Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Journal of Obstrectic Anaesthesia and Critical Care
Search articles
Home Print this page Email this page Small font size Default font size Increase font size Users Online: 150

 Table of Contents  
EDITORIAL
Year : 2023  |  Volume : 13  |  Issue : 1  |  Page : 1-2

Labour analgesia-epidural/combined spinal epidural/dural puncture epidural/entonox - A cafeteria choice for the patient or just research!


1 Department of Anaesthesiology and Perioperative Medicine, Penn State Milton S Hershey Medical Center, Hershey, PA, USA
2 Department of Anaesthesia and Perioperative Medicine, School of Medicine University of California, San Francisco, CA, USA

Date of Submission14-Feb-2023
Date of Acceptance18-Feb-2023
Date of Web Publication09-Mar-2023

Correspondence Address:
Dr. Manpreet Kaur
Department of Anaesthesiology and Perioperative Medicine, Penn State Milton S Hershey Medical Center, Hershey, PA
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOACC.JOACC_9_23

Rights and Permissions

How to cite this article:
Kaur M, Trikha A. Labour analgesia-epidural/combined spinal epidural/dural puncture epidural/entonox - A cafeteria choice for the patient or just research!. J Obstet Anaesth Crit Care 2023;13:1-2

How to cite this URL:
Kaur M, Trikha A. Labour analgesia-epidural/combined spinal epidural/dural puncture epidural/entonox - A cafeteria choice for the patient or just research!. J Obstet Anaesth Crit Care [serial online] 2023 [cited 2023 Mar 27];13:1-2. Available from: https://www.joacc.com/text.asp?2023/13/1/1/371324



Most medical treatment choices are made via shared decision-making where the patients' preferences and personal values are considered. This needs to be done while discussing multiple medically reasonable treatment options in concordance to the ethical principle of autonomy. The term patient autonomy in case of parturient reporting pain relief during labor would essentially mean her right to decide the modality of this pain relief without the anesthesiologist or the obstetrician making a choice on her behalf. In the developed world, it would be easier for the parturient to discuss all these issues, but this becomes tougher in the developing world where analgesia for labor is not as popular as in the developed countries. In the developing world, there are different challenges regarding such issues due to various languages and dialects spoken in the same region/country.[1]

The choices for the parturient under ideal circumstances would be—non-pharmacological techniques like—transcutaneous electrical nerve stimulation (TENS),[2] massage,[3] acupuncture, and acupressure,[4] pharmacological techniques that include parental pethidine, Entonox,[5] and invasive techniques like simple epidural, combine spinal epidural (CSE), and dural puncture epidural (DPE). Often, a parturient requests for inputs on these from the obstetrician with whom her interaction is more frequent as compared to the anesthesiologist who happens to be the primary analgesia provider!

The choice of the technique of labor analgesia in centers where all facilities are available basically depends upon the standard modality of practice at that place—most often this being a continuous epidural or less frequently a CSE. A parturient is usually never offered a choice—explaining impartially the pros and cons of all the techniques. It is a standard practice to 'push' a technique that the obstetrician or an anesthesiologist prefers.

Among the regularly used techniques, Entonox was popular a few decades ago. It is safe for the baby, easy to use and inexpensive. However, it has certain disadvantages—main being dizziness, nausea, and vomiting—but these usually disappears soon after the gas is discontinued. The pain relief has been documented to be unreliable and not as effective as a continuous epidural. However, it is ideal for birthing centers where the parturient can have a homelike experience. It would also be ideal for parturient who prefers to have a natural childbirth experience and have reservations on getting an epidural. Further after a natural childbirth it could be ideal for episiotomy repair.[6] Nitrous oxide may not be ideal, but it is still an option that needs to be given to a parturient. Usually, an anesthesiologist would lose interest in such a parturient—reasons being the fact that midwifes are supposed to use it and obviously the anesthesiologists is not paid for this kind of analgesia.

The choice between an epidural, combined spinal epidural and dural puncture epidural is often anesthesiologist dependent. Epidural has been time tested, considered to be a gold standard, however, has its issues that include back pain, and questionable prolongation of the duration of labor. It is popular not only because of the above-mentioned reason but also since globally anesthesiologists is familiar and experienced with this technique. Combined spinal epidural (CSE) came into vogue in early 2000 and the term walking epidural made it very attractive for the parturient, allowing her the possibility to ambulate with the epidural catheter. It offered rapid onset of analgesia, better sacral analgesia, reduced failure rates and higher maternal satisfaction. It is ideal when a parturient decides to shift from a non-pharmacologic technique to something more invasive when she finds pain unbearable as the onset of pain relief is quick. It has been described as more technically challenging and has a propensity to hemodynamic instability, fetal bradycardia due to side effects of local anesthetics and opioids that give immediate pain relief.

