OBSTETRIC ANALGESIA AND ANAESTHESIA

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DR SHABNAM NAZ ASSISTANT PROFESSOR OBGYN CMC,SMBBMU LARKANA OBSTETRIC ANALGESIA & ANAESTHESIA

OBJECTIVES:

OBJECTIVES Techniques of pain releif in labor Ideal analgesia Regional analgesia Systemic analgesia Local analgesia Analgesia for abnormal obstetrics

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Queen Victoria was given chloroform by John Snow for the birth of her eight child and this did much to popularize the use of pain relief in labour HISTORY

HISTORY:

HISTORY The first anesthetic used in obstetrics was chloroform and ether in 1848 1902- Morphine and Scopolamine were used to induce a twilight sleep. 1924 Barbituates were added for sedation 1940 Dr. Lamaze and Read advocated “natural child birth”

DEFINATIONS:

DEFINATIONS OBSTETRIC ANALGESIA Pain releif during labor ANALGESIA The loss or modulation of pain perception . (local, systemic) ANAESTHESIA: the total loss of sensory perception (light tough, pain, temperature, and her capacity for vasomotor control) , and may include loss of consciousness .

DEFINITION OF LABOR:

DEFINITION OF LABOR LABOR can be defined as spontaneous painful uterine contractions associated with the effacement and dilatation of the cervix and the descent of the presenting part’

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Stages of Labor

Pain of Childbirth:

Pain of Childbirth Visceral pain First stage T 10 - L 1 Somatic pain: Second stage S 2 -S 4

Medical Effects of Labour Pain :

Medical Effects of Labour Pain

Reasons for treating labor pain:

Reasons for treating labor pain Exhaustion and pain of labor can result in failure of progression of labor. Failure of progression can cause maternal exhaustion and / or foetal distress. The personal experience of extreme pain during labor or delivery is related to the occurrence of postnatal depression (Ferber et al 2005, Hiltunen et al 2004).

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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. “ Moir DD. Extradural analgesia for caesarean section. Br J Anaesth 1979; 51: 1093 .

THE IDEAL ANALGESIC FOR LABOUR:

THE IDEAL ANALGESIC FOR LABOUR

FACTORS ASSOCIATED WITH PAIN IN LABOR:

FACTORS ASSOCIATED WITH PAIN IN LABOR Anxiety (reduce fear and reduce pain) History of severe menstral pain Age ( negative correlation) Socio-economic status (negative correlation) Education

FACTORS THAT EFFECT THE TRANSFER OF A DRUG TO THE FETUS:

FACTORS THAT EFFECT THE TRANSFER OF A DRUG TO THE FETUS Amount of drug Site of administration Drug distribution in maternal tissue Maternal metabolism Renal or liver excretion of the drugs and there metabolites Lipid solubility and protein binding Molecular size Configuration of drug

FACTORS THAT EFFECT THE TRANSFER OF A DRUG TO THE FETUS:

FACTORS THAT EFFECT THE TRANSFER OF A DRUG TO THE FETUS Uteroplacental blood flow ( if diminished then less drug is delivered i.e.. PIH, DM as well as hypovolemia

PAIN MANAGEMENT OPTIONS :

PAIN MANAGEMENT OPTIONS Non-pharmacological Systemic analgesia Inhalation of nitrous oxide Epidural analgesia Combined Spinal Epidural Analgesia (CSE) Other regional technique General anesthesia Non-regional techniques are the most frequently employed methods for labor analgesia.

PAIN MANAGEMENT OPTIONS:

PAIN MANAGEMENT OPTIONS Non-pharmacological: Emotional Support Touch & Massage Heat & Cold Hydrotherapy/aroma therapy Vertical Position TENS Acupuncture Hypnosis

TENS:

TENS Electrical impulses are applied to skin via electrodes For ist stage electrodes are placed over t 10 --- l 1 on either side of spinous process For second stage analgesia electrodes are placed over s2-s4 Tense can diminishes the need of analgesia

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1, NARCOTICS/ OPOIDS Meperidine ( pethidine ) MORPHINE NALBUPHINE FENTANYL REMIFENTANYL PETHIDINE is the most frequently used opioid for labor analgesia. 50% to 70% of women are satisfied with intramuscular Pethidine . SYSTEMIC ANALGESIA

CONTINUE:

CONTINUE IM injections result in a significant delay in analgesic effect IM injections can have unpredictable blood concentrations IM absorbtion is highly variable from patient to patient

CONTINUE:

CONTINUE IV administration has advantages over IM injections. There is less variability in plasma levels, quicker onset of action and less medication is given per injection and it is easier to titrate dose. Observe patients for 15-20 min after IV narcotic injection

NARCOTICS AND LABOR:

NARCOTICS AND LABOR Narcotics may decrease the progress of labor by reducing the force or rate of contractions ( this is dose dependant as well as dependant on the timing of the doses Biggest effect is in the latent phase In the active phase of labor narcotics my speed up the progress of labor by decreasing anxiety and decreasing catecholamines.

CONTINUE:

CONTINUE Narcotics cause a decrease in long and short term variability (unsure if this is CNS or cardiac) Occasionally a sinusoidal pattern is observed after narcotic administration (severe anemia and hypoxia can cause this) There is no way to distinguish the two

NARCOTICS AND MOTHER:

NARCOTICS AND MOTHER

NARCOTICS AND THE FETUS:

NARCOTICS AND THE FETUS Fetal metabolism is slower to metabolize narcotics because of the immature liver, also the blood brain barrier is very permeable so the fetuses are more susceptible to depression from narcotics.

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IV dose can accumulate over time and cause respiratory depression Continuous IV infusion or PCA---- better pain control less placental transfer

NEONATAL EFFECTS OF NARCOTIC ANALGESICS:

NEONATAL EFFECTS OF NARCOTIC ANALGESICS Some studies have shown behavior changes up to 4 days post delivery Suck less effectively Depressed visual and auditory attention Decrease reflexes Take longer to habituate to noise Decrease social responsiveness

MANAGEMENT OF DEPRESSED NEONATE:

MANAGEMENT OF DEPRESSED NEONATE Narcotic Antagonist; Naloxan Hydrochloride (Narcan) “ New born respiratory depression is most likely to occur 2-3 hrs after Meperidine administration “ • Naloxan displacing the Narcotics from specific receptors in the central nervous system • Dose : 0.1 mg / Kg in the umbilical vein • Acts within 2 min with an effective duration of at least 30 min • It has to be repeated in 3 – 5 min

REMIFENTANIL IV /PCA:

REMIFENTANIL IV /PCA Remifentanil is a novel , ultra short acting synthetic opioid. It is a selective mu opioid agonist. Rapid onset; peak effect of blood/brain equilibration time (1.2 – 1.4 min) . It has ester linkage rendering it susceptible to rapid metabolism by non specific blood and tissue esterases. A short duration of action independent of duration of infusion ( context sensitive half time 3.7 minutes).

NITROUS OXIDE INHALATION:

NITROUS OXIDE INHALATION Inhalation of nitrous oxide relieves labor pain to a significant degree .

LOCAL ANAESTHESIA:

LOCAL ANAESTHESIA Cocaine was the 1 st local anesthetic later procaine was synthesized All local anesthetics cross the placenta quickly All local anesthetics are vasodilators except cocaine and mepivacaine (carbocaine) ESTERS : procain ,chlorprocain +allergic reactions,no fetal depression AMIDES : lidocain( xylocain) ,bupivicain ,no allergic reactions

continue:

continue Some have added with epinephrine to prolong the duration of effect Some local anesthetics will be found in the maternal and fetal blood stream from epidural and Para cervical anesthesia

REGIONAL ANAESTHESIA:

REGIONAL ANAESTHESIA EPIDURAL ANAESTHESIA SPINAL ANAESTHESIA COMBINED EPIDURAL SPINAL ANAESTHESIA PARACERVICAL BLOCK PUDENDAL BLOCK PERINEAL INFILTRATION

Spinal ( subarachnoid ) block:

Spinal ( subarachnoid ) block “ Subarachnoid space is smaller in pregnancy , most likely due to the engorgement of the internal vertebral venous plexus “ • All anesthetic agent can be used • Low spinal block , “ 10 th thoracic dermatome “ for vaginal delivery and instrumental delivery “ up to the 8 th thoracic dermatome “ for cesarean delivery

puncture sites:L2~3, L3~4:

puncture sites:L2~3, L3~4

Complication:

Complication 1) Hypotension: • Is the consequence of vasodilatation from sympathetic blockade • Obstructed venous return from uterine compression of the vena cava Treatment: Uterine displacement Hydration with 500-1000 ml of a balanced salt solution Ephedrine 5-10 mg Iv if hypotension persist 2 ) Total spinal blockade : “ as a result of excessive dose of analgesic agent “ Patient will develop, hypotension, apnea, cardiac arrest

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3) Spinal ( post puncture ) Headache: “ due to leakage of cerebrospinal fluid from the site of puncture of the meninges “ Prophylactic measures: Use a small – gauge spinal needle Avoiding multiple punctures Treatment: Hydration , abdominal support with a binder , blood patch 4) Convulsions: Rare instance , presumably caused by cerebrospinal fluid hypotension

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5) Bladder dysfunction: 6) Oxytocics and hypertension: 7) Arachnoiditis and meningitis: “ rare complication , the local anesthetic agents are no longer preserved in alcohol , formalin or toxic solute , and disposable equipment are used most of the time"

Contra indication to spinal analgesia:

Contra indication to spinal analgesia ● Obstetrical complications that are associated with maternal hypovolemia and hypotension ● Disorders of coagulation and defective homeostasis ● Infection at the site of puncture ● Neurological disorders ● Significant aortic stenosis & pulmonary hypertension

EPIDURAL ANALGESIA:

EPIDURAL ANALGESIA “ The epidural space is a potential space that contains areolar tissue , fat , lymphatic and the internal venous plexus , which becomes engorged during pregnancy “ Portal of entry: - lumbar intervertebral space for lumbar epidural analgesia - Sacral hiatus & sacral canal for caudal epidural analgesia The block should be from : - the level 10 th thoracic to the 5 th sacral for the pain of LABOR - the level of 8 th thoracic to the 1 st sacral for cesarean

LUMBAR EPIDURAL BLOCK:

LUMBAR EPIDURAL BLOCK Procedure : Inject 3ml of a 1.5% lidocaine as a test dose . If spinal anesthesia dose not result after 5~10min, inject an additional 5 ml

PUNCTURE WITH THE EPIDURAL NEEDLE AND PLACE THE CATHETER:

PUNCTURE WITH THE EPIDURAL NEEDLE AND PLACE THE CATHETER

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EPIDURAL ANALGESIA :

EPIDURAL ANALGESIA INDICATIONS Pain ! Obstetric Vaginal breech Vaginal twins Preeclampsia Medical Conditions Valvular heart disease

ABSOLUTE CONTRAINDICATIONS OF EPIDURAL :

Contraindicated In pregnancy ABSOLUTE CONTRAINDICATIONS OF EPIDURAL Patient refusal. Blood Coagulopathy Infection at the site of injection Sever hypovolemia Fixed cardiac out put - Sever aortic stenosis - Sever mitral stenosis - Hypertrophic obstructive cardiomyopathy

RELATIVE CONTRAINDICATIONS OF EPIDURAL:

Avoid in pregnancy RELATIVE CONTRAINDICATIONS OF EPIDURAL Systemic sepsis. Uncooperative patient. 3) Preexisting neurological deficits, e.g. demyelinating disease, peripheral neuropathy 4) Sever spinal deformity.

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Advantages of Epidural Analgesia Provides superior pain relief 90% to 95% are satisfied with epidural analgesia. Facilitates patient cooperation during labor and delivery Decreases maternal hyperventilation Avoids opioid-induced maternal and neonatal respiratory depression

Continue :

Continue Extend the duration of block to match the duration of labor Provides anesthesia for episiotomy or forceps delivery Allows extension of anesthesia for cesarean delivery

CONTINUOUS EPIDURAL INFUSION:

CONTINUOUS EPIDURAL INFUSION 0.0625% bupivacaine fentanyl 2.5 μ g/ ml at 12 ml/hr (early labor)+demand dose: 4 ml q 15 min 0.125% bupivacaine+fentanyl 2 μ g/ml at 8 ml/hr (advanced labor)+ demand dose : 3 ml q 15 min

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Evidence is presented that intermittent boluses of local anesthetic in labor are more effective than continuous infusions. P. D. W. Fettes et al.(Br J Anaesth, 97:359–364, 2006) Intermittent vs Continuous Administration of Epidural Ropivacaine With Fentanyl for Analgesia During Labour.

