Alternative Approaches to Labor Analgesia Jerrol B. Wallace,

Alternative Approaches to Labor Analgesia Jerrol B. Wallace, DNP, MSN, CRNA Disclaimer The views presented here are those of the speaker and are not to be construed as official or reflecting the views of the Department of Defense, Uniformed Services University of the Health Sciences, AANA, or VANA

Objectives History of OB Analgesia Review Anatomy for Labor Analgesia Discuss Traditional Approaches to Labor Analgesia Discuss Alternate Infusion Strategies Discuss CSE, ITN, and DPI Discuss Alternatives to Neuraxial Analgesia History of Obstetrical Anesthesia

1847: Simpson uses Diethyl Ether 1847: Fanny Longfellow receives Ether for delivery 1853: John Snow uses chloroform on Queen Victoria for birth of Prince Leopold 1857: First acknowledged OB Anesthetic Queen Victorias 9th child

History of Neuraxial Anesthesia August Bier- Painless lower extremity surgery using cocaine 1900- Oskar Kreis- total Anesthesa intrathecal injection of cocaine 1931- Eugene Bogdan Aburel- Placed catheter in the epidural space 1945- Touhy used for spinal catherization

History of Neuraxial Anesthesia cont. 1949- Epidural catheter used for labor and C/S 1957- Bupivacaine synthesized 1979- Morphine used in the epidural space 1988- PCEA introduced 1993- CSE introduced 1996- Ropivacaine synthesized

Obstetric Anatomy Cephalad- From brain stem Terminates at Conus Medularis L1-Conus Medularis L2-Cauda Equina Membranes Pia Mater Subarachnoid Space Subdural Space

Arachnoid Mater Dura Mater Layers to Space

Skin Subcutaneous layer Supraspinous Ligament Interspinous Ligament Ligamentum Flavum Epidural Space Dura SEVERAL SURGEONS

SUSPECT I LOVE EASY DAYS Obstetric Pain Pathway First Stage Pain from lower uterine and cervix changes Visceral Afferent Nerve

fibers T10-L1 Segments Second Stage Pain from distension of pelvic floor, vagina, and perineum Somatic Nerve fibers S2-S4 Segments Why Do We Need Alternative Options

Contraindications for neuraxial anesthesia Inability to perform neuraxial anesthesia Patient requests for natural childbirth Opioid crisis The Opioid Crisis Over 20% of pregnant patients are prescribed an opioid

Approximately 3% receive a prescription for greater than 30 days Maternal opioid use has more than doubled Analgesic Interventions Non-pharmacological techniques Hypnosis, TENS, and Acupuncture Systemic Analgesia Local Anesthetics Neuraxial Techniques

Alternative Approaches Hypnosis Benefits Reduces anxiety Increases pain tolerance Reduces birth complications Accelerates recovery Gives women a

sense of control of the labor process Things to Consider Must be open to hypnosis Preparation must be completed prior to labor Not a replacement for CLE for most

women Transcutaneous Electrical Nerve Stimulation Used as an adjunct to reduce labor pain Placed on lower back or acupuncture points Some relief noted Acupuncture

Good adjunct to conventional pain relief measures Used for induction of labor, ripening the cervix, and to reduce pain Parental Analgesia Systemic Medications Opioids

Morphine Sulfate Meperidine Fentanyl Sufentanil Remifentanyl Agonist-Antagonist Agents Non-Opioids/NSAIDs Anxiolytics Ketamine

Opioids Morphine Sulfate Fentanyl Meperidine Sufentanyl ??

Remifentanyl Remifentanil Beneficial for neuraxial placement 10-20 mcg initial 10 mcg incrementally Cost Use cautiously

Agonist-Antagonist Butorphanol (Stadol) Unlike Meperidine has a ceiling effect on respiratory depression Given in doses of 1-2 mg IV or IM Nalbuphine HCL (Nubain) Given in doses of 10 mg IV/IM Causes less dysphoria than

butorphanol Less N&V, dysphoria Both agents cause significant sedation Non-Opioids/NSAIDs IV Tylenol (Ofirmev) Ketorolac

Primarily PP Fetal issues Anxiolytics/Ketamine Midazolam Low doses (0.5 1 mg) IV given to help alleviate anxiety without causing detriment to parturient and fetus Particularly useful in C-section patients Ketamine

Occasionally intermittent doses of 10-15 mg IV useful to produce intense analgesia for 10-15 minutes without causing detriment to parturient & fetus Routinely co-administer low dose midazolam Local Anesthetics Amides Bupivacaine, Ropivacaine, Lidocaine Esters

Chloroprocaine (2-3%), Tetracaine Amino-Amide Local Anesthetics Lidocaine Most commonly used in 1-2% solutions Not used for continuous infusions Bupivacaine Most commonly used in concentrations 0.05% Infusion concentrations 0.0625% - 0.25% with or without an opioid

Ropivacaine Most commonly used in concentrations of 0.1% - 0.5% (Less cardiotoxic than bupivacaine) Less potency and duration than bupivacaine Bupivacaine vs Ropivacaine Standard Concentrations Bupivaciane 0.125% w/ Fentanyl 2 mcg/ml or

Ropivacaine 0.2% Sequence of Local Anesthetic CNS Toxicity *Apnea *Coma *Grand Mal Convulsion *Unconsciousness *Irrational Conversation Increasing *Muscle Twitching

