A comparison of fentanyl with pethidine for pain relief during childbirth: a randomised controlled trial

Subcutaneous vs intravenous fentanyl for labor pain management: a multicenter randomized controlled trial

BACKGROUND

Labor pain is the most intense pain a woman will experience during her lifetime. Epidural anesthesia is recommended as the most effective method for pain relief, but it has several limitations. Fentanyl has high analgesic potency with short-acting duration, but the large-scale trials that assessed the effectiveness and safety of it for labor pain management are still limited.

OBJECTIVE

This study aimed to compare the effectiveness and harm and maternal satisfaction of subcutaneous vs intravenous fentanyl for labor pain management.

STUDY DESIGN

We conducted a multicenter, open-label randomized controlled trial. A total of 226 women were randomized to receive intravenous or subcutaneous fentanyl for labor pain management. Pain scores were evaluated before and after fentanyl administration at 5, 30, and 60 minutes and then every 60 minutes until delivery. The data were analyzed based on the intention-to-treat principle.

RESULTS

Both intravenous and subcutaneous fentanyl significantly decreased labor pain from baseline to delivery (overall mean change, -1.39; 95% confidence interval, -1.62 to -1.17; and -0.89; 95% confidence interval, -1.24 to -0.05, respectively). The reduction in the pain score between the 2 groups was not different (overall mean difference, -0.35; 95% confidence interval, -0.76 to 0.05). Maternal satisfaction was high for both intravenous and subcutaneous fentanyl (89.4% and 93.8%, respectively). There was no difference in the maternal satisfaction rate between the 2 groups (relative risk, 0.95; 95% confidence interval, 0.88-1.03). No serious maternal and neonatal adverse effects were observed.

CONCLUSION

Both intravenously and subcutaneously administered fentanyl were safe and significantly reduced pain from baseline to delivery among low-risk pregnancies. Maternal satisfaction with the childbirth experience was high regardless of the route of administration of fentanyl. No serious adverse effects of fentanyl were observed in either the mothers or the neonates.

Comparative effects of epidural analgesia and intramuscular morphine on maternal and neonatal outcomes: a retrospective cohort study

BACKGROUND

The global practice of pain management during labor involves the use of epidural analgesia or intramuscular morphine. However, the impact of these methods on maternal and neonatal short-term outcomes remains uncertain.

OBJECTIVE

This study aimed to evaluate the effect of labor exposure to epidural analgesia and intramuscular morphine on neonatal intensive care unit admission rates and other associated maternal and neonatal outcomes such as sepsis, respiratory distress, instrumental delivery, birth trauma, low Apgar score, and chorioamnionitis.

STUDY DESIGN

A study at the Women's Wellness and Research Center in Qatar analyzed 7721 low-risk normal vaginal deliveries from January 2017 to April 2018. Results were analyzed using descriptive and backward stepwise multinomial regression analysis, categorizing outcomes on the basis of pain management during active labor.

RESULTS

Of the 7607 participants in the final sample, 2606 received epidural analgesia, 1338 received intramuscular morphine, 286 received both, and 3304 received neither. Multinomial regression analysis revealed no difference in neonatal intensive care unit admission in the epidural analgesia group or in the intramuscular morphine group compared with the group that received neither intervention. However, the analysis showed a significant association between the combined use of epidural analgesia and intramuscular morphine and neonatal intensive care unit admission due to respiratory depression (adjusted odds ratio, 8.63; 95% confidence interval, 1.07-69.46; P=.04). Moreover, there was a significant association between prolonged duration of the second stage of labor and receiving epidural analgesia alone (adjusted odds ratio, 1.02; 95% confidence interval, 1.01-1.02; P<.001) or the combination of epidural analgesia and intramuscular morphine (adjusted odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P<.001). In addition, the combined use of epidural analgesia and intramuscular morphine was associated with gestational age (adjusted odds ratio, 1.86; 95% confidence interval, 1.19-2.90; P=.01) and infant sex (adjusted odds ratio, 3.72; 95% confidence interval, 1.54-9.01; P=.003). Intramuscular morphine alone was only linked to low Apgar score at 1 minute (adjusted odds ratio, 6.29; 95% confidence interval, 1.33-29.83; P=.02).

CONCLUSION

In low-risk mothers, combining epidural analgesia and intramuscular morphine during labor increases NICU admission risk due to respiratory depression. However, the individual use of either method shows distinct clinical profile. Further research is warranted to enhance understanding and optimize pain management protocols.

