Pain in labour and relief

Dr Bellington Vwalika
 Causes of pain in labour
– Dilatation of the cervix
– Contraction and distension of the uterus ,possibly
due toaccumulation of pain-producing substances
during ischaemia
– Distension of vagina and perineum
– Pressure on organs (eg bladder and rectum) or
the lumbosacral plexus;spasm in skeletal muscles
 Sensory fibres are T10 t0 l1 for both body
and cervix.T11 and 12 are stimulated during
latent phase when pain is not severe,T10-L1
are stimulated during active phase
Factors affecting pain in child birth

 Physical factors such as

– Intensity and duration of contractions
– Speed of dilatation
– Vaginal and perineal distension
 Physiological factors
– Pain blocking,eg customs,culture,preparations,distractive
activity
– Pain aggravating,eg
custom,culture,fear,apprehension,anxiety,ignorance ,misinf
ormation
– Parentcraft very important
Methods of pain relief

 Psychological methods
– Counteract the `fear-tension ` sequence
– Pain relieving drugs can be used to supplement
mother`s own effort
– With proper training 30-40% women will not need
analgesia in labour
 Inhalational agents
– Nitrous oxide(50%) and oxygen(50%)-entonox
apparatus
 – Inhalation agents are usually used too late and
too hesitantly
– They can be highly effective and safe for the
mother

Transcutaneous electric nerve
stimulation

 This aims to reduce pain by stimulating large

myelinated nerve fibres to reduce input from small
myelinated and non-myelinated fibres linked to
peripheral pain receptors
 Low-intensity continous stimulation is applied to the
dermatomes associated with pain
 It can provide good to moderate pain relief but
success depends on time spent teaching and
supporting the mother before and during drug use
Narcotic drugs
 E.g intramuscular pethidine
 Combination with a phenothiazine (e.g
promethazine0 provides no additional benefit ,may
produce maternal and fetal tachycardia and can
rarely cause oculogyric crisis
 Advantages
– Ease of administration
– Reasonably rapid analgesia
– Antagonists available
– Low incidence of serious side-effects
 Disadvantages
– Inadquate analgesia in up to 40% of patients
– Nausea and vomitting common
– Psychic disturbance commone.g confusion.inability to
cooperate
– Delayed gastric emptying
– Neonatal respiratory depression
 Contraindications
– Previuos idiosyncratic reactions
– Current monoamine oxidase inhibitors
Epidural analgesia

 Lumbar analgesia will provide total or

adequate analgesia in up to 90% of patients
 Indications
– Prolonged labour ,- hypertension in labour
– Maternal distress, -?breech presentation
– Multiple pregnancy
– Instrumental delivery
contraindications
 Lack of experienced personnel
 Infection at injection site
 Coagulation defects or bleeding diathesis
 Idiosyncratic reactions to local anaesthetic
agents
 Shock and hypovolemia
 Bony abnormalities of spinal column
 Anticoagulant therapy
 Immediate maternal problems
– Dural tap-dural puncture by needle or catheter ;it leads to
`spinal` headache
– Total spinal block-loss of all sensory and motor
function ;can include unconsciousness,severe hypotension
and apnoea; results from subarachnoid injection of epidural
dose of local anaesthetic agent
– Hypotension-can be avoided by nursing the patient on her
side and by the intravenous infusion of crystalloid before
block is established
– Motor paralysis-reduces maternal expulsive
effort ,tends to prevent rotation of the fetal head
and makes instrumetal delivery more likely.Risk
of C/S may also be raised
– Prolongation of second stage of labour
– Toxic reactions to local anaesthetic agents
 Delayed maternal hazards
– Severe spinal headache due to spinla tap (infuse 1 litre of
normal saline through the epidural catheter over 24 hour;if
no improvement within 48 hours consider bloob patch(i.e.
injection of up to 20 ml autologous blood into epidural space
– Urinary retension
– Temporary diminished sensation of dermatomes affected
– Backache is an occasional problem
– sepsis
 Fetal effects –none
 Guidelines for use
– Regional block may be continous during labour or as a
single injection for operative delivery
– Bupivacaine (0.5,0.375 or 0.25%) is the preferred
anaesthetic-test dose initially
– Constant monitoring of maternal and fetal condition is
mandatory
– Top-up dose must be individually chosen when the patient
begins to experience discomfort
 Epidural analgesia may used in previous
caesarean section allowed vaginal delivery
 It does no mask uterine rupture
 Paracervical block –LA given at 3 and 9 o`clock as
1% lignocaine or .25% bupivacaine
– may be used in short procedures in the uterus
 Perineal infiltration as in episiotomy,outlet forceps
and vantouse traction
 Pudendal block used for forceps delivery and vaginal
breech delivery.Does not block pain of labour
Spinal anaesthesia

 Can alleviate pain of delivery and C/S.For

normal delivery and forceps block should
extend to S1
 Obtained with 5% lignocaine in subarachnoid
space of L3 and L4 with head tilt
 Side effects as in epidural block