11

22

ADVANCES IN LABOUR ADVANCES IN LABOUR ANALGESIA.ANALGESIA.

““WALKING EPIDURAL”WALKING EPIDURAL”BYBY

DR ZAHID AKHTAR RAODR ZAHID AKHTAR RAOMBBS;MCPS;FCPSMBBS;MCPS;FCPS

MILITARY HOSPITAL RAWALPINDIMILITARY HOSPITAL RAWALPINDI

33

THE DELIVERY OF THE INFANT INTO THE DELIVERY OF THE INFANT INTO THE ARMS OF A CONSCIOUS AND THE ARMS OF A CONSCIOUS AND PAIN FREE MOTHER IS ONE OF THE PAIN FREE MOTHER IS ONE OF THE MOST EXCITING AND REWARDING MOST EXCITING AND REWARDING MOMENTS IN MEDICINE.MOMENTS IN MEDICINE.

44

THE LABOUR IS REPORTED TO BE ONE THE LABOUR IS REPORTED TO BE ONE OF THE MOST PAINFULL EXPERIENCES OF THE MOST PAINFULL EXPERIENCES IN A WOMAN’S LIFE.IN A WOMAN’S LIFE.

55

IT IS NOW WELL RECOGNIZED THAT THE IT IS NOW WELL RECOGNIZED THAT THE ONLY CONSISTENTLY EFFECTIVE METHOD ONLY CONSISTENTLY EFFECTIVE METHOD OF PAIN RELIEF DURING LABOUR IS OF PAIN RELIEF DURING LABOUR IS LUMBER EPIURAL ANALGESIA.LUMBER EPIURAL ANALGESIA.

66

““EPIDURAL BLOCK IS THE MOST EFFECTIVE EPIDURAL BLOCK IS THE MOST EFFECTIVE AND LEAST DEPRESSANT (pharmacologic AND LEAST DEPRESSANT (pharmacologic Option) ALLOWING FOR AN Option) ALLOWING FOR AN ALERT,PARTICIPATING MOTHER.”ALERT,PARTICIPATING MOTHER.”

(guidelines American College of Obs & gynae)(guidelines American College of Obs & gynae)

77

““MATERNAL REQUEST IS MATERNAL REQUEST IS SUFFICIENT JUSTIFICATION FOR SUFFICIENT JUSTIFICATION FOR PAIN RELIEF DURING LABOUR.”PAIN RELIEF DURING LABOUR.”

88

OVER THE LAST 40-50 YEARS,LABOUR EPIDURAL OVER THE LAST 40-50 YEARS,LABOUR EPIDURAL ANALGESIA HAS UNDERGONE SUBSTANTIAL ANALGESIA HAS UNDERGONE SUBSTANTIAL CHANGES.CHANGES.

CURRENTLY,”STATE-OF THE-ART” TECHNIQUES CURRENTLY,”STATE-OF THE-ART” TECHNIQUES HAVE BEEN DEVELOPED AND ARE NOW USED IN HAVE BEEN DEVELOPED AND ARE NOW USED IN ROUTINE CLINICAL PRACTICE.ROUTINE CLINICAL PRACTICE.

99

THE IDEAL LABOUR ANALGESIC SHOULD ALSO THE IDEAL LABOUR ANALGESIC SHOULD ALSO GIVE A RESTED PARTURIENT THE GIVE A RESTED PARTURIENT THE ENERGY,STRENGTH AND SENSATION TO ENERGY,STRENGTH AND SENSATION TO PERFORM EXPULSIVE EFFORTS AT THE TIME OF PERFORM EXPULSIVE EFFORTS AT THE TIME OF DELIVERY.DELIVERY.

TO ACHIEVE THESE GOALS, RECENT TO ACHIEVE THESE GOALS, RECENT DEVELOPMENTS HAVE FACILITATED MATERNAL DEVELOPMENTS HAVE FACILITATED MATERNAL AMBULATION WHILE RECEIVING EFFECTIVE AMBULATION WHILE RECEIVING EFFECTIVE REGIONAL ANALGESIA.REGIONAL ANALGESIA.

1010

Why to walk?Why to walk?

