Anesthesia Student Survival Guide.pdf - Index of

312 ● AnesthesiA student survivAl Guide
Non-Pharmacologic Options for Labor Pain
The discomfort associated with vaginal delivery can be mitigated by a variety
of techniques. Supraspinal modulation of pain may underlie the effectiveness
of psycho-prophylactic techniques, such as the Lamaze technique of breathing
and relaxation. Other non-pharmacologic pain management techniques include
biofeedback, hypnosis, acupuncture, hydrotherapy, and massage.
Systemic Medications for Labor Pain
Systemic (intravenous) analgesia with opioids can cause undesirable fetal respiratory
depression. That being said, opioids such as morphine, fentanyl, meperidine,
hydromorphone, and remifentanil have been used, as well as mixed
agonist-antagonist opioids (e.g., butorphanol, nalbuphine). Patient-controlled
analgesia (PCA) has been employed utilizing some of the opioids mentioned
above. Benzodiazepines (midazolam) have also been used for anxiolysis. The
main disadvantage of systemic medications is that they can cause respiratory
depression in the fetus and the mother.
Regional Anesthesia
Paracervical blockade controls pain during first stage of labor only, associated
with cervical dilatation and uterine contractions. Unfortunately, the technique
places the viable fetus at risk for bradycardia and death, and has been mostly
abandoned. Though infrequently performed, a pudendal nerve block is safe
and provides excellent relief for the somatic pain of second stage labor. Though
far from ideal (see Table 19.3), neuraxial analgesia (lumbar epidural) is often
the best pharmacotherapeutic solution to the discomfort of childbirth. Most
consider lumbar epidural analgesia to be the gold standard for labor analgesia. It
is effective for both first and second stages of labor.
Epidural Analgesia
Continuous lumbar epidural analgesia (see Chap. 13, Regional Anesthesia)
is often employed for labor analgesia, with or without patient-controlled bolus
dosing. Patient-controlled epidural analgesia has been shown to improve analgesia
and decrease the number of provider interventions. The contemporary
use of dilute local anesthetics solutions with small doses of epidural opioids
provides effective analgesia with minimal motor block and low risk of opioidrelated
respiratory depression. Main side effects of the labor epidural include