Analgesia in labour Flashcards
Where is pain carried in the first stage of labour?
in T10-L1 roots (pain caused by dilation of lower segment of uterus and cervix)
L2-S1 roots (pain caused by pressure on pelvic structures)
Where is pain carried in the second stage of labour?
Pain of first stage continues
Pudendal nerves:
S2-4 roots (Pain caused by dilation and pressure on pelvic organs and pelvic floor structures)
How might the pain in first stage of labour present?
poorly localised
visceral/colicky
How might the pain in second stage of labour present?
somatic pain
sharp
well localised (to perineum)
What factors might impact pain?
Position of baby
Size of baby
Pelvic anatomy
Strength of contraction
Complications – APH, uterine rupture, trauma
Previous experience & expectations
Other factors – anxiety, fear of pain, social factors, educational background, etc.
What are some non-pharmacological methods of pain relief used in labour?
Support from birthing partner
Labouring in water
breathing and relaxation technique
massage
music
What are some pharmacological analgesics that can be used in labour?
entonox
opioids: pethidine or diamorphine
non-opioids: paracetamol
epidural
What are the benefits of entonox?
Significant analgesia
Non-invasive procedure
Quick onset/offset
What are the side effects of entonox?
dizziness
nausea
amnesia
What is a drawback of the entonox?
incomplete analgesia
How can opioids be given in labour?
usually IM/IV
What are some side effects of opioid analgesics?
sedation
nausea and vomiting
respiratory depression
What regional anaesthesia can be given in labour?
lumbar epidural
spinal
combined spinal and epidural
caudal (not really done in UK)
para-cervical infiltration (not really done in UK)
What takes place in a combined spinal epidural?
intrathecal injection and epidural catheter placement
When might a combined spinal epidural be used in labour?
advanced labour
perineal pain
Re-siting epidural
When are the complications associated with spinal epidural in labour?
Infection
Intrathecal migration of catheter
Immediate: failure
hypotension
LA toxicity
total spinal
Delayed: PDPH (post dural puncture headache) Infection haematoma neurological damage
What are some ABSOLUTE contraindications for spinal epidural?
patient refusal
anti-coagulants & bleeding disorders (incl. if had recent dose of tinzaparin - need to wait)
local or severe systemic infection
anaphylaxis to LA
What are some relative contra-indications for spinal epidural?
spinal surgery (only if simple, as many attempts = increased infection risk, which may lead to need of replacement of metal work etc.)
massive haemorrhage (this lowers BP, drugs may make this worse (sympathetic blockers))
23 year old, 40 weeks pregnant – SROM, admitted to delivery room. Complains of mild tightening and lower abdo pain.
How would you approach this? What would you advise this woman?
Non-pharmacological
Pharmacological: start low - paracetamol
codeine
entonox
30 year old, 38 weeks pregnant, hypertensive. Obstetric plan is to induce labour. 2 hours after Oxytocin infusion, she is beginning to get quite strong contractions….
What would you advise her?
Offer an epidural (may need to reduce oxytocin while you’re doing this)
This woman has three risk factors for C-section, therefore can advise her that this can stay in place for her C-section
What is entonox?
Nitrous oxide
Oxygen
50:50 mixture
25 year old woman, who has had a normal delivery. She had a good working epidural which came out an hour ago. She is complaining of weakness in both legs.
What could be causing this? What would you do?
wearing off of epidural
damage to spinal cord
haematoma
Involve anaesthetist
MRI of back
When assessing your patient with an epidural you find them laying flat in bed complaining of feeling breathless.
What is your:
Differential diagnosis?
Total spinal PE/amniotic embolism anxiety chest infection MI
Why do opioids last longer when given IM
has to be absorbed, takes longer therefore lasts longer
Why are spinal or epidural blocks generally done with patient sat up?
Prevent one-sided block
16 year old, 40 weeks gestation, primiparous, low-risk. 5 cm cervix on examination, struggling to cope with pain.
What would you advise her?
Advise her to have epidural.
Struggling, pain will get worse and she is young so may have difficulties due to small hips etc.