The upright posture helps shorten The upright posture helps shorten the duration of labour by walkingthe duration of labour by walking

Weight of fetus would dilate the Weight of fetus would dilate the cervixcervix

1111

Mothers who walk during labour had Mothers who walk during labour had reduced duration and operative reduced duration and operative delivery rate.delivery rate.

1212

ADVANCES IN LABOUR ANALGESIA INCLUDES:ADVANCES IN LABOUR ANALGESIA INCLUDES:

• TRADITIONAL EPIDURALS.TRADITIONAL EPIDURALS.• LOW DOSE EPIDURALS.LOW DOSE EPIDURALS.• WALKING EPIDURALS.WALKING EPIDURALS.• PATIENT CONTROLLED EPIDURAL ANALGESIA.PATIENT CONTROLLED EPIDURAL ANALGESIA.• COMBINE SPINAL EPIDURAL.COMBINE SPINAL EPIDURAL.• CONTINEOUS EPIDURAL INFUSION.CONTINEOUS EPIDURAL INFUSION.

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TRADITIONAL EPIDURALS: TRADITIONAL EPIDURALS:

•USING 0.25% Bup.USING 0.25% Bup.•HIGH INCIDENCE OF MOTOR BLOCK.HIGH INCIDENCE OF MOTOR BLOCK.

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EFFECT OF LOW DOSE MOBILE VS. EFFECT OF LOW DOSE MOBILE VS. TRADITIONAL EPIDURAL TECHNIQUES TRADITIONAL EPIDURAL TECHNIQUES

ON MODE OF DELIVERY.ON MODE OF DELIVERY. INCREASED RATE OF NORMAL VAGINAL DELIVERY INCREASED RATE OF NORMAL VAGINAL DELIVERY

WITH LOW DOSE MOBILE.WITH LOW DOSE MOBILE.

DECREASED RATE OF INSTRUMENTAL VAGINAL DECREASED RATE OF INSTRUMENTAL VAGINAL DELIVERY WITH LOW DOSE MOBILE.DELIVERY WITH LOW DOSE MOBILE.

INCREASED RATE OF CS WITH TRADITIONAL INCREASED RATE OF CS WITH TRADITIONAL EPIDURAL.EPIDURAL.

(COMET STUDY, LANCET 2001.(1054 PTS).(COMET STUDY, LANCET 2001.(1054 PTS).

1515

LOW DOSE EPIDURALSLOW DOSE EPIDURALS::

USING 0.125% Bup.USING 0.125% Bup.HIGH DEGREE OF PATIENT HIGH DEGREE OF PATIENT

SATISFACTION.SATISFACTION.MAY HAVE SOME DEGREE OF MAY HAVE SOME DEGREE OF

MOTOR WEAKNESS.MOTOR WEAKNESS.MAY NEED ADDITION OF MAY NEED ADDITION OF

NORCOTICS.NORCOTICS.

1616

WALKING EPIDURALS:WALKING EPIDURALS:

•USING 0.0625% Bup.+FENT USING 0.0625% Bup.+FENT 02ųg/ml.02ųg/ml.•HIGH DEGREE OF MATERNAL HIGH DEGREE OF MATERNAL SATISFACTION.SATISFACTION.•NO MOTOR WEAKNESS.NO MOTOR WEAKNESS.•LOW INCIDENCE OF CS.LOW INCIDENCE OF CS.

1717

PCEAPCEA

LOADING DOSE REQUIRED.LOADING DOSE REQUIRED.PATIENT/NURSE EDUCATION PATIENT/NURSE EDUCATION REQUIRED. REQUIRED.LOWER DRUG DOSE.LOWER DRUG DOSE.LESS ANAES VISIT.LESS ANAES VISIT.MORE PATIENT MORE PATIENT SATISFACTION.SATISFACTION.EQUIPMENT COST VERY EQUIPMENT COST VERY HIGH.HIGH.

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CSECSE•RAPID ONSET OF ANALGESIA.RAPID ONSET OF ANALGESIA.

