Pregnancy, Childbirth, and the Newborn: The Complete Guide, 4th Ed.

Appendixes

Common Medications Used for Pain Relief during Labor1

Effects and side effects vary for all medications, depending on the drug, total dosage, timing, your baby’s condition, and your reaction to the medication. For more information on any of these medications, see Chapter 10 and visit our web site, http://www.PCNGuide.com.

Systemic Medications

IV Narcotics or Narcotic-like Analgesics

How and When They’re Given

• Given intravenously by direct injection or injection into an IV line. Sometimes, a patient-controlled analgesia (PCA) device is used. Can also be given by intramuscular (IM) injection.

• Given in early to active labor, when it’s believed that the birth is at least 2 hours away. Also given after a cesarean birth.

Drugs Used

• Morphine

• Fentanyl (Sublimaze)

• Meperidine (Demerol)

• Butorphanol (Stadol)

• Nalbuphine (Nubain)

(Stadol and Nubain are combination drugs—a narcotic plus a narcotic antagonist, which reduces some of the narcotic’s side effects.)

Benefits

• During active labor, the drugs reduce your awareness of pain and promote relaxation between contractions.

• Large doses of narcotics (especially morphine) may be used in a prolonged prelabor in hopes of slowing or stopping contractions and allowing you to rest.

Possible Risks

To you

• May cause itching, nausea, vomiting, drowsiness, hallucinations, dizziness, or a feeling of being “high.”

• May lower your heart rate, respiratory rate, and blood pressure.

• May affect your ability to use self-help comfort techniques.

• May temporarily slow labor progress.

To your baby before birth

• May make his heart rate readings appear abnormal.

To your baby after birth

• May slow his breathing and alter his behavioral responses (for example, poor suckling) for several days.

Additional Precautions and Interventions

For you

• Possible restriction to bed and IV fluids

• Frequent monitoring of your blood pressure and your baby’s heart rate

• Frequent reminders for you to breathe deeply, and help to keep you oriented

• Narcotic antagonists, if needed to reduce side effects

• Changes in your position or administration of oxygen to improve your baby’s heart rate pattern

• Discontinuation of medications at least 2 hours before birth to reduce their effects on your baby

• Oxygen and resuscitation equipment on hand if your baby is born within 4 hours after narcotics are given

• Narcotic antagonists, if needed to reverse side effects

Additional Systemic Medications That Are Less Commonly Used in Labor

• Sedatives and barbiturates such as Nembutal or Phenobarbital, which are given by pill or injection. Used for anxiety or, in larger doses, to help you sleep during a slow, painful prelabor. May be used before 4 cm cervical dilation, but should be discontinued before active labor, to reduce effects on your baby. Rarely used in the United States and Canada.

• Tranquilizers such as Phenergan, Versed, or Valium, which are given by pill or injection. Used for anxiety in early labor or following a cesarean section. Not used in active labor because of their effects on newborns.

• Inhalation analgesia (nitrous oxide), which is inhaled through a mask. Doesn’t eliminate pain, but the effects on your mental state mean you’re less troubled by the pain. Drug is rapidly metabolized, which means few or no side effects on your baby. Rarely used in the United States, but common in Canada.

• Narcotic antagonists, such as Narcan, which are given by injection in labor if a narcotic medication is causing adverse side effects, or by injection to a newborn with breathing problems caused by narcotics given shortly before birth.

• General anesthesia, in which an induction agent is given intravenously, then an inhalation agent is inhaled through a mask. Causes unconsciousness as well as complete numbness. Used in less than 10 percent of cesarean births.

Local Anesthetics

Local Perineal Block

How and When It’s Given

• Given by injection around the vaginal opening.

• In the second stage, given before an episiotomy; in the third stage, given for repair of the episiotomy or tear.

Drug Used

• Lidocaine (most often)

Benefits

• Numbness in perineum

• Relief of pain during crowning, episiotomy, or stitching after the birth

Possible Risks

To you

• Injections may sting.

• If given during the second stage, the drugs may increase swelling in your perineum and increase the likelihood of vaginal tears.

To your baby

• Minimal to none

Additional Precautions and Interventions

• Postpone use until after the birth and use only if stitches are necessary.

Additional Local Anesthetics That Are Less Commonly Used

• Pudendal block, which is given by injection deep into the vagina. Numbs vagina and perineum during the birth. Rarely used, except with a forceps delivery.

