LABOUR PAIN RELIEF — a complex of the physiopsychoprophylactic and medicamentous influences directed to decrease or full removal of pain during a childbed. At the same time achievement of a boleutoleniye (analgesia), but not providing an anesthesia is provided.
- 1 History
- 2 Indications and Contraindications
- 3 Anesthesia by nitrous oxide
- 4 Anesthesia by trichloroethylene
- 5 Anesthesia by Ftorotanum
- 6 Anesthesia by Promedolum
- 7 Anesthesia by fentanyl
- 8 Anesthesia by a preion
- 9 Anesthesia by method of a long peridural analgesia in labor
- 10 Anesthesia by method of an electroanesthesia in labor
in an extreme antiquity the mankind aimed to anesthetize childbirth. For this purpose, in addition to various ceremonies, applied a number of means of a vegetable and mineral origin: inhaled smoke of wood charcoal, used the so-called sleepy sponge impregnated with opium or tincture of a plant of a mandrake, etc. Scientific development of methods O. ruble belongs only to the middle of 19 century when the anesthetizing properties of ether, chloroform, nitrous oxide, etc. became known.
The first data on successful O. ruble belong to 1847 when the Scottish obstetrician J. Simpson applied to this purpose ether in the beginning, and then chloroform. The same year ether was successfully used in Russia by N. I. Pirogov for achievement of a boleutoleniye during the imposing of obstetric nippers. Lakes of river are devoted fundamental works of a number of domestic researchers: A. Ya. Krassovsky (1865), H. N. So-chava (1867), S. K. Klikovich (1881), S. I. Halafova (1898), etc.
Development of this problem in the USSR is connected with the IX All-Union congress of obstetricians-gynecologists, nominated the idea of need of development of methods O. of river and their implementation in practice of work of obstetricians to A. Yu. Lurye (1936) Krom. The big contribution to scientific and practical development of O. of river was made by K. K. Skrobansky (1936), M. S. Malinovsky (1937), etc. During the period from 1950 to 1970 for O. the river tested combinations of inhalation anesthetics (ether, nitrous oxide, Ftorotanum) to narcotic analgetics (Promedolum), neurotropic and antispasmodics. The combined use of small doses of anesthetics and narcotic analgetics with tranquilizers and spasmolysants allowed to lower considerably degree of a narcotic depression of a fruit, to reduce their negative influence on sokratitelny function of a uterus.
Anesthesia of a childbed, except the humane value, is efficient prevention of exhaustion, disturbances of sokratitelny activity of a uterus, a pre-natal hypoxia of a fruit. At O. ruble optimum is achievement of an analgesia at preservation of consciousness when the woman in labor can actively participate in a childbed. The choice of a way O. of river is defined individually, with a psychoemotional condition of the woman in labor, an obstetric situation (duration of gestation, a current of a childbed), existence of extragenital pathology, a condition of a fruit.
Indications and Contraindications
Indications to O. the ruble establishes the obstetrician, the choice of a method is solved together with the anesthesiologist. At the same time proceed from the following principles: the way of anesthesia shall not oppress patrimonial activity or make negative impact on a fruit and the newborn; during O. of river the effect of a boleutoleniye at preservation at the woman in labor of consciousness shall be reached; the method O. of river shall be manageable and available.
One of the main methods O. of river is the psychoprophylactic method based on education at the woman of a conscientious attitude to a childbed, removal of fear of childbirth (see. Psychoprophylactic training of pregnant women ). And only in the absence of effect of the specified method it is possible to pass river to medicamentous O.
The indication to start an analgesia in childbirth (see) existence of the expressed pain at the established regular patrimonial activity and disclosure of a neck of uterus not less than on 3 — 4 cm is. On individual pokazaniyakhm (late toxicosis of pregnancy, cardiovascular pathology and other extragenital diseases) rubles begin O. in earlier terms.
There are practically no contraindications to O. of river, there are only contraindications to use of these or those methods and anesthetics. Carefully it is necessary to approach medicamentous O. river in the presence of a hem on a uterus, clinically narrow basin, considerable not wearing out of a fruit, anomalies of an implantation of placenta. It is impossible to use it is long the operating anesthetics (e.g., Promedolum) in two hours prior to the estimated birth of the child in order to avoid a narcotic depression of a fruit.
