Pain relief in labour Flashcards
1
Q
Non-pharm options of pain relief?
A
Reduction of painful stimuli
- Maternal movement
- Changing positions
- Counter pressure
- Breathing + relaxation
Activate peripheral sensory receptors
- Superficial heat
- Warm water bath
- Touch + massage
- Acupuncture / acupressure
- TENS (helpful in latent 1st stage)
- Intradermal sterile water injections
Enhance Descending Inhibitory Pathways
- Attention focusing + distraction
- Hypnosis
2
Q
Pharmacological options for pain relief?
A
Inhalational Analgesia
- Nitrous oxide
Parenteral Analgesia
- Morphine or pethidine IM
Regional Analgesia
- Lumbar epidural
- Caudal epidural
- Spinal analgesia
- Combined spinal-epidural
Nerve Blocks
- Pudendal nerve block
- Para-cervical block
3
Q
Who can have water immersion?
A
- WHO definition of normal birth
- Low risk pregnancy + labour
- Cephalic presentation
- >37 weeks GA
- Singleton
- BMI <35
Contraindications
- Narcotic analgesia in past 4 hours
- High-risk pregnancy
- Multiple pregnancy
- Requirement of continuous CTG
- Induced labour
BE PREPARED FOR UNINTENDED WATER BIRTH!!!
4
Q
General info for nitrous oxide?
A
- Acts quickly + eliminated quickly
- Does not affect foetus
- Associated with nausea, vomiting, dizziness, euphoria, disorientation, generalised tingling and sedation
- Effectiveness is variable
Contraindications
- Vitamin B12 deficiency or pernicious anemia
- Sedated / drowsy (cannot hold + use mask)
- Hx of pneumothorax, bowel obstruction, ↑ICP or
- intra-occular surgery (must seek anesthetist
- advice)
- Schizophrenia (seek advice)
- Bipolar disorder (seek advice)
5
Q
How to coach someone on using nitrous oxide?
A
- Commence breathing with early onset of contractions
- Breathe deeply at normal rate
- Cease when contraction ends
6
Q
Risk/benefit of IM morphine?
A
- Provides limited pain relief in labour (it induces useful euphoria + sedation)
- Takes ~30 mins to work
- Causes maternal drowsiness, nausea + vomiting (often administered with antiemetic)
- can’t have water immersion for 4 hrs
- avoid administration if birth is expected in the next 4 hrs
- can affect baby
- May have resp depression / drowsiness
- Require resus person on stand-by if needed
- May have breastfeeding issues
7
Q
What kind of analgesia is given in CS?
A
ANALGESIA IN CESAREAN
- Epidural
- Spinal
- General
8
Q
Advantages + disadvantages of epidural
A
Advantages
- Most effective form of analgesia
- Quick onset of pain relief (~ 15mins)
- Allows for “top-up” doses
- Low dose epidurals allow ambulation
- No maternal or foetal sedation
- No ↑ in caesarean section rates
- No ↑ in post-partum back pain
- No direct effect on the foetus (unlike opioids)
- Better maternal satisfaction
Disadvantages
- Prolonged labour (↑ duration of 2nd stage)
- ↑ rates of instrumental vaginal delivery (vacuum or forceps)
- ↑ risk of post-partum fever
- Maternal hypotension
- Foetal hypoxia from maternal hypotension
- Foetal bradycardia (less myometrial tocolysis)
- If epidural is not effective, ↑ likely for C/S
9
Q
Complications of epidural?
A
Common
- Nausea, vomiting, itching
- Maternal Hypotension (vasodilation + ↓ pain)
- Headache
- Inadequate block
- Pain / bruising at injection site
- Bloody tap / bleeding
- Parasthesias / motor blockade
- Urinary retention
- Foetal bradycardia (↓adrenaline ↓ from pain relief = ↓ myometrial tocolysis = ↓FHR)
Uncommon
- Infection at injection site
- Intense itching
- Bleeding
- Temporary nerve damage
- Inadvertent Dural puncture
- post dural puncture headache
Rare
- Permeant nerve damage
- Epidural haematoma spinal damage
- Epidural abscess
- Respiratory depression / paralysis
- Meningitis
10
Q
What is the difference in epidural vs spinal?
A
- spinal = into cerebrospinal fluid
- fast onset - 5mins
- smaller dose required
- single injection
- doesn’t last as long as epidural
- epidural = into epidural space
- slower onset - 25 mins
- catheter in situ (plastic tube stays inside) = regular top ups = lasts longer
- larger dose required
