Pain relief

Question 1

What is the ideal analgesia in labour?

Answer 1

Harmless to mother and baby
Good maternal co-operativity
Must not hinder uterine contractility/maternal mobility

Question 2

What forms of non-pharmacological analgesics are available?

Answer 2

Education (breathing exercises etc)
Presence of birthing partner
Acupuncture, homeopathy and hypnosis (may be useful, but not funded by NHS)
TENS
Hydrotherapy (water at <37 C; different to water birth - just for analgesia. Even so, may not always be possible)

Question 3

What pharmacological methods are available as analgesia?

Answer 3

Nitrous oxide/Entonox
Narcotic agents e.g. pethidine
Pudendal nerve block
Local anaesthetic (lidocaine)

Question 4

When is nitrous oxide appropriate for use?

Answer 4

Inhaled throughout labour
Self-administered
Short onset/duration
SE include nausea, vomiting, feeling faint
CI in pneumothorax

Question 5

When are narcotic agents appropriate for use?

Answer 5

Pethidine and diamorphine, given with anti-emetic (e.g. Pethidine 50-150mg IM + cyclizine 50mg IM)
Longer acting than NO but limited pain relief
SE include drowsiness and N&V in mother; several days resp depression and drowsiness in baby)
May interfere with breastfeeding
CI if given <2hrs before entering birthing pool

Question 6

What can be done if regional anaesthesia is contraindicated?

Answer 6

CI reasons include sepsis, low platelets, recent LMWH

Consider PCA e.g. remifentanil (unable to cross placental barrier)

Question 7

When is pudendal nerve block considered?

Answer 7

8-10ml lignocaine below and medial to ischial spine bilaterally
Indicated in perineal infiltration for instrumental delivery
Insufficient for rotational forceps

Question 8

When is lidocaine indicated?

Answer 8

Use before episiotomy and mending vaginal tears

Question 9

What regional anaesthetic is appropriate for use?

Answer 9

Epidural
Combined spinal epidural (CPE)
Spinal

Question 10

What are the advantages of epidural use?

Answer 10

Safe, effective analgesia (only pain-free method)
Reduced maternal catecholamine secretion
Easy to regularly top up
Help lower BP in pre-eclampsia

Question 11

What are the complications associated with epidural use?

Answer 11

Failure to site
Patchy block
Hypotension
Dural puncture (<1/1000) and post dural puncture headache
Transient/permanent nerve damage (v rare)
Increased risk vaginal operative delivery
Pressure sores from immobility
Urine retention
Transient foetal bradycardia (rarely consequential)

Question 12

How is epidural anaesthesia performed?

Answer 12

Check plts >75, consent, insert cannula
Woman sitting/lying on side
L3/L4 space used
After insertion, monitor BP every 5mins for 20 mins
Continuous electronic foetal monitoring required
Should work within 30mins
Top ups approx. every 2hrs

Question 13

How can foetal bradycardia following epidural insertion be managed?

Answer 13

IV fluids

Question 14

What considerations are involved with LMWH use and epidurals?

Answer 14

Wait 12hrs before inserting block if on prophylactic dose (24hrs if therapeutic dose)
Wait minimum 4hrs after block before giving next dose of heparin

Question 15

When is combined spinal epidural anaesthetic indicated?

Answer 15

Quicker pain relief, option of prolonging anaesthesia via epidural
Used in CS expected to be longer than normal e.g. placenta praevia, previous difficult surgery

Question 16

When is spinal anaesthetic used?

Answer 16

LSCS (simple)
Easier to insert, more reliable block
Only single injection, so may wear off in prolonged procedure
Risk of hypotension

Question 17

Anatomically, what is the difference between epidural and spinal anaesthetic?

Answer 17

Epidural - into epidural space, before ligamentum flavum

Spinal - into subarachnoid space, through ligamentum flavum