Anesthesiology

Nonpharmacologic analgesia for L&D

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What the Anesthesiologist Should Know before the Operative Procedure

Multiple modalities exist for nonpharmacologic analgesia for labor and delivery. While the laboring parturient has a sense of urgency secondary to pain, it is essential to understand that labor analgesia is considered elective. Nonpharmacologic analgesia is not relevant to operative delivery such as cesarean or forceps-assisted delivery, as anesthesia is then required. Most parturients who desire an unmedicated delivery are healthy, have an uncomplicated pregnancy, and may have received their antepartum obstetric care from a certified nurse midwife.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

As previously mentioned, analgesia for labor and delivery is elective. Anesthesia for operative delivery can be elective, urgent, or emergent based on maternal and fetal status.

Emergent: Not applicable to labor analgesia.

Urgent: Not applicable to labor analgesia.

Elective: Labor analgesia is elective. Multiple nonpharmacologic techniques may be considered and employed after a thorough history and focused physical exam. A discussion should occur with the patient about reasonable expectations regarding labor pain.

2. Preoperative evaluation

Based on the American Society of Anesthesiologists Task Force on Obstetric Anesthesia, the anesthesiologist should conduct a focused history and physical examination before providing anesthesia care. The history should include maternal health and past anesthetic and obstetric history. A baseline blood pressure measurement, along with an airway, heart, and lung examination are also recommended. For nonpharmacologic interventions, a preanesthetic evaluation provides an opportunity to discuss various treatment options for the different stages of labor and to help establish a positive relationship between the anesthesiologist and obstetrician, nurse midwife, patient, and family members.

Medically unstable conditions warranting further evaluation

Acute cardiac events such as myocardial infarction and ongoing ischemia, unstable arrhythmias, transient ischemic attack, stroke, acute asthma exacerbation, diabetic ketoacidosis, sepsis and maternal trauma are highly unusual in the laboring parturient and not relevant to this discussion. Obstetric and neonatal conditions such as acute bleeding or hemorrhage, severe preeclampsia and ongoing fetal compromise warrant further assessment, workup, consultation, and stabilization prior to initiating any method of labor analgesia.

Delaying surgery may be indicated if any of the above mentioned medically unstable conditions are present, but may not be possible if labor has already started. The decision to delay labor analgesia or anesthesia for an operative delivery would be at the discretion of the anesthesiologist and obstetrician. Pharmacologic techniques may be employed for the health of both the mother and fetus if operative delivery seems likely.

3. What are the implications of co-existing disease on perioperative care?

b. Cardiovascular system

Perioperative evaluation

Acute/unstable conditions

If the history, physical exam, or clinical suspicion suggests an acute cardiac condition, workup may include a 12-lead ECG, continuous ECG monitoring, cardiac biomarkers (troponin), resting echocardiogram (regional wall motion abnormality), or cardiac consultation. However, this would be highly unusual in the laboring parturient. Hypertensive disorders of pregnancy require immediate attention and medical management with intravenous medication and monitoring, although nonpharmacologic analgesic techniques could still potentially be utilized.

Baseline coronary artery disease or cardiac dysfunction—Goals of management

Physiologic changes of pregnancy affect all organ systems including the heart. There is a significant increase in cardiac output by as much as 35%-40% at the end of the first trimester. Cardiac output continues to increase throughout the second trimester until it reaches a level 50% higher than in nonpregnant women. In labor, cardiac output increases by an additional 40% in the second stage, with an additional 20% increase during uterine contractions. Immediately postpartum, cardiac output can be as high as 75% above prelabor values. These changes can be significant for the patient with preexisting cardiovascular disease.

The impact of vena caval compression by the gravid uterus can be significant, and cause up to a 30%-50% decrease in cardiac output, causing the fetus to experience a decrease in blood flow and oxygenation. In addition, about 10%-15% of parturients exhibit a supine hypotensive syndrome with hypotension, tachycardia, diaphoresis and, when severe, mental status changes, when they are placed supine for more than a few minutes. Therefore, the supine position should always be avoided by using left or right uterine displacement. In addition, if the mother has preexisting cardiac dysrrythmias, valvular abnormalities, or structural heart disease, cardiology consultation before pregnancy, and follow-up during labor and delivery, are essential.