Midwife led randomised controlled trials in Australia and New Zealand: A scoping review

BACKGROUND

Midwives are the largest workforce involved in caring for pregnant women and their babies, and are well placed to translate research into practice and ensure midwifery priorities are appropriately targeted in researched. Currently, the number and focus of randomised controlled trials led by midwives in Australia and New Zealand is unknown. The Australasian Nursing and Midwifery Clinical Trials Network was established in 2020 to build nursing and midwifery research capacity. To aid this, scoping reviews of the quality and quantity of nurse and midwife led trials were undertaken.

AIM

To identify midwife led trials conducted between 2000 and 2021 in Australia and New Zealand.

METHODS

This review was informed by the JBI scoping review framework. Medline, Emcare, and Scopus were searched from 2000-August 2021. ANZCTR, NHMRC, MRFF, and HRC (NZ) registries were searched from inception to July 2021.

FINDINGS

Of 26,467 randomised controlled trials registered on the Australian and New Zealand Clinical Trials Registry, 50 midwife led trials, and 35 peer-reviewed publications were identified. Publications were of moderate to high quality with scores limited due to an inability to blind participants or clinicians. Blinding of assessors was included in 19 published trials.

DISCUSSION

Additional support for midwives to design and conduct trials and publish findings is required. Further support is needed to translate registration of trial protocols into peer reviewed publications.

CONCLUSION

These findings will inform the Australasian Nursing and Midwifery Clinical Trials Network plans to promote quality midwife led trials.

Fentanyl for labour pain management: a scoping review

BACKGROUND

Labour pain has been identified as an important reason for women to prefer caesarean section (CS). Fentanyl is one of the short acting opioids recommended by World Health Organization for pain relief during labour. This study aimed to identify and describe the available evidence on the use of fentanyl (monotherapy) for labour pain management by any routes of administration or regime.

METHODS

We included the records published until 31 December 2021 which reported administration of fentanyl to women with normal labour for labour pain relief. Data were extracted by one reviewer and checked by another reviewer using a standardised agreement form. We mapped and presented data descriptively in figure and tabular format.

RESULTS

We included 51 records from 49 studies in our scoping review. The studies were conducted in 12 countries, mostly high-income countries. The study designs of the 51 included records were varied as follows: 38 (74.5%) experimental studies (35 randomised controlled trials and three quasi-experimental studies), and 12 (23.5%) observational studies (five retrospective cohort studies, four prospective cohort studies, two retrospective descriptive studies, and one descriptive study) and one qualitative study. Of the included records, six used intranasal fentanyl, five used subcutaneous fentanyl, 18 (35.3%) used intravenous fentanyl, 18 (35.3%) used intrathecal fentanyl, and nine used epidural fentanyl. Many records compared fentanyl with another analgesic agent while five records (9.8%) had no comparison group and seven records (13.7%) compared with no analgesia group. The doses of fentanyl varied by routes, study and the requirement depended on the women. Pain assessment was the most frequent outcome measure presented in the records (78.4%). Only nine records (17.6%) investigated women's satisfaction about labour pain relief using fentanyl and seven records (13.7%) reported the effect of fentanyl on breastfeeding. The most common reported neonatal outcomes were foetal heart rate (33 records, 64.7%) and Apgar score (32 records, 62.7%).

CONCLUSION

There is limited primary evidence especially randomised controlled trials to evaluate the effectiveness and harms of different routes of fentanyl in low- or middle-income countries. There is a need for high-quality research to establish the most effective route of fentanyl and associated effects for evidence-based international guidelines.

Intranasal Fentanyl for First-Trimester Uterine Aspiration Pain:A Randomized Controlled Trial

OBJECTIVE

To evaluate whether administration of intranasal fentanyl reduces reported pain during first-trimester uterine aspiration.

STUDY DESIGN

We conducted a multicenter, randomized, double-blind, placebo-controlled trial of patients with pregnancies less than or equal to 14 weeks gestation seeking uterine aspiration for induced abortion, early pregnancy loss, or failed medication abortion. We randomized participants 1:1 to either intranasal fentanyl 100 mcg or intranasal placebo. All participants received ibuprofen and a standardized paracervical block. The primary outcome was pain indicated at the time of uterine aspiration on a 100 mm visual analog scale (VAS). We designed the study to detect a 15 mm difference in mean pain scores, which required 53 people in each arm for a total of 106 participants. Secondary outcomes included post-procedure pain and patient satisfaction with pain control.

