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!
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