Management

Acute Pain Management

Several medications offer pain relief to women in labour. All medications cross the placenta and have some effect on the baby

Pain Care Planning during Patient's Stay

"The intensity of labour pain is not always the determining factor that drives women to seek pain management. Indeed, it is often the repetitive nature and length of time at which pain persists with each contraction" - Dr CK Pandey Senior Consultant Anaesthesiology Sahara Hospital Lucknow

This may apply to both surgical and medical patients. Before being admitted to the hospital, the patient should continue taking your medications as prescribed by the doctor. He/ she should bring along all the medications you that he/ she have been taking at the time of coming to hospital. The physician will review all the medications. Steps will be taken to make sure that all the medications required (including the ones brought from home) are being looked after during your stay at the hospital. In addition to all other medications, painkillers can be given by mouth, direct injection into veins, by patch to the skin or through Patient Controlled Analgesia (PCA) where the patient controls the amount of painkiller. There are pain management methods that are determined based on the levels of care required at that time.

Intravenous Patient Controlled Analgesia

The most common method of pain management is Patient Controlled Analgesia (PCA). The meditation from a PCA pump goes into a vein just like an intravenous way to give a drug. This kind of medication is called opioid. This is a way of letting the patient being in control of pain medication. A special pump will be set up to take a dose of painkiller whenever required. The pump has safety features so that patient cannot overdose with the medication.

Patient Controlled Epidural Analgesia

An epidural is a method of giving opioid (pain relieving medicine) and/ or local anesthetic (numbing medicine like at the dentist) through a very small tube placed in your back near your spinal nerves. This tube is in place with tape over the middle of your back. An epidural is usually put in while awake. The epidural may also be used to give anaesthesia during surgery. This is the most common method of relieving pain after surgery. An epidural may also be patient controlled. This means that patient has a button to push to give himself/ herself additional medicine into the epidural space. The medicine will take about 20 minutes to work.

Advantages of an Epidural

By this method, continuous delivery of medication for three-to-five days after surgery or until patient can take pain medicine by mouth, is ensured. Patients often report their pain level is less while using this method. There are decreased side effects with this type of medicine.

The side effects of epidural and analgesia:

• Constipation.
• Itching.
• Sleepiness.
• Numbness in your legs.
• Difficulty in moving your legs.
• Difficulty in urinating.
• Nausea.
• Numbness around your mouth.
• A funny taste in your mouth.

Labour Analgesia

Pain during labour is caused primarily by uterine muscle contractions and somewhat by pressure on the cervix. This pain manifests itself as cramping in the abdomen, groin and back. Labour ranges widely from woman to woman and even from pregnancy to pregnancy. For some, it resembles menstrual cramps while for others, severe pressure and for others, extremely strong waves that feel like diarrhea cramps. In addition, first-time mothers are more likely to give their pain a higher rating than women who have had babies before. The intensity of labour pain is not always the determining factor that drives women to seek pain management. It is often, the repetitive nature and length of time at which pain persists with each contraction.

Pain Relief Strategies during Labour

Several medications offer pain relief to women in labour. All medications cross the placenta and have some effect on the baby.

• Pain medications: Reduce pain and help take the edge off the contraction. Analgesics are given by injection often before the cervix has dilated.
• Nitrous oxide: Inhaled using a mask that the mother can hold herself.
• Trans Cutaneous Nerve Stimulation: Produces pain relief by counter irritation and is effective at early stage of labour and for mild pain only.
• Epidural analgesia: This is what most women think of when they consider pain medication during labour. Epidural, a form of local anesthesia, provides continuous pain relief to the body below the umbilicus during the entire process of labour. An epidural involves medication given by an anesthesiologist though a thin, tube-like catheter that is inserted in the woman's lower back. The amount of medication can be regulated according to a woman's needs. Some medication does reach the baby but it is much less than what the baby would get intravenously or under general anesthesia. Epidurals are usually given once a woman is in active labour. Epidurals do have some drawbacks. They may make it more difficult for the woman to push the baby out, and they can cause her blood pressure to drop. They can also cause itching, nausea, and headache. The risks to the baby are minimal, but include possible distress caused by the mother's lowered blood pressure. If woman has a caesarean delivery, then she will have epidural anesthesia which will block all feelings.

Walking Epidural

A low dose infusion epidural is a fairly new technique, which gives excellent pain relief but also allows retaining some sensation in your legs. However, important thing to remember is that the primary aim of this kind of epidural is to relieve pain and keeping the mobile is only a secondary concern, and some women find that they are not really mobile at all. A walking epidural is set up in the same way as an ordinary epidural, with a tube passed through a hollow needle into the lower part of back. The other end of the tube is attached to a pump, which sends a combination of anaesthetic and pain-killing drugs (bupivacaine and fentanyl) into the back throughout labour. It works in the same way as an epidural. The combination of drugs maximises pain relief while limiting the loss of sensation in your legs. The woman can have a walking epidural during the first stage of labour when patient feels that she cannot cope with contractions any longer, or early on in labour if the mother has decided to not have any pain at all.

Advantages of a Walking Epidural

Excellent pain relief for most women, depending on how patient (as an individual) responds to the 'cocktail' of drugs that the anesthesiologist uses. Moreover, it helps in keeping the mother mobile. She can push more effectively in the second stage of labour and is less likely to need forceps or ventouse than if she has a traditional epidural.

Disadvantages

• May find that the amount of movement she retains is very limited.
• Some women can manage to move from the bed to a chair and a few can walk with help.
• Will probably increase the length of labour

Combined Spinal Epidural

In the first stage of labour, the mother is given a spinal injection of a drug bupivacaine and fentanyl. Simultaneously, an epidural is set up. After half an hour, bupivacaine is given through the epidural tube to ensure continuous pain relief. The spinal injection gives rapid relief from pain. The disadvantages of CSE are the same as those of epidurals as listed above.

Patient Controlled Oral Analgesia

It is similar to the intravenous PCA except that patient receives oral medications which she can take herself. A nurse will leave her with one dose of medication. When she has pain, she will take the pill and notify the nurse so that he/ she can leave her with the next dose of medication. The nurse gives a container with one dose of medication in it. It is easier to prevent pain or to treat it before it starts. We make the patient mark a pain level on a flow sheet before she takes the medication and one hour after taking medication.

hospital@hqsimil.sahara.co.in