Awareness and attitudes towards labour pain and ...

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endovascular stapler while both lungs were ventilated using a tidal volume of 6 mL/kg and a rate of 25 cycles/ min with airway pressures ranging between 22 and 27 cm of H2O. Post-operative pain relief was achieved by local infiltration and non-steroid anti-inflammatory drugs. Emergence from anaesthesia and post-operative period was uneventful for both the patients. Because both our patients were small children, debilitated, with poor pulmonary reserve, scheduled for short procedures, one-lung ventilation was unnecessary and not without complications. They also had upper respiratory tract infection. Therefore, two-lung ventilation was used with a PLMA. Use of low tidal volumes with increased respiratory rate ensured that airway pressures remained lesser than leak pressures for PLMA. Even if the procedures are of a longer duration or intraoperatively, if visualization is inadequate, an Arndt bronchial blocker may be inserted through the PLMA as shown by Li et al. for paediatric scoliosis correction surgery.[8]

Conclusion We conclude that the need for one-lung ventilation and the airway device used should be highly individualized according to the surgical need, the procedure undertaken and the patient’s pulmonary status.

4. 5.

6. 7. 8.

Olsfanger D, Jedeikin R, Fredman B, Shachor D. Endotracheal anaesthesia for transthoracic endoscopic sympathectomy. Br J Anaesth 1995;74:141-4. Kim H, Kim HK, Choi YH, Lim SH. Thoracoscopic bleb resection using two lung ventilation anaesthesia with low tidal volume for primary spontaneous pneumothorax. Ann Thorac Surg 2009;87:880-5. McGahren ED, Kern JA, Rodgers BM. Anaesthetic techniques for pediatric thoracoscopy. Ann Thorac Surg 1995;60:927-30. Rolf N, Cote CJ. Frequency and severity of desaturation events during general anesthesia in children with and without upper respiratory infections. J Clin Anesth 1995;42:1017-23. Li P, Liang W, Gu H. One-lung ventilation using Proseal laryngeal mask airway and Arndt endobronchial blocker in pediatric scoliosis surgery. Br J Anaesth 2009;103:902-3. Access this article online Quick response code Website: www.ijaweb.org

DOI: 10.4103/0019-5049.96330

Awareness and attitudes towards labour pain and labour pain relief of urban women attending a private antenatal clinic in Chennai, India

ACKNOWLEDGMENTS Consent of parents of both the children was also sought to allow us to publish the case reports.

Munisha Agarwal, Divya Jain, Vijyant Sabarwal Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College, New Delhi, India Address for correspondence: Dr. Divya Jain, Department of Anaesthesia, Maulana Azad Medical College, New Delhi, India. E-mail: [email protected]

REFERENCES 1. 2. 3.

Miller JI. The present role and future considerations of video assisted thoracoscopy in general thoracic surgery. Ann Thorac Surg 1993;56:804-6. Hurford WE, Alfille PH. A quality improvement study of the placement and complications of double lumen endotracheal tubes. J Cardiothorac Vasc Anesth 1993;7:517-20. Wong RY, Fung ST, Jawan B, Chen HJ, Lee JH. Use of a single lumen endotracheal tube and continuous CO2 insufflation in transthoracic endoscopic sympathectomy. Acta Anaesthesiol Sin 1995;33:21-6.

Indian Journal of Anaesthesia | Vol. 56| Issue 2 | Mar-Apr 2012

INTRODUCTION The awareness and attitudes towards labour pain and labour pain relief in antenatal women are not clearly known, particularly in developing countries. Childbirth, however fulfilling, is a painful experience for the majority of women.[1,2] Various pharmacological and non-pharmacological methods of labour analgesia are available. This survey was carried out to assess the women’s awareness and attitudes towards labor pain and labor pain relief.

