1. DR. ANKITA GUPTA

2. DEBATE
 When the anesthetic effects of ether and
chloroform were discovered in the mid 1800's,
many members of the British clergy argued that
this human intervention in the miracle of birth was
sin against the will of God.
 If God had wished labor to be painless, he would
have created it so.
 According to Scripture, childbirth pain originated
when God punished Eve and her descendants for
Eve's disobedience in the Garden of Eden.
 They believed that it was wrong to avoid the pain
of divine punishment.

3. DEBATE
 James Young Simpson used diethyl ether to
anesthetize a woman with a deformed pelvis for
childbirth.
 Queen Victoria undaunted by the clergy chose one
day to use an anesthetic during labor and the
clergy's position crumpled like the great wall of
'Berlin'.
 The first woman anesthetized for childbirth in the
United States was Fanny Longfellow, wife of the
American poet Henry Wadsworth Longfellow.

4. DEBATE
Labor results in severe pain for many women.
There is no other circumstance where it is
considered acceptable for a person to
experience untreated severe pain, amenable to
safe intervention, while under a physician’s
care… Maternal request is a sufficient medical
indication for pain relief during labor.”
ACOG & ASA

5. SIR JAMES YOUNG SIMPSON (1847) FIRST USED
ANAESTHESIA IN OBSTETRICS

6. JOHN SNOW (1853) USED ANAESTHESIA ON QUEEN
VICTORIA FOR THE BIRTH OF PRINCE LEOPOLD.
The inhalation lasted for 53 minutes. The chloroform
was given on handkerchief in 15 minim doses : The
Queen expressed herself as greatly relived .

7. NATURE OF LABOUR PAINS
1st stage
Visceral pain
 Diffuse abdominal cramping
 Uterine contractions
 T10-L1
2nd stage
Somatic pain
 Perineum- sharper and more continuous
 Pressure or nerve entrapment-caused by
fetal head, may cause severe leg or back pain
S2-S4

8. WHAT DETERMINES MATERNAL SATISFACTION
 Pain relief
 Quality of relationship with caregiver
 Participation in decision making
 Home-like birth environment
 Caregivers with whom they are acquainted
personally

9. The goals of labor analgesia
"The delivery of the infant into the arms of a conscious and pain-free mother is
one of the most exciting and rewarding moments in medicine.“

10. THE IDEAL LABOUR ANALGESIC
 Good pain relief
 No autonomic block (hypotension)
 No adverse maternal or fetal side effects
 No motor block
 No effect on labour or delivery
no increase in caessarean or
instrumental deliveries
 Patient can ambulate
 Economical

11. Sensory innervation of upper genital tract
 Pain during the first stage of labor is generated
largely from the uterus cervix & upper vagina.
 Visceral sensory fibers traverse through the
Frankenhäuser ganglion, and enter into the pelvic
plexus and then into the middle and superior
internal iliac plexuses.
 From there, the fibers travel in the lumbar and
lower thoracic sympathetic chains to enter the
spinal cord through the white rami communicantes
associated with the T10 through T12 and L1 nerves.
 Early in labor, the pain of uterine contractions is
transmitted predominantly through the T11 and
T12 nerves.

12. Sensory innervation of lower genital tract
 Pain in second stage of vaginal delivery arises from
stimuli from the lower genital tract.
 These are transmitted primarily through the
Pudendal nerve, the peripheral branches of which
provide sensory innervation to the perineum, anus,
and the more medial and inferior parts of the vulva
and clitoris.
 sensory nerve fibers of the pudendal Nerve are
derived from ventral branches of the S2 through S4
nerves.
Note:The motor pathways to the uterus leave the spinal cord at the level of
T7 and T8 vertebrae. Theoretically, any method of sensory block that does
not also block motor pathways to the uterus can be used for analgesia
during labor.

14. METHODS OF LABOUR PAIN RELIEF
PHARMACOLOGICAL NON PHARMACOLOGICAL
1)SYSTEMIC PSYCHOPROPHYLAXIS+ BREETHING EXERCISES
PARENTRAL HYPNOSIS
NARCOTICS TENS
TRANQUILISERS ACCUPUNCTURE
INHALATIONAL HYDROTHERPY
N2O ELECTRO ANALGESIA
METHOXYFLURANE AUDIO ANALGESIA
ENFLURANE
ISOFLURANE
2)REGIONAL
EPIDURAL
SPINAL
PUDENDAL BLOCK
PARACERVICAL BLOCK
3) GA
4) LA or PERINEAL INFILTERATION

15. NON PHARMACOLOGICAL
METHODS:
Psych prophylaxis & breathing exercise:
 Lamaze technique.
 Principal concept is to have natural child birth.
 Antenatal education of patient about physiology of
child birth.
 Relaxation exercises to overcome fear and anxiety
-reduces oxygen demand and reduces CO2
production.

