|Year : 2018 | Volume
| Issue : 2 | Page : 96-98
Labor analgesia with intradermal sterile water block in a patient with dilated cardiomyopathy
Nitin Choudhary, Kirti Nath Saxena, Bharti Wadhwa
Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College, New Delhi, India
|Date of Web Publication||3-Oct-2018|
Dr. Nitin Choudhary
Flat No.-F/2, Plot No.-853, Vaishali Sector-5, Ghaziabad - 201 010, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Epidural analgesia is the gold standard for providing labor analgesia, but an obstetric anesthesiologist should be well versed with many other non-pharmacological modalities of pain management. The present case highlights the importance of non-pharmacological methods of labor analgesia that might be the only options available in certain subset of patients to provide adequate labor analgesia.
Keywords: Dilated cardiomyopathy, intradermal sterile water block, labor analgesia
|How to cite this article:|
Choudhary N, Saxena KN, Wadhwa B. Labor analgesia with intradermal sterile water block in a patient with dilated cardiomyopathy. J Obstet Anaesth Crit Care 2018;8:96-8
|How to cite this URL:|
Choudhary N, Saxena KN, Wadhwa B. Labor analgesia with intradermal sterile water block in a patient with dilated cardiomyopathy. J Obstet Anaesth Crit Care [serial online] 2018 [cited 2019 Feb 22];8:96-8. Available from: http://www.joacc.com/text.asp?2018/8/2/96/242621
| Introduction|| |
Central neuraxial blockade remains the gold standard for providing labor analgesia, but it has certain drawbacks. Non-pharmacological methods are not routinely used modalities of labor analgesia, but an obstetric anesthesiologist should have equal knowledge and expertise in them as they may prove boon in patients where central neuraxial blockade is contraindicated. Non-pharmacological methods are safer with no definite contraindication for their use in labor analgesia.
We discuss the case of a diabetic parturient with dilated cardiomyopathy and undiagnosed neuropathy; planned for labor analgesia. This case report lays emphasis on the non-pharmacological methods of labor analgesia especially intradermal sterile water injection as an effective tool for pain management in conditions where conventional epidural analgesia may not be practiced.
| Case Report|| |
33-year-old multigravida, 75 kg, body mass index 29.1 kg/m2, with history of 9 months amenorrhoea presented for preanesthetic check-up for labor analgesia. She was found to be a known case of dilated cardiomyopathy which was diagnosed during 7th month of pregnancy when she had presented to the antenatal clinic with complains of cough with expectoration and difficulty in breathing. Patient was a known diabetic since 8–9 years (diagnosed during last pregnancy) on oral hypoglycaemic agents. She also had loss of sensations over the anterior aspect of right thigh since 2 years. On physical examination of chest, she had bilateral rhonchi and pansystolic murmur. The rhonchi were ascribed to lower respiratory tract infection for which she was receiving treatment. Neurological examination revealed loss of sensations over the anterior aspect of right thigh with absent bilateral ankle jerk and absent right knee jerk. Neurology opinion was taken for the same, and the patient was advised magnetic resonance imaging (MRI) of the lumbar sacral region and nerve conduction velocity test. Because the neurological symptoms were neither acute in onset nor had worsened during the pregnancy, neurologist advised that MRI could be done after the patient had delivered. At the time of assessment, the medications that the patient was on were furosemide 20 mg twice a day, digoxin 0.125 mg once daily, metformin 1 gm twice daily, and carvidelol 3.125 mg once a day orally. Electrocardiogram showed sinus bradycardia. Echocardiography (ECHO) was suggestive of dilated cardiomyopathy, ejection fraction 25–30%, severe ventricular septal defect, moderate mitral regurgitation, and moderate tricuspid regurgitation. Glycosylated hemoglobin was 8.7%, while other hematological investigations were within normal limits. Patient was given ASA III physical status. At the time of preanesthetic check up, patient was counseled regarding the various modalities of pain management available in the institution and considering the risks, benefits, and comorbidities; the entire plan of labor analgesia was formulated. She was educated about intradermal sterile water block and visual analogue scale (VAS).
When the patient went into spontaneous labor, oxygen was administered with left lateral position, and the pain was hourly monitored using VAS along with the per vaginal findings as informed by the obstetrician. At VAS score of 3/10, paracetamol 1 gm IV infusion was administered. As patient progressed into active stage of labor (per vaginal finding of 4 cm cervical dilatation), her pain intensified with VAS score mounting to 8/10 and as planned intradermal sterile water block was administered to her. For administering the block, 4 injections each of 0.1 ml of sterile water (total 0.4 ml sterile water) were given intradermally at posterior superior iliac spine on each side and second point was 1 cm medial and 1 cm caudal to posterior superior iliac spine on each side using an insulin syringe. Within 15 min of block administration, the patient was almost pain free with a VAS score of 3/10. Intravenous paracetamol was readministered 6 h after the last dose. The VAS score remained 2–3/10 during the entire active phase of labor which lasted for 6 h. At the time of delivery, episiotomy was done after giving local anesthesia. The baby was healthy with APGAR score 9/10. The patient was comfortable thereafter and had no signs of respiratory distress or cardiac failure post delivery of baby.
| Discussion|| |
Labor analgesia is frequently administered to parturients when demanded or when there are medical indications, where labor analgesia is recommended especially in heart disease patients. Labor analgesia has come a long way from the use of chloroform in 1847 to the present day central neuraxial blockade in the form of epidural analgesia. Labor analgesia in the form of walking epidurals is routinely practiced in many institutions. However, central neuraxial blockade has certain absolute and relative contraindications and in patients where it cannot be offered one must know what other modalities of labor analgesia can be used in the best interest of the patient.
