Commentary
Crisco is an effective vaginal lubricant
Letters to the Editor from our readers
The American Society of Anesthesiologists and the American College of Obstetrics and Gynecology jointly state, “Labor causes severe pain for many women. There is no other circumstance where it is considered acceptable for an individual to experience severe pain, untreated. In the absence of medical contraindications, maternal request is a sufficient medical indication for pain relief during labor.”3
We decided to stretch this concept by allowing epidural anesthesia to be administered upon maternal consent in anticipation of pain, prior to onset. Our extensive literature search failed to find any comprehensive studies on the use of epidural anesthesia in anticipation of labor pain.
In theory, neuraxial local anesthetic in clinically relevant doses affect only skeletal muscles, not smooth muscles; therefore, this agent should not significantly decrease the amplitude or frequency of contractions in the myometrium.4 Randomized controlled trials of the effects of analgesia during labor do not exist since it is impossible to randomly assign women to a placebo group (no pain relief). Most trials have compared the use of epidural analgesia with that of systemic narcotics. In one large trial, 992 multiparous women were randomly assigned to either epidural analgesia or midwifery support supplemented by intramuscular narcotic injections. When pain was rated on a scale of 0–100 (100 is high), the median score before the study interventions was 80 in the group of patients who did not receive an epidural analgesia. With the administration of epidural analgesia, the median score was 27.5
Clinicians and patients also have been concerned about whether the use of epidural analgesia increases the risk of cesarean delivery. The results of three randomized controlled trials demonstrated that early administration of epidural analgesia does not increase the rate of cesarean delivery among women with spontaneous or induced labor as compared with early initiation of opioids.6–8 The fact that early epidural placement does not appear to increase the incidence of cesarean delivery is encouraging for our ongoing study but doesn’t necessarily mean that epidural analgesia prior to the onset of pain (preventive epidural) will have the same outcome. More research is needed.
Boris M. Petrikovsky, MD, PhD; Elya Kozlov, MD; Matthew Ackert, MD; Ralph Ruggiero, MD; and Crystal Behofsits, DO
Wyckoff Heights Medical Center, Brooklyn NY
References
1. Haukins GL. Epidural analgesia for labor and delivery. N Engl J Med. 2010;362(16):1502–1510.
2. Catterall WA, Mackie K. Local anesthetics. In: Brunton LL, Lazo JS, Parker KL, eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 11th ed. New York, New York: McGraw-Hill; 2005;369–386.
3. American College of Obstetricians and Gynecologists. ACOG Committee Opinion #295: pain relief during labor. Obstet Gynecol. 2004;104(1):213.
4. Fanning RA, Campion DP, Collins CB, et al. A comparison of the inhibitory effects of bupivacaine and levobupivacaine on isolated human pregnant myometrium contractility. Anesth Analg. 2008;107(4):1303–1307.
5. Dickinson JE, Paech MJ, McDonald SJ, Evans SF. Maternal satisfaction with childbirth and intrapartum analgesia in nulliparous labor. Aust N Z J Obstet Gynecol. 2003;43(6):463–468.
6. Wong CA, Scavone BM, Peaceman AM, et al. The risk of cesarean delivery with neuraxial analgesia in labor. N Engl J Med. 2005;352(7):655–665.
7. Ohel G, Gonen R, Vaida S, Barak S, Gaitini L. Early versus late initiation of epidural analgesia in labor: does it increase the risk of cesarean section? A randomized trial. Am J Obstet Gynecol. 2006:194(3):600–605.
8. Wong CA, McCarthy RJ, Sullivan JT, Scavone BM, Gerber SE, Yaghmour EA. Early compared with late neuraxial analgesia in nulliparous labor induction: a randomized controlled trial. Obstet Gynecol. 2009;113(5):1066–1074.
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