Analgesia in Obstetrics

Abstract

Background: An effective relief of labour pain has become an important part of obstetric medicine. Therefore regional nerve blocks, systemic analgesic and non-pharmacologic techniques are commonly used. This review article gives a summary of pathophysiology and anatomy of labour pain as well as advantages, disadvantages, risks and adverse reactions of analgesic techniques in newborns and parturients. Methods: We performed a selective literature search in Medline via PubMed using the search-terms “Analgesia” and “Obstetrics”. We also included the current guidelines of the German Society for Anesthesiology and Intensive Care Medicine. Results: PDA and CSE are safe techniques for the relief of labour pain if contraindications are excluded. The risk for instrumental delivery but not for caesarean section is increased under neuraxial analgesia. PDA and CSE should be performed in an early stage of labour using low doses of local anaesthetics if possible. It is not necessary to wait for a defined cervical dilatation before starting neuraxial analgesia. Anesthesiologists and obstetricians should inform patients as soon as possible before the situation of stress during labour. Systemic opioid analgesia is a possible alternative for neuraxial techniques. Because of possible side effects systemic remifentanil analgesia should only be performed under continuous monitoring. Several nonpharmacologic methods can also relieve labour pain, but results of studies about their effectiveness are inconsistent.

Zusammenfassung

Fragestellung: Eine effektive Schmerzbekämpfung ist zu einem wichtigen Bestandteil der geburtshilflichen Medizin geworden. Hierfür stehen Regionalanästhesietechniken, systemische Analgesieverfahren und nicht pharmakologische Methoden zur Verfügung. Die vorliegende Übersichtsarbeit gibt eine Zusammenfassung der anatomischen und (patho-)physiologischen Grundlagen des Geburtsschmerzes sowie der einsetzbaren Analgesieverfahren einschließlich ihrer Vorteile, Auswirkungen auf Mutter und Kind, Risiken und möglichen Komplikationen. Material und Methoden: Es erfolgte eine selektive Literaturrecherche zu den Stichwörtern Analgesie und Geburtshilfe in Medline via PubMed unter Einbeziehung der aktuellen Empfehlungen der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin. Ergebnisse: PDA und CSE sind unter Beachtung von Kontraindikationen sichere Verfahren zur Schmerzreduktion unter der Geburt. Die Sectio-Rate ist darunter im Gegensatz zur instrumentellen Entbindungsrate nicht erhöht. Ihr Einsatz sollte möglichst frühzeitig in der Eröffnungsphase und niedrigdosiert erfolgen. Das Abwarten einer definierten Muttermundsweite vor PDA-Anlage wird nicht empfohlen. Der Einsatz einer PDA sollte mit der Patientin schon im Vorfeld und nicht erst in der Stresssituation während der Wehen besprochen werden. Eine systemische Alternative zu PDA/CSE bietet die intravenöse Opioidanalgesie. Wegen möglicher Nebenwirkungen sollte eine systemische Analgesie mit Remifentanil nur unter kontinuierlichem Monitoring durchgeführt werden. Nicht medikamentöse Verfahren können ebenfalls Schmerzen unter der Geburt lindern. Studienergebnisse zu deren Wirksamkeit sind jedoch uneinheitlich.