EPIDURAL COMPLICATIONS:

EPIDURAL COMPLICATIONS Early IV toxicity LA toxicity Hypotension High block/total spinal Extensive motor block Fetal effects Urinary retention Labour progress Mode of delivery Late PDPH Neurological injury Epidural abscess Epidural hematoma Back pain

EFFECT OF EPIDURAL ON LABOR:

EFFECT OF EPIDURAL ON LABOR Prolongs first stage of labor Increases the need for labor stimulation with oxytocin Increases the chance of instrumental delivery Increase the rate of severe perineal trauma

TREATMENT OF EPIDURAL INDUCED HYPOTENSION :

TREATMENT OF EPIDURAL INDUCED HYPOTENSION 1. Left lateral position 2. The mother receive oxygen by mask 3. Ringer’s lactate is given 4. Ephedrine 5~10mg iv to sustain a mild vasopressor effect ↑BP: Effective

DIFFERENCES BETWEEN SPINAL AND EPIDURAL ANESTHESIA :

DIFFERENCES BETWEEN SPINAL AND EPIDURAL ANESTHESIA Spinal anaesthesia Extradural Anaesthesia Level: below L1/L2, where the spinal cord ends Level: at any level of the vertebral column. Injection: subarachnoid space i.e punture of the dura mater Injection: epidural space (between Ligamentum flavum and dura mater) i.e without punture of the dura mater Identification of the subarachnoid space: When CSF appears Identification of the Peridural space: Using the Loss of Resistance technique. Dosis: 2.5- 3.5 ml bupivacaine 0.5% heavy Doses: 15- 20 ml bupivacaine 0.5% Onset of action: rapid (2-5 min) Onset of action: slow (15-20 min) Density of block: more dense Density of block: less dense Hypotension: rapid Hypotension: slow Headache: is a probably complication Headache: is not a probable. 54

COMBINED SPINAL EPIDURAL (CSE) ANALGESIA :

COMBINED SPINAL EPIDURAL (CSE) ANALGESIA In 1993, anaesthetists in Queen Charlotte’s Hospital in London described the CSE technique. Touhy Needle is advanced in the lumber region. Then 25 –27 gauge, 120 mm-long pencil point spinal needle. 1 ml of 0.25% Bupivacaine + 25 Micgr Fentanyl injected intrathecally. Epidural bolus 15 mls 0.1% Bupivacaine + 2 Micgr/ml Fentanyl without test dose.

Puncture the spinal needle, fluid from the subarachnoid space:

Place the catheter Inject 1.5%lidocaine Puncture the spinal needle, fluid from the subarachnoid space Inject 0.5%bupivacaine

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CSE locking devices Portex CSEcure

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Women in severe pain Late first-stage labor Malpresentations Second-stage fetal distress Unsatisfactory epidurals (previous labor) Obese women INDICATIONS FOR CSE

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CSE ADVANTAGES Rapid Onset of Analgesia Analgesia is often nearly complete before the epidural cath. is taped up and the tray discarded Hepner Can J Anaesth 2000 Nickells Anaesth 2000

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CSE ADVANTAGES Better Blocks Quality of analgesia is improved by CSE Norris retrospectively compared epidural and CSE techniques in 1661 women who received either technique and found a lower incidence of failed blocks and a greater incidence of bilateral symmetrical analgesia with CSE. Norris MC .Anesth Analg 1995;79:529-37

CSE ADVANTAGES Better Patient Satisfaction:

CSE ADVANTAGES Better Patient Satisfaction An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia Anesthesiology 2007; 106:843–63 Several studies have found better patient satisfaction scores with CSE vs. conventional epidural. Others have found no difference, but none have found better satisfaction with conventional epidural analgesia

CSE ADVANTAGES Better in Difficult Backs:

CSE ADVANTAGES Better in Difficult Backs An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia Anesthesiology 2007; 106:843–63 CSE has been associated with improved chances of adequate analgesia in parturients with scoliosis or other causes of a difficult back.

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CSE ADVANTAGES Less Motor Block CSE associated with less total LA use for a given degree of analgesia Adding opioids < MB “Walking” epidurals: No evidence of improved labor pattern/outcome with ambulation !!!. Women don’t walk even if they can. Monitoring problems.