16.  Breathing exercises during different stages of
labour
in early labour – deep breathing
towards the end of 1st stage – more
rapid breathing
During bearing down – breath holding
 Constant human support during labour.
 Delivery in semi darkness.

17. Hypnotherapy
 Mongan method also known as Hypno Birthing
, Hypnobabies, Natal Hypnotherapy and the GentleBirth
program
 can significantly shorten labor, reduce pain and reduce
the need for intervention, produced higher apgar
scores, reduce the incidence of postpartum depression
and increase the incidence of spontaneous deliveries.
 No studies abort its efficacy.

18. TENS
 TENS (transcutaneous electrical nerve stimulation).
 A maternity TENS machine consists of a hand-held controller
connected by two sets of fine leads to four sticky pads. These are
placed on your back.
 The machine gives out little pulses of electrical energy that reach
your skin via the leads and pads.
 The pulses may give you a tingling or buzzing sensation, depending
on the setting
 stimulates the release of endorphins.
 Controls pain via Gate control.
 Most useful in labour before the pain becomes too intense.
 drug dose requirements may be less.

19. WATER BIRTHING
 Soviet researcher Igor Charkovsky and French
obstetrician Frederick Leboyer developed in
1960s
 Practices in United States, Canada, Australia,
and New Zealand, as well as many European
countries, including the United Kingdom and
Germany
 By 2005, over 9000 hospitals in the US and more
than three-quarters of all NHS hospitals (UK)
provided this option.

20.  Provides pain relief and a less traumatic birth
experience for the baby
 Redistribution of blood volume, which stimulates
the release of oxytocin and vasopressin (Katz 1990)
 Aid stretching of the perineum, slows crowning of
the infant's head, reduces the use of episiotomy
 a decrease in perinatal mortality (1.2 per 1,000
for waterbirth vs. 4 per 1,000 for conventional
birth) during 1994-1996 in the UK.
 The buoyance of water provides supports and
relaxes the ligaments and tissues of mother
which helps mother in taking comfortable
position during labour.

21.  Risks to the infant such as infection and water
inhalation?
 "there are no valid reports of infants deaths due to
water aspiration or inhalation" (Harper 2000)
 Slowed labor? A decrease in the intensity of
contractions.
 Maternal blood loss? - Difficult to assess.
 The amount of blood loss reduced due to lowering BP
and heart rate.

22. MUSIC:
 Ancient Greeks played soothing instrumental music
to women in labor.
 Alters mood, reduces stress and promotes positive
thoughts.
 A trigger for a breathing response or as a cue for
relaxation.
 used as a distraction.

23. MASSAGE
 Touch has been associated with the power of
healing since the beginning of civilization
 a source of counter-stimulation
 Examples; Therapeutic massage (eg:
shiatsu), perineal massage

24. METHOD OF TOUCH AND MASSGAE
 lightly stroking the abdomen.
 vigorously firm stroking where it hurts most.
 firm circular massage using the palm of the hand over
the center of the back or sacrum.
 rhythmical squeezing and letting go of the shoulder
muscles .
 a long stroke down the length of the back, buttocks and
down the back of the legs.
 stroking across the forehead, down the neck and down
the arms .
 simply holding hands!!!

25. SHIATSU
Japanese form of therapeutic massage. Shiatsu means
‘finger pressure’.
Similar to acupuncture.
Pain-relieving pressure points (‘tsubo’) are stimulated
without the use of needles

26. ACCUPUNCTURE:
 Traditional form of Chinese medicine.
 Involves insertion of needles at selected points to
get desired results.
 Mechanism is via endorphin release and Gate
control theory.
 Produces hypo analgesia but complete relief is
never achieved .
 Pain relief without the support of narcotics is very
poor.
 Advantages –no harmful effect
no effect on uterine contractions
 Disadvantages- time consuming
limits patient's movement
sterile aseptic techniques

27. PHARMACOLOGIC METHODS:
PARENTRAL AGENTS
 When uterine contractions and cervical dilatation
cause discomfort, pain relief with a narcotic such
as meperidine, plus one of the tranquilizer drugs
such as promethazine, is usually appropriate.
 the mother should rest quietly between
contractions.
 discomfort usually is felt at the acme of an
effective uterine contraction, but the pain is
generally not unbearable.