Dural puncture epidural technique (DPE) was advocated as a superior technique to an epidural in late 2015. Proponents of CSE and DPE have published numerous articles citing advantages—indirect confirmation of Tuohys needle placement in epidural, better midline placement confirmation in difficult anatomical landmarks, increased transfer of epidural medication into the intrathecal space, improving onset of analgesia, early bilateral sacral analgesia, lower incidence of asymmetric block, and fewer maternal and fetal side.[7] However, data regarding the efficacy of this technique compared to standard epidural is sparse and conflicting[8],[9],[10],[11],[12] though proponents insist that this is the ideal technique for labor analgesia. DPE involves intentional dural puncture with a spinal needle through the needle placed in the epidural space but without administration of intrathecal drug. It is possible that not many anesthesiologists would be comfortable in deliberately puncturing the dura followed by the instillation of the analgesic solution in the epidural space in a parturient. Besides, traditionally anesthesiologists have been taught that an accidental puncture of the dura mater would have a separate protocol to be followed due to high incidence of post-dural puncture headache. Hence, the idea of puncturing dura purposely is not well accepted yet.

In this era of patient autonomy, it is ideal that a parturient should be provided with all the information of the modalities available. In simple terms and the language that she understands well before the onset of labor so that she can discuss with her family, friends and medical personnel and decide what she would prefer.

Regarding the expertise of the anesthesiologists or the labor analgesia units there could be separate teams practicing or providing a particular technique so that the particular team could be summoned to provide analgesia to the parturient. This would not only lead to expert analgesia units that can manage better but lead to tremendous clinical data that could be collated after a given time to further suggest and frame guidelines. It is high time that research regarding labor pain relief is clinically utilized and the parturient can be allowed to choose what she prefers. However, there could be a possibility that the parturient finally leaves it to the obstetrician or the anesthesiologist for the decision!



 
  References Top

1.
Tilak A, Kasodekar S. Enigma of valid consent continues. J Obstet Anaesth Crit Care 2021;11:1-4.  Back to cited text no. 1
  [Full text]  
2.
Johnson MI, Paley CA, Jones G, Mulvey MR, Wittkopf PG. Efficacy and safety of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain in adults: A systematic review and meta-analysis of 381 studies (the meta-TENS study). BMJ Open 2022;12:e051073.  Back to cited text no. 2
    
3.
Smith CA, Levett KM, Collins CT, Dahlen HG, Ee CC, Suganuma M. Massage, reflexology and other manual methods for pain management in labour. Cochrane Database Syst Rev 2018;3:CD009290.  Back to cited text no. 3
    
4.
Smith CA, Collins CT, Levett KM, Armour M, Dahlen HG, Tan AL, et al. Acupuncture or acupressure for pain management during labour. Cochrane Database Syst Rev 2020;2:CD009232.  Back to cited text no. 4
    
5.
Beyable AA, Bayable SD, Ashebir YG. Pharmacologic and non-pharmacologic labor pain management techniques in a resource-limited setting: A systematic review. Ann Med Surg (Lond) 2022;74:103312.  Back to cited text no. 5
    
6.
Berlit S, Tuschy B, Brade J, Mayer J, Kehl S, Sütterlin M. Effectiveness of nitrous oxide for postpartum perineal repair: A randomised controlled trial. Eur J Obstet Gynecol Reprod Biol 2013;170:329-32.  Back to cited text no. 6
    
7.
Gunaydin B, Erel S. How neuraxial labor analgesia differs by approach: Dural puncture epidural as a novel option. J Anesth. 2019;33:125-30.  Back to cited text no. 7
    
8.
Layera S, Bravo D, Aliste J, Tran DQ. A systematic review of DURAL puncture epidural analgesia for labor. J Clin Anesth 2019;53:5-10.  Back to cited text no. 8
    
9.
Yin H, Tong X, Huang H. Dural puncture epidural versus conventional epidural analgesia for labor: A systematic review and meta-analysis of randomized controlled studies. J Anesth 2022;36:413-27.  Back to cited text no. 9
    
10.
Heesen M, Rijs K, Rossaint R, Klimek M. Dural puncture epidural versus conventional epidural block for labor analgesia: A systematic review of randomized controlled trials. Int J Obstet Anesth 2019;40:24-31.  Back to cited text no. 10
    
11.
Tan HS, Reed SE, Mehdiratta JE, Diomede OI, Landreth R, Gatta LA, et al. Quality of labor analgesia with dural puncture epidural versus standard epidural technique in obese parturients: A double-blind randomized controlled study. Anesthesiology 2022;136:678-87.  Back to cited text no. 11
    
12.
Yadav P, Kumari I, Narang A, Baser N, Bedi V, Dindor B. Comparison of dural puncture epidural technique versus conventional epidural technique for labor analgesia in primigravida. J Obstet Anaesth Crit Care 2018;8:24-8.  Back to cited text no. 12
  [Full text]  




 

Top
 
 
Search
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)  

 
  In this article
References

 Article Access Statistics
    Viewed308    
    Printed20    
    Emailed0    
    PDF Downloaded42    
    Comments [Add]    

Recommend this journal