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| |  ESRA: Single Shot Intrathecal Analgesics May Play Role in Late Labor Pain Management By Cameron Johnston Special to DG News WARSAW, POLAND -- September 23, 2001 -- For various personal, cultural and perhaps medical reasons, many mothers-to-be initially want their deliveries to be analgesia-free, then change their minds part way through the delivery. This might necessitate fast action on the part of the anaesthetist - trying to find the best solution quickly when the mother is late in the first stage of labor, or perhaps already into the second stage. It’s also a fact that most anaesthetists prefer not to commence an epidural in the late stages of labour, and therefore face the dilemma of how to manage a potentially urgent situation. In a Swedish trial, it was found that a single shot of intrathecal sufentanil/bupivacaine seems to have a beneficial effect, with little harm to either the mother or the neonate. According to Dr. Susanna Ledin-Eriksson, an anaesthetist at the Gavle-Sandviken County Hospital, in Gavle Sweden, 40 women in an observational study were allowed to progress through normal labor and delivery until such time as they asked for some form of analgesia. At that time, they were given a single intrathecal shot of bupivacaine 2 mg and sufentanil 7.5 µg. While the patient’s response to pain was the main outcome criterion, and was evaluated according to a 10 point visual analogue scale (0 = no pain 10 = incapacitating pain), side effects such as hypotension, pruritis, sedation, nausea and motor block were all noted. The visual analog scale (VAS) scores showed a clearly-defined drop in pain at five, 15 and 30 minutes, then a steady increase: 1.07 mean at 60 minutes, 1.96 at 90 minutes, 2.36 at 120 minutes and 3.37 at 150 minutes. Despite the increase in pain, however, 77 percent of the patients rated their pain experiences as excellent, and 20 percent said they were "good". None considered the analgesia they were offered "poor". Six patients (15 percent) had a greater than 30 percent decrease in blood pressure. Motor block was rare, and only two patients had a Bromage score of 1, meaning their leg strength was somewhat limited while they were lying on the surgical table. On the other hand 90 percent of the patients experienced some degree of pruritis. No Caesarean sections were performed, although six patients (15 per cent) did require vacuum extraction. Fetal heart rate was affected in four cases, which Dr. Eriksson noted was probably caused by the spinal blockade. None of the neonates experienced an Apgar of less than 7. There were three cases of bradycardia, lasting approximately 10 minutes each. Intrathecal blockade with sufentanil and bupivacaine gives good pain relief when there is no time for an epidural block, Dr. Eriksson said. However, since this has to be regarded as an urgent case situation, a knowledge of what to expect in the way of side effects is needed, and an active care obstetric management team must be in place. Such a study, she said, probably could not be done in a teaching hospital, and it is unlikely that it would pass the scrutiny of many ethics review boards. As an observational study she said, this was not the kind of study where the women could not be randomized, or the anaesthetists blinded to the product(s) they were using. Secondly, there is the issue of informed consent: were the women advised of the purpose of the study or the risks that faced by participating in it? It might be considered unethical to withhold analgesics from these women even though it was their choice to attempt labor without anaesthetics, Dr. Eriksson said. None the less, the study was possible at her hospital, she said, because this was a small-town hospital where only 1,300 deliveries are performed each year and this was the kind of hospital environment where everybody knew everybody else, and "everybody knew that there was a study going on and the patients were informed of the details, and asked if they would like to join, with each ante-natal visit to the hospital."
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