Pain in Labor Yusuf

Question 1

Contraindications to epidural anesthesia:

Answer 1

• Patient refusal
• Infection at the site of epidural
• Coagulopathy
• Haemodynamic instability

Question 2

Risks with haemodynamic instability:

Answer 2

• Foetal bradycardia
• Maternal arterial hypotension
• Post-dural puncture headache
• Local anesthetic toxicity
• Possible prolongation of labor

Question 3

1st vs 2nd stage of labor:

Answer 3

1st:
- Visceral pain
- Dilation of the cervix and lower uterine segment causes pain
- Mediated by spinal segment T10-L1
- Pain is dull and poorly localised
- Cervix dilates 4-5cm

2nd:
- Pain due to stretching of the pelvic floor and perineum
- Mediated by segment S2-S4
- Pain is sharp and localised

Question 4

Contraindications for spinal anesthesia:

Answer 4

• Patient refusal
• Infection at the site of puncture
• Coagulopathy
• Haemodynamic instability
• Increased intracranial pressure
• Fixed cardiac output states

Question 5

Complications of spinal anesthesia:

Answer 5

• Arterial hyptotension
• Post-dural puncture headache
• Post-operative nausea, vomiting and itching

Question 6

Indications for C-section under general anesthesia:

Answer 6

• Maternal refusal of regional anesthesia
• Bleeding - placental abruption
• Placental previa (the placeta is low in the uterus and covers the cervix)
• Altered homeostais - thrombocytopenia
• HELLP syndrome (Hemolysis, elevated liver enzymes, low platelets)

Question 7

Disadvantages of intravenous injection of
opioids:

Answer 7

maternal: nausea, vomiting, sedation, and
respiratory depression

neonatal: systemic effects, including respiratory
depression.

goal:
-lowest concentration
-smallest dose

Question 8

Most commonly used anelgesic in labor:

Answer 8

Paracetamol:
* Good for: mild – moderate
pain
* Dosage: can take 1g 4-6
hourly, maximum of 4 doses
in 24 hours
* Side effects: very rare

Codeine:
* What is it? Opioid analgesia
* Good for: mild – moderate pain
* Dosage: can take 60mg 4-6 hourly,
maximum of 4 doses in 24 hours
* Most common side effects: nausea,
vomiting, constipation
* PRESCRIPTION ONLY
* Not given postnatally if breastfeeding

Question 9

Fentanyl dose in labor:

Answer 9

It can be administered in boluses of 25–50 µg
every hour or as a continuous infusion of 0.25
µg/kg/h

Question 10

Tramadol in labor:

Answer 10

Tramadol is a pethidine-like synthetic opioid
having low affinity for mu(µ) receptors. Its
potency is 10% that of morphine. It has no
clinically significant respiratory depression at
usual doses of 1–2 mg/kg body weight. The
onset of action is within 10 min of
intramuscular administration and the
duration lasts for approximately 2–3 h.
high placental permeability for tramadol.

Question 11

Remifentanil in labor:

Answer 11

Remifentanil is an ultra-short acting synthetic
potent opioid.
rapid onset of action. The effective analgesia half-life is 6 min
It readily crosses the placenta, but is extensively
metabolized by the foetus..
The recommended dose of remifentanil is an
intravenous bolus of 20 µg, with a lock out interval
of 3 min on the PCA pump.
IThe initial infusion of 0.025 µg/kg/min was
increased in a stepwise manner to a maximum dose
of 0.15 µg/kg/min.
Be careful for maternal hypoventilation!