This patient was a multigravida parturient with heart disease and neuropathy which was under evaluation. Labor analgesia was required in our patient owing to her disease status to decrease the stress on the heart that would have aggravated the underlying pathology. However, the symptoms suggestive of neuropathic involvement prohibited us from going for central neuraxial blockade unless the exact etiology was known. Patient was a known case of diabetes mellitus since 8–9 years, not well controlled on oral hypoglycaemic agents. Diabetic neuropathy usually presents in glove and stocking distribution unlike the presentation in our patient where there was paraesthesia present over the anterior aspect of her right thigh that suggested spinal involvement.
In such a situation, the other pharmacological options are patient controlled intravenous or inhalational analgesia. They require special equipments; educated patient and proper monitoring with trained staff nurses. Our health facility lacks the infrastructure for it so we opted for intravenous paracetamol infusion for early labor pain.
There are many non-pharmacological methods for labor analgesia that are not routinely used either because of lack of evidence to support their definitive role in control of pain or the lack of experience and knowledge of the attending obstetric anesthesiologist about these modalities of pain management. Transcutaneous electrical nerve stimulation, continuous support in labor, touch and massage, water bath, intradermal sterile water injections, acupuncture, and hypnosis, all may be beneficial for the management of pain during labor.
Intradermal sterile water injection is a safe technique for labor analgesia., The injections are given at four points that overlie Michaelis rhomboid formed by L5 vertebrae superiorly, upper end of natal cleft inferiorly, and posterior iliac spines on either side. It is very well-known that uterine contractions are felt as back pain because rami of T10 – L1 supplying the uterus also supply the skin over the lumbo-sacral area. Injecting solutions of osmolality other than blood irritates biological tissues. Sterile water injection evokes intense pain, probably because of the difference in osmolality. Stimulation of skin during administration of sterile water gives rise to a similar gate control effect and/or a stimulation of the endogenous opioid system. The advantages of this technique are easy learning curve, can even be given by trained paramedics, give immediate effect, no effect on baby, no effect on mother's state of consciousness, does not limit mobility, and can be repeated if required., Saxena et al. in their study gave sterile water block (0.5 ml of sterile water at each of the 4 injection sites) to 50 pregnant patients and found significant reduction of pain scores in all the patients with sterile water block at 10, 45, and 90 min after injection with effective pain control. There was not a significant difference in the mean time between the administration of injection and delivery. They did not find any complication or side effect pertaining to this technique in any patient of the study group. Utility of this technique in second stage of labor has not been studied and requires further studies. In a meta-analysis by Hutton et al., they included 8 randomized control trials and found cesarean rate of 4.6% with sterile water injection group and 9.9% in comparison group.
Incorporating this technique as one of the component of multimodal analgesia helped us in attaining the goal of adequate pain management. Intradermal sterile water injection along with paracetamol provided adequate pain relief. There was never a need to repeat intradermal sterile injection as the parturient was multigravida and the first stage of labor lasted for only 8 h. The technique did not prolong the first stage of labor as the normal duration of first stage of labor in a multigravidae is 3–8 h. At the time of delivery, local anesthetic solution infiltration took care of the incision pain. The pain was well managed, and patient was able to deliver with no cardiovascular compromise. The post delivery period was uneventful for the patient.
To conclude, intradermal sterile water block is an effective non-pharmacological technique for labor. Non-pharmacological methods can make a significant difference in patient management and anesthesiologist practicing labor analgesia must be well versed with various modalities for the patient who is different. In this patient, meticulous planning with multimodal approach by inculcating pharmacological and non-pharmacological methods of labor analgesia resulted in fruitful outcome of healthy mother and child.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Hawkins JL. Epidural analgesia for labor and delivery. N Engl J Med 2010;362:1503-10.
Pandya ST. Labour analgesia: Recent advances. Indian J Anaesth 2010;54:400-8.
] [Full text]
Bansal V, Kalita J, Misra UK. Diabetic neuropathy. Postgrad Med J 2006;82:95-100.
Simkin PP, O'hara M. Nonpharmacologic relief of pain during labor: Systematic reviews of five methods. Am J Obstet Gynecol 2002;186:S131-59.
Ader L, Hansson B, Wallin G. Parturition pain treated by intracutaneous injections of sterile water. Pain 1990;41:133-8.
Trolle B, Møller M, Kronborg H, Thomsen S. The effect of sterile water blocks on low back labor pain. Am J Obstet Gynecol 1991;164:1277-81.
Bansal S, Guleria K, Agarwal N. Evaluation of sacral rhomboid dimensions to predict contracted pelvis: A pilot study of Indian primigravidae. J Obstet Gynaecol India 2011;61:523-7.
Bonica JJ. Peripheral mechanisms and pathways of parturition pain. Br J Anaesth 1979;51:s3-9.
Wreje U, Brorsson B. A multicenter randomized controlled trial of injections of sterile water and saline for chronic myofascial pain syndromes. Pain 1995;61:441-4.
Melzack R, Schaffelberg D. Low-back pain during labor. Am J Obstet Gynecol 1987;156:901-5.
Mårtensson L, Wallin G. Sterile water injections as treatment for low-back pain during labour: A review. Aust N
Z J Obstet Gynaecol 2008;48:369-74.
Saxena KN, Nischal H, Batra S. Intracutaneous injections of sterile water over the secrum for labour analgesia. Indian J Anaesth 2009;53:169-73.
] [Full text]
Hutton EK, Kasperink M, Rutten M, Reitsma A, Wainman B. Sterile water injection for labour pain: A systematic review and meta-analysis of randomised controlled trials. BJOG 2009;116:1158-66.
Steer P, Flint C. ABC of labour care: Physiology and management of normal labour. BMJ 1999;318:793-6.