Download Dr. Sadeghi

by :Dr sadeghi
Jun 7, 2010
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The physiologic process
sufficiently frequent,
strong uterine contractions
thinning and dilation of the cervix
permitting passage of the fetus
from the uterus through the birth canal.
Friedman divided labor into three stages :
 First stage: time from the onset of labor until
complete cervical dilatation
 Second stage: time from complete cervical
dilatation to expulsion of the fetus
Third stage: time from expulsion of the fetus to
expulsion of the placenta
latent phases
The first stage
active phases
the latent phase:
regular contractions
mild infrequent contractions
gradual change in cervical
dilation (usually <1 cm per hour)
Increase effacement.
the average duration of
latent phase in nulliparous
and multiparous women is
6.4and 4.8 hours
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1st stage of labor – mostly visceral
Dilation of the cervix and distention
of the lower uterine segment
Dull, aching and poorly localized
Slow conducting, visceral C fibers,
enter spinal cord at T10 to L1
2nd stage of labor – mostly somatic
• Distention of the pelvic floor,
vagina and perineum
• Sharp, severe and well localized
• Rapidly conducting A-delta fibers,
enter spinal cord at S2 to S4
T10
L1
S2
S4
Primarily dilation of the cervix
Small component from uterine
muscle stimulation of the
mechanoreceptor
Visceral pain
Only amputation of a digit exceeded
the pain of labor
Sensory words: sharp, cramping,
aching, throbbing, stabbing, tight
Sensory nerves from uterus and cervix:T10-L1
 Pass through par cervical region
 Accompany the sympathetic fibers
 To the white ramie communicants
 Dorsal horn, laminae V Referred pain

Fetus descends through the birth canal
Stretching and tearing of fascia, skin,
subcutaneous tissue, and other
somatic structures
Somatic pain
Anterior primary
divisions of sacral
nerves, S2-S4
Pudendal nerve
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provides total pain relief to the mother
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without adversely affecting the labour
process
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unwanted side effects in the mother or
baby.
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freely available
labor pains can be a
very real downside to a vaginal
delivery. Since labor pains can
extend over a long period of
time, it can be a harrowingly
difficult and painful time for a
woman.
Safe Maternal Health and
Safe Motherhood
Programmed
vaginal delivery represents
the safest route for the fetus
and newborn in the first and
subsequent pregnancies
 There
are many different techniques, both regional
and non-regional to provide labour analgesia.
 Non-regional
techniques are the most frequently
employed methods for labour analgesia.
 Meperidine
(pethidine) is the most frequently used
opioid for labour analgesia. Its limited efficacy and
side effects are well documented.
Inhalation
of nitrous oxide relieves labour pain
to a significant degree .
Epidural
analgesia, CSA , PCEA ,when
compared with other methods, provides
superior analgesia for labour.
Boundaries of epidural space
Superior - the foramen magnum
Inferior - the sacral hiatus and sacrococcygeal membrane
Anterior - the posterior longitudinal
lig.
Posterior - periosteum of laminae of the
vertebrae and the lig.
flavum
Lateral - periosteum of the pedicles
and
intervertebral foraminae
 Epidural space contains:

• Dural sac and nerve roots
• Blood vessels and
lymphatics
• Connective and fatty tissue
Epidural analgesia
is a commonly employed technique of
providing pain relief during labor. The
number of parturient given intrapartume
epidural analgesia is reported to be over
50 percent at many institutions in the
.United States
Safe
(for both mother and fetus)
Easy and painless placement
Fast onset, easy administration, tight control
Effective analgesia (for both stage I and II)
Reliable extension for indicated procedures
Minimal side effects (for both mother and fetus)
No adverse effects on labor progress
Minimal complications
High patient satisfaction overall
Epidural Contraindications:
1. patient refusal
2. maternal hemorrhage
3. coagulopathy
4. fever>38.5`c
TABLE
Complications of Epidural Analgesia
Immediate
Hypotension (systolic blood pressure <100 mm Hg or a
decrease of 25 percent below preblock average
Urinary retention)
Local anesthetic induced convulsions
Local anesthetic induced cardiac arrest
Delayed
Postural puncture headache
Transient backache
Epidural abscess or meningitis
Permanent neurologic deficit
.Very rare--*
The most common complications
occurring with epidural analgesia are
maternal hypotension and postural
puncture headache
STRATEGIES
TO MINIMIZE MATERNAL
MOTOR BLOCK — Decreasing the
intensity of motor block may be achieved by
administering lower concentrations of local
anesthetics by either the epidural or spinal
route. Low concentrations of some local
anesthetics (eg, bupivacaine)
Analgesic
adjuvant (fentanyl, sufentanil,
epinephrine) are often co-administered with
local anesthetics to offset the decreased
analgesic intensity resulting from the
reduction of local anesthetic dose. The
opioids do not produce any motor block,
and thus are ideally suited adjuvant for
labor analgesia.