Hypertensive diseases of pregnancy including preeclampsia, eclampsia, HELLP syndrome and gestational hypertension require close management by a high-risk obstetrician, and early anesthesia consultation for analgesia options.

Perioperative risk reduction strategies

Monitoring: Only routine maternal monitoring is required for nonpharmacologic labor analgesia. Some modalities such as water therapy will require use of intermittent fetal monitoring.

Goals: Goals of management include maintaining hemodynamic stability and optimizing uteroplacental blood flow.

c. Pulmonary

Physiologic changes in the respiratory system of parturients include increased minute ventilation and oxygen consumption, and decreased functional residual capacity (FRC). Despite an increased CO2 production, the relative increase in minute ventilation causes a decline in PaCO2. During periods of hypoventilation, the parturient is prone to more rapid development of hypoxia and hypercarbia. Parturients with preeclampsia are at increased risk for pulmonary edema as well, due to low colloid osmotic pressure and increased capillary permeability. Edema of the upper airway and larynx is exaggerated in preeclamptic patients, which has the potential to make endotracheal intubation difficult.

Asthma affects approximately 3% of parturients and these patients may have exacerbation of the disease process that may require inhaler and/or corticosteroid treatment during labor.

Perioperative evaluation

Perioperative respiratory evaluation involves a thorough respiratory history including any symptoms, their frequency, and smoking history. Physical exam includes a routine chest auscultation to look for acute processes. Imaging is not routinely indicated.

Perioperative risk reduction strategies

If applicable, patients should continue utilizing their current pulmonary medications during labor. Health care providers should consider starting a nebulizer (steroid or beta-agonist) or oral steroid therapy in cases of bronchospasm. Spirometry trends are beneficial in the asthmatic patient to assess exacerbations during labor.

d. Renal-GI:

Renal

Parturients normally have a 50% increase in both renal blood flow and glomerular filtration rate. They are susceptible to acute renal failure with severe forms of preeclampsia. In addition, significant blood loss can predispose patients to renal failure. Plasma bicarbonate levels are normally decreased approximately 4 mEq/L to compensate for the progesterone-induced respiratory alkalosis.

Perioperative evaluation

Laboratory studies are not necessary in the healthy parturient.

Dehydration: Pregnant patients with nausea and vomiting, and those in labor for a long time without drinking are at risk for dehydration. Although the parturient requesting nonpharmacologic forms of pain relief may also wish to avoid intravenous catheterization and fluids, it may be necessary if she cannot sustain oral intake of clear liquids.

Assess volume status: History of oral intake, vital signs, skin turgor, mucous membranes, and urine output should provide adequate information.

Acute anemia: Parturients have a relative anemia of pregnancy secondary to an increase in plasma volume that is greater than the increase in red blood cell volume. This will not affect use of nonpharmacologic analgesic techniques.

Perioperative risk reduction strategies

Maintain adequate hydration status during labor.

GI

Although gastric emptying is not altered during pregnancy, it is slowed during labor due to pain and opioid analgesics. Lower esophageal sphincter tone is decreased during pregnancy. Laboring parturients should be considered full stomach patients.

Perioperative evaluation

While the overall incidence of aspiration is low, maternal deaths related to anesthesia may be the result of aspiration in the setting of difficult intubation. A careful assessment of the airway is mandatory throughout labor, as the Mallampati classification may change as labor progresses and during delivery. Early neuraxial analgesia rather than nonpharmacologic techniques is strongly recommended in cases of anticipated difficult intubation, as well as in those with increased body mass index.

Perioperative risk reduction strategies

The most recent guidelines of the American Society of Anesthesiology have become more liberal on the issue of clear liquids during labor, since they are rapidly emptied from the stomach. Aspiration prophylaxis is not necessary during routine labor.