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Combined Spinal Epidural Anesthesia Vaginal Deliveries Ambulation

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CSE AND PROGRESS OF LABOR Tsen et al. reported faster initial cervical dilation and shorter time from induction of analgesia to full cervical dilation among women receiving CSE analgesia vs epidural analgesia. Tsen L.C,Thue BDatta S: Anesthesiology 2001;91;920-5

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CSE AND PROGRESS OF LABOR Tow large randomized trials have confirmed an increase in the spontaneous vaginal delivery rate with CSE vs. conventional epidural analgesia.

THE RISK OF CESAREAN DELIVERY WITH NEURAXIAL ANALGESIA GIVEN EARLY VERSUS LATE IN LABOR :

THE RISK OF CESAREAN DELIVERY WITH NEURAXIAL ANALGESIA GIVEN EARLY VERSUS LATE IN LABOR Wong et al, NEJM Feb 2005 Vol 352. No 7 P655-665 No difference in C/S rate

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CSE: FAILURES 10% failure rate / Collis, IJOA ’94 new technique senior & junior anaesthetists Albright & Forster, ’99 6000 CSEs in a community hospital senior anesthesiologists < 0.4% failure rate

CSE COMPLICATIONS:

CSE COMPLICATIONS Fetal bradycardia /FHR changes Pruritus Infection Neurotrauma Other side effects

INFECTION :

INFECTION There are least 8 case reports of spinal meningitis related to a CSE. Too many instrumentations- There is also a case report of epidural abscess after a CSE for labor.

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NEUROTRAUMA Cord trauma has been reported with the CSE technique in at least 5 cases. In a report of 7 cases with damage to the conus medullaris following spinal anesthesia by Reynolds of Saint Thomas Hospital in London, 4 were patients who had received a CSE and 3 after a single shot spinal. In all cases, an atraumatic needle was used, 25 or 27 gauge Whitacre and the anesthesiologist believed to be at L2-3.

Complications of Labor Analgesia: Epidural versus Combined Spinal Epidural Techniques Norris MC, et al. Anesth Analg 79:529-37, 1994:

Complications of Labor Analgesia: Epidural versus Combined Spinal Epidural Techniques Norris MC, et al. Anesth Analg 79:529-37, 1994 LEA (n=388) CSE (n=536) Nausea 1.0 % 2.4 % Vomiting 1.0 % 3.2 % Hypotension < 10.0 % < 10.0 % Dural Puncture 4.2 % 1.7 % Blood Patch 4 2

PARA CERVICAL BLOCK:

PARA CERVICAL BLOCK Good for the pain of cervical dilation but no help for the perineum Given at 4:00 and 8:00 as the cervix reflects onto the vaginal fornices 3-5cc in each site ( always aspirate 1 st ) Complications are lacerations, intravascular injection, Parametrial hematoma, abscess, and hypotension

FETAL COMPLICATIONS OF PARA CERVICAL BLOCK:

FETAL COMPLICATIONS OF PARA CERVICAL BLOCK Up to 70% get bradycardic (last 2-10min) Use chlorprocaine 2% Rarely used

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PARACERVICAL BLOCK

PUDENDAL BLOCK:

PUDENDAL BLOCK Can be done transvaginally or transperineal Use a needle guide (Iowa trumpet) Left hand to Left side and Right hand to Right side Medial and inferior to the sacrospinous ligament and ischial spine (aspirate 1 st ) 7-10cc each side of lidocaine1% or chlorprocaine 2%

PUDENDAL BLOCK:

PUDENDAL BLOCK

COMPLICATIONS OF PUDENDAL BLOCKS:

COMPLICATIONS OF PUDENDAL BLOCKS Systemic toxicity(IV) Vaginal laceration Vaginal or ischiorectal hematoma Retro psoas or sub gluteal abscess

PERINEAL INFILTRATION:

PERINEAL INFILTRATION Most common anesthetic Best choices are lidocaine or chlorprocaine

GENERAL ANESTHESIA A ) Inhalation Anesthesia:

GENERAL ANESTHESIA A ) Inhalation Anesthesia Gas Anesthetics : Nitrous Oxide (N 2 O) Self – administered nitrous oxide in a 50 % mixture with 50 % oxygen (Nitronox), provide excellent pain relief during labor & second stage of labor , It is also used as part of balanced general anesthesia Volatile Anesthetics : Isoflurane & Halothane Are potent non-explosive Halogenated hydrocarbon agents that produce remarkable uterine relaxation when given in high inhaled concentration They are used to supplement N 2 O during maintenance of Gen.Anes.