Key words

delivery - obstetrics - pregnancy

Schlüsselwörter

Geburt - Geburtshilfe - Wehen

• References

• 1 von Steinbüchel R. Vorläufige Mitteilung über die Anwendung der Skopolamin-Morphium-Injektionen in der Geburtshilfe. Zentralblatt Gyn 1902; 30: 1304-1306
• 2 Caton D. The History of obstetric Anesthesia. In: Chestnut DH, Polley LS, Tsen LC, Wong CA, eds. Obstetric Anesthesia Principles and Practice. 4th ed. Philadelphia: Elsevier Mosby; 2009: 3-13
• 3 Hingson RA, Edwards WB. Continuous caudal analgesia: An analysis of the first ten thousand confinements thus managed with the report of the authorʼs first thousand cases. JAMA 1943; 123: 538-546
• 4 Melzack R. The myth of painless childbirth (the John J. Bonica lecture). Pain 1984; 19: 321-337
• 5 Lang AJ, Sorrell JT, Rodgers CS et al. Anxiety sensitivity as a predictor of labor pain. Eur J Pain 2006; 10: 263-270
• 6 Henneborn WJ, Cogan R. The effect of husband participation on reported pain and probability of medication during labor and birth. J Psychosom Res 1975; 19: 215-222
• 7 Kennell J, Klaus M, McGrath S et al. Continuous emotional support during labor in a US hospital; a randomized controlled trial. JAMA 1991; 265: 2197-2201
• 8 Bonica JJ. Principles and Practice of obstetric Analgesia and Anesthesia. Vol. 2. Philadelphia: FA Davis; 1969
• 9 Ledermann RP, McCann DS, Work fr B et al. Endogenous plasma epinephrine and norepinephrine in last-trimester pregnancy and labor. Am J Obstet Gynecol 1977; 129: 5-8
• 10 Shnider SM, Abboud T, Artal R et al. Maternal catecholamines decrease during labor after lumbar epidural analgesia. Am J Obstet Gynecol 1983; 147: 13-15
• 11 Moir DD, Willocks J. Management of incoordinate uterine action under continuous epidural analgesia. Br Med J 1967; 3: 396-400
• 12 Dyer RA, Piercy JL, Reed AR et al. Hemodynamic changes associated with spinal anesthesia for cesarean delivery in severe preeclampsia. Anesthesiology 2008; 108: 802-811
• 13 Billard CG, Stanley AK, Brockington IF. Post-traumatic stress disorder (PTSD) after childbirth. Br J Psychiatry 1995; 166: 525-528
• 14 Liu EHC, Sia ATH. Rates of caesarean section and instrumental vaginal delivery in nulliparous women after low concentration epidural infusions or opioid analgesia: a systematic review. BMJ 2004;
• 15 Ngan Kee WD, Khaw KS, Tan PE et al. Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology 2009; 111: 506-512
• 16 Wong CA. Advances in labor analgesia. Int J Womenʼs Health 2009; 1: 139-154
• 17 Klöhr S, Roth R, Hofmann T et al. Definitions of hypotension after spinal anaesthesia for caesarean section: literature search and application to parturients. Acta Anaesthesiol Scand 2010; 54: 909-921
• 18 Veeser M, Hofmann T, Roth R et al. Vasopressors for the management of hypotension after spinal anaesthesia for elective caesarean section. Systematic review and cumulative meta-analysis. Acta Anaesth Scand 2012; im Druck
• 19 BDAktuell/DGAInfo. Anästh Intensivmed 2009; 50: 502-507
• 20 Mardirosoff C, Dumont L, Boulvain M et al. Fetal bradycardia due to intrathecal opioids for labour analgesia: a systematic review. BJOG 2002; 109: 274-281
• 21 Herman NL, Choi KC, Affleck PJ et al. Analgesia, pruritus and ventilation exhibit a dose-response relationship in parturients receiving intrathecal fentanyl during labor. Anesth Analg 1999; 89: 378-383
• 22 Mayberry LJ, Clemmens D, Anindya D. Epidural analgesia side effects, co-interventions, and care of women during childbirth: A systematic review. Am J Obstet Gynecol 2002; 186: 81-93
• 23 Segal S. Labor epidural analgesia and maternal fever. Anesth Analg 2010; 111: 1467-1473
