Pain relief during labor and delivery: A brief 2013 update

Labor is one of the most painful events in a womans life. Women have sought ways to eliminate the pain of childbirth for centuries, yet the idea of childbirth without pain continues to spark controversy and debate. There are vast differences that split caregivers, childbirth advocates, and pregnant women themselves regarding what is considered the best birth experience for her and the newborn. A variety of options, including both medications and non-medical methods, are available to use. What is the best? What should I use? Are there any risks? Can multiple methods be used in combination? How should I choose? There is no one method that is best for all women. Differences in preferences, pain tolerance, and labor patterns result in profound differences in the types of pain relief used during labor. Non-medical methods include the use of ambulation, breathing techniques, mind-body techniques or focused mental imagery (sometimes also known as hypnotic techniques), immersion in water (baths or showers), birthing balls, massage, TENS, and others. All of these non-medical techniques can provide some degree of pain relief, and entail virtually no risks or side-effects. In the USA today, approximately 80-90% of women in labor use some sort of medical pain relief, and approximately 75% are using epidural analgesia. Many changes have occurred in the way epidurals are administered over the last few years. These new methods include: Patient-controlled epidural analgesia (PCEA). PCEA allows the patient herself to determine how much epidural medication she gets by pressing a button attached to the epidural medication pump. Research shows that when patients are allowed to self-control their medication, on average, they use less overall medication, have better pain relief, and are more satisfied than when everyone gets the same standard dose. At Brigham & Womens Hospital, all of our epidurals are patient-controlled. Combined spinal-epidural (CSE). CSE is has the advantage of a very fast onset of pain relief, usually within one or 2 contractions there is complete pain relief, and almost complete ability to move the legs is retained. CSE is often used when someone gets an epidural very late in the labor process. Low-dose epidurals: Another way that epidurals have changed over t he years is an appreciation of the use of very low-dose combinations of medications. These low-dose epidurals can provide excellent pain relief, with fewer side effects than were seen years ago. Other medical techniques include renewed interest in inhalational methods, namely nitrous oxide (although at present this is not available at most American hospitals), and the use of narcotic injections. Narcotics are some of the oldest pain relieving medications known, and are derived from opium, which has been used for centuries for pain relief. Some of the newer synthetic narcotics may offer some advantages over older drugs, in particular for use during labor and delivery. Approximately one-third of all deliveries in the USA today are by cesarean. Almost all cesarean deliveries are done using regional anesthesia, (i.e., spinal or epidural), and thus patients can be awake, and you can have a support person in the operating room with you, and feel quite comfortable throughout the procedure. There have been advances made in the way we can help control pain during and after cesarean delivery, and thus most patients will feel quite comfortable after this type of surgery.

Hesham Abdel-Hady, Nehad Nasef Neonatal Intensive Care Unit, Mansoura University Children's Hospital, Mansoura, Egypt Abstract: The survival of preterm infants has improved significantly during the past several decades. However, bronchopulmonary dysplasia remains a major morbidity. Preterm infants have both structural and functional lung immaturity compared with term infants, making them more likely to require resuscitation and more vulnerable to developing bronchopulmonary dysplasia. Interventions in the delivery room may affect short-term and long-term outcomes for preterm infants. The paradigm of resuscitation of preterm infants has been changing over the past decade from being interventional and invasive to be observational and gentle. Recent developments in respiratory management of preterm infants in the delivery room include oxygen supplementation and monitoring, alveolar recruitment techniques, noninvasive ventilation, new surfactant preparations, and new techniques for administration of surfactant. Providing nasal continuous positive airway pressure (CPAP) rather than intubating has been identified as a potentially better practice. Experimental studies have demonstrated that early application of nasal CPAP is protective for the preterm lung and brain compared with mechanical ventilation. Several observational studies have suggested that early nasal CPAP and avoiding intubation leads to reduced oxygen requirements, intubation rates, duration of mechanical ventilation, and may decrease rates of bronchopulmonary dysplasia. Multicenter, randomized controlled trials support the use of nasal CPAP as a primary strategy in preterm babies with respiratory distress syndrome. This approach leads to a reduction in the number of infants who are intubated and given surfactant without an impact on bronchopulmonary dysplasia rates. On the other hand, half of the infants enrolled in these studies failed nasal CPAP treatment. New techniques for surfactant administration include INSURE ("intubate give surfactant and extubate"), administration through a laryngeal mask airway, nebulized surfactant administration, and minimally invasive surfactant therapy. Keywords: continuous positive airway pressure, lung injury, oxygen, resuscitation, surfactants

Newborn care in the delivery room

Babys first cry

Hearing your baby cry in the delivery room is a good sign. Crying helps him get rid of any excess fluid that may still be in his lungs, nose or mouth. Doctors will often encourage a baby to cry for this reason. If necessary, the health care provider will resuscitate a baby that is having trouble breathing.