28. Meperidine and Promethazine
 Meperidine, 50 to 100 mg, with promethazine, 25
mg, may be administered intramuscularly at
intervals of 2 to 4 hours.
 Rapid effect is achieved by giving meperidine
intravenously in doses of 25 to 50 mg every 1 to 2
hours. *
 Meperidine readily crosses the placenta, and its
half-life in the newborn is approximately 13 hours
or longer (American College of Obstetricians and
Gynecologists, 2002).
 Its depressant effect in the fetus follows closely
behind the peak maternal analgesic effect.

29.  According to Bricker and Lavender (2002),
meperidine is the most common opioid used
worldwide for pain relief from labor.
 Women randomized to self-administered analgesia
were given 50-mg meperidine with 25-mg
promethazine intravenously as an initial bolus.
Thereafter, an infusion pump was set to deliver 15
mg of meperidine every 10 minutes as needed until
delivery. Neonatal sedation, as measured by need
for naloxone treatment in the delivery room, was
identified in 3 percent of newborns.

30. Butorphanol (Stadol)
 This synthetic narcotic, given in 1- to 2-mg doses
 The major side effects are somnolence, dizziness,
and dysphoria.
 Neonatal respiratory depression is reported to be
less than with meperidine, but care must be taken
that the two drugs are not given contiguously
because butorphanol antagonizes the narcotic
effects of meperidine.
 Angel and colleagues (1984) and Hatjis and Meis
(1986) described a sinusoidal fetal heart rate
pattern following butorphanol administration.

31. Fentanyl
 This short-acting and potent synthetic opioid may
be given in doses of 50 to 100 g intravenously every
hour.
 Its main disadvantage is a short duration of action,
which requires frequent dosing or the use of a
patient-controlled intravenous pump.
 Atkinson and associates (1994) reported that
butorphanol provided better initial analgesia than
fentanyl and was associated with fewer requests
for more medication or for epidural analgesia.

32. NOTE :Parenteral sedation is not without risks. Hawkins and colleagues
(1997b) reported that 4 of 129 maternal anesthetic-related deaths were
from such sedation—one from aspiration, two from inadequate
ventilation, and one from overdosage.
Narcotics used during labor may cause newborn respiratory depression

33. INHALATIONAL AGENTS:
N20:
A self-administered mixture of 50-percent nitrous oxide (N2O)
and oxygen provides satisfactory analgesia during labor.*
The use of intermittent nitrous oxide for labor pain has been
reviewed by Rosen (2002a) and the following technique
suggested:
 Instruct the woman to take slow deep breaths and to begin
inhaling 30 seconds before the next anticipated contraction
and to cease when the contraction starts to recede
 Remove the mask between contractions and encourage her
to breathe normally. No one but the patient or
knowledgeable personnel should hold the mask
 Instruct a caregiver to remain in verbal contact with the
patient
 Provide the expectation that the pain will likely not be
eliminated, but that the gas should provide some relief
 Ensure intravenous access, pulse oximetry, and adequate
scavenging of exhaled gases

34. REGIONAL BLOCK
 Various nerve blocks have been developed over the years to provide pain relief
during labor and delivery. They are correctly referred to as regional blocks.

35. Pudendal Block
 This block is a relatively safe and simple method of
providing analgesia for spontaneous delivery.
 The end of the introducer is placed against the vaginal
mucosa just beneath the tip of the ischial spine. The
needle is pushed beyond the tip of the director into the
mucosa and a mucosal wheal is made with 1 mL of 1-
percent lidocaine solution or an equivalent dose of
another local anesthetic.
 The needle is then advanced until it touches the
sacrospinous ligament, which is infiltrated with 3 mL of
lidocaine.
 The needle is advanced farther through the ligament*
Another 3 mL of solution is injected into this region.
 Next, the needle is withdrawn into the introducer,
which is moved to just above the ischial spine. The
needle is inserted through the mucosa and 3 more mL is
deposited.
 The procedure is then repeated on the other side.

37. Paracervical Block
 This block usually provides satisfactory pain relief
during the first stage of labor.
 Not use it routinely because the pudendal nerves
are not blocked,
 Additional analgesia is required for delivery.
 For paracervical blockade, usually lidocaine or
chloroprocaine, 5 to 10 mL of a 1-percent
solution, is injected into the cervix laterally at 3
and 9 o'clock.
 Bupivacaine is contraindicated because of an
increased risk of cardiotoxicity (American Academy
of Pediatrics and American College of Obstetricians
and Gynecologists, 2007; Rosen, 2002b).
 Relatively short acting, paracervical block may
have to be repeated during labor.

38. Spinal (Subarachnoid) Block
 Introduction of a local anesthetic into the
subarachnoid space to effect analgesia .
 Advantages include a short procedure time, rapid
onset of blockade, and high success rate.
 Smaller subarachnoid space during pregnancy,
(engorgement of the internal vertebral venous
plexus) the same amount of anesthetic agent in the
same volume of solution produces a much higher
blockade in parturients than in nonpregnant
women.
 Low spinal block can be used for forceps or vacuum
delivery.
 The level of analgesia should extend to the T10
dermatome(umbilicus).