For cesarean deliveries, regional anesthetic techniques are preferred to general anesthesia. If general anesthesia is induced, a rapid sequence induction should be performed by the most senior laryngoscopist. Aspiration prophylaxis during operative delivery may include a nonparticulate antacid, an H2-recepter blocker, and/or metoclopramide.

e. Neurologic:

During pregnancy, women are more sensitive to anesthetic agents. The MAC for volatile anesthetic agents is reduced 25%-40% and local anesthetic requirements are about 30% less in neuraxial techniques. Central sympathetic output is increased and vagal activity is decreased in women during normal pregnancy. Although the moderate sympathetic hyperactivity during the late months of normal pregnancy may help to return the arterial pressure to nonpregnant levels, an excessive increase in activity may result in hypertension.

Perioperative evaluation

A baseline blood pressure should be obtained prior to any anesthetic intervention. Parturients should be asked about neurological symptoms. For example, low back pain and symptoms of carpal tunnel syndrome are common during pregnancy. These should not affect provision of non-pharmacologic labor analgesia.

Perioperative risk reduction

Not applicable.

Chronic disease

Parturients with a history of chronic neurologic disease, such as myasthenia gravis or multiple sclerosis, should have early consultation with an anesthesiologist prior to labor and delivery. An anesthetic plan for labor and delivery should be discussed with the patient’s obstetrician and neurologist.These patients may not be appropriate candidates for nonpharmacologic analgesia and may benefit from analgesics to reduce the stress of labor pain.

f. Endocrine:

N/A

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

N/A

4. What are the patient's medications and how should they be managed in the perioperative period?

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

Parturients who request nonpharmacologic techniques for labor analgesia are generally healthy and are rarely on chronic medications.

Aspirin: Parturients may be on chronic aspirin therapy for thromboembolism prophylaxis or for a history of recurrent fetal loss, and it should be continued throughout labor and delivery.

Low molecular weight heparin (LMWH): LMWH is one of the most common medications used for thromboprophylaxis. Neuraxial techniques are contraindicated for 10-12 hours following a prophylactic dose and 24 hours following a therapeutic dose. Therefore, knowledge of the particular dose utilized and of its timing is essential in determining whether a neuraxial technique may be performed. These patients may not be candidates for neuraxial analgesia and may require alternative methods of pain control.

i. What should be recommended with regard to continuation of medications taken chronically?

Pulmonary: It is recommended the patient continue medications that have been taken throughout pregnancy including inhaled beta agonists and steroids, leukotriene inhibitors and oral steroid therapy perioperatively.

Psychiatric: It is important to continue taking antidepressant and antianxiety medications that have worked effectively perioperatively. They may help the patient cope with the stress of labor. In addition, chronic opioids should be continued throughout the perioperative period. Consultation with the parturient’s psychiatrist and/or chronic pain specialist should be performed, ideally prior to labor and delivery. Parturients with chronic pain issues will probably not be candidates for no-pharmacologic labor analgesia techniques.

Herbals:Parturients commonly take prenatal vitamins, folic acid, and docosahexaenoic acid (DHA, an omega-3 fatty acid) throughout pregnancy. These should be continued at the discretion of the obstetrician, since clinical doses do not affect anesthetic care. Herbal products are also increasingly being used during pregnancy. Since herbal supplements are not Food and Drug Administration (FDA)-approved products, we do not endorse their use during pregnancy. Most institutions recommend that patients discontinue the use of these products while hospitalized.

j. How To modify care for patients with known allergies -

During labor, delivery and cesarean section, parturients are exposed to multiple medications, including antibiotics and environmental agents such as latex, all which can cause mild to severe allergic reactions.During labor and delivery, the most common triggers are penicillins and other beta-lactam antibiotics given as prophylaxis against neonatal group B streptococcal infection. Other agents in descending order of frequency include latex, succinylcholine and laminaria. Of these, penicillin is the leading cause of anaphylaxis related mortality. The most common trigger during cesarean section is latex.

k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

Obstetric examinations sensitize women to latex. Latex-mediated reactions include irritant contact dermatitis, allergic contact dermatitis (Type IV cell-mediated reaction), and anaphylaxis (Type I IgE-mediated hypersensitivity reaction). Chemical antioxidants added to help stabilize latex products may cause type IV allergic reactions. While latex allergy refers to immune-mediated reactions associated with clinical symptoms, latex anaphylaxis is an immediate hypersensitivity reaction that, although it may include mild symptoms such as urticaria, rhinitis, and conjunctivitis, ranges from pruritus, bronchospasm, and tachycardia to angioedema, generalized urticaria, cardiovascular collapse, and anaphylactic shock.

