Options for labour analgesia when an epidural is not possible

Damien Hughes

Ulster Hospital

Belfast

Why are we here?

Why are we here?

Basis of presentation

• Evidence…

• Anecdote….

• Opinion…..

Plus ça change…..

• Basic choices…..

• Pharmacological or non-pharmacological

• Systemic or regional

• Opioid based or local anaesthetic based

Plus ça change…..

• Basic choices…..

• Pharmacological or non-pharmacological

• Systemic or regional

• Opioid based or local anaesthetic based

Non-pharmacological analgesia

• Usually not us,

– TENS, water, acupuncture etc but…

Non-pharmacological analgesia

• Hypnosis…?!

• Antenatal self-hypnosis for labour and childbirth: A pilot study– 77 women (control 3249)

– Nulliparous: fewer epidurals, fewer augmentations

– Possible benefit, further research needed• AM Cyna et al

– Anaesthesia and Intensive Care, 2006; 34 (4):464-469, Australian Society of Anaesthetists

However…

• Hypnosis for pain management during labour and childbirth (Review)

– Madden K, Middleton P, Cyna AM, Matthewson M, Jones L • The Cochrane Library 2012,

Issue 11

• No benefit shown for analgesia requirements

Pharmacological options

• Systemic– Entonox

– IM opioid

– Opioid PCA • remifentanil

• Regional– Epidural

– CSE

– Spinal

50% don’t have an epidural

• Patient preference

• No “epidural service”

• Thrombocytopenia

• Anticoagulation

• “Back problems”

• “Neurological”

• “Sepsis”

Systemic analgesia

• Nitrous Oxide

– Ubiquitous UK (not USA!)

– Patient control• Psychological benefit

– Low blood-gas solubility• Ideal for intermittent use

• Rapid on-off effect

• Doesn’t accumulate with intermittent use

– Often as an adjunct

No “laughing” matter

• Disadvantages

– Drowsiness, sedation

– Nausea (labour itself)

– Hyperventilation (sole agent)• Reduced UBF

• Hypocapnia

– Hypoventilation (with opioid)

– Marrow depression• Repeated use, longer term

• Recent case pancytopaenia UHD

– NISA study day 2013

Pancytopaenia with nitrous use

0

2

4

6

8

10

12

0

50

100

150

200

250

300

350

400

Plts

Hb

WBC

Entonox

Opioids

• Mainstay of systemic analgesia

• Intermittent bolus regimen

• Administered by midwives

I.M Pethidine• “more sedation than analgesia”1

• gastric stasis & hypoventilation 2

• fetal effects after 40 mins 3

• dose-delivery <2-3hrs 4

• modifies CTG & EEG 5

• fetal acidosis 6

• active metabolites for days 7

1. Olofsson et al. B J Obs Gynaecol 1996;103:968-72

2. Nimmo et al. Lancet 1975;1(7912):890-3

3. Tomson G et al. B J Clinical Pharmacology 1982;13:653-9

4. Shnider SM, Moya F. Am J Obstet Gynecol 1964;89:1009-15

5. Kariniemi V, ammala P. B J Ob Gynaecol 1981;88:718-20

6. Kariniemi V, Rosti J. J Perinatal Med 1986;14:131-5

7. Hodgkinson R, Farkhanda JH. Anesthesiology 1982;56:51-2

The search for an alternative...

• Match time course of labour

• Not midwife delivered, patient control

• Few maternal & neonatal adverse effects

Rapid onset and offset & intravenous

PCA device

Non cumulative

% o

f p

eak

eff

ect

site

con

centr

atio

n

Fentanyl

Alfentanil

100

0

Time since bolus (min)

2 4 6

Effect site concentration after opioid bolus

80 10

Remifentanil

Remifentanil pharmacokinetics in neonates

• Infants under 2 months

• Pharmacokinetics similar

– to older children

– to adults

Davis, Ross Henson et al, Remifentanil pharmacokinetics in neonates.

Anesthesiology 1997; 87: A 1054

Remifentanil PCA

• Theory behind technique– PCA giving control improves

satisfaction

• Theory behind choice of drug– Ultra short-acting, rapidly

metabolised

– Placental transfer, but rapid metabolism in neonate• Kan et al Anesthesiology1998;

88: 1467-74

– Context sensitive t1/2 3-5min

– Ideal for intermittent pain of labour?

