what physiologic change can the nurse expect to see in the patient during labor pain?

Open access peer-reviewed affiliate

Physical and Psychological Aspects of Pain in Obstetrics

Submitted: April 5th, 2012 Reviewed: October 1st, 2012 Published: October 24th, 2012

DOI: 10.5772/53923

Longinus North. Ebirim
- Department of Anaesthesiology, University of Port Harcourt Instruction Hospital, Rivers State, Nigeria
Omiepirisa Yvonne Buowari
- Department of Anaesthesiology, University of Port Harcourt Teaching Infirmary, Rivers State, Nigeria
Subhamay Ghosh
- Pain Medicine, Kettering General Infirmary, Kettering, Northants, United Kindgom

*Address all correspondence to:

1. Introduction

Childbirth is said to be a highly blithesome feel [1] and a universally celebrated issue. Childbirth yet fulfilling is a painful experience for the majority of women [ii,3] and analgesia is regularly required for relieving hurting [four]. In non-human primates, labour is thought to be relatively painless, and of brusque duration, unremarkably unassisted, although changes in behaviour in the days prior to delivery may suggest some degree of labour pains [v]. Exceptionally, very few women may not feel any hurting, others can control their responses to reduce pain [3]. Most women recall that hurting is going to be a major part of giving nascence. Each labour has the personal seal of each woman [6]. For religious, cultural and philosophical reasons many groups have sought to prevent and care for hurting. Pain may have adverse effects on the other and foetus. The psychological effects of astringent pain should non be over looked particularly where it is associated with an adverse fatal maternal outcome [7]. Childbirth is an emotional experience for a woman and her family unit. The mother needs to bond with the new baby as early as possible and initiate early chest-feeding, which helps to contract the uterus and accelerate the procedure of uterine involution in the postpartum period [8]. This is affected past hurting after delivery whether the delivery is spontaneous vaginal delivery or operative.

Labour as a life event is characterised by tremendous physiological and psychological changes that require major behavioural adjustments in a curt menstruum of fourth dimension [9, 10]. Hurting is an individual and multi-factorial feel influenced by civilisation, previous pain events, beliefs, moods, and ability to cope. The patients' personality affects pain perception and response to pain relieving drugs. Maternal satisfaction has to be taken into consideration when evaluating quality and planning a maternal and child health care service [eleven]. Labour presents a physical and psychological challenge for women. The latter stages of pregnancy tin exist a difficult time emotionally. Fear and apprehension are experienced aslope excitement. There emotions both positive and negative will affect the woman'due south birth experience.

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2. Pain in obstetrics

Maternal comfort is of major importance during and after labour [12]. Pain in obstetrics arises from numerous sources and reasons from labour hurting, caesarean section, episiotomy and postpartum. Attending to comfort and analgesia for women during and after labour is important for physical reasons and out of compassion. Hurting management in obstetric exercise therefore focuses on pain relief in labour, pain control during caesarean section and postpartum hurting treatment [13]. Pain related to childbirth may present during pregnancy, during labour when more than than 95% of women written report pain occasionally during caesarean section if there is a poor quality nerve block or prolonged surgery and subsequently delivery when more than than 70% of mothers report astute or chronic hurting [14].

ii.1. Labour pain

Labour although varies with the individual may be the nearly painful experience, whatsoever women may ever encounter. Concerns about pain in labour are as former as flesh [15]. Hurting can make patients experience uncomfortable and become sleepless and agitated. Pain also stimulates the sympathetic nervous system, which causes increase in the heart charge per unit, blood force per unit area, sweat production, endocrine hyperfunction, and delays the patients prognosis [16, 17]. Pain management makes low priority in many low to heart income countries that are struggling to meet Un Millennium Development Goals such as eradication of poverty and hunger, universal master education and reduction in child and maternal morbidity and mortality [eighteen].