39.  Several local anesthetic agents have been used for
spinal analgesia. Addition of glucose to any of
these agents creates a hyperbaric solution, which is
heavier and denser than cerebrospinal fluid.
 A sitting position causes a hyperbaric solution to
settle caudally, whereas a lateral position will have
a greater effect on the dependent side.
 Lidocaine given in a hyperbaric solution produces
excellent analgesia and has the advantage of a
rapid onset and relatively short duration.
Bupivacaine in an 8.25-percent dextrose solution
provides satisfactory anesthesia to the lower
vagina and the perineum for more than 1 hour..

40. COMPLICATIONS:
 Hypotension
 Postdural puncture headache
 Failed regional blockade
 High spinal blockade
 Chemical meningitis or epidural abscess or
hematoma

41. CONTRAINDICATIONS
 Refractory maternal hypotension
 Maternal coagulopathy
 Maternal use of once-daily dose of low-molecular-
weight heparin within 12 hours
 Untreated maternal bacteremia
 Skin infection over site of needle placement
 Increased intracranial pressure caused by a mass
lesion

42. LOCAL INFILTRATION
 Local infiltration refers to the injection of an
anesthetic medicine (such as Lidocaine/Xylocaine)
into a specific area of the body.
 For use during labor, the anesthetic is injected just
under the skin surrounding the opening of the
vagina.
 This method is used mainly during normal vaginal
delivery, episiotomy (cutting of the perineum), and
repair of episiotomy or tears.
 While simple to administer, local infiltration with
anesthetic is not risk-free and rarely may be
associated with poisoning and inadvertent
administration of the drug to the baby.
 It works only at the site of injection and does not
alleviate pain caused by contractions or pelvic
floor stretching.

44. General Anesthesia
 The increased safety of regional analgesia has
increased the relative risk of general anesthesia.
 The case-fatality rate of general anesthesia for
cesarean delivery is estimated to be approximately
32 per million live births compared with 1.9 per
million for regional analgesia (Hawkins and
associates, 1997b).

45. Patient Preparation
Prior to anesthesia induction, several steps should be taken to
help minimize the risk of complications for the mother and
fetus. These include the use of
 Antacids
 Uterine Displacement- The uterus may compress the inferior
vena cava and aorta when the mother is supine. With lateral
uterine displacement, the duration of general anesthesia has
less effect on neonatal condition than when the woman
remains supine (Crawford and colleagues, 1972).
 Preoxygenation- Because functional reserve lung capacity is
reduced, pregnant women become hypoxemic more rapidly
during periods of apnea than do non pregnant patients.
 To minimize hypoxia between the time of muscle relaxant
injection and intubation, it is important first to replace
nitrogen in the lungs with oxygen.
 This is accomplished by administering 100-percent oxygen
via face mask for 2 to 3 minutes prior to anesthesia
induction.

46. Induction of Anesthesia
 Thiopental- This thiobarbiturate given
intravenously is widely used and offers easy and
rapid induction, prompt recovery, and minimal risk
of vomiting..
 Ketamine- This agent also may be used to render a
patient unconscious. Doses of 1 mg/kg induce
general anesthesia.
 Or, intravenously in low doses of 0.2 to 0.3 mg/kg,
ketamine may be used to produce analgesia and
sedation just prior to vaginal delivery.
 It usually causes a rise in blood pressure, and thus
it generally should be avoided in women who are
already hypertensive.
 Unpleasant delirium and hallucinations are
commonly induced by this agent.

47. Intubation
 Immediately after a patient is rendered
unconscious, a muscle relaxant is given to aid
intubation.
 Succinylcholine, a rapid-onset and short-acting
agent, commonly is used.
 Cricoid pressure—the Sellick maneuver—is used by
a trained assistant to occlude the esophagus from
the onset of induction until intubation is
completed.
 Before the operation begins, proper placement of
the endotracheal tube must be confirmed.

48.  Gas Anesthetics- Once the endotracheal tube is
secured, a 50:50 mixture of nitrous oxide and
oxygen is administered to provide analgesia.
 A volatile halogenated agent is added to provide
amnesia and additional analgesia.
 Volatile Anesthetics- The most commonly used
volatile anesthetics in the United States include
isoflurane and two of its derivatives, desflurane
and sevoflurane.
 They are usually added in low concentrations to
the nitrous oxide-oxygen mixture to provide
amnesia.
 They are potent, nonexplosive agents that produce
remarkable uterine relaxation when given in high
concentrations.

49. THANK YOU