Anesthesia apparatus:

Anesthesia apparatus Sevoflurane: isoflurane:

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Indications for use in high concentration : • Internal podalic version of the second twin • Breech decomposition • Replacement of the acutely inverted uterus

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Side effect : • Fetal narcosis Cardio-depressant Hypotension Hepatitis & massive hepatic necrosis Increased blood loss

GENERAL ANESTHESIA B) Intravenous anesthesia:

GENERAL ANESTHESIA B) Intravenous anesthesia Thiopental (Thiobarbituate) It is given along with muscle relaxant and N 2 O to produce general anesthesia Advantage : It is easily and rabidly induce anesthesia with prompt recovery and minimal risk of vomiting Ketamine In a small dose of 0.2 - 0.3 mg / kg is used to produce analgesia and sedation just prior to delivery In a dose of 1 mg / kg it induce general anesthesia It causes rise in blood pressure , for that it may be useful in patient with acute hemorrhage

HAZARD OF GENERAL ANESTHESIA:

HAZARD OF GENERAL ANESTHESIA ● Fetal central nervous system depression ● Aspiration of gastric content and particulate matter ● Failed tracheal intubation

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Aspiration during general anesthesia ( pneumonitis from inhalation of gastric contents ) “ Mendelson Syndrome” Prophylaxis: Fasting for at least 8 hours Use of agents to reduce gastric acidity Skillful tracheal intubation “ Cricoids pressure “ Passage of nasogastric tube to empty the stomach content Awake intubation Use of regional analgesia when appropriate

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Failed intubation: Is uncommon , It is the major cause of anesthesia related maternal mortality Prevention: History , careful assessment and examination and appropriate pre-operative preparation for immediate management by : - Short handled laryngoscope - Fiber-optic laryngoscope - A wake intubation

TOXICITY :

TOXICITY Symptoms of Central nervous system Toxicity Light – Headedness , Dizziness , Slurred speech , Tinnitus , Bizarre behavior , Metallic taste . Numbness of the tongue & mouth, Muscle fasciculation & excitation , Generalized convulsion & loss of cosciousness . Management: establish air way, Oxygen ,Succinylcholine Thiopental ,or Diazepam , MgSO 4 Cardiovascular Toxicity : Hypertension & tachycardia soon followed by Hypotension & cardiac arrhythmias Management: Turn patient to her side Crystalloid infusion I.V ephedrine

ANALGESIA AND ANESTHESIA FOR ABNORMAL OBSTETRICS :

ANALGESIA AND ANESTHESIA FOR ABNORMAL OBSTETRICS

THE TRAPPED HEAD IN BREECH DELIVERY:

THE TRAPPED HEAD IN BREECH DELIVERY If an epidural block is in place, no further analgesia will be required (forceps?) General anesthesia is acceptable

FETAL DISTRESS:

FETAL DISTRESS Fetus development of bradycardia and appearance of meconium Uterine perfusion is correlated with BP. Hypotension will aggravate fetal distress The probable choice are no analgesia, minimal systemic analgesia (small dose), or segmental epidural block Neonatal resuscitation is needed

PREECLMPSIA-ECLAMPSIA:

PREECLMPSIA-ECLAMPSIA Composed of hypertension, generalized edema, and proteinuria. The primary pathologic characteristics is generalized arterial spasm Regional and general anesthesia are used Contraindications to regional anesthesia include coagulopathy, urgercy for fetal distress

HEMORRHAGE AND SHOCK:

HEMORRHAGE AND SHOCK Placenta previa and aruptio placenta are accompanied by serious maternal hemorrhage. Treatment of shock must be formulated. Ketamine can support BP for induction Regional block is contraindicated in the presence of hypovolemia

SUMMARY:

SUMMARY Pain and suffering in child birth is no longer acceptable in modern delivery suites. Epidural analgesia or CSE are the best methods of analgesia available at present . We have to find an alternative method for patients in whom epidural analgesia is unsuitable. There is a place for PCA Remifentanil in controlling labour pain. But more research is needed.

Moen Jo Daro Larkana Sindh:

Moen Jo Daro Larkana Sindh THANKS 100