Parturient perception and response to labour pain depends on the intensity of pain, psychological factors, cultural beliefs, previously painful experiences, history of pregnancy, social and marital status [19]. Another factors influencing labour pain and commitment are the parturient psychological state, mental preparation, family support, medical support, cultural background, primipara versus multipara, size and presentation of the foetus, size and anatomy of the pelvis, use of medications to broaden labour (oxytocin) and duration [xv]. A long, painful labour may lead to an exhausted, frightened, and hysterical mother incapable of determination-making [20]. The degree of pain experienced during labour is related to the frequency, intensity, and duration of uterine contractions and dilatation of the cervix. In add-on, the position of the foetus, decent of the presenting part, stretching of the perineum and force per unit area on the bladder, bowel, and sensitive pelvic structures too contribute to hurting levels [21]. Labour hurting is a complex and subjective interaction between multiple physical, psychosocial, environs plus cultural factors and a adult female's interpretation of the labour stimuli [22]. Women experience varying degrees of pain in labour and exhibit an equally varying range of responses to it. An individual'southward reaction to pain of labour may be influenced by the circumstances to her labour, the environment, her cultural background preparations towards her labour and the support available to her [23]. During labour, the woman is dealing not merely with the contractions only besides with the myths that the culture has created for her. Labour and birth, although viewed as a normal physiological procedure, can produce significant pain requiring appropriate pain management [24].

Labour pain is acquired by stretching of the cervix during dilation, ischemia of the muscle wall of the uterus with the build-upwards of lactate and stretching of the vagina and perineum in the second stage of labour. Both the experience and perception of pain are regarded as subjective and this remains difficult for an observer to measure objectively [3,21].

At that place are 3 stages of labour namely get-go, 2d and third stage of labour. The starting time stage of labour begins with the onset of regular contracts and ends with complete cervical dilation [25, 26]. The second stage of labour commences from full cervical dilation to the delivery of the baby while the third stage is from the commitment of the infant until the delivery of the placenta. Pain during the offset stage of labour occurs mostly during contractions and is caused by uterine contractions and cervical dilatations [27, 28]. Pain is carried by the visceral afferent fibres of T10-11 from the uterus, cervix, and upper vagina from the cervical plexus and enters the spinal cord at the T10-xi levels. The visceral afferent fibres also enter the sympathetic chain at L2 and L3 levels [29,xxx]. Pain at the terminate of the kickoff stage signals the beginning of foetal descent. Pain in the 2nd stage of labour is due to stretching of the nativity canal, vulva, and perineum and is conveyed past the afferent fibres of the posterior roots of the S2 to S4 nerves. In the second stage of labour, expulsion of the foetus activates somatic afferent pain fibres from the mid and lower vagina, vulva, and perineum. These signals are conveyed via the S2 – S4 spinal nerve roots that class the pudendal nervus. The pudendal nerve projects bilateral through the inferior sciatic foramen, where it is accessible for blockade by local anaesthetist. Neuraxial representation of labour hurting is not continuous and the interceding segments represent and mediate the sensory and motor innervations of the lower extremities.

Painful contractions may lead to maternal hyperventilation and respiratory alkalosis, which in turn shift the oxygen haemoglobin dissociation curve to the left, decrease delivery of oxygen to the foetus [31]. The pain of labour is associated with reflex increment in blood force per unit area, oxygen consumption, and liberation of catecholamines, all of which could adversely touch on uterine claret menses. Increased carbon dioxide, peripheral vascular resistance, and increased oxygen consumption in plough back-trail this. This could be unsafe for women with pre-existing cardiopulmonary problems [15].

2.2. Cultural aspects, beliefs and myths of labour and labour pain

Cultural and religious beliefs tin bear upon the perception and interpretation of labour pain. In some cultures the woman is expected to scream and cry uncontrollable while in others the woman may not externally limited much distress in her labour. Cultural influences on labour pain tin can take many varied forms. Cultural beliefs and ethnicity are known to influence the perception of pain such factors can play a vital function in how a woman copes with pain in labour [18].

In some cultures, lonely, and unassisted births are valued and seen equally a source of pride [5]. Considering the mysterious qualities of formulation, it'south piece of cake to encounter why it'due south the discipline of then many myths [32]. Some women believe that labour pain is natural and would not accept hurting relief in labour. Some feel that it is best to limited their pain and let their feelings get. Others may come across labour every bit an opportunity to demonstrate their forcefulness and stoicism in a particular fashion. They may for case moan, scream, sway, click their fingers or tap rhythmically, milk shake their heads, chant, pray or phone call god. Every bit a daughter grows up into a woman, she becomes involved through the stories of other women with the female torso that suffers desperation and pain during labour.

Some Hispanic women may believe that they should non take whatsoever pain medications every bit the indication may not be good for the baby. Screaming during the labour and commitment is considered to be harmful to the infant as the civilization considers pregnancy to be a hot stage of life [33].