RESULTS

From March 2017 through June 2018, we screened 355 people for eligibility and enrolled 107 participants. Those who received intranasal fentanyl reported similar uterine aspiration pain to participants receiving placebo (58.4±28.0 fentanyl vs 58.6±24.5 placebo, p=0.97). Participants receiving intranasal fentanyl also reported similar post-procedure pain scores compared to participants receiving placebo (19.1±19.4 fentanyl vs 17.2±19 placebo, p=0.63), and were equally satisfied with procedure pain control (66.8±31.2 fentanyl vs 63.3±29.2 placebo, p=0.57).

CONCLUSION

Intranasal fentanyl did not decrease reported pain with first-trimester uterine aspiration, nor did it decrease post-procedure pain compared to placebo. As an adjunct to ibuprofen and paracervical block, intranasal fentanyl did not improve patient satisfaction with pain control.

The Effect of Pethidine Analgesia on Labor Duration and Maternal-Fetal Outcomes

Background and Aim:

Opioid analgesics had been used from time to time for treating labor pain. However, their use have been concerning. The aim of this study is to evaluate the effect of pethidine on duration of active phase of labor, labor pain and maternal-neonatal outcomes.

Methods:

In the present case-control study, the study group received a 50 mg pethidine intramuscular injection upon the start of active phase of labor, and the control group consisted of patients who receive placebo injeciton. In both groups, vital signs were measured before, and at 0, 5, 15, 30, 45 and 60 minutes after the injection. Pain intensity was evaluated with Visual Analogue Scale (VAS) prior to, and 1 hour and 2 hours after injection. Data regarding labor phase durations, maternal side effects, newborn APGAR scores and fetal respiratory problems were recorded.

Results:

102 patients in Pethidine group and 92 patients in control group, were included into the study. Labor pain VAS-scores were significantly lower in the study group (p<0.001). Moreover, active phase of labor duration was significantly shorter in the study group (p<0.001). Maternal pulse significantly decreased, and maternal nausea-vomiting was frequent in the study groups. However, the groups were similar in terms of other side effects and neonatal outcomes.

Conclusions:

Pethidine significantly reduces active phase of labor duration, has a favorable analgesic effect in treating labor pain and is not associated with serious maternal or neonatal complications. It is therefore considered an acceptable agent for use during active phase of labor. (www.actabiomedica.it)

Efficacy and safety of intravenous paracetamol in management of labour pains in a low resource setting: a randomized clinical trial

OBJECTIVE

To assess the use of single dose of paracetamol intravenously in management of labour pains.

BACKGROUND

Pain during labour is a complex, subjective and multi-faceted physiological phenomenon that varies in intensity among women and is subjected to many social and cultural modifiers.

SUBJECTS AND METHODS

This randomized clinical study was conducted in Obstetrics and gynecology department from March 2019 to March 2020 including 96 primiparous women randomized into paracetamol group (n = 48) received 1000 mg of paracetamol IV infusion and pethidine group (n = 48) received 50 mg of pethidine given slowly IV. Primary outcome is the change of the intensity of perceived labor pain. Pain score was followed and recorded by visual analogue scale (VAS). Our study protocol was registered at ClinicalTrials.gov; NCT04744727.

RESULTS

VAS score was highly significant improved gradually after 30 min, 1, 2 and 3 h of paracetamol and pethidine taken compared at start study, but participants in paracetamol group had lower pain after 2 and 3 h (3.92 ± 1.42 and 5.69 ± 1.07) than those of the pethidine groups (4.42 ± 1.87 and 5.38 ± 1.34). Also, 2.1% of paracetamol group developed dizziness and 4.2% developed nausea and vomiting, while there was 29.2% of pethidine group developed dizziness and 37.5% developed nausea and vomiting.

CONCLUSIONS

Intravenous paracetamol as labour analgesia is effective, safe, inexpensive, available and with no maternal or fetal side effects as compared to Pethidine. Paracetamol needs to have more chance in comparison to other forms as a labour pain analgesia, especially in our communities.

Safety and efficacy of fentanyl versus pethidine in cataract surgery under propofol- based sedation: A double-blind randomized controlled clinical trial

Background:

The study was aimed to evaluate the safety and efficacy of fentanyl and pethidine on the sedative quality of patients who underwent phacoemulsification cataract surgery with Propofol.

