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

2. 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

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

4. 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

5. 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
Committee Opin 594. Obstet Gynecol

6. 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
Evron S et. al. Curr Opin Anaesthesiol

7. 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
Evron S et. al. Curr Opin Anaesthesiol
Marr et. al. Anaesthesia
Liu et. al. Anesth Analg
Stocki et. al. Anesth Analg
Birnbach D, Ranasinghe J. Anesth Analg

8. 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
Likis et. al. Anesth Analg

9. 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
Likis et. al. Anesth Analg

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

11. Thank You