In rural parts of Republic of india and Bangladesh, a common belief is that women should bear the pain of childbirth in silence to demonstrate their courage and graphic symbol. The Japanese believe that the greatest experience of a woman's life is to hear her baby's cry and this should be the simply sound heard during labour [32]. Several African studies have found that many women would desire to have labour analgesia if given the opportunity. In boiling Republic of benin, Africa the Bariba women are also expected to requite nascence in silence and girls are taught that a woman who fusses or cries during childbirth is lower than an ant. In Nigeria, amid the Hausa, in that location is neat social pressure not to bear witness any sign of pain. Labouring quietly and patiently is thought to demonstrate proper modesty. The Fulani girls from Nigeria are taught from an early on age how shameful it is to show fear of childbirth [32]. The Bonny people of southern Nigeria belief that a adult female shouting and crying during labour will cry in subsequent deliveries therefore she is advised by her female parent and elder female relatives when pregnant not to shout or weep during labour. They are taught it shows how strong and capable she is every bit a woman to endure pain that no corporeality of shouting or screaming can reduce the pain so why not merely behave it in silence. This psychological preparedness is handed downwards from generations to generation. Many of these beliefs are 'myths' because they are untrue, notwithstanding there are many behavior and practices that have been used in not-western cultures for years that are constructive [32].

iii. Physical and psychological aspects of labour

Psychological factors help to explain the efficacy of psychotherapy. People who take painful conditions or injuries are often additionally affected past emotional distress, depression and anxiety [34]. Fear and anxiety are significant influences on pain experiences which is one reason why mothers are accompanied by another person during childbirth. Psychosocial factors take been implicated in the pain experienced during childbirth, which tin take both short and long-term consequences on the mother'due south health and her relationship with her infant [33]. For several decades, childbirth educators have focused on the alleviation or reduction of pain and suffering. During the childbirth experience a wide array of non-pharmacological pain relief measures as well every bit pharmacological interventions are presently available to woman in labour. Relaxation, breathing techniques, positioning, massage, hydrotherapy, music, are some self-help comfort measures women may initiate during labour to achieve an effective coping level for their labour experience. A woman's reactions to labour pain may be influenced by the circumstances of her labour including the environment and the support she receives [35]. During childbirth in addition to or in place of analgesia women manage hurting using a range of coping strategies. Antenatal teaching provides an opportunity prior to birth to help women to fix for an often painful event [36]. Loneliness, ignorance, unkind or insensitive treatment during labour, along with unresolved past psychological or physical distress increases the take a chance that the woman volition suffer. The concrete sensation of pain is magnified and frequently becomes suffering when it coexists with the negative psychological influences [37]. Maternal satisfaction is influenced by upshot of labour, support and interactions with staff, command over pain rather than amelioration. Good advice and team endeavour are needed to reap the benefits of pain free labour while minimizing the potential effect of epidural analgesia on labour outcome. Many women in labour each day in sub-Saharan Africa particularly in Nigeria, childbirth is experienced not as a joyful event but as sad experience due to midwives attitude towards the labouring adult female who shout and yell at labouring women especially if she screams cries or complains of labour pain.

four. Hurting relief in labour

Modern views on pain and influence of western concepts of pain are gradually changing the perception and desires for pain relief in labour [5]. Adequate analgesia is important as pain causes an increase in circulating catecholamines which in turn impair uteroplacental perfusion [38]. Analgesia may mask the signs of early preterm labour and therefore tocometry is useful to detect contractions [39]. The choice of analgesic technique depends on the medical status of the patient, progress of labour and resources at the facility [40,41]. In that location are a number of different forms of hurting relief in labour with differing side furnishings and efficacious labour pain relief is an important aspect of women'southward health [42]. Hurting relief during labour is desirable in society to reduce maternal distress and enhance the progress of labour as nigh women wish they had some caste of pain relief during labour [43].

In depression income countries, pain relief in labour remains essentially rudimentary. Reasons for this are largely theoretical and include racial differences in pain threshold with some women non minding the pains of labour, religious background which makes some women call back that labour pains is a divine will [44, 45]. Good antenatal care in may not exist available in some countries, it is important that the few who seek for modernistic intendance of the parturient be immune to derive maximum benefit, then as to encourage others to attend infirmary for commitment [46].