Latex-mediated anaphylaxis is more prevalent among atopic asthmatic patients and is likely to manifest as bronchospasm in this patient population. Health care facilities must have institutional guidelines for precautions used during management of patients with latex allergy including the use of non–latex-containing gloves and other medical equipment. These precautions are particularly important in patients with IgE-mediated hypersensitivity reactions undergoing obstetrical and gynecological examinations. Epinephrine should be readily available to treat anaphylactic reactions. Most medical equipment, especially anesthesia related, is latex free. However, Penrose drains and Foley catheters are often made out of latex.

l. Does the patient have any antibiotic allergies- [Tier 2- Common antibiotic allergies and alternative antibiotics]

Although most allergic reactions to penicillin occur in patients with a history of a prior reaction to penicillin, a recent review of the literature found that only 10%-20% of patients who report a penicillin allergy have a documented allergy. Patients usually refer to side effects such as gastrointestinal symptoms or do not remember their reaction to penicillin. They may remember that a health care provider or family member told them not to take penicillin or that someone in their family had a reaction when they received penicillin. Taking a detailed history of the reaction to penicillin will remove most of the questionable cases.

Cross reactivity between penicillin and cephalosporin is often quoted as 8%-10%. However, (1) most of the reported reactions consist of rashes that are not immunologic in origin, (2) earlier generations of cephalosporins contained trace amounts of penicillin, and (3) patients with an allergy to penicillin are more likely to experience an anaphylactic reaction to any other drug (three-fold). A practical approach is to avoid cephalosporins in those with positive penicillin skin tests or a definitive history of penicillin anaphylaxis. Alternative antibiotic choices such as clindamycin should be used for cesarean delivery, unless cephalosporin allergy has been ruled out by skin testing.

m. Does the patient have a history of allergy to anesthesia?

If the patient suggests a personal or family history of malignant hyperthermia, early consultation with the anesthesiologist is essential. It is recommended that these parturients have an early regional analgesic technique for labor and delivery and avoid all triggering agents, which include succinylcholine and inhalational anesthetics.

Local anesthetics

Parturients may report an allergy to local anesthetics, which is often due to intravascular injection, epinephrine added to the local anesthetic, or a vasovagal episode. A thorough history will rule out most of these reported cases. If a true allergic reaction is suspected, referral to an allergist is warranted. If indeed an allergy exists to a certain class of local anesthetic, then an alternative class should be selected, as there is no cross-reactivity between amide and ester local anesthetics. True allergic reactions are likely to be to the ester class, due to its metabolism to para-amino benzoicacid (PABA). Preservatives used in amide local anesthetics, such as methylparaben, are also metabolized to PABA and may precipitate an allergic reaction.

Muscle relaxants

Not applicable for nonpharmacologic analgesia techniques.

5. What laboratory tests should be obtained and has everything been reviewed?

Routine labs are often performed by obstetricians for parturients who present in labor, including a type and screen and a complete blood count. For healthy parturients with no comorbidities as determined by a focused history and physical exam, no laboratory exams are required prior to initiating labor analgesia.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Multiple modalities exist for labor analgesia, which may be divided into pharmacologic and nonpharmacologic techniques. Regardless of the planned techniques, parturients benefit from antenatal counseling about the various analgesic methods and a birth plan to assess their desires for their childbirth experience. In addition, it is important to discuss the various coping techniques other than analgesics. The parturient, family, obstetric health care provider, and anesthesiologist must have reasonable expectations about the efficacy of nonpharmacologic therapy. These therapies include emotional support, biofeedback, hydrotherapy, intradermal sterile water injections, transcutaneous electrical nerve stimulation (TENS), acupuncture, maternal movement and positioning, and hypnotherapy. Outcome studies for each method will be discussed.

