Analgesia and Anesthesia in Emergency Obstetric Care

1. Analgesia and Anesthesia in Emergency Obstetric Care Managing Complications in Pregnancy and Childbirth These presentation graphics are based on the guide Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors (2000) by the World Health Organization. These presentation graphics are based on the guide Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors (2000) by the World Health Organization.

2. 2 Analgesia and Anesthesia Session Objectives To describe the principles of pain relief in emergency obstetric care To describe different methods of pain relief in emergency obstetric care

3. 3 Analgesia and Anesthesia Basic Requirements of Pain Relief Supportive attention from staff before, during and after procedure to reduce anxiety Method of pain relief that is: Appropriate for procedure Adequate for pain relief Safe for woman (and baby) Skill and expertise of provider in using instruments gently and minimizing tissue damage 

4. 4 Analgesia and Anesthesia Pain Relief in Labor Non-pharmacological methods of pain relief include: Support from birth companion Encouragement, compassion and support from provider Ambulation and change of position Back massage Breathing techniques Warm showers and baths

5. 5 Analgesia and Anesthesia Pain Relief in Labor (continued) If non-pharmacological methods of pain relief are not adequate: Give: Pethidine 1 mg/kg body weight (maximum dose 100 mg) IM or IV slowly OR Morphine 0.1 mg/kg body weight IM Give drug every 4 hours as needed Give promethazine 25 mg IM or IV if vomiting occurs

6. 6 Analgesia and Anesthesia Local Anesthesia Blocks sensory nerves Commonly used preparation is 0.5% with or without adrenaline Addition of adrenaline reduces absorption and prolongs action Premedication with pethidine and diazepam may be required for longer procedures

7. 7 Analgesia and Anesthesia Local Anesthesia (continued) Because the woman will be awake during the procedure: Counsel her before the procedure to increase cooperation and reduce fears Tell her what you are doing at each step of the procedure Wait until the anesthetic has taken full effect before performing procedure

8. 8 Analgesia and Anesthesia Local Anesthesia (continued) Prevent complications of local anesthesia by: Using dilute solutions (0.5% preferred) Adding adrenaline when more than 40 mL will be used (e.g., cesarean section) Using lowest effective dose Not exceeding maximum dose Without adrenaline 4 mg/kg body weight With adrenaline 7 mg/kg body weight Injecting slowly Avoiding IV injection

9. 9 Analgesia and Anesthesia Nerve Blocks Target specific nerves to anesthetize a region of the body Paracervical block can be used for dilatation and curettage and manual vacuum aspiration Pudendal block can be used for instrumental delivery, breech delivery, episiotomy, repair of perineal tears, craniotomy/ craniocentesis

10. 10 Analgesia and Anesthesia Spinal (Subarachnoid) Anesthesia Can be used for cesarean section, laparotomy, repair of extensive perineal tears, manual removal of placenta Pre-load woman with 500�1,000 mL IV fluids to avoid hypotension Ensure sterile technique Use finest needle available Keep the woman flat on her back for at least 6 hours after procedure to prevent post-spinal headache When oxygen is available, it is also important to pre-oxygenate the woman before administering spinal anesthesia.When oxygen is available, it is also important to pre-oxygenate the woman before administering spinal anesthesia.

11. 11 Analgesia and Anesthesia Ketamine Ketamine is a general anesthetic Can be used for any relatively short procedure where muscle relaxation is not required AVOID ketamine in women with hypertension, pre-eclampsia, eclampsia or heart disease ..

12. 12 Analgesia and Anesthesia Ketamine (continued) Usual dose: 6�10 mg/kg body weight IM OR 2 mg/kg body weight IV slowly over 2 minutes When used alone, ketamine can cause unpleasant hallucinations For ketamine infusion, premedicate with: Atropine sulfate 0.6 mg IM 30 minutes before surgery AND Diazepam (for cesarean section, give after the newborn is delivered)

13. 13 Analgesia and Anesthesia Postoperative Analgesia Good postoperative pain control regimens include: Paracetamol 500 mg by mouth as needed Pethidine 1 mg/kg body weight IM or IV slowly Morphine 0.1 mg/kg body weight IM Repeat every 4 hours as needed Give Promethazine 25 mg IM or IV every 4 hours if vomiting occurs