Connection to mom
While in the womb, your baby received her nutrition and oxygen through the umbilical cord that connected you both. Now that she is born and breathing on her own, her blood supply is redirected to her lungs, allowing the medical staff to cut and clamp the umbilical cord.

Keeping baby warm

When a baby is born, he is wet from the fluid in the womb and can easily become cold. Nurses will dry his skin, wrap him in a blanket, place a knitted hat on his head and may even use heat lamps to help him stay warm. Holding your baby close to you so that your skin touches his also helps keep him warm.

Apgar score
The Apgar score is designed to check your babys condition at 1 minute and 5 minutes after birth. Your baby will be checked for five things: A Activity; muscle tone P Pulse rate G Grimace; reflex (measured by placing a bulb syringe in the babys nose and seeing his response) A Appearance; skin color R Respiration Each category is given a score ranging from 0-2. The numbers are then added up for a final score. Babies who receive an Apgar score of 7 or more probably have come through delivery with flying colors and are in good condition. Those with lower scores may need extra watching or special care, though most will do fine.

Vitamin K shot
Your baby will receive a shot of vitamin K immediately after she is born. For a few days after birth, newborns are unable to make vitamin K, which is needed for blood clotting. The vitamin K shot protects your baby from developing a rare, serious bleeding problem that can affect newborns.

Eye drops
Your babys eyes will be treated with medicated drops or ointment. This protects her eyes from bacterial infections that can be contracted during delivery.

Newborn screening tests

Your babys heel will be pricked to obtain a few drops of blood. This blood sample will be used to screen for genetic and biochemical disorders. These birth defects may not be obvious at first in a baby. But, unless detected and treated early, they can cause physical problems, intellectual disabilities and, in some cases, death. Most babies receive a clean bill of health. A newborn may also receive a hearing test. The test measures how the baby responds to sounds. A tiny soft earphone or a microphone is placed in the baby's ear. Without testing, hearing loss often is not diagnosed until a child is about 2 to 3 years old. By that time, the child has often developed speech and language problems. Early treatment helps to prevent these problems. Currently each state or region operates its own newborn screening program. State programs vary widely in the number and types of conditions for which they test. The March of Dimes recommends that all babies be screened for at least 29 disorders, including hearing loss. Most likely, your baby will be found in good health after her tests. But for the few babies who have different test results, early diagnosis and proper treatment can make the difference between healthy development and lifelong problems.

Other newborn attention

Measurement: Your baby will be measured for weight, length and the size of his head to ensure that he is at a healthy range for the number of weeks of pregnancy. Bath: Once your babys body temperature is stable, she will be given her first bath. Footprints and medical bracelets: As part of your babys first medical record, his footprints will be taken and added to the record. Babies are usually given two identity bracelets (one on his foot, the other on his arm). You, too, will be given a matching bracelet.

Special care
Some babies may face challenges after birth. Babies that need special care may be placed in the neonatal intensive care unit (NICU). This is a part of the hospital where babies are cared for using advanced technology and specially trained health care professionals. Having a baby in a NICU can leave many parents feeling stressed and sad. While you may be separated from your baby for a period of time, take comfort in knowing that you will still be able to build a bond with her. Rest assured that scientific advances in this field are helping more babies become healthy and go home sooner.

Republic of the Philippines University of Northern Philippines Tamag, Vigan City

COLLEGE OF HEALTH SCIENCES

In partial fulfilment Of the Requirement in RELATED LEARNING EXPERIENCES (DELIVERY ROOM)

DR UPDATES

Presented to: FE R. RODILLAS, MAN (Clinical Instructor)

Presented by: JEANNE CLAUDE FLORES IV-A