5. Non-pharmacological methods of labour hurting relief

The non-pharmacological methods avoid the employ of drugs for pain relief in labour [47]. Transcutaneous electrical nerve stimulation (TENS), hypnosis and acupuncture to relieve labour pains has been shown in many studies [15,xix]. The non-pharmacological approach to hurting includes a wide diverseness of techniques to address non but the physical sensations to pain but as well to prevent suffering by enhancing the psychological and spiritual components of care [ten]. The non-pharmacological methods of labour hurting relief require patient preparation and antenatal teaching. Psychological and non-pharmacological techniques are based on the premise that the pain of labour can be surpassed by recognising one's thought.

half dozen. Continuous support

Continuous back up in labour is associated with shorter labour labours and reduced requirement for analgesia. Traditional cultures take always had the support of experienced women to be with the woman in labour. In some places doulas are available. Continuous labour support provided by a doula, a lay woman trained in labour support, consistently has decreased the apply of obstetric interventions. Intermittent labour support does not convey the same benefits as continuous support low income women who otherwise would labour with minimal or no social support receive the greatest do good from a doula [48]. Continuous support from a partner or caregiver can reduce the frequent use of epidural analgesia and the corporeality of other analgesia administered to a mother [14].

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7. Tens

A low voltage electrical impulse is delivered to the pare via four pads which are placed over the lower back with a boost during uterine contractions. Its mechanism of activity is also based on the gate control theory of pain [28].

7.1. Massage

This is commonly used to help reflex tense musculus and soothe an calm the individual. Touching some other man tin can communicate positive messages such every bit caring, concern, reassurance or dearest. Massage is the intentional and systemic manipulation of the soft tissues of the body to enhance health and healing is used during labour to enhance relaxation and reduce pain [44].

Other methods similar water immersion and acupuncture are known to reduces labour pain intensity and analgesic utilise.

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8. Pharmacological methods of pain relief in labour

Hurting relief in labour is teamwork between the anaesthetist, midwife and obstetrician. In considering analgesia for the woman in labour, information technology should exist borne in mind that whatever the method of pain relief employed it should exist safe for both mother and baby [46].

The ideal analgesia for labour should provide rapid onset excellent pain relief in both the start and 2nd phase of labour without risk or side effects to mother or foetus and should too retain the mother's ability to mobilise and be independent during labour [49]. The ideal labour analgesic should also provide effective pain relief, tailored to the irresolute needs of the parturient throughout the unlike phases of labour with minimal motor blockade and adverse fabric, foetal effects so as to provide the parturient with a highly satisfactory birthing process. There is growing awareness of the importance of empowering the parturient in determination making procedure in labour and delivery [nineteen]. The platonic properties of labour analgesia should produce good analgesia without loss of consciousness, should non prolong or depress the process of labour, should not produce neonatal low, should not produce maternal cardiorespiratory depression, should non possess unpleasant maternal side furnishings, should have high technical success charge per unit, be predictable and constant in its furnishings, exist reversible if necessary, be piece of cake to administer, be nether the control of the female parent, should not interfere with uterine contractions, should not prolong the period of labour [l, 49].

Pharmacological methods of hurting relief in labour include parenteral opioids, inhalational and regional techniques [46,47]. Epidural and parenteral opioids are superior to non-pharmacological techniques for relieving pain in labour. Systemic analgesia has get less mutual, whereas the use of newer neuraxial techniques with minimal motor blockade have become more popular [24].

8.1. Parenteral analgesics

About all parenteral opioids analgesics and sedatives readily cross the placenta and can depress the foetus and reduce foetal heart charge per unit variability due to depression of the central nervous organization [19,46]. Systemic analgesics are still widely used around the world, despite being significantly less efficacious than epidural analgesia. Pentazocine is withal used in some developing countries where pethidine, morphine are not readily available. Many parenteral opioids accept been used to provide obstetric analgesia but the nearly popular have been pethidine, morphine and diamorphine [xx].

8.2. Pethidine

This is an analgesic and antispasmodic drug is normally given intramuscularly. It is decreased in popularity as nausea; vomiting, drowsiness and lack of control are of import side effects. Information technology works when given intramuscularly in about twenty minutes given good pain relief for some and sedation for well-nigh patients [3]. Pethidine readily crosses the placenta and ionizes in the relative acids foetal circulation, leading to accumulation. Information technology is a neonatal respiratory depressant. Its onset of fourth dimension is within x minutes when given intramuscularly and lasts up to two-three hours.

Pethidine causes analgesia, amnesia, dysphonia and sedation with a series of adverse furnishings like maternal and neonatal respiratory depression, nausea, sedation and hallucinations. Information technology is metabolised to norpethidine which has pro-convulsant properties therefore it should be used with caution in patients with pre-eclampsia, renal failure or uncontrolled epilepsy.