Emotional support:

May be continuous or intermittent and include the significant other, a family member, close friend, or a female nonmedical, nonfamily member known as a doula.

Benefits: Women without emotional support during labor have a greater sense of isolation and adverse perceptions of labor than those who have support. Some evidence suggests that continuous emotional support during labor by a female, nonmedical attendant (doula) reduces analgesic requirements. Labor support via a doula has been demonstrated to have positive effects on obstetric outcomes for young, socially disadvantaged, low-income women who would normally have minimal or no social support. These benefits include fewer operative deliveries. Many insurance companies will cover attendance by a doula during labor because of the evidence supporting positive obstetric outcomes. Support by her husband and his participation has been associated with decreased maternal anxiety and medication requirements. Women with self-chosen female emotional support persons have higher breast-feeding rates 6-8 weeks after delivery.

Drawbacks: Better outcomes for emotional support have been shown in Central America, Europe and Africa than in North America. Intermittent support does not have the same benefits as continuous support.

Issues: We encourage the use of continuous emotional support that begins before the onset of labor. Although the presence of non-medical support persons should be encouraged throughout labor, they should not try to make medical decisions for the care of the mother and fetus. Medical decision making should be left to the parturient and her physicians.

Biofeedback:

Biofeedback is a relaxation technique employed as an adjuvant to Lamaze relaxation and breath training. Two modalities for biofeedback exist including skin-conductance (autonomic) and electromyographic (voluntary muscle) relaxation methods.

Benefits: This technique is easily taught during routine childbirth education programs.

Drawbacks: Studies have not found a difference in duration of first stage of labor, use of epidural analgesia, incidence of instrumental delivery or newborn Apgar scores among electromyographic, skin conductance, and control groups. One small study found that only the electromyographic biofeedback group showed a minimal reduction in pain perception during labor and delivery and a lower rate of epidural utilization.

Issues: Better outcome studies are needed before suggesting this non-pharmacologic method of analgesia.

Hydrotherapy:

Hydrotherapy has potential for providing analgesia during labor. This technique usually involves a simple shower, bathtub, or the use of a whirlpool or Jacuzzi designed for pregnant women.

Benefits: Women who were offered a whirlpool or Jacuzzi required fewer pharmacologic agents for analgesia. Decreased anxiety and pain have been demonstrated with hydrotherapy.

Drawbacks: There is little risk to mother or fetus as long as fetal monitoring is appropriately done and water is kept at a comfortable body temperature. Fetal monitoring is difficult to perform during immersion and should follow ACOG guidelines for intermittent monitoring. Pain relieved during the bath, returns soon afterward, especially during the second stage of labor.

Issues: Warm baths may be employed during latent phase and active labor, but should be limited to 1-2 hour duration with fetal monitoring capabilities.

Intradermal sterile water injections:

This technique is used to treat severe low back pain during labor. It involves the intradermal injection of sterile water into four locations overlying the sacrum. The mechanism is thought to be counterirritation caused by the burning sensation of the injection itself.

Benefits: This is a simple but temporary method to reduce severe low back pain during labor. Effects last 45-120 minutes with high patient acceptability and no adverse effects.

Drawbacks: Sterile water injections do not decrease the rate of utilization of other analgesic techniques and provide only short-term relief.

Issues: Sterile water injections appeal to midwives and natural childbirth advocates who prefer nonpharmacologic methods. An intense burning sensation usually accompanies the injection.

TENS (transcutaneous electrical nerve stimulation):

This technique involves the transmission of low-voltage electrical currents to the skin via surface electrodes.

Benefits: TENS is easy to use and discontinue, is non-invasive, and there is no potential harm to the fetus.