The rate of operative vaginal delivery fell 45
percent, from 9.4 percent of live births in 1994 to
Vacuum deliveries comprised 5.2 percent in 200
4.1 percent of all live births in 2004, whereas
forceps deliveries dropped dramatically, from 5.5
percent of births in 1989 to 1.1 percent in 2004
Training in forceps use also has decreased, with
one study showing that only one half of graduating
obstetrics and gynecology residents surveyed felt
comfortable performing forceps deliveries in their
practice
1994
2004
Operative vaginal delivery
1994
9.4%
4.1%
2004
5.1%
Vacuum delivery
1989
5.5%
4.4%
2004
1.1%
forceps
INDICATIONS FOR OPERATIVE VAGINAL DELIVERY
 Prolonged second stage of labor
nulliparousi
Without
more than
2hours
With regional
more than3
hours
multiparious
Without
With regional
regional more more than 2
than 1 hours hours
immediate potential fetal compromise
Shortening for maternal benefit
vacuum
Vacuum vaginal delivery
A.Cephalo hematomas
B. subgaleal hematomas
When the c-section rate reached its peak
in 1988, it came under closer scrutiny.
Critics expressed alarm at the frequency of
a procedure that places the mother at risk
for infections, hemorrhage and other
.complications
The World Health Organization
recommends that the caesarean
section rate should not be
higher than 10% to 15%
Moreover, caesarean delivery
1. high maternal complication
2. neonatal complication rates
3. increased health-care costs
Vaginal delivery
Faster recovery rate
Decreased risk for respiratory distress syndrome in
babies
Faster bonding with baby and ability to breastfeed
immediately
Less risk and more safe option in most cases
Lower cost and shorter hospital stay
More involvement during the birth process
The World Health Organization
recommends that cesarean rates in
developed countries like the U.S.
.
should be closer to 10-15 percent
WHO recommends that the rate of
Caesarean sections should not exceed
15% in any country. However, in recent
years the rate has risen to a record level
of 46% in China and to levels of 25% and
above in many Asian countries, Latin
America, and the USA
Caesarean section is associated :
risks of post-operative adhesion
incision hernias
 wound infections
Server blood loss
Increasing the anesthesia risk
a placenta accrete The risk of
potentially life-threatening condition,
is only 0.13% after two Caesarean
sections but increases to 2.13% after
four and then to 6.74% after six or
more surgeries
Among developing countries,
Brazil has one of the highest
rates of caesarean sections in
the world. In the public health
network, the rate reaches 35%,
while in private hospitals the
rate approaches 80%
A caesarean is a life
threatening medical
procedure that is obviously
ultimately decided upon by a
.doctor or several doctors
Cesarean section

Risks associated with anesthesia use
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Increased risk of infection
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Risk of bowel or bladder injury resulting from surgery

Risk for air or amniotic embolism
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Risk of uncontrolled bleeding

Risk to fetus of respiratory distress syndrome
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Increased risk of placenta previa or uterine abruption in
future pregnancies
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Risks for recurrent cesarean sections
Which one is better for choose ?
vaginal
delivery
or
cesarean section
women choosing primary elective
cesarean delivery will have a higher
incidence of maternal morbidity,
including hemorrhage,infection, and
venous thromboembolism. Maternal
mortality, while a rare event in developed
nations, is 2 to 3 times higher in elective
cesarean delivery than in vaginal
delivery, although there are no large
studies of maternal mortality risk for
primary elective cesarean delivery.
vaginal delivery
A normal fetal heart rate is
between 110 and 160 beats per
minute. Hypertension (systolic
blood pressure ≥ 140 mmHg or
diastolic blood pressure ≥ 90
mmHg) is one of the two criteria
for preeclampsia (the other is
proteinuria, a random urine
protein determination of 30
mg/dL or 1+ on dipstick).