8.3. Morphine

Main maternal outcomes include maternal satisfaction with hurting relief 1 or two hours afterward drug administration and characteristic of the labour procedure, secondary outcomes include subsequent utilize of epidural analgesia, adverse symptoms (case nausea, drowsiness) inability to urinate or participate in labour, caesarean delivery or instrument assisted vagina delivery and maternal qualitative outcomes such equally satisfaction with the overall nascence experience. Some of the advantages of systemic analgesia are like shooting fish in a barrel availability, simple to administer. Disadvantages of systemic analgesia less efficacious compared to epidural analgesia. Non-steroidal anti-inflammatory drugs have been used in some centres merely this may bear upon the foetus adversely.

9. Inhalational pain relief in labour

Nitrous oxide is relatively insoluble in blood and has these backdrop. Entonox is premixed 50% nitrous oxide and 50% oxygen under force per unit area in a cylinder [47] and is administered usually via on an on-demand valve with a face mask or mouth piece [20]. Nitrous oxide has a depression blood gas solubility coefficient [0.47] and so it equilibrates quickly with the blood. At that place is minimal accumulation with intermittent use in labour as information technology is apace washed out of the lungs. Adverse effects of entonox include drowsiness, disorientation and nausea which results in bodily loss of consciousness in 0.4% of cases after prolonged use [46].

x. Regional labour hurting relief techniques

Regional analgesia for labour encompasses pudendal nerve block, paracervical cake, spinal, epidural and combined spinal epidural block. Regional analgesia is the most effective form of analgesia in labour [27,29]. Information technology reduces maternal pain, cardiovascular piece of work and anxiety with minimal effects on the foetus. Regional analgesia is widely available in the developed world and has changed the labour feel for many women making it much more pleasurable and satisfying and requires dedicated staff and monitoring. The pulse, blood force per unit area, oxygen saturation and consciousness of the patient must be monitored to check for signs of toxicity of the local anaesthetic being used or adverse effects of the methods of the technique. This is why it is not normally available in developing countries. It is widely accepted that the most reliable method for labour analgesia is neuraxial analgesia via the conventional spinal and epidural technique [xix]. There are relatively few contraindications to regional analgesia, the accented contraindications are maternal refusal, coagulopathy, infection at the injection site, uncontrolled hypovolaemia and raised intracranial force per unit area due to a space occupying lesion [27]. Regional analgesia is ofttimes performed early in labour to optimise positioning and may be easier in the sitting position since the midline may be identified more than easily than the lateral position [51].

Bupivacaine has been the most widely used local anaesthetic for regional analgesia in labour [52]. The use of epidural, spinal and combined spinal epidural techniques for obstetric intendance has increased dramatically considering of the quality and safety of the analgesia and amazement produced the ability to titrate the degree and duration of hurting relief and the expanding number of situations for which their apply is advisable. In a randomised, not-blinded controlled trial at a academy hospital in the Us of America by Wong et al, in 728 nulliparous women, neuraxial analgesia started in early labour did not increment the risks of caesarean section or instrumental delivery, compared to initial employ of systemic analgesia with epidural started later, at 4cm or at least two requests for analgesia [53].

10.1. Unmarried shot spinal

This regional labour analgesia can be provided in depression resources settings however care must be taken during ambulation and manpower shortages are significant limitation. Spinal labour analgesia using whitcare needles and bupivacaine [2.5 mg) with or without narcotic.

Spinal amazement is a unproblematic and reliable technique with rapid onset. Spinal (subarachnoid) anaesthesia provides an awake and comfortable patient with minimal risks for pulmonary aspiration of gastric contents. Despite the lower intestinal incision sensory dermatome level is required to prevent referred pain from traction on the peritoneum and uterus [30].

