Recent updates on labor Analgesia

1. Labor analgesia: What is new?
(The Recent Trends & Future scope)
Dr Ashok Jadon,
MD, DNB, MNAMS, FIPM, FIPP, FAMS
Chief Consultant Anesthesia & In-charge Pain Relief Service
Tata Motors Hospital, Jamshedpur

2. Nociception at various stages
of labor
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3. TECHNIQUES OF LABOR PAIN RELIEF
Regional Technique
Epidural and its
modifications
Spinal: Single/ Continuous
Paravertebral
Paracervical
Pudendal
Caudal
Inhalational &
Intravenous
Entonox,
Sevoflurane
IV –PCA: Fentanyl,
Remifentanil
IV & IM: Ketamine
Pethidine
Tramadol,
Ketorolac
Ether/ Chloroform/ Triline
Miscellaneous
Pharmacological & Non
Antenatal Education/ birth
training/ Counselling
Biofeedback/ Massage
Hydro-therapy
Water Injection
Acupuncture
TENS
Presence of Husband
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4. Analysis of 13 Cochrane Reviews
WHAT WORKS
Epidural, CSEA and IV
PCA remifentanil &
Inhaled analgesia
effectively manage
pain in labour.
But may give rise
to adverse effects.
WHAT MAY WORK
Immersion in water,
acupuncture,
Massage,
local nerve blocks,
non-opioid drugs &
Relaxation (Yoga)
may improve management
of labour pain, with few
adverse effects.
INSUFFICIENT EVIDENCE
Hypnosis, Biofeedback,
Sterile water injection,
Aromatherapy, TENS, “are
more effective than
placebo”.
Women receiving
pethidine experienced
adverse effects including
drowsiness and nausea.
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7. ENTONOX = NITRONOX
N2O (50%)+ O2 ( 50%)
• The use of N2O has increased across the United States since 2011.
• Moderately high satisfaction (7/10) with N2 O for pain management
• Despite inferior analgesic properties compared to epidural analgesia, N2O offers
a safe alternative.
Broughton et al. Nitrous Oxide for Labor Analgesia: What We Know to Date. Ochsner J. 2020
Ultimately, 68.9% of women who used nitrous oxide switched to
another pain management technique, with the majority (92%)
opting for an epidural.
Annual meeting ANESTHESIOLOGY 2019. https://www.asahq.org/annualmeeting
 31% who chose N2 O for analgesia did not convert to any other
analgesic method.
Nodine et al. J Midwifery Women’s Health. 2020

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9. Remifentanil IV-PCA
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No basal infusion,
A typical dose of remifentanil is 40 μg bolus with a 2 min lockout.
 10,000 cases have been evaluated (2009-2019):
 Better than Nitrous
 Almost equal to Fentanyl (better in 1st h)
 Inferior to Epidural
 Excessive sedation to mother
 Safe to fetus due to less placental transfer
RemiPCA SAFE Network. The Swiss remifentanil PCA network.
https://www.remipca.org/php/en/index.php (accessed 14 August 2019).
Ronel et al. Non-regional analgesia for labour: remifentanil in obstetrics. BJA 2019.

10. Gold standard: Lumbar Epidural
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Ronel et al. Non-regional analgesia for labour: remifentanil in obstetrics. BJA 2019.
India
??

11. Epidural (was) is “Gold Standard”
•High dose epidural Vs Low-dose epidural (walking
epidural)
•Bupivacaine or levobupivacaine 0.0625 % or
ropivacaine 0.1 % plus a small dose of fentanyl
(2µg/ml) or Sufentanyl are used
•Early Vs Late epidural…(2014----2019) No effect
•Indian context….

12. Lumbar Epidural
Infusion or Manual Bolus
•Continuous Epidural Infusion (CEI )
•Manual top-ups

13. Comparison of Continuous infusion Vs Intermittent Bolus

14. CSEA
• The ideal labor analgesic ?
• Rapid onset of analgesia
• Reliable, fewer failed, or patchy blocks
• Effective sacral analgesia in advanced
labor
• Less motor block
• Better patient satisfaction
• Aids epidural localization in difficult backs
• Faster cervical dilation in early nulliparas
• Side effects are acceptably low
• Does a few minutes advantage in
analgesic onset matter?
• Fetal bradycardia ( Incidence of 11-
30%)
• PDPH (1%)
• Pruritus 3-95% of patients
• No randomized trial has yet
appeared
• Infection/ Neurotrauma/ Other
side effects 14

15. Dural Puncture Epidural (DPE)
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16. Comparison between CSE, DPE & Epidural
1. Analgesia onset was most rapid with CSE.
2. No difference between DPE and EPL techniques.
3. DPE has improved block quality over Epidural.
4. DPE has fewer maternal and fetal side effects than the CSE.
5. DPE with PIEB mode achieved the greatest drug-sparing
effect without increasing maternal or neonatal side effects.
1. Chau, Anthony et al . Anesthesia & Analgesia 2017
2. Song, et al, Anesthesia & Analgesia: April 2021

