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PAINLESS LABOR

Dr. Reza AminnejadAnesthesiologist, MD.

Assistant professor of Anesthesiology,Qom University of Medical Sciences

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Iran in 2014Azami-Aghdash S. et al. .Prevalence and Causes of Cesarean Section in Iran: Systematic Review and Meta-Analysis. Iran J Public Health. 2014

May; 43(5): 545–555.

• The prevalence of Cesarean was estimated 48%.

• Social and demographic factors (maternal education and grand multiparity), obstetric-medical causes (previous CS) and non-obstetric-medical causes (fear of NVD) are three main factors influencing incidence of CS.

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Benefits of NVD for mothers

• Three times less likely to die during delivery• Shorter hospital stay• Shorter recovery time• Avoidance of major surgery and its associated risks• Shorter-lasting pain• Shorter-lasting soreness• Sooner breast feeding• Less physical complaints after delivery• Lesser risk of future pregnancy complications• Avoidance of postoperative complications• Avoidance of postanesthesia complications

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Benefits of NVD for babies

• Boost of the immune system• Protection of intestinal tract• Less likely to have breathing problems

at birth and even during childhood, such as asthma

• Lesser risk for stillbirth• Lesser risk of becoming obese as

children and even as adults

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Painless labor may assist lactogenesis

Long labor, stress to the mother and fetus during labor and delivery, negative affects and high score of posttraumatic stress are risk factors for delayed lactogenesis.

Dimitraki M et al. Evaluation of the effect of natural and emotional stress of labor on lactation and breast-feeding. Arch Gynecol Obstet. 2016 Feb;293(2):317-28. doi: 10.1007/s00404-015-3783-1. Epub 2015 Jun 26.

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Continuation of pain control after delivery may assist breast feeding too!

Breastfeeding increased cramping pain after vaginal and cesarean delivery. The increase in cramping pain is most likely due to the breastfeeding-associated oxytocin surge increasing uterine tone.

Wen L et al. The impact of breastfeeding on postpartum pain after vaginal and cesarean delivery. J Clin Anesth. 2015 Feb;27(1):33-8. doi: 10.1016/j.jclinane.2014.06.010. Epub 2014 Nov 21.

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In the United States

According to newly released Medscape data approximately 60% of laboring women (2.4 million each year) choose regional analgesia for pain relief during labor.

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A brief history

• Pain management from the time of recorded history had been crude and largely ineffective.

• suggestion and distraction were primitive attempts for pain alleviation in labor & delivery.

• Magicians had a great role in ancient attempts.

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Gynecologists are the pioneers of PL

One of the earliest references to the management of childbirth pain is• A gynecologic text • Written in the first

century C.E. • Written by the Greek

physician Soranus of Ephesus

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In the Middle Ages

• various herbal concoctions based on extract of poppy, mandragora, henbane and hemp were introduced.

• There is evidence that alcohol was also used in labour.

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In the first decades of the 19th century

• Pain of childbirth stimulated a woman's central nervous system to the point of causing serious side effects.

• Copious bleeding, as many as three or more pints of blood can depress the nervous system and thereby counteract the danger from the pain.

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Sir Humphry Davy (1778-1829)

• Sir Humphry Davy (1778-1829) a famous English chemist, having discovered the anaesthetic properties of Nitrous oxide in 1799

• It would be 45 years later before nitrous oxide would be used as an anesthetic by dentists.

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In this caricature by James Gillray, a young Davyworks the bellows demonstrating his experimentswith N2O or laughing gas.

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Dr. Crawford Long (1815-1878)

• He did not have access to the nitrous oxide that had been used in his college experiences, so he began experimenting with sulfuric ether.

• on March 30, 1842 could be the ether day!

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William Morton

William Morton is credited with the discovery of Ether Anaesthesia for its use in Dentistry in 1846.

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What seduction can do!

• During the 18th and early 19th centuries, because of the indiscriminent use of these drugs, many physicians had been reluctant to use either opium or morphine for labor.

• They believed that either compound diminished uterine contractions and depressed the child and, therefore, constituted an unacceptable risk for normal labor.

• Later, in 1847, physicians used the same arguments against the use of ether or chloroform to treat the pain of childbirth.

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In 1847 an era of conflict began predominantly between two groups.

against pain-free childbirth

According to Scripture, hildbirth 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.

adapting pain-free childbirth

Pioneering physicians who discovered the value of ether and chloroform in childbirth, did it despite the resistance of the powerful clergy of the time.

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Three famous women of the time who were known to be very enthusiastic about use

of painless labor

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United States, 1847Fanny Longfellow used ether for her 3rd childbirth.

England, 1847 Emma Darwin used chloroform for the last 2 of her 8 births

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Queen Victoria

with the strong encouragement of her husband Prince Albert, convinced her reluctant physicians, to have chloroform administered to her by Dr.John Snow for her 8th confinement of Prince Leopold.

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• Sir James Simpson (1811-1870) was a leading Obstetrician of England.

• On January 19, 1847 he administered ether to an obstetric patient and thus began a new era in the effective management of pain in childbirth.

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• In defending anesthesia against clerical criticism, Simpson noted that some churchmen also first spoke against optical glasses, spectacles and the telescope as ‘offsprings of man’s wicked mind’, because they changed the natural appearance of things and presented them in an untrue light.