•RELIABLE, FEWER FAILED,OR RELIABLE, FEWER FAILED,OR PATCHY BLOCKS.PATCHY BLOCKS.•EFFECTIVE SACRAL ANALG IN EFFECTIVE SACRAL ANALG IN ADVANCED LABOUR.ADVANCED LABOUR.•LESS MOTOR BLOCK.LESS MOTOR BLOCK.•BETTER PATIENT SATISFACTION.BETTER PATIENT SATISFACTION.•FASTER CERVICAL DILATATION.FASTER CERVICAL DILATATION.

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SIDE EFFECTS OF CSESIDE EFFECTS OF CSEPDPH.PDPH.

PRURITIS.PRURITIS.INFECTION.INFECTION.

NEUROTRAUMA.NEUROTRAUMA.HYPOTENTION.HYPOTENTION.

RESPIRATORY DEPRESSION.RESPIRATORY DEPRESSION.

2020

ON THE OTHER HAND……..ON THE OTHER HAND……..HOW FAST DO WE NEED A BLOCK TO HOW FAST DO WE NEED A BLOCK TO

BE ?BE ?Nickells et al:Nickells et al:Time to first painless contraction with Time to first painless contraction with

CSE was at 10 vs 12.1 min with epid.CSE was at 10 vs 12.1 min with epid.

Hepner:Hepner:Mentioned at 5min the VAS was<3 in Mentioned at 5min the VAS was<3 in

26/26 with a CSE vs. 17/24 with an 26/26 with a CSE vs. 17/24 with an epid.epid.

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CONTINUOUS EPIDURAL INFUSIONCONTINUOUS EPIDURAL INFUSION

DOSE USED IS HIGH.DOSE USED IS HIGH.DURATION OF LABOUR IS DURATION OF LABOUR IS

LONGER.LONGER.MAY NEED RESCUE DOSE.MAY NEED RESCUE DOSE.

2222

PCEA VS.CEI FOR PCEA VS.CEI FOR LABOUR ANALGESIA.LABOUR ANALGESIA.

(80 Parturient)(80 Parturient)PCEA group used less PCEA group used less drug(5.2 v 6.9 ml/hr)drug(5.2 v 6.9 ml/hr)

Had shorter duration of Had shorter duration of labour(296min v 357min) labour(296min v 357min)

(ERIKSON,GNTELE AND OLLFSSON ACTA (ERIKSON,GNTELE AND OLLFSSON ACTA ANAESTHESIOLOGICA SCANDINVICA 2003.)ANAESTHESIOLOGICA SCANDINVICA 2003.)

2323

STUDY CARRIED OUT BY DR. STUDY CARRIED OUT BY DR. C.HARMS AND HIS COLLEGUES.C.HARMS AND HIS COLLEGUES.

COMPARISON OF THREE COMPARISON OF THREE DIFFERENT BUPIVACAINE DIFFERENT BUPIVACAINE

CONC.CONC.0.25% WAS ASSOCIATED WITH 0.25% WAS ASSOCIATED WITH

INCREASE INCIDENT OF MOTOR BLOCK.INCREASE INCIDENT OF MOTOR BLOCK.0.125% WAS MOST SUITABLE CONC. 0.125% WAS MOST SUITABLE CONC.

FOR LABOUR ANAGESIA.FOR LABOUR ANAGESIA.WITH 0.0625% CONC. ANALGESIA WAS WITH 0.0625% CONC. ANALGESIA WAS

INADEQUATE.INADEQUATE.(Fetal Diagnosis and Therapy 1999;14:368-74)(Fetal Diagnosis and Therapy 1999;14:368-74)

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DR GUPTA AND HIS COLLEGUES COMPARED THE DR GUPTA AND HIS COLLEGUES COMPARED THE CSE & LOW DOSE EPID.; IN RELATION TO CSE & LOW DOSE EPID.; IN RELATION TO

AMBULATORY LABOUR ANALGESIA:AMBULATORY LABOUR ANALGESIA:

Ambulation achieved in 100% of parturient in both groups. Ambulation achieved in 100% of parturient in both groups.

Rapid analgesia was achieved in CSE gp.(80% v 0%<5 min.)Rapid analgesia was achieved in CSE gp.(80% v 0%<5 min.)