• 24 Camann WR, Hortvet LA, Hughes N et al. Maternal temperature regulation during extradural analgesia for labour. Br J Anaesth 1991; 69: 565-568
• 25 Liebermann E, Lang JM, Frigoletto jr. F et al. Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation. Pediatrics 1997; 99: 415-419
• 26 Philip J, Alexander J, Sharma SK et al. Epidural analgesia during labor and maternal fever. Anesthesiology 1999; 90: 1271-1275
• 27 Kapusta L, Confino E, Ismajovich B et al. The effect of epidural analgesia on maternal thermoregulation in labor. In J Gynaecol Obstet 1985; 23: 185-189
• 28 Weiniger CF, Wand S, Nadjari M et al. Post-void residual volume in labor: a prospective study comparing parturients with and without epidural analgesia. Acta Anaesthesiol Scand 2006; 50: 1297-1303
• 29 Olofsson CI, Ekblom AO, Ekman-Ordeberg GE et al. Post partum urinary retention: a comparison between two methods of epidural analgesia. Eur J Obstet Gynecol Reprod Biol 1997; 71: 31-34
• 30 Choi PT, Galinski SE, Takeuchi L et al. PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies. Can J Anaesth 2003; 50: 460-469
• 31 Allen C, Glasziou P, Del MC. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 1999; 354: 1229-1233
• 32 Apfel CC, Saxena A, Cakmakkaya OS et al. Prevention of postdural puncture headache after accidental dural puncture: a quantitative systematic review. Br J Anaesth 2010; 105: 255-263
• 33 Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anaesthesia: a retrospective analysis of 19,259 deliveries. Int J Obstet Anesth 2004; 13: 227-233
• 34 Marucci M, Cinnella G, Perchiazzi G et al. Patient-requested neuraxial analgesia for labor. Impact on rates of Cesarean and instrumental vaginal delivery. Anesthesiology 2007; 106: 1035-1045
• 35 Polley LS, Columb MO, Wagner DS et al. Dose-dependent reduction of the minimum local analgesic concentration of bupivacaine by sufentanil for epidural analgesia in labor. Anesthesiology 1998; 89: 626-632
• 36 Lyons G, Columb M, Hawthorne L et al. Extradural pain relief in labour: bupivacaine sparing by extradural fentanyl is dose dependent. Br J Anaesth 1997; 78: 493-497
• 37 Beilin Y, Guinn NR, Bernstein HH et al. Local anesthetics and mode of delivery: bupivacaine versus ropivacaine versus levobupivacaine. Anesth Analg 2007; 105: 756-763
• 38 Lacassie HJ, Habib AS, Lacassie HP et al. Motor blocking minimum local anesthetic concentrations of bupivacaine, levobupivacaine and ropivacaine in labor. Reg Anesth Pain Med 2007; 32: 323-329
• 39 Justins DM, Francis D, Houlton PG et al. A controlled trial of extradural fentanyl in labour. Br J Anaesth 1982; 54: 409-414
• 40 Steinberg RB, Powell G, Hu XH et al. Epidural sufentanil for analgesia for labor and delivery. Reg Anesth 1989; 14: 225-228
• 41 DʼAngelo RD, Anderson MT, Phillip J et al. Intrathecal sufentanil compared to epidural bupivacaine for labor analgesia. Anesthesiology 1994; 80: 1209-1215
• 42 Simmons SW, Cyna AM, Dennis AT et al. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database Syst Rev 2007; (3) CD003401
• 43 Nageotte MP, Larson D, Rumney PJ et al. Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women. N Engl J Med 1997; 337: 1715-1719
• 44 Van der Vyver M, Halpern S, Joseph G. Patient-controlled epidural analgesia versus continuous infusion for labour analgesia: a meta-analysis. Br J Anaesth 2002; 89: 459-465
• 45 ACOG Committee Opinion. Analgesia and Cesarean delivery rates. ACOG Committee on Obstetric Practice No. 339. Obstet Gynecol 2006; 106: 1487-1488