METHODS The survey was conducted in the antenatal clinic of a 30-bedded private hospital in Chennai, India. After institutional approval and informed consent, the prepared questionnaire was handed to the women to be filled up while waiting for the antenatal check-up. Two hundred questionnaires were handed out, 109 were returned and 100 had answered most of the questions. 195



RESULTS The demographic data are presented in Table 1. The median age was 27.39 years. Almost all of the women (98/100) were educated (completed a minimum of study up to class 10 or more). Half of the women were home makers (56/100, 56%). Most of the women were primiparous (63/100, 63%). The primiparous women were assessed for their expectations about labour pain. Forty-one (41/63, 65.08%) expected to experience some degree of pain during labour [Table 2]. Fifty-one women (51/100, 51%) felt that labour pain should be relieved [Table 2]. Reasons to opt for pain relief were: To relieve pain (n=7), to relieve stress (n=5), to feel confident (n=2), to enjoy the experience (n=3) and better assessment of the baby (n=1). Some (24/100, 24%) felt that labour pain should not be relieved and a few of them gave the following reasons: It is a natural process (n=7), to be able to push the baby (n=2), no pain no gain (n=3) and it may lead to some other problem (n=1). The rest (25/100, 25%) had no opinion on whether labour pain should be relieved. Only 23% of the women (23/100) planned to ask for pain relief during the forthcoming delivery. Thirtysix percent of the women (36/100) did not intend to use any labour pain relief and 10% (10/100) wanted to have more information before they made a decision. Most of the women (78/100, 78%) had heard about methods to relieve labour pain mainly through the media and through their doctor [Table 3], but the majority (65/78, 83.33%) had no idea which method is useful. The rest (13/78, 16.67%) chose epidural injection, breathing exercises, injections, entonox and music therapy as useful methods. Thirty-six women (36/78, 46.15%) had concerns relating to the relief of labour pain. Their concerns were baby related (20/36, 55.56%) (baby may be affected, mother–baby bonding may be affected), labour related (n=14/36, 38.89%) (contractions may be unnatural, inability to push or use lower body parts, may lead to caesarean section or instrument use, labour may be unnatural) and/or pain relief method related (n=23/36,63.89%) (method may not work, back ache). 196

Table 1: Demographic data Demographic data Ages (years) 18–24 25–30 31–36 37–42 Total Education No education Class 10 Class 12 Graduate Post-graduate Total Occupation Home makers Software professional Other (teacher, medical professional, business) Total

Frequency

Percentage

20 60 19 1 100

20 60 19 1 100

2 3 4 49 42 100

2 3 4 49 42 100

56 12 32

56 12 32

100

100

Table 2: Awareness of nature of labour pain and attitude towards labour pain Awareness about labour pain No idea Pain free Painful (n=41) Mild Moderate Severe Should labour pain be relieved Yes No No opinion

Primipara (n=63) Frequency Percent 16 25.40 6 9.52 1 9 31

1.59 14.29 49.21

51 24 25

51 24 25

Table 3: Knowledge about labour pain relief methods Question Answer Frequency Percent Aware of labour pain Yes 78 78 relief methods Source of information* Media (radio, TV, 45 56.69 newspaper, internet, magazines, books) Doctor 34 43.59 Relatives and friends 31 39.74 Other (own 19 24.36 experience, labour class, medical professional) Knowledge of types Breathing exercises 42 53.85 of labour pain relief methods* Epidural injections 39 50.00 Injections 28 35.90 Entonox 17 21.79 Water birth 13 16.67 Music therapy 9 11.54 TENS 2 2.56 Hypnosis 1 1.28 *Women could choose more than one option ; TENS: Transcutaneous electrical nerve stimulation

Indian Journal of Anaesthesia | Vol. 56| Issue 2 | Mar-Apr 2012



DISCUSSION Two-thirds of the primiparas were aware that labour is painful. Uterine contractions, cervical dilatation and stretching of the lower uterine segment are responsible for pain during the first stage of labour. Visceral afferent C-type fibres accompanying the sympathetic nerves carry the pain impulses and enter the spinal cord at the T10-L1 levels. In the second stage of labour, somatic afferent fibres from the vagina and perineum convey pain impulses in the pudendal nerves to the S2-S4 spinal nerve roots.[1,2]

Further studies are necessary to ascertain and compare awareness and attitudes towards labour pain and labour pain relief in rural areas as opposed to urban areas, as also among men and non-pregnant women. The timing, best method and benefits of educating the antenatal woman also need to be determined in the Indian context.[4,10,11] Clinical studies may also be required to determine the most cost-effective method. Based on the information gained, necessary changes may be made in patient care and health policy.