Remi pca in practice• Feasibility for labour analgesia

2001 – Blair et al, BJA 2001

• Optimum bolus 0.5mcg/kg, no background infusion– Superior to pethidine

• Blair et al, BJA 2005

• Shown superior to pethidine– efficacy, satisfaction, conversion to

epidural• Thurlow et al BJA 2002, Douma et al

BJA 2010

• No difference in neonatal outcomes– Review by Leong et al Anes & Analg

2011

Remi pca protocol

• Strict guideline

– Dedicated IV cannula

– Locked pump programme• 40mcg bolus, 2min lockout

– Obs chart• SpO2, resp rate, pain /

sedation scores

– Anaes present for first 4-5 boluses

– Trained midwife in attendance

Safety with remi

• One-to-one midwifery care

• Anaesthetist prescribes and starts pca

• Strict monitoring

• Observation chart

• Immediate oxygen and resuscitation availability

• Continuous audit

Side effects

• Nausea

– approx 90% use Entonox

• Itch

• Sedation

• Respiratory depression

• Episode of desaturation <94%: 25-30%

• Almost all recover with nasal specs oxygen

Patient info sheet

• Salient points

– Unlicensed use

– Audit data re safety

• Given out at ante-natal clinic

• Laminated copy in rooms

• Reiterate in labour ward at request

Remifentanil PCA documentation • Informed about Remifentanil □ At least 37 weeks □• Information leaflet read □ No recent opiate use □• Aware unlicensed use □• PCA technique explained – lockout/timing of demands/patient use only □•

• Risks discussed:• Sedation □ Respiratory depression □ Epidural conversion □• Itch □ Supplementary oxygen □• Nausea □ Failure/inadequate pain relief □ Verbal consent □•

• Prerequisites: Kardex:• Dedicated IV canula □ Remi pump no. □ PCA prescribed □• SpO2 monitoring □ Anaesthetist present Naloxone □• At initiation □• Midwife present □ Anti emetic □•

• Signature: _________________ Date & time: ______________________

Remi PCA in Belfast

• 4000 deliveries – Elective LSCS 14%

• Routine use since 2004

• 100-120 remi pca/mth

• 40% of labouring women choose remi pca

• Epidural rate dropped to 35%

Complications of CNB

Complications and controversy…

• Case reports of respiratory arrest– Bonner JC, McClymont W.

Anaesthesia 2012; 67: 538–40.– Pruefer C, Bewlay A. Anaesthesia

2012; 67: 1044–5.

• Recent editorials: – College Bulletin

• Hughes, Foley. March 2013,

– Anaesthesia• Kinsella, 2013

Complications and controversy…

Recent adverse reports

• Case reports of respiratory arrest– Bonner JC, McClymont W.

Anaesthesia 2012; 67: 538–40.

– Pruefer C, Bewlay A. Anaesthesia 2012; 67: 1044–5.

• Recent editorials: – College Bulletin

• Hughes, Foley. March 2013,

– Anaesthesia • Kinsella, 2013

Issues arising

• Systemic maternal effects an issue– Also management of the

cases: lack of dedicated midwifery care, recent opioid administration

– Prompt assessment and management essential

– Training and familiarity

• No room for complacency

Complications and controversy…

Issues arising

• Systemic maternal effects an issue– Also management of the

cases: lack of dedicated midwifery care, recent opioid administration

– Prompt assessment and management essential

– Training and familiarity

• No room for complacency

“hot off the press”

• August 2013 audit data

• 128 women

• Efficacy and side effects

• Outcomes

Satisfaction and efficacy

• 81% satisfied or very satisfied

• Only 9% dissatisfied or very dissatisfied

• 88% “would use again”

• Pain scores:

– 51% none or mild pain

– 35% moderate pain

• Conversion rate to epidural 11%

• Spinal in theatre 7%

Side effects

• Nausea 50%

• Itch 18%

• Sedation 0.8%

• Respiratory depression

• Episode of desaturation <94%: 32%

• All recovered with nasal specs oxygen

Remi pca offers…• Modest analgesia

• High maternal satisfaction

– 1400 per year

• Safe for mothers and babies

• Reduced epidural rate

• BUT ESSENTIAL TO HAVE…

• “one-to-one” midwifery

• Training

• Monitoring

If you ask me….• CONTEXT IS EVERYTHING

• Strict protocol– One to one care– Trained midwives– Intensive monitoring

• Familiarity with regimen (good and bad points)

• Audit of practice and outcomes

• NOT FOR THE OCCASIONAL PRACTITIONER

So finally….!

• Always a rôle for systemic analgesia

• Non-pharmacological methods may be useful in early labour

• PCA remifentanil can be a positive addition but strict protocol needed

Thank you!