Duration of analgesia was significantly increased in epid gp.Duration of analgesia was significantly increased in epid gp.(102.8 v 79.1 min)(102.8 v 79.1 min)

In epid gp. 84% parturient were painless b/w 5-15 min.In epid gp. 84% parturient were painless b/w 5-15 min.(Drug used:bup 0.15% +fen 2ųg/ml in epid & in CSE-1.25mg (Drug used:bup 0.15% +fen 2ųg/ml in epid & in CSE-1.25mg

bup.+20ųg fen.)bup.+20ųg fen.)

(Indian J. Anaesth.2002; 46(1):44-48)(Indian J. Anaesth.2002; 46(1):44-48)

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With 15ml bolus of 0.1%(15mg) bup. With 15ml bolus of 0.1%(15mg) bup. +05ug/ml (75ug) fent.+05ug/ml (75ug) fent.

Ambulation achieved in 65% Ambulation achieved in 65% of parturient with epidural of parturient with epidural

analgesiaanalgesia..(Anaesthesia 1998;53: 951-5)(Anaesthesia 1998;53: 951-5)

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Epidural analgesia with 20ml of Epidural analgesia with 20ml of 0.08%(16mg) bup.+2ug/ml (40ug) 0.08%(16mg) bup.+2ug/ml (40ug)

fent.fent.

Pain free ambulation Pain free ambulation achieved in 65% of parturient.achieved in 65% of parturient.

(Canadian Journal of Anesthesia 50:R8(2003))(Canadian Journal of Anesthesia 50:R8(2003))

2727

With 20ml of either 0.08% With 20ml of either 0.08% ropivacaine+2ug/ml fentanyl or 0.08% ropivacaine+2ug/ml fentanyl or 0.08% bupivacaine+2ug/ml fentanyl given in bupivacaine+2ug/ml fentanyl given in

epidural space.epidural space.

Ambulation in 100% Ambulation in 100% parturients receiving parturients receiving

ropivacaine.ropivacaine.Ambulation in 75% Ambulation in 75% parturients receiving parturients receiving

bupivacaine.bupivacaine.

(Anesth Analg 2000; 90:1384-9)(Anesth Analg 2000; 90:1384-9)

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DR MAHARJAN SK AND HIS COLLEGUEDR MAHARJAN SK AND HIS COLLEGUEMATERNITY HOSPITAL, THAPATHALI KHATMANDU, MATERNITY HOSPITAL, THAPATHALI KHATMANDU,

NEPAL.NEPAL.

USING 10ml of USING 10ml of Bup.0.1%+25mg Bup.0.1%+25mg

Pethidine.Pethidine. 75% Spontaneous 75% Spontaneous vaginal deliveries.vaginal deliveries.

20% Instrumental 20% Instrumental deliveries.deliveries.

5% Caesarean 5% Caesarean section.section.

0

10

20

30

40

50

60

70

80

spont.inst.cs

2929

A POPULATION BASED STUDY OF 94,217 A POPULATION BASED STUDY OF 94,217 PRIMIPARAE. EPID ANALG & ITS RELATION TO CS & PRIMIPARAE. EPID ANALG & ITS RELATION TO CS &

INSTRUMENTAL DELIVERIES.INSTRUMENTAL DELIVERIES.(Eur J Obstet Gynecol Report Biol. 2005 Dec 09.)(Eur J Obstet Gynecol Report Biol. 2005 Dec 09.)

Normal deliveries-Normal deliveries-70.6%.70.6%.

Instrumental Instrumental deliveries-18.8%deliveries-18.8%

C.S. 10.6%C.S. 10.6%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

N.Deliv

Instru.Deliv

CS

3030

STUDY BEING CARRIED OUT AT STUDY BEING CARRIED OUT AT MILITARY HOSPITAL RAWALPINDI.MILITARY HOSPITAL RAWALPINDI.

LABOUR ANALGESIALABOUR ANALGESIACOMPARISION OF COMPARISION OF

BUPIVACAINE 0.25%+5mg/ml BUPIVACAINE 0.25%+5mg/ml TRAMADOL VS. BUPIVACAINE TRAMADOL VS. BUPIVACAINE 0.1%+5mg/ml TRAMADOL.0.1%+5mg/ml TRAMADOL.