Hypothermia in the immediate newborn
period increases oxygen consumption
and metabolic demands and is
independently associated with increased
mortality; therefore, maintaining body
heat is an important initial step in caring
for the newborn
Drying
the newborn is crucial, as it significantly
reduces heat loss. There are several
additional ways to keep the infant warm after
drying: swaddling in warm towels/blankets,
"skin to skin" contact with mother, placement
in a warm (36.5ºC) isolette, raising the
environmental (room) temperature, and
clothing.
The Apgar
score assesses neonatal heart
rate, respiratory effort, muscle tone, reflex
irritability, and color. Assign Apgar scores at
one and five minutes after birth (show
calculator). About 90 percent of neonates have
Apgar scores of 7 to 10, and generally require
no special intervention.
 Catheter
manipulation
 Additional volume of local anesthetic
 Patient’s position manipulation
 Replacement of the epidural catheter
 A single shot spinal anesthesia
 Continuous spinal anesthesia
 Combined spinal-epidural anesthesia
 Placement of an additional epidural catheter
 Supplementation with intravenous medications
 Conditions
for a cesarean section:
 There
are several conditions which may make having a
baby by cesarean section more likely. These include, but
are not limited to, the following: previous cesarean section
 fetal
distress
 abnormal
a
delivery presentation (i.e., breech, shoulder, face)
labor that fails to progress or does not progress normally
 placental
complications (i.e., placenta previa, in which the
placenta blocks the cervix and presents the risk of
becoming detached prematurely from the fetus)
Regional Analgesia
Regional analgesia tends to be the most
effective method of pain relief during labor and
causes few side effects. Epidural analgesia,
spinal blocks, and combined spinal–epidural
blocks are all types of regional analgesia that
are used to decrease labor pain.
Epidural Analgesia.
Epidural analgesia, sometimes called an epidural
block, causes some loss of feeling in the lower
areas of your body, yet you remain awake and
alert. An epidural block may be given soon after
your contractions start, or later as your labor
progresses. An epidural block with more or
stronger medications (anesthetics, not analgesics)
can be used for a cesarean delivery or if vaginal
birth requires the help of forceps or vacuum
extraction. Your doctors will work with you to
determine the proper time to give the epidural.
Lumbar epidural analgesia provides complete
pain relief for eighty-five percent and partial
relief in a further twelve percent of labouring
women. Only three percent have no relief at all
(Crawford JS, 1979). A continuous infusion
maybe started early in the first stage and can
be continued for anaesthesia if a caesarean
section is required.
well-trained anaesthesiologist with an interest
in obstetric analgesia is needed to provide an
epidural analgesia service. Ideally, a twentyfour hour obstetric analgesia service should be
in operation. The labouring woman should
have had an informed discussion about the
procedure, benefits and risks of epidural
analgesia in the prenatal period. The epidural
catheter should be inserted early in labour
when the patient is more co-operative and the
Epidural analgesia, also called an epidural
block, numbs the lower area of a woman's
body, and allows her to remain awake and
alert. A spinal block, usually given only once
during labor, works right away but for only an
hour or two. A combined spinal-epidural block,
sometimes called the 'walking
epidural,' works immediately and allows pain
relief drugs to be given
throughout labor.
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Advantages of the Epidural
A pain free labor!
Rapid pain relief
Medications can be increased or decreased based on your comfort
level-without additional injections
No groggy feeling or cloudy-headed side effects
Disadvantages of the Epidural
A common side effect is a drop in mom's blood pressure
(repositioning or medications are used to correct this)
Fewer than 10 percent of women report itching all over their body
Labor time may increase by approximately an hour
You will need to be connected to an IV and monitor- and if you are
mobile, need to move with your equipment
A small percentage of women, usually first time moms, will spike a
 Advantages
 Advantages
of epidural anesthesia during childbirth
 These are the main advantages of having an epidural
during childbirth:
 It provides complete pain relief without making you feel
confused or drowsy.