• Paracervical block, which is given by injection into the cervix. Numbs cervical pain and pressure in your lower uterus. Given between 5 and 9 cm cervical dilation. Rarely used, because of the effects on the baby.

Neuraxial Medications (Epidural or Spinal)

Epidural Analgesia with Combination of Narcotics and Anesthetics

How and When It’s Given

• Given by epidural catheter. See page 198 for information on placement and procedures.

• Typically given in active labor until birth.

Drugs Used

• A combination of a narcotic and a “-caine” anesthetic (To learn more about the effects of narcotics and analgesics, see pages 197 and 448.)

Benefits

• Decreased pain and numbness (or reduced sensation) in your abdomen, back, and perineum

• Increased ability to relax and sleep

• Mental clarity

Possible Risks2

To you

• Reduced mobility

• Drop in blood pressure

• Fever

• Discomforts such as itching, nausea, and vomiting (caused by narcotics)

• Slowed labor progress

• Decreased urge to push, which may lead to a forceps delivery or vacuum extraction

• Spinal headache caused by an epidural needle that has been inserted too far (2 percent chance)

• Secondary side effects from precautions and additional safety interventions (see next column)

To your baby

• Same as for IV narcotics and narcoticlike analgesics (although effects are milder), plus:

• Worrisome changes to her heart rate pattern

• Fever

Additional Precautions and Interventions

Routine

• Restriction of food and drink

• IV fluids

• Bladder catheter

• Restriction to bed

• Various devices to closely monitor you and your baby

Used as needed

• Oxygen by mask

• Pitocin to speed labor

• Episiotomy, vacuum extraction, forceps delivery, cesarean section

• Blood patch for spinal headache (a small amount of your blood is injected in the epidural space near the dural puncture)

• Additional medications to control itching and nausea

If your baby is showing effects of narcotics

• Same as for IV narcotics and narcoticlike analgesics

If your baby is born with a fever

• Admittance to special care nursery for 48 hours for observation and antibiotics

• Septic workup to check for infection (blood test and spinal tap)

Spinal (Intrathecal) Narcotic Analgesia

How and When It’s Given

• Given by spinal injection

• Given in early to active labor.

Drugs Used

• Narcotic only.

Benefits

• Decreases your perception of pain.

• Allows for the ability to move freely in bed.

• You may be able to stand with assistance (if policy allows).

• You still feel sensations other than pain (touch, pressure, temperature).

• When compared to IV narcotics, you receive more pain relief with less medication.

• Effects last up to 2 hours.

Possible Risks3

To you

• Itching, nausea, and vomiting

• Weakness in legs or loss of balance while walking

• Possible altered mental state, but less so than with IV narcotics and narcotic-like analgesics

• Spinal headache (less than 1 percent chance)

To your baby

• Same as for IV narcotics and narcoticlike analgesics (although effects are milder)

Additional Precautions and Interventions

If you have a spinal headache

• Blood patch (see page 452)

• Lying flat for hours or days

If your baby is showing effects of narcotics

• Same as for IV narcotics and narcotic-like analgesics

Combined Spinal-Epidural (CSE)

How and When It’s Given

• See details of placement on page 198.

• Given by spinal as injection as early 2 cm cervical dilation, with addition of anesthetic at 5 to 8 cm.

Drugs Used

• Spinal narcotics are given first; epidural analgesia is given when needed.

Benefits

• Same as for spinal narcotics and epidural analgesia

Possible Risks4

• Same as for spinal narcotics and epidural analgesia

Additional Precautions and Interventions

• Same as for spinal narcotics and epidural analgesia

Spinal Block

How and When It’s Given

• Given by spinal injection.

• Used for a planned cesarean section.

Drugs Used

• “-caine” drugs

Benefits

• Total numbness from your chest to toes, although you may still feel some pressure or pulling during the delivery of your baby.

• Provides excellent pain relief without impairing your mental awareness.

• Can be administered quickly and takes effect almost immediately.

• Effects last a few hours.

Possible Risks5

To you

• Drop in blood pressure

• Occasional feeling of being unable to breathe (because your chest becomes anesthetized)

• Spinal headache (1 percent chance)

To your baby

• Fetal distress

• Subtle neurobehavioral effects for days

Additional Precautions and Interventions

• Same as for spinal narcotics and epidural analgesia, plus:

• Assisted ventilation if breathing difficulties arise

Additional Neuraxial Anesthetics That Are Less Commonly Used

• Epidurals that use an anesthetic only (more commonly used for a cesarean section than for labor)

• Epidurals that use narcotics only