3131

GROUP-A: 25 PARTURIENTS GIVEN GROUP-A: 25 PARTURIENTS GIVEN 10 ml OF BUP.0.25%+5mg/ml 10 ml OF BUP.0.25%+5mg/ml

TRAMADOL.TRAMADOL.

100% of parturients were 100% of parturients were pain free in 10-20 min.pain free in 10-20 min.

None of them were able to None of them were able to ambulate.ambulate.

All were able to move in All were able to move in bed.bed.

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GROUP-B: 50 PARTURIENTS GIVEN GROUP-B: 50 PARTURIENTS GIVEN 10ml OF BUP.0.1%+5mg/ml 10ml OF BUP.0.1%+5mg/ml

TRAMADOL.TRAMADOL.45 parturients were pain 45 parturients were pain

free within 10-20 min.free within 10-20 min.05 needed initial rescue 05 needed initial rescue

dosedose46 of them were able to 46 of them were able to ambulate independently.ambulate independently.04 of them were able to 04 of them were able to ambulate with support.ambulate with support.

3333

MODE OF DELIVERIES EPID. 0.25% Bup. (GP-A)MODE OF DELIVERIES EPID. 0.25% Bup. (GP-A)

40% spontaneous 40% spontaneous deliveries.deliveries.

40% instrumental 40% instrumental deliveries.deliveries.

20% c-section.20% c-section.

0

5

10

15

20

25

30

35

40

spontinstru.c-s

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MODE OF DELIVERIES EPID. 0.1% Bup.(GP-B)MODE OF DELIVERIES EPID. 0.1% Bup.(GP-B)

37 spontaneous 37 spontaneous deliveries.deliveries.

06 instrumental 06 instrumental deliveries.deliveries.

03 c-sections.03 c-sections. (expected)(expected) 04 patients 04 patients

( planned for C-( planned for C-section; were section; were delivered vaginally delivered vaginally (instrumental)(instrumental)

0

10

20

30

40 Spont-DelInstru

C-Sec

3535

““DURING THE FIRST STAGE OF DURING THE FIRST STAGE OF LABOUR THE PATIENT USUALLY LABOUR THE PATIENT USUALLY PREFERS TO MOVE ABOUT HER PREFERS TO MOVE ABOUT HER

ROOM…… ROOM…… THEREFORE, SHE SHOULD NOT BE THEREFORE, SHE SHOULD NOT BE COMPELLED TO TAKE TO HER BED COMPELLED TO TAKE TO HER BED UNLESS SHE FEELS SO INCLINED.”UNLESS SHE FEELS SO INCLINED.”

RECOMMENDATIONRECOMMENDATIONSS

3636

The CSE technique should The CSE technique should ideally be reserved for only ideally be reserved for only

those parturients who require those parturients who require rapid onset of analgesia as in rapid onset of analgesia as in

later stages of labour.later stages of labour.

Routine use of the epidural Routine use of the epidural technique in early active technique in early active

labour.labour.

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CONCLUSIONCONCLUSION

MODERN LABOUR EPIDURAL MODERN LABOUR EPIDURAL ANALGESIC TECHNIQUES AND ANALGESIC TECHNIQUES AND

MEDICATIONS HAVE RESULTED IN MEDICATIONS HAVE RESULTED IN MORE CONSISTENT, PRIDICTABLE AND MORE CONSISTENT, PRIDICTABLE AND

EFFECTIVE ANALGESIA.EFFECTIVE ANALGESIA.OUR GOAL IS TO IMPROVE PATIENT OUR GOAL IS TO IMPROVE PATIENT

CARE AND SAFETY;CARE AND SAFETY;WHILE INCREASING THE SATISFACTION WHILE INCREASING THE SATISFACTION

AND PARTICIPATION OF WOMEN IN AND PARTICIPATION OF WOMEN IN THEIR LABOUR AND DELIVERY THEIR LABOUR AND DELIVERY

EXPERIENCE. EXPERIENCE.

3838