Materials and Methods:

In this double-blind randomized controlled clinical trial, patients who were candidates for elective phacoemulsification surgery with topical anesthesia were enrolled. The selected patients were randomly allocated into the two groups for receiving sedation with Propofol-Pethidine (PP) or propofol-fentanyl (PF) combinations. Demographic characteristics, hemodynamic parameters before, during, and after the operation, sedation and pain scores, and patients' and surgeons' satisfaction scores were compared in the two studied groups.

Results:

In this trial, 70 patients (35 patients in each group) have completed the study. Mean (standard deviation) operation time was 22.9 (6.8) and 25.46 (7.7) minutes in PF and PP groups (P = 0.118).Mean pain score in PF 0.46 (0.14) was significantly higher than PP groups 0.236 (0.06) (P = 0.011). The mean value of diastolic and systolic blood pressures, pulse rate, and mean arterial pressure dioxide were significantly decreased in both PF and PP groups (P_Time < 0.001), although there was no significant difference between groups.

Conclusion:

Our findings indicated the equivalence effects on hemodynamic parameters for both pethidine and fentanyl in combination with propofol in which they could provide appropriate sedation and safe anesthesia with lower complications and acceptable patients' and surgeons' satisfaction.

Subcutaneous fentanyl for labour analgesia: a retrospective case note review

BACKGROUND

In 2017, a South Australia Perinatal Practice Guideline was introduced state-wide for the use of subcutaneous fentanyl for labour analgesia as a replacement for intramuscular pethidine. We retrospectively reviewed the implementation of this practice change in our institution.

METHODS

A retrospective review of maternal and neonatal case notes for the first 100 women administered subcutaneous fentanyl in labour at a single tertiary referral centre for maternity care, between February and June 2017.

RESULTS

Of the 102 women administered subcutaneous fentanyl, the majority (55%) were primipara, with an average maternal age of 29 years and body mass index of 27 kg/m². The median total fentanyl dose administered was 200 µg and the average time from last dose to birth was 3 h. The majority of women (70%) did not require additional rescue labour analgesia and 80% had a spontaneous vaginal birth. All neonates had a 5-min Apgar score >7. The median Apgar score at 1 and 5 min was 9. No neonate had an arterial cord blood pH <7.1. The mean arterial and venous cord blood pH was 7.3. The average time for neonates to establish breathing was 1 min and the median postnatal length of stay was two days.

CONCLUSIONS

Subcutaneous fentanyl for labour analgesia appears effective and has a low incidence of adverse events.

Effectiveness comparison of nonpharmacological analgesia delivery methods: A protocol for systematic review and network meta-analysis

BACKGROUND

Childbirth is a complex and special physiological process. Pain often accompanies the whole process of delivery. Long term pain will affect the physiological and psychological of pregnant women, and severe pain will affect the delivery process and the life of maternal and fetal. There are 2 ways to relieve delivery pain: drug analgesia and nonpharmacological analgesia. Nonpharmacological analgesia has less effect on the fetus than drug analgesia and is currently a more popular method for labor analgesia. Due to the lack of randomized trials comparing the efficacy of various nonpharmacological analgesia, it is still difficult to judge the relative efficacy. Therefore, we intend to conduct a network meta-analysis to evaluate the benefit among these nonpharmacological analgesia.

METHODS

According to the retrieval strategies, randomized controlled trials on nonpharmacological analgesia delivery will be obtained from China National Knowledge Infrastructure, WanFang,SinoMed, PubMed, Web of science, Embase, and Cochrane Library, regardless of publication date or language. Studies were screened based on inclusion and exclusion criteria, and the Cochrane risk bias assessment tool will be used to evaluate the quality of the literature. The network meta-analysis will be performed in Markov Chain Monte Carlo method and carried out with Stata14 and OpenBUGS14 software. Ultimately, the evidentiary grade for the results will be evaluated.

RESULTS

This study will provide more reasonable choice for clinic than the effect of nonpharmacological analgesia in parturient delivery.

CONCLUSION

Our findings will provide references for future guidance developing and clinical decision.INPLASY registration number: INPLASY202080097.

