Enumerate various methods for pain relief in labour and elaborate Technique, advantages and disadvantages of any one of them

                          Various methods of pain relief during labour are
                              |                                                                  |
Nonpharmacological                                                       Pharmacological

1. Childbirth Education                                               Systemic medication
2. Hydrotherapy                                                           Opiods like meperidine,fentanyl
3. Aromatherapy                                                         Sedative-Tranquiliser like barbiturate
4. Audiotherapy and massage                                     Phenothiazines and benzodiazepine
5. Psychoprophylasix                                                  Inhalational Analgesia like
6. Trancutaneous electrical nerve stimulation             Entonox 50 : 50 N₂O/O₂ mixture
7.                                                                                  Desflurane (0.2%), enflurane, and                                                                                                      isoflurane (0.2% to 0.25%)

In addition to the above pharmacological and nonpharmacogical methods there are certain regional techniques like

1. Epidural Analgesia
2. Spinal Analgesia
3. Combined Spinal-Epidural Analgesia
4. Continuous Epidural Infusion
5. Patient-Controlled Epidural Analgesia
6. Paracervical and Pudendal Blocks
7. Lumbar Sympathetic Blocks

EPIDURAL ANALGESIA

Advantages: 

• Effective pain relief and attenuation of adverse physiological response to pain 
• Reduction in maternal catecholamine levels
• Increased maternal intervillous blood flow
• Improved uteroplacental blood flow
• Can be converted into continuous epidural and patient controlled epidural analgesia
• The epidural catheter can be used to provide anesthesia in inadvertent ceaserian section and post operative analgesia of the same

DISADVANTAGES

• Hypotension
• Unintentional intravascular injection
• Unintentional intrathecal injection
• Post puncture dural headache
• Maternal fever

TECHNIQUE

Assess all patients before placement of a regional block with history, clinical examination, and evaluating the airway.Informed consent is obtained, and the patient explained the procedure and the potential complications of the technique. 

A full check of emergency equipment ,immediate availability of resuscitative drugs and an intravenous infusion  started, and appropriate maternal and fetal monitoring should be in place before starting the procedure.
Epidural technique requires placement of the needle tip into the ligamentum flavum for the loss-of-resistance and hanging-drop methods.

With a lumbar approach  Touhy 18G needle is used and  the depth from skin to the ligamentum flavum commonly approaches 4 cm, the midline, which requires needle control if unintentional dural puncture is to be prevented.The loss-of-resistance technique involves inserting the needle to the ligamentum flavum and then attaching a 3- to 5-mL glass syringe filled with 2 mL of saline and a small (0.25-mL) air bubble.  When the epidural space is entered, the pressure applied to the syringe plunger allows the solution to flow without resistance into the epidural space.
epidural catheters should be inserted only 2 to 3 cm into the epidural space for surgical or obstetric patients needing rapid onset of analgesia. Threading more catheter may increase the likelihood of catheter malposition but in obstetric patients the catheter can be inserted between 4 and 6 cm to optimize efficacy and prevent unintentional movement of the catheter during prolonged labor analgesia. Multiport (three lateral ports) or single–end-hole (uniport or distal port) catheters are available.  Despite an adequately positioned catheter during first use of a local anesthetic, each subsequent injection should be preceded by aspiration and an epidural test dose because catheter migration into vessels and the subarachnoid or subdural space does occur.

Long-acting amides such as bupivacaine or ropivacaine are most frequently used because they produce excellent sensory analgesia while sparing motor function, particularly at low concentrations (<0.1%). Analgesia for the first stage of labor may be achieved with 5 to 10 mL of bupivacaine or ropivacaine (0.125%) combined with fentanyl (50 to 100 µg) or sufentanil (5 to 10 µg).    

                                                                                         

Criteria for Discharge after day care surgery

All patients must be evaluated prior to discharge from PACU and discharge criteria are established depending whether the patient is going to ICU, regular ward, outpatient department or directly to home
Mandatory stay in PACU for specified time is not required,patient are observed for their ability to protect airways with no respiratory depression and mental function is clear.

Evaluation of the patient in PACU for discharge is under the following guidelines

 Patients should be alert and oriented or mental status returned to baseline.
   2.     A minimum mandatory stay is not required.
   3.     Vital signs should be stable and within acceptable limits.
   4.     Discharge should occur after patients have met specified criteria.
   5.     Use of scoring systems may assist in documentation of fitness for discharge.
   6.     The requirement to urinate before discharge and drink and retain clear liquids should not be part of a routine discharge protocol although they may be appropriate for selected patients.
   7.     Outpatients should be discharged to a responsible adult who will accompany them home.
   8.     Outpatients should be provided with written instructions regarding postprocedure diet, medications, activities, and a phone number to call in case of emergency.

Two Most Commonly Used Postanesthesia Care Unit Discharge Criteria Systems

MODIFIED  ALDRETE SCORING SYSTEM POSTANESTHETIC DISCHARGE SCORING SYSTEM Respiration Vital signs 2 = Able to take deep breath and cough 2 = BP + pulse within 20% preop baseline 1 = Dyspnea/shallow breathing 1 = BP + pulse within 20–40% preop baseline 0 = Apnea 0 = BP + pulse >40% preop baseline O2 saturation Activity 2 = Maintains Spo2 >92% on room air 2 = Steady gait, no dizziness or meets preop level 1 = Needs O2 inhalation to maintain O2 saturation >90% 1 = Requires assistance 0 = O2 saturation <90% even with supplemental oxygen 0 = Unable to ambulate Consciousness Nausea and vomiting 2 = Fully awake 2 = Minimal/treated with PO medication 1 = Arousable on calling 1 = Moderate/treated with parenteral medication 0 = Not responding 0 = Severe/continues despite treatment Circulation Pain 2 = BP ± 20 mm Hg preop Controlled with oral analgesics and acceptable to patient: 1 = BP ± 20–50 mm Hg preop 2 = Yes 0 = BP ± 50 mm Hg preop 1 = No Activity Surgical bleeding 2 = Able to move four extremities voluntary or on command 2 = Minimal/no dressing changes 1 = Able to move two extremities 1 = Moderate/up to two dressing changes required 0 = Unable to move extremities 0 = Severe/more than three dressing changes required Score ≥9 for discharge Score ≥9 for discharge BP, blood pressure; PO, oral. Controlling post operative pain,controlling nausea and vomiting and re-establishing normothermia. Patients in majority meet the above criteria within 60 minutes and in addition to the above pateint receiving regional anesthesia should show signs of proprioception,sympathetic,bladder resolution and motor blockade Day care cases should be further evaluated for home readiness and complete psychomotor recovery. All out patients shouls be discharged home in the company of a responsible adult and with written post operative notes and emergency help details and perform routine follow up.