10.2. Epidural pain relief in labour

The epidural technique may enable a lesser incidence and extent of maternal hypotension considering of the power to administrate the dose of local anaesthetic in a fractionated manner and allow compensatory cardiovascular medicines to reply to the more slowly developing sympathetic blockade [30]. The epidural technique is the nearly common neuraxial technique used for labour analgesia because of relative rapid sensory analgesia with minimal motor blockade; uterine affects a maternal or foetal toxicity. Epidural bupivacaine provides excellent pain relief during labour and delivery and is still the near widely used local anaesthetic in obstetric analgesia. However, it is potential for motor blockade and key nervous arrangement and cardiac toxicity by accidental intravenous injection of loftier dose is clinically undesirable especially for obstetric patients [54]. Many factors such equally gestational age, ruptured membranes, cervical dilatation can influence hurting intensity. The degree of motor block during epidural analgesia depends not only on the drug used but also on the cumulative dose of the local anaesthetic. Epidural analgesia provides effective pain relief during labour and delivery and has no significant adverse furnishings on infant and consequence [55]. Epidural analgesia has been safely and effectively used since the 1960s. The introduction of low dose epidural low anaesthetics to maintain labour as well as the use of patient controlled epidural analgesia intra-partum has reduced the use of local anaesthetic and minimised its side effects [56]. In some studies epidural analgesia increases the duration of the second stage of labour rates of instrument assisted vagina deliveries and the likelihood of maternal fever [57]. Though women who receive epidural analgesia during labour are more likely to require instrumental or caesarean delivery at that place is little evidence to suggest that the epidural itself is to blame. There is an association betwixt epidural analgesia and labour outcome but this is probably not causative. Epidurals have consistently been shown to provide superior analgesia when compared with non-epidural analgesia for labour pain, although this is non always associated with greater maternal satisfaction. Analgesia can exist readily converted to anaesthesia by increasing the local anaesthetic concentration, facilitating instrumental or caesarean delivery. Labour analgesia benefits patients with hypertension and some types of cardiac disease example mitral stenosis because it blunts the haemodynamic effects that back-trail uterine contraction are increased preload, tachycardia, increase systemic vascular resistance, hypertension and hyperventilation [31]. For mobile epidurals affects motor role leading to weakness of the lower limbs, decrease the concentration and adding an opiate provides good hurting relief with sparing of motor function and convalescent epidural service is not still available in all centres [3].

Epidurals have some potential disadvantages. The dura may exist accidentally punctured and causes severe postural headache. This can exist cured in most cases with an autologous epidural blood patch, the claret clots in the epidural infinite and presumably works by sealing the leak of cerebrospinal fluid, thus restoring intracranial pressure level. Urinary retention afterwards an epidural is best prevented by careful attending to float emptying. Labour epidural analgesia techniques and medications have progressed to provide more predictable and effective labour analgesia. It is now possible for a parturient to experience pain free labour with minimal side effects to both the mother and the foetus while maintaining maternal autonomy.

The use of a patient controlled modality for labour pain control such every bit patient controlled epidural analgesia has been shown to confer a greater sense of maternal command over the birthing procedure and has gained maternal acceptance worldwide [xix]. Patient controlled epidural analgesia allows patients to self-administer a pre-prepare amount of local anaesthetic and/or opioid epidurally to meet their ain requirements via a patient controlled analgesia device, thus maintaining the neuraxial block within an effective therapeutic range [56].

10.two. Combined spinal epidural labour analgesia

Combined spinal epidural labour analgesia involves injection of an analgesic agent or local anaesthetic drug or both into the intrathecal infinite immediately earlier or subsequently epidural catheter placement. A number of variations in this technique have been described. Nevertheless, information technology is known that despite these variations this technique results in an firsthand and significant reduction in hurting during labour [11]. This technique offers some benefits including faster onset of analgesia, decreased incidence of motor blockade, more reliable technique, higher level of patient satisfaction and decreased incidence of accidental dura puncture [57]. Combined spinal epidural or labour analgesia allows for use of smaller doses of local spinal anaesthetic because the block can be supplemented at whatever time.

10.3. Pudendal nerve block

Information technology is possible for a pudendal nerve block to be sited on each side of the birth culvert to provide analgesia for the second stage of labour or a straight forward instrumental delivery [28,29]. The pudendal nervus arises from the sacral plexus of S2 to S4 and supplies the perineum, vulva and vagina [28]. Pudendal nerve block is often combined with perineal infiltration of local anaesthetic to provide perinael amazement during the 2d stage of labour [29].

11. Amazement for caesarean section

Delivery by caesarean section is becoming more frequent and is one of the most common major operative procedures performed worldwide [59]. It is estimated that some 1-2% of pregnant women undergo amazement during their pregnancy for surgery unrelated to delivery [threescore,61,62]. The about common surgical procedures include appendectomy, cholecystectomy, ovarian torsion and trauma [60]. Less commonly cardiac and neurological procedures are undertaken during pregnancy [60]. Consideration of possible foetal effects of the maternal illness process is important [62]. Obstetric anaesthesia can be very challenging as the risks are largely related to changes in anatomy and physiology associated with the birthing procedure or surgical intervention and pharmacological changes that characterise the three trimesters of pregnancy these changes. Anaesthetists who intendance for pregnant patients undergoing non-obstetric surgery must provide condom amazement for both the mother and foetus. Anaesthetic techniques and drugs administered are modified accordingly foetal well-being is related to avoidance of foetal asphyxia, teratogenic drugs and preterm labour [38]. Left lateral tilt is done to prevent aortacaval compression meticulous pre-oxygenation to forbid hypoxia [38].