17. Still there was a gape to achieve the ideal pain relief
• Allowing ambulation,
• Preserving the expulsive forces
• Safe
• Uninterrupted pain relief (reduce breakthrough pain)
• Diminishing physician’s workload and
• Reducing the total local anesthetic dose.
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18. Advanced Epidural Methods
• PCEA (Bolus by patient as desired)
• Limitations: Volume, lock-out & limit of drug to be infused/1-4h
• Basal infusion with PCEA ( More LA used & No superiority)
• Automated Intermittent Mandatory Boluses (AMB),
• Programmed Intermittent Epidural Boluses (PIEB),
• Computer integrated PCEA (CIPCEA) and its associated settings.
• All 3 are superior to BI +PCEA
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19. (Computer Integrated-PCEA)
• Devices to adjust background infusion rates according
to the frequency of earlier demands
• Depending on the number of PCEA patient requests
over the last hour, automatically adjust the basal
infusion rate,
• Continually recording the patient’s analgesic
requirements and modifying the basal infusion
• Rate depending on whether the parturient needed
one, two, or three demand boluses, respectively, in
the previous hour
• Newer devices can modulate (IMB) bolus dose also

20. PIEB+PCEA Vs CEI+PCEA
• Two large meta-analysis (2019 & 2020) proved:
• PIEB + PCEA regimen was more advantageous than CEI + PCEA.
• Moderate- to high-quality evidence of superiority of PIEF +PCEA support its use
as a safe and effective technique for labor analgesia.
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1. Xu J. et al. A Systematic Review and Meta-Analysis Comparing Programmed Intermittent
Bolus and Continuous Infusion as the Background Infusion for Parturient-Controlled Epidural
Analgesia. Sci Rep 9, 2583 (2019).
2. Nasir Hussain et al. Comparative analgesic efficacy and safety of intermittent local
anaesthetic epidural bolus for labour: a systematic review and meta-analysis. BJA , 2020.

21. Adjuvant drugs in labor analgesia
• A small dose of intrathecal clonidine (15—30 μg) .
• Bupivacaine-fentanyl & addition of clonidine 30 mcg and neostigmine 10 mcg.
• In PCEA addition of clonidine (22—45 μg/hour) to bupivacaine (0.0625%) and fentanyl (2 μg/mL)
produced better pain relief and reduced the need for PCEA boluses during the first stage of
labor .
• Epidural clonidine 75 μg with neostigmine 750 μg was shown to be effective in initiating labor
analgesia without motor or sympathetic block.
• Hypotension by Neostigmine is difficult to treat. High incidence of nausea Vomiting.
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Dario Galante. Adjuvant drugs in labor analgesia, BJA 2010; V105.

22. Adjuvants:
Dexmedetomidine vs Sufentanyl
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Conclusion: Dexmedetomidine is superior to sufentanil in analgesic effect and duration in first-stage labor during epidural
analgesia when combined with 0.1% ropivacaine . Tao Zhang et al. Drug Design, Development and Therapy 2019 Volume
13.

23. Progress in Concept of Labor Pain Relief
• “Childbirth without pain” was a concept introduced by Lamaze
• “Childbirth without fear” introduced Dick-Read
• The concept is to improve the experience of labor & childbirth:
1. Encouraging women to believe they can cope with the pain
2. Husband in the delivery room (reducing anxiety levels)
3. Education of women to expect pain during labor may reduce
the need for labor analgesia
• Antenatal classes

24. Moving Beyond the 0–10 Scale for Labor Pain
Measurement
• Angle Labor Pain Questionnaire (ALPQ)
• Labor Pain Relief Attitude Questionnaire for pregnant women
(LPRAQ-p)
• Both are multidimensional labor pain score includes 5-13 questions.
• May be helpful for future strategies for labor management
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25. Ultrasound in Labor epidural analgesia
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26. Take Home Message
• Every laboring mother needs labor analgesia and should be provided.
• DO not wait for modern gadgets to start labor analgesia.
• Optimize the available resources and knowledge.
• Epidural is Gold Standard but “only when” it matches with requirements of
mother, baby, anaesthetist and surgeon.
• We should work for improving the overall laboring experience rather only
pain relief
• We should use multi-dimensional scores for assessment
• We have to up-breast ourselves (lots of scope) with advancement to
provide standard of care

27. Labor epidural at Tata Motors Hospital
• Since 2007 October, 75-100 cases/ year
• Bupivacaine 0.125% 12 ml bolus followed by
• Bupivacaine 0.08% +fentanyl 1.66 mc/ml @ 10 ml/ h (increased 12, 14, 16 ml/h)
• Intermittent bolus 0.125 (5-10 ml)
• Ropivacaine 0.2% 10 ml bolus and infusion 0.125% with Fentanyl)
• CSEA few case
• DPE 15 cases (2018-2021)
• Early Vs Late comparison
• We have PCA but not used for Labor analgesia
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28. Could not be covered
• Dural puncture management
• Sevoflurane,
• Use of IV Fentanyl as rescue (Intermittent bolus or
infusion).
• Tramadol
• Ketorolac
• COVID-19 & labor analgesia
• Anticoagulation & labor analgesia
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