 It can be topped up if you need surgery (a Caesarean).
 A low-dose (mobile) epidural will allow you to feel your
contractions.
 It immediately calms the baby if your labor pains were
previously causing stress.
 It can allow you to have a rest, giving you more energy for
An epidural delivers continuous pain relief
to the lower part of your body while allowing
you to remain fully conscious. Medication is
delivered through a catheter, a very thin,
flexible, hollow tube that's inserted into the
epidural space just outside the membrane
that surrounds your spine.
Since the effect of the medication is
localized, you'll be awake and alert during
labor and birth. And, because you're painfree, you can rest if you want (or even
sleep!) as your cervix dilates. As a result,
you may have more energy when it comes
time to push.
You have to stay in an awkward
position for ten to 15 minutes while the
epidural is put in, and then wait
another five to 20 minutes before the
medication takes full effect. This may
seem like a minor inconvenience,
though, when the tradeoff is hours of
pain relief.
Conclusions
In 2002, the American College of
Obstetricians and Gynecologists and the
American Society of Anesthesiologists issued
a joint statement indicating that a woman's
request for pain relief is sufficient medical
indication for its use. Our opinion is that
epidural analgesia is a safe, widely used,
effective means of pain relief during labor and
From
1985 to present use of epidural
analgesia for labor has increased from 10% to
over 50% of laboring women in the U.S.
Advances
include low dose epidurals,
“walking” epidurals, PCEA, and CSE
Early:
increased doses of LA = increased SE
PDPH
7-10%
OB/GYN
perspective
 1054
nulliparous women were randomized into 3
groups to receive either a traditional epid (0.25%
BUP), a low-dose CSE, or a low-dose infusion epid
 Increased
rate of normal vaginal delivery with CSE
and low-dose infusion
 Decreased
 Increased
rate of instrumental vaginal delivery
rate of CS with traditional epidural
Epidural initiated: 8 ml
0.25% BUP
0.125% BUP
PCA: 4 ml basal, 4 ml bolus,
Lockout 20 min, 16 ml/hr max
CIEA: 12 ml/hr infusion
 The
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•
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•
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•
 Is
ideal labor analgesic:
Rapid onset
Long duration
Easy to administer
No side effects on mother
No side effects on baby
Allow ambulation, unrestricted expulsive efforts
No effect on length of labor or mode of delivery
CSE the ideal labor analgesic?
Rapid
onset of analgesia
Reliable,
fewer failed, or patchy blocks
Effective
sacral analgesia in advanced labor
Less
motor block
Better
Aids
epidural localization in difficult backs
Faster
Side
patient satisfaction
cervical dilation in early nulliparas
effects are acceptably low
 A retrospective
analysis in a large academic
medical center involving near 20 thousand
patients found incidences of overall failure,
IV epid cath, wet tap, inadequate epid
analgesia and cath replacement were all
lower in patients receiving CSE
 Sacral
analgesia is difficult to obtain with
conventional epidural, CSE is good at
providing it
 CSE
is an obvious choice in advanced labor
Several studies have found better patient
satisfaction scores with CSE vs. conventional
epid. Others have found no difference, but
none have found better satisfaction with
conventional epid analgesia
No
randomized trial has yet appeared
CSE
has been associated with improved
chances of adequate analgesia in parturient
with scoliosis or other causes of a difficult
back
 Patients
progress rapidly through labor
 One
explanation for an apparent increase in FHR
abnormalities occurring after CSE is this rapid
progress
2
large randomized trials have confirmed an
increase in the spontaneous vaginal delivery rate
with CSE vs. conventional epid analgesia
 As
is the case with epidural analgesia, the CS rate
is not increased with CSE
PDPH
Fetal
bradycardia/FHR changes
Pruritus
Infection
Neurotrauma
Other
side effects
 PDPH
• Rate ~ 1%
• CSE technique might actually decrease the
incidence of dural puncture with the epid needle
by allowing the anesthesiologist to confirm an
equivocal loss of resistance by passage of a
pencil point spinal needle rather than advancing
the large bore epid needle futher
 Fetal
bradycardia/ FHR changes
• Incidence of 11-30%
• Meta - analysis of 24 randomized trials including
