Modern techniques to optimize neuraxial labor analgesia (original) (raw)

Update on modern neuraxial analgesia in labour: a review of the literature of the last 5 years

Anaesthesia, 2011

Several strategies and alternative therapies have been used to provide analgesia for labour pain. Over the last few years, a number of improvements have enhanced the efficacy and safety of neuraxial analgesia and ultimately have improved mothers' satisfaction with their birth experience. As labour analgesia is a field of obstetric anaesthesia that is rapidly evolving, this review is an update, from a clinical point of view, of developments over the last 5-7 years. We discuss advantages and controversies related to combined spinal-epidural analgesia, patient controlled epidural analgesia and the integration of computer systems into analgesic modalities. We also review the recent literature on future clinical and research perspectives including ultrasound guided neuraxial block placement, epidural adjuvants and pharmacogenetics. We finally look at the latest work with regards to epidural analgesia and breastfeeding.

Modern Neuraxial Anesthesia for Labor and Delivery

F1000Research

The availability of safe, effective analgesia during labor has become an expectation for women in most of the developed world over the past two or three decades. More than 60% of women in the United States now receive some kind of neuraxial procedure during labor. This article is a brief review of the advantages and techniques of neuraxial labor analgesia along with the recent advances and controversies in the field of labor analgesia. For the most part, we have aimed the discussion at the non-anesthesiologist to give other practitioners a sense of the state of the art and science of labor analgesia in the second decade of the 21st century.

Update on Non-neuraxial Labor Analgesia

Current Anesthesiology Reports, 2021

Purpose of Review This review will present recent updates for the use of non-neuraxial analgesia for laboring women. Recent Findings Non-neuraxial labor analgesia by nitrous oxide and intravenous opioids are described, and safety concerns with regard to remifentanil administration have been a major focus of recent studies. Fentanyl and nitrous oxide offer some efficacy, albeit less than remifentanil, however with a greater safety margin. Summary Women may request or require alternatives to neuraxial labor analgesia, in some cases due to concurrent comorbidities. Remifentanil offers the most efficacious alternative analgesia option; however, safety concerns may preclude widespread use.

Patient-requested Neuraxial Analgesia for Labor

Anesthesiology, 2007

A systematic review, including a meta-analysis, on the timing effects of neuraxial analgesia (NA) on cesarean and instrumental vaginal deliveries in nulliparous women was conducted. Of 20 articles identified, 9 met the inclusion quality criteria (3,320 participants). Cesarean delivery (odds ratio, 1.00; 95% confidence interval, 0.82-1.23) and instrumental vaginal delivery (odds ratio, 1.00; 95% confidence interval, 0.83-1.21) rates were similar in the early NA and control groups. Neonates of women with early NA had a higher umbilical artery pH and received less naloxone. In the early NA group, fewer women were not compliant with assigned treatment and crossed over to the control group. Women receiving early NA for pain relief are not at increased risk of operative delivery, whereas those receiving early parenteral opioid and late epidural analgesia present a higher risk of instrumental vaginal delivery for nonreassuring fetal status, worse indices of neonatal wellness, and a lower quality of maternal analgesia.

Perspective Chapter: Epidural Administration-New Perspectives and Uses

IntechOpen eBooks, 2023

Neuraxial techniques are commonplace in labor analgesia. Techniques for labor analgesia range from intrathecal and epidural anesthesia to peripheral nerve blocks, nitrous oxide, intravenous infusions, and acupuncture. The epidural approach is the most popular as it allows for local anesthetics to diffuse into the intrathecal space along with repeated or continuous doses of medication for labor and primary anesthetic for surgeries. The epidural technique affects differing spinal nerves (i.e., pain, autonomic, sensory, and motor) with varied effects depending on the concentration and volume of LA used. Adverse effects do exist following these techniques with hypotension being a major concern. A multitude of anesthetic agents can be given in the epidural; opioids are the most frequently used local anesthetic adjuvants. Alpha 2 adrenoreceptor agonists are also used as local anesthetic adjuvants. Although not performed routinely, peripheral nerve blocks play a complementary and supplementary role in epidural analgesia and anesthesia. There are absolute and relative contraindications to epidural anesthesia. Alternatives to neuraxial anesthesia that can be offered include infusion of ultrashort acting opioids, nitrous oxide, opioid agonist-antagonists, ketamine, TENS, and acupuncture. Local Anesthetic Systemic Toxicity may be more prevalent in the pregnant.