Anesthesia by nitrous oxide
Nitrous oxide (see) does not irritate a mucous membrane of respiratory tracts and does not make toxic impact on parenchymatous bodies. Lack of cumulative effect, negative impact on a fruit and sokratitelny function of a uterus, and also easy controllability depth of anesthesia do nitrous oxide by the most widespread anesthetic for these purposes. Nitrous oxide gets through a placenta, however at the termination of its inhalation it eliminirutsya quickly from an organism of mother and a fruit through respiratory tracts of the woman in labor.
The lake of river is carried out by nitrous oxide in combination with oxygen by means of the devices of series NAPP or Avtonarkon intended for a long analgesia in the discontinuous way. In them the mix containing 50 — 75% of nitrous oxide and 50 — 25% of oxygen is used. Other ratios of nitrous oxide and oxygen are selected individually. At inhalation of nitrous oxide with oxygen in the ratio 1: 1 or 2: 1 analgetic effect occurs within 5 — 10 min. At most of women in labor between pains there comes the drowsy state. The satisfactory effect of O. of river nitrous oxide, according to different researchers, fluctuates from 62 to 82%.
According to separate indications (a nephropathy, cardiovascular diseases, etc.) the analgetic effect of nitrous oxide can be strengthened by introduction of 10 — 20 mg (1 — 2 ml of 1% P ~ Ra) Promedolum intramusculary. For achievement of spasmolytic effect 1 — 2 ml of 2% of solution of Nospanum or 1 ml of 1% of solution of aprophene is intramusculary entered. To women in labor, at to-rykh psychomotor excitement is expressed, before anesthesia appoint inside small tranquilizers.
Anesthesia by trichloroethylene
For achievement of an analgesia in labor inhalation trichloroethylene (see) it is carried out in concentration 0,3 — 0,5 about. %. Trichloroethylene is used in mix with oxygen or air. Inhalation is performed by means of the devices NAPP-2, Avtonarkon, «Trilanum». Trichloroethylene gets through a placenta therefore in order to avoid a narcotic depression of a fruit inhalation of trichloroethylene is performed in the discontinuous way (15 — 20 min.) and stops in 30 — 40 min. prior to the beginning of the second period of childbirth. The satisfactory effect of anesthesia is reached at 80 — 90% of women in labor. At long inhalation of trichloroethylene there is a cumulative effect that can be followed by a narcotic depression of the newborn.
For reduction of negative influence of anesthetic by an organism of mother and a fruit inhalation of trichloroethylene (0,3 — 0,5 about. %) combine together with nitrous oxide with oxygen (1: 1 and 2: 1). Decrease in concentration of trichloroethylene to the ratios stated above reduces danger of depressive impact of anesthetic on a fruit and the newborn.
Contraindications to use of trichloroethylene: dekompensirovanny heart diseases persistent funkts, disturbances and morfol, changes of parenchymatous bodies, anemia, severe forms of toxicosis of pregnant women, and also premature pregnancy.
Anesthesia by Ftorotanum
Ftorotanum (see) possesses powerful narcotic action. The stage of an analgesia at inhalation of Ftorotanum is short-term. Due to the small range of analgetic action and considerable toxicity Ftorotanum is applied very restrictedly. It gets through a placenta, has the expressed cumulative effect, oppresses patrimonial activity. Ftorotanum is used only for bystry removal of patrimonial activity at the menacing hysterorrhesis. To these purposes it is applied in concentration 0,5 — 0,9 about. %. Inhalation of Ftorotanum is performed via the special evaporator, the Crimea the devices NAPP-2, Avtonarkon are supplied.
The negative effect of Ftorotanum considerably decreases at its combination with nitrous oxide; at the same time the analgesia is carried out generally by nitrous oxide with oxygen in the ratio 1: 1, and Ftorotanum is connected only in small concentration (0,3 — 0,5 about. %) for achievement of a superficial dream.
Anesthesia by Promedolum
For O. of river. Promedolum (see) enter subcutaneously or intramusculary in a dose of 10 — 20 mg (1 — 2 ml of 1% of solution). The analgetic effect is noted in 10 — 15 min. and proceeds within 1,5 — 2 hour. If necessary the analgetic is entered repeatedly in 2 — 3 hours in the same dose. In optimum picked up doses Promedolum does not exert negative impact on sokratitelny activity of a uterus and a fruit. Promedolum gets through a placenta therefore its last injection can be not less than in 2 hours prior to alleged delivery in order to avoid a narcotic depression of the newborn. For increase in effect of an analgesia in labor it is reasonable to combine introduction of Promedolum with one of antispasmodics (Nospanum, Estocinum, aprophene).
