4/8/2019 HOW TO HANDLE LABOR PAIN: THE MYTHS AND THE REALITY By Meredith A. Albrecht, MD PhD Associate Professor Chief of OB Anesthesiology Department of Anesthesiology Medical College of Wisconsin NO FINANCIAL DISCLOSURES 1
4/8/2019 OBJECTIVES What is the perfect labor analgesia? What are the typical ways to help patients with labor pain? What are the advantages/disadvantages of nitrous for labor pain relief? What are the common myths about epidurals/neuraxial anesthesia? WHAT IS THE “IDEAL” LABOR ANALGESIC? Safe for Mother and Baby -- minimal to low risk Minimal effects on the progress of labor Flexible as the situation changes (vaginal delivery, operative delivery, C-section delivery) Long lasting but consistent pain relief – that can be adjusted as the patient desires Low cost and low resources used 2
4/8/2019 CURRENT METHODS OF LABOR PAIN RELIEF: Nonpharmacological IV/IM/po opioids or agonist-antagonists Nitrous oxide Neuraxial anesthesia Epidural (Epi) Serial labor spinals Combined spinal epidural (CSE) Dural puncture epidural (DPE) HOW PAINFUL IS LABOR? 3
4/8/2019 PAIN DURING LABOR PAIN DURING LABOR T10-L1 T10-L1 and S1 S1-S4 4
4/8/2019 ADVERSE CONSEQUENCES OF LABOR PAIN Hyperventilation Stress and pain – decreased placental perfusion and fetal oxygenation (increased catecholamines) Psychological – trend towards increased postpartum depression and rarely PTSD (1-7% incidence -- UpToDate pharmacological management of pain during labor accessed 4/1/2019) LABOR PAIN: WHAT DO PATIENTS WANT? Focus: How to better cope with pain – NOT to make pain disappear Patient’s overall desires: Desire to be informed and participate in the decision making process around pain management (BMC Med 2008; 6:7.) Continuous individualized support (reduced feelings of loneliness and fear) Acceptance of the need for experiencing some pain to birth their infant (Midwifery 2015; 31:349) 5
4/8/2019 NON-PHARMACOLOGICAL PAIN RELIEF Childbirth Education (lack of evidence – trend to decreased anxiety or fear – Birth 2018; 45:7.) Support person during labor (partner, family, friends, doula) Low resource: movement, birth ball, touch and massage, acupressure, application of cold or heat, breathing techniques with relaxation, showers, music and audio stimulation Moderate resource: aromatherapy, acupuncture, yoga, sterile water injection (water blocks), hypnosis, biofeedback, transcutaneous electrical nerve stimulation (TENS), water immersion High resource: pharmacological therapies PHARMACOLOGICAL PAIN RELIEF: SYSTEMIC Generally opioids or mixed opioid agonist-antagonists Not as effective at pain relief as neuraxial anesthesia Side effects of sedation, respiratory depression (maternal and fetal), nausea, and vomiting Examples: IV fentanyl, nalbuphine (nubain), morphine, merperidine, etc. PCA – fentanyl or remifentanil – generally better pain relief Advantages: easy, readily available, lower cost, less invasive Associated with moderate patient satisfaction with labor pain relief but 2/3 reported poor or moderate pain relief after 2 hours Fetal effects unknown Smith LA, Burns E, Cuthbert A. Parenteral opioids for maternal pain management in labour. Cochrane Database of Systematic Reviews 2018, Issue 6. 6
4/8/2019 PHARMACOLOGICAL PAIN RELIEF: INHALATIONAL – NITROUS OXIDE Mix of 50% oxygen and 50% nitrous oxide Colorless and odorless gas First synthesized in the late 1700s by the English theologian and scientist Joseph Priestly In 1881 nitrous oxide was first administered as a labor analgesic by Stanislav Klikovich While used commonly worldwide – increased use in the USA since FDA approval of delivery devices in 2012 PHARMACOLOGICAL PAIN RELIEF: INHALATIONAL – NITROUS OXIDE Patient self-administers with mask (demand valve) – requiring sealed inhalation and exhalation 50 sec lag to effect – should start 30 sec prior to contractions Side effects: nausea 13%, dizziness 3% to 5%, and drowsiness 4% Avoid in patients with: serious lung conditions, B12 deficiency, PTX, bowel obstruction, recent inner ear or eye surgery 7