Intranasal Fentanyl versus Subcutaneous Fentanyl for Pain Management in Prehospital Patients with Acute Pain: A Retrospective Analysis

Objective: Retrospective analysis evaluating and comparing the feasibility, effectiveness and safety of intranasal fentanyl (INF) and subcutaneous fentanyl (SCF) for pain management of patients with acute severe pain in a rural/suburban Emergency Medical Services (EMS) system. Methods: Pre- and post-pain management data of all patients (aged ≥14 years) who were transported to the emergency department (January 2015-August 2017) were extracted from EMS and online medical control center records, and compared for groups receiving INF or SCF. Kaplan-Meier analysis and the log-rank test were used to describe and compare the percentage of patients in both groups who experienced relief according to their clinically significant pain relief score. Subgroup analysis was performed by patient age (<70 years, ≥70 years). Results: 94.6% (SCF = 94.8%; INF = 94.4%) of patients successfully received fentanyl and 82.7% (SCF = 81.2%; INF = 84.0%) had complete data and were included in the analysis. No difference was observed in time to administration or in the effectiveness of INF and SCF, and neither route of administration resulted in major adverse events that required intervention by paramedics. Upon subgroup analysis, INF patients ≥70 years were more likely to experience relief compared to those <70 years. Conclusion: This retrospective analysis of prehospital patients in the Chaudière-Appalaches EMS system demonstrates that both IN and SC are feasible, effective and safe routes for administering fentanyl. The observed effects of INF were found to be greater among patients ≥70 years. Further research is required to compare these routes with more conventional methods of pain management.

Pethidine in Low Doses versus Dipyrone for Pain Relief in Labor: A Randomized Controlled Trial

OBJECTIVE

 To compare low doses of pethidine with dipyrone in labor analgesia.

METHODS

 In a randomized prospective study conducted by Universidade de Fortaleza, in the state of Ceará, Brazil, between May and December 2016, 200 full-term parturients, with very painful uterine contractions and exhibiting uterine cervix dilatation ≥ 5 cm, were selected to receive a single intravenous dose of either 0.25 mg/kg of pethidine (n = 100) or of 25 mg/kg of dipyrone (n = 100). Pain was assessed using the visual analogue scale. The data were analyzed using the Student t-test, the chi-square test and the likelihood ratio.

RESULTS

 There was a significant improvement in pain in 35% of the parturients. Both drugs presented a similar analgesic effect 1 hour after the intervention (p = 0.692). There was no analgesic effect during the evaluation of the second hour after the intervention with pethidine or dipyrone. There were no adverse effects, such as maternal drowsiness, nausea or vomiting, related to the drugs used.

CONCLUSION

 Pethidine in low doses and dipyrone presented equivalent analgesia during labor.

PUBLIC REGISTRY OF CLINICAL TRIALS

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Safety and efficacy of a combination of pethidine and levallorphan for pain relief during labor: An observational study

AIM

To evaluate the safety, effect on breastfeeding and efficacy of a combination of pethidine and levallorphan (Pethilorfan) for pain relief during labor.

METHODS

We compared maternal or neonatal morbidities, suckling difficulties in newborns and breastfeeding rates between 177 women who received 50-200 mg (as pethidine) of Pethilorfan during labor (Pethilorfan group) and 354 women who delivered their infants without analgesic drugs immediately before or after each woman in the Pethilorfan group (control group) from January 1, 2005 to December 31, 2016. We performed univariate and multivariate analyses for comparison between the two groups. We also evaluated the efficacy of Pethilorfan retrospectively.

RESULTS

The Pethilorfan group included more women with prolonged and/or operative deliveries than the control group. Nevertheless, no significant differences were seen between the two groups in the rates of Apgar scores less than 7 at 1 or 5 min, composite neonatal morbidities, hyperbilirubinemia or respiratory disturbances. The incidence of suckling difficulties lasting over 24 h and the breastfeeding rates at discharge or after 1 month were also similar. Maternal adverse effects of Pethilorfan were generally mild and transient. The efficacy ratio of Pethilorfan was 83.6%, although its analgesic effect was usually incomplete.

CONCLUSION

Pethilorfan can be used safely for labor pain relief without increasing maternal or neonatal morbidities, or impeding breastfeeding, if it is administered at a prudent dosage. Parenteral opioids including Pethilorfan should remain as an option for treating women in labor pain, particularly when epidural analgesia is not readily available or contraindicated.

Parenteral opioids for maternal pain management in labour

BACKGROUND

Parenteral opioids (intramuscular and intravenous drugs including patient-controlled analgesia) are used for pain relief in labour in many countries throughout the world. This review is an update of a review first published in 2010.

