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Analgo-anesthetic techniques

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embarazada ANALGESIC AND ANAESTHETIC TECHNIQUES

INTRODUCTION

Regional techniques have replaced general techniques in the the treatment of pain in childbirth because they fulfill three fundamental premises:

  • The high maternal and foetal safety provided
  • Maximum effectiveness in pain relief
  • The active participation of the pregnant woman throughout the process
EPIDURAL ANAESTHESIA

What is it?

It consists of the sensory block of the nerve roots that transmit pain during the different stages of labour.

Advantages:

  • Highly safe for the mother and the child
  • It can be performed at any time during labour, at the beginning or at the end
  • Pain relief throughout the childbirth process
  • It permits the active participation of the mother
  • It permits all kinds of obstetric manoeuvres
  • The Caesarean Section can be used
  • Residual post-operative analgesia

Drawbacks or side effects:

  • Failure of the technique
  • Tremors and Pruritus (itchy skin)
  • Latency time (time between the application of the epidural anaesthesia and the beginning of the desired effect)
  • Decrease in blood pressure. Headache (< 0.005%)
  • Post-partum bladder retention: delay in recovery of bladder tone in post-partum

At which point in childbirth is epidural anaesthesia given?

Once labour has commenced, pain is the main indication for epidural anaesthesia

The electrocardiogram is checked and coagulation is verified by means of analyses

A brief medical history of the pregnant woman is taken, ruling out any allergies and diseases that might contraindicate the technique

The patient is placed lying down on her left side (left lateral supine position) or in the sitting position. The skin is sterilised and infiltrated with the local anaesthetic agent and the epidural space is identified. Once it has been located, a catheter is placed and the anaesthetic medication is given through it.

fases-peridural

He is administered anesthetic through the catheter, first a test dose of test and subsequently the rest of the starting dose.

When does it start to take effect and how long does it last?

  • Pain relief begins approximately 15 minutes after the initial dose
  • Being a continuous administration technique, the effect can be maintained for the duration of childbirth

What we do monitor after the administration of the epidural anaesthesia?

  • The mother's blood pressure and heart rate
  • Uterine contractility and heart rate
  • Fetal level and extent of sensory block
  • Degree of motor block

Who CANNOT receive peridural anaesthesia?

Contraindications

  • Active bleeding
  • Neurological disease
  • Local or systemic infection
  • Altered coagulation
  • Spine deformity or previous spinal surgery
  • Lower back tattoo

These contradictions are relative and each case must be studied individually

Potential complications

Any anaesthetic procedure involves a number of risks. The individual decision to undergo anaesthesia is based on a comparison of the risk and the potential benefit

The most important complications associated with epidural block are:

  • Failure of the technique, leading to the failure to obtain the desired analgesic effect
  • Incomplete analgesia: unilateral pain at inguinal level, pain at perineal level due to rapid parturition progression or unilateral analgesia
  • Accidental puncture of the dura mater: our hospital has a relatively low incidence (0.6%)
  • It may be performed with the needle or the catheter, and in certain cases may go unnoticed
  • The key symptom is a fronto-occipital headache appearing in the first 48 hours, worsening with mobilisation, so the patient should rest in bed for the first 24-36 hours
  • In most cases it remits after 72 hours with pain killers and rest
  • Other minor complications are post-partum urinary retention, nausea and vomiting, tremors and back pain
INTRADURAL ANAESTHESIA

It consists of the sensory block of the nerve roots that transmit pain during labour through the injection of local anaesthesia into the subarachnoid space. It requires traversing the dura mater with a very fine gauge needle.

image023-267x254

When is it recommended?

The use of the intradural technique in vaginal birth is fundamentally indicated in situations when, for reasons of time, the use of epidural analgesia is not feasible.

Advantages

  • Fast-acting
  • Highly effective and easy to perform
  • Important perineal relaxation
  • Minimum maternal and foetal toxicity
  • General anaesthesia can be avoided

Disadvantages

  • Major incidence of high hypotension
  • Increased risk of post-dural puncture headache
  • Limited duration of the analgesic effect
COMBINED INTRADURAL/EPIDURAL BLOCK

This technique is the latest contribution to pain treatment during labour. Although numerous procedures have been described for the combined block, the most commonly used one consists of inserting an intradural needle through an epidural needle pre-positioned in the epidural space.

image024-267x315

Fármacos anestésicos

Once a small dose of intradural anaesthetic has been given, the intradural needle is withdrawn and a catheter is placed in the epidural space through the corresponding needle.