4/8/2019 PHARMACOLOGICAL PAIN RELIEF: INHALATIONAL NITROUS OXIDE IS NOT AN EPIDURAL https://www.mdedge.com/obgyn/article/164290/obstetrics/inhal ed-nitrous-oxide-labor-analgesia-pearls-clinical-experience accessed 4/1/2019 PHARMACOLOGICAL PAIN RELIEF: INHALATIONAL – NITROUS OXIDE DOES ITS USE AFFECT THE EPIDURAL RATE? 8
4/8/2019 PHARMACOLOGICAL PAIN RELIEF: INHALATIONAL – NITROUS OXIDE PATIENT PAIN RELIEF NOT GREAT!! Anesth Analg 2017;124:548–53 PHARMACOLOGICAL PAIN RELIEF: INHALATIONAL – NITROUS OXIDE PATIENT SATISFACTION AMAZING among parturients who reported poor analgesia effectiveness (0−4; n = 257), those who received nitrous oxide as the sole analgesic modality were more likely to report high overall satisfaction than those who received neuraxial analgesia alone (OR 2.5; 95% CI 1.4−4.6; P = .002) Anesth Analg 2017;124:548–53 9
4/8/2019 PHARMACOLOGICAL PAIN RELIEF: EPIDURAL PHARMACOLOGICAL PAIN RELIEF: COMBINED SPINAL EPIDURAL (CSE) 10
4/8/2019 PHARMACOLOGICAL PAIN RELIEF: DURAL PUNCTURE EPIDURAL (DPE) Anesthesia & Analgesia124(2):375, February 2017. 11
4/8/2019 EPIDURAL VS. CSE VS. DPE – SHOULD I CARE? Epidural DPE CSE Fastest onset: 5-8 min Slower onset: 15-20 Medium onset: 10-15 min min Dense block Less dense block Less dense block Untested catheter Tested catheter Tested catheter Slight increase increase in PDPH risk Slight increase in PDPH No increase in PDPH risk Increased intervention risk when transitioning Better sacral coverage Increased from spinal to epidural than epidural interventions at start of epidural Less side effects (itching, hypotension, 1 Anesthesia & sided catheters) Analgesia124(2):375, February 2017. Less interventions EPIDURAL COMPLICATIONS: SCORE PROJECT 12
4/8/2019 EPIDURAL COMPLICATIONS: MINOR Hypotension Pruritus Nausea and vomiting Fever Urinary retention Shivering Postdural puncture headache (PDPH) – 1-0.5% EPIDURAL MYTHS: DOES WHEN THE EPIDURAL IS PLACED DURING LABOR MAKE A DIFFERENCE? NO Early (<4 cm) vs. Late in labor placement of epidural – NO DIFFERENCE ON Cesarean Delivery rate, instrumental delivery, duration of second stage or fetal outcomes Neuraxial anesthesia should be given at patient request Early versus late initiation of epidural analgesia for labour; Cochrane Database Syst Rev. 2014 American College of Obstetricians and Gynecologists. Obstetric analgesia and anesthesia. ACOG practice bulletin #36. Obstet Gynecol 2002; 100;177 13
4/8/2019 EPIDURAL MYTHS: INCREASED C- SECTION RATE? NO Multiple RCTs and a meta-analysis in 2018 have shown neuraxial anesthesia DOES NOT increase the risk of Cesarean delivery (RR 1.07 with 95% CI 0.96-1.08) Epidural versus non-epidural or no analgesia for pain management in labour Cochrane Database Syst Rev. 2018;5. Epub 2018 May 21. EPIDURAL MYTHS: INCREASED INSTRUMENTED DELIVERY RATE? IT DEPENDS… Neuraxial analgesia with high concentrations of local anesthetic may increase the rate of instrumental delivery (more motor block) Use of low concentration local anesthetics with opioids is now standard practice (i.e. bupivacaine <= 0.1%) 2013 meta-analysis of RCT low vs. high concentrations (>0.1% bupivacaine or >0.17% ropivacaine) of local anesthetics – OR 0.70 (95% CI 0.56 to 0.86) for instrumented deliveries (The effect of low concentrations versus high concentrations of local anesthetics for labour analgesia on obstetric and anesthetic outcomes: a meta-analysis. Can J Anaesth. 2013;60(9):840) 2017 meta-analysis of RCTs including only dilute LA found no difference in the instrumental delivery rate (Effects of Epidural Labor Analgesia With Low Concentrations of Local Anesthetics on Obstetric Outcomes: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Anesth Analg. 2017;124(5):1571) 2018 meta-analysis of RCTS after 2005 no difference in instrumental delivery rate (Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev. 2018;5) 14
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