Drawbacks: There may be interference with the electronic fetal heart rate monitor. It does not reduce the additional use of analgesics. Patients do not report its use as beneficial in randomized controlled trials, and there are no significant differences in the use of epidural analgesia, time for request of epidural analgesia, or rate of cesarean or operative delivery.

Issues: TENS unit needs to be obtained from a physical therapist or by prescription from the obstetrician or midwife. There must be personnel who can provide appropriate placement of the electrodes. Ideally, training with the unit should occur in the antepartum period.

Acupressure or acupuncture:

This is an ancient Chinese technique of placing needles into pressure points throughout the body to relieve stress and pain.

Benefits: Randomized trials found lower pain scores in women assigned to receive acupuncture. Its use results in lower utilization of other methods of analgesia including epidurals and intravenous medications.

Drawbacks: Most randomized trials were performed outside the United States where neuraxial labor techniques are less utilized. There is a lack of standardized acupuncture points for labor, as it has not been traditionally treated with this method.

Issues: There must be professionals trained in acupuncture present at all times, and they must be credentialed to provide patient care in your institution.

Maternal positioning and movement:

Maternal position may be vertical or horizontal during labor. The vertical position includes sitting, standing, walking, and squatting. The horizontal position includes supine and lateral recumbent.

Benefits: Women in upright positions experience less or no difference in pain compared to supine groups. Less perineal trauma may occur in the sitting position. There are minimal effects on the fetus.

Drawbacks:Walking or standing does not enhance or impair active labor. Women may not have the muscular strength to sustain a sitting or squatting position throughout labor. Giving birth in the upright position via a birthing chair may facilitate delivery but is associated with higher intrapartum and postpartum blood loss.

Issues: While there are minimal fetal effects, it cannot be recommended as an effective intervention to reduce the duration of labor.

Hypnotherapy:

Some controversy exists on whether breathing and relaxation techniques taught in childbirth classes are variations of self-hypnosis. Purists of self-hypnosis believe that it should be taught during the antepartum period.

Benefits: A few studies have shown that hypnosis may reduce analgesic requirements and may also be associated with decreased perineal trauma. It has been demonstrated that patients who are susceptible to hypnosis have a decreased use of parenteral opioids, decreased oxytocin use, shorter first and second stage of labor, and a higher incidence of spontaneous delivery.

Drawbacks: Hypnosis must be practiced in the antepartum period. Personnel trained in hypnosis are required during labor. Parturients must be susceptible to hypnosis to benefit from it.

Issues:Little benefit has been proved with the use of hypnosis, yet it is a technique that requires extensive preparation and teaching.

6. What is the author's preferred method of anesthesia technique and why?

Additional well-designed studies are warranted to further clarify the effectiveness of nonpharmacologic techniques on maternal pain relief and fetal outcomes. However, women who wish to use nonpharmacologic techniques during labor should be supported by all her providers including the anesthesiologist. At present, none of the techniques discussed have strong scientific evidence for their benefit but also have little or no potential for harm other than inadequate pain relief. Acupuncture seems to have the most promise.

We do certainly encourage the use of non-pharmacologic techniques mentioned here as adjuncts. In women who have certain comorbidities we encourage early anesthesia consultation and labor pain management. Many parturients present with a birth plan which may include a birthing doula. We support and encourage the use of pharmacologic and nonpharmacologic analgesia in an environment most beneficial to the mother and neonate.

What prophylactic antibiotics should be administered?

No antibiotics are required for labor or for routine nonpharmacologic methods of labor analgesia.

What do I need to know about the surgical technique to optimize my anesthetic care?

It is essential to be aware of the obstetric plan for labor and delivery for parturients requesting both pharmacologic and non-pharmacologic analgesics.

What can I do intraoperatively to assist the surgeon and optimize patient care?

Communication is essential to assist the obstetrician and optimize patient care. Knowing the status of both mother and fetus and the obstetric plan is imperative. Being aware of maternal comorbidities is also essential in assisting the obstetrician. The mother should be counselled that she may change her birth plan at any time to include use of medications or neuraxial analgesia.