The aim in the non-obstetric surgery in pregnancy is to optimise and maintain utero-placental claret flow and oxygen delivery, avert unwanted drug effects on the foetus, avoid stimulating the myometrium( oxytocic effects ), avert sensation nether anaesthesia under full general anaesthesia and use of regional anaesthesia if possible [60]. Caesarean section is often said to be the unique situation where the anaesthetist has to deal with two patients under the same anaesthetic. Protection of the mother is paramount only other goals of anaesthetic management include maintenance of uterine blood flow and foetal oxygenation, avoidance of teratogenic changes and prevention of preterm labour [62].

12. Regional anaesthesia for caesarean department

Though general anaesthesia was previously the favoured technique for caesarean department, in that location has been a move in favour of regional technique in recent years [59]. Regional amazement is preferred in obstetrics considering it is safer than general amazement especially for emergency for emergency caesarean section [63]. Regional anaesthesia is promoted in obstetric practice for reasons of safety. Most women also wish to be awake for caesarean section and anaesthetist attempt to comply with this whenever possible [63]. Absolute contraindications to regional analgesia and anaesthesia are maternal refusal because the woman's wishes should be respected at all times, allergy, sepsis, increased intracranial pressure, clotting abnormalities and lack of appropriate trained staff and or equipment [64].

12.one. Spinal anaesthesia

Single-shot spinal anaesthesia has get the most popular anaesthetic technique for caesarean department [65]. The ease of establishing subarachnoid cake, the rapid onset of intense and reliable block without missed segments make subarachnoid block more than attractive for caesarean department [59]. Spinal anaesthesia offers a fast profound and high quality sensory and motor block in women undergoing caesarean delivery. The most common complication of spinal amazement for caesarean commitment is hypotension with a reported incidence greater than 80% [66]. Maternal hypotension may have detrimental effects on uterine claret menstruation, foetal well-beingness and ultimately neonatal outcome as measured by unilateral arterial pH and APGAR scores [66]. Lateral uterine displacement and intravenous prehydration are commonly used to forestall hypotension but these have limited efficacy and a vasopressor drug is often required [66].

Continuous spinal anaesthesia can provide excellent labour analgesia and surgical anaesthesia if required and is a very reliable technique [67]. Despite its inherent advantages, it is also one of the most underutilised of regional anaesthetic techniques. Following administration of a subarachnoid technique, the patient may mutter of dyspnoea. This can occur because of several factors including blunting of thoracic proprioception, partial blockade of the abdomen and intercostal muscle and increase pressure of the abdominal contents confronting the diaphragm in the recumbent position. Despite these diagnoses, meaning respiratory compromise is unlikely equally the blockade rarely affects the cervical nerves that command the diaphragm [30].

12.2. Epidural anaesthesia

Epidural cake demands loftier technical skills and is still favoured by many when gradual establishment of block is desired to minimise hypotension, although combined spinal epidural techniques are gaining popularity [65]. The method is still same for establishing epidural labour analgesia.

12.3. Combined spinal epidural anaesthesia

The combined spinal epidural technique consists of epidural needle placement and administration of subarachnoid medications via a spinal needle placed through the shaft of the epidural needle and placement of an epidural catheter appears to combine the best of both techniques with a blockade that is rapid in onset, it reliable and tin can be prolonged [xxx].

13. General anaesthesia for caeserean section

A general amazement is often needed for an emergency caesarean section if at that place is not enough time to put in a spinal anaesthetic or an epidural [68]. There is an increased risk during pregnancy of aspiration of gastric contents and command of gastric acidity and volume and encountering a different airway [69, lxx].

Maternal bloodshed has decreased, cheers to the utilize of regional anaesthesia and decreased employ of general amazement, improved aids for hard intubation, more precise respiratory and cardiovascular monitoring [69]. Maternal dangers linked to full general anaesthesia in obstetrics are typically represented by pulmonary aspiration of gastric contents (known every bit mendelson'southward syndrome), hypoxaemia related to difficult or failed intubation and magnified by physiological changes of pregnancy, multifactorial hypotension( aortacaval compression and regional anaesthesia, possible obstetric haemorrhage, uterine relaxation due to inhalation agents and inhalation [70].

