Alternative Techniques For Labor Analgesia Kelly g. elterman, md Assistant professor University of texas medical branch

Introduction Central neuraxial techniques have been mainstay of labor analgesia Not an option for ALL patients Alternatives include: Non-pharmacologic Labor Analgesia Natural childbirth (no analgesia) “Alternative” techniques Intravenous Labor Analgesics Nitrous oxide

Non-Pharmacologic Labor Analgesia Examples Relaxation, massage therapy Hypnotherapy Aromatherapy Music Acupuncture Water immersion

Non-Pharmacologic Labor Analgesia Goals are to improve coping, not lessen pain Closely tied to maternal satifaction Often related to cultural/regional acceptance Personal support has been shown most beneficial Improved maternal, neonatal, analgesic, satisfaction outcomes Arendt K. Clin Perinatal. 2013.

Non-Pharmacologic Labor Analgesia Most have little risk Except water immesion in second stage Often compatible with regional techniques Except water immersion Studies lacking, efficacy difficult to determine Some data show that acupuncture, acupressure, TENS, relaxation/massage provide modest relief Arendt K. Clin Perinatal. 2013. Committee Opin 594. Obstet Gynecol. 2014.

Intravenous Labor Analgesics Opioids Bolus vs Patient-Controlled Analgesia Equipment/staffing Choice of agent Nubain Fentanyl Meperidine Remifentanil Non-opioid Analgesics Acetaminophen Paracetamol Dexmedetomidine Abd-El-Maeboud KH, et. al. J Obstet Gynaecol Res. 2014. Evron S et. al. Curr Opin Anaesthesiol. 2007.

Intravenous Labor Analgesics Opioids Nubain frequently administered as bolus Fentanyl PCA common Remifentanil PCA gaining popularity Quick on/off Difficulty timing bolus increases risks Strict monitoring necessary Non-opioid Analgesics Acetaminophen/Paracetamol Dexmedetomidine Abd-El-Maeboud KH, et. al. J Obstet Gynaecol Res. 2014. Evron S et. al. Curr Opin Anaesthesiol. 2007. Marr et. al. Anaesthesia. 2013. Liu et. al. Anesth Analg. 2014. Stocki et. al. Anesth Analg. 2014. Birnbach D, Ranasinghe J. Anesth Analg. 2014.

Nitrous Oxide Frequently used in Europe, gaining popularity in US Colorless, sweet-smelling gas NMDA receptor antagonist Administered with oxygen, blender device or pre-mixed Patient can self-administer King T, Wong C. Anesth Analg. 2014. Likis et. al. Anesth Analg. 2014.

Nitrous Oxide Advantages Disadvantages Easy to administer Avoids neuraxial technique Anxiolytic effect Disadvantages Analgesic effects inferior to neuraxial technique Safety and efficacy largely unknown Good studies lacking Existing studies difficult to analyze King T, Wong C. Anesth Analg. 2014. Likis et. al. Anesth Analg. 2014.

Summary Multiple analgesic modalities exist All inferior to neuraxial technique Multi-modal approach is best Personal support is key for patients

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