The main advantage of this technique lies in the minimal doses of anaesthetic given to alleviate pain quickly from the outset and the analgesia is subsequently maintained as in traditional epidural anaesthesia. Since only a small amount of local anaesthetic agent is given, many patients can still walk and can moreover participate actively in their childbirth process, while also enjoying satisfactory pain relief.

The combined technique is a valid procedure both for the relief of childbirth pain and in Caesarean section. The invasive nature of the technique, our centre's healthcare characteristics and the excellent outcomes we have obtained with epidural anaesthesia all lead us to reserve this procedure for very specific situations (poor uterine dynamics, major pain in the very early stages of labour...) and not to use it systematically in delivery analgesia.

GENERAL SEDATION/ANAESTHESIA

General anaesthesia in vaginal delivery has gradually made way for regional techniques, which are known to be much more safe and effective in relieving childbirth pain.

Regardless of the anaesthetic agent used, general techniques should always ensure that the pregnant woman remains conscious at all times and that her protective laryngeal reflexes remain intact in order to avoid possible asphyxia due to bronchial aspiration.

Is therefore recommended to all the pregnant women to remain in fasting, allowing only small amounts of clear liquids intake since the beginning of the suggestive regular contractions of the onset of childbirth. Surgical fasting times.

Times Food Guide Precautions
2 h Clear liquids Water, herbal teas, light tea, black coffee without milk, gelatin, strained fruit juices without pulp, high-carbohydate beverages, fat or grease-free consommé Must not contain: protein, fats or alcohol
6 h Dairy milk, light meal Bread or toast or biscuit. Herbal drinks with or without skimmed milk. Juices with pulp. Jelly Gastric emptying of dairy milk according to its composition, due to the presence of casein
8 h Solid, full meal Sweets or candy, lollipops and chewing gum should be avoided beginning eight hours before surgery

The therapeutic arsenal available for systemic pain relief in childbirth includes mainly the following drugs:

INHALED ANAESTHETICS

NITROUS OXIDE

  • This agent, which reached Obstetrics in 1880, is one of the most harmless analgesic methods, both for the mother and the unborn child, provided that it is administered with 50% oxygen and properly.
  • Its effectiveness is highly variable and to a large extent depends on the pregnant woman self-managing the mixture properly, and coinciding with the beginning of uterine contraction

HALOGENATES

  • Of these agents, the only one that is suitable for analgesia in childbirth is Isoflurane at concentrations of 0.2% - 0.7%.
  • Halothane presents very low analgesic effectiveness, and tends to stop uterine contractions as of concentrations of 0.5%, which is why this agent should be used exclusively as a uterine relaxant in specific obstetric situations (internal or external version, foetal entrapment, placental extraction or retention) and not as an anaesthetic
  • The combined use 0.2-0.25% Isoflurane and 50% nitrous oxide-oxygen delivers more or less adequate pain relief without a significant impact on the mother or child

The use of inhaled agents in childbirth pain relief may be an analgesic alternative in cases where a regional technique is inviable, especially during the later phases of labour, although their analgesic limitations must be accepted, as must the the fact that their effectiveness is largely dependent on the mother's cooperation.

INTRAVENOUS ANAESTHETICS

Intravenous anaesthetic agents, particularly pentothal, were once the most commonly used technique in obstetrics, although this is no longer the case.

OPIATES

  • They help the patient to tolerate pain better, although they do not provide total relief.
  • Meperidine (Dolantin) is one of the most widely-used analgesic methods in the treatment of childbirth pain due to its ease of administration and the fact that the staff who attend obstetric patients are highly familiar with it
  • Our protocol specifies the use of remifentanil in a continuous perfusion. It is a potent short-acting opiate with rapid clearance (3 minutes), which means that the newborn only requires minimal surveillance in the first few hours of life
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