• Medical men may oppose for a time the superinduction of anaesthesia in parturition, but they will oppose it in vain; for certainly our patients themselves will force use of it upon the profession. The whole question is, even now, one merely of time."

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Indications

• Maternal request is a sufficient medical indication for pain relief during labor.

• Decisions regarding analgesia should be coordinated among the obstetrician, the anesthesiologist, the patient, and support personnel.

ACOG Committee Opinion number 269 February 2002. Analgesia and cesarean delivery rates. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2002 Feb. 99(2):369-70.

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Analgesia is indicated for patients with certain risk factors even in the absence

of maternal request.• Marked obesity• Obstetric complications with potential for operative delivery (eg, placenta

previa, high order multiple gestation)• Severe preeclampsia• Bleeding disorders (eg, thrombocytopenia) & Use of anticoagulants• Difficulty in airway management (Severe edema, trauma, surgery, or

anatomical abnormalities of the face, neck, or spine, abnormal dentition, small mandible, or difficulty opening mouth, extremely short stature, short neck, or arthritis of the neck, Goiter & etc.)

• Prior history of anesthesia complications, such as malignant hyperthermia

• Cardiovascular, neurological, or respiratory disease• Hyperreflexia in parturients with a high spinal cord lesion (prevention or

treatment)• For patients with mitral stenosis, regional analgesia (epidural) is the

preferred method.

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Contraindications

• Patient refusal• Presence of actual or anticipated serious maternal hemorrhage • Refractory maternal hypotension• Coagulopathy• Untreated bacteremia• Raised intracranial pressure• Skin or soft tissue infection at the site of the epidural or spinal

placement• Anticoagulant therapy• Inadequate practitioner training and experience• Presence of a neurological diseases (?)• Maternal aortic stenosis, pulmonary hypertension, or right-to-left

shunts (IT Opioids can be used)

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What can we do for preeclamptic parturients?

• In women with severe preeclampsia, analgesia is controversial.

• Over the past 2-3 decades, most obstetric anesthesiologists have come to favor epidural blockade for labor analgesia in women with severe preeclampsia.

Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol. 2000 Jul. 183(1):S1-S22.

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Some Concerns in Performing RA

• Thrombocytopenia (absolute count/rate of decline)

• Anticoagulation (aspirin/UFH/LMWH)• Nonreassuring fetal heart tone is not a

contraindication to regional analgesia.

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Methods of Pain Relief

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Non-pharmacological

• 1) continuous labor support• 2) hydrotherapy• 3) intradermal water blocks• 4) movement and

positioning• 5) touch and massage• 6) acupuncture• 7) hypnosis

• 8) transcutaneous electrical nerve stimulation (TENS)

• 9) aromatherapy• 10) heat and cold• 11) childbirth education• 12) self-help techniques such

as patterned breathing and relaxation

• 13) music and audioanalgesia

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Spinal anesthesia; Corning or Bier?!

• One year after the discovery of the anesthetic properties of cocaine, the American neurologist Corning injected the drug between the spinous processes of the lower dorsal vertebrae.

• For many years, there has been controversy as to whether Corning's injection was a spinal or an extradural block.

• Corning's injection was extradural, and Bier deserves the laurels for introducing spinal anesthesia.

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Iran in 2014Azami-Aghdash S. et al. .Prevalence and Causes of Cesarean Section in Iran: Systematic Review and Meta-Analysis. Iran J Public Health. 2014

May; 43(5): 545–555.

The prevalence of Cesarean was estimated 48%.

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China can be our model Lower rates of cesarean delivery, episiotomy, postpartum blood transfusion, and better neonatal

outcomes were documented in 3 impact studies comprising approximately 55,000 deliveries.

• Nongovernmental No Pain Labor & Delivery (NPLD)• Step by step approach• Establishment of NPLD centers around the country• Multidisciplinary approach & 24/7 obstetric anesthesia

coverage • Continues policy including problem-based learning

discussions, bedside teaching, daily debriefings, simulation training drills, and weekend conferences

Hu LQ et al. No Pain Labor & Delivery: A Global Health Initiative's Impact on Clinical Outcomes in China. Anesth Analg. 2016 Jun;122(6):1931-8. doi: 10.1213/ANE.0000000000001328.

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Recent Advances

Technical• Combined spinal epidurals• Low-dose epidurals

facilitating ambulation• Ultrasound guided

technics• PCEA pumps• Computer-integrated drug

delivery pumps

Pharmacological• Remifentanil for PCIVA• Ropivacaine &

Levobupivacaine for intrathecal & epidural inj.

• Sufentanil, Clonidine and Neostigmine for RA

• Sevoflourane for patient-controlled inhalational analgesia

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• Recent randomized controlled trials and Cochrane studies have concluded that the association of epidurals with increased caesarean section and long-term backache remains only a myth.

• Newer, low-dose regimes do not have a statistically significant impact on the duration of labour and breast feeding and also that these reduce the instrumental delivery rates thus improving maternal and foetal safety.

Sunil T Pandya. Labour analgesia: Recent advances. Indian J Anaesth. 2010 Sep-Oct; 54(5): 400–408.

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painless labor and delivery

campaign

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