• 46 Simkin P, Bolding A. Update on nonpharmacologic approaches to relieve labor pain and prevent suffering. J Midwifery Womens Health 2004; 49: 489-504
• 47 Field T. Pregnancy and labor alternative therapy research. Altern Ther Health Med 2008; 14: 28-34
• 48 Tournaire M, Theau-Yonneau A. Complementary and alternative approaches to pain relief during labor. Evid Based Complement Altern Med 2007; 4: 409-417
• 49 Simkin PP, OʼHara M. Nonpharmacologic relief of pain during labor: systematic reviews of five methods. Am J Obstet Gynecol 2002; 186 (5 Suppl. Nature) S131-S159
• 50 Hodnett ED, Gates S, Hofmeyr GJ et al. Continuous support for women during childbirth. Cochrane Database Syst Rev 2007; (3) CD003766
• 51 Dowswell T, Bedwell C, Lavender T et al. Transcutaneous electrical nerve stimulation (TENS) for pain relief in labour. Cochrane Database Syst Rev 2009; (2) CD007214
• 52 Cluett ER, Nikodem VC, McCandlish RE et al. Immersion in water in pregnancy, labour and birth. Cochrane Database Syst Rev 2004; (2) CD000111
• 53 Huntley AL, Coon JT, Ernst E. Complementary and alternative medicine for labor pain: a systematic review. Am J Obstet Gynecol 2004; 191: 36-44
• 54 Smith CA, Collins CT, Cyna AM et al. Complementary and alternative therapies for pain management in labour. Cochrane Database Syst Rev 2006; (4) CD003521
• 55 Borup L, Wurlitzer W, Hedegaard M et al. Acupuncture as pain relief during delivery: a randomized controlled trial. Birth 2009; 36: 5-12
• 56 OʼMeara OP, Brazie JV. Neonatal intoxication after paracervical block. N Eng J Med 1968; 278: 1127-1128
• 57 Bricker L, Lavender T. Parenteral opioids for labor pain relief: A systematic review. Am J Obstet Gynecol 2002; 186: 94-107
• 58 Schnabel A, Hahn N, Muellenbach R et al. Geburtshilfliche Analgesie in deutschen Kliniken. Remifentanil als Alternative zur Regionalanalgesie. Anaesthesist 2011; 60: 995-1001
• 59 de Boer FC, Shortland D, Simpson RL et al. A comparison of the effects of maternally administered meptazinol and pethidine on neonatal acid-base status. Br J Obstet Gynaecol 1987; 94: 256-261
• 60 Leong WL, Snq BL, Sia AT. A comparison between remifentanil and meperidine for labor analgesia: a systematic review. Anesth Analg 2011; 113: 818-825
• 61 Douma MR, Verwey RA, Kam-Endtz CE et al. Obstetric analgesia: a comparison of patient-controlled meperidine, remifentanil, and fentanyl in labour. Br J Anaesth 2010; 104: 209-215
• 62 Frambach T, Wirbelauer J, Schelling P et al. Remifentanil zur geburtshilflichen Schmerzerleichterung per patientenkontrolliertem Analgesieverfahren: Fallserie und Diskussion medikolegaler Aspekte. Geburtshilfe Neonatol 2010; 214: 145-150
• 63 Hill D. The use of remifentanil in obstetrics. Anesthesiol Clin 2008; 26: 169-182
• 64 Rosen MA. Nitrous oxide for relief of labor pain: A systematic review. Am J Obstet Gynecol 2002; 186: 110-126
• 65 Volmanen P, Akural EI, Raudaskoski T et al. Comparison of remifentanil and nitrous oxide in labour analgesia. Acta Anaesthesiol Scand 2005; 49: 453-458
• 66 Halpern SH, Muir H, Breen TW et al. A multicenter randomized controlled trial comparing patient-controlled epidural with intravenous analgesia for pain relief in labor. Anesth Analg 2004; 99: 1532-1538
• 67 The ASA Committee on Obstetrical Anesthesia led by Palmer C, Baysinger C. Nitrous oxide for labor analgesia. http://www.asahq.org 2012
• 68 Striebel HW. Die Anästhesie – Grundlagen und Praxis. Stuttgart: Schattauer-Verlag; 2010: 118
• 69 Yeo ST, Holdcroft A, Yentis SM et al. Analgesia with sevoflurane during labor: II. Seviflurane compared with Entonox for labour analgesia. Br J Anaesth 2007; 98: 110-115