of pain relief in labor:in labor:
Individual anaesthetists’ impressions, Patient satisfaction surveys, The midwives’ ability to work with a
specific analgesic technique, The adequacy of pain relief or, even, on
the flexibility offered by the analgesia technique to the obstetrician?
Or a ‘good patient outcome’
Good patient outcomeGood patient outcome
Superior quality of pain relief achieved with: – be safe (technique and drugs) for
mother and baby, – have only minimal effects on the
process of labor process,– be able to provide long lasting and
consistent pain relief – be customized to patients’ needs– be affordable to most
Myles PS: Improving quality of recovery: what anaesthetic Myles PS: Improving quality of recovery: what anaesthetic techniques make a difference? in Best Practice & Research techniques make a difference? in Best Practice & Research
Clinical Anaesthesiology. Vol 15, No 4, pp. 621-631, 2001.Clinical Anaesthesiology. Vol 15, No 4, pp. 621-631, 2001.
Practising evidence-based medicine in anaesthesia can be difficult
Even more in OB anaesthesia because other – mainly, obstetrical and pregnancy - factors are often much more important determinants of outcome
Which evidence is relevant to pain Which evidence is relevant to pain relief in labour:relief in labour:
Shorter time to onset of pain relief improved maternal satisfaction with the
neuraxial block Lower overall pain score Longer duration of pain relief Shorter duration of labour Reduced intensity of motor block.
Reynolds F, Sharma S, Seed P: A Meta-Analysis Reynolds F, Sharma S, Seed P: A Meta-Analysis Comparing Epidural with Systemic Opioid Comparing Epidural with Systemic Opioid
Analgesia. Br J Ob Gyn 109:1344-1353, 2002Analgesia. Br J Ob Gyn 109:1344-1353, 2002
Concluded that a low concentration Concluded that a low concentration epidural is better than ‘natural childbirth’ epidural is better than ‘natural childbirth’ and that a ‘modern’ epidural’ is better and that a ‘modern’ epidural’ is better than ‘systemic opioids’ in terms of than ‘systemic opioids’ in terms of umbilical artery base deficit.umbilical artery base deficit.
Gambling D, Sharma S, Ramin S, et al: A Randomised Study of CSE analgesia vs IV meperidine. Anesthesiol 89, 1336-1344, 1998
In their randomized study of CSE analgesia vs IV meperidine In their randomized study of CSE analgesia vs IV meperidine (pethidine), showed that fetal bradycardia can follow CSE.(pethidine), showed that fetal bradycardia can follow CSE.
Holdcroft A, Dob D: Regional Analgesia for Labour and Fetal Distress: Culprit or Innocent Bystander. IJOA 12:153-155, 2003.
Reflected that CSE is probably no worse than epidural in Reflected that CSE is probably no worse than epidural in producing fetal bradycardia and that it occurs with both producing fetal bradycardia and that it occurs with both intrathecal opioids and intrathecal local anaesthetics.intrathecal opioids and intrathecal local anaesthetics.
Summary:Summary: RA: epidural, spinal, or combination, is
an integral part of pain relief in labor Although childbirth has become much
safer for mother and neonate, there is still room for improvement
Labor analgesia is it attainable, the answer is yes
Epidural analgesia Epidural analgesia
the most effective method of providing pain relief during labor.
However, there’s a big challenge in providing epidural analgesia in remote areas, particularly in developing countries and also in small birthing centres where there is lack of expertise, resources and logistical support to provide safe epidural analgesia
Intrathecal Labor Analgesia (ILA) may have a role to play in these situations.
ILA ILA
single shot spinal technique to provide labor analgesia;
it has the advantage of being a low cost technique that could be easily and safely executed.
If appropriately monitored and managed, ILA may result in reasonably prolonged analgesia and good maternal satisfaction
General Considerations in ILAGeneral Considerations in ILA
The timing for the institution of ILA is vital.
However, the effects of cervical dilation and stage of labor on the duration of effective intrathecal analgesia have not been well characterized
Comparison of ILA with other Comparison of ILA with other neuraxial techniques: neuraxial techniques:
Onset of action: ILA produces a more rapid onset of action than epidural analgesia. The rpaidity of onset is comparable with combined spinal epidural analgesia (CSE) but CSE, being inherently a ‘2 procedure’ technique, ie. spinal AND epidural, often takes a longer to complete.
Duration of action: As ILA is not ‘extendable’ it suffers from a soreter duration of action of analgesia wehn compared with CSE and epidural analgesia. The use of a multi-modal combination of intrathecal drugs, i,e local anaesthetics, opioids and other adjuvants may potentially prolong the duration of analgesia and reduce the need for a repeat ILA.
Comparison of ILA with other Comparison of ILA with other neuraxial techniques: neuraxial techniques:
Affordability: this is the greatest advantage of ILA when compared with epidural or CSE. ILA dose not involve the insertion of catheters and does not require sophisticated pumps and infusion systems to maintain labour analgesia.
Simplicity of technique: most anaesthesiologists are familiar with the isntitution of spinal anaesthesia and ILA is just a modification of the technique of providing spinal anaesthesia but for the labouring women.
Reliability: With the use the correct technique and drugs, ILA provides reasonably relaible analgesia with preservation of motor power.
Practical Considerations in ILAPractical Considerations in ILA
Analgesic drug regimen: A combination of local anaesthetics, opioids and clonidine is recommended
Labor Analgesia• Hyperbaric upivacaine• Plain bupivacaine• Levobupivacaine• Ropivacaine • LidocaineHypotension • Ephedrine
RECIPE
• Adjuvant Adrenalin ClonidineOpioid Morphine Fentanyl
•OUR RECIPE250 µg of morphine + 2.5 mg bupivacaine + 30-45 µg clonidine/25 µg fentanyl Breakthrough pain --> repeat spinal
RECIPE
•OUR RECIPE for BREAKTHROUGH PAINIf < or = 4 hours fentanyl + bupi + clonidine If > 4 hours to Mo + fentanyl/clonidine + bupi
RECIPE
Conclusion Conclusion
In attempting to provide optimal labor analgesia, it is important to weigh the risks against benefits of any particular technique.
This must take in to consideration factors such as the timing of intervention and the place of practice.
Cost, accessibility, and human resources are other considerations.
Conclusion Conclusion
It inadvisable to use an expensive or complicated technique in rural areas where there is limited medical access.
A properly performed ILA is a very cost effective technique for a pain relief in labour that can be recommneded as an alternative to CSE or epidural analgesia in areas where access to medical care is limited
THANK YOUTHANK YOU
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