CONCLUSION

Half the participants were in favour of labour pain being relieved but very few (18/51, 35.29%) could guess the beneficial effects of relieving pain and stress. This lack of knowledge is further confirmed by the poor response for plans to use labour analgesia (23/100, 23%). Labour pain results in the stimulation of the sympathetic nervous system leading to maternal hypertension and reduced uteroplacental blood flow. During labour, the woman may also hyperventilate, leading to leftward shift of the maternal oxygen– haemoglobin dissociation curve and a consequential reduction in the foetal arterial oxygen tension. Relief of pain and anxiety during labour may benefit the mother and foetus by decreasing maternal hyperventilation and catecholamine secretion.[2]

This descriptive study revealed that there is sufficient awareness that labour is painful and that there are ways to relieve labour pain. However, there is a lack of knowledge regarding the need for pain relief during labour, the various types of labour pain relief methods and their advantages and disadvantages.

The women in our survey are better informed than antenatal women in Nairobi, South Africa and Nigeria that labour pain can be relieved. However, their level of knowledge is similarly low.[3-6] There are many methods to relieve labour pain. The pharmacological methods known are parenteral opioids, epidural [1,7] analgesia, nitrous oxide and paracervical block. Some of the non-pharmacological methods are breathing exercises, transcutaneous electrical nerve stimulation, sterile water injections, acupressure, acupuncture, hydrotherapy, immersion bath, audioanalgesia, aromatherapy, hypnosis, labour support, massage and relaxation.[8,9] The ideal labour pain relief method must be safe and effective, and should not interfere with labour or the mobility of the parturient.[1] Only 36 women had any such concerns.

Joyce Nilima James, Kunder Samuel Prakash, Manickam Ponniah

Our survey had only 100 participants and did not study the effect of religion, age, parity or education on the awareness and attitudes to labour pain and labour pain relief. There are no Indian studies to determine these issues. Indian Journal of Anaesthesia | Vol. 56| Issue 2 | Mar-Apr 2012

Antenatal women should be educated about the need for labour pain relief and the available options. This may be done at an appropriate time during the antenatal visits by the obstetrician or Anaesthetist. The pregnant women’s knowledge may also be improved by the provision of information leaflets, labour pain websites and childbirth preparation classes.

Department of Anaesthesiology, CMC Velore, Tamil Nadu, India Address for correspondence: Dr. Joyce Nilima James, Department of Anaesthesiology, CMC Vellore - 632 004, Tamil Nadu, India. E-mail: [email protected]

REFERENCES 1.

Findley I, Chamberlain G. ABC of labor care. Relief of pain. BMJ 1999;318:927-30. 2. Ferne RB, Barbara MS, Cynthia AW, Alan CS. Obstetrical Anesthesia. In: Paul GB (editor). Clinical Anesthesia, 6th ed. New Delhi: Wolters Kluwer (India) Pvt. Ltd; 2009. p. 1142-5. 3. Mung’ayi V, Nekyon D, Karuga R. Knowledge, attitude and use of labour pain relief methods among women attending antenatal clinic in Nairobi. East Afr Med J 2008;85:438-41. 4. Mugambe JM, Nel M, Hiemstra LA, Steinberg WJ. Knowledge and attitude toward pain relief during labour of women attending the antenatal clinic of Cecilia Makiwane Hospital, South Africa. SA Fam Pract 2007;49:16-24. 5. Ibach F, Dyer RA, Fawcus S, Dyer SJ. Knowledge and expectations of labour among primigravid women in the public health sector. S Afr Med J 2007;97:461-4. 6. Olayemi O, Aimakhu CO, Udoh ES. Attitudes of patients to obstetric analgesia at the University College Hospital, Ibadan, 197