OBJECTIVES

To assess the effectiveness, safety and acceptability to women of different types, doses and modes of administration of parenteral opioid analgesia in labour. A second objective is to assess the effects of opioids in labour on the baby in terms of safety, condition at birth and early feeding.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (11 May 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials examining the use of intramuscular or intravenous opioids (including patient-controlled analgesia) for women in labour. Cluster-randomised trials were also eligible for inclusion, although none were identified. We did not include quasi-randomised trials. We looked at studies comparing an opioid with another opioid, placebo, no treatment, other non-pharmacological interventions (transcutaneous electrical nerve stimulation (TENS)) or inhaled analgesia.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of each evidence synthesis using the GRADE approach.

MAIN RESULTS

We included 70 studies that compared an opioid with placebo or no treatment, another opioid administered intramuscularly or intravenously or compared with TENS applied to the back. Sixty-one studies involving more than 8000 women contributed data to the review and these studies reported on 34 different comparisons; for many comparisons and outcomes only one study contributed data. All of the studies were conducted in hospital settings, on healthy women with uncomplicated pregnancies at 37 to 42 weeks' gestation. We excluded studies focusing on women with pre-eclampsia or pre-existing conditions or with a compromised fetus. Overall, the evidence was graded as low- or very low-quality regarding the analgesic effect of opioids and satisfaction with analgesia; evidence was downgraded because of study design limitations, and many of the studies were underpowered to detect differences between groups and so effect estimates were imprecise. Due to the large number of different comparisons, it was not possible to present GRADE findings for every comparison.For the comparison of intramuscular pethidine (50 mg/100 mg) versus placebo, no clear differences were found in maternal satisfaction with analgesia measured during labour (number of women satisfied or very satisfied after 30 minutes: 50 women; 1 trial; risk ratio (RR) 7.00, 95% confidence interval (CI) 0.38 to 128.87, very low-quality evidence), or number of women requesting an epidural (50 women; 1 trial; RR 0.50, 95% CI 0.14 to 1.78; very low-quality evidence). Pain scores (reduction in visual analogue scale (VAS) score of at least 40 mm: 50 women; 1 trial; RR 25, 95% CI 1.56 to 400, low-quality evidence) and pain measured in labour (women reporting pain relief to be "good" or "fair" within one hour of administration: 116 women; 1 trial; RR 1.75, 95% CI 1.24 to 2.47, low-quality evidence) were both reduced in the pethidine group, and fewer women requested any additional analgesia (50 women; 1 trial; RR 0.71, 95% CI 0.54 to 0.94, low-quality evidence).There was limited information on adverse effects and harm to women and babies. There were few results that clearly showed that one opioid was more effective than another. Overall, findings indicated that parenteral opioids provided some pain relief and moderate satisfaction with analgesia in labour. Opioid drugs were associated with maternal nausea, vomiting and drowsiness, although different opioid drugs were associated with different adverse effects. There was no clear evidence of adverse effects of opioids on the newborn. We did not have sufficient evidence to assess which opioid drug provided the best pain relief with the least adverse effects.

AUTHORS' CONCLUSIONS

Though most evidence is of low- or very-low quality, for healthy women with an uncomplicated pregnancy who are giving birth at 37 to 42 weeks, parenteral opioids appear to provide some relief from pain in labour but are associated with drowsiness, nausea, and vomiting in the woman. Effects on the newborn are unclear. Maternal satisfaction with opioid analgesia was largely unreported. The review needs to be examined alongside related Cochrane reviews. More research is needed to determine which analgesic intervention is most effective, and provides greatest satisfaction to women with acceptable adverse effects for mothers and their newborn.

ABM Clinical Protocol #28, Peripartum Analgesia and Anesthesia for the Breastfeeding Mother

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Non-Neuraxial Labor Analgesia: Options

Although it is the most effective method to treat labor pain, neuraxial analgesia may be undesired, contraindicated, unsuccessful, or unavailable. Providing safe choices for labor pain relief is a central goal of health care providers alike. Consequently, knowledge of the efficacy, clinical implementation, and side effects of various non-neuraxial strategies is needed to provide appropriate options for laboring patients. In addition to nonpharmacologic alternatives, inhaled nitrous oxide and systemic opioids represent two broad classes of non-neuraxial pharmacologic labor analgesia most commonly available. This review summarizes the current published literature for these non-neuraxial labor analgesic options.