Failed endotracheal intubation was the leading cause of anaesthetic related maternal mortality. This event in failure to intubate, ventilate and hypoxaemia, which may eventually pb to brain damage or death [70]. The incidence of failed intubation in the full general surgical population is approximately i, 2303 ≈0.04% and in obstetric population 1: 300 ≈ 0.33%. reasons for this include a broad spectrum of anatomical and physiological changes which occur in women during pregnancy such as the presence of full dentition, increased airway oedema especially in pre-eclamptic patients, enlargement of the breasts may impact on the ability to identify a laryngoscope blade into the mouth due to increased difficulty in navigating the blade handle, failure to allow adequate fourth dimension for paralysis with suxamethonium and incorrectly applied or over enthusiastic cricoid pressure may distort the larynx [70].

14. Local infiltration

Local infiltration of the incision and surgical site may be washed for unstable patients especially in developing countries where patients present late. Up to 100 ml of 0.5% lignocaine with adrenaline can be used to raise two weals on each side of the midline from the symphysis pubis to a point 5cm higher up the umbilicus. The layer of the abdominal wall should be infiltrated with the solution using a long needle. Once the baby has been delivered additional analgesia or sedation tin can exist given to the female parent. The advantage is that there are no ill effects on the mother or baby. The disadvantage is that information technology is unsuitable for nervous patients and needs the surgeons' co-operation. Local infiltration of the surgical sites is used in developing countries and low income countries where patients present late to health facilities and in areas where home delivery is mutual. It is indicated in patients with deranged electrolytes and patients who cannot withstand general of regional anaesthesia such as eclamptics.

15. Postpartum pain

Pain in the postpartum period could be 'subsequently hurting' due to acute uterine contractions which are intense during breast feeding. It could besides arise from episiotomy, chest engorgement, cracked nipple or mastitis [71]. Afterward pains fabricated worse by the act of breastfeeding considering of the consequence of serum oxytocin which is secreted from the posterior pituitary gland primarily as role of the milk allow down reflex [71.72]. Reassurance and mild analgesics similar acetaminophen and non-steroidal anti-inflammatory drugs are usually sufficient [71].

15.i. Episiotomy

An episiotomy is a surgical incision fabricated on the perineum to increase the diameter of the vulva outlet during childbirth [73]. Pain from episiotomy and perineal tears during childbirth is associated with significant pain in the postpartum catamenia. Pain from episiotomy may be severe and can result in significant discomfort and interference with bones daily activities and adversely impact on motherhood [74]. Episiotomy may increment risk of chronic perineal hurting, which is estimated to occur in 13% to 23% of women afterward episiotomy. Post episiotomy pain has been treated with systemic analgesia including non-steroidal anti-inflammatory drugs and oral or intravenous opioids [74].

xv.2. Mail service caesarean section pain

Prompt and adequate postoperative pain relief is an important component of caesarean delivery that can make the period immediately after the operation less uncomfortable and more emotionally gratifying. Postoperative hurting produces adverse physiologic furnishings, which manifests on multiple organ systems such as hypoventilation, atelectasis, pneumonia, stress induced hypercoagulable land and incidence of deep venous thrombosis [75, 76]. Proper management of postoperative hurting can meliorate patient condolement, decreased peri-operative morbidity, and decreased cost by shortening the time spent in post anaesthesia care units, intensive intendance units, and hospitals [74]. Uncontrollable pain tin can impair functions such as ambulation and dietary intake breast feeding and early on maternal bonding with the infant and can impair the female parent'due south ability to optimally care for her baby in the immediate postpartum period [76,77,78,79,lxxx]. High quality pain relief is important after delivery to promote early recovery and optimise the mother's ability to care for her new built-in [81]. Inadequate pain control can besides negatively affect the normal development of infants past affecting nursing activities such every bit breast-feeding [76,79].

The ideal post caesarean section analgesic regimen would exist one that is price effective, simple to implement and which minimally bear on staff workload [81].

Currently opioids class the foundation of post caesarean section analgesia with patient controlled techniques being preferred by mothers. A number of non-opioid analgesics have been used in conjunction with epidural and intrathecal opioids to optimise postoperative analgesia [81]. Patient controlled intravenous opioids are pop after caesarean delivery because of convenience, safety, and consistently high patient satisfaction. The epidural analgesia has more analgesic benefit than intravenous analgesia and provides splendid postoperative pain relief [82].

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Written By

Longinus N. Ebirim, Omiepirisa Yvonne Buowari and Subhamay Ghosh