over 3,500 patients comparing CSE to
conventional epid analgesia found no difference
in the rate of FHR changes but an increase in the
risk of bradycardia
• Usually a reduction in uterine activity (decreasing
or interrupting oxytocin administration, or short
acting tocolytic administration), raising maternal
BP, position change, or simply patience will
resolve the problem
• The meta – analysis showed no difference
in the rate of CS due to bradycardia or for
all indications, and neonatal Apgar scores
were equivalent
 Pruritus
• 3-95% of patients
• Effect is time limited, peak at 30min and
largely resolved within 1hr
• Prophylactic Ondansetron
• Patient satisfaction remains high
 Numerous
studies of varying quality
 Bradycardia
more frequent
 Management:
LUD, fluids, oxygen, treat BP if
applicable, IV or SL NTG has been shown to be
effective in treating fetal bradycardia associated with
uterine hyperactivity
 However,
there is no data demonstrating an
increased risk of CS due to CSE
CSE:
No
2.5mg BUP + 25mcg fentanyl
test dose
Infusion
started
Inhalation
of nitrous oxide relieves labour pain
to a significant degree .
Epidural
analgesia, CSA , PCEA ,when
compared with other methods, provides
superior analgesia for labour.
well-trained anaesthesiologist with an interest in
obstetric analgesia is needed to provide an epidural
analgesia service. Ideally, a twenty-four hour
obstetric analgesia service should be in operation.
The labouring woman should have had an informed
discussion about the procedure, benefits and risks
of epidural analgesia in the prenatal period. The
epidural catheter should be inserted early in labour
when the patient is more co-operative and the
epidural veins are not dilated.
An epidural delivers continuous pain relief to
the lower part of your body while allowing
you to remain fully conscious. Medication is
delivered through a catheter, a very thin,
flexible, hollow tube that's inserted into the
epidural space just outside the membrane
that surrounds your spine.
When
the parturient think that is no way for
their problem they have to choose
cesarean section and never think about
vaginal delivery
Can
It
we help them or not?
is one of the most our responsibility as
anesthetists
Water birth is an option chosen by
some women for pain relief during labor
 Why
do some women consider caesarean delivery
more advantageous and more in
keeping with the 21st century?
 Caesarean section or vaginal birth? What difference
does it make?
A caesarean is a modern way to have a baby, involving
the use of technology. Modern technology features
highly in our daily lives. We are at ease with it and find
it reassuring. The latest and most up-to-date
technological equipment is much prized and sought
after in all areas of our lives . A caesarean is a medical
operation. Birth is currently seen a
For epidural catheterization, the tip of a
specialized needle (eg, 17 or 18 gauge) is
positioned within the epidural space. A thin
catheter (eg, 19 or 20 gauge) is then
threaded through the needle, and the
needle is withdrawn. The catheter is
secured to the skin of the parturient ’s back
with an adhesive dressing.
Intermittent epidural bolus dosing was the
standard technique used for providing labor
analgesia
Continuous infusion of analgesics into the
epidural space avoids the peaks and valleys
of intermittent administration and results in a
smoother analgesic experience for the
parturient with fewer provider interventions.
Continuous infusion of analgesics into
the epidural space avoids the peaks
and valleys of intermittent
administration and results in a
smoother analgesic experience for the
parturient with fewer provider
interventions.
The phrase "walking epidural" is a
generic description of any neuraxial
analgesic technique that preserves
motor function in a parturient.
However, for various reasons 34 to
85 percent of women do not
actually ambulate during labor
The addition of opioids to
neuraxial analgesia, namely
to provide pain relief while
avoiding opioid side effects
in the mother and neonate
new mode of analgesia is sterile water
injection placed just underneath the
skin in the most painful spots during
labor. A control trial in Iran of 0.5mL
injections was conducted with normal
saline which revealed a statistical
superiority with water over saline
From
my daughter for preparing these slides
From
my husband for his supporting
Form
you dear audience for your attention