Acute and Chronic Pain management Flashcards
What are the pharmacological pain relief options in pregnancy
Non-opioid: paracetamol, NSAIDs (not really)
Opioid: codeine, dihydrocodeine, tramadol, morphine
What are the risks of NSAID use in pregnancy
<30 weeks: Miscarriage
>30 weeks: neonatal pulmonary hypertension, premature ductus arteriosus closure
Adversely affects renal function and platelet function
Asthma exacerbation
Gastric irritation/ulcers
What are the risks of opioid use in pregnancy
Constipation
Nausea and vomiting
Dependence, withdrawal
May lead to neonatal respiratory depression around term
What are the risks of using opioid while breastfeeding
Bradycardia
Resp. depression
Lethargy
Drowsiness
Poor feeding
Cyanosis
What are the pain relief options antepartum
First line: non-pharmacological
- Adequate rest, relaxation
- Hot and cold compression
- Massage, acupuncture, aromatherapy
- Physiotherapy, exercise
Second line: paracetamol
Third line: opioids e.g. morphine
What are the options for pain relief intrapartum
Pain-relieving strategies (conservative)
Inhalational analgesia
IV and IM opioids + anti-emetics
Regional analgesia
What are the conservative pain-relieving strategies used intrapartum
Breathing and relaxation techniques
Massage techniques
Offer labour in water (Temperature should not be >37.5)
Playing music during labour
Bring a partner, friend, or relative to support
Keep mobile - try different positions, kneeling, walking, rocking
Describe inhalational analgesia use intrapartum
Entonox (gas and air): 50:50 mixture of oxygen and nitrous oxide
Side effects: nausea and light-headedness
NO side effects for the baby
Describe IV and IM opioid use intrapartum
Pethidine, diamorphine, or others
Provides limited pain relief during labour - takes 20 minutes to work and lasts 2-4 hours
You will not be able to get into water for 2 hours after an injection, or longer if you feel sleepy
May interfere with breastfeeding
What is a pudendal nerve block
Pudendal nerve supplies the clitoris, perineum and anus
Local anaesthetic is useful for quick pain relief prior to instrumental delivery
Ischial spine bony prominences are used to guide nerve blocks
Ischial spines can be palpated at 4 and 8 o clock
Describe the path of the pudendal nerve
Arises from the rami of S2,3,4
Leaves through the greater sciatic foramen, crosses behind the ischial spine, and re-enters through the lesser sciatic foramen
What is spinal anaesthesia
Medication is given directly into the dural space (between membranes)
Describe epidural anaesthesia
Medication is given directly into the epidural space (between dura mater and vertebral wall) via a catheter placed between L3 and L4
Usually combined opiate and local anaesthetic
For more rapid analgesia, combined spinal-epidural analgesia can be given - bupivacaine and fentanyl
What are the considerations for epidural anaesthesia intraprtum
Delay pushing for 1 hour or longer after full cervical dilation is confirmed (unless urge to push or head is visible)
Ensure adequate platelet count before
Monitoring: BP, CTG for at least 30 mins after admin, ensure adequate fluids (prevent hypotension)
Don’t routinely use oxytocin in the second stage
What are the side effects of epidurals
Feeling of heaviness
Transient hypotension
Pressure sores (immobility)
Urinary retention
Transient foetal bradycardia
Spinal tap: puncture of the dura mater → CSF leakage → severe headache (worse sitting up, better lying down)
Inadvertent IV injection → convulsions, cardiac arrest
IV injection of local anaesthetic into the CSF → progression up the spinal cord → total spinal analgesia and resp. paralysis
