Items in AFP with MESH term: Analgesia, Epidural
ABSTRACT: A group of family physicians, obstetricians, midwives, obstetric anesthesiologists, and childbirth educators attended an evidence-based symposium in 2001 on the nature and management of labor pain and discussed a series of systematic reviews that focused on methods of labor pain management. Parenteral opioids provide modest pain relief in labor, and little evidence supports the use of one agent over another. Epidural analgesia is used during labor in most large U.S. hospitals, and its use is rapidly increasing in small hospitals. Although epidural analgesia is the most effective form of pain relief, its use is associated with a longer labor, an increased incidence of maternal fever, and increased rates of operative vaginal delivery. The effect of epidural analgesia on rates of cesarean delivery is controversial. Nitrous oxide provides a modest analgesic effect, but it is used less often in the United States than in other developed nations. Paracervical block provides effective analgesia in the first stage of labor, but its use is limited by postblock bradycardia. Research is needed regarding which pain-relief options women would choose if they were offered a range of choices beyond epidural analgesia or parenteral opioids.
Dystocia in Nulliparous Women - Article
ABSTRACT: Dystocia is common in nulliparous women and is responsible for more than 50 percent of primary cesarean deliveries. Because cesarean delivery rates continue to rise, physicians providing maternity care should be skilled in the diagnosis, management, and prevention of dystocia. If labor is not progressing, inadequate uterine contractions, fetal malposition, or cephalopelvic disproportion may be the cause. Before resorting to operative delivery for arrested labor, physicians should ensure that the patient has had adequate uterine contractions for four hours, using oxytocin infusion for augmentation as needed. For nulliparous women, high-dose oxytocin-infusion protocols for labor augmentation decrease the time to delivery compared with low-dose protocols without causing adverse outcomes. The second stage of labor can be permitted to continue for longer than traditional time limits if fetal monitoring is reassuring and there is progress in descent. Prevention of dystocia includes encouraging the use of trained labor support companions, deferring hospital admission until the active phase of labor when possible, avoiding elective labor induction before 41 weeks' gestation, and using epidural analgesia judiciously.
Epidural Analgesia During Labor - Article
ABSTRACT: Epidural analgesia is a commonly employed technique of providing pain relief during labor. The number of parturients given intrapartum epidural analgesia is reported to be over 50 percent at many institutions in the United States. The procedure has few contraindications, the primary ones being patient refusal, maternal hemorrhage and coagulopathy. Induction of epidural analgesia in early labor remains controversial. However, many physicians induce analgesia as soon as the diagnosis of active labor has been established and the patient has requested pain relief. The most common complications occurring with epidural analgesia are maternal hypotension and postdural puncture headache. Retrospective studies have demonstrated an association between epidural analgesia and increases in duration of labor, instrumental vaginal delivery and cesarean section for labor. However, several recent prospective studies have concluded that epidural analgesia does not adversely affect the progress of labor or increase the rate of cesarean section. These remain controversial issues among practicing physicians.
Spontaneous Vaginal Delivery - Article
ABSTRACT: Vaginal delivery is a natural process that usually does not require significant medical intervention. Management guided by current knowledge of the relevant screening tests and normal labor process can greatly increase the probability of an uncomplicated delivery and postpartum course. All women should be screened for group B streptococcus; women who test positive should be treated with antibiotics during labor. Routine human immunodeficiency virus screening of all pregnant women, and treatment with antiretroviral medication for those who test positive, can reduce perinatal transmission of the infection. Once a woman is in labor, management should focus on the goal of delivering a healthy newborn while minimizing discomfort and complications for the mother. In a patient who tests negative for group B streptococcus, delaying admission to the labor ward until she is in active labor decreases the number of possible medical interventions during labor and delivery. Once a patient has been admitted to the hospital, providing her with continuous emotional support can improve delivery outcomes and the birthing experience. Epidural analgesia is effective for pain control and should not be discontinued late in labor to reduce the need for operative vaginal delivery. Epidurals prolong labor, but do not increase the risk of cesarean delivery. Research has shown that labor may not progress as rapidly as historically reported; this should be considered before intervening for dystocia. Routine episiotomy increases morbidity and should be abandoned. Once the infant has been delivered, active management of the third stage of labor decreases the risk of postpartum hemorrhage.
Management of Labor Pain: Promoting Patient Choice - Editorials
Effects of Discontinuing Epidurals in Late Labor - Cochrane for Clinicians
Complications of Epidural Analgesia During Labor - Editorials
Labor Analgesia - Article
ABSTRACT: Regional analgesia has become the most common method of pain relief used during labor in the United States. Epidural and spinal analgesia are two types of regional analgesia. With epidural analgesia, an indwelling catheter is directed into the epidural space, and the patient receives a continuous infusion or multiple injections of local anesthetic. Spinal injections are usually single injections into the intrathecal space. A combination of epidural and spinal analgesia, known as a walking epidural, also is available. This technique combines the rapid pain relief from the spinal regional block with the constant and consistent effects from the epidural block. It allows sufficient motor function for patients to ambulate. Complications with regional analgesia are uncommon, but may include postdural puncture headache. Rare serious complications include neurologic injury, epidural hematoma, or deep epidural infection. Regional analgesia increases the risk of instrument-assisted vaginal delivery, and family physicians should understand the contraindications and risks of complications. Continuous labor support (e.g., doula), systemic opioid analgesia, pudendal blocks, water immersion, sterile water injections into the lumbosacral spine, self-taught hypnosis, and acupuncture are other options for pain management during labor.
Epidural Analgesia for Labor Pain - Cochrane for Clinicians