HOW TO HANDLE LABOR PAIN: THE MYTHS AND THE REALITY By Meredith A. - - PDF document

4/8/2019 1

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

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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,

• perative delivery, C-section delivery)

 Long lasting but consistent pain relief – that can be

adjusted as the patient desires

 Low cost and low resources used

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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?

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PAIN DURING LABOR PAIN DURING LABOR

T10-L1 T10-L1 and S1 S1-S4

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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)

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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.

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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

• bstruction, recent inner ear or eye

surgery

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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?

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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

Anesth Analg 2017;124:548–53 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)

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PHARMACOLOGICAL PAIN RELIEF: EPIDURAL PHARMACOLOGICAL PAIN RELIEF: COMBINED SPINAL EPIDURAL (CSE)

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PHARMACOLOGICAL PAIN RELIEF: DURAL PUNCTURE EPIDURAL (DPE)

Anesthesia & Analgesia124(2):375, February 2017.

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EPIDURAL VS. CSE VS. DPE – SHOULD I CARE?

Epidural

 Slower onset: 15-20

min

 Less dense block  Tested catheter  No increase in PDPH

risk

 Increased

interventions at start of epidural

CSE DPE

 Fastest onset: 5-8 min  Dense block  Untested catheter  Slight increase

increase in PDPH risk

 Increased intervention

when transitioning from spinal to epidural

 Medium onset: 10-15

min

 Less dense block  Tested catheter  Slight increase in PDPH

risk

 Better sacral coverage

than epidural

 Less side effects

(itching, hypotension, 1 sided catheters)

 Less interventions

Anesthesia & Analgesia124(2):375, February 2017.

EPIDURAL COMPLICATIONS: SCORE PROJECT

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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

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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

• r >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)

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EPIDURAL MYTHS: INCREASED LENGTH OF LABOR? MAYBE FOR SECOND STAGE

 First Stage: Several RCTS – have shown decreased first stage

duration with epidural vs. opioid analgesia (Am J Obstet

• Gynecol. 2006;194(3):600; Obstet Gynecol. 2009;113(5):1066; and
• Anesthesiology. 2009;111(4):871)

 Second Stage: difficult to measure since depends on timing of

cervical exam rather than an event – RCTs of recent trials with lower local anesthetic concentrations

 2011 (low and high dose LA) meta-analysis – increase of 14 min

(Cochrane Database Syst Rev. 2018;5)

 2017 (only low concentration LA) meta-analysis – mean increase of 6

min (Anesth Analg. 2017;124(5):1571)

EPIDURAL MYTHS: BACK PAIN? NO DIFFERENCE BUT IT IS REALLY HIGH…

 Patients with no history of pre-pregnancy lower back pain (LBP)

 Epidural vs. no Epidural NO DIFFERENCE in incidence of back pain at

3 months (34%), 6 months (29%) and 1 year (10 %)

 BMJ. 1996 Jun 1;312(7043):1384-8, Br J Anaesth. 2002;89(3):466, and

Anesth Analg. 1997 Nov;85(5):1066-70

 Patient with a history of chronic lower back pain

 Epidural use does cause an increased rate of postpartum back pain

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EPIDURAL MYTHS: EPIDURALS EFFECT BREAST FEEDING? MOST LIKELY NO…

 Very difficult to study  Literature insufficient to make recommendations and is

contradictory

 RCT with N=950 no difference in breast feeding at 6 weels

• r 3 months in patients with epidurals that had bupivacaine

with no fentanyl, 1 mcg/ml fentanyl, or 2 mcg/mL fentanyl.

 Patients had breast fed in the past and planed to for this

pregnancy

 Epidural Labor Analgesia-Fentanyl Dose and Breastfeeding

Success: A Randomized Clinical Trial. Anesthesiology. 2017;127(4):614

QUESTIONS