Regional Anesthesia and Analgesia for Labor and Delivery

New England Journal of Medicine, 2003

n 1847, the scottish obstetrician james simpson administered ether to a woman during labor to treat the pain of childbirth. He was impressed with the degree of analgesia associated with the use of the drug. Nevertheless, he expressed concern about the possible adverse effects of anesthesia: "It will be necessary to ascertain anesthesia's precise effect, both upon the action of the uterus and on the assistant abdominal muscles; its influence, if any, upon the child; whether it has a tendency to hemorrhage or other complications." 1 One and a half centuries later, the maternal and fetal effects of analgesia during labor remain central to discussions among patients, anesthesiologists, and obstetrical caregivers. A number of randomized trials have sought to address the effects of different strategies for analgesia on maternal and fetal outcomes. Despite this effort, it has become increasingly clear that potentially unwanted effects of analgesia for women in labor and their children cannot be determined easily. Remaining controversies in obstetrical anesthesia include that over the effects of regional anesthesia on the progress and outcome of labor, as well as that over its effects on the neonate. In this article we will concentrate on advances in the administration of epidural, spinal, or combined spinal-epidural analgesia during labor. However, there are many other methods of pain management that may be chosen by women in labor, such as opioids, 2 hydrotherapy, hypnotherapy, the use of labor-support personnel (doulas), massage, movement and positioning, and sterile-water blocks, among others. 3 These alternative methods can be used successfully either alone or in conjunction with epidural analgesia. In addition, successful relief of labor pain in itself is not necessarily associated with high levels of satisfaction on the part of parturient women. 4,5 Factors such as the woman's involvement in decision making, social and cultural factors, the woman's relationship with her caregivers, and her expectations regarding labor may be equally, if not more, important.

Programmed Intermittent Epidural Bolus Versus Continuous Epidural Infusion for Labor Analgesia

Anesthesia & Analgesia, 2011

BACKGROUND: Programmed intermittent epidural anesthetic bolus (PIEB) technique may result in reduced total local anesthetic consumption, fewer manual boluses, and greater patient satisfaction compared with continuous epidural infusion (CEI). In this randomized, double-blind study, we compared the incidence of motor block and labor outcome in women who received PIEB or CEI for maintenance of labor analgesia. The primary outcome variable was maternal motor function and the secondary outcome was mode of delivery. METHODS: Nulliparous, term women with spontaneous labor and cervical dilation Ͻ4 cm were eligible to participate in the study. Epidural analgesia was initiated and maintained with a solution of levobupivacaine 0.0625% with sufentanil 0.5 g/mL. After an initial epidural loading dose of 20 mL, patients were randomly assigned to receive PIEB (10 mL every hour beginning 60 minutes after the initial dose) or CEI (10 mL/h, beginning immediately after the initial dose) for the maintenance of analgesia. Patient-controlled epidural analgesia (PCEA) using a second infusion pump with levobupivacaine 0.125% was used to treat breakthrough pain. The degree of motor block was assessed in both lower extremities using the modified Bromage score at regular intervals throughout labor; the end point was any motor block in either limb. We also evaluated PCEA bolus doses and total analgesic solution consumption. RESULTS: We studied 145 subjects (PIEB ϭ 75; CEI ϭ 70). Motor block was reported in 37% in the CEI group and in 2.7% in the PIEB group (P Ͻ 0.001; odds ratio ϭ 21.2; 95% CI: 4.9-129.3); it occurred earlier (P ϭ 0.008) (hazard ratio ϭ 7.8; 95% CI: 1.9-30.8; P ϭ 0.003) and was more frequent at full cervical dilation in the CEI group (P Ͻ 0.001). The incidence of instrumental delivery was 20% for the CEI group and 7% for the PIEB group (P ϭ 0.03). Total levobupivacaine consumption, number of patients requiring additional PCEA boluses, and mean number of PCEA boluses per patient were lower in the PIEB group (P Ͻ 0.001). No differences in pain scores and duration of labor analgesia were observed. CONCLUSIONS: Maintenance of epidural analgesia with PIEB compared with CEI resulted in a lower incidence of maternal motor block and instrumental vaginal delivery.

Patient-Controlled Epidural Analgesia for Labor

Anesthesia & Analgesia, 2009

Patient-controlled epidural analgesia (PCEA) for labor was introduced into clinical practice 20 yr ago. The PCEA technique has been shown to have significant benefits when compared with continuous epidural infusion. We conducted a systematic review using MEDLINE and EMBASE (1988 -April 1, 2008) of all randomized, controlled trials in parturients who received PCEA in labor in which one of the following comparisons were made: background infusion versus none; ropivacaine versus bupivacaine; high versus low concentrations of local anesthetics; and new strategies versus standard strategies. The outcomes of interest were maternal analgesia, satisfaction, motor block, and the incidence of unscheduled clinician interventions.

Epidural analgesia for labor: Current techniques

Local and Regional Anesthesia, 2010

Epidural analgesia is an extremely effective and popular treatment for labor pain. In this review, we trace the history of the use of epidural analgesia and its refinements. We then outline the goals of treatment and methods used to attain those goals. The use of low concentrations of local anesthetics, combined with lipid-soluble opioids, does not impede the progress of labor or depress the newborn. The incidence of side effects is low. Maintenance of analgesia that allows patient control enhances patient satisfaction.