What are the most common intraoperative complications and how can they be avoided/treated?

Minimal complications result from nonpharmacologic analgesia. The most significant would be that the technique is not successful and the parturient experiences significant pain throughout labor. We encourage parturients to keep an open mind and consider neuraxial techniques if severe labor pain is present. We emphasize the fact that labor patterns, fetal positions and maternal pelvic size vary and affect the level of discomfort. All labors are different and levels of pain vary tremendously between parturients.

a. Neurologic:

N/A

b. If the patient is intubated, are there any special criteria for extubation?

N/A

c. Postoperative management

What analgesic modalities can I implement?

N/A

What level bed acuity is appropriate?

Most routine postpartum patients remain on the labor floor until they are hemodynamically stable, their pain is well-controlled and analgesia/anesthesia has worn off. Only patients with significant comorbidities require special ICU care or telemetry.

What are common postoperative complications, and ways to prevent and treat them?

Common postdelivery complications include postpartum hemorrhage and perineal trauma from vaginal birth. Having a patient who is comfortable during labor and delivery may prevent some perineal trauma. Postpartum hemorrhage is more difficult to predict, although certain risk factors do exist, unrelated to method of labor analgesia. Hemorrhage is controlled by uterine massage, oxytocin, various uterotonic medications, and surgical interventions.

What's the Evidence?

"Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia". Anesthesiology. vol. 106. 2007. pp. 843-63.

(The ASA task force is a group of delegates elected by the most prestigious anesthesia society in this country and the world. The task force closely examines all literature and its validity.)

Hepner, DL, Harnett, M, Segal, SB, Bader, AM, Camann, WR, Tsen, LC. "Herbal medicine use in parturients". Anesth Analg. vol. 94. 2002. pp. 690-3.

(This group at Brigham and Women's Hospital in Boston is at the forefront in obstetric anesthesia research. The use of herbal medicine is growing in all patient populations.)

Huntley, AL, Coon, JT, Ernst, E. "Complementary and alternative medicine for labor pain: a systematic review". Am J Obstet Gynecol. vol. 191. 2004. pp. 36-43.

(Getting the perspective of our obstetric colleagues is essential.)

Leeman, L, Fontaine, P, King, V, Klein, M, Ratcliffe, S. "The nature and management of labor pain: part 1 nonpharmacologic pain relief". Am Fam Phys. vol. 68. 2003.

(Understanding the fundamentals of labor pain is a precursor for looking for alternatives for pain management.)

Hodnett, ED. "Pain and women’s satisfaction with the experience of childbirth: a systematic review". Am J Obstet Gynecol. vol. 186. 2002. pp. S160-72.

(Patient satisfaction is a driving force to find better management techniques.)

Simpkin, PP, O’Hara, M. "Nonpharmacologic relief of pain during labor: systematic reviews of five methods". Am J Obstet Gynecol. vol. 186. 2002. pp. S131-59.

(An obstetric perspective for nonpharmacologic management is essential and a systematic review is the most efficient.)

Hodnett, ED, Gates, S, Hofmeyr, GJ, Sakala, C, Weston. "Continuous support for women during childbirth". Cochrane Database Syst Rev. vol. 16. 2011. pp. CD003766.

(Cochrane database reviews provide evidence-based approaches to pain management and labor.)

Cluett, ER, Pickering, RM, Getliffe, K, St George Saunders, NJ. "Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour". BMJ. vol. 328. 2004. pp. 314-7.

(Randomized controlled trials are the gold standard for research, and the British Medical Journal provides a world view of our practice.)

Wong, CA. "Advances in labor analgesia". Int J Womens Health.. vol. 1. 2010. pp. 139-54.

(Understanding new advances in labor analgesia is a precursor to searching for non-pharmacologic alternatives.)

Lee, H, Ernst, E. "Acupuncture for labor pain management: a systematic review". Am J Obstet Gynecol. vol. 191. 2004. pp. 1573-9.

(Acupuncture is fast becoming an alternative pain management technique that is mainstream. Once again systematic reviews are essential and efficient.)
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