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Nigeria. J Obstet Gynaecol 2003;23:38-40. Leeman L, Fontaine P, King V, Klein MC, Ratcliffe S. The nature and management of labor pain: Part II. Pharmacologic pain relief. Am Fam Physician 2003;68:1115-20. Brown ST, Douglas C, Flood LP. Women’s evaluation of intrapartum nonpharmacological pain relief methods used during labor. J Perinat Educ 2001;10:1-8. Tournaire M, Theau-Yonneau A. Complementary and Alternative Approaches to Pain Relief During Labor. Evid Based Complement Alternat Med 2007;4:409-17. Raynes-Greenow CH, Roberts CL, McCaffery K, Clarke J. Knowledge and decision-making for labour analgesia of Australian primiparous women. Midwifery 2007;23:139-45. Stewart A, Sodhi V, Harper N, Yentis SM. Assessment of the effect upon maternal knowledge of an information leaflet about pain relief in labour. Anaesthesia 2003;58:1015-19. Access this article online Quick response code Website: www.ijaweb.org

DOI: 10.4103/0019-5049.96331

A rare case of hypertrophic obstructive cardiomyopathy posted for adrenalectomy for pheochromocytoma INTRODUCTION Phaeochromocytoma is a tumour of the adrenal medulla that secretes excessive amounts of catecholamine. The patients present with fluctuating blood pressure, sweating and palpitations.[1] Preoperative management consists of control of blood pressure and restoration of intravascular volume.[2] Hypertrophic obstructive cardiomyopathy is characterized by asymmetric hypertrophy of the myocardium resulting in left ventricular outflow tract obstruction. Decrease in venous return and systemic vascular resistance or increase in myocardial contractility worsens the outlet obstruction. Management of anaesthesia in these patients entails maintenance of haemodynamic parameters and management of specific complications like hypotension, dysrrhythmias and congestive heart failure.[3] The presence of both of these conditions together poses a unique problem because the opposite 198

management strategies like the use of vasodilators for control of blood pressure in pheochromocytoma intraoperatively can lead to sudden collapse in hypertrophic obstructive cardiomyopathy; also, presence of both the conditions increase the chances of cardiac failure and ischaemia. Hence, we present here a case of hypertrophic obstructive cardiomyopathy posted for adrenelectomy.

CASE REPORT A 56-year-old female weighing 45 kg came with complaints of palpitations, sweating, headache and episodes of dizziness since 4 years. On examination, she had a blood pressure of 180/106  mmHg and Mallampatti class I, while the rest of the examination was normal. The vinyl mandelic acid levels were 21.4 mg/24 h. Computed tomography of the abdomen showed a mass at the right adrenal of size 8 cm×7 cm. The iodine-131-meta-iodobenzylguanidine scan confirmed the tumour. The electrocardiogram showed severe left ventricular hypertrophy. 2d echocardiography showed an asymmetrical hypertrophy of the septum of 23.9 mm, severe left ventricular outlet obstruction with pressure gradient of 104 mmHg and diastolic dysfunction. Blood sugar level was normal. She was posted for adrenelectomy. To control her blood pressure, she was cautiously started on Tab. Phenoxybenzamine and Labetalol, which was gradually increased to the current dose of 100 mg and 40 mg BD, respectively. She was posted for surgery after control of blood pressure to 140/90 mmHg. Haematocrit before surgery was 30. After appropriate written informed consent, she was taken into the operation theatre. A pulseoximeter and defibrillator were attached. Intravenous fluids were started to preload the patient. An epidural was inserted at the T9-10 levels for post-operative analgesia with opioids only. Pre-medication consisted of Inj. Glycopyrrolate 225 µg IM, Inj. Midazolam 1 mg IV, Inj Fentanyl 50 µg IV, Inj. Clonidine 60 µg IV, Inj. Hydrocortisone 100 mg and Inj. Dexamethasone 8 mg along with antiemetics and antacids. The pulse was 80/min and blood pressure 140/96 mmHg. An arterial line and central venous line was inserted. Indian Journal of Anaesthesia | Vol. 56| Issue 2 | Mar-Apr 2012