分娩镇痛.ppt

laboranalgesia xiangyahospitaldr yan laborpainpathways firststage painisdueprimarilytouterinecontractionsthatcausestretchingandthinningoftheuterinecervix painimpulsestravelviavisceralafferentfibersandenterthespinalcordatthet10 t11andl1spinalsegments painisgenerallypoorlylocalizedandisdullorcramping laborpainpathways secondstage stretchingoftheperineumproducesadditionalpain moresomaticinnature iswelllocalizedandsharp theseimpulsestravelviathepudendalnervesfromthes2 s3ands4spinalsegments laborpain theamountofpainexperiencedbyawomanduringlaboranddeliverycanbeinfluencedbymanyfactors includingparticipationinchildbirthpreparationclasses parity anduseofoxytocin analgesiaforlabourpain psychologictechniques hypnosis psychoprophylaxis positiveconditioning patienteducation acupuncture trenscutaeouselectricalnervestimulation systemicmedication benzodiazepines diazepancrossestheplacentarapidly andmaternalandfetalbloodlevelsareequalwithinminutesofanivdoseiftotalmaternaldosageexceeds30mg thedruganditsactivemetabolitepersistinpharmacologicalactiveconcentrationsforatleastaweekintheneonate systemicmedication diazepam theadverseeffectsinneonate inlargedose hypotonia lethargy decreasedfeeding andhypothermia insmalldose reducedbeat to beatvariability midazolam ifitisusedforinduction problemwithgenralbodytoneandbodytemperatureofneonateseen systemicmedication meperidine peakanalgesiaeffectoccurs40to50minutesafterimand5to10minutesafteriv thedurationis3 4hours cancausedose dependentneonatealdepression asevidencedbyprolongedtimetosustainedrespiration decreasedapgarscores andabnomalresultsfromneurobehavioralexamination systemicmedication fentanyl 50ugto100ugimand25ugiv peakeffect iv 3 5minandduration30 60min adoseof1ug kgivtothemotherwithin15minofcesareandeliverydidnotproduceadverseeffects newborndruglevelswerealwayslessthanmaternallevels systemicmedication morphine peakanalgesiceffectoccurs1 2hoursimand20minutesiv durationis4 6hours inequianalgesiadoses morphineproducesmorerespiratorydepressionofthenewbornthandosesmeperidine morphineisreservedforearlylabor systemicmedication butorphanolandnabuphine syntheticagonist antagonistnarcoticanalgesics donotcauserespiratorydepressioninlaborpt causematernaldizzinessandsomnolenceandadverseneonatalneurobehavioraleffects rapidlycrossplacentaandincreasefhr causehighoutputcardiacfailure noadvantageoverotheropioides systemicmedication ketamine lowdoseivketamine 10 25mg or0 25mg kgincrements canbeusedwithinhaledagentstoproduceanalgesia whichcanbeusefulduringoperateivevaginaldeliveryorcesareandelivery systemicmedication inhaledanalgesia properadministionofinhaledanalgesiabymaskinlowconcentrationstopreventlossofconsciousnessandprotectiveaiewayreflexes vomitingorsilentregurgitationarepossibleaspirationrisk nitrousoxidein50 withoxygen reliableanalgesiahasnotbeendemonstrated regionalanesthesia mosteffective providepainrelief keeppatientawakeandallowpatienttoparticipateinthelabouranddeliveryprocessunlikelytoproducedrug induceddepressioninthefetusormotherreducelevelsofcatecholaminesinthemother whichmaybeneficialtofetus regionalanesthesia earlyplacementofepiduralcatheterhelpscontrolbloodpressurewithgoodanalgesiaforlaborpaininpre eclampsiapatient afterwellhydrationandbeforecoagulopathyoccurs itmaybethemeanstoreducecesareansectionrateinchina regionalanesthesia patientpreparation iv equipmentforresuscitationandcomplication o2 airways laryngoscope endotrachealtubes suctioningapparatus thiopenalordiazepam ephedrineandnaloxone preanestheticevaluation obplanandunderstandfetalstatus bp ecgandfhrand500mlivfluid regionalanesthesia contraindications absolute patientrefusal infectinatthesiteofneedleplacement overtmaternalcoagulopathy andmaternalhemodynamicinstability relative preexistingneurologicdisease priorbacksurgery isolatedcoagulationabnomalities somecardiacdisease regionalanesthesia timingofadministration chestnutet al