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.
b. If the patient is intubated, are there any special criteria for extubation?
c. Postoperative management
What analgesic modalities can I implement?
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.)