Anesthesia by fentanyl
For O. rubles enter fentanyl subcutaneously or intramusculary in a dose of 0,05 — 0,1 mg (1 — 2 ml of 0,005% of solution). Analgesic effect short-term — within 20 — 25 min. For anesthesia of uncomplicated childbirth intramuscular introduction of 0,05 — 0,1 mg of fentanyl and 2,5 — 5 mg (1 — 2 ml) of Droperidolum is optimum (see. Neyroleptanalgeziya ).
Use of fentanyl at premature births is contraindicated, to a pre-natal hypoxia of a fruit. The analgetic gets through a placenta and can exert depressive impact on a respiratory center of a fruit. The last administration of fentanyl can be not less than for 1 — 2 hour before alleged delivery.
Anesthesia by a preion
Analgetic property preion (see) it is expressed poorly; generally it has narcotic and somnolent effect. In this regard anesthesia of normal childbirth by means of a preion was not widely adopted. However to Dion's pra it is successfully appointed to women in labor at heavy late toxicosis and arterial hypertension of any etiology. Pre Dion is entered intravenously slowly (1 g within 3 — 5 min.) at the rate of 8 — 10 mg/kg. Usually use 2,5% the solution of a preion which is previously warmed up to t ° 35 — 36 °. As premedication intramusculary enter Promedolum (10 — 20 mg) in combination with isopromethazine (5 — 25 mg). In 3 — 5 min. after intravenous administration of a preion there comes the narcotic dream lasting 1 — 2 hour.
Contraindications to use of a preion in labor: arterial hypotonia, thrombophlebitis, suspicion on a «full» stomach (danger of vomiting and aspiration). Anesthetic gets through a placenta and can exert depressive impact on a fruit.
Anesthesia by method of a long peridural analgesia in labor
For carrying out the so-called prolonged peridural anesthesia carry out catheterization of peridural space by means of a special catheter. The puncture of peridural space is made according to the practical standard between acanthas of the II—V lumbar vertebrae (see. Anesthesia local, peridural ). Enter 10 — 15 ml of 2% of solution of Trimecainum or 10 — 15 ml of 2% of solution of a xycain (lidocaine) into peridural space. Regional anesthesia comes in 8 — 10 min. and proceeds within 50 — 60 min. For continuation its anesthetic is entered repeatedly in the same or in a half dose. Duration of finding of a catheter in peridural space is defined by a duration of delivery and fluctuates of several hours to 1 days. The full analgesic effect is noted at 82,3 — 97% of women in labor.
Indications: severe forms of late toxicosis, diskoordinirovan-ny patrimonial activity, a serious extragenital illness (the inborn and acquired heart diseases, the hypertension in a stage of an aggravation which is not giving in to medicamentous correction). The peridural analgesia in labor is justified only when simpler methods of anesthesia are insolvent. In the USSR peridural anesthesia, especially for the purpose of anesthesia of uncomplicated childbirth, did not find broad application in obstetric practice.
Contraindications: organic lesions back and a brain, diseases of blood, bleeding in labor, dysfunction of bodies of a small pelvis, long childbirth.
Anesthesia by method of an electroanesthesia in labor
Electroanesthesia (see) renders soothing and psychosedation that contributes to normalization of patrimonial activity and acceleration of childbirth.
Impact on c. the N of page is carried out by means of the device «Elektro-narkon-1». For these purposes the rectangular impulse current with the following parameters is used: frequency of current is from 500 to 1000 Hz, force 0,5 — 1 ma, duration of an impulse is 0,3 — 0,5 ms. Electrodes of a special design are imposed on frontal area (the doubled cathode) and under mastoids of a temporal bone (the doubled anode). Under electrodes enclose gauze napkins in 8 — 10 layers, the moistened 0,9% solution of sodium chloride. Duration of a session of an electroanesthesia 2 — 3 hours. If necessary the session can be repeated in 20 — 30 min. For increase in analgesic effect depending on a condition of the woman in labor Premedication by intramuscular introduction of 1 ml of 2% of solution of Promedolum or 1 ml of 2,5% of solution of isopromethazine is carried out.
Contraindications: organic diseases of c. N page, nervous and mental diseases, severe form of a nephropathy, preeclampsia, eclampsia.
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