performedastudywhereinpatientswererandomizedtoearly ie 1strequest0epiduralorlate waitinguntilatleast5cmcervicaldilation nodifferenceincesareanrateswasfoundbetweenthetwogroupsforeitherspontaneousorinducedlabors andthecesareanratewaslow approximately8 inboth regionalanesthesia encourageearlyadministrationofepiduralanesthesiainlaboringwomenwithpreeclampsiaepiduralanesthesiadidnotincreasetheincidenceofcesareandeliveryorpulmonaryedemaamonglaboringwomenwithseverehypertensivedisease regionalanesthesia oneshotspinalanalgesiausingalipidsolubleopioidisrapidandsimple butisassociatedwithalimiteddurationofaction regionalanesthesia epiduralanalgesiaprovidesexcellentpainreliefandtheabilitytoextendthedurationoftheblocktomatchthedurationoflabour butitisnot instant inonsetandmaybeassociatedwithmotorblock regionalanesthesia thecombinationofepiduralandspinalanesthesiaintoonetechnique termed combinedspinal epidural providestheadvantagesofaspinalwiththeadditionalflexibilityofrenewalwithanepiduralcatheter regionalanesthesia intrathecalnarcoticprovidesexcellentpainrelieveinstantlywithoutmotorblockcsehasspecialbenefitifpatient scervicaldilationisabout8cmmorethan60 ofpatientsinmyhospitalreceivecseanalgesianow regionalanesthesia intrathecalopioids sufentanil2 5ug 10ug fentanyl10 25ugsideeffectsprurtus nausea vomiting hypotension urinaryretention uterinehyperstimulationandfetaldradycardia maternalrespiratorydepression epiduralanesthesia theblockisplacedoncethepatientisinestablishedlabor lowdosesoflocalanesthesicsoropioidsareoftensufficientduringthefirstpartoflabortoprovideaneffectivet10 l1segmentalblock increasedlocalanestheticstocovers2 s4forsecondsstagesoflabor epiduralanalgesia usedilutelocalanestheticsandopioidsolutions 0 125 bupivacaineorropivacainewithfentanylorsufentanil makeeverydoseatestdose 2 3mlinitialbolus lookforintrathecalinjection epiduralanalgesia valueofepinephrine testdose 15ugproduceincreasedheartrateof20 30 min intheparturient epinephrineproducesanindistincttachycardia whichcanbeconfusedwithpain inducedheartratechanges epinephrineproducesamorereadilydetectedtachycardiaifpatientsarealreadypainfree afterantrathecaldruginjection epiduralanalgesia epiduralopioidsforlabor meperidine100mg last2 5hours fentanyl100 200ug onset5 10min last1 2hours sufentanil5 15uglast1hr 40 50uglast5hr epiduralanalgesia bupivacaine longduration lowermotorblockthanlidocaine bewareofcardiotoxicityanddonotusetheconcentrarionof0 75 lidocaine mostcommonusedforcesareandelivery epiduralanalgesia 2 chloroprocaine estertype fastonset briefduration usefultorapidlyextendalaborepiduralblockforoperativevaginal 2 3 orcesarean 3 delivery adisadvantageisitapprarentantagonismofsubsequentlyinjectedepiduralopioidsandbupivacaine epiduralanalgesia ropivacaineneweramidelocalanestheticssimilarinstructure potency andpharmacodynamicstobupivacainecardiotoxicitythatisintermediatebetweenthoseoflidocaineandbupivacaie epiduralanalgesia continuousepiduralinfusion 0 04 bupivacaineplusfentanyl almostallpatientswillrequireatleaseoneresusebolus someneedmorethanseven 0 083 bupivacaineplussufentanil 53 requreatleastonerescue 18 needtwoormore complication intravascularorintrathecalinfusion epiduralanalgesia patientcontrolledepiduralanalgesiaminimizedrugdosage flexibilityandbenefitsofselfadministrationreduceddemandonprofessionaltimecontroversystillexistsregardingtheuseofacontinuousbasalinfusioninadditiontopatientcontrolledboluseswhichwouldprovideforamoreevenblockandlargerdoses epiduralanalgesia complications hypotension convulsion cardiacarrestdeliverthefetus externalcardiacmassagedefibrillationepinephrinebretylium totalspinalairway trendelenburg fluid pressuresupport epiduralanalgesia complicationsnerveinjuryrareepiduralhematomainfection meningitisheadache regionalanesthesia cserapidonsetreliabilitypatientcanwalkifonlyintrathecalopiategiven inobpatient epinephrinetestdoseforepiduralcatheterplacementismorereliableafterintrathecalopiateisgiv