Concentration *Slurring of Speech of Local Anesthetic *Visual Disturbances *Tinnitus *Lightheadedness *Circumoral numbness

Neuraxial Analgesia/Anesthesia Techniques Epidural analgesia/anesthesia Intrathecal opioids (narcotics) ITNs Spinal analgesia/anesthesia

Combined Spinal-Epidural analgesia/anesthesia Epidural Anesthesia/Analgesia How Much Do I leave in?! Lumbar Epidural Analgesia Can be delivered by intermittent or continuous infusion

Intermittent doses of 0.0625-0.25% bupivacaine or 0.1-0.2% ropivacaine with 50-100 mcg fentanyl, generally 3-5 mls Infusion of 0.0625-0.2% bupivacaine or ropivacaine with 1-2 mcg/ml fentanyl @ 8-12 ml/hr PCEA-Combination of both methods

PIEB VS CEI My Formula Test Dose (3 mls) 2 mls test dose + 3 mls bag solution: 5 minutes after test dose (5mls) 3 mls bag solution after programming pump: 8 minutes (8mls) 2 mls bag solution (if necessary) after blood pressure and dermatome check: 1215 minutes (10mls)

Intrathecal Analgesia Often used when epidural analgesia is not viable Rapid onset of action Most commonly given in combination fentanyl (10-25 mcg) Bupivacaine (2.5-5.0 mg) Goldilocks Approach to C/ S Analgesic Dosing How much do you use?

Combined dosing? Alternative opioids? The CSE Technique Viewed as most significant advancement in OB anesthesia in the last decade Intrathecal opioids very effective in controlling 1st stage labor pain Fentanyl 10-25 mcg Less effective for 2nd stage

labor pain (bupivacaine 2.5-5 mg) Given by needle-thru-needle technique CSE Criteria for CSE Previously failed epidural/More Confirmation

Patient very uncomfortable Larger patient Multiple patients in queue Dural Puncture Technique Capiello et al. (2008) Other Anesthesia Blocks

Caudal Block Paracervical Block- First Stage Labor Pudendal Block- Second Stage Labor Analgesic Alternatives Remifentanyl PCA and Nitrous Oxide Only in selected patients Only in coordination with nursing, obstetrics, and anesthesia

Remifentanyl PCA Advantages Fast Onset, Potent Blood Metabolism Minimal fetal effects Pain reduced by 50% in stage 1 Disadvantages Short acting

Not as effective as an epidural Not as effective for stage 2 Extra vigilance required 1 to 1 nursing Pulse ox monitoring No other opioids during or 4 hours prior Remifentanyl PCA (cont.) Basal

0.025 mcg/kg/min to 0.05 mcg/kg/min Bolus 0.25 mcg/kg to 0.5 mcg/kg q 2-5 min 100KG + Parturient Basal rate: 2.5-5 mcg/min Bolus: 25 mcg- 50 mcg q 2 min Remifentanil Studies

Nitrous Used in stage 1 as a temporizing measure 50:50 mix O2 and nitrous Facility Dependent Nitronox Machine Installation Staff training

Nitrous Continued Questions ?? References Barash, P. G. (2013). Clinical Anesthesia. (7th ed.). Philadelphia, PA: Wolters Kluwer. Butterworth, J. F., Mackey D. C., & Wasnick, J. D. (2013). Morgan & Mikhails Clinical Anesthesiology. (5th ed). Connecticut: Appleton & Lange. Campogna, G., Camorcia, M., Stirparo, S., Farcomeni, A. (2011). Programmed intermittent epidural bolus versus continuous epidural infusion for labor analgesia: The effects on maternal motor function and labor outcome. A randomized doubleblind study in nulliparous women. Anesthesia and Analgesia, 113(4), 826-831.

Capiello, E., ORourke, N., Scott, S., & Tsen, L. C. (2008). A randomized trial of dural puncture technique compared with the standard epidural technique for labor analgesia. Anesthesia and Analgesia, 107(5), 1646-1651. Chestnut, D.H., et. al. (2014). Chestnuts obstetric anesthesia: principles and practice, fifth edition. Elsevier Saunders. Philadelphia, PA. References Collins, M. R., Starr, S. A., Bishop, J. T., Baysinger, C. L. (2012). Nitrous oxide for labor analgesia: Expanding options for women in the United States. Review of Obstetrics and Gynecology, 5 (3-4), 126-131. Francis, E. L. et al. (2014). Nitrous oxide for the management of labor pain: A

systematic review. Anesthesia and Analgesia, 118(4), 885. George, R. B., Allen, T. K., Habib, A. S. (2013). Intermittent epidural bolus compared with continuous epidural infusions for labor analgesia: A systematic review and meta-analysis. Anesthesia and Analgesia, 116(1), 133-144 Schauble P. G., Werner W. F., Rai S. H., Martin A. (1998). Childbirth preparation through hypnosis: The hypnoreflexogenous protocol. American Journal Clinical Hypnosis, 40, 273-283 Wong, C. A., Ratcliff, J. T., Sullivan, J. T., Scavone, B. M., Toledo, P. McCarthy, R. J. (2006). A randomized comparison of programmed intermittent epidural bolus with continuous epidural infusion for labor analgesia. Anesthesia and Analgesia, 102(3), 904-909.

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